Medical Assessment

Focused History and Physical Examination

The patient may be en route to the hospital when this part of the assessment is being conducted. The EMT should be focused on the region of the body that is most likely responsible for the current condition of the patient. The SAMPLE history method should be used. It may be performed simultaneously with other tasks such as the physical examination or interventions. To further evaluate the patient's problem as defined by signs, symptoms, and events, the EMT should use the mnemonic OPQRST:

When taking a history, use an open-ended question, at first, such as, "Can you tell me what happened?" Afterwards, use the OPQRST mnemonic to obtain more information.

Rapid Focused History and Physical Examination of Medical Patients

Medical problems are usually less visible than injuries. With the alert and oriented patient, use the SAMPLEhistory and OPQRST mnemonic to determine the medical problem and direct the rapid, focused physical examination.

Medical problems can be less obvious than injuries. Baseline pulse, respirations, and blood pressure can help determine significant medical illness. These should be obtained as early as possible.

Watch the patient's facial expressions and eyes. They are a guide to the severity of the patient's illness. Check for breath odors, such as alcohol. Note uneven movement or facial weakness.

Look for dilated neck veins, which may indicate a poorly functioning heart. Note any swelling in the neck and any tightening of the neck muscles, which may indicate breathing difficulty.

Observe the chest during respiration. Look for uneven movement or evidence of labored breathing such as retractions or abdominal breathing. Retractions occur above the clavicles, between the ribs, and/or just below the ribs. They appear as indentations or "sucked in" areas during inspiration due to increased work required to breath. Abdominal breathing is the pushing out of the abdomen with inspiration, which helps the diaphragm move downward, causing the lungs to expand. Listen for breath sounds.

• Check for distention, tenderness, firmness, and lumps of the abdomen. Look for obvious pregnancy in females.

• In the pregnant patient in labor, check the perineum for evidence of imminent delivery.

• Cool, clammy extremities may indicate poor perfusion. Observe extremity movement. Look for edema, which is the result of water leaking from the capillaries.

• When edema is present in the back, this fluid generally collects in the lower part of the body - the legs in the upright patient and the sacrum in the bed-bound patient.

• The physical examination is conducted the same way as described in the previous trauma lesson.

Overview

For responsive medical patients, you will generally obtain a focused history and physical exam as follows:

1. Gather the history OPQRST.
2. Gather a SAMPLE history.
3. Conduct a focused physical exam (focus on the complaint areas) using DCAP-BTLS.
4. Obtain baseline vital signs (respirations, pulse, skin, pupils, BP).

 For the unresponsive patient, you will obtain a focused history and physical exam as follows:

1. Conduct a rapid physical exam using DCAP-BTLS.
2. Obtain baseline vital signs (respirations, pulse, skin, pupils, BP).
3. Gather the history (OPQRST) from family/bystanders if possible.
4. Gather a SAMPLE history from bystanders/family if possible.

Review Questions:

1. How would you get a medical history from an upset, hysterical mother of a child who was unresponsive?

2. How does the medical focused history and physical exam differ from trauma?

3. How does the focused history and physical exam differ between responsive and unresponsive patients?

4. How would you handle a situation where an elderly man takes a long time to tell you his history and answer your questions? He wants to talk to you about all kinds of things besides his problem.

5. Describe your procedure, step by step, for handling a 50-year old man who complains of chest pains?

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