hello and welcome to the emergency care in the streets chapter 11 patient assessment lecture upon completion of this chapter and the related coursework you will be able to form a field impression using scene and patient assessment findings you will be able to identify the components of a patient assessment process and describe the essential actions or steps within each okay so let's get started one of the most important skills you will develop as a paramedic is the ability to assess a patient combines a number of steps including assessing the scene obtaining the chief complaint and medical history and performing a secondary assessment the process should seem seamless to the patient and it leads to a differential diagnosis which is a list of possible diagnoses based on assessment findings and a working diagnosis which is one diagnosis on which you base your treatment the assessment process should be organized and systematic but flexible as well after the primary survey and identification and treatment of life threats the sequencing of the history gathering and secondary assessment can be tailored to each patient so your job is to quickly identify your patient's problems set your care priorities and develop a patient care plan then execute that plan so let's talk about sick versus not sick an important assessment skill is determining whether the patient is sick or not sick and this could be based on the chief complaint respirations pulse mental status skin color temperature and condition for trauma patients it includes the mechanism of injury and obvious signs and symptoms of trauma it provides you with the basis for determining whether the patient is stable or unstable and if the patient's sick the next step is to determine how sick minor illness versus life-threatening events so every time you assess a patient you have to qualify if your patient is sick or not sick and quantify how sick the patient is so let's talk about establishing the field impression based on your patient's history and chief complaint a determination of what you think is the patient's current problem you must be able to communicate with the patient and ask the right questions to make the best decisions you must be a good detective shift through information gain to ask increasingly relevant questions develop a patient assessment style that works for you but is based on sound medical practice is the medical or trauma so is this medical trauma medical patients identify the chief complaint and shift through medical history whereas trauma patients the patient's medical history may be less impact on your care plan the destination may be very important and remember that medical events can cause trauma and trauma events can produce medical problems so keep an open mind so you are ready to respond to your patients needs this flow chart explains the scene size up the first steps of the patient assessment so the scene size up the scene size up involves looking around and evaluating the overall safety and stability of the scene before initiating any patient care so make sure you have safe and secure access to the scene make sure you are ready to egress out of the scene and consider any specialty resources you need and get them in route the sooner you call for help the sooner it arrives your main focus is to ensure the safety of the well-being of the ems team and any other emergency responders if the scene does not appear safe do what is necessary to make it safe or request additional resources to secure the scene before beginning patient care it requires constant reassessment crash and rescue scenes often in include multiple risk and extrication hazards the threat of another motorist disrupting the scene is always a possibility where an american national standards institute 107 or 207 certified high visibility public safety vest and consider also wearing specialty reflective gloves coats and boots assured that your team can safely gain access to the scene and the patient and then safely exit with the patient if the scene cannot be stabilized consider a snatching grab do not do the absolute least you have to do for the patient to be moved to safety that's what a snatching grab is and establish a safe parameter to keep bystanders out of harm's way formulating a basic plan and visually scanning the scene should take place before you and your team exit the vehicle request additional resources if necessary and be wary of toxic substances and toxic environments proper body and respiratory protection is a must so be wary of potential crime scenes law enforcement should enter and secure the scene first if the ems team unknowingly enters the scene first request law enforcement immediately and if the scene is unstable consider retreating to your rig so formulate an escape plan and park your vehicle away from the scene refrain from entering until law enforcement personnel have secured the scene be aware of the potential for violence from bystanders patients who abuse methamphetamines can have a much larger threat than the average person they're often paranoid and emotionally unstable and um arms sometimes so they may experience delirium never hesitate to call for law enforcement assistance risk related to physical environment include unstable surfaces snow and ice rain consider the stability of the structures around you if you have any doubts leave the area establish a safe perimeter request additional resources and once the safety of the ems team has been insured the safety of the patient is the next priority if you are unable to minimize a hazard consider moving the patient to a safe area and ensure safety of bystanders next establish a perimeter or barrier around the scene okay next we're going to talk about the mechanism of injury or the nature of illness so that's written as the moi and mechanism of injury is the way the traumatic injury occurred the forces that act on the body to cause the damage and it can help you predict the likelihood of certain injuries having occurred and estimate their severity and then there's the nature of illness that's the general type of illness a patient is experiencing if there is more than one patient or if the patient is obese you may need to request additional resources if multiple patients are present and have similar problems or complaint consider carbon monoxide poisoning or contact with other noxious agent or possibly food poisoning the presence of multiple patients means they must be a must be triaged so listen for clues in the dispatch information and activating law enforcement or the incident man incident command system so ics may be necessary be familiar with the various specialized resources available to you and only specially trained responses responders should participate in rescue operations assess the need for manual stabilization and spinal motion restriction your first priority is your own safety and the safety of your ems team members all patients should be treated as potentially infectious wear properly sized gloves on all calls and wear eye protection if blood or fluids may potentially splash or spray wear a hippa or an 95 mask if inhaled particles are a risk factor and wear a gla a gown if indicated better to err on the side of caution personal protective equipment or ppe includes clothing or specialized equipment that provides protection to the wearer from substances that may pose a health or safety risk such as steel toed boots or helmets or heat resistant outerwear also maybe self-contained breathing apparatus or leather gloves okay so now we're flowing down the patient assessment and we're into the primary survey it's the second step in the patient assessment so you have the primary survey and there's an examination techniques and you may use three exam techniques during your primary survey or the secondary assessment depending on the urgency of the patient's condition so inspection you want to look over the patient and noting any abnormalities or asymmetry that may indicate soft tissue emergencies there's palpation you want to touch to feel for abnormal abnormalities and at times palpation is gentle but a firm touch will help you identify areas of pain and tenderness fingertips are good for detecting texture and consistency while the back of your hand is better for noting skin temperature and then there's auscultation and that's listening to sounds within the body with the stethoscope so next and the primary survey you're going to form a general impression and based on your initial presentation and chief complaint the primary survey is the most time intensive portion of this process you should be able to form a general impression within 60 to 90 seconds as you look at talk to and touch the patient the general impression is your overall initial impression that determines your priority of patient care it's based on the surroundings the mechanism of injury signs and symptoms and chief complaint it enables you to identify threats to the abcs but you have to avoid tunnel vision and you make conscious objective and systematic observations answer two questions is the patient in stable or unstable condition and is the patient sick or not sick the level of consciousness may provide the first clue to the alteration in the patient's condition decide whether to implement spinal immobilization and restricted procedures and determine your patient's priorities so identify the mechanisms of injury or the nature of illness and identify the age and sex of the patient treat the life threats as you would find them and decide what additional care is needed and what needs to be done on scene or when it when to initiate transport and which facility is the most appropriate okay so assess the mental status by using afu and also the um whether they're alert to person place time or event and that's alert in oriented times four now are they responsive to verbal stimuli are the response of the pain or are they unresponsive and that's the app to score and then assess the airway is the airway open and patent and then the responsive patients who are talking or crying provide a clue about the airway patency so snoring respirations indicates a position problem and gurgling or bubbling indicates a need for suctioning and when considering airway options move from simple to complex the possibility of a spinal injury determines which technique to use to open the airway so of course we know it's the head tilt chin lift maneuver if there's medical and jaw thrust maneuver for trauma if you're going to use a mechanical means to like bag valve mask the patient you need to use an airway adjunct so an oropharyngeal or nasopharyngeal but remember it takes considerable time to prepare so if the patient cannot maintain their airway use a more invasive techniques and this includes an endotracheal tube innovation or a rescue airway such as a king or a laryngeal mask or a surgical airway now assess the breathing so is the patient breathing if not you have to breathe for them and if they are breathing is it adequate expose the chest and inspect for injuries and consider the minute volume so respiratory rate multiple by the tidal volume inspired with each breath also consider consider the breathing rate the work of breathing and assess for chest rise and fall note the symmetry of the chest wall in the depth and rhythm of the respirations and then auscultate lung sounds note the presence clarity and any abnormal sounds and then of course it's the sea and that's circulation so perform that full body scan look for any major bleeding or life-threatening injury and check for the pulse and evaluate the skin assess and control external bleeding so perform a rapid exam to identify any major external bleeding venous bleeding is characterized by steady flow arterial bleeding is characterized by spurting and evaluate unresponsive patients by doing a sweep for blood by quickly and lightly running your gloved hands from head to toe palpate the pawls and of course we're doing the radial if they're responsive and the carotid if they're unresponsive adults or children and then the brachial artery and infants count the number of beats in 30 seconds and multiply them by two the quality so a normal pulse is easy to feel a weak one is difficult to feel and with hyper tension the pulse should it can feel bounding and then check the rhythm of it and is it normal and that will be regular irregular if some beads come earlier late or are skipped and that can indicate a serious condition and then report your findings by describing the rate quality and rhythm and we talked about the skin color so color people of color mucous membranes can be assessed normal skin color and light skin is pink and dry and temperature so rises as peripheral blood vessels dilate a fever high environmental temperatures and then it falls as blood vessels constrict so shock the table on this slide shows the results for inspection and palpation of the skin so restoring circulation if a patient has inadequate circulation you must restore it control severe bleeding and improve oxygen delivery to the tissues if you cannot feel a pulse and an unresponsive adult begin cpr until the aed in the manual defibrillation is available defibrillator remember the follow standard precautions and you must evaluate the cardiac rhythm of any patient in cardiac arrest with a manual cardiac monitor defibrillator regardless of the trauma or age oxygen delivery is improved through the administration of oxygen and then you want to assess for the patient's disability so a b c d perform a neurologic exam or evaluation a mini neurologic exam includes afu and pupils a quick assessment for neurologic deficits so the glass calcoma score most commonly employed reliable and consistent method of assessing mental status and neurologic function it it assigns a point value for opening eye verbal response and motor response and these values are added for a total score assess for gross neurologic deficits so move the patient um have the patient move through all the extremities assess for motor strength and weaknesses and grip strengths and assess for loss of sensation and then you have the e so a b c d e exposing then cover visually inspect areas being examined to make an accurate and thorough assessment you cannot assess what you cannot see and then make the transport decision so you have to identify priority patients typically deemed to be in either an unstable or potentially unstable condition and need definitive care that cannot be accomplished in the field expedite transport by doing only what is necessary on scene and handling everything else in route so there's a list of priority patients on the slide and they include cpr hyper perfusion some complicated birth and i'll let you guys read through those priority patients okay now in the patient assessment we're down to the history taking and this is the third step in the patient assessment so the purpose of the history taking is to gain information about the patient and learn about the events surrounding the incident history of the immediate event and the pertinent past medical so you want to ask open-ended questions close-ended questions can be useful but generally or usually garner limited info so avoid asking leading questions and ask age-appropriate and education appropriate questions so be patient and use opportunities for patient teaching so the patient information so name and chief complaint are the most important pieces to obtain obtain other info in whatever order is most conducive to good patient care and the most convenient so techniques for the history taking your appearance and demeanor you should be clean neat and look professional and project a good attitude note taking let the patient know that you will be asking a number of questions and writing info so position yourself at eye level and maintain good contact and pay attention okay so when you're doing the history taking you want to have some good communication techniques and you want to always introduce yourself and address the patient ask the patient his or her name and how he or she would like to be addressed so avoid catch-all nicknames be familiar with the cultural groups in your area and with any issues that could lead to misunderstanding and asking about feelings so you will need to ask the patient if they're tired or depressed or any number of feelings that are most easily dealt with by denial so try to keep unpleasant sights sounds and smells from the patient who is feeling badly validate the patient's feelings be empathetic but effective with your questioning communicate with empathy so put yourself in the patient's shoes do not hesitate to communicate your feelings and address the emotional impact of what has been said and offering reassurance so be cautious about what you tell your your patients and inappropriate reassurance harms your credibility reading nonverbal cues is what we're going to talk about next so changes in body movements and facial expressions may suggest pain or psychological distress or fear so being a good listener involves patient listening encourage dialogue so care decisions are based on answers to your questions combined with data from your diagnosis avoid medical jargon so use layperson terminology and match your terminology to the patient's level of knowledge and understanding social history is not typically gathered in the pre-hospital setting however it provides valuable info regarding the patient's overall health status and helps to identify risk factors for various disease processes all right so obtaining a history of alcohol and drug abuse so alcohol is often involved in motor vehicle crashes alcohol can mass a number of signs and symptoms including pain so be alert for the smell of alcohol on the patient's breath patients may give an unreliable history and if asked how much alcohol or drug has been consumed the amount is routinely understated right so intoxicated patients can be impatient aggressive and non-compliant the fear of punishment for legal drugs use may lead to denial and keep a professional attitude okay don't judge the patients by appearance or attitude and then taking the sexual history so talk to the patient in a setting that is as private as possible keep your questions focused and do not interject any opinions or biases about sexual choices or behaviors every patient you care for deserves to be treated with compassion and respect okay so when it comes to domestic violence and sexual assault or rape you are required to report a case if you suspect physical abuse or domestic violence look for clues to indicate and emergency scenes involving domestic violence are some of the most dangerous for ems and law enforcement so maintain evidence per protocol in situations involving sexual abuse or rape be supportive caring and non-judgmental handling physical attraction to patients so it's never appropriate for a clinician to act on feelings of attraction to the patient if a patient becomes seductive or makes sexual advances firmly make it clear that your relationship is professional and keep someone else in the room with you at all times and then ensuring confidentiality so it is your duty to maintain confidentiality of a patient information be familiar with relevant laws such as hipaa and state laws and then protecting the patient's privacy you need to interview the pri the patients in a private setting and be persistent enough to obtain information that patient may be reluctant to share but do not hesitate to ask non-essential personnel to leave the room when you gather information from third parties if patients can't provide info other sources on scene may be used the further away the further you go from the primary source the greater the chance of information will contain inaccuracies though family and friends often function as filters for information okay so they may be able to describe the patient's chief complaint history and past pertinent and possibly other current health statuses but remember you cannot reveal medical info about your patients to their family law enforcement personnel and bystanders can also provide info if emergency care responders are already on scene find out what info they already have obtained and the results of any care they've provided for routine transfers take a few minutes to review the transfer paperwork all right so you must strive to understand the differences inherent in all people most common barriers are in communication of breath race authenticity age gender language education religion geography and economic status beliefs can affect many medical decisions and treatment plans dietary practices and family relationships need to be considered during transport and some cultures have identified an identified leader of the household so establish good relationships with the person to enhance that patient care always obtain consent before administering any medicine you must provide the best possible care for all patients regardless of their socioeconomic status and remember the importance of manners like using phrases such as yes sir or ma'am or possible would you facilitating cross-cultural communication so identify an interpreter so consider using a close-ended questions to avoid enact translations right so remind interpreter that information is confidential and use a certified medical interpreter if possible it ensures confidentiality and it understands medical terminology speaking louder will not always overcome a language barrier so special challenges and history taking dealing with talkative or reserved patients so overly talkative patients determine whether they use uh they it's from some type of medical problem and keep your patient and patients who do not offer enough information ask open-ended questions to encourage that there's also patients who are going to have anxiety so expect your patient to initially be somewhat anxious okay so if your patient remains anxious consider why because high anxiety is an early sign of shock talking to patients with depression so consider the patient might be depressed if he or she seems sad hopeless restlessness or irritable and then there's situational depression and that's a reaction to a stressful event in the person's life but then there's chronic depression and you must ask about the patient's feelings to assess for risk of suicide also follow your local protocols dealing safely with anger and hostility so anger and hostility at unfairness or and harsh realities are normal but be attentive to changes in body language so establish a safe and secure scene call for law enforcement if necessary and also retreat if necessary clarify a confusing history or unusual behaviors so the patients may give you information to the physician that he or she doesn't did not provide to you consider the possible reasons for that confusing behavior might be lack of oxygen or toxic environment or stroke or some type of mental illness manage patients with sensory or development challenges so limited education or intelligence and a skillful question answer approach often yields adequate information so be alert for partial answers or omissions and you may need to get some information from family members or caregivers when it comes to hearing loss low vision or blindness so hearing loss for some patients speaking slowly and slightly louder may be all that's necessary low vision be careful to announce yourself and your reason for being there alright so managing age related considerations pediatric patients so initial approach should be similar to that of the adult you want to obtain an accurate history but it could be difficult so listen to the parents and be sensitive to the fears of the parents as well pay attention to the relationship between the parent and child tailor your questions to the age of the child right in neonates and infants maternal history and birth history is going to be important gather an accurate family history and travel history and renew of the system should pay special attention to skin ears nose and teeth geriatric patients so can be challenging due to a variety of medical and traumatic conditions not seen in other patients so accommodate sensory losses and patients tend to have multiple chronic conditions and it might complicate the history taking process so they may have multiple complaints or multiple medications gather all accurate medical history along with current dosages signs may be less dramatic in older patients so consider including a functional assessment during systems review alright so responsive medical patients the chief complaint the most serious thing that the patient is concerned about the reason the patient called you or or someone else called you and it should be recorded in the patient's own words okay so don't determine the patient's alertness ask about the events and look for clues on scene or in the home to better understand the patient's condition vague complaints challenge you to ask the right questions and be a patient listener all right and so we know with the history of the present illness we this information should provide a clear sequential and chronologic account of the patient's signs and symptoms so signs of course are what we observe and then symptoms are subjective information that the patient gives us the history of the present illness is the opqrst and then the history of the patient is ample or sample begin with what is going on today and why did you call 9-1-1 if the patient's behavior is inappropriate consider a medical problem such as hypoxia or low blood glucose and then the current health status so it's made up of many unrelated pieces of information it often ties together some of the past history with the history of the current event questions that will be most helpful are what prescription medications are you taking and do you take any over-the-counter meds or are you allergic to anything do you smoke do you take illicit drugs what did you eat today or yesterday do you exercise and what kind of hazards are present in the household so the use of safety belts or protective wear or bike helmets gun locks medication lock boxes and do you have any specific disease in your family or where do you live perhaps how do you spend your time during the day have you had any important experiences lately are you optimistic or decide which items you want to explore and which you do not okay so for family history it helps to establish patterns and risk factors for potential diseases not every aspect of family history is necessary and information should be related to the patient's current medical condition so social history occupational identification may provide information about possible toxic exposures and the environment provides information about lifestyle and chronic exposures travel history is relevant long plane rides may cause pulmonary embolisms and questions regarding diet may be appropriate and then the patient's medical history so the opportunity to learn about any pertinent and chronic underlying conditions frequently linked to the patient's current medical problem and it should include current medications and dosages and also allergies and childhood illnesses and adult illnesses maybe past surgeries and past hospitalizations disabilities a patient's emotional effect provides insight into the overall mental health of the patient determine whether the patient has ever experienced the current problem before and a new problem in condition is best considered serious until you prove it otherwise when it comes to unresponsive patients you're going to have to rely on a thorough head to toe plus the normal diagnostics tools to acquire information needed to care for your patient with trauma patients revisit information from that primary survey consider the mechanism of injury and also mechanisms that may be life-threatening include falls so an adult that's greater than 20 feet children it's greater than 10. also high-risk motor vehicle crashes and those are any intrusion ejection death of the other patient person in the vehicle or vehicle telemetry data consistent with the high risk of injury or vehicle pedestrian collision also motorcycle and atv crashes okay so this slide shows significant mechanisms of injury such as ejections um or death of another patient in the pasture compartment also um falls of greater than 20 feet and high speed mechanisms of injuries and motor vehicle crashes of greater than 20 miles an hour or penetrating injuries to the head neck or chest torso or extremities okay if the patient is an infant or child mechanisms that indicate a high priority include falls more than 10 feet falls of less than 10 feet with lots of consciousness or medium to high speed vehicle crashes or bike crashes so multiple mois often come into play during a traumatic event so in motor vehicle crash determine whether seat belt or air bags were involved improperly installed child safety seats can be rendered useless and if the patient shows any systemic involvement with what appears to be a minor nmoi continue the assessment to find the more serious problem so let's talk about a review of the body systems and um pertinent negatives may be way to gain information so some general symptoms so vague non-specific signs and symptoms make it difficult to differentiate between various field diagnoses but ask questions like um are do you have a fever or chills or night sweats or some type of weight variations hair skin or nails so ask questions about a rash or itching in multi-skeletal so ask about joint pain or loss of range of motion or swelling redness or some type of localized heat or deformity with the head and neck pay particular attention to complaints of headaches or loss of consciousness and so eyes and ears with the eyes ask about visual acuity and the ears ask about hearing throat and mouth so for the nose ask about the smell throat and mouth focus on complaints of a sore throat or bleeding or pain or any like dental issues when it comes to the endocrine system ask the patient has enlarged enlargement of the thyroid gland or ask about temperature intolerance chest and lungs you want to screen for dips knee on chest pain focus on any coughing or wheezing ask the patient if they've had pretty previous cardiac events or um pain or discomfort so hematology in lymph nodes so ask about the history of anemia or bruising and then ask about tender or enlarged lymph nodes gi you want to ask about appetite or general digestion pay attention to signs and symptoms that point towards gi bleeding and ask about urinary habits or changes jenna tayuria ask about a current or history of sexually transmitted disease and for women reporting acute abdominal pain um ask about their menstruation cycle or when was the last period or if they've had sexual um intercourse question men about erectile dysfunction and for men who report pain on urination discharge when was their most recent sexual encounter and if they use condoms for the neurologic ask about the history of seizures or syncope loss of sensation or weakness in the extremities or paralysis look for signs of facial symmetry and if you suspect a stroke use the cincinnati scale stroke or the los angeles pre-hospital stroke screen or another tool used in your region okay so now we're going to talk about critical thinking the goal of assessment is to figure out the most likely reason for the patient's chief complaint and how best to address it so recognize that there are five aspects of critical thinking there's concept formation data interpretation application of principles reflection in action and reflection in action so basically there's two reflection in actions the first one being willing to change course as you interpret the patient's condition and then the second is doing honest and thorough post-run fatigue to benefit learning you must be able to think and perform well under pressure and you must be a great listener and a patient listener okay so clinical reasoning we're going to talk about next and this combines knowledge of anatomy physiology pathophysiology and the patient's complaints to help direct questioning when you are obtaining history so note any abnormal symptoms of physical findings as well as their anatomic location pay attention to signs and symptoms that are inconsistent with your working diagnosis and then your differential diagnosis and that's a working hypothesis of the nature of the problem start with broad possibilities and consider the patient's chief complaint and once you have determined your working diagnosis continue to question the patient to help confirm the diagnosis all right so now we're moving into the fourth step which is the secondary assessment the secondary assessment is the process by which quantifiable objective information is obtained from a patient about his or her overall state of health compared to subjective historic information that is obtained from the patient together these types of information can give you a comprehensive field impression and a differential diagnosis secondary assessments consist of two elements obtaining vital signs and performing a systemic physical exam such as a full body exam a focused exam on a specific injury or an exam that is based on the body system of the chief complaint the appropriate abnormalities on ex on examination so you must understand the wide variety of normal as you approach the patient consider body systems and anatomic locations and the start of the exam is determined by factors such as the stability the chief complaint the history and the ability to communicate not every aspect of the secondary assessment will be completed in every patient so factors to consider when beginning an exam include the location or the position the patient's point of view maintaining professionalism so always protect the patient's privacy the physical exam of priority patients so the physical exam performed depends on the patient's need if traditional physical exam isn't possible a full rapid full body scan may be required a 60 to 90 second non-systematic review and palpation of the patient's body inspect the soft tissue and look for open wounds and palpate for pain and tenderness okay and so to perform a rapid full body scan see skill drill 11-1 assessment techniques include you're inspecting and so you're just looking at the patient palpation and palpation is you're touching for the purpose of obtaining information and then percussion so this entails gently striking the surface of the body typically where it underlies various cavities it detects changes in the denseness of the underlying structures so normal lung is medium to loud with low pitched sounds muscle and bone is soft high pitch and hollow organs are loud high pitched and tympanic it requires a lot of practice so to perform percussion c skill drill 11-2 and then auscultation then that involves listening with a stethoscope and it requires keen attention to thorough understanding of what normal sounds like and a lot of practice and so this table shows normal vital signs at every age in different ages so vital signs their baseline is the first set and then serial vital signs are additional sets you want to do the pulse of course the rate rhythm and quality and then palpate the pulse so um several several points including the following areas so radial brachial femoral and carotid count 30 seconds and multiply by two these photos show the location of common pulse points in the body and then the respirations so the rate rhythm and quality and then um so the respiratory rate typically assessed by inspecting the patient's chest the quality so you can learn um to recognize the pathologic respiratory patterns or rhythms such as tachypnea or acoustimal respirations and the rate should be measured for 30 seconds and multiplied by 2 in pediatric patients and the table on this slide shows pathologic respiratory patterns then you want to do the blood pressure and that's the measurement of force exerted on the walls of the blood vessels it's commonly measured in the peripheral artery it's a product of the cardiac output and peripheral vascular resistance it's measured using a cuff that is appropriate to the patient's size and i ideally should be auscultated blood pressure cuff gauge should be inspected periodically because it can lose accuracy and require recalibration then the temperature so when using a device for measuring the tympanic membrane's temperature make sure that the external auditory canal is free of serum and position the probe in the canal so that the infrared beam is aimed at the tympanic membrane wait two to three seconds until the digital temperature reading appears then use your pulse ox so you should never be used as an absolute indicator of the need for oxygen it requires the percentage of hemoglobin saturation it measures that and it can provide inaccurate information for a variety of reasons so equipment used in the secondary it includes the stethoscope blood pressure cuff reflex hammer sometimes gloves and sheets and blankets capnography or glucometry and then you have your stethoscope so the acoustic it does not amplify sounds it blocks out ambient sounds and then your electronic it converts sound waves into electronic signals and amplifies your cuff is used to measure the blood pressure it consists of an inflatable cuff and a nanometer which is the pressure meter okay so the physical exam we're going to talk about next and that's the most important skill a healthcare provider can master you will begin to gain information regarding the patient's overall presentation as you approach the scene so look for signs of significant distress such as mental status changes or labored breathing obvious pain or deformity other aspects that may be worth noting is the dress and hygiene expression and overall size or posture and also odors in overall state of health so there are terms that describe the degree of distress such as mild moderator acute severe and there's other terms that describe the general state of the patient's health such as chronic or frail robust robust or vigorous the secondary assessment is driven by the information you gathered during your primary and the history taking when it comes to the full body exam it's a systematic head-to-toe exam the goal is to identify hidden injuries or identify causes that may not be found during the rapid exam so to correctly perform a full body exam see skill drill 11-3 so a focus exam it's performed on patients who have sustained non-specific mois and are responsive it's based on the chief complaint and the most common complaints involve the head heart lungs and abdomen mental status so for any patient who has had a head related problem such as a concussion or headache you should assess and palpate the head for trauma so look for facial symmetry and look at the pupils and assess the cognitive function and that is the ability to use reasoning so you could use the avpu score and assess whether the patient is alert and oriented in four areas so person place time day of event day of the weekend event and use the glass calcoma score and once the basic mental status has been assessed conduct a thorough mental status exam so you're looking for general appearance speech and language mood and thoughts and perceptions information relevant to the thought content insight and judgment and then of course cognitive function and that's the attention and you want to pay attention to memory such as remote memory or recent and then you want to look at the skin so the hair and nails the skin is perhaps the quickest and most reliable way of assessing a patient's overall distress and that's to look at the skin there are several uh the skin serves as three major functions and we remember it is uh transmits information protects the body and regulates the temperature in cold environments a constriction of the blood vessels shunt split away from the skin and in hot environments the vessels in the skin dilate you want to examine the skin and inspect and palpate the color temp condition and look for evidence of diminished perfusion such as polar cyanosis diaphoresis and vasodilation or flushing okay so you look also look at the fingernails and lips for perfusion and that's where the epidermis is the thinnest okay so vasoconstriction may indicate pale skin um and it correlates with low arterial oxygen saturation so that's cyanosis also modeling is found in severe protracted hypoperfusion and shock so skin turgor relates to hydration and lesions may only be the only external evidence of a serious internal injury okay hair so examine the hair by inspection and palpation and note the quality texture and distribution all right recent changes in growth and hair loss may indicate an underlying endocrine disorder also look at the nails so the color texture or shape normal nail may be firm and smooth and overly thick nails or nails with lines running parallel to the fingers suggest a fungal infection so this table shows abnormal findings in the nails so eyes ears nose and throat so h e e n t so the head so you're going to examine the head for it by feeling and inspecting looking for asymmetry or deformity or tenderness evaluate the face the color moisture symmetry and contour and to correctly assess the head c skill drill 11-5 the eyes you want to look they're the examiner to focus you focus on the because of the central nervous system looking in the anterior chamber posterior chamber inspect and palpate the under in upper and lower orbits you could also assess for visual acuity and um look to see you could do use finger counting and it's done from a noted distance and then look at the pupils so normally round and appropriately equal size in light pupils dilate and in high light or when the light is bright it suddenly introduces pupils inconsistency can constrict okay so evaluate whether the eyes move in harmony and uh can con track in all fields so up down left and right to currently or correctly examine the eyes c skill drill 11-6 then the ears so involved with hearing sound perception and balance so they consist of the outer middle and inner so you want to assess for changes in the hearing wound swelling or drainage when it comes to the nose it's divided in the two chambers by the nasal septum each chamber consists of three layers the superior middle and inferior ss anterior and inferiorly and look for symmetry in foreign bodies discharge and tenderness and note any evidence of respiratory disease the throat is evaluate the mouth and pharynx the neck as part of the overall hydration status pay attention to the teeth lips oral mucosa and the mouth so the lips and um the symmetry and gums should be pink with no lesions or edema inspect airway for instructions when it comes to the throat the size color and moisture the oral pharynx discolorations usually odors of the patient's breath and also fluids that might need suctioned when it comes to the neck look for symmetry or masses palpate the carotid pulses and to examine the neck look at skill drill 11-17 okay so the cervical spine that of course is the pathway by which the spinal cord makes its way out of the brain and into the torso so consider the mechanism and evaluate for any pain or altered mental status indications for spinal immobilization of course are tenderness on palpation complaint of pain in the spine altered mental status a glass count of less than 15 and evidence of a distracting injury or paralysis inspect and palpate so for tenderness and deformity and continue assessment of the patient's range of motion should take place only when there is no potential for serious injury when you're going to the chest inspect of the superior aspect of the torso and then the anterior and posterior portions remember it contains the heart lungs and great vessels and so to examine the chest c skill drill 11-8 you're looking for symmetry and respiratory effort in the general shape of the chest wall or for any deformities or crepitus and then of course you're going to auscultate for breath sounds remember normal breast sounds are clear and quiet tracheal sounds are loud and harsh brachial are low and high pitched brachial vascular sounds are soft and breezy vascular sounds are fine and somewhat fainter advantageous breath sounds are abnormal breath sounds and they include wheezing which is high piss pitch whistling crackles also called rails and that's wet wrong guy that's congested breast sounds with a higher pitch and rattling strider that's a crowing sound and plural friction rubs that's squeaking or grating the figure shows locations for auscultating those breath sounds and this one shows locations and descriptions of abnormal versions of normal breast sounds it may be helpful to describe the sounds rather than attempt to immediately classify him so are the sounds dry or moist continuous or coarser fine determine if the breast sounds are diminished or absent and localize assess transmitted voice sounds so the cardiovascular system it circulates the blood through the body and blood flows in two currents you have the systemic it carries oxygen rich blood and then the pulmonary circulation it carries oxygen poor blood okay so you have the cardiac cycles and they involve cardiac relaxation and that's diastole filling and then contraction of that left ventricle that's systole the contraction and relaxation of the heart combined with flow of blood generates characteristic heart sounds through auscultation with the stethoscope you have s1 s2 s3 and s4 heart sounds can be heard at the chest wall in a parasternal areas superiorly and inferiorly as well as in the region superior to the left nipple okay the sounds related to the patient's blood pressure and as i mentioned there are five but only the first and the fifth are clinically significant so phase one is clear faint tapping sound that gradually increases in intensity and correlates with the systolic contraction and then phase five it's when all sounds disappear and it correlates with diastolic pressure feel the chest wall to locate the point at maximum impulse and appreciate the a apical pulse palpate for any lifts in the chest wall suggesting hydroperf hypertrophy and be prepared or be aware of any thrills which is humming vibrations also a murmur and that's abnormal whoosh like sound heard over the heart that indicates turbulent flow around the cardiac valve and it could be graded by a range of intense intensity one through six arterial pulses are a physical expression of the systolic blood pressure and the venous pressure tends to be low assess the extremities for signs of venous obstruction or insufficiency okay jugular vein distension and if the patient has a penetrating left chest trauma jvd may indicate cardiac tamponade and if the patient has petal edema it could be heart failure in older patients the ability to compensate for cardiovascular insult may be compromised arterial sclerosis or atherosclerosis and diabetes medications for high blood pressure as well cause that pay attention to arterial pulses so the location rate rhythm and quality and obtain an accurate blood pressure and repeat periodically palpatine auscultate the carotid arteries and you're assessing for bruits for a suspected heart problem assess the pulses regularity and strength and signs look for the skin for hypoperfusion breast sounds baseline vitals and extremities for peripheral edema the abdomen can be divided into imaginary quadrants so you have the left upper right upper left lower right lower the ninth so you could also divide them into nine areas and you could see those on the slide contains almost all of the organs of digestion and the peritoneum is a well-defined layer of fascia made up of the parental and visceral peritoneum okay there are three basic mechanisms which produce abdominal pain you have visceral pain this results when hollow organs are obstructed you have inflammation and that's an irritation of sonomic pain fibers located in the skin and then you have referred pain and this has origins in a particular organ but is described by the patient as pain in different locations you want to look for and obtain baseline vitals and orthostatic vitals and then you have in the abdomen generally considered positive if the blood pressure shows a decrease in systolic of 20 and the blood pressure shows an increase in the diastolic of 10 an increase in pulse rate by 20. so documentation whether the patient was pulse was regular if the patient was being monitored and whether the patient was experiencing any other symptoms when examining the abdomen make the patient as comfortable as possible and always proceed with abdominal assessment in the systemic fashion so routinely performed by inspection auscultation percussion and palpation and in the order quadrant by quadrant so you want to refer to skill drill 11-9 ascites so that's fluid within the peritoneal cavity abdominal may appear markedly distended okay so and then bluish discoloration in the periumbilical area that's a colon sign or along the flanks that's a gray turner sign and it's indicative of a ruptured atopic pregnancy or acute peritonitis pancreatitis pancreatitis sorry and then auscultation so it may be limited um but setting must be quiet for you to hear bowel sounds so practice on healthy people and note presence or absence of vowel sounds okay so there's hyperactive which is increased or hypoactive is decreased or you know absent palpation so that yields to tenderness palpate each quadrant gently but firmly and a normal abdomen should clear soft without tenderness or masses the patient's responses are going to be the indicate pain or distress and also guarding that's a voluntary or involuntary contraction of the abdominal muscles palpate the liver so you want to place your left hand behind the patients parallel to and supporting the 11th and 12th rib and place your right hand on the right abdomen just below the ribcage ask the patient to take a deep breath and try and feel the liver edge as it comes down to meet your fingertips also palpate the gallbladder and use the same technique as you palpate for the liver and generally you cannot feel the gallbladder but a patient's response indicating pain may mean possible inflammation you could also palpate the spleen and you may be able to palpate it if it's inflamed with your left hand under reach reach over and around the patients of support and press forward with the forward the lower left rib cage and adjacent soft tissues with your right hand below the costal margin press in towards the spleen when it comes to an aortic aneurysm it may be seen as a pulsating mass in the upper midline of the abdomen don't palpate it okay if you suspect an aortic aneurysm you want to minimize manipulation there's also hernias so that's a locate localized weakening of the abdominal wall it's not always visible but place the patient in a supine position and ask him or her to raise their head and shoulders you'll see it when it comes to the female genitalia of course we're just it's the external genitalia ovaries fallopian tubes uterus and vagina assessment should only be performed it's very limited and reasons to exam would be any type of life threatening hemorrhage right or immediate childbirth clinical reasons for pain and palpation of the fallopian tube and ovary region include etopic pregnancies and pelvic infections make note of any bleeding inflammation discharge swelling or lesions and then the male genitalia of course consists of the things on the slide so the reproductive ducts testes urethra prostate gland and penis an examination is limited with your partner present so assess for bleeding injury or underlying fractures [Music] and a priapism so that's a prolonged direction usually the result of a spinal cord injury and look for evidence of urinary incompetence and then the anus that's the distal orifice of the canal and often evaluated in the same time as the genitalia and assess the need for bleeding control or any other intervention when it comes to the muscular skeletal system you have the joints skeletal muscles principal joints of the upper extremities and then the principal joints of the lower extremities joints become more vulnerable to injury stress and trauma as we age common types of muscular skeletal and soft tissue injuries include fractures and sprains dislocations contusions and hematomas and open wounds in a fracture you could have a physiological fracture or a pathogenological fracture when examining the skeletal and joints so pay close attention to their structure and function consider how the joint and extremity look and how well they work okay and then refer to skill drill 11-10 you can have problems with the shoulders or related structures often determined by noting the patient's pulse posture so you want to look for tenderness swelling crepitus deformity rotation and echomosis and assess the range of motion so raise their arms above their head have them demonstrate rotation and perform in internal rotation as well also inspect the elbows you want to palpate between and see if there's pain or tenderness or swelling and the range of motion as well so have them flex and extend pronate the forearms while they the elbows are flexed and then look at the hands so palpate the hands palpate the carpal bones and range of motion of all so make the fists and extend and flex move the hands laterally and medially and then inspect the knees the range of motion as well palpate the hips and palpate the pelvis observe the ankles palpate the feet and ankles assess the range of motion so you want to have the patient inert and exert the ankles and feet and inspect palpate and check the foot and toes the peripheral vascular system so of course it compromises aspects of the circulatory system and you have the lymphatic system and it's a network of lymph nodes and ducts so the lymph nodes are large accumulations of lymphatic tissue they manage a key function in the body's immune system so perfusion occurs in the peripheral circulation and disease of the peripheral vascular system are often seen in patients with underlying medical conditions such as diabetes or hypertension or obesity or tobacco use during the assessment pay attention to both upper and lower extremities look for signs of that indicate acute or chronic problems and refer the skill drill 11-11 inspect the upper extremities from fingertips to shoulders and the five ps of the acute arterial insufficiency include pain poller and pulselessness inspect the lower extremities from the groin to the buttocks to the feet and palpate the pulses in the lower extremities and note the temperature of the feet and legs and palpate the superficial lymph nodes we know that the spine is can it consists of 33 vertebrae inspect the back from both the posterior and lateral aspects okay so you have this cervical thoracic and lumbar spine and just understand kyphosis is the outward curvature of the thoracic spine scoliosis and that's the curvature of the spine and so this figure shows abnormalities of the spine so lordosis kyphosis and scoliosis the spine using the thumb to touch four spinal processes and check the rest of the back for any significant findings on palpations range of motion so check passively first then actively and if the pain or tingling um stop the exam and mobilize the spine so exam the spine examine you could see the skill drill on 11-12. next we're going to talk about the nervous system so the structure and function of the nervous system the brain is an extraordinary complex structure with enormous perfusion requirement all nerves are channeled to the brain via the spinal cord and the nervous system is divided into the voluntary and the involuntary so you have reflexes involuntary motor response is specific sensory stimuli and you have like primitive reflexes and then you have the babinski reflex test that may be used to check for that neurogenic or neural okay so the neurologic exam it's to determine the patient's mental status and functions and reflexes mental status exam that's that coast map you can see it on the slide it's consciousness orientation activity speech thought memory effect and perception cranial nerve exam so it determines the presence and degree of disability and it can be performed in less than three minutes so evaluation of the motor system you're going to evaluate and observe the posture and body position watch for involuntary movements evaluate muscle strength check for coordination and also with the finger to the nose and the heel to the shin check sensory function and that's tested bilaterally so assess primary sensory function so the response to stimuli or assess cortical sensory function and that's the perception of gross various light touches to evaluate deep tendon reflexes refer to skill drill 11-13 all right so there are results of the neurologic exam and so you um so there could be delirium and that's um uh consists of an acute sun change in the mental status there's dementia and that's representative of a gradual deterioration of the cognitive cognitive functions and then common encountered abnormalities so you have the facial and extremity strength of symmetry so you could have aphasia or dystonia or seizures vertigo visual changes or tremors secondary assessment of unresponsive so when you're ruling out trauma or after you have positioned unresponsive patients in the recovery position if there's trauma position the patient in a neutral alignment place a properly sized and fitted cervical collar and implement spinal motion restriction look for signs of illness perform at least two set of vitals and always assess the posture of an unresponsive patient so always consider unresponsive patients to be unstable transport rapidly and reassess so when you do the the secondary of the trauma there's two classifications there's isolated and then there's multi system okay so a high visibility factor so don't become distracted by obvious non-life-threatening injuries any trauma patient who's unresponsive or has an altered mental status is considered high risk before examining a trauma patient make sure that the patient's cervical spine is manually immobilized in the neutral position when it comes to recording secondary assessments it should be done in an orderly and concise manner and documentation requires and ensures that an accurate history accounting of the patient's problems prior to entering the hospital will exist in a formal medical record so remember that not everything can be discovered in the secondary keep total time in the field a minimum an evaluation by a trained physician coupled with lab and radiographic studies may be needed for that diagnosis when it comes to monitoring devices continuous ecg monitoring the purpose is to establish a baseline and so patients who present with any cardiac related signs and symptoms with a cardiac input should have continuous cardiac monitoring the electrodes must be placed on the patient properly bipolar leads are used for monitoring purposes and those consist of two electrodes positive and negative and they're placed on two different limbs right so there are times when the ecg looks normal but the heart is not functioning properly and we know that's pea 12 lead allows you to look at the heart from several angles to localize that site of injury to the heart muscle it's indicated in any patient who might have a cardiac related condition it's appropriate for older patients in many situations and the only way to learn to take a 12 lead is to practice with the equipment okay so this flow chart explains reassessment and that's the final step in the patient assessment and reassessment so stable patients should be reassessed every 15 minutes in the unstable every five reassessment of medical or mental status and abcs so compare the patient's level of consciousness with your baseline assessment review the airway the breathing and circulation and reassess the pulse reassessment of the patient care and transport priorities so have you addressed all life threats do priorities need to be revised and is your initial transport decision still appropriate obtain another complete set of vitals and compare with expected outcomes of your therapies and also look for trends so remember with cushing's reflex or cardiac tamponade you're gonna start to see changes either with cushing's reflex it's going to be slowing up the pulse or raising of the blood pressure and then erratic respiratory patterns but with cardiac tamponade you're going to have muffled pulse pressures or narrow pulse pressures muffled heart tones and jvd and so document all your findings with each reassessment okay so we have reached the end of chapter 11 patient assessment lecture if you've liked this lecture go ahead and subscribe to our channel because we're going to be putting out the rest of the screencasts from um the 8th edition of the paramedic book oh great and thank you have a great night