21 MEDICAL ASSESSMENTS

ASSESSMENT OF THE MEDICAL PATIENT

Institute for Emergency Medical Services

MEDICAL ASSESSMENTMEDICAL ASSESSMENT

Trau m a A ssessm en t

D ete rm in eM .O .I.

Y es

M ed ica l A ssessm en t

N o

Trau m a C om p on en t?

M ed ica l

Is th is a m ed ica l o r a trau m a p a tien t?


MECHANISM OF INJURYMECHANISM OF INJURY

YESYES NONO

TRAUMA SURVEYTRAUMA SURVEY MEDICAL ASSESSMENTMEDICAL ASSESSMENT

&&

PHYSICAL EXAMPHYSICAL EXAM

MEDICAL ASSESSMENT

PRIMARY SURVEYResponsive Medical PatientResponsive Medical Patient


BODY SUBSTANCE ISOLATION

BODY SUBSTANCE ISOLATION

GlovesGloves

GlassesGlasses

MaskMask

ApronApron

OverallsOveralls

(As appropriate)(As appropriate)


SCENE SIZE-UPSCENE SIZE-UP

SScene safecene safe

UUniversal precautionsniversal precautions

NNumber of patientsumber of patients

MMechanism of injuryechanism of injury

DDo I need Additional helpo I need Additional help


INITIAL ASSESSMENTINITIAL ASSESSMENT

General impression of patientGeneral impression of patientSkin colour, rate and depth of respirations, Skin colour, rate and depth of respirations, effort, patients position, age, sex, weight, heighteffort, patients position, age, sex, weight, height

Considers C-spine stabilisationConsiders C-spine stabilisation

Determine level of consciousnessDetermine level of consciousnessShake and shout / “hello can you hear me?”Shake and shout / “hello can you hear me?”

Determine chief complaint/apparent life Determine chief complaint/apparent life threatsthreats


AIRWAYAIRWAY

Assessment of the airwayAssessment of the airway

““Can you open your mouth for me?”Can you open your mouth for me?”

Establishes and maintains a patent Establishes and maintains a patent airwayairway


BREATHINGBREATHING

Assessment of breathingAssessment of breathing

Initiate appropriate Initiate appropriate oxygen therapyoxygen therapy

Assure adequate ventilationAssure adequate ventilation


CIRCULATIONCIRCULATION

Assessment of pulseAssessment of pulse

Assess and control any major bleedingAssess and control any major bleeding

Assess skin (colour, temperature, Assess skin (colour, temperature, condition)condition)

Assess capillary re-fillAssess capillary re-fill


DISABILITYDISABILITY

AA = Alert= Alert

VV = Verbal= Verbal

PP = Pain= Pain

UU = Unresponsive= Unresponsive

PP = Pupils= PupilsEE = Equal= EqualAA = And = And RR = Round= RoundRR = React= ReactLL = Light= Light


CUPS DECISION CUPS DECISION


CUPS DECISIONCUPS DECISION

CC CCriticalritical

UU UUnstablenstable

PP PPotentially unstableotentially unstable

SS SStabletable



CC CCriticalritical

UU UUnstablenstable


SS SStabletable

Load & go adult

Load & go infant/child


Why gather the history before physical exam or vital signs ?

For a medical patient the history usually For a medical patient the history usually provides the most important informationprovides the most important information


Respiratory & CardiacRespiratory & Cardiac

Altered Mental StatusAltered Mental Status

Allergic ReactionAllergic Reaction

Piosoning/OverdosePiosoning/Overdose

Environmental EmergencyEnvironmental Emergency

Obstetrics*Obstetrics*

BehaviouralBehavioural

DIFFERENT “FOCUSED MEDICAL” QUESTIONS


FOCUSED MEDICAL HISTORY QUESTIONS

O = OnsetO = Onset P = ProvocationP = Provocation Q = QualityQ = Quality R = RadiationR = Radiation S = SeverityS = Severity T = TimeT = Time

CARDIAC AND RESPIRATORYCARDIAC AND RESPIRATORY


ONSET

What were you doing when it started?What were you doing when it started?

Do you think it was caused by anything Do you think it was caused by anything in particular ?in particular ?


PROVOKES

Can you think of anything that might Can you think of anything that might have triggered this pain?have triggered this pain?

Does anything make the pain better or Does anything make the pain better or worse?worse?

Can you make the pain happen ?Can you make the pain happen ?


Can you describe the pain for me?Can you describe the pain for me?

Dull ache.Dull ache. // TearingTearing

SharpSharp // GrippingGripping

ThrobbingThrobbing // StabbingStabbing

ShootingShooting / Worst headache of my life/ Worst headache of my life

QUALITY


Where exactly is the pain?Where exactly is the pain?

Does it spread anywhere?Does it spread anywhere?

Gallbladder pain in R shoulderGallbladder pain in R shoulder

Cardiac pain in Jaw.Cardiac pain in Jaw.

RADIATION


SEVERITY

How bad is the pain?How bad is the pain?

On a scale of 1 to 10, with 10 being the On a scale of 1 to 10, with 10 being the worst you could possibly imagine, how worst you could possibly imagine, how would you rate your pain?would you rate your pain?


TIME

When did the pain start?When did the pain start?

Has it changed at all since it started?Has it changed at all since it started?


QUESTIONING TECHNIQUES

Open QuestionsOpen Questions

Closed QuestionsClosed Questions

Leading QuestionsLeading Questions

Comparative QuestionsComparative Questions


RESPIRATORY & CARDIACRESPIRATORY & CARDIAC

O = Onset?O = Onset? P = Provocation?P = Provocation? Q = Quality?Q = Quality? R = Radiation?R = Radiation? S = Severity?S = Severity? T = Time?T = Time?

Interventions: Interventions: Has anything helped or Has anything helped or made the problem worsemade the problem worse


ALTERED LEVEL OF CONSCIOUSNESS

ALTERED LEVEL OF CONSCIOUSNESS

Description of episodeDescription of episodeOnset?Onset?Duration?Duration?Associated symptoms?Associated symptoms?Evidence of trauma?Evidence of trauma?Seizures?Seizures?Fever?Fever?



ALLERGIC REACTION

History of allergies?History of allergies?

What were you exposed to?What were you exposed to?

Duration of exposure?Duration of exposure?

Effects?Effects?

Progression?Progression?

Interventions: Interventions: Has anything helped or made Has anything helped or made the problem worsethe problem worse


SubstanceSubstanceWhen was substance injested when did the When was substance injested when did the exposure occur?exposure occur?How much did you injest?How much did you injest?Over what time period?Over what time period?Estimated weight?Estimated weight?

Interventions: Interventions: Has anything helped or made Has anything helped or made the problem worsethe problem worse

POISONING


ENVIRONMENTAL EMERGENCIES

Source?Source?

Environment?Environment?

Duration?Duration?

Loss of consciousness?Loss of consciousness?

Effects- general/local?Effects- general/local?


OBSTETRICS

Are you pregnant?Are you pregnant?

How long have you been pregnant?How long have you been pregnant?

Pain or contractions?Pain or contractions?

Bleeding or discharge?Bleeding or discharge?

Do you feel the need to push?Do you feel the need to push?

Last menstrual period?Last menstrual period?


BEHAVIOURAL

How do you feel?How do you feel?

Determine suicidal tendenciesDetermine suicidal tendencies

Is the patient a threat to self or others?Is the patient a threat to self or others?

Is there a medical problem?Is there a medical problem?



HISTORY OF PRESENT ILLNESS (HPI)

SS = Signs and Symptoms= Signs and Symptoms

AA = Allergies= Allergies

MM = Medications= Medications

P P = Pertinent past history= Pertinent past history

LL = Last oral intake= Last oral intake

EE = Events leading to problem= Events leading to problem


SIGNS & SYMPTOMS

Can you describe Can you describe what is wrong?what is wrong? Chief complaint Chief complaint (C.C)(C.C)

Have you any Have you any other symptoms?other symptoms?


ALLERGIES

Are you allergic to Are you allergic to anything?anything?


MEDICATIONS

Do you take any Do you take any medication?medication?

What do you take What do you take those for?those for?


MEDICATIONS

PrescriptionsPrescriptions

CurrentCurrent

RecentRecent

Birth Control PillsBirth Control Pills


MEDICATIONS

Non-PrescriptionNon-Prescription

CurrentCurrent

RecentRecent

Vitamin supplements Vitamin supplements


PERTINENT MEDICAL HISTORY

Do you have any Do you have any medical conditions medical conditions that we should that we should know about?know about?

Have you ever had Have you ever had a problem like this a problem like this before?before?


LAST ORAL INTAKE

When was the last When was the last time you ate or time you ate or drank?drank?

What did you eat What did you eat or drink?or drink?


EVENTS

Sequence of events leading up to the Sequence of events leading up to the illnessillness

How have you felt today?How have you felt today?

Anything out of the ordinary Anything out of the ordinary happen?happen?


RE-CAP SO FARRE-CAP SO FAR

Scene size up ( SUNMD )Scene size up ( SUNMD )

Initial assessment ( general impressions etc.. )Initial assessment ( general impressions etc.. )

AirwayAirway

BreathingBreathing

CirculationCirculation

DisabilityDisability

CUPS decisionCUPS decision

Focused medical questions / SAMPLEFocused medical questions / SAMPLE


BASELINE VITAL SIGNS

PulsePulse

RespirationsRespirations

Blood PressureBlood Pressure

Breath soundsBreath sounds

SpOSpO22

Skin colour, temperature, conditionSkin colour, temperature, condition

Capillary refill Capillary refill

PupilsPupils


INTERVENTIONS

Obtain medical directionObtain medical direction

Employ Dublin Fire Brigade Employ Dublin Fire Brigade ProtocolProtocol

PHECC C.P.G’sPHECC C.P.G’s


INTERVENTIONS

Cardiac monitorCardiac monitor

Glucose measurementGlucose measurement

OO2 , 2 , GTN , ASA , Glucose gel , SalbutomolGTN , ASA , Glucose gel , Salbutomol

Patient Positioning Patient Positioning (e g : trendellenburg for hypovolaemia) (e g : trendellenburg for hypovolaemia)


RE-EVALUATES CUPS

Re-evaluate transport decisionRe-evaluate transport decision

It’s now Time to goIt’s now Time to go


REPEATS FOCUSED EXAM

Based on patients Based on patients Chief ComplaintChief Complaint



Re-evaluate patient for obvious Re-evaluate patient for obvious indications of illness that may have been indications of illness that may have been missedmissed

Look for less obvious evidence of Look for less obvious evidence of illness/injuryillness/injury



As appropriate, As appropriate, assess:assess:

HeadHead

NeckNeck

ChestChest

AbdomenAbdomen

PelvisPelvis

ExtremitiesExtremities

PosteriorPosterior


RE-CHECKS INTERVENTIONS

Cardiac monitor Cardiac monitor

OO22

PositioningPositioning


COMMUNICATIONS

It is imperitave that you strive to It is imperitave that you strive to communicate well with your patient communicate well with your patient

TrustTrust

RespectRespect

Professionalism Professionalism


REPEAT VITAL SIGNS

PulsePulse




SpOSpO22



PupilsPupils


FROM THE TOPFROM THE TOP

Scene size up ( SUNMD )Scene size up ( SUNMD )

Initial assessment ( general impressions etc.. )Initial assessment ( general impressions etc.. )

AirwayAirway

BreathingBreathing

CirculationCirculation

DisabilityDisability

CUPS decisionCUPS decision

Focused medical questions / SAMPLEFocused medical questions / SAMPLE



Baseline vital signsBaseline vital signs

InterventionsInterventions

Re-evaluates CUPS decisionRe-evaluates CUPS decision

Repeats focused examRepeats focused exam

Re-checks interventionsRe-checks interventions

CommunicationsCommunications

Repeats vital signsRepeats vital signs

MEDICAL ASSESSMENT

PRIMARY SURVEYUnresponsive Medical PatientUnresponsive Medical Patient


UNRESPONSIVE PATIENT

ABCD / consider C spine controlABCD / consider C spine control

CUPSCUPS

Rapid assessment Rapid assessment

History of present illness (bystanders)History of present illness (bystanders)

S.A.M.P.L.E. history (bystanders)S.A.M.P.L.E. history (bystanders)

Baseline Vital Signs Baseline Vital Signs

Make relevant interventionsMake relevant interventions


Position patient to correct airway


INITIAL ASSESSMENTPrimary Survey

AA BB CC DD


CUPS DECISION CUPS DECISION



CC CCriticalritical

UU UUnstablenstable


SS SStabletable



CC CCriticalritical

UU UUnstablenstable


SS SStabletable

Load & go adult

Load & go infant/child


RAPID ASSESSMENT

Start with rapid Start with rapid assessmentassessment

HeadHead

NeckNeck

ChestChest

AbdomenAbdomen

PelvisPelvis

ExtremitiesExtremities

PosteriorPosterior


RESPIRATORY & CARDIACRESPIRATORY & CARDIAC

O = Onset?O = Onset? P = Provocation?P = Provocation? Q = Quality?Q = Quality? R = Radiation?R = Radiation? S = Severity?S = Severity? T = Time?T = Time?



HISTORY OF PRESENT ILLNESS (HPI)

SS = Signs and Symptoms= Signs and Symptoms

AA = Allergies= Allergies

MM = Medications= Medications

P P = Pertinent past history= Pertinent past history

LL = Last oral intake= Last oral intake

EE = Events leading to problem= Events leading to problem


BASELINE VITAL SIGNS

PulsePulse




SpOSpO22



PupilsPupils


INTERVENTIONS

Cardiac monitorCardiac monitor

Glucose measurementGlucose measurement

OO2 , 2 , GTN , ASA , Glucose gel , SalbutomolGTN , ASA , Glucose gel , Salbutomol

Patient Positioning Patient Positioning (e g : trendellenburg for hypovolaemia) (e g : trendellenburg for hypovolaemia)



Scene size up ( SUNMD )Scene size up ( SUNMD )Initial assessment ( general impressions etc.. )Initial assessment ( general impressions etc.. )AirwayAirwayBreathingBreathingCirculationCirculationDisabilityDisabilityCUPS decisionCUPS decisionRapid physical exam ( head to toe )Rapid physical exam ( head to toe )Focused medical questions / SAMPLEFocused medical questions / SAMPLE



Baseline vital signsBaseline vital signs

InterventionsInterventions

Re-evaluates CUPS decisionRe-evaluates CUPS decision

Repeats physical examRepeats physical exam

Re-checks interventionsRe-checks interventions

CommunicationsCommunications

Repeats vital signsRepeats vital signs

QUESTIONS ?QUESTIONS ?

Documents

21 MEDICAL ASSESSMENTS