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105 Chapter 14
Secondary Assessment Systems
| Term | Definition |
|---|---|
| History of Present Illness (HPI) Questions | Onset - What were you doing when it started? Provokes - Does anything make it better? What make it worse? Quality - Can you describe the pain? Sharp, dull Radiation - Where is the pain? Does it spread? Severity - Scale of 1-10? Time -When pain start? |
| a sign | something you see - an extremity deformed from trauma or swollen ankles from fluid accumulation after a heart attack |
| a symptom | something the patient tells you, ie. abdominal pain or difficulty breathing |
| Order of Sec. Assessment in Medical patients | perform the history first to acquire the most relevant info, then perform the physical examination based on what u find from history |
| Order of Sec. Assessment in Trauma patients | perform on hands-on physical exam first after asking where hurts. (head-to-toe exam or just palpate one area) |
| Order of Sec. Assessment in Unresponsive | Physical Exam will provide most information after asking family/bystanders if possible |
| Past Medical History (PMH) Questions SAM | S - What's wrong? A - to food or medicine, have a med id tag? M- What are you currently taking or supposed to be? Birth control? Any herbal supps or vitamins? |
| Past Medical History (PMH) Questions PLE | P - Have medical problems? Surgeries/injuries? Seeing a doctor? Name? L- When is last time you ate/drink? What? Last medicine intake? E - Event that lead to illness? |
| 3 Abdominal Pain Questions | *Does pain feel better/worse when you eat food? Ulcer or digestive issue * Does the pain spread to the shoulder? Shoulder pain can be from some abdominal organs * Legs drawn up make you feel better? |
| Three Physical Examination Techniques | I - Inspect/observe P- Palpate A - Auscultate |
| Respiratory Assessment History | *Pedal and Sacral Edema * Lung Sounds * Pulse Oximetry * Respiratory Specific History, meds and if taken, does episode match * Dyspnea on exertion (difficulty catching breath) * Orthopnea (difficulty lying down) * Weight Gain = fluid buildup/heartfailure |
| Respiratory Phys. Exam | - Chest expands significantly and equally (trauma or pneumothorax) - AUSCULTATE lungs for presence + absence of sounds, abnormal sounds like wheezes (narrowing of airway), popping/crackling (rhonchi &rales - fluid in airway) -O2 SAT - EDEMA - FEVER |
| Cardiovascular System Patient Types (2) | Cardiac patient + patient in shock or vascular problem |
| Cardiovascular Assessment History | *Previous condition + medications, were they taken? *Episode matches previous episodes * OPQRST *Does pain change with position, breathing, movement? |
| Cardiovascular Phys. Exam | *skin color, temp, condition *Pulse, carotid + radial for perfusion level * Blood Pressue * normal, hyper/hypotensive - take both arms in transit for comparison (>20mmHg may be aortic aneurysm) *Note Pulse Pressure for shock *JVD *posture + breathing |
| Nervous System Assessment History | * Mental Status (name, place, time, and purpose) * Normal state of mental functioning * history of neurological conditions |
| Neurologic Phys. Exam | * Perform Stroke Scale (CPSS) * Peripheral sensation + movement (wiggle your fingers) * Gentle Palpate Spine for tenderness or deformity * Check Extremity Strength finger grab, leg lift test * Check pupils for equality + reactivity |
| Endocrine Assessment History | * History of diabetes, mellitus, thyroid disease * Meds? Last Taken? Normal dose? Recent Dose Change? * Eaten +when? Quantity? All normal? * Exerting at unusual level? *Sick? * Taken blood glucose? Can you control it or does it fluctuate? * Insulin Pump? |
| Endocrine Phys. Exam | *Mental Status - hypoglycemia treated by EMT, unless unable to control own airway * Skin - cold, moist typically hypoglycemia * Obtain Blood Glucose Level (70-100mg/dL) * Look for insulin pump |
| Gastrointestinal Assessment History | * Oral Intake, solids + liquids and if it is the norm * Pain - OPQRST, begin/get better after eating? * GI conditions, medications? * Vomited - qty./frequent, describe coffee grounds/dark/bright red blood *Bowel Movements - last, how frequent, normal? |
| Gastrointestinal Phys. Exam | * Observe Position of patient -fetal or hands blocking abdominal from touching * Inspect then palpate 4 quadrants, ones with pain last, (Auscultate for bowel sounds before palpate) * Inspect Vomit/Feces volume + color for GI bleeding |
| Immune System Assessment History | * Allergies?/ Been exposed to Allergy? * If so what are reactions like, have previous reactions needed EMS? * Feel tightness in chest/throat, difficulty breathing, swelling? * Medications (epinephrine auto-injector) |
| Immune System Phys. Exam | * Point of contact? bee stinger, or swelling in mouth/airway * Skin Hives * Swelling in lips, mouth, face * Auscultate lungs for adequate breathing, wheezes |
| Musculoskeletal System History | *Prior injuries in suspected area? * Do you take blood-thinning medications or anything that may delay clotting? * Use the history to determine if a medical problem (loss of consciousness) caused the traumatic injury |
| Musculoskeletal Phys. Exam | *Inspect for deformity, swelling, bruising * Palpate for Crepitation* Compare for asymmetry * Palpate Head-to-toe if unresponsive and/or multiple injuries |
| Endocrine Conditions to be aware of (3) | Diabetes (hypoglycemia), Mellitus, Thyroid Disease |
| Respiratory Conditions to be aware of (6) | Flu, bronchitis, cold, or chronic such as asthma or emphysema/COPD, pneumonia |
| Neurological Conditions to be aware of (4) | Strokes, TIAs, Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease), Guillain-Barre Syndrome |
| Crepitation | grating sounds or feeling of broken bones rubbing together |
Created by:
jon.kowalski
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