Detail Guide to Secondary Exam

EMS Study Guide – Draft Patient Assessment Detail Guide to Secondary Exam

The next lesson will explain how to document your patient assessment in your narrative.

On Exam

OE can be used in your patient care report.

Describe the findings of the physical examination, including vital signs, general appearance, and any objective observations related to the chief complaint. Use specific and measurable terms when describing physical findings.

On Exam Structure and layout

Here is one way to Format your on exam documentation

LOC

Here’s a breakdown of what each component represents:

Responsiveness: The first step in assessing LOC is to determine the patient’s responsiveness. Paramedics initiate a verbal and tactile stimulus to evaluate the patient’s level of alertness. A responsive patient may be fully awake, whereas a non-responsive patient may indicate altered consciousness, unconsciousness, or even a state of coma.
Glasgow Coma Scale (GCS) Evaluation: Paramedics often employ the Glasgow Coma Scale, a standardized tool used to assess a patient’s LOC based on eye, verbal, and motor responses. The GCS score ranges from 3 to 15, with higher scores indicating better neurological function. A lower GCS score suggests a more severe impairment of consciousness.
Pupillary Response: Assessing the patient’s pupils is an essential part of the LOC examination. Paramedics observe the size, equality, and reactivity of the pupils to light. Abnormalities, such as unequal or non-reactive pupils, could indicate neurological issues or brain injuries.
Motor Response: Paramedics evaluate the patient’s motor responses by assessing their ability to follow commands or move spontaneously. Decerebrate or decorticate posturing, which involves abnormal limb movements, can provide critical insights into the level of brain dysfunction.
Speech and Communication: The ability to speak and communicate effectively is another crucial aspect of assessing LOC. Paramedics observe the patient’s speech for coherence, comprehension, and appropriateness. Slurred or nonsensical speech may indicate neurological impairment or intoxication.
Postictal State (Seizure Evaluation): In cases of suspected seizures, paramedics observe the patient’s postictal state, which is the period after a seizure. This evaluation helps determine the patient’s recovery status and any lingering neurological effects.
Confusion and Disorientation: Paramedics look for signs of confusion or disorientation in the patient’s responses, such as not knowing the date, location, or the events leading to their current situation. These findings may indicate altered mental status or cognitive impairment.
Monitoring Trends and Changes: Throughout their assessment, paramedics remain vigilant in monitoring LOC trends and changes over time. A deterioration in consciousness may signal worsening neurological conditions, requiring prompt intervention and further evaluation.

Breathing

Here’s a breakdown of what each component represents:

Airway Patency: Paramedics begin by evaluating the airway’s patency, ensuring it is open and unobstructed. Clearing the airway allows for proper oxygen flow into the lungs and prevents complications that could arise from blocked air passages.
Positioning of the Head and Neck: The position of the patient’s head and neck is essential for maintaining a patent airway. Paramedics ensure the head is in a neutral or slightly extended position to keep the airway straight and open. Proper positioning minimizes the risk of airway obstruction due to the tongue falling back and blocking the throat.
Breathing Sounds: Listening to the patient’s breathing sounds is another crucial aspect of the airway examination. Paramedics use a stethoscope to detect abnormal breath sounds, such as stridor (high-pitched sound), wheezing, or gurgling, which may indicate airway obstruction or respiratory distress.
Foreign Objects and Secretions: Paramedics carefully inspect the airway for the presence of any foreign objects, such as food particles or small items, which could obstruct airflow. They also check for excessive secretions or blood that may impede breathing.
Signs of Obstruction: Paramedics remain vigilant for signs of airway obstruction, which can manifest as gasping, choking, or difficulty in speaking. Prompt identification of these signs enables them to take immediate measures to clear the airway and restore normal breathing.
Jaw Thrust and Chin Lift Maneuvers: To open the airway in patients with suspected spinal injuries or unconsciousness, paramedics use specific maneuvers like the jaw thrust or chin lift. These techniques lift the tongue off the back of the throat and help maintain an unobstructed air passage.
Suctioning: In cases where the airway is blocked by secretions or foreign objects, paramedics may use a suctioning device to remove the obstruction, ensuring unimpeded airflow.
Use of Airway Adjuncts: When necessary, paramedics may employ airway adjuncts like oral or nasal airways to maintain airway patency and aid in ventilation.

Pulse Circulation

Here’s a breakdown of what each component represents:

Pulse Rate: The first aspect paramedics assess is the pulse rate, which indicates the number of heartbeats per minute. A normal resting pulse rate typically ranges from 60 to 100 beats per minute (bpm) for adults. An abnormal pulse rate may signify underlying medical conditions such as tachycardia (rapid heart rate) or bradycardia (slow heart rate).
Pulse Quality: Beyond the pulse rate, paramedics also evaluate the pulse quality, which refers to the strength and regularity of each beat. A strong, regular pulse indicates effective blood flow, while a weak or irregular pulse may suggest potential circulatory issues or cardiac abnormalities.
Capillary Refill Time (CRT): Paramedics often assess capillary refill time, which involves pressing on the patient’s nail bed and observing how quickly the color returns after releasing pressure. A normal CRT is typically less than 2 seconds and can help determine peripheral circulation and blood perfusion.
Radial and Carotid Pulses: Paramedics primarily check the radial pulse located on the wrist and the carotid pulse located in the neck. These pulse points are easily accessible and provide essential information about the heart’s efficiency in pumping blood to different parts of the body.
Blood Pressure: While examining pulse circulation, paramedics also monitor the patient’s blood pressure. Blood pressure readings provide valuable insights into the patient’s cardiovascular health and can help diagnose conditions like hypertension (high blood pressure) or hypotension (low blood pressure).
Jugular Venous Distention (JVD): In certain medical emergencies, paramedics may assess for Jugular Venous Distention, a condition where the jugular veins in the neck become enlarged, indicating potential heart failure or fluid overload.
Peripheral Edema: Paramedics observe for peripheral edema, which refers to swelling in the hands, feet, and ankles. Peripheral edema can be a sign of circulatory problems, heart failure, or other medical issues.

HEENT

In a patient care report, HEENT stands for Head, Eyes, Ears, Nose, and Throat. It is an acronym used by healthcare professionals to systematically document and assess a patient’s head and neck region during a physical examination.

Here’s a breakdown of what each component represents:

Head: This includes a general assessment of the patient’s head, looking for any abnormalities, tenderness, or deformities. It may involve palpation of the skull, examination of the scalp, and checking for any signs of trauma or injury.
Eyes: The healthcare provider examines the patient’s eyes to assess visual acuity, eye movement, pupils equal and reactive to light, any abnormalities such as redness, swelling, or discharge.
Ears: The ears are inspected for any signs of infection, inflammation, or abnormal discharge. The provider may also assess the patient’s hearing and look for any abnormalities in the ear canal and eardrum.
Nose: The healthcare professional examines the patient’s nasal passages for any signs of congestion, discharge, or deformities. They may also assess the sense of smell if relevant to the patient’s condition.
Throat: The examination of the throat involves checking the mouth, tonsils, and pharynx for any signs of infection, inflammation, or abnormalities. The provider may use a tongue depressor to get a better view of the throat.

Chest

One of their primary responsibilities is to conduct thorough chest examinations, which can reveal vital information about a patient’s condition.

Here’s a breakdown of what each component represents:

Chest Movement and Symmetry: Observing the movement of the chest during breathing is crucial. Lack of chest expansion on one side could indicate a collapsed lung or other underlying conditions. Similarly, asymmetrical chest movement may suggest an injury, inflammation, or pneumothorax, which requires immediate attention.
Chest Pain and Tenderness: Chest pain can be a symptom of various medical conditions, including heart attacks, pulmonary embolisms, or musculoskeletal issues. By evaluating the location, intensity, and characteristics of the chest pain, paramedics can better pinpoint the possible cause and prioritize treatment accordingly.
Chest Trauma and Deformities: In cases of trauma, paramedics must carefully inspect the chest for injuries, such as fractures, contusions, or puncture wounds. Identifying these issues is critical for proper immobilization and preventing further damage during transportation.

Abdominal

One of their primary responsibilities is to conduct thorough chest examinations, which can reveal vital information about a patient’s condition.

Here’s a breakdown of what each component represents:

Abdominal Pain and Tenderness: Paramedics begin by assessing the patient’s description of abdominal pain and its location. The nature and intensity of the pain can be indicative of various conditions, such as appendicitis, kidney stones, or gastrointestinal issues. Tenderness upon palpation can further help identify the specific area of discomfort and guide further evaluation.
Abdominal Rigidity: Detecting abdominal rigidity, where the abdominal muscles feel tense and rigid upon touch, can be crucial. It may indicate serious conditions like peritonitis, which requires immediate medical attention. The presence of rigidity often suggests an inflammatory or infectious process within the abdomen.
Distention and Swelling: Paramedics carefully observe the abdomen for any signs of distention or swelling. Abdominal distention could arise due to gastrointestinal obstructions, ascites (fluid accumulation), or other abdominal pathologies. Identifying distention aids in narrowing down potential causes and guiding appropriate interventions.
Organ Enlargement or Masses: By palpating the abdomen, paramedics can identify any abnormal masses or organ enlargement. This finding can help recognize conditions like an enlarged liver, spleen, or tumors. The presence of masses may indicate underlying medical issues that require further investigation and management.
Bowel Sounds: Listening for bowel sounds is a crucial part of the abdominal examination. Absent or hyperactive bowel sounds could be indicative of gastrointestinal obstructions or paralytic ileus. Normal bowel sounds provide reassurance about the intestinal function.
Abdominal Trauma and Bruising: In cases of trauma, paramedics assess the abdomen for any external signs of injury, such as bruising, lacerations, or abrasions. Internal abdominal injuries may be suspected if there is evidence of external trauma, which requires immediate medical attention.
Rebound Tenderness: Rebound tenderness is a significant finding during an abdominal exam. Paramedics gently press down on the abdomen and quickly release their hand. Pain that worsens upon the release (rebound pain) might indicate peritoneal irritation, possibly due to inflammation or infection.

Pelvis

Here’s a breakdown of what each component represents:

Pelvic Pain and Tenderness: The initial step in a pelvic examination involves assessing the patient’s description of pelvic pain and tenderness. Understanding the location, intensity, and nature of the pain helps paramedics identify potential sources, such as fractures, dislocations, or internal injuries.
Swelling and Deformities: Paramedics visually inspect the pelvic area for any visible signs of swelling, bruising, or deformities. Swelling may indicate underlying soft tissue injuries, while deformities may suggest pelvic fractures or dislocations. Identifying these signs is crucial for providing appropriate immobilization and reducing further harm during transportation.
Pelvic Stability: Assessing pelvic stability is vital, especially in cases of trauma. Paramedics perform specific maneuvers to check for pelvic instability, which can be indicative of fractures or disruptions in the pelvic ring. Identifying pelvic instability helps determine the level of trauma and guides the best approach for extrication and transport.
Open Pelvic Fractures: In severe trauma cases, paramedics carefully examine the pelvic region for any open fractures where the bone breaks through the skin. These open injuries are at higher risk of infection and may require immediate interventions to control bleeding and protect the wound during transport.
Pelvic Stability Testing: To determine pelvic stability, paramedics may perform specific stability tests, such as the pubic symphysis compression test or the lateral compression test. These tests help in identifying specific types of pelvic fractures and guiding the appropriate management plan.
Genital and Perineal Assessment: In cases of suspected sexual assault or pelvic injuries involving the genital and perineal region, paramedics approach the examination with sensitivity. The assessment helps document any evidence of trauma, facilitating the legal and investigative process.

Lower Extremities

Here’s a breakdown of what each component represents:

Visible Injuries and Deformities: Paramedics begin by visually inspecting the lower extremities for any visible signs of injuries, such as cuts, abrasions, bruises, or deformities. Identifying such injuries helps determine the extent of trauma and guides initial treatment decisions.
Lower Limb Movement and Function: Assessing the patient’s ability to move the lower limbs is crucial in determining the presence of fractures or dislocations. Paramedics will ask the patient to move their legs and feet and note any limitations, pain, or loss of function that may suggest musculoskeletal injuries.
Circulation and Color: Paramedics carefully examine the color of the skin on the lower extremities, as well as the temperature and capillary refill time. Pale or cyanotic (bluish) skin color, coolness, and delayed capillary refill might indicate circulatory problems, such as arterial occlusion or impaired blood flow.
Pulses and Peripheral Vascular Status: Checking for pulses in the lower extremities, such as the femoral, popliteal, posterior tibial, and dorsalis pedis pulses, is a critical part of the examination. Absent or weak pulses may indicate arterial issues, while strong pulses suggest normal vascular perfusion.
Sensation and Neurological Assessment: Paramedics evaluate sensation in the lower extremities by testing for touch, pain, and temperature perception. A comprehensive neurological assessment also involves checking reflexes and motor strength, which can help identify nerve injuries or neurological conditions.
Edema and Swelling: The presence of edema or swelling in the lower extremities might indicate various conditions, such as deep vein thrombosis (DVT), fractures, or inflammatory disorders. Assessing the degree and location of edema can aid in pinpointing potential underlying causes.
Joint Stability: For patients with suspected joint injuries, paramedics assess the stability of the ankle, knee, and hip joints. Ligamentous injuries can significantly impact mobility, and identifying unstable joints is crucial for proper immobilization and pain management.
Assessing for Compartment Syndrome: In trauma cases, paramedics are vigilant in monitoring for signs of compartment syndrome in the lower extremities. This condition occurs when pressure within a muscle compartment builds up, compromising blood flow and leading to potential limb-threatening consequences.

Lower Extremities

Here’s a breakdown of what each component represents:

Visible Injuries and Deformities: Paramedics begin by visually inspecting the upper extremities for any visible injuries, such as cuts, bruises, or deformities. Identifying these issues is crucial for immediate management, wound care, and possible splinting to prevent further harm during transportation.
Range of Motion: Assessing the patient’s range of motion in the shoulders, elbows, and wrists helps paramedics identify potential fractures, dislocations, or soft tissue injuries. Limitations in movement can indicate musculoskeletal problems that may require immobilization.
Motor Strength and Function: Paramedics evaluate motor strength in the upper extremities by assessing the patient’s ability to perform tasks such as gripping, pushing, and pulling. Weakness or inability to perform these actions may indicate nerve injuries or neurological conditions.
Sensation and Neurological Assessment: Conducting a sensory examination involves testing the patient’s ability to perceive touch, pain, and temperature. Additionally, paramedics may check for reflexes and evaluate sensory perception to identify potential nerve injuries or neurological problems.
Circulation and Color: Careful observation of skin color, temperature, and capillary refill time in the hands and fingers can indicate the status of blood circulation. Pallor, cyanosis, or delayed capillary refill may suggest vascular issues that require immediate attention.
Edema and Swelling: Swelling in the upper extremities may indicate various conditions, such as fractures, sprains, or inflammatory disorders. Paramedics assess the degree and location of edema to help pinpoint potential underlying causes.
Joint Stability: In cases of suspected joint injuries, paramedics assess the stability of the shoulders, elbows, and wrists. Identifying unstable joints is critical for proper splinting and pain management during transportation.
Compartment Syndrome Assessment: For patients involved in traumatic incidents, paramedics remain vigilant for signs of compartment syndrome in the upper extremities. Elevated pressure within a muscle compartment can compromise blood flow and necessitate immediate intervention to prevent serious complications.

Back

Here’s a breakdown of what each component represents:

Pain and Tenderness: The primary concern during a back examination is assessing the patient’s description of pain and tenderness. Understanding the location, intensity, and nature of the pain helps paramedics identify potential sources, such as fractures, muscle strains, or spinal cord injuries.
Visible Injuries and Deformities: Paramedics visually inspect the back for any visible signs of injuries, such as cuts, abrasions, bruises, or deformities. Detecting these issues guides immediate wound care and management to prevent further complications.
Range of Motion: Evaluating the patient’s range of motion in the back helps identify potential injuries to the spine, muscles, or ligaments. Limitations in movement or severe pain during certain motions may indicate possible fractures or sprains.
Sensation and Neurological Assessment: Conducting a sensory examination involves testing the patient’s ability to perceive touch, pain, and temperature in various regions of the back. Additionally, paramedics may assess reflexes and evaluate motor strength to identify potential nerve injuries or neurological conditions.
Signs of Spinal Cord Injury: Paramedics are particularly vigilant in examining the back for any signs of a possible spinal cord injury. These may include the presence of neurological deficits, loss of sensation, weakness, or paralysis below the level of injury. Proper immobilization and positioning of the patient are crucial to prevent exacerbation of spinal cord damage.
Swelling or Bruising: In cases of trauma, paramedics carefully inspect the back for signs of swelling or bruising. These observations may indicate underlying soft tissue injuries, fractures, or internal bleeding that require immediate attention.
Assessment of Midline Tenderness: Gentle palpation along the midline of the spine helps paramedics identify potential vertebral fractures or other spinal column injuries. Midline tenderness may indicate significant trauma and requires careful handling during transportation.
Prior Medical History: As part of their assessment, paramedics inquire about the patient’s prior medical history, especially any previous back injuries or chronic conditions. Understanding the medical background helps in forming a comprehensive picture of the patient’s condition and guiding appropriate treatment.