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History And Physical Examination

In the field, the Paramedic or E.M.T. are the eyes and ears of the physician. Knowing what happens from onset, to the time the victim gets to the Emergency Room can save a victim's life. Accomplishing a good PATIENT ASSESSMENT is one of the most important skills a provider can have. A patient assessment is composed of the PRIMARY SURVEY, which is recognizing any life- threatening conditions, taking a HISTORY, performing a PHYSICAL EXAMINATION, and SECONDARY SURVEY, making a field DIAGNOSIS, and COMMUNICATING all this information to the primary care physician.

There are several reasons for the physical examination and taking a proper history. Initially, it is to establish the patient's affliction and establishing what sequence of care must be carried out. This also helps in gaining the patient's confidence and thereby helps alleviate anxiety. Information also should be obtained about the environment in which patient was found. This is referred to as the MECHANISM OF INJURY. If a victim has a head injury due to being hit by a boat, he is different than the head injury due to falling down. Both are head injuries, but being hit by a boat can be far worse than falling down. You never tell the ER that the victim hit his head and leave it at that.

A SYSTEMATIC APPROACH to the patient assessment is needed. This is conducting the physical exam and history in an orderly and thorough manner. Circumstances dictate the order in which things are accomplished. Severe bleeding or the victim not breathing requires these being taken care of before anything else is done. Different circumstances dictate different priorities, judgment is required to make decisions and select the appropriate approach, to any given situation.

History taking begins as soon as the rescuer arrives on the scene. He should note the environment in which the victim is found. He needs to also note any mechanisms of injury such as in boating accidents. Then the rescuer needs to get a HISTORY OF THE PRESENT ILLNESS (HPI).

The very first thing that needs to be noted is the CHIEF COMPLAINT, the reason you where called. Let the victim or the caller state it to you. Even in obvious situation such as broken bones, ask the victim what is bothering him. He may have a broken leg, but to him his chief complaint maybe he cannot breathe. This may be due to hyperventilation caused by the injury or a pneumothorax caused by another injury.

Next you need to know the LOCATION. This is where the problem is experienced. In decompression sickness the victim may complain of hurting all over. In this case you need to get more specific. Ask him if he is in pain. Where the pain is, and under what circumstances. You need to find out if the pain radiates. This is expressed by the victim saying: "It hurts when I straighten may arm", or "The pain goes all over my chest when I take a deep breath".

QUALITY is finding out how the pain is felt, or limited motor function is experienced. Is the pain sharp, dull, shooting, throbbing? If it is a limited function, how is it limited? Some people may say they cannot open their hand, but when you ask them to try, they can.

How bad the pain is, is hard to determine. Some people tolerate pain very well, and do not complain, while other scream from a mosquito bite. But the rescuer must form some impression of the victim's pain INTENSITY. Judge his temperament in interpreting his description of the pain. Sometimes it best to ask the patient to gauge the pain on a scale from one to ten with ten being the worst pain he ever had.

QUANTITY refers to how many episodes, and how often the patient has had one. In the decompression sickness victim he may state that the problem first appeared in his right elbow and now his left elbow is involved.

Finding out when the first symptoms started and then the duration and frequency is establishing the CHRONOLOGY. In multiple symptom maladies such as decompression sickness, determine which came first and their relationship to each other.

What precisely occurred is the SETTING. In trauma find out how the injury took place. Where there any contributing factors. This would be stated by the victim as: "I was swimming on the surface and blacked out." this may indicate an underlying medical problem. Can the symptom be related to the patient's activity or environment, such as chest pain due to cold weather or fatigue due to being active.

What the victim was doing at the time of onset is the SCENARIO OF THE FIRST SYMPTOM.

Does anything make the symptom worse or better. This is AGGRAVATION AND ALLEVIATION. Watch to see if the victim assumes a position of comfort.

ASSOCIATED COMPLAINTS are related symptoms.

Finally the rescuer needs to find out if the patient has taken anything or have any attempts been made to modify his symptoms, known as PRIOR TO ARRIVAL TREATMENT (PTA). This may be oxygen given, CPR, or anything that was done before you arrived. Be sure to document who did what, and when.

After the history of the present illness is complete it is necessary to get a PAST MEDICAL HISTORY. In pre-hospital care all the rescuer is interested in is are there aspects that may have something to do with the present condition. These are conditions directly related to the present condition, or could affect the outcome of the present condition. An example of this would be a trauma victim may be a diabetic, which has nothing to do with the trauma itself, but the shock to the system may cause some metabolic problems latter on.

It must be found out is if the victim has any MAJOR MEDICAL PROBLEMS. These would be, heart problems, diabetic, high blood pressure and so on, also known as CHRONIC MEDICAL CONDITIONS. Some medical professionals consider smoking as a chronic medical condition, and in some cases may have a bearing on the present illness.

MEDICATIONS are any drugs the patient takes regularly, prescribed or recreational. These might gives clues to the patient's underlying condition. Daily medications include amino acids and birth control pills. Many women do not think of birth control pills as a daily medication. Also find out if the patient has taken his medication as prescribed, and today. The present illness may be because the patient forgot to take his meds or took to much. For any medication find out when the last one was taken, and when the next is due. Be sure to monitor a patient's medication as to when the next is due so they do not miss it. If it is time for the next med, consult with the hospital the patient will be transported to as to if the attending physician wants it given. If it is not time, inform the nurse when the next medication is due once the patient reaches the hospital.

Alcohol (ETOH) is considered a recreational drug. Also it may have something to do with the present illness. Find out the amount consumed. If the victim has taken cocaine, it can present itself as a heart attack.

Does the victim have any ALLERGIES? Ask specifically about Novocain, Penicillin, and when around water, bees. Any the patient states he has log, if they say none write it "NKA" (no known allergies).

Finally find out the patient's DOCTOR and the last HOSPITAL, he was in. This gives the Emergency Room staff a place to look for an in depth medical history that they may need.

For the unconscious victim check his ABCs (Airway, Breathing, Circulation, Spine) immediately upon reaching him. If the victim is not breathing it may only be due to an obstruction, or position of the neck. The blockage may be partial or total. An airway must be established first and if the victim does not breathe spontaneously than artificial respirations need to be started. Remember to protect the C-spine if trauma is suspected.

When the victim is breathing, note the rate, and if it is regular or not. Appraise the depth of breathing, as to if it is normal, deep, gasping, or shallow. Listen for any unusual sounds such as gurgling (drowning victim) or snoring.

The carotid artery must be checked for a pulse. Determine its rate, rhythm, and force, is it full, bounding, weak, thready? Checking the radial pulses does not determine adequate brain perfusion. Cardiac compression are not to be started for lack of a radial pulse but for too slow of or lack of a carotid pulse.

Severe bleeding must be arrested immediately and any deformities need to be noted. Long bone deformity indicates breaks that can cause massive internal bleeding.

Whenever acquiring a history, always ask questions that stimulate explanations. They are far more effective than asking basic "yes" or "no" questions. Most patients are anxious to cooperate, and try to tell you what he thinks you want to hear. If you ask: "Does your chest hurt?" the reply may be "yes" even if it does not, because he believes that is the answer you wanted. Do not use leading questions. When your question yields an incomplete, or uninformative response, immediately rephrase it to allow for a fuller answer, or say, "tell me more about that."

Try always to use common words and expressions instead of medical terms. Clear and simple language is the key to successful communication. The average person does not understand medical terminology, and asking if he suffers from nocturia does not help the person or impress him with your vocabulary. Most "why" questions institute a defensive attitude by the patient, and will cause him to guard everything he says. Just stating an observation lets the patient respond without feeling threatened. Asking a person why he got the bends just serves to alienate him.

Make sure the patient understands that your questions are designed to be beneficial. He should understand that his answers are to help improve the quality of care. Many people "clam up" and say nothing. If a patient has been drinking or using drugs he wont want to say so, you have to convince him to trust you.

With every female patient as part of your history you must ask three basic questions:
  • Are you sexually active?

  • Do you think you may be pregnant?

  • When was your last menstrual period(LMP)?

Do not be embarrassed to ask these questions, they are important in treatment. Another rule when treating women is that all are pregnant unless proven otherwise. The otherwise is a negative Beta HCG, even when they say they are not pregnant.

At the end of your history be sure to give the patient an opportunity to add any additional information, or ask any questions. Do not cut him short leaving a feeling of uncertainty about their care.

After interviewing the patient the thorough examination is begun. This is necessary data for your initial assessment. Always observe the patient at all times and do not be afraid to touch him. Set the priorities. Explain to your patent that you will be doing a physical exam. If needed get the person to stand so you can observe the stature. Note how the patient stands; is it erect or slumped? Is the spine straight or does it curve? How old does the patient look? Do they look older or younger than the age recorded? Are the patient's body proportions normal? Note the size of his trunk arms, legs, head and hands. Remember that the distance from the top of the head to the symphysis pubis should approximately equal the distance from the symphysis pubis to the bottom of the feet. Ask the patient to walk across the room. Does he have a brisk gait? Does one foot drag or is there a limp. Check for any signs of unusual rapidity, slowness, uncoordinated, paralysis, or spasticity. What is your patients facial expression. Is it fixed? Does it change in ways appropriate to the circumstances?

Check and record the vital signs and time done. Vital signs are, heart rate or pulse, respirations and blood pressure.

When trauma is involved then a TRAUMA SCORE may be useful to you and the receiving ER, as to the status of the victim. The Trauma Score is used similar to the Glasgow Score, it gives a number value based on certain physical findings. The higher the number the better the patient is, with 11 being the highest and 0 the lowest. Assessment of the respiratory rate, respiratory excursion, blood pressure and capillary refill make up the trauma score and can be done in about one minute.

HISTORY OF PRESENT ILLNESS (HPI)
Chief Complaint
Location
Quality
Intensity
Quantity
Chronology
Setting
Scenario of The First Symptom
Aggravation and Alleviation
Associated Complaints
Prior to Arrival Treatment

PAST MEDICAL HISTORY (PMH)
Major Medical Problems
Medications
Allergies
Doctor/Hospital

RAPID PHYSICAL EXAMINATION
Vital Signs,
Skin
Head, Ears, Eyes, Nose, Throat
Neck
Chest (Heart, Lungs and External [front and back])
Abdomen (soft, hard and/or tender, note pulsations)
Extremities
Neuro Exam

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