Chapter 13 – Medical Overview 1
Chapter 13 – Medical Overview
I. Objectives
Knowledge Objectives / 1. Describe the approach to the assessment of a responsive medical patient.2. Describe the unique needs for assessing an individual who is unresponsive or has an altered mental status.
3. Recite examples and explain why patients should receive a rapid medical assessment.
Attitude Objectives / 4. Attend to the feelings that the medical patient might be experiencing.
Skill Objectives / 5. Demonstrate the techniques for performing a medical patient assessment.
II. Preparation
Corresponding textbook pages: / · 301-308Audiovisual equipment: / · Chapter 13 PowerPoint® presentation
· Computer
· Multimedia projector
EMS equipment: / · Exam gloves, stethoscope (1:6), blood pressure cuffs (adult)(1:6), penlight (1:6
Course administration materials: / · Attendance sign-in sheet
III. Personnel
Primary instructor qualifications: / · One Emergency Medical Responder instructor knowledgeable in medical patient assessment.Assistant instructor qualifications: / · The instructor-to-student ratio should be 1:6 for psychomotor skill practice.
· Individuals used as assistant instructors should be knowledgeable about medical patient assessment.
IV. Key Terms Presented In This Lesson
· Abrasion Damage to the outermost layer of skin (epidermis) by shearing forces (such as rubbing or scraping).
· Altered Mental Status A change in a patient’s level of awareness; also called an altered level of consciousness (ALOC).
· Anisocoria Unequal pupil size that is normal in 2 to 4 percent of the population.
· Arteries Large blood vessels that carry blood away from the heart to the rest of the body.
· Asymmetry Unevenness.
· AVPU Scale A memory aid used to identify a patient’s mental status. Each letter of the scale refers to a level of awareness. A = alert, V = responds to verbal stimuli, P = responds to painful stimuli, U = unresponsive. A patient who is oriented to person, place, time, and event is said to be “alert and oriented X (‘times’) 4” or “A and O X 4.”
· Baseline Vital Signs An initial set of vital-sign measurements.
· Battle’s Sign A bluish discoloration behind the ear that is a sign of a possible skull fracture.
· Binaurals The metal pieces of the stethoscope that connect the earpieces to the plastic or rubber tubing.
· Capillary Refill Assessment tool used in infants and children; performed by pressing on the patient’s skin or nail beds and determining the time for return to initial color; normal capillary refill in infants and children is less than 2 seconds, delayed (greater than 2 seconds) capillary refill suggests circulatory compromise.
· Central Pulse A pulse found close to the trunk of the body.
· Chief Complaint The reason EMS has been called, usually in the patient’s own words.
· Conjunctiva A paper-thin mucous membrane that covers the sclera (the white of the eye).
· Contusion Bruise.
· Crackles Abnormal breath sounds that sound like hair rolled between the thumb and forefinger close to one’s ear, indicating the presence of fluid in the alveoli or larger airways; also called rales.
· Crepitation (Crepitus) A crackling sensation heard and felt beneath the skin caused by bone ends grating against each other or air trapped between layers of tissue.
· Crowing A long, high-pitched sound heard on inhalation.
· Cyanosis Blue-gray color of the skin or mucous membranes that suggests inadequate oxygenation or poor perfusion.
· DCAP-BTLS Memory aid used for patient assessment: deformities, contusions, abrasions, punctures or penetrations, burns, tenderness, lacerations, and swelling.
· Diastolic Pressure The pressure in an artery when the heart is at rest.
· Direct Questions Questions that require a yes or no answer.
· Distention Bulging or swelling.
· Ecchymosis Bluish discoloration caused by leakage of blood into the skin or mucous membrane.
· Edema Swelling.
· Field Impression The conclusion you reach about what is wrong with your patient.
· Flail Chest A condition in which two or more adjacent ribs are fractured in two or more places or when the sternum is detached. The section of the chest wall between the fractured ribs becomes free-floating because it is no longer in continuity with the chest. This free-floating section of the chest wall is called the flail segment.
· Focused Physical Examination An assessment of specific body areas that relate to a patient’s illness or injury.
· Focused Trauma Assessment A focused physical exam performed on an injured patient.
· General Impression An “across-the-room” assessment of a patient that is completed in 60 seconds or less to decide if the patient looks “sick” or “not sick”; also called a first impression.
· Hemothorax Blood in the pleural space.
· History of the Present Illness A chronological record of the reason a patient is seeking medical assistance that includes the patient’s chief complaint and the patient’s answers to questions about the circumstances that led up to his request for medical help.
· Hyphema Blood in the anterior chamber of the eye.
· Index of Suspicion Anticipating potential injuries based on the patient’s chief complaint, mechanism of injury, and assessment findings. In the case of a medical patient, anticipating potential complications of an illness on the basis of the patient’s chief complaint, SAMPLE history, and assessment findings.
· In-Line Stabilization A technique used to minimize movement of the head and neck.
· Jugular Venous Distention (JVD) Bulging of the neck veins when the patient is placed in a sitting position at a 45-degree angle.
· Laceration A break in the skin of varying depth that may be linear (regular) or stellate (irregular); caused by forceful impact with a sharp object (such as a knife, razor blade, or glass).
· Laryngeal Stoma Surgical opening in the neck.
· Mandible Lower jawbone.
· Maxilla Upper jawbone.
· Mottling An irregular or patchy skin discoloration that is usually a mixture of blue and white; usually seen in patients in shock, with hypothermia, or in cardiac arrest.
· Nasal Flaring Widening of the nostrils; a sign of increased breathing effort.
· Objective Findings A medical or trauma condition of the patient that can be seen, heard, smelled, measured, or felt; also called signs or clinical findings.
· Occlusive Airtight.
· Ongoing Assessment Reassessment of the patient to ensure the delivery of appropriate patient care.
· Open-Ended Questions Questions that require a patient to answer with more than a “yes” or “no,” such as, “What is troubling you today?” or “How can I help you?”
· Paradoxical Uneven, inconsistent.
· Patent Open.
· Patient History The part of a patient assessment that provides pertinent facts about the patient’s current medical problem and medical history.
· Perfusion The flow of blood through the body’s tissues.
· Peritonitis Inflammation of the abdominal lining.
· Physical Examination A head-to-toe assessment of the patient’s entire body.
· Pneumothorax A buildup of air between the outer lining of the lung and the chest wall, causing a complete or partial collapse of the lung.
· Primary Survey A rapid assessment of the patient to find and care for immediate life-threatening conditions.
· Pulmonary Contusion Bruising of the lung.
· Pulse The rhythmic contraction and expansion of the arteries with each beat of the heart.
· Raccoon Eyes Bilateral bluish discoloration (ecchymosis) around the eyes that suggests a possible skull fracture.
· Rapid Medical Assessment A quick head-to-toe assessment of a medical patient who is unresponsive or has an altered mental status.
· Rapid Trauma Assessment A quick head-to-toe assessment of a trauma patient with a significant mechanism of injury.
· Rhonchi Abnormal breath sounds produced when air flows through passages narrowed by mucus or fluid.
· SAMPLE A memory aid that serves to remind healthcare professionals of the information that should be gathered when obtaining a patient history. SAMPLE stands for signs and symptoms, allergies, medications, pertinent past medical history, last oral intake, and events leading to the injury or illness.
· Secondary Survey A full body assessment performed to discover medical conditions and/or injuries that are not immediately life-threatening but may become so if left untreated. In addition to a head-to-toe (or focused) assessment, it includes obtaining vital signs, reassessing changes in the patient’s condition, and determining the patient’s chief complaint, history of present illness, and significant past medical history.
· Sign A medical or trauma condition of the patient that can be seen, heard, smelled, measured, or felt; also called objective findings or clinical findings.
· Snoring Sound that results from partial obstruction of the upper airway by the tongue.
· Sphygmomanometer A device used to take a blood pressure.
· Spinal Precautions Precautions made to stabilize the head, neck, and back in a neutral position to prevent movement that could cause injury to the spinal cord.
· Stethoscope An instrument used to hear sounds within the body, such as respirations.
· Stridor A harsh, high-pitched sound (like the bark of a seal) that is associated with severe upper airway obstruction and is most often heard during inhalation.
· Subcutaneous Emphysema Air trapped beneath the skin; a crackling sensation under the fingers that suggests laceration of a lung and the leakage of air into the pleural space.
· Subjective Findings A patient’s interpretation and description of his or her complaint; also called symptoms.
· Symmetry Evenness.
· Symptom A condition described by the patient, such as shortness of breath; also called subjective findings.
· Systolic Pressure The pressure in an artery when the heart is pumping blood.
· Tension Pneumothorax A life-threatening condition in which air enters the pleural cavity during inspiration and progressively builds up under pressure.
· Tracheal Deviation Shifting of the trachea from a midline position.
· Vital Signs Measurements of breathing, pulse, temperature, pupils, and blood pressure.
V. Skills Presented In This Lesson
· Patient Assessment/Management – Medical, was presented in Chapter 12.
VI. Lesson Outline
1 / A. Medical Overview
2 / 1. Objectives
3 / B. Introduction
1. A medical patient is a person whose complaint is related to an illness.
2. For the medical patient, the patient’s level of responsiveness is the first important factor in determining the type of physical examination you need to perform.
3. A focused physical exam is usually performed for a responsive medical patient because he or she can usually tell you what is wrong that prompted a call for medical help.
4. If the patient is unresponsive or has an altered mental status, a rapid medical assessment (head-to-toe examination) needs to be done to find out what is wrong.
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Objective 1 / C. The Responsive Medical Patient
1. If your patient is responsive and ill (not injured), spend a few minutes learning about his medical history before beginning your physical examination.
2. If your patient is complaining of pain or discomfort, remember to use the OPQRST memory aid to help identify the type and location of the patient’s complaint.
3. Finding out the patient’s medical history will often help you pinpoint the patient’s present problem.
4. The information you collect will help guide where you look and what you are looking for in the focused physical exam.
5. For example, if your patient is complaining of abdominal pain, your physical exam will be focused on that area.
6. Performing the physical exam helps to establish if your initial assumption about what is wrong is accurate.
5 / 7. After the focused physical exam, obtain vital signs.
a. Assess the patient’s pulse, respirations, blood pressure, and oxygen saturation.
b. Assess the skin for color, temperature, and moisture.
c. Assess the pupils for size, equality, and reactivity.
d. Check capillary refill in infants and children younger than six years of age.
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Objectives 2, 3 / D. Unresponsive Medical Patient
1. After performing a scene size-up and making sure the scene is safe to enter, an unresponsive medical patient or a patient who has an altered mental status needs a primary survey and then a rapid head-to-toe physical examination, similar to a rapid trauma assessment.
a. Because the rapid assessment is performed on a medical patient, it is called a rapid medical assessment.
2. Performing a quick head-to-toe physical exam will help you identify the patient’s problem.
a. Treat problems as you find them.
3. The DCAP-BTLS memory aid used for the rapid trauma assessment is also used for the rapid medical assessment.
a. Remember that DCAP-BTLS stands for deformities, contusions, abrasions, punctures or penetrations, burns, tenderness, lacerations, and swelling.
7 / 4. As you begin the rapid medical assessment, it is important not to have “tunnel vision.”
a. For instance, although you may have been called for a diabetic emergency, do not assume that this is the actual (or only) problem.
b. If you approach the patient looking only for signs and symptoms consistent with a diabetic emergency, you may miss important indicators of other illnesses or injuries.
c. An unresponsive patient who is known to have a history of diabetes may have fallen when he lost consciousness.
d. In situations like this, you must consider the possibility of an injury to the head, neck, or back.
e. Assign another rescuer to manually stabilize the head and neck in a neutral position while you examine the patient.
8 / 5. Head and Neck
a. Begin the rapid medical assessment by reassessing the patient’s mental status and then checking the patient’s head.
b. The skull normally feels smooth and symmetric. There is normally no tenderness to palpation.
c. Check for DCAP-BTLS.
d. Look and feel for signs of trauma from a previous injury.
e. Look at the patient’s face for symmetry focusing on the symmetry of the eyebrows, eyelids, and sides of the mouth. Asymmetry, such as drooping on one side of the face, is a sign of a possible stroke.
f. Examine the sclerae, which are normally white in color. Note any color change, such as jaundice, which suggests liver disease.
g. Look in the ears and nose for leakage of blood or fluid.
h. Note if the patient is wearing a hearing aid.
i. Note any deformity of the nose and look for signs of nasal flaring.
j. Check the pupils for size, reactivity, and equality.
k. Assess the conjunctiva, which should be pink and moist.
l. Reassess the mouth for blood, vomitus, a foreign body, or secretions. Suction as needed. The oral mucosa should be pink and moist.
m. Note the presence of any unusual odors on the patient’s breath, body, or clothing.
n. Assess the neck and look at the neck veins.
1) Flat neck veins may be a sign of dehydration or blood loss.
2) The presence of jugular venous distention when the patient’s torso is at a 45° angle suggests fluid overload, which may be seen in heart failure.
o. Look to see if the patient has a laryngeal stoma (surgical opening in the neck).
p. Is the patient using the accessory muscles in the neck during breathing?
q. Check to see if the patient is wearing a medical identification necklace or other medical jewelry.
9 / 6. Chest
a. Expose the patient’s chest.
b. Check for DCAP-BTLS.
c. Assess the ease of the patient’s respiratory effort. Is the patient using accessory chest muscles during breathing?
d. Note if the chest rises and falls symmetrically.
e. Note the shape of the patient’s chest.
f. Look at the skin for signs of a rash and surgical scars.
g. Note if breathing is normal or noisy.
h. Note the presence of any medical devices, such as a pacemaker, or medication patches.
10 / 7. Abdomen and Pelvis
a. Assess the abdomen.
b. Check for DCAP-BTLS.
c. If applicable, look for signs of obvious pregnancy.
d. Look to see if abdominal distention is present.
e. Also, note the presence of any surgical scars.
f. Using the pads of your fingers, palpate all four quadrants of the abdomen.
1) Watch the patient’s face while you palpate.
2) A grimace may indicate tenderness over a particular abdominal area.
3) Determine if the abdomen is soft or hard (rigid).
4) Note the presence of any masses, pulsations, or medical devices.
g. In a pregnant patient, note movement or the absence of movement in the fetus.
h. Assess the pelvis for DCAP-BTLS.
i. Look for signs of obvious bleeding or incontinence of urine or stool.
11 / 8. Extremities
a. Check for DCAP-BTLS.
b. Look for a medical identification bracelet.
c. Assess pulses, motor function, and sensation in each extremity.
d. Look for edema of the hands, feet, and ankles.
e. Look for signs of a possible insect bite or sting, or signs of possible intravenous drug abuse.
12 / 9. Posterior Body
a. Assess the posterior body for DCAP-BTLS.
b. Look for swelling in the sacral area. In patients confined to bed, fluid collects in this area.
13 / 10. After the rapid medical assessment, assess the patient’s vital signs, and then proceed with getting the patient’s medical history from family and friends and from clues such as medical jewelry, pill containers, and medical devices.
a. Provide emergency care based on your physical exam findings.
11. Do not forget about family members at the scene.
a. Explain to the family the emergency care provided and where the patient will be transported for further care.
14 / 12. Questions?
VI. Lesson Enhancements