BLOCK 4: PATIENT ASSESSMENT Flashcards
differential vs. working diagnosis
differential: list of possible diagnoses based on patient assessment findings
working: one diagnosis from differential list that you are basing your treatment plan on
most of your assessment and physical exam can be in any order AFTER ____
primary survey and life threats have been addressed
what sequence does primary survey use and what’s the exception to it
ABCDE (airway, breathing, circulation, disability, exposure)
exception: patient appears lifeless or severe external bleeding, use CABDE
what two things make up the history taking part of a patient assessment
history of PRESENT illness (OPQRST)
past medical history (SAMPLE)
what two things make up the secondary assessment during a patient assessment
baseline vitals and monitoring devices (ECG)
systematic physical examination
what make up the primary assessment during a patient assessment
general impression, mental status
ABCDE
chief complaint
priority decision
what is SOAP for an assessment
Subjective info (symptoms)
Objective info (signs)
Assessment (differential diagnosis)
Plan (working diagnosis)
what is CTC in an assessment
skin color, temperature, condition
what three systems are the critical systems that balance the body
respiratory, cardiovascular, neurological
you must ____ whether the patient is sick or not sick, then _____ how sick the patient is
qualify
quantify
what is a field impression
initial summary of the patient’s condition based on presentation and exclusion of other possible causes based on the differential diagnoses
two basic patient classifications in prehospital care
medical and trauma
injury rate of EMS is how many times greater than general workforce
3
what is it called when a motorist is distracted by trying to view the incident scene
“rubbernecking”
safety vests must have what
a five-point breakaway feature
what is delirium and who are at high risk of experiencing this
sudden acute change in mental status secondary to a significant underlying factor
meth and crack users
MOI vs NOI
MOI: mechanism of injury - forces that act on body to cause injury/how a traumatic injury occurs
NOI: nature of illness - general type of illness patient is experiencing
if multiple patients have similar symptoms/complaints, suspect what two things
carbon monoxide or other noxious agent, or food poisoning
applying a cervical collar and backboarding do or do not completely immobilize the spine
do not completely immobilize the spine
what is the best way to prevent transmission of most diseases
hand washing
definition of patient safety
reduction of risk of unnecessary harm associated with EMS care - best available medical evidence, equipment, technology, and human skill
the three exam techniques in patient assessment
inspection: looking over patient for abnormalities
palpation: touching to feel for abnormalities
auscultation: listening to sounds within body
how long should it take to form a general impression
60-90 seconds
what do you do with patients who may have no complaints and may not be in any distress
give them a “well-patient exam” which is more comprehensive and takes more time
the two types of questions on a medical or trauma call
question 1: qualification (is this person sick/hurt?)
question 2: quantification (how sick/injured are they?)
what is one of the primary indicators of how sick a patient is
mental status
AVPU
alert (responds appropriately)
verbal (responsive to verbal stimuli)
pain (responsive to pain)
unresponsive
alert and oriented is measured in what four areas
person, place, time, and event
in what order of the A/Os do patients generally exhibit disorientation
forget events, the time, where they are, and then who they are
snoring respirations think ____ problem
gurgling sounds think ____ problem
position problem (obstruction by tongue)
blood or vomit in mouth (suction)
when patient appears lifeless, how does the ABCDE approach change
CABDE
when patient has life threatening bleeding, how does the ABCDE approach change
XABCDE
what is considered bradycardia
less than 60bpm
what is considered tachycardia
faster than 100bpm
what is pallor and what causes it
paleness occurring if arterial blood flow ceases to part of body and from hypothermia
excessive blood loss, anaphylaxis, hypoglycemia, anxiety
what is cyanosis
dusky gray or blue skin from low oxygen levels
how is the temp of the skin related to the vessels
vasodilation causes temp to rise (fever/hot weather)
vasoconstriction causes temp to drop (shock)
what is diaphoresis and how is it caused
excessive/intense sweating caused by stimulation of the SNS
what is minute volume in regards to breathing
amount of air move in/out of lungs each minute
multiplying the respiratory rate and tidal volume
best measure of breathing adequacy
minute volume
general respiration rate for adult patients before treatment is needed
8-24
what is jaundice and what causes it
yellow skin
liver dysfunction
what is flushed skin and what causes it
red skin
fever, hypertension, allergic reaction, alcohol intake, late sign of CO poisoning
what causes mottled skin
cardiovascular shock and disseminated intravascular coagulopathy
skin conditions and their possible causes
hot, dry
hot, wet
warm, dry
cool, dry
cool, wet
hot, dry: excessive body heat (heatstroke)
hot, wet: increased internal/external temperature
warm, dry: fever
cool, dry: exposure to cold
cool, wet: shock
absence of a palpable pulse in a responsive patient indicates what?
low cardiac output, not cardiac arrest
4 medical conditions that cause sudden death
airway obstruction, respiratory arrest, cardiac arrest, severe bleeding
components of a mini neuro exam
AVPU scale, pupils, assessment for neurologic deficits (sensation, movement, and grip strength in limbs), GCS
glasgow coma scale eye opening scoring
4 - spontaneous
3 - to verbal command
2 - to pain
1 - no response
glasgow coma scale verbal response scoring
5 - oriented conversation
4- disoriented conversation
3 - nonsensical speech
2 - unintelligible sounds
1 - no response
glasgow coma scale best motor response scoring
6 - follows commands
5 - localizes pain
4 - withdraws to pain
3 - abnormal flexion
2 - abnormal extension
1 - no response
what does GCS of 15 indicate
no neurologic disabilities
what does GCS of 13-14 indicate
mild dysfunction
what does GCS of 9-12 indicate
moderate to severe dysfunction
what does GCS of less than 8 indicate
severe dysfunction
lowest and highest GCS score possible
lowest: 3
highest: 15
what is an apparent life threatening event
episode of combination of apnea, color change, change in muscle tone, and choking/gagging
six quality aims that health care should embrace
(STEEEP)
safety, timeliness, effectiveness, efficiency, equity, patient centeredness
what type of questions yield more information
open-ended
two most important pieces of patient history to obtain
name and chief complaint
one of the most critical elements of the interview process is _____
being a great listener
what is facilitation communication technique
encouraging patient to feel open to give you any info you need
what is reflection communication technique
pause to consider something significant your patient has told you
what is clarification communication technique
ask for more info when some aspect of patient history is vague or unclear
what is confrontation communication technique
make patient aware of inconsistencies between behavior and your findings
what is interpretation communication technique
infer the cause of patient’s distress and then ask the patient if you are right
what are social history examples
tobacco/alcohol/drug use, sexual behavior, diet, travel history, occupation, housing environment
what to do if patient denies neck/back pain after trauma but smells of alcohol
apple manual stabilization anyway
what condition causes the patient to be sweaty and restless and often misinterpreted as anxiety or panic
hypoxia
situational vs chronic depression
situational: normal reaction to stressful event
chronic: ongoing with no apparent cause
confusing behavior is often related to lack of ___ or ___
oxygen, glucose
most pediatric problems encountered in the field are ___ or ___ related
respiratory, fluid
two types of history important during neonate and infant exams
maternal health history
birth history
any patient taking five or more drugs likely has some form of ___
drug interaction
what is an iatrogenic condition
caused by medications or other medical treatment and can mask other illnesses that may need immediate medical attention
signs vs symptoms
signs: objective observations or measurements
symptoms: subjective information that the patient tells you
travel history is useful when suspecting a ____ because people on long flights are susceptible to ____
pulmonary embolism
blood clots
when are falls considered a high-energy impact? (adult and children)
adults: greater than 20ft
children: greater than 10ft or 2-3x their height
when are MVAs considered a high-energy impact? (6)
intrusion greater than 12in on occupant site or 18in on any site
ejection
death in the same passenger compartment
vehicle telemetry data
vehicle vs. pedestrian greater than 20mph
ATV or motorcycle over 20mph
what are pertinent negatives
absence or lack of certain signs/symptoms characteristic of particular illness
what is diplopia
double vision
what is photophobia
sensitivity to light
what is tinnitus
ringing in the ears
what is vertigo
sensation of the room spinning
what is rhinorrhea
runny nose
what is epistaxis
nose bleed
what is polyuria
increased frequency of urination
what is polydipsia
increased thirst
what is polyphagia
increased appetite
what is dyspnea
shortness of breath
orthopnea
difficulty breathing when lying down
hemoptysis
coughing up blood
atraumatic bruising is usually an indication of what
a clotting disorder
what is hematemesis
blood in vomit
what is dysuria
painful urination
what is nocturia
waking up in middle of sleep to urinate
what is hematuria
blood in urine
what is dysmenorrhea
menstrual pain
five aspects of critical thinking
concept formation
data interpretation
application of principles
reflection in action (changing course as needed)
reflection on action (debriefing)
5 steps of patient assessment starting with scene size up
scene size up
primary assessment
history taking
secondary assessment
reassessment
what is a rapid full body scan
60-90second nonsystematic review of patient’s body to identify injuries that must be managed immediately
open vs. closed injury types
open: abrasions, amputations, avulsions, punctures, penetrations, lacerations
closed: deformities, swelling, burns, contusions, crush injuries
inspection vs palpation
inspection: looking at patient
palpating: touching patient
what is percussion
gently striking surface of body where it overlies various body cavities
what are the additional sets of vital signs after the first set called
serial vital signs
what is vital signs trending
trends based on vitals showing patient improvement or deterioration
what is blood pressure
measurement of force exerted against walls of blood vessels
systolic vs diastolic pressure
systolic: left ventricle contracting (systole)
diastolic: residual pressure in system when left ventricle is relaxing (diastole)
what does a drop in diastolic pressure mean
less myocardial perfusion
BP cuff should be how big in comparison to the size of the upper arm
1/2 or 2/3rds
cuffs that are too small or tight yield ___ pressures and too large or too loose cuffs yield ____ pressures
artificially high
inaccurately low
cerumen in the ear canal has what affect on temperature reading
lowers it
what is the eupnea waveform and causes
normal breathing
what is the tachypnea waveform and causes
rapid, shallow, regular pattern respirations caused by stimulants, exercise, pulmonary/heart disease, anxiety
what is bradypnea waveform and causes
decreased rate, regular pattern respirations caused by opioids, sedatives, CO exposure
what is apnea waveform and causes
absence of breathing caused by hypoxia, MI, submersion
what is hyperpnea waveform and causes
rapid, regular, deep respirations caused by stimulants, overdose, and exercise
what is cheyne-stokes waveform and causes
gradual increase/decrease in rate and depth with intermittent periods of apnea caused by pre-death and brain stem injury
what is biot-ataxic waveform and causes
irregular pattern, rate, and depth with periods of apnea caused by brainstem injury and increased intracranial pressure
what is kussmaul waveform and causes
deep, gasping respiration(extreme tachypnea and hyperpnea) caused by acidosis and diabetic detoacidosis
what is apneustic waveforms and causes
prolonged inspiratory phase with shortened expiratory phase and bradypnea caused by brainstem injury
oxygen is applied to patients with SpO2 of less than ___
94%
what is a sphygmomanometer
BP cuff
two pieces to the chest piece of a stethoscope and their different uses
diaphragm (plastic disk) placed FIRMLY on skin to listen to high-pitched sounds like breathing
bell (hollow cup) placed LIGHTLY on skin to listen to low pitched sounds like heart sounds
degrees of distress (5)
no apparent distress
mild (slight)
moderate (average)
acute (very great/bad)
severe (dangerous/difficult to endure)
who is a focused exam performed on and what is it based on
patients who sustained insignificant MOIs and on responsive medical patients
it is based on the chief complaint
two methods commonly used to assess patient’s attention
serial 7s (counting backward from 100 by 7s) and spelling backward
which two forms of memory to assess and how
remote memory (birthdays, schools attended)
recent memory (today’s events)
how to assess skin turgor in an older patient
skin of the upper chest
what to pay attention to when assessing the skin
CTC (color, temperature, condition)
what is ecchymosis
localized bruising or blood collection within or under the skin
in what conditions is flushing usually seen
(vasodilation) fever and allergic reactions
in what conditions is pallor usually seen
(vasoconstriction) anemia, cardiac events, shock states, hypothermia
what are beau lines and what cause them
transverse depressions in nails indicating period of growth inhibition caused by systemic illness, severe infection, or nail injury
what is clubbing and what causes it
angle between nail and nail base approaches or exceeds 180 caused by chronic respiratory disease
what is psoriasis and what causes it
pitting, discoloration, and subungual thickening of the nail caused by autoimmune disease
what is splinter hemorrhages and what causes it
red or brown linear streaks in the nail bed caused by bacterial endocarditis or trichinosis
what is Terry nails and what causes it
transverse white bands covering the nail except for the distal tip caused by cirrhosis
overly thick nails or nails that have lines running parallel to the finger often suggest ____
fungal infection
blood or CSF from ears or nose after trauma suggests what
basilar skull fracture
if wheezing is unilateral, suspect ____
if wheezing is bilateral, suspect ____
aspirated foreign body or infection
asthma
what does crackles or rales may indicate
heart failure, pneumonia, pulmonary diseases, asthma
what does rhonchi indicate and what is usually associated with it
fluid in the larger airways, pneumonia, bronchitis
often associated with a productive cough
what is stridor and what does stridor indicate
narrowing, swelling, or obstruction of the upper airway by 85% and is caused by epiglottitis, croup, airway burns, or foreign body obstruction
what are pleural friction rubs caused by and what are they associated with
pleural inflammation associated with pain on inspiration
what conditions cause decreased breath sounds
pneumothorax, hemothorax, pleural effusion, PE, COPD, opiate intoxication
continuous lung sounds suggest ____ process but intermittent sounds suggest ____ process
pathological process
reversible process
S3 sound is associated with what
heart failure in patients over 35
S4 sound represents what
decreased compliance of left ventricle or increased pressure in atria
what are Korotkoff sounds
related to a patient’s BP, only 1st and 5th phase are important
1st and 5th phase of Korotkoff sounds
Phase 1: tapping sounds increasing in intensity correlating to systolic contraction
Phase 5: all sounds disappear correlating to diastolic pressure
what is a lift/heave
perception of heart beating strongly that suggests hypertrophy
what is thrill
humming vibration that suggests a bruit or murmur
what is a bruit
whooshing sounds heard in carotid arteries that indicates turbulent blood flow in arteries
what is a murmur
whooshing sounds heard over heart that indicated turbulent blood flow around a cardiac valve
how are murmurs graded
1 (softest) to 6 (loudest)
three basic mechanisms producing abdominal pain
1: visceral pain -
2: inflammation -
3: referred pain -
- when hollow organs are obstructed, causes cramping and diffuse pain
- inflammation that produces sharp, localized pain
- originates in a particular organ but is felt in a different location
when is an orthostatic change considered positive
systolic BP decreased up to 20
diastolic BP increases more than 10
pulse increases by 20
what is ascites
collection of fluid within peritoneal cavity
what is rebound tenderness and what is it a symptom of
pain on release of pressure
indicative of inflammation like appendicitis
LUQ pain should always be assumed to be ____
the spleen
LLQ pain should be suspected of having ____
diverticulitis
RLQ pain should be suspect of having ____
appendicitis
generalized abdominal pain in women should be suspect of ____
ectopic pregnancy, ruptured ovarian cyst
tendons vs ligaments
tendons: muscle to bone
ligaments: bone to bone
pathologic vs traumatic fracture
pathologic: normal forces applied to an abnormal bone structure
traumatic: abnormal forces are applied to a normal bone structure
bilateral pitting edema occurs with ____ conditions like ____
unilateral edema occurs with ____ conditions like ____
systemic, heart failure
local, deep vein occlusion
5 P’s of acute arterial insufficiency
pain, pallor, paresthesia, paresis, pulselessness
lordosis vs kyphosis vs scoliosis
lordosis: inward curve of lumbar spine above butt
kyphosis: outward curve of thoracic spine
scoliosis: sideways curve of the spine
what is the Babinski reflex test
running a pen along the length of the sole of the foot will cause the big toe to flex
COASTMAP mnemonic
used for assessing mental status
consciousness, orientation, activity, speech, thought, memory, affect, perception
how to assess cranial nerve 1
olfactory - smell - not usually assessed by use ammonia inhalant
how to assess cranial nerve 2
optic - vision - ask if they can see your finger in front of their face
how to assess cranial nerve 3
oculomotor - movement of eye/eyelid - blinking and follow your finger
how to assess cranial nerve 4
trochlear - eye movement - same as nerve 3
how to assess cranial nerve 5
trigeminal - chewing, touch of face - patient to smile
how to assess cranial nerve 6
abducens - eye movement - same as nerve 3
how to assess cranial nerve 7
facial - movement of face/tears - same as nerve 5
how to assess cranial nerve 8
(vestibocochlear) auditory - hearing/balance - ask patient to follow spoken commands
how to assess cranial nerve 9 and 10
vagus and glossopharyngeal - swallowing - ask patient to smile and swallow
how to assess cranial nerve 11
accessory - movement of head/shoulders - ask patient to shrug shoulders
how to assess cranial nerve 12
hypoglossal - movement of tongue - ask patient to stick tongue out
manual muscle testing scale
scale 0-5
0: no muscle activation
1: twitch
2: without gravity full range
3: against gravity full range
4: against some resistance full range
5: against full resistance full range
what is pronator drift
patient closes eyes and holds arms out palms up, if it drifts
scoring of deep tendon reflexes
0: no response
1: sluggish
2: active
3: slightly hyperactive
4: hyperactive
what is expressive aphasia
difficulty speaking
what is paresthesia
tingling or sensory changes
two categories of trauma patients
isolated and multisystem
which ECG lead is often sufficient for rhythm interpretation
lead 2
what is the first set of vital signs called
baseline
pupil size is regulated by which cranial nerve
oculomotor (third)
what is anisocoria
pupils are asymmetric by greater than 1mm
what are Battle signs
discoloration and tenderness of the mastoid process of the skull
how often to reassess vitals on stable and non-stable patients
stable: 15 mins
unstable: every 5 mins if possible
what is the Cushing reflex indicative of and what are the symptoms of it
head trauma
slow pulse, rising BP, erratic respiratory pattern
what is the Beck triad indicative of and what are the symptoms of it
cardiac tamponade
narrowed pulse pressure, muffled heart tones, JVD
