Chapter 14 | Principles of Assessment Flashcards
• How examinations are conducted • History-taking techniques • Physical examination techniques • Body system examinations • Critical thinking concepts for the EMT
List:
components of patient history
2 points
- HPI: history of the present illness
- PMH: past medical history
Define:
HPI
(history of present illness)
information gathered regarding symptoms and nature of patient’s current concerns
Define:
PMH
(past medical history)
information gathered regarding patient’s health problems in the past
Define:
OPQRST
(AS/PN)
- Onset: gradual or sudden
- Provocation: factors that improve/worsen condition
- Quality: type of pain
- Region (or radiation): where pain is located/spreading
- Severity: scale of 1 to 10
- Time: time since start of symptoms
(associated signs / pertinent negatives)
Define:
SAMPLE
(R)
- Signs and Symptoms
- Allergies
- Medications
- Pertinent Past history
- Last oral intake
- Events leading to injury/illness
(risk factors)
Fill in the blank:
Patient history is usually obtained by [BLANK].
Patient history is usually obtained by talking to the patient.
(remember SAMPLE)
FIll in the blank:
If the patient is unable to respond, gather history from [BLANK].
(list of 4)
gather history from family, bystanders, medications, or other observations.
Answer:
What acronym could you use to obtain HPI?
OPQRST
Explain:
What acronym could you use to obtain PMH?
SAMPLE
Define:
*OPQRST-AS/PN
(the part in bold)
- associated symptoms: symptoms expected to be related to condition
- pertinent negatives: assurance that greater trauma did not occur
Define:
SAMPLER
(the part in bold)
risk factors
List:
primary techniques of physical examinations
3 points
- Observe: look at patient for overall sense of patient condition
- Auscultate: listen for sounds of abnormal condition
- Palpate: feel an area for deformities or other abnormal findings
Fill in the blank:
When conducting a pediatric physical exam, approach frightened children [BLANK].
approach frightened children slowly.
Fill in the blank:
When conducting a pediatric physical exam, explain [BLANK] to the child before use.
When conducting a pediatric physical exam, explain all equipment to the child before use.
True or false:
When conducting a pediatric physical exam, never lie to a child about something that hurts.
true
True or false:
When conducting a pediatric physical exam, start from the least invasive parts to the most invasive.
true
True or false:
When conducting a pediatric physical exam, start from the most invasive parts to the least invasive parts.
false
(least invasive to most invasive)
True or false:
When conducting a pediatric physical exam, start with the toes or trunk and work your way toward the head.
true
True or false:
When conducting a pediatric physical exam, start with the head work your way toward the toes or trunk.
false
List:
components of body system examinations
2 points
- history
- physical exam
Fill in the blank:
It is better to ask patients [OPEN/CLOSED]-ended questions during an assessment.
It is better to ask patients open-ended questions during an assessment.
You can ask yes/no questions if they are difficult to communicate with.
Define:
crepitation
grating sound or feeling of broken bones rubbing together
Define:
diagnosis
description/label for a patient’s condition that assists a clinician in further evaluation and treatment
Answer:
Why are patients who are pale and sweaty considered more serious than patients who aren’t?
pale/sweaty skin may signify lack of blood flow to skin (poor perfusion)
possible sign of shock
Fill in the blank:
OPQRST is a mnemonic initialism used by medical professionals to gather [BLANK].
OPQRST is a mnemonic initialism used by medical professionals to gather HPI.
history of present illness
Fill in the blank:
SAMPLE is a pneumonic device used to gather [BLANK].
SAMPLE is a pneumonic device used to gather PMH.
(past medical history)
Define:
associated symptoms
signs or symptoms that accompany a condition
Define:
pertinent negatives
negative findings that help to rule out suspected problems
Fill in the blank:
Pertinent negatives are used when the clinician documents [BLANK].
Pertinent negatives are used when the clinician documents why they did not perform a procedure.
Answer:
You are on the scene in the bad part of town for an unresponsive 18-year-old type-1 diabetic patient. His mother states that he is very noncompliant with his diabetes management and often goes unresponsive due to low blood sugar. After performing the primary assessment, you believe that this is the most likely cause of his unresponsiveness. However, after taking a capillary glucose reading you are surprised to see that the patient’s sugar level is normal.
How will you now determine the field diagnosis?
continue patient care by getting a complete PMH and perform a complete secondary assessment
use SAMPLE
Choose:
When you begin interviewing your patient, he tells you that he has not felt well for several months, ever since he had his gallbladder removed. He goes on to tell you that he cannot get his wife to schedule a doctor’s appointment for him and when she remembers to call, the office is always closed.
Which of the following is the best way to proceed?
A: begin your assessment of his vital signs
B: try to call his doctor to schedule an appointment
C: ask him why he decided to call 911 today
D: ask him for a list of his medications
C
Choose:
You respond to the scene of a motor vehicle crash to find a middle-aged man on a long spine board being cared for by first responding firefighters. He appears to be bleeding from his head and he is unconscious.
For what should check the car?
A: a deployed passenger-side air bag
B: personal items too valuable to leave on-scene
C: a bent steering wheel or starred windshield
D: insurance information or identification
C
Choose:
You are performing a rapid trauma assessment on an unresponsive 30-year-old male. As you evaluate his head, which of the following should you check for?
A: unequal facial muscles
B: function of the cranial nerves
C: crepitation
D: whether the patient can follow your finger with his eyes
C
Choose:
If a patient complains of abdominal pain localized to a specific area of the abdomen, which of the following techniques should be used to assess the abdomen?
A: palpate the painful area last
B: palpate the painful area first
C: palpate the area at the beginning and end of the exam
D: do not palpate the painful area
A
Choose:
You are assessing a patient who has been involved in a motor vehicle crash. Which of the following questions would be the most important to ask him?
A: How much fuel is in your car?
B: Why were you in such a hurry?
C: Have you been in a crash before?
D: How fast was the vehicle going?
D
Fill in the blank:
If a patient complains of abdominal pain localized to a specific area of the abdomen, you should palpate the painful area [FIRST/LAST].
If a patient complains of abdominal pain localized to a specific area of the abdomen, you should palpate the painful area last.
Answer:
What is the feeling of bone ends rubbing together called?
crepitation
a grating or crackling sound
Answer:
When using the memory aid OPQRST, what would you ask to find out about P?
Does anything make the pain better or worse?
looking for answers like “hurts when I’m breathing” or “gets better when I sit”
Answer:
When using the memory aid OPQRST, what would you ask to find out about Q?
Can you describe the pain in your own words?
looking for answers like “sharp,” “dull,” or “intermittent”
Answer:
When using the memory aid OPQRST, what would you ask to find out about R?
Can you show me where the pain is? Does it extend to any other points of the body?
looking for answers like “chest pain that is also shooting down my arm”
Answer:
When using the memory aid OPQRST, what would you ask to find out about S?
Can you rate your pain on a scale of 1 to 10?
Answer:
When using the memory aid OPQRST, what would you ask to find out about O?
How did the pain start?
looking for answers like “suddenly” or “gradually”
Answer:
When using the memory aid OPQRST, what would you ask to find out about T?
How long ago did the pain start?
looking for an answer like “10 minutes ago”
Fill in the blank:
[BLANK] is another word for crepitation.
Crepitus is another word for crepitation.
Fill in the blank:
Crepitus is another word for [BLANK].
Crepitus is another word for crepitation.
List (in order):
components of medical assessment skill sheet
6 points (and describe them)
- scene size-up: arrival considerations
- primary assessment: alertness and ABCs
- history taking: OPQRST and SAMPLE
- secondary assessment: system checks (plus 1 above and 1 below)
- vital signs: must include HR, BP, and RR
- reassessment: how often
List (in order):
components of trauma assessment skill sheet
5 points (and describe them)
- scene size-up: arrival considerations
- primary survey: alertness and ABCs
- history taking: SAMPLE and vitals
- secondary assessment: rapid trauma exam
- reassessment: how often
List (in order):
components of rapid trauma exam
8 points (and explain it all)
- head: scalp, facial features, and leaking fluids
- neck: JVD, tracheal deviation, and spine step-off
- chest: sternum palpation (not frisky), flail segments, lung sounds
- upper extremities: feeling all the way around, checking PMS
- abdomen: palpating all 4 quadrants, should be soft and not rigid or distended
- pelvis: pushing in or down on pelvis
- lower extremities: feeling all the way around, checking PMS
- back: log roll with partner, palpate spine, gross blood sweep
clarifications:
- cervicle spine collar may be applied after examination of neck
- order of arms, abdomen, and pelvis steps may be altered
- long backboard may be applied after exam of back
