1. Introduction to Emergency Medical Care 1
Advance Preparation
Prepare assessment equipment for demonstration and psychomotor sessions.
Invite programmed patients.
Invite assistant instructors to assist with psychomotor sessions.

2. How to perform a secondary assessment for a responsive medical patient
The difference between assessment procedures for a responsive medical patient and for an unresponsive medical patient
How to perform a secondary assessment for a responsive medical patient
continued
continued

3. How to tailor the physical exam for a responsive medical patient using a body systems approach
How to perform a secondary assessment for an unresponsive medical patient

4. Secondary Assessment of the Medical Patient
Teaching Time: 30 minutes
Teaching Tips: The aim of assessment is making a diagnosis. Teach that assessment is not merely a list of questions but rather a means to an end. Use programmed patients of different ages and cultures to add reality to patient interview practice. Create standardized skill sheets for patient history to provide students with a practice reference. Do not discount the value of physical examination in the medical patient.

5. State Standard
20) Accurately perform the components of patient assessment to identify and manage immediate life threatening illnesses and injuries within the scope of practice of the EMR for pediatric, adult, and geriatric patients, utilizing rubrics from textbooks, National HOSA guidelines, or clinical standards of practice. Include the following areas: a. Scene Size-up b. Primary Survey or Assessment c. History Taking d. Secondary Assessment e. Reassessment

6. Objectives Students will be able to…
Identify steps for providing assessment for a medical patient
Perform an assessment for a medical patient using the OPQRST acronym
Determine history for a medical patient using the SAMPLE acronym

7. Responsive vs. Unresponsive Patient
Assessment varies depending on patient’s ability to communicate
Responsive medical patient: focus on chief complaint
Unresponsive medical patient: focus on physical findings
Knowledge Application: Prior to the lesson, brainstorm with students to define what they feel are the important elements of a patient history.

8. Conscious Vs. Unconscious
Primary Assessment
Aggressive ABC’s
Maintain Airway
Check circulation
Skin assessment, pulse, cap refill
Secondary Assessment
Rapid body systems exam first
History
Conscious
Primary Assessment
Quickly assure that pt. has adequate breathing, and pulse
Secondary Assessment
Begin with History First
Focused body system exams as needed

9. Secondary Assessment of Responsive Medical Patient
History of present illness
Past medical history
Focused physical exam
Baseline vital signs

10. History of Present Illness
Point to Emphasize: Speaking to a medical patient often provides important assessment information.
Talking Points: Use open-ended questions. For example, don’t ask, “Is your chest pain dull and crushing?” Ask instead, “How would you describe your pain?” In this way, you avoid giving the patient the impression that you want a particular answer.
Discussion Question: Describe the procedure for establishing the history of the present illness in a medical patient.
Obtain from patient
Obtain from family or bystanders
Ask open-ended questions
continued

11. History of Present Illness
Chief complaint
Why patient activated EMS
What is bothering patient most
Point to Emphasize: Use the history of the present illness to expand upon the chief complaint.
Talking Points: The chief complaint is why the patient activated EMS. Let the patient use his or her own words to describe this.

12. History of Present Illness—OPQRST
Onset: What were you doing when it started?
Provokes: What makes pain worse?
Quality: Describe pain.
Radiation: Where is pain? Does it seem to spread?
Severity: How bad is pain? (1–10 scale)
Time: When did pain start?
Points to Emphasize: Use OPQRST to standardize details. The chief complaint and the history of the present illness will help focus the physical examination of the conscious medical patient.
Discussion Topic: Define and describe OPQRST.

13. Past Medical History S-ymptoms A-llergies M-edications
P-ertinent past history
L-ast oral intake
E-vents leading to illness
Point to Emphasize: SAMPLE is a mnemonic used in discussing patient history.
Talking Points: SAMPLE is used to aid exploration of past medical history. Symptoms are explored during the history of the present illness.
Discussion Questions: Define and describe SAMPLE.
Knowledge Application: Have each student complete a SAMPLE history on the student beside him.

14. Tailoring Past History
Important information can be gained by tailoring history to patient’s chief complaint
Ask questions pertinent to complaint
Body systems approach: focus questioning and examination on particular body system most likely involved

15. Pediatric Note— Gathering History
Get on same level with child
Put questions in simple language
Gather information from caregivers

16. Perform Focused Physical Exam
Usually brief
Examine areas of concern based on chief complaint
Talking Points: For example, if your patient has difficulty breathing, listen to the patient’s chest with a stethoscope for presence and equality of breath sounds. For a patient who is at risk for hypoxia, check oxygen saturation. If your patient has a complaint that does not fit into any of the categories you learned in your EMT course, you should focus the exam on the body part that the patient has a complaint about.
Discussion Topic: Describe the assessment of a conscious and responsive medical patient.
Class Activity: Take a field trip. Visit a local nursing home and practice the assessment of a conscious medical patient with residents there.

17. Obtain Baseline Vital Signs
Essential to assessment of medical patient
Later assessments of vital signs will be compared to baseline

18. Think About It
Where would you focus your physical examination on a patient complaining of shortness of breath?
Talking Points: You would focus on the chest and the respiratory system in general. Look at the chest. Listen to lung sounds. Palpate the chest looking for abnormalities.

19. Secondary Assessment of Unresponsive Medical Patient
Inability to communicate shifts initial focus from chief complaint and history taking
Begin with physical exam and baseline vital signs
Gather history from bystanders or family members
Do rapid assessment of entire body
Point to Emphasize: In an unresponsive medical patient, physical findings and vital signs will guide the patient assessment.
Talking Points: For a responsive patient, you will be able to focus your exam on just the part of the body the patient complains of. Since an unresponsive patient cannot tell you where the problem is, you will need to do a rapid assessment of the entire body.
Class Activity: Give students a variety of written medical scenarios as homework. Have them consider the findings and detail the appropriate assessment strategies.
Critical Thinking: In what ways might the assessment of an unconscious medical patient be similar to the assessment of a patient who does not speak your native language?

20. Rapid Physical Exam Similar to physical exam for trauma patient
Assess head, neck, chest, abdomen, pelvis, extremities, and posterior
Talking Points: For a responsive patient, you will be able to focus your exam on just the part of the body the patient complains of. Since an unresponsive patient cannot tell you where the problem is, you will need to do a rapid assessment of the entire body.

21. Important Physical Findings
Neck: Jugular venous distention, medical identification devices
Chest: breath sounds
Abdomen: distention, firmness or rigidity
Pelvis: incontinence of urine or feces
Extremities: pulse, motor function, sensation, oxygen saturation, medical identification devices
Talking Points: Medical identification devices can provide important information. One of the most commonly used medical identification devices is the Medic Alert emblem. One side of the device has a Star of Life emblem. The patient’s medical problem is engraved on the reverse side, along with a telephone number to call for additional information. When doing the physical exam, look for necklaces and bracelets or wallet cards.

22. Determine if Advanced life support services are Required
Obtain baseline vital signs
Consider a request for ALS personnel
Talking Points: Assess the patient’s pulse, respirations, skin, pupils, and blood pressure and note any abnormalities. Determine the patient’s oxygen saturation if you can. In accordance with local protocols, and if advanced life support personnel are available, consider at this time if the additional services paramedics can provide would benefit your patient.

23. History of Present Illness and Past Medical History
Question bystanders
What is patient’s name?
What happened?
Did you see anything else?
Did patient complain before this happened?
Does patient have any illnesses or problems?
Is patient taking medications?
Discussion Topics: Describe the assessment of an unresponsive medical patient. Discuss how assessment of an unresponsive medical patient will differ from assessment of a responsive medical patient.
Class Activity: Assign each student a medical scenario. Ask the student to determine which medical assessment strategy would be most appropriate.
Knowledge Application: Divide the class into small groups. Use programmed patients to present a variety of assessment scenarios. Discuss assessment strategies.

24. Think About It
What other mechanisms might you have to obtain patient history other than speaking to bystanders?
Talking Points: Consider contacting the patient’s family. Review the patient’s medications. Review the scene for additional clues such as medical devices.

25. Comparing Assessments
Teaching Time: 15 minutes
Teaching Tips: Use real-world examples or the examples listed in the chapter to illustrate the different assessments.

26. Responsive Adult Medical Patient
Primary assessment
Patient alert; no life-threatening problems
Secondary assessment
History of present illness
Past medical history and physical exam
Vital signs
Transport
Points to Emphasize: The assessment of a medical patient will vary, depending upon the status of the patient and his ability to communicate. In a conscious medical patient, assessment will focus on chief complaint, history of the present illness, and past medical history.
Discussion Topic: Describe the assessment of a conscious and responsive medical patient.
Knowledge Application: Have students work in groups, using programmed patients to complete various medical scenarios.

27. Unresponsive Adult Medical Patient
Primary assessment
Patient not alert; ABCs compromised
Rapid physical exam
Vital signs
Past medical history from family
Transport
Prepared for more detailed exam en route
Point to Emphasize: Physical findings will guide the assessment of the unresponsive medical patient.
Discussion Topic: Describe the assessment of an unresponsive medical patient.
Class Activity: Give students a variety of written medical scenarios as homework. Have them consider the findings and detail the appropriate assessment strategies.
Knowledge Application: Have students design their own customized medical assessment skill sheet/memory prompt. Discuss the elements that they must include.
Critical Thinking: Describe how a pediatric patient might change a medical assessment.

28. Activity
-You will now practice assessing a conscious medical patient (your partner will have a script) using the OPQRST and SAMPLE acronyms. Make sure you use open ended questions. -You will also perform a focused physical exam based upon your results and obtain a set of baseline vital signs while I observe. Exit ticket: Individually answer the questions What assessments would you perform for a person complaining of chest pain? Give an example of an open ended question.

29. Chapter Review

30. Chapter Review
The history and physical exam of the medical patient takes two forms, depending on whether the patient is responsive.
continued

31. Chapter Review
You assess the responsive patient by getting a history of the present illness and a past medical history, then performing a physical exam of affected parts of the body before getting baseline vital signs.
continued

32. Chapter Review
Since unresponsive medical patients cannot communicate, it is appropriate to start the assessment with a rapid physical exam. Baseline vital signs come next, and then you interview bystanders, family, and friends to get any history that can be obtained.
continued

33. Chapter Review
You may not change any field treatment as a result of the information gathered here, but the results of the assessment may be very important to the emergency department staff.

34. Remember
Determine if the patient is responsive enough to provide a history.
If a patient cannot provide a history, can someone present at the scene do so?
continued

35. Remember
Consider what kind of history and physical exam the patient’s chief complaint suggests.

36. Questions to Consider
Explain how and why the history and physical exam for a medical patient differs from the history and physical exam for a trauma patient.
Talking Points: The history and physical exam of a trauma patient focuses on injuries and, in particular, the mechanism of injury. In a medical patient, the history and physical exam focuses on the chief complaint and the events and past medical history that contributed to today’s event.
continued

37. Questions to Consider
Explain how and why the history and physical exam for a responsive medical patient differs from the history and physical exam for an unresponsive medical patient.
Talking Points: A responsive medical patient will be able to communicate and therefore the assessment will focus on the chief complaint. In an unresponsive medical patient, the assessment will focus on physical findings.

38. Critical Thinking
You are trying to get information from the very upset son of an unresponsive man. He is the only available family member. He is so upset that he is having difficulty talking to you.
continued

39. Critical Thinking
How can you quickly get him to calm down and give you his father’s medical history?
Talking Points: Speak in calm tones. Use calm body language. Explain the importance of gathering history and the relevance of the history gathering to the wellbeing of the patient.

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