1. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 2 Patient Assessment

2. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 2 Physical Exam Techniques

3. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Physical Examination Approach and Overview Overview of a Comprehensive Examination Anatomical Regions Physical Examination of Infants and Children Recording Examination Findings

4. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction The physical examination begins when you first set eyes on your patient. The purpose of the physical exam is to investigate areas that you suspect are involved in your patient’s primary problem.

5. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Physical Examination Approach and Overview

6. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Physical Examination Approach and Overview Topics –Examination techniques –Equipment –The general approach to the patient

7. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Examination Techniques Inspection Palpation Percussion Auscultation These 4 techniques are the foundation of the physical exam.

8. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Inspection Informed observation that allows the paramedic to judge clinical status immediately Consciously evaluate each body area. –Focus on areas of expected signs and symptoms.

9. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Palpation Using your sense of touch to gather information Palpation may be either deep or light.

10. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Percussion The production of sound waves by striking one object against another Resonance –The denser the medium, the quieter the tone –Compare with what you know to be normal May be impractical in the field setting

11. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Auscultation Listening for sounds produced by the body You should perform auscultation in a quiet environment. Listen for the presence of sound. –Intensity, pitch, duration, and quality

12. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Equipment Stethoscope Sphygmomanometer (BP cuff) Ophthalmoscope Otoscope Scale Other

13. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Use a stethoscope to auscultate most sounds.

14. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Sphygmomanometer Measures blood pressure Auscultate movement of blood through an artery Calibrated in millimeters of mercury (mmHg)

15. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Visualize the interior of the eye with an ophthalmoscope.

16. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ An otoscope is used to inspect the ear.

17. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ A Platform Scale

18. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Additional Equipment Sterile tongue blades Penlight Visual acuity chart Reflex hammer Thermometer

19. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Approach How the patient is approached sets the stage for efficient and effective assessment. Systematically assess your patient’s complaints. Maintain a calm, professional, and confident demeanor.

20. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Overview of a Comprehensive Examination

21. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Overview of a Comprehensive Examination The General Survey –Appearance –Measurement of Vital Signs –Additional Assessments

22. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Appearance Level of consciousness Signs of distress Apparent state of health Vital statistics Sexual development

23. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Appearance Skin color and obvious lesions Posture, gait, and motor activity Dress, grooming, and personal hygiene Odors of breath or body Facial expression

24. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Vital Signs Pulse, respiration, blood pressure, and body temperature Primary indicators of your patient’s health Measure early and repeat –Observe trends

25. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pulse A valuable indicator of circulatory function Measure rate, rhythm, and quality. Normal pulse rate for an adult is 60 to 100 beats per minute.

26. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Know each pulse position

27. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Respirations Observe your patient’s respiratory rate, effort, and quality. Observe for subtle signs of distress. Recognize the need for rapid intervention.

28. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Breathing Patterns Associated with Specific Diseases

29. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Pressure Measures the force of blood against the arteries’ walls as the heart contracts and relaxes –Systolic –Diastolic –Korotkoff’s sounds

30. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Blood Pressure Average blood pressure in the adult patient is 120/80. –Hypertension –Hypotension Pulse pressure is the difference between systolic and diastolic. Orthostatic vital signs –May indicate hypovolemia

31. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Body Temperature Normal body temperature is 98.6°F(37°C). –Hyperthermia –Hypothermia May be obtained orally, axillary, or rectally. –Axillary is the least accurate Thermometers

32. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Use a battery-operated oral thermometer to take the patient’s temperature.

33. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ A Tympanic Thermometer

34. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Additional Assessment Techniques Pulse Oximetry –Measures the oxygen saturation of your patient’s blood. –Normal oxygen saturation at sea level should be between 96 and 100 percent.

35. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Additional Assessment Techniques Several factors affect the accuracy of a pulse oximetry reading: –Reduced blood flow to tissue Hypovolemia, hypothermia –Carbon monoxide (CO) poisoning Causes saturation of hemoglobin with CO instead of oxygen

36. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Additional Assessment Techniques Capnography –Real-time measurement of exhaled carbon dioxide concentrations. –End-tidal CO 2 detector The low CO 2 content of inspired air makes the device purple, whereas the higher CO 2 content of expired air makes it yellow.

37. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Capnography ColormetricElectronic Monitor

38. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Additional Assessment Techniques Cardiac Monitoring –Monitors the electrical activity of the heart in three “leads” or positions Adequately identifies life- threatening cardiac rhythms –12-lead monitors are essential in gathering data to confirm a myocardial infarction. ECG reading does not necessarily correlate with the mechanical function of the heart!

39. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Additional Assessment Techniques Blood Glucose Determination –Procedure takes less than one minute to perform –Read the manufacturer’s instructions carefully

40. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomical Regions

41. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomical Regions Following the general survey, specific systems may be examined in detail. The specific situation, your experience, and common sense will determine whether you conduct a thorough examination.

42. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomical Regions Click here to view an interactive exercise on anatomical landmarks.here

43. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Skin The largest organ in the human body Protects against pathogens, minor trauma, excretion, and maintenance of body temperature Consists of 2 layers that lie atop the subcutaneous fat –Dermis –Epidermis

44. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Skin Characteristics to assess: –Color –Moisture –Temperature –Texture –Mobility and turgor –Lesions

45. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Hair Hair is a tactile sensory organ. Note color, quality, distribution, quantity, and texture. May indicate a pituitary or hormonal problem

46. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Nail Inspect and palpate the fingernails and toenails. Observe the color beneath the transparent nail. Look for lesions, ridging, grooves, depressions, and pitting.

47. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Head The scalp consists of 5 layers of tissue: – Skin – Connective tissue – Aponeurosis – Loose tissue – Periosteum Extremely vascular

48. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Skull Consists of the cranium and the face Bones of the skull fuse at their sutures. Bones of the face have sinuses.

49. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Skull The Cranium –Palpate from front to back. –Examine the skull when you inspect and palpate the scalp and hair.

50. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Skull Facial Bones –Inspect the face. –Observe the bony orbits of the eye. –Palpate the facial bones for stability. –Evaluate the TMJ.

51. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Eyes The eye consists of internal and external structures. The internal eye consists of the sclera, cornea, iris, lens, and retina. –The opening in the center of the iris is the pupil.

52. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Eyes The external eye consists of the eyelid, conjunctiva, lacrimal gland, ocular muscles, and the bony skull orbit.

53. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Eyes Examining the Eye –Test for visual acuity. –Test the visual fields. –Examine the external eyes. –Inspect each cornea for opacities. –Inspect the size, shape, and symmetry of the pupils. Assess reactivity

54. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Eyes Ophthalmoscopic Exam –Requires a significant amount of practice to master this physical exam skill

55. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Eyes Ophthalmoscopic Exam –Red reflex –Optic disk should appear as a yellowish orange to pink round structure. © James P. Gillman/Phototake

56. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Ears Three Components: –The outer ear –The middle ear –The inner ear

57. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Ears Examine the External Ear. –Inspect: Size Shape Position Lesions –Palpate : Mastoid process Tragus

58. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Ears Visualize the interior ear with an otoscope. –Auditory canal –Tympanic membrane Color Integrity Landmarks

59. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Examining the Ear Click here to view a video on ear examination.here

60. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 2: Patient Assessment, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ View Through the Otoscope © ISM/Phototake