The Assessment of the Medical Patient Essential EMS Training Program - Block 2

Introduction In Block 1, Students were introduced to the concept of Trauma Assessment or Head to Toe exam A Medical Assessment will focus on: History taking Medical Assessment skills If a patient is Unresponsive or confused without a known cause: Perform Head to toe Trauma assessment

Important Point The ability to gather a good history lays the foundation for good patient care. .

TOPICS Patient Rapport (establishing a conversation) History Taking Techniques Active Listening The Comprehensive Health History

Before Seeing the Patient Review the Dispatch Information in your Mind to think about possible issues. If a patient’s chart is available, review it before interviewing the patient. Use this information to gain clues about the patient.

The First Impression Present yourself as a caring, competent, and confident health care professional. Dress Professionally, clean, neat Uniforms = good first impression You only get one chance to make a Good First Impression

Build Rapport When you introduce yourself to the patient, shaking hands, Sampi or offering a comforting touch will help build trust.

ASK Questions Use a combination of open-ended and close-ended questions. Open Ended questions, Who, What , when, How, Describe, etc. Closed Ended Questions, Yes - No

Language & Communication Use appropriate language. Keep a neutral Body stance Use an appropriate level of questioning, but do not appear condescending. When encountering communication barriers, try to enlist someone to help. Actively listen.

Elements of a Patient History Preliminary Data (all Patients) Date and time Age Sex Race Birthplace Occupation

The Chief Complaint This is the pain, discomfort, dysfunction that caused the patient to request help. Ask, “Why are you here or why did you call us?”, Ask “Where are you hurting, can you describe or point to it?”

The Present Illness OPQRST-ASPN Onset of the problem Provocative/ Palliative (makes issue better or worse) Quality Region/Radiation Severity Time Associated Symptoms Pertinent Negatives

Past Medical History General state of health Childhood diseases Adult diseases Psychiatric illnesses Accidents or injuries Surgeries or hospitalizations

Current History Current medications Allergies Tobacco Alcohol, drugs (not Medications), and related substances Diet Screening tests Immunizations Sleep Exercise Family History

Patient’s Medications You should take your patient’s medications with you to the hospital, when practical. Medications can quickly tell you what a patient has been treated for previously for. It can give you a faster medical history than asking the patient sometimes. If a patient is taking predominately Cardiac drugs then you know that he has a underlying cardiac problem. Even if the complaint this time is not related to the cardiac history, you knowledge of the history will help you be prepared for associated symptoms.

Review of Systems A system-by-system series of questions designed to identify problems your patient has not already identified. General Skin HEENT Respiratory Cardiac Gastrointestinal Urinary Male/Female genitalia Peripheral Vascular Musculoskeletal Neurologic Hematologic Endocrine Psychiatric

Special Challenges Silence Overly talkative patients Multiple symptoms Anxiety or Depression Sexually attractive or seductive patients Confusing behaviors or symptoms Patients needing only reassurance Anger and hostility Intoxication Crying Language Barriers Silence is when a patient will not speak to you or answer your questions. Often the patient is afraid to answer the questions or has stranger anxiety. If faced with this situation have another same sex caregiver with you in the room . You may need to have family and friends wait outside while you interview the patient. Overly talkative and especially multiple symptom patients can quickly give too much extraneous information that has nothing to do with the present illness.

Special Challenges If the patient cannot provide useful information, gather it from family or bystanders. Sometimes a person is hurting too much, may have dementia , or unresponsive due to drugs and alcohol and cannot answer your questions. Gather the history from family members if they are present. If you are busy with patient care have your partner quickly gather the information.

Summary Preparation is key Rapid initial assessment leads to initial actions Be professional Take a focused history Chief Complaint Present Illness Past history Review of systems

Title - 36 Detail - 24

Title - 36 Detail - 24