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

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

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

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

5. 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.

6. 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

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

8. 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

9. 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.

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

11. 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?”

12. 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

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

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

15. 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.

16. 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

17. 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.

18. 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.

19. 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

20. Title - 36
Detail - 24

21. Title - 36
Detail - 24