* Learning To Perform a Medical Assessment - Part 2: Objective Findings - Examining the Patient *
By: Haumana
19 February 2005

Learning To Perform a Medical Assessment - Part 2: Objective Findings - Examining the Patient

Here’s a review of the SUBJECTIVE part of the medical assessment in an easy to follow format (from Part 1 of this series):

Rapid Initial Assessment: “How are you feeling?” A - Airway is open an the neck (cervical spine) is stabilized B - Breathing is present with normal depth, rate and pattern C - Circulation: Heart is present and functioning and there is no significant bleeding D - Disabilities: Can use the same number of extremities as they usually do and their mind is working (they are alert and can answer questions and follow commands) SAMPLE - OPQRST S- Signs and symptoms of Present Illness/Injury:

A - Allergies or adverse reactions to medications, foods, etc? M - Medications - current and recent P - Past Medical History: L - Time of last food or drink E - Events and environment related to injury or illness Family History Social History Review of Systems

Some of you may have the idea that all of this is done sequentially. Not necessarily. The ABCD’s are objective, but you got them out of the way (hopefully) with the question “How are you feeling?”

Now we’re going to take a look at the OBJECTIVE portion of the medical assessment and we are going to try to keep it as basic as possible. In Rescue and Paramedic units, there is a mnemonic that we will modify slightly and use as an aid, but first, you must understand that the physical examination should be done in a certain order:

  1. Inspection/Observation - What you see.
  2. Auscultation - What you hear.
  3. Palpation - What you feel.

The modified trauma mnemonic that we will use to evaluate many of the body areas is DCAP-BTLS Deformities and Decreased motion Contusions or other abnormal Colorations Abrasions Punctures, Penetrations Burns, Bleeding Tenderness & Temperature Lacerations Swelling

How does it work? Let’s continue with our patient with knee pain.

First you take as many vital signs as you know that you can do correctly. Everyone should be able to use a thermometer and count how many times the patient breathes in 60 seconds. Can the patient stand on scales? If so, you now only need to learn to correctly take a pulse and a measure a blood pressure and you will be doing more vital signs than many doctors. While you’re doing the vital signs, use some of the time to observe the patient and to ask questions from the SUBJECTIVE portion of the medical assessment. Many people seem to think that an ideal time to ask things is when there is a thermometer in the mouth (that’s a joke, by the way--the information yield of this practice is low).

Observe the General Appearance of the patient. Are they alert and aware of the time, place and situation? Do they appear comfortable or uncomfortable? Are they looking pretty stable (“no acute distress”) or do they look as though they may die if something isn’t done soon?

Now look at the knees (both the “good” one and the “bad” one). Use the DCAP-BTLS to evaluate them. If you need to stop and write what you’ve found, do so. Talk to the patient and ask more questions while you do the exam. This repeats your ABCD evaluation and distracts them so that you can get a more accurate exam.

When you’ve finished examining the knees, examine the joint above them (hips) and the joint below them (ankles). While examining these joints, do a quick survey for any other bone or joint abnormalities.

Can you see how this can be “tweaked” to work on other body regions and organ systems? It doesn’t cover everything that you need to know about physical examination, but if you remember the correct order of Inspection, Auscultation, and, lastly, Palpation along with the mnemonic DCAP-BTLS, you can handle a lot of stuff.

People frequently ask, “How do I know if the breath sounds/heart sounds/abdominal sounds are normal? “Experience” is the answer. You should get a stethoscope and start listening to well people and to people who have known problems (asthmatics who wheeze or known heart murmurs).

Let’s put our medical assessment together:

SUBJECTIVE: Rapid Initial Assessment: “How are you feeling?” A - Airway is open an the neck (cervical spine) is stabilized B - Breathing is present with normal depth, rate and pattern C - Circulation: Heart is present and functioning and there is no significant bleeding D - Disabilities: Can use the same number of extremities as they usually do and their mind is working (they are alert and can answer questions and follow commands) SAMPLE - S- Signs and symptoms of Present Illness/Injury:

A - Allergies or adverse reactions to medications, foods, etc? M - Medications - current and recent P - Past Medical History: L - Time of last food or drink E - Events and environment related to injury or illness Family History Social History Review of Systems OBJECTIVE: #1 - Inspection/Observation - What you see. #2 - Auscultation - What you hear. #3 - Palpation - What you feel. General: Level of consciousness, appearance, uncomfortable or does there seem to be an immanent threat to life or limb (this is called “acute distress”) DCAP-BTLS Deformities and decreased motion Contusions or other abnormal colorations Abrasions Punctures, Penetrations Burns, Bleeding Tenderness & Temperature Lacerations Swelling

If you practice, you should soon be able gather information and do a fairly adequate physical evaluation. What’s the point? Well, it depends on your situation and your medical training and experience. Learn as much as you can and learn what you don’t know. For some of you, it will be a review and for others it will be a strange and awkward challenge. Don’t quit practicing and honing your medical skills and don’t get discouraged and give up. Much of medicine is common sense and, to paraphrase one of the laws from Samuel Shem’s The House of God, to do as much nothing as possible. In a survival situation, some medical texts and this will carry you a ways and, in any situation, being able to perform a medical assessment will serve you well. You might even be better able to communicate with medical personnel. Once again, this article is no substitute for proper training and experience. It is meant to get you started on an important part of medical preparedness and should not be substituted for evaluation by a trained medical professional.
Haumana


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