Personal Assessment

Patient Assesment

By Korinne Janezich

After scene size up, You start your primary assessment, Which leads into more assessments depending on the patients conditions, Start by using SAMPLE and OPQRST to help.

• S- Signs & Symptoms; What do you see? What are they complaining of?
• A- Allergies; Any allergies
• M- Medications- Did or do they take anything
• P- Past medical history- Is this pain normal? Past Surgeries?
• L- Last Oral intake- Last eat or drink?
• E- Events leading up to- What started the pain?

Personal Examples of SAMPLE when obtaining history

• S- I observed the patient has a bump on his head, Patient complains of head hurting

• A- Are you allergies? Are you allergic to any medications?
• M- Are you on any medications? Have you taken anything for the head pain?
• P- Are headache or migraines common for you? How long has that bump been there? How long have you had this bump? Have you seen anyone for this head injury? Do you have any past surgeries and medical conditions?
• L- When is the last time you ate or drank anything? Did you drink anything with any medications? How much water have you drank today
• E- How did you say you got this bump? Did you fall beforehand? How long has that bump been there till you noticed? When did you notice your head start hurting? What were you doing when your head started hurting?

OPQRST

• O- Onset; When did this start?
• P- Provocation; Does anything make the pain better
• Q- Quality; What kind of pain?
• R- Radiation; Does the pain move anywhere?
• S- Severity; Rate the pain 1-10
• T- Time; When did you feel this?

Personal Example of OPQRST

• O- When did you notice the pain started?
• P- Has anything changed since then? Does anything make it better?
• Q- Can you explain what type of pain youre feeling?
• R- Do you feel the pain anywhere else?
• S- Can you rate the pain on a scale from 1-10?
• T- Have you felt this pain before?

Pertinent Negatives

Targeted symptoms towards the injury or sickness, but the patient or test results denies having it.

Example;

Patient States he has

1. Shortness of breath2. Coughing

Patient denies having

• Chest pain
• Anixety
• A fever
• Breathing problems
• Airway restriction

Secondary assessment

A secondary assessment is the assessment after scene size up and the pimary assessment when youre done managing immediate life threating conditions

3 major steps of a secondary assessment

• Conduct a physical exam
• Take vital signs
• Obtain a history

Physical exam on secondary assessment

Always start from the head and assess down to the toes. Assess and check for deformities, punctures, burns, swelling, discoloration in

• Head (Including ears, face, eyes, nose, and neck)

• Chest
• Abdomen
• Pelvis

• Lower extremities (Hip to toe)
• Upper extremeties (Shoulder to fingertip)
• Posterior (Spine and back)

For example;

You and your partner just finished scene size up and the primary assessment, with no life threatening conditions. You start by conducting a physical exam starting at the head ending at the toes. As your assessing, Your patient states his neck is hurting suddenly. You immeditately start to ask questions in regards to SAMPLE in regards to the neck while laying the patient in a supine position. You assess the neck by looking for lacerations, vein distention, swelling, and listening for any sign of airway obstruction and examine the chest closely. If there is no abnormal signs including after checking the patients trachea is staying midline, Make sure the patient is in a supine position, toes are pointed, and apply a cervical collar and transport and finishing the assesment with vitals and obtaining history on the patient.

Found in Book Prehospital Emergency Care (12th edition) Page 379.

All of these steps depend on the patients conditions and needs

Example;

• Trauma or medical
• Responsive or unresponsive
• Serious or minor complaint