Unit 3: Secondary Assessment
Patient History & Physical Examination
Understanding a patient’s symptoms and medical history helps EMTs recognize potential emergencies and make informed treatment decisions. This NREMT study guide lesson explains how to obtain a patient history using SAMPLE and OPQRST, perform a focused physical examination, and identify important assessment findings. Review these essential EMT skills, then complete five practice questions with detailed answer explanations.
After identifying and treating immediate life threats during the primary assessment, EMTs gather additional information about the patient’s condition through history taking and a secondary assessment.
The goal is to better understand the patient’s chief complaint, identify relevant medical conditions, and look for injuries or symptoms that may require further treatment.
Obtaining a Patient History
A patient history provides valuable information about the current emergency and any underlying medical conditions.
When interviewing a patient, begin with open-ended questions such as, "Can you tell me what happened?" or "What is bothering you today?"
Listen carefully and ask follow-up questions to clarify important details.
Whenever possible, obtain information directly from the patient. If the patient is unconscious, confused, or unable to communicate, family members, caregivers, or bystanders may provide helpful information.
Two important tools for gathering patient information are SAMPLE and OPQRST.
SAMPLE History
The mnemonic SAMPLE helps EMTs remember the essential information to collect during history taking.
- S – Signs and Symptoms: What symptoms is the patient experiencing? What signs can you observe?
- A – Allergies: Does the patient have allergies to medications, foods, or other substances?
- M – Medications: What prescription medications, over-the-counter drugs, or supplements does the patient take?
- P – Pertinent Past Medical History: Does the patient have any relevant illnesses, previous injuries, or medical procedures?
- L – Last Oral Intake: When did the patient last eat or drink?
- E – Events Leading Up to the Illness or Injury: What was happening before the symptoms or injury occurred?
For example, a patient experiencing difficulty breathing may report a history of asthma and the use of a prescribed inhaler. This information helps EMTs understand the possible cause of the emergency.
A SAMPLE history should be obtained as completely as the patient’s condition allows. Do not delay urgent treatment or transport to finish every question.
OPQRST Assessment
The mnemonic OPQRST helps EMTs gather more detailed information about pain and other symptoms.
- O – Onset: When did the symptoms begin? Did they start suddenly or gradually?
- P – Provocation/Palliation: What makes the symptoms better or worse?
- Q – Quality: How does the patient describe the symptoms? For example, are they sharp, dull, burning, or pressure-like?
- R – Region/Radiation: Where are the symptoms located? Do they spread to another part of the body?
- S – Severity: How severe are the symptoms, often measured on a scale from 0 to 10?
- T – Time: How long have the symptoms lasted? Have they changed since they began?
For example, a patient with chest pain might report that the discomfort began 20 minutes ago, feels like pressure, radiates into the left arm, and has a severity of 8 out of 10.
This information helps EMTs communicate the patient’s symptoms clearly and recognize potentially serious medical conditions.
Focused Physical Examination
A focused physical examination concentrates on the body regions or systems related to the patient’s chief complaint.
For example:
- Chest pain: Assess the cardiovascular and respiratory systems.
- Abdominal pain: Examine the abdomen for tenderness, swelling, or rigidity.
- Difficulty breathing: Evaluate breathing effort, lung sounds, and chest movement.
- Arm injury: Examine the injured extremity for deformity, swelling, circulation, sensation, and movement.
Three important techniques are used during a physical examination:
Inspection
Visually examine the patient for abnormalities such as swelling, bruising, bleeding, unusual movement, or changes in skin condition.
Palpation
Use your hands to feel for tenderness, deformities, swelling, or other abnormalities.
Auscultation
Listen to sounds produced by the body, usually with a stethoscope. EMTs commonly auscultate lung sounds and blood pressure.
These techniques help identify findings that may not be obvious from the patient’s history alone.
Systematic Head-to-Toe Examination
A systematic head-to-toe examination is used when a broader physical assessment is needed, particularly in patients with significant trauma or an unreliable examination.
This approach involves examining the patient for injuries or abnormalities in an organized sequence.
Common areas of assessment include:
- Head and face: Look for bleeding, deformities, swelling, and other signs of injury.
- Neck: Assess for tenderness, wounds, swelling, and other abnormalities.
- Chest: Evaluate chest movement, tenderness, injuries, and breath sounds.
- Abdomen: Check for tenderness, distention, rigidity, and visible injuries.
- Pelvis: Assess for pain, obvious injury, and other concerning findings without repeatedly manipulating the pelvis.
- Extremities: Examine for deformities, swelling, bleeding, and circulation, sensation, and movement.
- Back: Assess for injuries when it is safe and appropriate to do so.
A useful mnemonic for identifying traumatic injuries is DCAP-BTLS:
- D: Deformities
- C: Contusions
- A: Abrasions
- P: Punctures or penetrations
- B: Burns
- T: Tenderness
- L: Lacerations
- S: Swelling
The examination should be adapted to the patient’s condition. Avoid unnecessary movement, particularly when a spinal injury is suspected.
Assessing Patients Who Cannot Communicate
Some patients cannot provide a reliable history because of unconsciousness, confusion, communication difficulties, or other medical conditions.
In these situations, EMTs may obtain useful information from:
- Family members or caregivers.
- Witnesses and bystanders.
- Medication containers or lists.
- Medical identification bracelets.
- Available medical records or transfer documents.
For example, a medical identification bracelet indicating diabetes may provide an important clue when assessing an unconscious patient.
Information from others can help guide the assessment, but it should not replace examination findings or appropriate diagnostic testing.
Documenting Assessment Findings
Accurate documentation allows other healthcare professionals to understand the patient’s condition and the care provided.
Important findings include:
- The patient’s chief complaint.
- Relevant SAMPLE and OPQRST information.
- Positive and negative physical examination findings.
- Information obtained from family members or witnesses.
- Treatments performed and the patient’s response.
Whenever possible, document the patient’s own words when describing important symptoms.
Clearly distinguish between what the patient reports and what you observe during the examination.
Key Tip
Use SAMPLE to gather the patient’s medical history and OPQRST to investigate specific symptoms. Remember that an unstable patient’s immediate treatment and transport take priority over completing a lengthy interview or physical examination.