The focused history and physical exam answers the question, “why am I here?”

When the EMS crew is confronted with a patient who has a medical problem but there is no mechanism of injury, the medics have to figure out the complaint and formulate a differential diagnosis. A differential diagnosis is a temporary or working diagnosis. The differential diagnosis for EMS is always based on a high index of suspicion (awareness and concern for potentially serious underlying and unseen injuries or illness) of the worst diagnosis that could be causing the patient’s problem. So if a patient is complaining of slurred speech, the working or differential diagnosis should be stroke.

The public calls 911 for a variety of reasons, many of which would not be classified as an emergency (or even a medical) problem. For these calls the focused history and physical exam provides a pattern of behavior that the ambulance crew can employ to determine the patient’s problem. The focused history and physical examination can be performed on scene or enroute to the hospital (whatever makes sense). There are always 3 steps to this assessment; SAMPLE history, vital signs, and a focused physical exam.

SAMPLE history

The interview is always the same and follows a set pattern of questions. Questions that occur to the ambulance crew after this conversation would be referred to as a follow up question.

• Subjective – This is the patient’s chief complaint as defined in terms of onset, provocation, quality, radiation, severity, and time. The patient says they have chest pain, then the medics ask about OPQRST (onset, provocation, quality, radiation, severity, and time).
• Allergies – The patient is probably allergic to a medication. Having a drug allergy means that when the patient takes the medication they have an allergic reaction. Many patients will confuse a medications side effect with an allergy. Not a problem for the ambulance crew. Simply write down the allergy and what happens when they take the medication.
• Medications – Patients are prescribed numerous medications. The EMS crew should write down each medication, the dosage for each mediation, and how many times they take the medication per day. Having a good list of medications is important to the rest of the health care team.
• Previous medical history – Inquire about the patient’s medical history. What medical conditions are they being treated for? What surgeries have they had? Is the patient undergoing some sort of holistic health treatment such as exercising, special diet, or fasting?
• Last meal or oral intake – What was the last thing the patient ate. It doesn’t make that big of a deal most of the time, but if the patient needs surgery, the anesthesiologists are definitely going to want to know.
• Events preceding the complaint – What was the patient doing before they started experiencing the pain that led them to call 911?

Any question formulated after having this conversation would be referred to as a follow up question. Examples of follow up questions could be:

• Do you have any plans to kill yourself?
• Did you go back to the same doctor after the incident?
• Have you ever eaten octopus before?

Vital signs

Vital signs are consistent physical assessment that are performed on all patients. Vital signs form the basis of determining a patient’s health and are used in all venues of medicine. Vital signs are commonly thought to be the following:

• Respiratory rate – A rapid respiratory rate usually indicates respiratory distress and the need to administer oxygen. Patients with noticeable work of breathing or inability to speak in complete sentences indicates a patient who is having problems breathing and needs immediate oxygen therapy.
• Pulse rate – Minimally, the presence of a radial pulse indicates that the patient has a blood pressure that is sufficient enough to result in distal circulation, and by extension perfusion to the distal extremities. The absence of a radial (or otherwise distal) pulse usually means that the patient’s blood pressure is insufficient to perfuse the patient’s extremities. The finding of no radial pulse usually means the patient is in shock, a condition where the patient’s blood pressure is insufficient to result in distal perfusion. The finding of shock should be treated immediately with oxygen therapy, preventing heat loss (with a blanket), and elevating the extremities (when possible). A rapid resting heart rate indicates the patient is in distress or is compensating for shock (hypoperfusion).
• Blood pressure – The measurement of blood pressure is a tried and true assessment technique that not only assesses the circulatory system’s ability to perfuse the distal extremities, but gives the EMS crew a number. The measurement of blood pressure provides 2 numbers for evaluation; a systolic and diastolic measurement. The circulatory system of the body is unique in that the pressure in the arteries are always changing. There is a residual pressure (diastolic) that indicates the pressure between heart beats and a systolic pressure that reflects an increase in pressure that results when left ventricle pumps blood to the body. This oscillating pressure caused by the contraction of the left ventricles creates a wave of blood flow that overcomes all the resistance created by thousands of tiny blood vessels. A properly sized blood pressure cuff is placed on the patient’s arm and inflated until the blood flow stops. When the blood flow stops, now sounds will be heard through the stethoscope (placed on the artery below the blood pressure cuff). When heart beats are heard in the stethoscope, this marks the systolic blood pressure. The medic will continue to listen until the pulse sound trails off (lowers in volume) and mark the number where it completely disappears. This finding marks the diastolic blood pressure.

Focused physical exam

Only after the complaint has been determined and other clues revealed about the nature of the patient’s problem with the SAMPLE history and vital signs, a physical examination based on the complaint is conducted. The physical examination will differ between patients with different complaints, but should generally be the same for patients with similar complaints. Common complaints and a physical examination that should be performed are below:

• Shortness of breath – Auscultation of breath sounds
• Dizziness – Assess the patient’s blood glucose level
• Leg pain – Visual inspection of the affected and unaffected leg
• Abdominal pain – Visual inspection and palpation of the abdomen
• Slurred speech – Performance of the Cincinnati Prehospital Stroke Scale and assessment of the patient’s blood glucose level to determine if the patient is experiencing a stroke.

It is impossible to come up with an assessment for all the various complaints an ambulance crew will encounter during a normal shift. There are always 4 basic principles of physical examination that could be employed based on the patient’s complaint:

• Inspection – Look at the affected area
• Auscultation – Listen to the affected area with a stethoscope
• Palpation – Touch the affected area to see if it is rigid, distended, or tender
• Percussion – Not the most useful, but tapping on an affected area to see if the response is hyporessonate, hyperresonate, or normal (low pitched sound, high pitched sound, or normal).

The focused history and physical exam can only be performed on patients who are conscious

Most patients encountered by EMS are conscious and are able to explain their problem to the rescuers when the arrive. As such, the focused history and physical exam can really only be performed on a patient that talk (or can be relayed by family members or bystanders). When a patient is unresponsive, EMS must be concerned about the possibility of injuries and the need to look for injuries. Obviously, if the ambulance crew knew why the patient was unresponsive, the need to look for injuries could be mitigated.