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 SAMPLE History and Vital Signs Formulate The Index Of Suspicion

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.

The Focused Physical Exam Is Based On The Index Of Suspicion

The focused physical exam is the part of the exam where the medics assess the patient’s complaint or confirm their index of suspicion. If the patient says their arm hurts, the medics look at their arm. If the patient says their leg hurts, the medics look at their leg. It’s that easy. If the the question is what should the medics be looking at? The answer is where the patient told them or where the patient’s story points to.

The focused physical exam is tailor made to the patient’s complaint. There are a number of physical examinations used in medicine. The focused physical examination at it’s most basic and core level can be said to be comprised of 4 different techniques:

• Inspection (looking at the body) – This can mean looking for specific injuries or just comparing one ankle to the other.
• Palpation (feeling the body with fingers or hands) – Palpation can be used to feel for something specific (like subcutaneous emphysema) or just assessing the patient for tenderness (pain upon palpation).
• Auscultation (listening to sounds) – Medics can use the practice of auscultation to differentially diagnose a variety of respiratory conditions.
• Percussion (producing sounds, usually by tapping on specific areas of the body) – Medics can use percussion to determine if there is fluid or air trapped in a body cavity. This practice is used to check for trapped air in the thoracic cavity and can help confirm the suspicion of pneumothorax.