Respiratory
The Paramedic starts by inspecting the patient for respiratory effort and cyanosis. As previously discussed, findings of severe respiratory distress are significant and require rapid intervention.
Figure 16-27 Assessment of a patient with the chief concern of chest pain.
Also note if the patient appears to be tiring. As the respiratory distress progresses, the patient will begin to grow weary of breathing. Immediate intervention at this point with airway management is key to preventing respiratory arrest. One additional feature to assess is the tracheal position. Tracheal position is assessed just above the sternal notch (Figure 16-28). Normally, the trachea is found in the center of the neck, centered in the sternal notch. Deviation of the trachea toward one side can indicate conditions that cause a shift of the heart and lungs to one side, and is usually a late sign of the condition.
The Paramedic assesses the patient using auscultation to identify normal and abnormal lung sounds as previously described. Rales can indicate a cardiac cause for the shortness of breath while many of the other sounds indicate a respiratory cause. As previously described, a hyperresonant percussion note can indicate a pneumothorax while a dull percussion note can indicate fluid or pneumonia if present in one lung field. When palpating the chest, ask the patient to speak. Vibrations palpated on the chest wall that occur with speech are called tactile fremitus, and can also indicate an infective process in that portion of the lung. These abnormal vibrations are produced as the vocal sounds are transmitted into the lung and are altered in the area of the infection, causing a vibration that can be palpated over that portion of the lung.
Figure 16-28 Assessing for tracheal position.
Cardiovascular
The Paramedic should inspect the patient for an elevated jugular venous pressure and the presence of peripheral edema. These may indicate a cardiac cause for shortness of breath. The Paramedic then auscultates the heart sounds for the presence of additional heart sounds and murmurs. These may also indicate a cardiac cause for the shortness of breath. Finally, the Paramedic assesses the peripheral pulses and capillary refill to determine the patient’s perfusion. Poor perfusion with a lack of oxygen to the body’s organs can produce the sensation of shortness of breath without respiratory disease.
Neurovascular
The Paramedic assesses the patient’s mental status to determine the level of alertness. As respiratory distress worsens and the patient becomes tired, the patient’s mental status will begin to decline.43 This can result from lack of energy, but also may be due to the buildup of the blood’s carbon dioxide (CO2) level. Patients in respiratory distress use more energy to breathe, thus producing more CO2. As the level of distress increases, the ventilation becomes poorer and the patient is not able to exhale the CO2 that is produced. The CO2 levels increase in the blood. When the CO2 levels become high enough, the patient’s respiratory drive and mental status is further depressed, again impairing the patient’s ability to remove the CO2 from the blood. This cycle continues until the patient becomes unconscious and develops respiratory arrest. Patients with a chief concern of shortness of breath who have an altered mental status require aggressive airway management and ventilatory support in order to halt this dangerous cycle.
Put It All Together
The assessment of a patient presenting with the chief concern of shortness of breath includes many possibilities (Figure 16-29).
Abdominal Pain
Sorting out the cause of abdominal pain is challenging as the abdominal cavity contains many organs with a multitude of causes for pain. There are many conditions that cause abdominal pain; some are life-threatening while others are not. Following is the physical assessment for a patient who has a chief concern of "abdominal pain."
Gastrointestinal
The focused examination of a patient with the chief concern of abdominal pain begins with an examination of the gastrointestinal system. The abdomen is inspected for distention, or protruding of the abdomen past its normal size (Figure 16-30). Localized protrusions at the umbilicus or in the midline of the abdomen may be a hernia, or openings in the muscle and tissue layers that allows the intestines to protrude through the opening. The abdomen is also inspected for prominent surface veins, especially around the umbilicus, that may indicate a history of liver failure. The skin is also inspected for jaundice, a yellowish hue of the skin, which can indicate liver failure or obstruction of the bile duct (Figure 16-31). Ecchy-mosis, or bruising, may also be present in several locations on the abdomen, including the umbilicus, the flanks, or across the lower abdomen, and can indicate internal bleeding from either a medical condition or traumatic injury.
The bowels produce sounds from the rhythmic movement of material through the gastrointestinal tract. These sounds can be auscultated by the Paramedic and may provide some clue as to the cause of the patient’s abdominal pain. Bowel sounds are generally softer pitched gurgling sounds as compared to lung sounds and may be difficult to hear in the prehospital environment.44 In order to declare bowel sounds completely absent, the Paramedic would be required to listen for sounds for approximately three minutes, which is not realistic in the prehospital environment. High-pitched, loud sounds that sound like water dripping may indicate a bowel obstruction.
The Paramedic can also assess the abdomen using percussion. The percussion note over the liver and spleen, which are solid organs, should be dull. The percussion note over other parts of the abdomen should be a normal sound similar to that of the lung. If the abdomen is distended, a percussion note can help differentiate between a fluid-filled abdomen and an air-filled abdomen. If the distended abdomen is distended with ascites, or fluid, the percussion note will be dull. If the distended abdomen is filled with air, as in the case of a bowel obstruction, then a tympanic percussion note will be heard. Tenderness with percussion over a portion of the abdomen may indicate irritation of the peritoneum, the inner lining of the abdomen. Irritation of the peritoneum can occur with infection, inflammation, or blood in the peritoneal cavity. Finally, costovertebral angle tenderness, also known as CVA tenderness, can indicate kidney irritation from a kidney stone or infection. The costovertebral angle is located over the lower ribs just medial to the posterior axillary line (Figure 16-32).
Figure 16-29 Assessment of a patient with the chief concern of shortness of breath.
Figure 16-30 Abdominal distention.
Figure 16-31 Jaundice of the skin and scleral icterus.
Figure 16-32 Percussion of the costovertebral angle.
Two different methods are used to divide the abdomen. One method utilizes quadrants and the other method uses "nines." Quadrants are made by running both an imaginary vertical line and an imaginary horizontal line through the umbilicus (Figure 16-33a) such that there are four quadrants. Nines are made by dividing the abdomen into three horizontal sections and three vertical sections, similar to a tic-tac-toe board (Figure 16-33b) such that there are nine sections. Either method is acceptable. When the abdomen is divided up into quadrants, findings correspond to the quadrant where the finding was discovered. The Paramedic should decide which method to use and stick with it. Each section should be palpated at least one time by applying gentle, but firm pressure with one hand while the other hand lies on top and helps guide the first. Rebound tenderness is tenderness that becomes worse when the pressure is suddenly released during palpation and may indicate irritation of the peritoneum. Rovsing’s sign is pain in the right lower quadrant that occurs when the left lower quadrant is palpated.Murphy’s sign is right upper quadrant tenderness that worsens when the patient takes a deep breath while the quadrant is palpated and may indicate gallbladder inflammation.
In addition to looking for tenderness, the abdomen is palpated to detect masses. An abdominal mass is a general term used to describe an abnormally firm area of the abdomen. Masses can be tender or nontender, firm or soft, or pulsatile. Pulsatile masses in the setting of hypotension raise concern for vascular rupture of the abdominal aorta. Protrusions through the patient’s midline are likely related to a ventral hernia.
Cardiovascular
A limited cardiovascular examination is performed in patients with a chief concern of abdominal pain. For patients who have epigastric pain, the Paramedic should be diligent and perform a more extensive cardiovascular examination.45
Inspect the patient’s skin for color and perfusion. Auscultate the heart for heart tones and murmurs. Palpate the extremities for equality of the pulses, especially in the lower extremities that may indicate a vascular problem with the abdominal aorta. When the abdomen is palpated, also assess the patient for hepatojugular reflux.
Put It All Together
The assessment of a patient presenting with the chief concern of abdominal pain includes many possibilities (Figure 16-34).
Figure 16-33 Abdominal territories. (a) Quadrants. (b) Nines.
Figure 16-34 Assessment of a patient with the chief concern of abdominal pain.
Syncope
Syncope is a transient loss of consciousness that resolves spontaneously. Near syncope is the feeling that one is going to pass out, although one does not actually lose consciousness. Though these are two separate conditions, both are treated the same in regard to assessment and treatment. While there are many causes of syncope—ranging from benign to life-threatening— the Paramedic should focus her examination on the more life-threatening ones. Following is the physical examination of a patient with a chief concern of syncope or near syncope.
