Examination Matrix
An examination matrix (Table 16-5) provides a guide to the systems the Paramedic should assess based upon the patient’s chief concern. The table is divided into columns that indicate the primary system to focus upon during the exam, as well as a secondary and a tertiary system to include in the examination. The primary system is most closely associated with the conditions that produce the chief concern listed in the first column. The secondary system is also associated with conditions that can produce that chief concern, but not as closely. The tertiary system generally can be affected by disease conditions from the other systems that cause the chief concern. For example, the chief concern of shortness of breath has the respiratory system as its primary system. However, cardiovascular conditions (e.g., angina) can cause shortness of breath. The cardiovascular system is listed as the secondary system. The neurological system may have findings associated with shortness of breath, so it is listed as the tertiary system in the matrix under the shortness of breath chief concern.
As previously discussed, this matrix should be used to guide the Paramedic’s focused physical examination based upon the patient’s chief complaint. The systems and features examined in a specific patient may be different based upon the history obtained from the patient as well as the Paramedic’s findings.
General Exam
During the overall scene assessment, the Paramedic assesses the scene to determine and call for appropriate resources to handle the situation. On each individual patient, the goal of the primary assessment is to rapidly detect and treat any life-threatening conditions (e.g., inadequate respirations, shock, or massive bleeding). Triage algorithms based on the primary assessment exist to help the Paramedic treat and transport patients in order of severity.
Once the primary assessment is completed, the focused assessment follows. As part of the focused physical exam, some general features should be assessed for every patient. These features include vital signs, appearance, and the scene. All three of these features are part of the Paramedic’s initial impression; an assessment of these features should be performed during every single patient encounter.
The constitutional examination consists of the assessment of the patient’s vital signs. At a minimum, this includes the blood pressure, pulse, and respirations. The Paramedic should obtain a baseline set of vital signs on every patient after completing the primary assessment. A room air pulse oximetry reading should also be obtained on patients with chief concerns that involve the respiratory system. If a thermometer is available, the patient’s body temperature can be assessed. The patient’s approximate weight is also important in determining medication dosages for certain medications. At least two sets of vital signs should be taken during every patient encounter as an assessment of stability and to identify changes during treatment.
The patient’s appearance can also provide an indication of her ability to compensate for the disease process. Document the position in which the patient was found (e.g., "seated on the couch" or "supine on the ground 50 feet from the vehicle"). The level of distress experienced by the patient on initial contact should also be noted as part of the constitutional examination. This may include distress from painful conditions or respiratory distress. Skin condition and color can also provide clues toward level of distress and compensation for the disease process causing the chief concern. The patient’s position may provide clues to the level of distress. For example, a patient in severe respiratory distress may be leaning forward in a tripod position to help ease her breathing. A patient experiencing the pain from a kidney stone may not be able to sit still and will pace or roll on the stretcher in an attempt to find a comfortable position.
Observations made about the scene also provide important clues to the Paramedic and the ED staff. During the primary assessment, the Paramedic views the scene for hazards to his health and safety. As part of the focused exam, the scene should be viewed for evidence of the patient’s ability to care for herself. A patient with a disheveled appearance with torn and dirty clothing in an unkempt apartment may not be able to care for herself. Empty pill bottles present at the scene of a patient who has altered mental status may suggest an intentional overdose. For trauma patients, the scene can provide important clues as to the mechanism of injury that can help focus the Paramedic’s examination to areas most likely injured. Position in the vehicle, restraint use, or proximity to hazards all provide the Paramedic with important information.
Chest Pain
Approximately 15 million Americans suffered from cardiovascular diseases in 2004, with half of those people suffering a myocardial infarction.37 Heart disease remains the top cause of death in the United States. Chest pain is one of the more common chief concerns which patients provide to dispatchers during the 9-1-1 call and tell Paramedics during the patient interview. As part of the focused examination, the Paramedic should assess the cardiovascular system as the primary system, and the respiratory, gastrointestinal, and neurological systems as the secondary and tertiary systems. The physical examination elements for a patient with a chief concern of "chest pain" are inspection, auscultation, and palpation.
Cardiovascular System
Inspection of features related to the cardiovascular system starts with an assessment of jugular venous pressure (JVP). The jugular veins run on either side of the neck at an angle from the corner of the mandible to the mid-clavicle on the same side. The jugular veins feed into the large veins that feed into the superior vena cava and into the right atrium. When the heart is not pumping effectively or when the patient has a significant amount of extra fluid in the circulation, the external jugular veins will distend, or stretch and become larger. This can be measured by positioning the patient in a semi-Fowler’s position at approximately a 45-degree angle, asking her to turn her head away from you, and inspecting the external jugular vein for distention (Figure 16-22a).38 It can be helpful for the Paramedic to shine a penlight perpendicular across the vein to improve visualization. In a patient with a normal jugular venous pressure, the external jugular vein will be distended about three centimeters above the sternal notch. Distention greater than three centimeters above the sternal notch is considered an elevated JVP (Figure 16-22b).
Inspect the patient’s extremities for peripheral edema, a condition that also can indicate heart failure. The most common areas where peripheral edema occurs are in the ankles and feet. However, edema can occur up into the thighs and scrotum in males and external labia in females, as well as in the upper extremities. Pitting edema is a term that refers to the amount of indention produced when the edematous limb is pressed over the tibia by the examiner’s finger (Figure 16-23). The level of pitting edema is often described as trace, mild, moderate, or severe based upon the size and duration of the indention.
Auscultation of the heart involves listening to the heart with the diaphragm of the stethoscope in four locations (Figure 16-24). Lightly hold the diaphragm of the stethoscope against the chest for approximately 20 seconds in each area. The normal sounds heard at these locations correspond to the heart valves closing during the contraction and relaxation phases of the heart. The two normal heart sounds are called the S1 and S2 sounds (Figure 16-25a). The S1 sound corresponds to the closing of the mitral and tricuspid valve at the beginning of systole, or ventricular contraction. The S2 sound corresponds to the closing of the aortic and pulmonic valves at the end of systole, marking the beginning of diastole, or ventricular relaxation and filling. Two extra heart sounds, S3 and S4, are diastolic sounds that occur with changes in ventricular filling (Figure 16-25b). When either sound is present it is often called a gallop, as the combination of the normal and extra sounds produces a galloping rhythm, similar to hearing a horse gallop. The S3 sound is sometimes normal in children and young adults as the heart fills quickly. In patients with a chief concern of chest pain or shortness of breath, it can indicate fluid overload associated with heart failure. The S4 sound occurs close to the S1 sound and can indicate the ventricles are stiff and are not filling properly.
Figure 16-22 (a) Patient positioning for evaluation of jugular venous pressure. (b) Elevated jugular venous pressure.
Figure 16-23 Assessment of the severity of peripheral edema.
Figure 16-24 Locations for auscultation of heart sounds. A = aortic area. P = pulmonic area. T = tricuspid area. M = mitral area.
Murmurs are abnormal heart sounds produced by turbulent blood flow across the four valves. Different types of murmurs are associated with different conditions and can occur during both systole and diastole. Many murmurs are described as a low pitched "whoosh" sound. This sound is sometimes separate from, and sometimes integrated with, the normal heart sounds (Figure 16-25c). A discussion of all the different murmurs is beyond the scope of this text; however, one that may be clinically important to the Paramedic is the murmur associated with aortic stenosis.
Figure 16-25 Heart sounds. (a) Normal. (b) Extra sounds. (c) Murmurs.
Aortic stenosis is a condition in which the leaflets of the aortic valve become scarred over time and the pathway through the valve narrows. The murmur associated with aortic stenosis is best heard over the aortic area and is a high-pitched, sometimes loud sound that begins just after the S1 sound and runs until just before the S2 sound. This is clinically important because, in patients with severe stenosis, a higher pressure is required to propel blood out of the left ventricle and into circulation. The patient tends to have significant hypertension; however, this hypertension is necessary for the patient to circulate blood. Medications that can lower the blood pressure should be used with caution in patients with a loud murmur from aortic stenosis (one that can almost be heard before the stethoscope is placed on the chest) as that higher blood pressure is essential to maintain circulation.
Another abnormal heart sound that is sometimes heard is called a rub. A rub is a low-pitched, soft scratching sound that occurs at any time during the cardiac cycle and indicates pericarditis, or an inflammation of the pericardial sac that surrounds the heart. The sound of the rub is produced when the inflamed pericardium rubs against the heart muscle during heart contraction or relaxation. This sound can be difficult to hear in the loud prehospital environment.
Several features of the cardiovascular system are assessed by palpation. While auscultating the chest for heart sounds, the Paramedic can spread her fingers out over the diaphragm and simultaneously palpate the chest for a thrill, or vibration of the chest associated with heart contraction. Forceful contractions can produce a significant pounding inside the chest wall, causing a heave. Peripheral pulses are also assessed by palpation for strength and equality in the left and right extremities.
Capillary refill is a measure of the patient’s ability to perfuse the extremities with oxygenated blood. Capillary refill is assessed by squeezing the tip of a digit hard enough to blanch it, releasing it, and then counting the number of seconds for it to return to a normal color. A normal capillary refill is two seconds or less. A delayed capillary refill indicates poor perfusion.39
Blood pressure is normally equal in both arms. If pulses are unequal in both arms, assess the arms for a difference in systolic pressures. A significant difference in blood pressure in both arms can indicate a problem with the aorta.
Respiratory System
Assessment of the respiratory systems begins with inspecting the patient for respiratory effort. Assessment findings that indicate the patient has increased respiratory effort include use of accessory muscles, sternal or intercostal retractions, increased respiratory rate, or tripod positioning. Accessory muscles of respiration include the muscles in the front of the neck. When the patient is in severe respiratory distress, these muscles contract to help lift the upper portion of the rib cage during inspiration (Figure 16-11a). Sternal and intercostal retractions occur when the patient struggles to move air into the lungs (Figures 16-11b and 16-11c). Patients in severe respiratory distress will frequently assume a tripod position where they sit leaning slightly forward resting their hands on their knees (Figure 16-11d) in an effort to improve their ability to inhale.
The patient’s skin and mucous membranes should also be inspected for color. In a well-oxygenated patient, the mucous membranes will be pink. Cyanosis is a bluish hue that develops when the patient develops hypoxemia, or a decreased oxygen level in the blood (Figure 16-26). In patients with a darker complexion, the Paramedic may have to inspect the oral mucous membranes or the nail beds to assess for cyanosis. In severe hypoxemia, the patient’s entire skin becomes cyanotic. The Paramedic needs to intervene rapidly with supplemental oxygen, airway management, and ventilatory support to correct the hypoxemia.
The Paramedic should then auscultate the lungs for lung sounds. Lung sounds should be assessed posteriorly and on both sides of the chest, assessing both the left and right lung at the same level, so that sounds can be compared between the left and right lung. Normal sounds differ depending on the location in the chest. Lung sounds auscultated over the peripheral, smaller airways are called vesicular sounds, and sound like leaves rustling in the wind. Lung sounds auscultated over the larger airways are called bronchial sounds. These sounds are louder and sound like air rushing through a hollow tube. Normal respiration involves an inspiratory phase that is longer than the expiratory phase. In addition, there is good movement of air in and out of the lungs. Certain conditions cause a prolongation of the expiratory phase. For example, several abnormal lung sounds can indicate specific conditions that help guide the Paramedic toward determining a cause for the patient’s chief concern (Table 16-6).
Figure 16-26 A cyanotic patient.
STREET SMART
To differentiate a pericardial rub from a pleural rub, have the patient hold his breath. Pleural rubs are heard when the patient is breathing while pericardial rubs occur with each heartbeat.
Percussion of the chest can also offer additional information about lung findings (Figure 16-5). One figure is placed against the chest wall in-between two ribs while the other taps the first finger. This should be performed at several levels on both the left and right side of the chest, comparing sides for equality. A normal chest percussion note is a somewhat hollow sound. A hyperresonant percussion note sounds similar to striking a drum and indicates an increased amount of air in the chest. This is often seen with a pneumothorax on the side of the hyperresonant percussion note. A hyporesonant percussion note is dull in character, and often indicates fluid in the lung from either a pleural effusion or hemothorax. Due to noise at the scene of the call, it may be difficult to assess a percussion note until the patient is in the back of the ambulance.
Palpation of the chest is used to assess for stability of the rib cage, tenderness, equal expansion of the chest, and the presence of subcutaneous emphysema. Point tenderness along the rib or sternum may indicate a fracture in the setting of an injury to the chest. Place the hands on either side of the lower rib cage. During inspiration and expiration, the chest should expand equally with inspiration. Subcutaneous emphysema is the presence of air between the layers of the skin and indicates a leak in the respiratory system. Most often this is due to a pneumothorax with air escaping into the skin. At other times, it can occur after a tracheal or larger airway rupture. Subcutaneous emphysema is often described as feeling like bubble wrap underneath the skin. Subcutaneous emphysema can become extensive, traveling up the neck into the face or down the abdomen into the genitals.40
Table 16-6 Abnormal Lung Sounds
|
Sound |
Description |
Conditions Associated |
|
Wheezing |
High-pitched sounds, often heard in inspiration, but can be present on expiration |
Asthma Chronic obstructive pulmonary disease (COPD) Heart failure |
|
Rales |
Crackles similar to Rice Krispies™ crackling in milk |
Fluid in smaller airways Heart failure |
|
Rhonchi |
Coarse crackling in larger airways |
Mucus in larger airways Acute bronchitis Pneumonia |
|
Consolidation |
Bronchial sounds heard over periphery, unequal compared to same field on opposite lung |
Pneumonia |
|
Stridor |
High-pitched inspiratory upper airway sound |
Upper airway obstruction from upper airway edema or foreign body |
|
Absent |
• Specific field |
• Pleural effusion, pneumonia, lower airway obstruction |
|
• Entire lung |
• Pneumothorax, hemothorax, massive pleural effusion |
|
|
Friction rub |
Intermittent coarse rubbing sound similar to sandpaper rubbing with inspiration or expiration |
Indication of inflammation of pleura |
Gastrointestinal
The abdominal exam in a patient with a chief concern of chest pain is limited to assessing for pain and signs of fluid overload related to right heart failure. The abdomen is palpated to assess for tenderness, especially over the epigastrium, which may indicate a gastrointestinal origin for the patient’s chief concern. Hepatojugular reflux is assessed by placing the patient in a semi-reclined position at approximately a 45-degree angle. The jugular vein is first assessed for level of distention (Figure 16-22). The Paramedic then applies firm pressure to the patient’s right upper quadrant over the liver. The hepatojugular reflux is positive if the jugular vein distention increases. This is seen in conditions that cause the patient to become fluid overloaded, including heart failure and kidney failure.41,42
Neurological
The patient’s mental status is the best indicator of the brain’s perfusion with oxygenated blood. All of the body systems are designed to support adequate blood flow and oxygen delivery to the brain. A normal mental status indicates that the brain is receiving a sufficient amount of oxygenated blood. An altered mental status, which may vary from confusion to unconsciousness, can indicate that the brain is not receiving enough oxygenated blood.
Put It All Together
The assessment of a patient presenting with the chief concern of chest pain includes many possibilities (Figure 16-27).
Shortness of Breath
Shortness of breath is another common chief concern of patients calling EMS. Shortness of breath occurs primarily from respiratory causes (e.g., asthma or pneumonia), but can also occur from cardiac causes (e.g., heart failure or angina). The physical exam for a patient with a chief concern of "shortness of breath" is similar to that of patients who have a chief concern of chest pain. However, the emphasis is on the respiratory system.
