Rapid vs Detailed vs Focused Exam

[Shog]

I'm really confused by the difference between Rapid Medical Assessment, Detailed Assessment and Focused Exam for a Unresponsive Medical Patient. Can anyone please list the steps for them?

 

[Eltdolly]

With the rapid medical assessment you are looking for DCAPBTLS and it's done within 60 to 90 seconds a focused assessment means you are only focused on the chief of complaint like if the patient tells you where it hurts and so on...

 

[Shog]

So Rapid Medical Assessment is just looking for DCAPBTLS?
If patient is unresponsive then is obtaining chief complaint possible ONLY through Rapid Medical Assessment? If so then just focusing on his chief complaint doesn't seem to make sense since I'll check his whole body anyway during RMS. And what's the Detailed Assessment? I'm sorry that I sound dumb, but I've been trying to figure it out since Friday + studying 2 chapters for exam and I feel like my brain is on a brink of shutting down. :wacko:. Can you post complete step-by-step for these three assessments?

 

[Aprz]

I answered it here a long time ago.

I also wrote a really long thing on the NREMT patient assessment skill here.

Those two threads should definitely answer your question. In the first link, I briefly mentioned what the rapid physical exam is in the very last paragraph, but I'll mention it here too since it can easily be missed. Per the NREMT, a rapid physical exam is a full physical exam excluding the distal extremities. That means you'll check the head, neck, chest, abdomen, pelvis, proximal extremities (upper arm above the antecubital region and the thighs above the popliteal region).

Edit:

So Rapid Medical Assessment is just looking for DCAPBTLS?

No. Typically a rapid physical exam is done because of an unreliable (eg unconscious patient) or significant mechanism of injury (trauma). Head trauma can cause bleeding from the ears, nose, and mouth, cerebrospinal fluid discharge, and unequal pupils. They could have a pericardial tamponade causing jugular venous distention and muffled heart sounds. They could have unilateral chest wall movement, jugular venous distention, tracheal deviation, unilateral dimished breath sounds if they have a tension pneumothorax. Those are examples. There are many things to look for than just "DCAPBTLS".

If patient is unresponsive then is obtaining chief complaint possible ONLY through Rapid Medical Assessment? If so then just focusing on his chief complaint doesn't seem to make sense since I'll check his whole body anyway during RMS.

What's RMS? I am not familiar with that acronym. Their chief complain is none if they are unresponsive. You'd document it as "The patient is unable to give a chief complaint because they are unresponsive". You could say their chief complain is "altered mental status" or "unresponsive", but the first way I mentioned it "Unable to give one because of XYZ" is probably most appropriate.

And what's the Detailed Assessment?

It's a full head to toe. You check everything. A rapid physical exam is a full head to toe without checking the distal extremities.

In your test, it's probably best to tell them what you'd like to do e.g. a focus physical exam or a rapid physical exam, but if time permits during transport while you do your ongoing assessment and reevaluate the patient, you'd do a full physical exam. You could also verbalize in your test "I'd do a rapid/focus exam, which I'd check XYZ, but for testing purposes, I am going to do a full physical exam instead" and then do a full physical, I think that'd be fine too. Probably the best thing to do is when your proctor as you "Do you have any questions", ask them whether if he'd like to see you do a full physical exam or only a rapid/focus exam if appropriate.

Edit: I feel obligated to say this. My answers here are strictly my annotation on the NREMT patient assessment algorithm. There are a lot of posts here in the General Discussion, BLS, ALS, and Scenario section of the forum on patient assessments. The most common book recommended and one I personally recommend is Bates' Guide to Physical Exam & History Taking (I own the 10th edition I think, I've never seen or read the 11th edition that I linked to). The book will way exceed what is expected of an EMT and paramedic.

 

[Akulahawk]

The rapid exam is, for lack of a better description, a very quick check of the patients to determine what, if anything, is going to have massively adverse outcomes for the patient right away. In effect, you are checking for those things that will cause the patient to die right now. This exam is nowhere close to comprehensive. It is, however, a lot more comprehensive than looking for DCAPBTLS.

The focused exam is more specifically focused on what you have identified the problem is. It is a slower and more methodical exam and evaluation of the patient. It can involve a full head to toe evaluation, or it can involve simply one or two body systems. In the medical world, you can think of the focused exam as an H&P. With this type of exams you are looking for more subtle clues to the patient's condition. Some of the problems that you uncover during this exam can kill the patient right away. However, these are the problems that you would probably have missed during the rapid exam. This is because the rapid exam is, well, rapid.

Here's the kicker of the whole thing: the more you know about assessing patients, the more you will pick up on during those exams. When we're doing a rapid exam, you might miss something that I would pick up on, and I might miss something that a physician would pick up on, and that physician might miss something that a specialist physician would pick up on. At the same thing goes for the detailed exams. The more you know, the better you get at it, the more likely it is that you were going to be able to more effectively care for the patient.

One can easily blend into another. I always do some kind of rapid exam on my patients. It can be as simple as "still breathing, noticing I'm in with them, and they're talking to me" and I just have to focus in from there.

 

[Shog]

Thanks for you time Aprz. You've made it much clear. However, I still have some questions. Since Focused Exam FOCUSES on patient's chief complaint how am I going to obtain chief complaint from unresponsive patient? In other words, does Focused Assessment for Unresponsive Patient make any sense? Btw, I made RMS abbreviation from Rapid Medical Assessment to not keep repeating (yeah it should've been RMA, sorry for that).

Head, Eyes, Ears, Nose, and Throat (HEENT): Look for head and facial symmetry, check for blood when palpating, Battle's sign/Racoon eyes, sclera white, pupils 4 mm equal, reactive, round to light 2 mm, and accommodate (look up accommodate, people usually don't know what this is and don't assess it, but they still say it), check for injury or debris in the eyes, contact lenses, cataracts, do they follow movement equally, moist or dry, nystagmus, nasal flaring, singed nares, foreign objects, blood, cerebral spinal fluid (CSF) in nose or ears, burn around mouth (I forget how to word this all of the sudden, what people usually say at least), symmetry of the tongue (are the making an O sign or Q sign? Just kidding... a little), bit tongue, foreign objects or blood in the mouth, oral hydration, and if teeth are intact.

Neck: Trachea midline, subcutaneous emphysema, stoma, medic alert tag, JVD, accessory muscle use (platysmal indrawing or strenocleidomastoid), neck veins distending.

Chest: Supraclavicular indrawing, intercostal retraction, pacemaker/AICD, nitropatch, equal rise and fall, assess breath sounds (bare minimum 2 breadths midclavicular from clavicle and about 6th intercostal space (ICS) midaxillary is what I was taught), excessive chest movement, subcutaneous emphysema also.

Abdomen: Distention. Is it soft and non tender? Pulsating mass (I was told not to touch it if it's pulsating). Palpate in the 4 quadrants or 9 regions (learn the 9 regions if you don't know it, it'll help you relay more exactly where the pain is and better form a differential diagnosis (DDx), which isn't the final diagnosis (Dx) doctors make and not the whole "we don't diagnose" thing). I hear Cullen's sign thrown around and McBurney's point mentioned sometimes.

Pelvis: Urinary/Fecal incontinence, priapism, rectal or vaginal bleeding if applicable.

Extremities: Check for track marks, and assess CMSTP: capillary refill, motor, sensory, temperature, pulse. I've seen a lot of variations of CMSTP e.g. CMS, PMS, etc. A lot of times, C is circulation instead. Look for medical alert tags on wrist and feet. Check for pedal edema at the feet. Sometimes I hear clubbed fingers tossed in. You can toss in equal grip test too and pronator drift if you suspect stroke (palm face up when you have them hold up their hand)s in front of them for 10 seconds and their eyes closed).

Posterior: Symmetry and sacral edema. Breath sounds paravertebral from above the scapula, mid scalpula, and below it I think is the easiest way for me describe it, not over the bone.

Does is mean that the only difference between Rapid Medical Assessment (Rapid Physical Exam) and Detailed Assessment is not checking extremities below the knee and elbow? (I'm not trying to sound like smartarse). Sorry for having such a trouble understanding it. Today my brain accepts only KISS information.

 

[Eltdolly]

Well obviously there's more to look for than just dcapbtls like when you palpate the head you would check for battle signs, raccoon eyes, and other stuff.... When you palpate the neck you would look for jvd, stoma, medical tags alert, tracheal deviation, & so on the list goes on. Perhaps you should ask your instructor to clarify each assessment I wouldn't want to confuse you :/

 

[JPINFV]

...and this is why I hate this "assessment 1, assessment 2, assessment red, assessment blue" junk. Everyone gets a full exam... eventually. It's just a question of prioritizing, and depending on what you find is going to determine that prioritization. Knowing what and how to look is going to change that prioritization further.

 

[Shog]

I guess I'll listen to Eltdolly and just ask my instructor for instructions the way he want them . I'll try to post later what he told me.

 

[Handsome Robb]

Thanks for you time Aprz. You've made it much clear. However, I still have some questions. Since Focused Exam FOCUSES on patient's chief complaint how am I going to obtain chief complaint from unresponsive patient? In other words, does Focused Assessment for Unresponsive Patient make any sense? Btw, I made RMS abbreviation from Rapid Medical Assessment to not keep repeating (yeah it should've been RMA, sorry for that).


Does is mean that the only difference between Rapid Medical Assessment (Rapid Physical Exam) and Detailed Assessment is not checking extremities below the knee and elbow? (I'm not trying to sound like smartarse). Sorry for having such a trouble understanding it. Today my brain accepts only KISS information.

Some may disagree with me but if they're unresponsive that can kinda be inferred as their chief complaint... As far as documentation goes the only difference would be "Upon arrival we find an unconscious xx year old male..." vs. "Upon are we find a xx year old male complaining of xxx..."

I'm not sure how to exactly dumb it down further than it already has been. A rapid exam is exactly that, rapid. It's a quick head to toe looking for obvious life threats that need to be addressed immediately or can give you clues as to why they're unresponsive. For example: Is this person unresponsive because they got shot in the chest? (bullet wounds don't always bleed, externally, as much as you'd think. Do they have a flail chest and they're hypoxic? Maybe they're a diabetic and have a medic alert tag. Speaking of which, I'd include the extremities in their entirety in your rapid exam, generally but not always, medic alert tags are bracelets or anklets so if you stopped at the elbow/knee you may miss them. Think of the rapid exam as a quick "once-over"

While you do your rapid exam your partner can check vitals and you can start delegating treatments to them while you ask bystanders if they saw what happened, if they know him do they know the patient's history, allergies and meds, where they complaining of anything prior to this?

Package him then during transport you repeat your exam only are much more thorough about it, take more time on each body part/system rather than just a quick glance.

Does that make sense at all?

 

[Clare]

I believe you are referring to the primary and secondary survey, while a focused exam to me means like a system specific exam e.g. cardiovascular for somebody with chest pain?

 

[Handsome Robb]

I believe you are referring to the primary and secondary survey, while a focused exam to me means like a system specific exam e.g. cardiovascular for somebody with chest pain?

TomAto, tomAHto.

 

[Clare]

TomAto, tomAHto.

Small round red vegetable with seeds?

No capsicum, I don't mean you!

 

[Aprz]

In what I wrote, I talked about a reliable and unreliable patient. An unresponsive patient is unreliable because they cannot tell you anything. An unreliable patient in the algorithm gets a rapid physical exam, not a focus exam. If you want, I'd consider AEIOUTIPS a focused exam for altered mental status.

A - alcohol/arrhythmia: their breath, bottle, environment (at a bar, club, concert), red skin, nausea/vomiting, frequent urination (polyurea), put them on a 3-lead to see if they are having an arrhythmia reducing blood flow to their brain. Do they have a pulse? Is their pulse rate regular? Is it fast or slow?
E - environment/epilepsy/electrolyte: Where are they at? Have they been taking in fluid? Sports? Do they have a history of seizures? On their 12-lead/ECG, peaked narrow T waves, increase QT, intraventricular conduction delay? Do they have a AV fistula/go on dialysis?
I - insulin: What time is it? Did they take their insulin? What's their blood glucose level? Kussmaul respiration?
O - overdose: pupils pinpoint (miosis)? Slow breathing? (Opiate triad). Correct amount of medications? ECG will signs of electrolyte problems too so 3-lead again. Is their pulse fast or slow? Low blood pressure? Have they been prescribed any new drugs? Has their dose increase?
U - underdose/uremia: Have they been compliant with their meds? Do they have a fistula?
T - trauma: Did they hit their head? Cerebrospinal fluid? Blood? Blood pressure? Pulse present? Equal rise and fall of chest? Etc.
I - infection: Skin signs? Rhonchi? Foley? Are they in a nursing home?
P - psychosis
S - shock/stroke/seizure: Pupils? Cushing triad? History of atrial fibrillation? Regular pulse? Recent surgery? Skin signs? Syncope? Seizure?

There are other variations of that mnemonic I'm sure. You are gonna ask and look for a lot more than what I list. It's unrealistic for me to tell you everything to look for and ask, and some of these you fan only get if time permits.

But like I said, per NREMT, you should be doing a rapid physical exam on altered/unresponsive patients "unreliable".