Conduct your physical exam in a systematic manner starting at the top and working your way down (a neck-head-to-toe exam). Keep the chief complaint in mind as you inspect and palpate each region of the body. Look for:
Bleeding
Signs of shock such as poor skin signs or sustained tachycardia
Pain and tenderness
Limited movement
Deformity or angulation
Discoloration
Swelling
Crepitus
Absence of distal circulation, motor function or sensation
You should also document baseline vital signs.
When there is a significant MOI or an obvious significant injury, immediately perform a rapid trauma survey to assess for life-threatening injuries. If time permits, you may conduct a detailed physical exam while en route.
Always consider the possibility of a head or spinal injury when the head is involved and the MOI is significant.
EMTs are not expected to make an accurate diagnosis in the field. The language that you use in your report will reflect that
your assessment is only an impression based on the evidence you collect (for example, MOI, chief complaint, signs and symptoms). Here are some terms that
may help you in documenting your assessment.
It is often difficult to distinguish sprains and strains from dislocations. Keep in mind that dislocations are serious injuries that
require prompt attention.
