Evaluation of a Medical Patient: The Secondary Assessment

By Marven Ewen, MD
Medical Director

The purpose of the Primary Assessment (aka Primary Survey or Initial Assessment) is to determine the nature of the primary complaint and rule out, prioritize, and treat any immediate life-threatening airway, breathing and circulation problems. The purpose of the Secondary Assessment is to fill in gaps in your understanding of the patient’s condition that did not become apparent in the Primary Assessment. There may be associated conditions that are present that the patient has not volunteered to tell you in the Primary Assessment because the patient didn’t think it was significant or related.

 

My approach to the Secondary Assessment is to simply collect information about the patient in a head-to-toe direction. You will examine and inquire at each level, thereby combining a review of systems and physical exam at the same time. Having a systematic approach that you do the same way with every patient will make you more efficient and accurate.

 

Here is the Secondary Assessment step-by-step with the physical exam and review of systems for each area in both video format as well as the written steps below the video. This is a basic screening history and exam that can be done very rapidly. It is not meant to be comprehensive for each system. When a complaint pertains to a particular system you would do more on that particular system than what I list here. I have included in brackets the relevant systems you are examining in each area.

Head (Neuro, integumentary, GI, Respiratory) Exam:

 

– Orientation questions
– Facial symmetry (both sides of the face moving symmetrically)
– Speech (clear or slurred).

 

SKIN: Color/temp/condition – flushed vs pale, dry vs diaphoretic, rashes.

NOSE: Just note bleeding or drainage.

EYES: Color of sclera (yellow=Jaundice), pupil size (do they look abnormally small or large? Are they symmetrical?), and light reactivity (look for symmetry of extraocular movement of the eyes also while you are evaluating the patient). Just be observant.

MOUTH: Have patient say ‘ah’ and shine your pen light to see color and level of hydration of mucus membranes, size of tongue and symmetrical movement of tongue and throat, state of their teeth.

Head (Neuro, GI, Respiratory) History: Do you have a headache or dizziness? Have you had any changes in your vision recently? Do you have any pain or swelling in your mouth or throat?

Neck (Integument, Vascular, Endocrine) Exam: Inspect for rashes, swelling, asymmetry.

Neck (MSK, GI) History: Do you have pain in your neck or problems swallowing?

Chest (Respiratory) Exam: Auscultate chest, back first then front, working from your left to right; note also any tenderness when you place your stethoscope. Always compare air entry side to side.

Chest (Respiratory) History: Does it hurt to take a breath? Are you short of breath? Do you have a cough?

Heart (Cardiovascular) Exam: Auscultate heart (if you did the chest exam in the order I recommended, you would find your stethoscope near the heart after finishing listening to the lungs).

Heart (Cardiovascular) History: Do you have chest pain or funny beating of the heart?

Abdomen (GI, GU) Exam: Inspect for obvious asymmetry or masses (does the patient’s abdomen look pregnant? Or distended?); lightly palpate the abdomen once in all 4 quadrants (is it soft and non-tender?).

Abdomen (GI) History: Do you have any abdominal pain? Have you had any constipation or diarrhea? Have you had any black stools or blood in your stools?

Pelvic (GU) Exam: You don’t need to examine the genital area unless there is an injury to the area or a pregnant female feels the urge to push – your abdominal exam would have alerted you to possible pelvic pathology when you palpated the lower abdominal quadrants

Pelvic (GU) History: Have you had any pain or difficulty with urination?

Upper Extremities (Integument, Cardiovascular, Neuro, MSK) Exam: Inspect skin for rashes, check both radial pulses at the same time to be efficient, and ensure pulses are not only present, but equal, side to side. While you are doing this ask the patient if he can feel you doing this. Then ask the patient to raise his hands a few inches and open and close his hands. Note any weakness, tremor or complaints of pain.

Upper Extremities (MSK, Neuro, Integumentary) History: Do you have any pain, swelling or weakness of your arms or hands? Are you itchy?

Lower Extremities (Integumentary, Cardiovascular, MSK, Neuro) Exam: Inspect ankles for rashes or swelling (edema). Check both posterior tibial pulses at the same time to be efficient and ensure pulses are not only present, but equal, side to side. (Note that palpation of posterior tibial pulses can be difficult. Don’t waste too much time on this if you can’t find them. If you really need to know if the patient has pulses down there, you could ask the patient to remove their shoes and check for the Dorsalis Pedis pulses. However, be aware that around 15% of the population do not have palpable Dorsalis Pedis pulses.) As you do this ask the patient if he can feel it and if he is tender. Then gently squeeze both calf muscles for tenderness. Ask the patient to wiggle his feet.

Lower Extremities (MSK, Cardiovascular) History: Do you have any pain or swelling in your legs or feet?

This seems like a lot to do, but in fact it takes longer to read it than actually do it. You should be able to do a secondary assessment in 1-2 minutes. The key is to practice doing it the same way every time so it becomes automatic. Also practice verbalizing what you are doing so your NREMT examiner knows what you are observing.

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