Once all the critical issues have been addressed, you can move onto the secondary exam.
Unlike critical first aid where you treat the problems as you find them, with the secondary exam you complete the full assessment and then treat them in order of priority.
The assessment is comprised of three areas, physical exam, SAMPLE history and vital signs. The order in which you do them is dependent on the situation.
While doing your exam let the patient know what you are doing and record your findings.
Use the acronym SOAAP to record your findings.
Subjective information: history, scene, story and symptoms.
Objective information: exam findings, vital signs.
Assessment: all the problems you found.
Anticipated Problems: any problems that may arise.
Plan: what you are going to do.
Write the patient’s personal details at the top, including name, age, sex, birth date, weight, phone number etc.
There are many SOAAP (SOAP) Note templates that can be downloaded from the internet, but a pencil and paper is really all that is needed.
Examine the areas about which the patient has a specific complaint about.
Compare any outer physical complaints to the patient’s non-injured side.
Check range of motion, circulation, motor skills, sensation etc. Be very careful about forcing something to move or perform an action that is beyond its capability.
Depending on the circumstances, a full body physical exam may be needed to discover problems of which the patient may not be aware.
Do this in a systematic manner, from head to toe. Use only as much physical pressure as is necessary to discover injury, or lack thereof. Check the whole body for obvious signs of injury, e.g., bumps, bruises, bleeding.
A stethoscope, pen light, gloves and tongue depressor will be useful.
Head: bumps, bruises, bleeding from orifices etc.
Eyes: redness, whether the pupils respond equally to light.
Mouth (inside and outside): redness, sores, dental issues.
Neck: all around neck and back of the head, neck bones (vertebrae).
Chest: use a stethoscope if available and check lungs for abnormal sounds, e.g., wheezing, gurgles, crackles.
Heart: rhythm of heart beat, e.g., fast, slow regular, irregular.
Ribs: possible fracture.
Armpits: injury, parasites (lice, ticks etc.), tenderness.
Breast: move your fingers in a circular motion over the breast tissue, starting from where the arm connects to the shoulder and ending at the nipple.
Abdomen: press on the abdomen with your open hand checking for pain, tenderness, swelling, abnormal masses etc.
Listen for bowel sounds and note if there is too much or too little.
Check percussion by placing your open hand on the different quadrants of the abdomen and tap on your middle finger. It should sound hollow.
Liver and spleen: press down on the patient’s right side below the rib cage to determine if the liver is enlarged (you won’t feel it if it isn’t).
An enlarged spleen will appear as a mass on the left side under the bottom of the rib cage.
Spine: check along the patient’s spine for evidence of pain or injury. Never press directly on the vertebrae.
Kidneys: pound lightly with a closed hand on each side of the back below the last rib. An injury or infection of the kidneys will result in pain.
Extremities: check each extremity by feeling the muscle groups for pain or decreased range of motion.
Check perfusion; Must Read - Immediate First Aid - Critical First Aid - Circulation – Perfusion.
Check for sensation by lightly tapping with sharp and dull sensations on all four extremities (hands and feet), e.g., by using a safety pin.
General strength: place your hands on their thighs and ask them to lift up.
Ask them to grasp your fingers with each hand then try to pull your hand away; if you can’t, that’s good.
Strength should be about equal on both sides of the body.
If you suspect a spinal injury, e.g., a large fall, and the situation allows, you can perform a spinal test. In a survival situation, this can help you determine whether you need to stabilize the person’s spine before moving.
To rule out a spinal injury, the patient should meet the following criteria:
Reliable: cooperative, sober, alert and free of distracting injuries.
No spinal pain.
No numbness or tingling.
No spinal tenderness: using slight pressure, press down the patients back to the sides of the vertebrae; never press directly on the vertebrae.
Normal motor/sensory function in all four extremities, done during the extremities test in the physical exam. This does not apply if the extremity has a specific injury that would affect the outcome, e.g., broken wrist.
If the spinal test cannot be passed, stabilize the spine.
Keep the neck and back as stable as possible.
Note: a collar alone does not stabilize the spine.
Consider stabilizing the patient’s spine while he/she is on his/her side, especially if patient is already like that, or you have to leave him/her.
Before you stabilize the spine, you may have to bring the body back into its correct anatomic position, i.e., standing straight with legs together and arms down his/her sides, but with the patient lying down, preferably on his/her back.
Be very careful.
Move only one body part at a time.
Undo kinks.
Straighten joints.
Move arms and legs close to the body.
Stop if increased pain or resistance is met.
If moving the patient, it is preferably to secure him/her well to a rigid litter; Must Read – Moving a Patient – Improvised Litters – Rigid Litters.
A rolled up blanket, a sleeping mat or a stuff-sack filled with sand (or similar) are just a few ways you can improvise head stabilization.
Talk to the patient. Use the acronym SAMPLE:
Symptoms: what are the patient’s symptoms?
Allergies: does the patient have any known allergies (including medication)?
Medications: is the patient on any medication?
Past History: is the problem reoccurring, or does the patient or the patient’s family have a history of a suspected ailment?
Last: a history of the last things that went in and out of the person’s body.
Events: a detailed description of the events that led up to the problem.
Count the pulse for 15 seconds and multiply it by 4; Must Read - Immediate First Aid - Critical First Aid - Circulation – Pulse.
60 to 100 beats per minute is normal.
Evaluate for an entire minute.
Normal rate of breaths per minute (BPM) for an adult at rest is 12-18 breaths per minute. Over 20 is a sign of distress.
The younger a child, the faster their respiratory rate, e.g., an infant may have between 30 to 60 breaths per minute whereas a school age child (6 to 12 years) may have 18 to 30.
Note any unusual noises, e.g., wheezing or gurgling.
Check blood pressure if the equipment is available.
Blood pressure measures the amount of work the heart has to do to pump blood through the body.
A reading less than 140/90 at rest is normal. It may be high after extreme physical exertion but goes back down after a short while.
High blood pressure may be a medical condition and low blood pressure may mean hemorrhage or shock.
Check color (red, pale), temperature (hot, cold) and moisture (clammy, dry, moist etc.).
A normal temperature ranges between 36.1 °C (97 °F) and 37.2 °C (99 °F).
Above 38 °C (100.4 °F) or below 35 °C (95 °F) and there is something wrong. Hyper or hypothermia may be an issue; Diagnoses and Treatments – Environmentally Induced.
Gauge with AVPU: Must Read - Immediate First Aid - Critical First Aid - Mental Status – AVPU.
If there is a problem with the patient’s mental status, use the acronym STOPEATS to discover the cause:
Sugar: hypo or hyperglycemia; Diagnoses and Treatments – Circulatory System – Diabetes.
Temperature: hypo or hyperthermia; Diagnoses and Treatments – Environmentally Induced.
Oxygen: abnormal levels of oxygen.
Pressure: increasing ICP; Diagnoses and Treatments – Head – Brain – Increasing Intracranial Pressure.
Electricity: trauma from electric shock or problems in the brain.
Altitude: high altitudes can result in various altitude related illnesses; Diagnoses and Treatments – Environmentally Induced – Altitude Induced, or very low altitudes (i.e., underwater) can result in various diving related illnesses; Diagnoses and Treatments – Environmentally Induced – Cold and/or Water Induced - Diving Induced.
Toxins: drugs, alcohol, poisons etc.
Salts: low sodium or potassium levels.