LESSON 1
PERFORM A BASIC PHYSICAL ASSESSMENT
1-1.
GENERAL
As a medical specialist, there will be many times when you will be confronted to
physically evaluate a patient. This type of evaluation is called performing a basic
physical assessment, which is considered the first step in patient care. Procedures to
perform a standardized physical examination in a logical sequence will be presented in
this lesson. It will be to your advantage, as well as the patient and the medical staff, to
develop the techniques that will enable you to provide quality patient care.
1-2.
ASSESSMENT TOOLS/EQUIPMENT
A penlight, stethoscope, blood pressure cuff, wrist watch with second hand, your
eyes for inspection, your ears for hearing, and your hands for palpation will be needed
to perform a complete physical assessment.
1-3.
ENVIRONMENT CONDITIONS ON ASSESSMENT
a. Clinical (Hospital,Medical Treatment Facility, Troop Medical Clinic, and
so forth). A complete examination is possible in a clinical environment. The degree of
injury, illness, or condition will determine the extent of the examination.
b. Field. In a field setting, or environment, complete examination may not be
possible, therefore, some situations may necessitate incomplete or quick physical
examinations. Examples are as follows:
(1)
Initial evaluation of front line battlefield casualties under fire.
(2)
Initial evaluation of a casualty in mass casualty situations.
(3) Conditions of inadequate light or environment, such as power failure at
night, or tropical rains.
NOTE:
If any of the above or similar situations prohibit a complete physical
evaluation, remember to document or inform your supervisor of the situations.
These situations may affect the physical findings or decisions.
NOTE:
All data (what you see, feel, and/or hear) must be as objective as possible
and documented over a period of time so that changes in a patient's status
are readily observed and identified.
MD0550
1-2