Patient Assessment & Documentation Flashcards
7 cards from real EMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Patient Assessment & Documentation flashcards as text
A patient presents with unequal pupils after a head injury. This finding is documented as:
Answer: Anisocoria
Anisocoria refers to unequal pupil sizes and in the context of head trauma suggests increased intracranial pressure or herniation.
Which of the following is considered a 'pertinent negative' in EMS documentation?
Answer: Documenting that the patient denies chest pain when evaluating dyspnea
A pertinent negative is a symptom the patient denies that is relevant to the chief complaint, such as denying chest pain when assessing shortness of breath.
During assessment of an elderly patient who fell, you note a shortened and externally rotated leg. This finding is MOST consistent with:
Answer: Hip fracture
A shortened, externally rotated lower extremity following a fall in an elderly patient is the classic presentation of a proximal femur (hip) fracture.
The term 'diaphoresis' used in patient assessment documentation refers to:
Answer: Profuse sweating
Diaphoresis is the medical term for profuse sweating, often indicating sympathetic nervous system activation in shock, cardiac events, or hypoglycemia.
When triaging patients using the START system, a patient with a respiratory rate of 10 breaths per minute, radial pulse present, and who follows commands is categorized as:
Answer: Yellow — Delayed
In START triage, a patient with respiration present, perfusion intact (radial pulse), and who can follow mental status commands is tagged Yellow (delayed).
A patient's skin is described as 'mottled.' This appearance indicates:
Answer: Patchy, irregular discoloration suggesting poor perfusion
Mottled skin shows irregular patches of discoloration (blotchy red/purple/pale) and is a sign of poor peripheral perfusion, often seen in shock or sepsis.
When documenting patient care, which of the following entries represents correct use of objective vs. subjective information?
Answer: 'Patient states chest hurts 8/10' (subjective) vs. 'SpO2 94%' (objective)
Subjective information comes from what the patient says (symptoms, pain scale), while objective information is measurable data obtained by the EMT (vital signs, SpO2).