Medical Patient Assessment (OPQRST, SAMPLE and Focused Exam)

Adult assessment runs as a timed sequence: airway, breathing, circulation and mental status first, then vital signs, history and a focused exam. Repeat every measurement after an intervention; the trend matters more than one value.

Assessment is not a form to fill in. It is a structured, repeated search for the time-critical problem. You collect the airway, breathing, circulation, mental status, vital signs, history and focused exam, then you collect them again. That repetition sets your priorities and shows whether treatment is working.

How It Works

• Priority first: Threats to life come first. The primary survey finds them before any history is taken.
• Numbers in context: Don't read a vital sign alone. Set it against the patient's appearance, baseline and trend. One abnormal value is a reason to look again.
• History with a frame: SAMPLE covers the whole patient. OPQRST pins down each complaint.
• Focused exam: Examine what the complaint and findings point to. You don't need every system on every patient.
• Reassess: Reassess after every intervention, move and change in condition. Repeat the vital signs and mental status each time.

Where It Fits

Protocol decides the next move: treat now, transport, or evaluate further. NEWS2 is a hospital early-warning score. It turns vital signs into points. EMS and ED/ICU services run their own triggers, so apply the one your protocol names. Early-warning scores have limits too. Do not use qSOFA alone as a sepsis screen (Surviving Sepsis Campaign guidance, reference 4).

Indications

• Any medical complaint, including a change in breathing, mental status or pain
• Abnormal vital signs, or a patient who looks unwell even with normal numbers
• Need to prioritize between several patients or several problems
• Reassessment after treatment, a change in condition, or before every transfer of care

Absolute Contraindications

Nothing stops an assessment the patient needs. Scene and crew safety come first. Do not enter an unsafe scene to assess.

Relative Contraindications & Cautions

• Children: Adult NEWS2 bands do not fit a child, and neither do the adult BTS oxygen targets. The BTS guideline covers patients over 16 years only. Use the pediatric pages.
• Darker skin pigmentation: Oximeters can be less accurate on darker skin (FDA).
• Carbon monoxide exposure: Don't let a normal SpO₂ rule out hypoxemia.
• Anaemia or abnormal blood gas: SpO₂ can read normal while pH or PCO₂ is abnormal, or while oxygen content is low from anaemia (BTS guideline).
• No history available: Use family, bystanders and medication containers, and document what is unknown.

Consider an Alternative

A child needs a different starting point. Begin with the Pediatric Assessment Triangle and the Pediatric Vital Signs reference, then apply the age-based ranges.

Abort / Stop Criteria

• Immediate threat found in the primary survey: Treat it now (airway, breathing or circulation), then return to the history and focused exam.
• Arrest: Start resuscitation per current protocol; assessment continues during treatment.

Typical roles, not verified against the National EMS Scope of Practice Model. State and agency rules decide which skills each level may perform.

Team Roles During the Assessment

• Assessor: Leads the primary survey, the history and the focused exam.
• Airway and oxygen manager: Watches breathing and the airway and sets oxygen to target.
• Monitor and recorder: Applies the pulse oximeter and cuff, times each set, records GCS and glucose.
• Scene and safety: Keeps the scene safe, manages PPE, and requests help early.

Equipment

• Pulse oximeter with a visible plethysmograph waveform
• Blood pressure cuff in several sizes, or a manual set with stethoscope
• Thermometer suited to the patient's age and site
• Glucometer with test strips within expiry
• Penlight or pupil gauge and a GCS reference card
• Cardiac monitor and 12-lead ECG per protocol (see the 12-lead page)
• PPE and standard precautions

Sizing

Choose the BP cuff by arm size, following the manufacturer's sizing. Match the SpO₂ probe to the site and device. For children, use the pediatric size and range references.

Phase 1: Prepare & Size Up

1. Confirm scene safety: Check hazards, PPE and the number of patients before you approach.
2. Form a general impression: Note appearance, work of breathing, color and responsiveness from the doorway.
3. Request help early: Call for resources when the general impression is poor, before you start the detailed exam.

Phase 2: Perform

4. Assess the airway: Check for speech, noisy breathing or obstruction, and act per protocol.
5. Assess breathing: Count the rate, depth and effort. Give oxygen to the target range: 94–98% for most adults, 88–92% for hypercapnia risk.
6. Assess circulation: Palpate the pulse and check rate and rhythm, skin color and temperature, and bleeding. Press the nail bed and time the capillary refill.

   

   

7. Assess mental status: Use AVPU or the GCS (3–15). Record the GCS total with each component when you can.
8. Take a full set of vital signs: Heart rate, respiratory rate, blood pressure with the correct cuff, SpO₂ with a clean waveform, temperature (note the site, as oral, tympanic and temporal readings differ), and glucose when mental status or diabetes makes it relevant.
9. Take a SAMPLE history: Signs and symptoms, Allergies, Medications, Pertinent history, Last oral intake, Events leading to the call.
10. Characterize each complaint with OPQRST: Onset, Provocation, Quality, Radiation, Severity (0–10) and Time.
11. Perform a focused exam: Target the exam to the complaint and the findings so far, using the table below.
12. Reassess after each intervention: Repeat vital signs, GCS and glucose, and compare with the first set.

Phase 3: Reassess & Document

12. Compare with the trigger: Calculate the NEWS2 total if your service uses it, or apply your protocol's trigger, and note any single parameter scoring 3.
13. Decide the priority: Treat now, transport or evaluate further per protocol, and record the reasoning in one line.

Focused Exam by Complaint

Orthostatic vitals (syncope, dehydration, bleeding): Get BP and pulse lying or seated first. Repeat both standing at 1 and 3 minutes. A positive test means SBP falls 20 mmHg or more, DBP falls 10 mmHg or more, or symptoms appear within 3 minutes of standing (Freeman R et al., Clin Auton Res 2011;21:69–72, doi 10.1007/s10286-011-0119-5). Stop the moment symptoms appear or the stand is unsafe.

Stroke Screen (BE-FAST)

Any new focal complaint gets a stroke screen. Write down the time last known well. This site has no separate stroke scale page. BE-FAST is a screen, not a diagnosis, and a positive screen starts the stroke pathway per local protocol. For early management of acute ischemic stroke, see the 2026 AHA/ASA guideline (reference 8).

• Balance: sudden loss of balance or coordination
• Eyes: sudden vision loss or double vision
• Face: one-sided droop when the patient smiles
• Arm: one arm drifts down or cannot be lifted
• Speech: slurred, absent or wrong words
• Time: last known well time; notify the receiving stroke center early, per your local stroke system

Check glucose before the stroke pathway is confirmed. Oral intake waits until swallowing is screened, per protocol. Hypoglycemia can mimic stroke, so correct a low glucose and examine again. Pick your system's validated prehospital stroke scale (for example CPSS or LAPSS), along with any large-vessel occlusion triage tool your service uses. Transport is not held up for the scoring.

Primary Confirmation

Confirmation starts with a full set of vital signs: a waveform-verified SpO₂, a GCS, and a glucose when indicated. Repeat it. Stable or improving findings on the repeat set mean the trend is on your side.

Secondary Confirmation

• Consistency: The history, the exam and the vital signs should tell the same story. If one disagrees, look again.
• Perfusion: Look at the skin. Color, temperature and capillary refill should match the pulse and BP.
• Pain: Record a 0–10 numeric score at each set, and reassess it after treatment. When the patient cannot self-report, use a validated observational scale, per protocol.

Ongoing Monitoring

• Vital signs: Repeat at the interval your protocol sets and after every intervention.
• SpO₂: Keep the probe on and watch the waveform while on oxygen and in transport.
• GCS: Repeat whenever mental status changes.
• Capnography: Waveform ETCO₂ adds to monitoring in sedated, ventilated or transported patients, per protocol.
• Trend: Record each set so the change over time is visible to the next clinician.

Pediatrics

Adult bands do not fit a child. The BTS oxygen guideline covers patients over 16 years only. Build the assessment on the age-based references and your pediatric protocol.

• Vital signs: Age-specific ranges in Pediatric Vital Signs
• Appearance first: Pediatric Assessment Triangle before a detailed exam
• Fever: ≥38.0 °C (100.4 °F) rectal, per the pediatric vital signs reference
• Doses and sizing: Weight-Based Dosing and the Broselow reference

Older Adults

• Atypical presentation: Chest pain, sepsis and stroke can look like confusion, weakness, falls or vague abdominal pain.
• Blunted responses: Fever and pain may be muted. A normal temperature does not rule out infection.
• Rate control: Beta-blockers and other rate-control drugs can blunt the heart rate response. A normal rate does not rule out shock, so check BP, perfusion and mental status.
• Baseline: Before you judge a change, find out the usual mental status and mobility from family or care staff.

Pregnancy

• Normal changes: Heart rate rises and blood pressure falls mildly. A value that looks reassuring can still matter.
• Positioning: From about 20 weeks, the uterus can press on the great vessels when supine and cause hypotension. Use left lateral positioning per protocol.
• History: Ask about pregnancy status and gestation with every abdominal, chest and syncope complaint.
• Priorities: Treat hypoxia and hypotension promptly. Both affect the fetus.

Skin Pigmentation

The FDA says pulse oximeters may be less accurate on darker skin pigmentation. Its draft guidance, "Pulse Oximeters for Medical Purposes", was issued January 7, 2025. The FDA page still showed it as a draft when checked for this revision. Keep the clinical picture ahead of the number.

Low Oxygen Content and Carbon Monoxide

• Anaemia: Low oxygen content can hide behind a normal SpO₂ (BTS guideline).
• Carbon monoxide: Don't trust a normal or high SpO₂ here. Treat the exposure (see Complications).

Immediate Aftercare

• Record a full set of vital signs, GCS and glucose before the first move.
• Hand off the trend across sets, not only the last value.

Ongoing Maintenance

• Reassess after every change in condition, intervention or medication.
• Repeat vital signs at the protocol interval, and after each oxygen change.

Transport Considerations

• Reassess after every move. Vibration and noise can make SpO₂ and BP harder to read; repeat and check the waveform.
• Reassess mental status and breathing whenever sedation, oxygen or a medication changes.
• Keep the SpO₂ probe on and the oxygen device checked at each handover.

Pearls

• Trend beats one number: Compare each set with the one before it. The change tells you more than any single number.
• Waveform first: No clean plethysmograph waveform, no trust. A reading without one is not a reliable SpO₂.
• Check glucose in altered patients: Measure it before you settle on another cause, per protocol.
• One red parameter is enough: One parameter scoring 3 on NEWS2 calls for urgent response (RCP chart), even when the total is low. Use your service's trigger.
• Oxygen to target: Titrate to 94–98% in most adults. Use 88–92% when hypercapnia is a risk.

Common Pitfalls

• Trusting a normal SpO₂ in CO exposure → Treat the exposure with high-concentration oxygen.
• Using adult ranges for a child → Switch to the pediatric references.
• Using qSOFA alone for sepsis → Use the trend and your protocol's screening trigger (Surviving Sepsis Campaign, reference 4).
• Taking one set of vital signs → Repeat after every intervention.
• Starting with the history before the primary survey → Airway, breathing, circulation and mental status first.

Skill Maintenance

• Practice a timed primary survey with a partner, then repeat it with a new problem added.
• Rehearse SAMPLE and OPQRST histories on scenario cards with a different complaint each time.
• Practice repeat vital signs and a GCS after a simulated intervention, and compare the trend.
• Check your GCS scoring against a partner's score on the same patient.
• Hold a short debrief after each scenario: what the primary survey found and what changed the priority.