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48 JULY 2016 | EMSWORLD.com » CHF or any history of heart disease; » Pulmonary embolus or DVT. Social history—Risk factor analysis helps to determine the like- lihood of a given prehospital diagnosis. Ask about the following: » Smoking (increases risk of COPD and pneumonia); » ETOH (increases risk of aspiration pneumonia); » Recent travel (increases risk of pulmonary embolus); » Living conditions (patients in nursing homes and other high- density living arrangements are frequently exposed to infections and are at higher risk of pneumonia). Medications—The most commonly prescribed medications and their indications should be committed to memory. The skilled para- medic will find that the current emergency is often related to the patient's prior underlying medical problems, and the medication list will give useful information regarding what should be considered in the list of potential prehospital diagnoses. Diuretics such as furosemide, as well as hypertension and cardiac medications, are associated with CHF. Respiratory medications such as albuterol suggest asthma or COPD. Oral contraceptives increase the risk of DVT/pulmonary embolus. Physical Exam Once the history has been obtained, the paramedic should be able to formulate a list of likely prehospital diagnoses. The physical exam is then performed looking for evidence to support or refute each. Vital signs—Looking at specific vital signs gives an enormous amount of information about the patient's condition. » Pulse rate: Normal is 60–100. A rapid rate occurs in response to several etiologies. However, as a simplification, tachycardia can be thought to occur in three general instances: 1) The tissues are not getting enough nutrients/oxygen, and the body is compensating for this (i.e., the patient is in shock/has high metabolic demand); 2) the patient is taking a medication or has a condition that causes tachycardia, such as a stimulant/anxiety/pain; 3) the patient has an arrhythmia. » Respiratory rate: Normal is 12–20. Tachypnea, or a fast breath- ing rate, as a simplification, can be thought to occur for one of three main reasons: 1) The oxygen level is low; 2) the acid level is high (as in shock or high metabolic demand states); 3) pain, anxiety or certain drugs. » Blood pressure: Normal is a systolic of 90–120 over a dia- stolic of 60–90. The top and bottom number both give significant information. Systolic BP depends on stroke volume and strength of myocardial contraction. It occurs during systole. The bottom number occurs while the heart is at rest during diastole and indicates the vascular tone of the patient's arteries. The difference between the top and bottom number is known as the pulse pressure. A wide pulse pressure occurs in septic, anaphylactic and neurogenic shock. A narrow pulse pressure occurs in hypovolemic/hemorrhagic shock. As an example, a patient with the vitals of pulse 110, RR 24 and BP 105/50 is likely in septic shock. The fast heart rate may be an indication of shock. The rapid respiratory rate indicates the patient is blowing off acid (which increases in shock) and/or compensating for a low oxygen level. While the systolic blood pressure of 105 is often falsely reassuring, the skilled paramedic will look closely at For More Information Circle 36 on Reader Service Card