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AGR-FIRE51-06 · Lesson 5 · 10 clock hours · lab

Patient Assessment: Secondary Survey, Vital Signs, and SAMPLE History

Objective. Students will accurately obtain a full set of baseline vital signs (pulse, respiration, blood pressure, SpO2, pupils, skin signs) and a SAMPLE history, and document findings using correct medical terminology within a realistic time frame.

⚠ Pending professional review

This lesson, its worked examples and its practice questions has not yet been verified by a licensed professional in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it as instructions for work on a job site or on live equipment. Always follow your instructor, your supervising professional, and current official references and regulations.

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Patient Assessment: Secondary Survey, Vital Signs, and SAMPLE History

Why This Skill Matters

After you complete the primary survey and address life threats, you move to the secondary survey. This structured head-to-toe evaluation gives you a complete clinical picture of your patient. At its core are two tools every EMT must master: obtaining a full set of baseline vital signs and gathering a SAMPLE history. Together they tell you what is happening now, what led to it, and how the patient's body is responding. Accurate, timely documentation on a Patient Care Report (PCR) ensures continuity of care when you transfer the patient to the hospital team.

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Baseline Vital Signs

A "full set" of baseline vital signs includes six components. Always note the time each set is taken — trends matter as much as single values.

1. Pulse

Palpate the radial pulse (wrist, thumb side) in most responsive adults; use the carotid pulse (neck) when a radial pulse cannot be felt. Count beats for at least 30 seconds and multiply by 2 (count a full 60 seconds if the rhythm is irregular). Note rate, rhythm (regular or irregular), and quality (strong/bounding, weak/thready).

Normal adult resting range: approximately 60–100 beats per minute (bpm).

2. Respirations

Count each complete rise-and-fall cycle as one breath. Count for 30 seconds and multiply by 2 (or 60 seconds for irregular breathing). Do not tell the patient you are counting — people alter their breathing when aware. Note rate, rhythm, and quality (normal, labored, shallow, noisy).

Normal adult range: approximately 12–20 breaths per minute.

3. Blood Pressure (BP)

Use an aneroid sphygmomanometer and stethoscope (auscultatory method). Apply the cuff to the upper arm over the brachial artery, inflate above the point where the radial pulse disappears, then release slowly. The first sound you hear through the stethoscope (Korotkoff sound) is the systolic pressure; the point at which sound disappears is the diastolic pressure. Record as systolic/diastolic in mmHg (e.g., 122/78 mmHg).

A general normal adult range is roughly 90–140 mmHg systolic and 60–90 mmHg diastolic, but always compare to the patient's baseline when possible.

4. Oxygen Saturation (SpO₂)

Attach a pulse oximeter to a clean, well-perfused fingertip. Nail polish, extreme cold, carbon monoxide poisoning, and poor circulation can give false readings — be aware of these limitations. Normal SpO₂ in a healthy adult is typically 95–100%. Values below 94% in most patients indicate a need for supplemental oxygen per your local protocols.

5. Pupils

Use a penlight in a dim environment. Shine light into each eye and observe:

Document using the abbreviation PERRL — Pupils Equal, Round, Reactive to Light — when normal.

6. Skin Signs

Assess color (pink/normal, pale, cyanotic/blue-gray, flushed, jaundiced), temperature (warm, hot, cool, cold), and moisture (dry, moist/diaphoretic). In darker-pigmented patients, check the mucous membranes inside the lips, nail beds, and conjunctiva for color assessment.

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SAMPLE History

SAMPLE is a mnemonic for the six elements of a patient history:

| Letter | Stands for | Example question |

|--------|-----------|------------------|

| S | Signs & Symptoms | "What are you feeling right now?" |

| A | Allergies | "Are you allergic to any medications, foods, or environmental triggers?" |

| M | Medications | "What prescription or over-the-counter medications do you take?" |

| P | Pertinent Past History | "Have you had this problem before? Any hospitalizations or surgeries?" |

| L | Last Oral Intake | "When did you last eat or drink anything, and what was it?" |

| E | Events Leading Up | "What were you doing when this started?" |

For the chief complaint (the patient's main problem), expand your questioning using OPQRST: Onset, Provocation/Palliation, Quality, Radiation, Severity (0–10 scale), and Time.

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Documentation

Every vital sign and history element must be recorded on the PCR with the correct unit and a timestamp. Use accepted medical abbreviations (e.g., BP, HR, RR, SpO₂, PERRL). Accuracy is a legal and clinical obligation — what you write becomes part of the medical record.

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Safety Points for This Lab

Key terms9

Baseline vital signsThe first complete set of vital-sign measurements taken during patient assessment, used as a reference point against which later sets are compared to identify trends.
Auscultatory methodThe technique of measuring blood pressure by listening through a stethoscope for Korotkoff sounds over the brachial artery while releasing pressure from an inflated cuff.
SpO₂Peripheral oxygen saturation measured non-invasively by a pulse oximeter, expressed as a percentage of hemoglobin saturated with oxygen.
SAMPLE historyA structured mnemonic (Signs/Symptoms, Allergies, Medications, Pertinent past history, Last oral intake, Events leading up) used to gather a complete patient history.
OPQRSTA mnemonic (Onset, Provocation/Palliation, Quality, Radiation, Severity, Time) used to fully characterize a patient's chief complaint, especially pain.
PERRLAbbreviation meaning Pupils Equal, Round, and Reactive to Light — the normal finding documented after pupil assessment with a penlight.
Patient Care Report (PCR)The official written or electronic record of a patient encounter, including assessment findings, treatments, and times; a legal and clinical document.
Korotkoff soundsThe sounds heard through a stethoscope during auscultatory blood pressure measurement; the first sound marks systolic pressure and the disappearance of sound marks diastolic pressure.
DiaphoresisExcessive sweating; a skin-moisture finding documented as 'diaphoretic,' often associated with shock, cardiac events, or severe pain.

Worked examples4

1. You count 23 pulse beats in 30 seconds during a radial pulse assessment. What is the patient's heart rate in beats per minute, and how would you classify it?
  1. Multiply the 30-second count by 2 to extrapolate to one minute: 23 × 2 = 46 bpm.
  2. Compare to the normal adult resting range of approximately 60–100 bpm.
  3. 46 bpm falls below 60 bpm, which is the lower boundary of the normal range.
Answer: Heart rate = 46 bpm. This is bradycardia (slower than normal). Document as 'HR 46 bpm, regular' (or irregular, depending on your assessment), note the time, and reassess. Report the finding to medical direction or receiving facility per protocol.
2. During BP measurement you hear the first Korotkoff sound when the gauge reads 138 mmHg and the sounds disappear when the gauge reads 86 mmHg. How do you record this and what does it mean?
  1. The first sound heard = systolic pressure = 138 mmHg.
  2. The point sounds disappear = diastolic pressure = 86 mmHg.
  3. Record as: BP 138/86 mmHg.
  4. Compare to general normal range (roughly 90–140 systolic, 60–90 diastolic). The systolic is at the upper boundary of normal; the diastolic is slightly above the traditional upper normal of 90 mmHg — note it, gather the SAMPLE history, and trend with repeat vitals.
Answer: BP = 138/86 mmHg. Document with timestamp. This reading warrants attention and reassessment; inform receiving staff and consider the patient's history of hypertension if present.
3. You count 8 respiratory cycles in 30 seconds. What is the respiratory rate, and is it within normal limits for an adult?
  1. Multiply the 30-second count by 2: 8 × 2 = 16 breaths per minute.
  2. Normal adult resting range is approximately 12–20 breaths per minute.
  3. 16 falls within that range.
Answer: Respiratory rate = 16 breaths per minute — within normal limits. Document as 'RR 16, regular, unlabored' (adjust quality descriptor based on your observation).
4. Your instructor simultaneously measures a patient's blood pressure as 124/80 mmHg while you record 131/76 mmHg. Do your readings meet the lab sign-off standard?
  1. Calculate the systolic difference: 131 − 124 = 7 mmHg.
  2. Calculate the diastolic difference: 80 − 76 = 4 mmHg.
  3. The sign-off standard requires BP within 8 mmHg of the reference value.
  4. Systolic difference = 7 mmHg (within 8 mmHg ✓). Diastolic difference = 4 mmHg (within 8 mmHg ✓).
Answer: Both values meet the ≤8 mmHg tolerance required for sign-off. Your reading passes. If either value had exceeded 8 mmHg, you would need additional coached practice before reassessment.

The math in this lesson1

Learners double a 30-second pulse count to beats per minute and compare it to the 60–100 normal range.
6.RP.3
In class: Vital-signs circuit: students rotate through stations to practice radial and carotid pulse assessment, respiratory rate counting, auscultatory blood pressure, SpO2 reading, pupil assessment with penlight, and skin color/temperature/moisture evaluation on each other and on manikins. · SAMPLE interview role-play: one student acts as a patient with a prepared symptom card; the EMT student conducts a structured interview using OPQRST for the chief complaint and SAMPLE for history, then reads findings back to verify accuracy. · Documentation drill: students transcribe vital signs and SAMPLE findings from a recorded role-play audio clip onto a blank patient care report form, ensuring correct units, abbreviations, and time-stamps.
Materials: Sphygmomanometers (manual aneroid), stethoscopes, pulse oximeters, penlights, wristwatches with second hands, blank PCR forms, scenario symptom cards, Brady textbook
Check: Instructor compares student-recorded vital signs to reference values measured simultaneously by instructor; blood pressure must be within 8 mmHg, pulse within 4 bpm, respirations within 2 breaths/min; SAMPLE history must include all six components; 100% of critical elements required for sign-off.

Practice check8

Answer each question, then check it. Nothing is recorded; this is your own practice.

Patient Assessment
1. When assessing a patient's pulse, you should count for at least 30 seconds and multiply by 2. Under which circumstance should you count for a full 60 seconds instead?
Airway, Respiration, and Ventilation
2. A patient's pulse oximeter reads 91% on room air. The probe is on a warm, unpainted fingertip and the waveform is strong. What is your most appropriate next action?
Patient Assessment
3. During pupil assessment you note that the left pupil is 4 mm and reacts briskly to light, while the right pupil is 7 mm and does not react. How should you document this finding?
Patient Assessment
4. Which letter of the SAMPLE mnemonic would prompt you to ask, 'When did you last eat or drink anything?'
Patient Assessment
5. You are using OPQRST to assess a patient with chest discomfort. Which question specifically addresses the 'P' component?
Medical Emergencies
6. A patient has pale, cool, and diaphoretic skin, a heart rate of 118 bpm, respirations of 24/min, and BP of 88/60 mmHg. These findings together are most consistent with which condition?
Patient Assessment
7. When measuring blood pressure by auscultation on a patient with a very noisy scene, which of the following is most likely to compromise accuracy?
EMS Operations
8. During the documentation drill, a student records a blood pressure as '124/80' without a unit. What is the most significant problem with this entry on the PCR?
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