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EMT-Basic NREMT Exam Study Guide

Key concepts, definitions, and exam tips organized by topic.

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Patient Assessment – EMT-Basic NREMT Exam Study Guide


Overview

Patient assessment is the foundation of EMT practice and one of the most heavily tested domains on the NREMT exam. The assessment process follows a systematic sequence — from scene size-up through reassessment — designed to identify and prioritize life threats. Mastering this sequence, along with key mnemonics and normal values, is essential for both the exam and real-world patient care.


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Scene Size-Up


Key Concepts

Scene size-up is the first phase of every patient encounter and must be completed before physically approaching any patient. It establishes situational awareness and protects both the EMT and the patient.


The Four Components of Scene Size-Up

1. Scene Safety — Is the environment safe to enter?

2. Mechanism of Injury (MOI) / Nature of Illness (NOI) — What happened? What type of patient is this?

3. Number of Patients — Are there more patients than initially apparent?

4. Need for Additional Resources — Is backup, ALS, or specialized equipment needed?


Key Terms

  • • MOI (Mechanism of Injury) — The force or event that caused trauma; helps predict injury patterns
  • • NOI (Nature of Illness) — The medical complaint or condition prompting the call
  • • BSI (Body Substance Isolation) — Standard precautions using PPE (gloves, mask, eye protection) taken before every patient contact
  • • Spider-web windshield pattern — Significant MOI suggesting head, neck, and cervical spine injuries

    • Critical Rule

    > PPE/BSI comes first — before everything else, including approaching the patient.


    Watch Out For

  • • ⚠️ Never skip scene safety to rush to a patient — an injured EMT cannot help anyone
  • • ⚠️ MOI applies to trauma patients; NOI applies to medical patients — know the difference
  • • ⚠️ A significant MOI (e.g., high-speed MVC, fall from height) should trigger a rapid full-body assessment, even if the patient appears stable

    • ---


    Primary Assessment


    Key Concepts

    The primary assessment identifies and addresses immediate life threats to airway, breathing, and circulation. Every intervention found during this phase must be corrected before moving on.


    Correct Order of Primary Assessment

    1. General Impression — Age, sex, appearance, chief complaint

    2. Level of Consciousness (AVPU)

    3. Airway — Open and maintain; use jaw thrust if spinal injury suspected

    4. Breathing — Rate, quality, adequacy

    5. Circulation — Pulse, major bleeding, skin signs

    6. Transport Decision — Priority designation


    AVPU Scale

    | Letter | Meaning |

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

    | A | Alert — patient is awake and aware |

    | V | Verbal — responds to voice |

    | P | Painful — responds only to painful stimulus |

    | U | Unresponsive — no response to any stimulus |


    Normal Adult Respiratory Rate

  • • Normal: 12–20 breaths per minute
  • • Inadequate (requires intervention): < 8 or > 24 breaths per minute

    • Circulation — Three Key Elements

    1. Pulse — Present or absent?

    2. Major bleeding — Control life-threatening hemorrhage immediately

    3. Skin signs — Color, temperature, and moisture (CTM)


    High-Priority Transport Indicators

    A patient is high priority if any of the following are found during primary assessment:

  • • Poor general impression
  • • Unresponsive or altered mental status
  • • Airway problems
  • • Inadequate breathing
  • • Signs of shock
  • • Uncontrolled major bleeding
  • • Complicated childbirth

    • Watch Out For

  • • ⚠️ For an unresponsive patient, the first action after BSI and scene safety is establishing responsiveness and opening the airway
  • • ⚠️ If spinal injury is suspected, use a jaw thrust — never a head-tilt chin-lift
  • • ⚠️ Do not move to history taking until all life threats in the primary assessment are managed

    • ---


    History Taking


    Key Concepts

    History taking gathers subjective information from the patient or bystanders to understand the illness or injury. Two key mnemonics guide this process: SAMPLE and OPQRST.


    SAMPLE History

    | Letter | Stands For | Example Question |

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

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

    | A | Allergies | "Are you allergic to any medications?" |

    | M | Medications | "What medications do you take?" |

    | P | Pertinent Past History | "Have you had this before? Any major illnesses?" |

    | L | Last Oral Intake | "When did you last eat or drink?" |

    | E | Events Leading to Illness/Injury | "What were you doing when this started?" |


    OPQRST — Pain Assessment

    | Letter | Stands For | Example Question |

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

    | O | Onset | "When did the pain start?" |

    | P | Provocation/Palliation | "What makes it better or worse?" |

    | Q | Quality | "Is it sharp, dull, crushing, burning?" |

    | R | Region/Radiation | "Where is the pain? Does it move anywhere?" |

    | S | Severity | "On a scale of 0–10, how bad is it?" |

    | T | Time | "Has it been constant or does it come and go?" |


    Chest Pain Example

    > "Chest pain radiating to the left arm" = Region/Radiation (R) in OPQRST — a classic finding suggesting cardiac origin


    Alternate History Sources (Altered Mental Status)

    When a patient cannot provide history, use:

  • • Medical alert jewelry (bracelets, necklaces)
  • • Medication bottles at the scene
  • • Bystanders or family members
  • • Written medical history (medication list, medical ID card)

    • Key Terms

  • • Chief Complaint — The patient's primary reason for calling EMS, in their own words
  • • Pertinent negatives — Symptoms the patient denies that help narrow the diagnosis

    • Watch Out For

  • • ⚠️ Last Oral Intake is critical for surgery/sedation risk and for clues in diabetic emergencies and toxicological cases
  • • ⚠️ OPQRST is used for pain and symptom assessment; SAMPLE covers the broader medical history
  • • ⚠️ Always ask about allergies specifically to medications — this is tested frequently

    • ---


    Secondary Assessment & Physical Exam


    Key Concepts

    The secondary assessment is a systematic head-to-toe or focused physical exam performed after life threats are addressed. It identifies injuries or findings that were not detected during the primary assessment.


    DCAP-BTLS — Physical Exam Mnemonic

    Used to assess every body region systematically:


    | Letter | Stands For |

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

    | D | Deformities |

    | C | Contusions |

    | A | Abrasions |

    | P | Punctures/Penetrations |

    | B | Burns |

    | T | Tenderness |

    | L | Lacerations |

    | S | Swelling |


    Type of Assessment Based on Patient

    | Patient Type | Assessment Used |

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

    | Trauma with significant MOI | Rapid full-body (head-to-toe) trauma assessment |

    | Trauma with no significant MOI | Focused assessment of the injury site |

    | Medical patient | Focused assessment based on chief complaint |


    Key Physical Exam Findings

  • • Flail chest — Paradoxical movement of a chest wall segment; caused by 3+ consecutive ribs broken in 2+ places
  • • PERRL — Pupils Equal, Round, Reactive to Light; 4 elements assessed: size, equality, reactivity, accommodation
  • • Abdominal rigidity/guarding/tenderness — Suggests internal bleeding or peritoneal irritation
  • • Spider-web windshield crack — Suggests head, neck, and cervical spine injury

    • Key Terms

  • • Paradoxical movement — Chest segment moves in during inhalation and out during exhalation (opposite of normal)
  • • Guarding — Voluntary or involuntary muscle tension over a painful abdominal area
  • • PERRL — Standard notation for normal pupil findings

    • Watch Out For

  • • ⚠️ Apply DCAP-BTLS to every region — head, neck, chest, abdomen, pelvis, extremities, and posterior
  • • ⚠️ Flail chest is a life threat — manage with positive pressure ventilation
  • • ⚠️ Unequal pupils (anisocoria) may indicate head injury or herniation — treat as critical

    • ---


    Vital Signs


    Key Concepts

    Baseline vital signs provide objective data about patient stability and serve as a reference for trending during reassessment. All four must be obtained, documented, and compared over time.


    The Four Baseline Vital Signs

    1. Respirations — Rate (breaths/min) and quality (depth, effort, sounds)

    2. Pulse — Rate (beats/min) and quality (strong/weak, regular/irregular)

    3. Skin — Color, temperature, and condition (moisture)

    4. Blood Pressure — Systolic and diastolic values


    Normal Adult Values

    | Vital Sign | Normal Range |

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

    | Respiratory Rate | 12–20 breaths/min |

    | Pulse Rate | 60–100 beats/min |

    | Blood Pressure (Systolic) | 90–140 mmHg |

    | Blood Pressure (Diastolic) | 60–90 mmHg |


    Skin Signs and Their Meaning

    | Finding | Significance |

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

    | Cool, pale, diaphoretic | Shock (hypoperfusion) — blood shunting to vital organs |

    | Hot, red, dry | Hyperthermia or fever |

    | Cyanotic (blue/gray) | Hypoxia — inadequate oxygenation |

    | Jaundiced (yellow) | Liver dysfunction |


    Pulse Quality Interpretation

  • • Rapid and weak (thready) → Shock or significant blood loss
  • • Rapid and strong (bounding) → Hypertension, fever, or early compensation
  • • Slow and weak → Late shock, hypothermia, or medication effect

    • Key Terms

  • • Tachycardia — Heart rate > 100 bpm
  • • Bradycardia — Heart rate < 60 bpm
  • • Tachypnea — Respiratory rate > 20 breaths/min
  • • Diaphoretic — Sweaty; a key sign of shock
  • • Hypoperfusion — Inadequate circulation to tissues; clinical term for shock

    • Watch Out For

  • • ⚠️ Skin signs are often more immediately telling than blood pressure — cool, pale, diaphoretic skin signals shock before BP drops
  • • ⚠️ A falling blood pressure combined with a rising heart rate is a classic sign of decompensating shock
  • • ⚠️ Know pediatric normal values differ significantly from adults — the NREMT may ask about pediatric patients

    • ---


    Reassessment


    Key Concepts

    Reassessment is a continuous process during transport that monitors the patient's response to treatment and detects any changes in condition. It is not a one-time event — it is performed repeatedly until patient handoff.


    Reassessment Frequency

    | Patient Status | Frequency |

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

    | Stable patient | Every 15 minutes |

    | Unstable/critical patient | Every 5 minutes |


    Five Components of Reassessment

    1. Repeat primary assessment — Recheck airway, breathing, circulation, LOC

    2. Reassess chief complaint — Is it better, worse, or unchanged?

    3. Reassess and record vital signs — Compare to baseline trends

    4. Repeat physical exam as needed — Focused on areas of concern

    5. Check effectiveness of interventions — Is the oxygen/splinting/bleeding control working?


    Responding to Deterioration

    > A patient who was Alert (A) on AVPU and is now only responding to Verbal (V) stimuli represents a significant decline in level of consciousness.


    Immediate action: Reassess A-B-C (Airway, Breathing, Circulation) and increase transport priority — this is a potentially life-threatening deterioration.


    Key Terms

  • • Trending — Comparing serial vital signs to identify improving or deteriorating patient condition
  • • Intervention effectiveness — Assessing whether treatments (O₂, splinting, hemorrhage control) are producing the desired result

    • Watch Out For

  • • ⚠️ Never skip reassessment — stable patients can deteriorate rapidly
  • • ⚠️ Any decline in LOC on AVPU is a red flag requiring immediate primary reassessment
  • • ⚠️ Document all vital signs with times — trending requires accurate timestamps

    • ---


    Quick Review Checklist


    Use this checklist before your exam to confirm mastery of the most critical concepts:


  • • [ ] I can list the 4 components of scene size-up in order
  • • [ ] I know BSI/PPE comes first before approaching any patient
  • • [ ] I can recite the AVPU scale and identify when each level is concerning
  • • [ ] I know the correct order of primary assessment (General Impression → AVPU → Airway → Breathing → Circulation → Transport Decision)
  • • [ ] I know adult normal ranges: Respirations 12–20, Pulse 60–100, BP 90–140/60–90
  • • [ ] I can define all letters in SAMPLE and OPQRST without hesitation
  • • [ ] I can define all letters in DCAP-BTLS and explain when it is used
  • • [ ] I know cool, pale, diaphoretic skin = shock and can explain why
  • • [ ] I know flail chest = paradoxical movement from 3+ consecutive ribs broken in 2+ places
  • • [ ] I know reassessment frequency: 15 min (stable) vs. 5 min (unstable)
  • • [ ] I can identify high-priority transport criteria from the primary assessment
  • • [ ] I know the immediate response to any decline in AVPU during transport is to recheck A-B-C
  • • [ ] I know to use a jaw thrust (not head-tilt chin-lift) when spinal injury is suspected
  • • [ ] I understand the difference between trauma assessment (MOI) and medical assessment (NOI)

    • ---


    Good luck on your NREMT exam! Remember: systematic, sequential assessment is your most powerful tool — in the field and on the test.

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