M4st3rkr0n
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As I did in a earlier post I am going to write from memory my script for assessment of a medical patient and leave it up to the pros on this site to pick it apart and tell me what I am missing or have done wrong.
Scene safety, BSI, call for ALS if needed
get general impression of patient (MOI/NOI)
determine need for C SPINE
assess patients mental status (AVPU)
assess patients Airway (obstructed or patent)
assess patients Breathing (if inadequate begin O2 intervention NRB 15lpm)
assess patients Circulation (check pulse, BP, skin color temp and condition)
identity patients priority and transport decision
FOCUSED HISTORY AND EXAM
SIGNS & SYMPTOMS
RESPIRATORY - ask patient OPQRST and what interventions usually taken
CARDIAC - ask patient OPQRST and what interventions usually taken
ALTERED MENTAL STATUS - ask description of episode, onset, duration, associated symptoms, evidence of trauma, interventions usually taken. assess for possible seizures or fever as cause of mental status
ALLERGIC REACTION - ask patient history of allergies, what they where exposed to, how they became exposed, effects of exposure and if effects are becoming worse, interventions usually taken
Poisoning/OD - ask patient what substance was taken, how much of the substance was taken, how long was exposure to substance, interventions taken and patients weight
Environmental - ask patient what source was, environment, duration of exposure, loss of consciousness, and effects of exposure
Obstetrics - ask patient if pregnant, how long, pain or contractions, bleeding or discharge, need to push and last cycle
Behavioral - ask patient how they feel, determin SI HI and if so ask if patient has plan to do so, determine if patient is threat to self or others, determine if problem is related to medication, ask patient what interventions usually taken
ALLERGIES
MEDICATION
PAST MEDICAL HISTORY pertinent to situation
LAST ORAL INTAKE
EVENTS LEADING TO ILLNESS
PERFORM FOCUSED PHYSICAL EXAMINATION
Uptain set of baseline vitals
Interventions (obtain medical direction or verbalize standing orders
Transport (re-evaluate the transport decision)
consider completion detailed physical exam
repeat initial assessment
repeat vitals (every 5mins for unstable 15mins for stable)
repeat focused assessment of patients complaint
TRANSFER TO HOSPITAL
OK thats me script for a medical patient assessment please take a look and tell me what i did wrong or what i am missing this is how I will be taking my retest so be as hard on it as you need to be. THANKS AGAIN GUYS YOU ARE A VERY BIG HELP
POSTED TRAUMA ASSESSMENT HERE http://www.emtlife.com/showthread.php?p=436992#post436992
Scene safety, BSI, call for ALS if needed
get general impression of patient (MOI/NOI)
determine need for C SPINE
assess patients mental status (AVPU)
assess patients Airway (obstructed or patent)
assess patients Breathing (if inadequate begin O2 intervention NRB 15lpm)
assess patients Circulation (check pulse, BP, skin color temp and condition)
identity patients priority and transport decision
FOCUSED HISTORY AND EXAM
SIGNS & SYMPTOMS
RESPIRATORY - ask patient OPQRST and what interventions usually taken
CARDIAC - ask patient OPQRST and what interventions usually taken
ALTERED MENTAL STATUS - ask description of episode, onset, duration, associated symptoms, evidence of trauma, interventions usually taken. assess for possible seizures or fever as cause of mental status
ALLERGIC REACTION - ask patient history of allergies, what they where exposed to, how they became exposed, effects of exposure and if effects are becoming worse, interventions usually taken
Poisoning/OD - ask patient what substance was taken, how much of the substance was taken, how long was exposure to substance, interventions taken and patients weight
Environmental - ask patient what source was, environment, duration of exposure, loss of consciousness, and effects of exposure
Obstetrics - ask patient if pregnant, how long, pain or contractions, bleeding or discharge, need to push and last cycle
Behavioral - ask patient how they feel, determin SI HI and if so ask if patient has plan to do so, determine if patient is threat to self or others, determine if problem is related to medication, ask patient what interventions usually taken
ALLERGIES
MEDICATION
PAST MEDICAL HISTORY pertinent to situation
LAST ORAL INTAKE
EVENTS LEADING TO ILLNESS
PERFORM FOCUSED PHYSICAL EXAMINATION
Uptain set of baseline vitals
Interventions (obtain medical direction or verbalize standing orders
Transport (re-evaluate the transport decision)
consider completion detailed physical exam
repeat initial assessment
repeat vitals (every 5mins for unstable 15mins for stable)
repeat focused assessment of patients complaint
TRANSFER TO HOSPITAL
OK thats me script for a medical patient assessment please take a look and tell me what i did wrong or what i am missing this is how I will be taking my retest so be as hard on it as you need to be. THANKS AGAIN GUYS YOU ARE A VERY BIG HELP
POSTED TRAUMA ASSESSMENT HERE http://www.emtlife.com/showthread.php?p=436992#post436992
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