# My "script" for medical assessments



## thatJeffguy (Mar 4, 2010)

Next week we have our written and practical mid-terms.  Tonight we did a Module exam (95% and 25/25 on the practical) and I felt a bit lost during the medical patient assessment.

So I developed a little "script" that I could try to remember and work from that has my words in place of "SAMPLE/OPQRST" etc.

Any commentary would be appreciated.  I know that this script wouldn't be appropriate for every medical situation but it's the one we were given tonight and I'm basing it off of that.  It's got a few stroke-specific questions.  For a hernia I'd be asking more questions regarding the acute abdomen and less Cincinnati Stroke Scale / PMS stuff.


Each "Point" that's listed on the exam I've placed in bold and underlined so that I'd know what it was and I could ensure I verbalized what I need to get my "PASS".
******


Medical Assessment

A. Scene Size up (6)

"Is the *scene safe*? *BSI* precautions taken.  *One patient*,* a X victim* due to the NOI I'll* call for ALS assistance* and I'll consider the need for* C-spine immobilization*"

B.  Initial Assessment
	"My *general impression* is <poor, stable>.  Hello, *my name is Jeffrey I'm with the ambulance* what is your *name*?  Do you know *todays date*?  And *where are we* right now?  OK, *why are we here* today?"  "Is it OK if I ask you some more questions and *take some vital signs*?"   "Patient is *ALERT TO P,P,T,E has consented to treatment *and is speaking, *airway* is patent. "

 Observe *breathing* and auscultate breath sounds.  "Breathing is <ADEQUATE / INADEQUATE>.  Breath sounds are biliateral".

Assess *Circulation* "Pulse is present <weak, bounding, thready, not present>, bilateral <absent on ...>" and *bleeding* "No major bleeding taking place"

"Due to the *poor general impression* of the patient I classify them as *high priority* and *initiate immediate tranfer* per protocols.  I also* place the patient on 15lpm via NRB*"

C.  Focused History / Physical Exam
SAMPLE OPQRST  CSS  PMS

"How do you *currently feel*?  Do you have any *allergies* to foods or medicines?  Are you currently taking any *prescription medicines or OTC substances*?  Has this *ever happened to you before*?  Have you *been in the hospital before*?  What all *substances have you eaten or drank in the past few hours*?  How *long ago* did the .. start? What were you *doing prior to* .. ?  Is their anything you can do that makes it feel* better or worse*?  *Describe* the pain for me.  Does it stay in that general area or does it* shoot or radiate anywhere else*?  On a *scale of 1-10 *1least 10greatest how do you rate the pain?  Is the pain c*onstant or is it intermittent*?"

"OK sir thank you very much.  I've got a few things I'd like you to do for me, look right at my fingertip and let me see a *big grin, show me all of your teeth*.  Allright now I'm going to place both of your hands right here in front of you with your palms up.  Please close your eyes and when I let go, *keep your hands just like this for ten seconds*.  Ok thank you very much.  Can you wiggle your fingers on your left hand for me?  Thank you, and your right?  OK what am I doing to your hand right now?  and the other hand?"

Assess bilateral distal radial pulse*
"Patient has/does not have Pulse, Motor and Sensory in both arms"*

"Sir with your left foot press down like you're pressing down on a gas pedal.  Now pull your left foot back the other way.  Wiggle your toes.  Now the right foot, down like a gas pedal.  And up.  Wiggle your toes."

Assess bilateral dorsalis pedis pulse
*
"Patient has/does not have P, M, S, in both legs"*

"Sir could you please repeat this saying 'The sky is blue in Cincinnati'"
*
"Patient passed/failed the CSS based on SPEECH, ARM DRIFT, and/or FACIAL DROOP"*


D.  Baseline vital signs
LOC, SKIN, SpO2, CAP REFILL, PULSE, RESP, PUPIL, BP

"The patient has been speaking with me, tracking with their eyes and is *conscious and alert*.  His *skin* is dry, pink (appropriate for ethnicity with pink conjunctiva) and warm  "I'm going to place this over your finger sir, just rest your hand here for me. " * Pt's pulseox* is X% ON 15LMP SUPPLEMENTAL O2   Assess *CAP REFIL *"Patients capillary refil time is under two seconds"

"I'm going to check your pulse sir" "*Pulse* # (rate, strength and regularity) “Now I’m going to listen to your breaths.  Deep breath in/out/in/out etc” *respirations* (rate, quality and depth)

"If you could please look right at my finger here sir" "*Pupils* PEARRL (Pupils Equal and round, regular in size, reactive to light)

"and I'll take your blood pressure..."
"*BP *is..."

E.  Treatment - *Already stated 15lmp Supplemental via NRB*
*****

Does this sound right/

Thanks again


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## MrBrown (Mar 4, 2010)

I commend you for such spending the time to think up such a thorough process. 

Would you perform this exam on every medical patient? Some parts are not necessary, for example somebody complains of a stubbed toe so are you going to look at distal pedi pulses?

Depending on where they feel pain or problem dictates where else we look; somebody with "sore tummy" doesn't need a stroke score taken.

You cannot create the perfect "script" for every patient because every patient will be different and requires adding and changing elements of our primary and secondary survey.

If somebody complains of "not feeling well" I would look at the following signs and observations (BP, RR, PR, lung sounds, WOB, ECG, SPO2 etc) and ask some questions; has it happened before, if so better or worse, when did it start, has it been getting better/worse/same, where does it hurt etc etc I suppose you would call them AMPLE/QRST questions.

Don't approach every patient the same way.

Oh, and no need for fifteen litres of oxygen for every patient; there is nothing magic about oxygen, more is not better unless hypoxemic and for most people 2-3 litres on a cannula is fine.


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## thatJeffguy (Mar 4, 2010)

Thanks Mr Brown.

I realize that this script would be wholly inappropriate if applied to a patient with anything but a suspected stroke, or perhaps on a hypoglycemic patient or a patient that might be postictal, but I think that's what our medical assessment will be.

The more directed questions will be changed apropos to the given scenario.


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## dave3189 (Mar 4, 2010)

As much as it is tempting to create a script or an exact order of the steps for an assessment it is best not to.  In my class some people tried that and they failed terribly!  The problem with scripts is when something gets "thrown in" that is unexpected you get thrown off.  The only true way to learn it is good old fashioned repetition.  Use a basic template for the various steps, and use the acronyms as an outline.  However, in my opinion scripts will only get you in to trouble, especially if you have an ornery evaluator who likes to mix things up a bit.


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## medichopeful (Mar 4, 2010)

You MIGHT want to consider verbally stating "I will consider an OPA/NPA," and verbalize what you decide.  Also, you might want to mention the fact that you are checking for breathing injuries (flail chest/ sucking chest wound/etc) and breath sounds.

Also (I didn't read the whole thing so I may not have mentioned it), but mention treating for shock.  VERY easy one to miss.

Just things to consider.

Eric


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