My assessment?

ADyingBreed

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Hey all, I'm a fairly new EMT and still working on my assessment questions

I know each call is different but I want a general list of questions to add to my list to ask.

Anything you can add will help me greatly!


For medical I have:

What seems to be the problem?
When did it start?
What were you doing? Was it sudden or more gradual?
What makes it better/worse?
Where is the pain? Does It radiate anywhere? Can you describe it?
Is it constant or does it come and go?
How severe? pain scale 1-10
Has this happened before? Does it feel different than before?
Have you taken anything for it?
Have you done anything different recently? (New meds, new diet?)
Is there anything that you think is important that you want me to know?


My Trauma is sort of lacking questions. I know you want to do a physical assesment but on the conscious and alert trauma patients I feel like there can be more questions to ask.


Trauma assessment:
What happened?
Where does it hurt?
Did you hit your head
Did you lose consciousness?
(trauma assessment)
(check for alert/orientation, PMS, pupils)


That's about it :/




If you add anything, thanks for the feedback in advance!
 
The more you do it and the more you learn the more questions you will have. A lot of times open ended questions will get you a lot of info you neither need not care about whereas if you ask more direct questions about what you want to know you'll cut to the chase quicker. The trick is asking direct questions while not leading the patient and skewing the assessment.

Once you understand the physiology and pathophysiology you can start asking more pertinent questions.

Example: Renal patients or suspected UTI you might ask about their urine output, color, odor, particulate matter. Not sure if that really helps. There's a thread about pneumonic aids that might help you. I can't remember which forum though.
 
Here you go (copy and pasted)
and also not a list made by me, they gave this to us in medic school



General Assessments Questions Based on Chief Complaint

Chest Pain:
O.P.Q.R.S.T.
Do you feel nauseated or have you been vomiting?
Does the pain increase with palpation, or with inspiration?
Are you short of breath?
Which came first? Chest pain or short of breath?
Has this ever happened before?
Did a doctor tell you what causes this?
On a scale of 0-10 with 10 being the worst pain you have ever felt, and zero being no pain at all, how does your chest pain rate?
Have you taken anything to relieve the pain?
Have you taken any sexually enhancing medications in the past 48 hours?
S.A.M.P.L.E.

Shortness of Breath:
O.P.A.S.T.E - Onset, Provoke, Associated Chest Pain, Sputum, Talking, Exercise tolerance. Including sudden or gradual onset?
Can you say “you cannot teach old dogs new tricks”
Do you have a prescribed inhaler? Have you used your inhaler today? How many times?
If there is chest pain, Did the chest pain start before or after the onset of difficulty breathing?
Are you coughing or spitting up anything?
What does the sputum look like?
Has this ever happened before?
In comparison to other SOB events, is this more or less severe?
Have you ever been intubated? Or a tube put down your throat?
Have you had fever or chills?
S.A.M.P.L.E.

Abdominal Pain:
O.P.Q.R.S.T?
Do you have any associated nausea or vomiting or diarrhea?
Is the pain constant or does it come and go?
Does the pain increase with palpation or movement?
Does the pain increase with food or drink?
When was your last BM? Was it normal? Have you been constipated lately?
Female - When was your last menstrual period? Is there any possibility that you could be pregnant?
Have you had any vaginal bleeding/discharge? How much? For how long? Abnormal smell?
S.A.M.P.L.E.

ALOC:
Is there any need to take spinal precautions?
How long has the patient been like this?
When was the last time you saw the patient acting normal?
What is their normal mental status?
Is there any history of recent head injury?
What were they doing prior to being like this?
Has this ever happened before?
AEIOUTIPS - Alcohol, Epilepsy, Insulin, Overdose, Underdose/Uremia, Toxins/Tumor/Trauma, Infection, Psychiatric, and Syncope/Stroke.
If suspect OD, what take? When? How much? Why?
S.A.M.P.L.E.

ALOC/CVA (Stroke):
What was the patient doing when the symptoms started?
Do you have pain or a headache?
What is the normal and current level of consciousness? When was the patient last seen normal?
Do you have blurred vision or are your ears ringing?
Do you have a history of high blood pressure?
Can you repeat the words “The sky is blue in Cincinnati”?
Can you smile for me? Is there facial drooping?
Can you raise your arms straight in front of you and hold them in place with your eyes closed?
Can you squeeze by hands? Are there equal grips?
S.A.M.P.L.E.

General Weakness/Syncope
O.P.Q.R.S.T.
How long have you been feeling like this?
What were you doing before you started feeling like this?
Do you feel differently when you sit up or stand? If yes, how do you feel?
Have you recently been sick?
Do you have any pain anywhere?
Have you had this problem in the past or is this new?
If syncope, how long did pt lose conscious?
Have you been eating and drinking normally? Have you had bowel or bladder problems?
S.A.M.P.L.E.

Seizures:
Is the airway protected?
Has this ever happened before?
What did the activity look like? Is this similar to previous seizures?
How long did it last?
Do you get an aura before a seizure?
Did the patient fall?
Has there been a history of a recent head injury?
Has the patient had a fever?
Have you been taking your medications as prescribed? Have you missed a dose recently?
When was the last time your medication levels were checked?
Does the patient have incontinence or oral trauma?
S.A.M.P.L.E.

ALOC/Diabetic Problems:
S.A.M.P.L.E.
Do you take insulin?
When did you last take your insulin? How much?
When did you last eat, and what did you eat?
Have you changed your daily routine (exercise, stress…)?
Has this ever happened before?
What is your normal blood sugar level? Have you check your sugar levels recently?
Did you fall?
Did you have a seizure?

General Trauma Patients (Falls, Assault):
Where do you hurt? OPQRST.
Do you have any shortness of breath or chest pain?
Was there a loss of consciousness?
Does your neck or back hurt?
Do you have numbness, tingling, or weakness in your arms, legs, hands of feet?
Is your pain from the trauma or are they preexisting?
How far did you fall?
What were you struck with?
Were on your body did you get hit?
S.A.M.P.L.E.

Emergency Childbirth:
EDC, Estimated Date of Confinement/due date?
How many times have you been pregnant? How many live births have you had?
Have you had access prenatal care? Expecting any complications?
Blood/Fluid discharge?
Multiple births expected?
Any history of drug or alcohol use during the pregnancy?
Length and time in between contractions?
Do you feel an urge to push?
S.A.M.P.L.E.

Behavioral Emergencies:
Is the patient trying to harm him/herself or others? Has the patient ever been violent with others?
Does patient have a psychiatric history?
What is their normal mental status? When was the last seen the patient was seen acting their normal self?
AEIOUTIPS to rule out underlying medical issue.
Hallucinations?
S.A.M.P.L.E.
 
So far it appears you're covering the basics. The who, what, where, when, and how along with all the other questions you've listed. Take your time. Let them answer. If they're truly sick and/or broken they will usually obviously look sick and/or broken. Keep asking and work on it. All of those cute acronyms confuse me and get on my last nerve. So I would suggest to first understand the why behind the complaints and your assessments and treatments and the right questions will come in time.
 
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