Neuro Deficits
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JPINFV
Gadfly
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A/Ox3/4 (what ever you use)
Acting appropriately.
CN2-XII grossly intact.
DTR 2/4 and equal bilaterally in UE and LE.
No loss of sensation to either light touch/vibration, proprioception, or temperature/pain.
Muscle strength 5/5 and equal in UE and LE.
Rapid alternating test is negative.
Finger to nose test is negative.
Romberg is negative.
Normal gait (adjusted for any muscle or skeletal issues... someone who has a chronic limp wouldn't be positive in the sense of neuro deficit).
Off the top of my head, the only thing hard to test prehospitally would really be the vibration, but vibration and light touch share a common neuro pathway anyways.
Acting appropriately.
CN2-XII grossly intact.
DTR 2/4 and equal bilaterally in UE and LE.
No loss of sensation to either light touch/vibration, proprioception, or temperature/pain.
Muscle strength 5/5 and equal in UE and LE.
Rapid alternating test is negative.
Finger to nose test is negative.
Romberg is negative.
Normal gait (adjusted for any muscle or skeletal issues... someone who has a chronic limp wouldn't be positive in the sense of neuro deficit).
Off the top of my head, the only thing hard to test prehospitally would really be the vibration, but vibration and light touch share a common neuro pathway anyways.
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Your med school is showing. Not that the Romberg test can't be easily performed in the field, but I would be curious how often it's actually done.
Bullets
Forum Knucklehead
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Neurological deficits are
Abnormal Gait
Confusion
Facial Droop
Motor Drift, Left
Motor Drift, Right
Paralysis-Left Side
Paralysis-Right Side
Seizures
Speech Normal
Speech Slurring
Tremors
Weakness-Left Sided
Weakness-Right Sided
If none of these are present then they are normal
And then there is a separate field for whichever stroke scale you prefer (MEND!), pupil assessment, sensory and motor, GCS, mentation
Abnormal Gait
Confusion
Facial Droop
Motor Drift, Left
Motor Drift, Right
Paralysis-Left Side
Paralysis-Right Side
Seizures
Speech Normal
Speech Slurring
Tremors
Weakness-Left Sided
Weakness-Right Sided
If none of these are present then they are normal
And then there is a separate field for whichever stroke scale you prefer (MEND!), pupil assessment, sensory and motor, GCS, mentation
How about:
Pt found CA&O4 U/A, and demonstrates adequate decisional capacity
Physical exam unremarkable
Stroke assessment negative
12 lead negative for ischemic changes
That's all you need, other than complaints/pertinent negatives, and any interventions done (pt treated as above may suffice in many cases). Keep it simple
The last line of every report should say: All times are approximate
Pt found CA&O4 U/A, and demonstrates adequate decisional capacity
Physical exam unremarkable
Stroke assessment negative
12 lead negative for ischemic changes
That's all you need, other than complaints/pertinent negatives, and any interventions done (pt treated as above may suffice in many cases). Keep it simple
The last line of every report should say: All times are approximate
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Achilles
Forum Moron
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Usually BLS aren't allowed to interpret ECG strips.
Also, I would add PMS to that too.
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JPINFV
Gadfly
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No problem
What is your physical exam? If the physical exam was negative, how come ____ physical exam finding was present on arrival?
Which stroke assessment? Cincinnati? LAPHSS? As with the PE above, what did it consist of?
Neuro deficit on 12 lead?
I forgot that this was a BLS thread, but a 12 lead is indicated for a CVA pt so long as it doesn't delay txp.
"Phys exam unremarkable" means that there were no observable deficiencies or injuries present on the exam. There's no need to say HEENT clear, neg JVD, airway self-maintained, L/S clear = bilat, + motor, sensory, circulation present × four ext's, pt ambulates steadily, abd soft non tender/non distended x 4 ext's, pelvis stable.
Phys exam unremarkable says all that in three words.
"Stroke assessment negative" can mean whatever I want it to if questioned. It stands for whatever type of assessment local guidelines mandate.
The less that said, the better.
I forgot that this was a BLS thread. "PMS" is covered under the blanket term "Physical exam unremarkable." This statement would be invalid if there were a pertinent abnormal finding onthe exam. Then, it would change to "Remainder of exam unremarkable."
JPINFV
Gadfly
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So... basically your PCR is useless to anyone providing care downstream from you because we have no clue what you looked at or didn't look at. Was there no observed deficiencies because there wasn't any or you didn't look for it? It's like the old joke about the abbreviation "WNL" meaning "We Never Looked."
Unless you want to provide your cell phone number so that when the admitting team finally gets the patient at 2am we can clarify what your exam meant. ...and yes... on multiple occasions at multiple facilities did the inpatient team seriously look at the prehospital PCR.
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I don't abbreviate anything any more. My standard negative neuro exam reads:
"Alert and oriented to person, place, and time. No gross visual defects. Pupils mid-line, equal, round, and react to light. Extra ocular movements are intact. No facial asymmetry. Hearing intact grossly. Shoulder shrug strong and symmetric. Tongue mid-line. Upper and Lower extremity strength 5/5 and symmetric. Distal sensation intact to light touch. Romberg, heel-to-shin, rapid-alternating-movements, and finger-to-nose intact bilaterally. Biceps, Brachioradials, Patellar, and Achilles reflexes 2+ and symmetric."
In the hospital I do this to every patient. Pre-hospital it gets pruned down.
"Alert and oriented to person, place, and time. No gross visual defects. Pupils mid-line, equal, round, and react to light. Extra ocular movements are intact. No facial asymmetry. Hearing intact grossly. Shoulder shrug strong and symmetric. Tongue mid-line. Upper and Lower extremity strength 5/5 and symmetric. Distal sensation intact to light touch. Romberg, heel-to-shin, rapid-alternating-movements, and finger-to-nose intact bilaterally. Biceps, Brachioradials, Patellar, and Achilles reflexes 2+ and symmetric."
In the hospital I do this to every patient. Pre-hospital it gets pruned down.
If I say that the exam is unremarkable, that means that there was nothing pertinent to report. If the ptnhas a BKA, skin tag, hemiparesis, adventitious lung sounds, abnormal gait, bruising, accessory muscle use in breathing, orthostatic changes, etc. I'm going to document that, of course. If I had a complaint of dyspnea, I might include pertinent negatives related to breathing, for example, but the rest is superfluous.
As far as the Admitting team is concerned, the ER staff always does their own assessment, and uses my verbal report. I'll submit that our written report technically doesn't have to be completed for up to 24 hours after completion of the call. Given that, how important is the PCR? It's obviously not time sensitive or relevant to the admitting team if we have 24 hours to post the report.
I'll include petinents, when warranted, of the presence and absence of orthostatic changes, CVA signs, accessory muscle use in breathing, exertional dyspnea, general weakness, ataxia, etc. Many of our patients are just not that ill; their physical exam is quite unremarkable.
Our verbal report to the RN will be more comprehensive. The less I write, the less the QA/QI people have to scrutinize.
Brandon O
Puzzled by facies
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Depending on the provider this probably means there are no focal, unilateral deficits in motor function or sensation. If you have any appreciable index of suspicion you should be assessing and documenting with more detail, because otherwise the person reading it will have the same question you're asking.