Patient Assessment- Medical Flashcards
Skills
Scene size up
BSI scene is safe
I have 1 50 y/o female patient who’s noi is chest pain.
I’m going to request additional assistance and im not going to consider c-spine stabilization at this time
Primary survey 5 things
- General impression of patient
- LOC
- Chief complaint
- ABCs
- Transport
My general impression of the patient is
Poor
LOC
Level of consciousness
How to test LOC
AVPU
2 short term questions and 2 long term questions
AVPU
Alert
Verbal
Pain
Unresponsive
4 LOC Questions
- Do you know where you are
- Do you know what happened
- How many quarters are in a dollar
- Name 2 colors
A and O #
Chief complaint
Whatever they say when you ask then and there
ABCs
Airway
Breathing (apply oxygen)
Circulation (go up arm 3 things)
4 Airway possibilities
Clear- good
Blocked- can I move the object
Gurgling- roll to recovery position and suction
Snoring- head tilt chin lift
Circulation up the arm
Radial pulse
Color/temperature
Major bleeding
Transport?
This patient needs immediate transport
History
- OPQRST- present illness
2. SAMPLE- past medical history
OPQRST
Onset Provocation Quality Radiation Severity Time
SAMPLE
Signs and symptoms Allergies Medication Past pertinent history Last oral intake Events leading to present illness
Patient Assessment- medical
Order of 6 steps
Scene size up Primary survey/ resuscitation Vitals History Secondary assessment Reassessment
Onset- 1 question
What were you doing when symptoms began?
Provocation- 2 questions
Does anything make a symptom better or worse?
How are you the most comfortable?
Quality- 4 questions
What does the symptom feel like?
Is it sharp, dull, crushing, tearing?
Does it come in waves?
Can you describe the symptom?
Region/ Radiation- 2 questions
Where do you feel the symptom
Does it move anywhere
Severity- 1 question
On a scale from 1-10 how would you rate your symptom
Timing- 3 questions
Has the symptom been constant or does it come and go?
How long have you had the symptom?
When did it start?
Signs and symptoms
What’s signs and symptoms occured at the onset of the incident?
Did the patient report pain?
Allergies
Is the patient allergic to any food, medication, or other substances?
What reactions did they have to them?
If no known allergies note NKA on report
Medications-
Mnemonic: TACOS
Tobacco Alcohol Caffeine Over there counter Sexual or street drugs
Past pertinent medical history
History of medical, surgical, or trauma occurrences?
Recent illness, injury, fall, or blow to head?
Important family history?
Last oral intake
Last eat or drink? (When, what, how much)
Drugs or alcohol?
Any other intake in the last 4 hours?
Events leading up to injury or illness
Key events leading up to this?
What happened between onset and our arrival?
What were you doing when illness started/ injury happened?
Events leading up to injury or illness
Key events leading up to this?
What happened between onset and our arrival?
What were you doing when illness started/ injury happened?
