Patient Assessment Terminology

Question 1

HPI

Answer 1

History of Present Illness

Question 2

PMH

Answer 2

Past Medical History

Question 3

O in OPQRST

Answer 3

Onset
What were you doing when it started?

Question 4

P in OPQRST

Answer 4

Provocation/Palliation
Anything make it better or worse?

Question 5

Q in OPQRST

Answer 5

Quality
How would you describe the pain?

Question 6

R in OPQRST

Answer 6

Radiation
Where is the pain and does it go anywhere?

Question 7

S in OPQRST

Answer 7

Severity
On a scale of 1-10, what would you rate your pain?

Question 8

T in OPQRST

Answer 8

Time
How long ago?

Question 9

AVPU

Answer 9

Assessing the level of consciousness

Question 10

A in AVPU

Answer 10

Alert
addressing you enter the room

Question 11

V in AVPU

Answer 11

Verbal
only notices you/looks at you when spoken to

Question 12

P in AVPU

Answer 12

Painful
needs pain to stimulate response (sternal rub)

Question 13

U in AVPU

Answer 13

Unresponsive
no reaction

Question 14

S in SAMPLE

Answer 14

Signs & Symptoms

Question 15

A in SAMPLE

Answer 15

Allergies

Question 16

M in SAMPLE

Answer 16

Medications

Question 17

P in SAMPLE

Answer 17

Pertinent past history

Question 18

L in SAMPLE

Answer 18

Last oral intake

Question 19

E in SAMPLE

Answer 19

Events leading up to

Question 20

D in DCAP-BTLS

Answer 20

Deformities

Question 21

C in DCAP-BTLS

Answer 21

Contusions

Question 22

A in DCAP-BTLS

Answer 22

Abrasions

Question 23

P in DCAP-BTLS

Answer 23

Penetrations/Punctures

Question 24

B in DCAP-BTLS

Answer 24

Burns

Question 25

T in DCAP-BTLS

Answer 25

Tenderness

Question 26

L in DCAP-BTLS

Answer 26

Lacerations

Question 27

S in DCAP-BTLS

Answer 27

Swelling

Question 28

ABC’s

Answer 28

if patient has signs of life, assess in this order

Question 29

CAB’s

Answer 29

if patient appears lifeless, this is the order to confirm pulselessness for cardiac arrest and bleeding control (severe bleeds = arterial)

Question 30

A in ABC

Answer 30

Airway

Question 31

Airway

Answer 31

• manually open airway (always first step)
• insert airway adjunct (OPA or NPA)
• suction when needed

Question 32

OPA

Answer 32

oropharyngeal airway

Question 33

NPA

Answer 33

nasopharyngeal airway

Question 34

B in ABC

Answer 34

Breathing

Question 35

Breathing

Answer 35

are they breathing? is it adequate?

Question 36

deliver oxygen to patients in respiratory distress

Answer 36

• agitation
• stridor
• wheezing
• tachypnea
• tachycardia
• nasal flaring
• accessory muscle usage

Question 37

assist ventilations for patients with inadequate breathing

Answer 37

• alter mental status
• shallow respirations
• rates over 30 and under 10
• bradycardia

Question 38

C in ABC

Answer 38

Circulation

Question 39

Circulation

Answer 39

do they have a pulse? do they have a significant bleed?
- stop any exsanguinating bleeds immediately (“heavy, severe, arterial, spurting”)

Question 40

if scene is not safe

Answer 40

LEAVE

Question 41

Patient’s environment

Answer 41

does the environment give clues to the condition?

Question 42

Chief complaint

Answer 42

reason they called 911

Question 43

Appearance

Answer 43

mental status (AVPU)

Question 44

normal adult pulse

Answer 44

60-100 bpm
assess quality (regular, strong, weak (“thready”)

Question 45

normal adult respirations

Answer 45

12-20 bpm

Question 46

normal adult temperature

Answer 46

98.6 degrees F

Question 47

normal adult bp

Answer 47

120/80

Question 48

normal adult blood glucose

Answer 48

80-120 (can range nominally for patient’s normal)

Question 49

normal (pulse oximetry)

Answer 49

96-100% (could be greater than or equal to 94%)

Question 50

mild hypoxia (pulse oximetry)

Answer 50

91-95%

Question 51

moderate hypoxia (pulse oximetry)

Answer 51

86-90%

Question 52

severe hypoxia (pulse oximetry)

Answer 52

< 85%