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Medical Patient Assessment. Aaron J. Katz, AEMT-P, CIC www.es26medic.net. Scene size-up . BSI Scene safety Mechanism of illness Number of patients Need for additional resources  ALS Consider c-spine precautions. Initial assessment. General impression Level of consciousness (AVPU)

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medical patient assessment

Medical Patient Assessment

Aaron J. Katz, AEMT-P, CIC

www.es26medic.net

scene size up
Scene size-up
  • BSI
  • Scene safety
  • Mechanism of illness
  • Number of patients
  • Need for additional resources  ALS
  • Consider c-spine precautions
initial assessment
Initial assessment
  • General impression
  • Level of consciousness (AVPU)
  • Chief complaint / Apparent life threats
  • ABCs
  • Identify priority patients
  • Transport decision
    • Rapid vs. delayed
focused history pe
Focused history & PE
  • Perform an “illness dependent” History of Present Illness
  • Essentially “OPQRST” with adjustments
  • Illnesses follow…
respiratory
Respiratory
  • Onset
  • Provokes / palliates
  • Quality
  • Radiation
  • Severity
  • Time
  • Interventions
cardiac
Cardiac
  • Onset
  • Provokes / palliates
  • Quality
  • Radiation
  • Severity
  • Time
  • Interventions
altered mental status
Altered Mental Status
  • Description of episode
  • Onset
  • Duration
  • Symptoms
  • Trauma?
  • Interventions
  • Seizures
  • Fever? – especially in elderly
allergic reaction
Allergic reaction
  • Allergic history?
  • Exposed to?
  • How?
    • Ingested, injection…
  • Effects
  • Progression
  • Interventions
poisoning overdose
Poisoning / overdose
  • Substance
  • When?
  • How much?
  • Over how long?
  • Weight
  • interventions
environmental
Environmental
  • Source
  • Environment
  • Duration
  • Loss of consciousness?
  • Local or systemic
obstetric
Obstetric
  • Pregnant?
  • How long?
  • Pain/contractions
  • Bleeding/discharge
  • Water broken?
  • Need to push?
  • LMP
behavioral
Behavioral
  • How do you feel?
  • Suicidal?
  • Threat to self or others?
  • Medical problem?
  • Interventions
assessment continued
Assessment continued…
  • SAMPLE
    • In “E” consider traumatic causes
  • Focused physical exam
    • Consistent with illness
  • Vital signs
  • Treatment
  • Transport
  • Consider detailed physical exam especially for patients with “minimal” Level of consciousness
  • Ongoing assessment (initial, vitals, focused)