Emergency Care
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Baseline Vitals &
Baseline Vitals and Sample History Company Drill Instructor Guide Session Reference: 1 Topic: Baseline Vitals and Sample History Company Drill Level of Instruction: 2 Time Required: Three Hours Materials Blood Pressure cuff & stethoscope Pen light Clock or wrist watch with second hand Writing paper Writing pencil Personal protective equipment: gloves References Brady Emergency Care, 11th Edition, The Maryland Medical Protocols for Emergency Medical Services Providers, Effective July 1, 2011, Maryland Institute for Emergency Medical Services Systems Preparation Motivation The Baseline Vitals and SAMPLE History are part of the essential information necessary to obtain and document in order to give a patient the best possible care in the field. This information can alert the provider to call for additional resources if necessary and can give those accepting care of the patient at the next level of patient care a good idea of what may be going on inside the patient’s body. Objective (SPO) 1-1: Given a live victim; blood pressure cuff; stethoscope; pencil; paper; pen light; clock or wrist watch, the student will be able to demonstrate, from memory and without assistance, the proper procedures in obtaining a set of Baseline Vitals, to include: pulse, respirations, skin color, skin temperature and condition, pupil appearance, blood pressure and be able to document the same at a practical station, as governed by The Maryland Medical Protocols for Emergency Medical Services Providers, Effective January 1, 2002 and the Brady Emergency Care, 7th Edition, EMT-Basic National Standard Curriculum. The student will also be able to score a 70% or above on a written exam. -
ABCDE Approach
The ABCDE and SAMPLE History Approach Basic Emergency Care Course Objectives • List the hazards that must be considered when approaching an ill or injured person • List the elements to approaching an ill or injured person safely • List the components of the systematic ABCDE approach to emergency patients • Assess an airway • Explain when to use airway devices • Explain when advanced airway management is needed • Assess breathing • Explain when to assist breathing • Assess fluid status (circulation) • Provide appropriate fluid resuscitation • Describe the critical ABCDE actions • List the elements of a SAMPLE history • Perform a relevant SAMPLE history. Essential skills • Assessing ABCDE • Needle-decompression for tension • Cervical spine immobilization pneumothorax • • Full spine immobilization Three-sided dressing for chest wound • • Head-tilt and chin-life/jaw thrust Intravenous (IV) line placement • • Airway suctioning IV fluid resuscitation • • Management of choking Direct pressure/ deep wound packing for haemorrhage control • Recovery position • Tourniquet for haemorrhage control • Nasopharyngeal (NPA) and oropharyngeal • airway (OPA) placement Pelvic binding • • Bag-valve-mask ventilation Wound management • • Skin pinch test Fracture immobilization • • AVPU (alert, voice, pain, unresponsive) Snake bite management assessment • Glucose administration Why the ABCDE approach? • Approach every patient in a systematic way • Recognize life-threatening conditions early • DO most critical interventions first - fix problems before moving on -
Clinical Handbook Health Care for Children Subjected to Violence Or Sexual Abuse
KINGDOM OF CAMBODIA NATION RELIGION KING MINISTRY OF HEALTH CLINICAL HANDBOOK HEALTH CARE FOR CHILDREN SUBJECTED TO VIOLENCE OR SEXUAL ABUSE 2017 PREFACE Violence against children is a serious public health concern and a human rights violation with consequences that impact their lives in various ways. Violence and sexual abuse suffered in childhood adversely affects the body as well as the mind, which can lead to a broad range of behavioral, psychological and physical problems that persist into adulthood. Healthcare practitioners play a significantly important role in prevention and response to violence against children. They are often the first or only point of reference for children who have experienced violence, detecting abuse and providing immediate and longer-term care and support to children and families. In 2015, the Ministry of Health developed “the National Guidelines for Management of Violence Against Women and Children in the Health Sector”, which provides health care centers and referral hospitals with an overview of prevention and response in the health sector to violence against women and children. This “Clinical Handbook on Health Care for Children Subjected to Violence or Sexual Abuse” elaborates on knowledge and skills required to implement the National Guidelines. It aims to serve as a guide to ensure a prompt and adequate response to child victims of violence or sexual abuse for all healthcare practitioners. It provides further guidance on first line support, medical treatment, psychosocial support, and referral to key social and legal protection services. It can be also used as a resource manual for capacity development and training. Phnom Penh, 30th January 2017 Prof. -
Central Venous Pressure Venous Examination but Underestimates Ultrasound Accurately Reflects the Jugular
Ultrasound Accurately Reflects the Jugular Venous Examination but Underestimates Central Venous Pressure Gur Raj Deol, Nicole Collett, Andrew Ashby and Gregory A. Schmidt Chest 2011;139;95-100; Prepublished online August 26, 2010; DOI 10.1378/chest.10-1301 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/139/1/95.full.html Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright2011by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692 Downloaded from chestjournal.chestpubs.org at UCSF Library & CKM on January 21, 2011 © 2011 American College of Chest Physicians CHEST Original Research CRITICAL CARE Ultrasound Accurately Refl ects the Jugular Venous Examination but Underestimates Central Venous Pressure Gur Raj Deol , MD ; Nicole Collett , MD ; Andrew Ashby , MD ; and Gregory A. Schmidt , MD , FCCP Background: Bedside ultrasound examination could be used to assess jugular venous pressure (JVP), and thus central venous pressure (CVP), more reliably than clinical examination. Methods: The study was a prospective, blinded evaluation comparing physical examination of external jugular venous pressure (JVPEXT), internal jugular venous pressure (JVPINT), and ultrasound collapse pressure (UCP) with CVP measured using an indwelling catheter. We com- pared the examination of the external and internal JVP with each other and with the UCP and CVP. -
Bates' Pocket Guide to Physical Examination and History Taking
Lynn S. Bickley, MD, FACP Clinical Professor of Internal Medicine School of Medicine University of New Mexico Albuquerque, New Mexico Peter G. Szilagyi, MD, MPH Professor of Pediatrics Chief, Division of General Pediatrics University of Rochester School of Medicine and Dentistry Rochester, New York Acquisitions Editor: Elizabeth Nieginski/Susan Rhyner Product Manager: Annette Ferran Editorial Assistant: Ashley Fischer Design Coordinator: Joan Wendt Art Director, Illustration: Brett MacNaughton Manufacturing Coordinator: Karin Duffield Indexer: Angie Allen Prepress Vendor: Aptara, Inc. 7th Edition Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2009 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2007, 2004, 2000 by Lippincott Williams & Wilkins. Copyright © 1995, 1991 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appear- ing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia PA 19103, via email at [email protected] or via website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Bickley, Lynn S. Bates’ pocket guide to physical examination and history taking / Lynn S. -
Vital Signs and SAMPLE History
CHAPTER 9 Vital Signs and SAMPLE History Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Overall Assessment Scheme Scene SizeSize--UpUp Initial Assessment Trauma Medical Physical Exam SAMPLE History Vital Signs & Physical Exam SAMPLE History & Vital Signs HOSP Detailed Ongoing Physical Exam Assessment Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Baseline Vital Signs Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Baseline Vital Signs Pulse Respirations Skin Pupils Blood Pressure Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Pulse Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Pulse Rate Adults generally 60-100/minute. Tachycardia is pulse more than 100/minute. Bradycardia is pulse less than 60/minute. More than 120 or less than 50 may be a critical finding. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Pulse Quality Strong or weak Regular or irregular Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ If you cannot feel a radial or brachial pulse, check the carotid pulse. Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Respirations Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. Upper Saddle River, NJ Respiratory Quality Normal Shallow Labored Noisy Limmer et al., Emergency Care Update, 10th Edition © 2007 by Pearson Education, Inc. -
1- Assessing Pain
Foundations of Assessing and Treating Pain Assessing Pain Table of Contents Assessing Pain........................................................................................................................................2 Goal:..............................................................................................................................................2 After completing this module, participants will be able to:..............................................................2 Professional Practice Gaps............................................................................................................2 Introduction............................................................................................................................................. 2 Assessment and Diagnosis of Pain Case: Ms. Ward..........................................................................3 Confidentiality..........................................................................................................................................4 Pain History: A Standardized Approach..................................................................................................4 Evaluating Pain Using PQRSTU: Steps P, Q, R, S T, and U..............................................................5 Ms. Ward's Pain History (P, Q, R, S, T, U)..........................................................................................6 Video: Assessing Pain Systematically with PQRTSTU Acronym........................................................8 -
Wilderness First Aid Reference Cards
Pulse/Pressure Points Wilderness First Aid Reference Cards Carotid Brachial Prepared by: Andrea Andraschko, W-EMT Radial October 2006 Femoral Posterior Dorsalis Tibial Pedis Abdominal Quadrants Airway Anatomy (Looking at Patient) RIGHT UPPER: LEFT UPPER: ANTERIOR: ANTERIOR: GALL BLADDER STOMACH LIVER SPLEEN POSTERIOR: POSTERIOR: R. KIDNEY PANCREAS L. KIDNEY RIGHT LOWER: ANTERIOR: APPENDIX CENTRAL AORTA BLADDER Tenderness in a quadrant suggests potential injury to the organ indicated in the chart. Patient Assessment System SOAP Note Information (Focused Exam) Scene Size-up BLS Pt. Information Physical (head to toe) exam: DCAP-BTLS, MOI Respiratory MOI OPQRST • Major trauma • Air in and out Environmental conditions • Environmental • Adequate Position pt. found Normal Vitals • Medical Nervous Initial Px: ABCs, AVPU Pulse: 60-90 Safety/Danger • AVPU Initial Tx Respiration: 12-20, easy Skin: Pink, warm, dry • Move/rescue patient • Protect spine/C-collar SAMPLE LOC: alert and oriented • Body substance isolation Circulatory Symptoms • Remove from heat/cold exposure • Pulse Allergies Possible Px: Trauma, Environmental, Medical • Consider safety of rescuers • Check for and Stop Severe Bleeding Current Px Medications Resources Anticipated Px → Past/pertinent Hx • # Patients STOP THINK: Field Tx ast oral intake • # Trained rescuers A – Continue with detailed exam L S/Sx to monitor VPU EVAC NOW Event leading to incident • Available equipment (incl. Pt’s) – Evac level Patient Level of Consciousness (LOC) Shock Assessment Reliable Pt: AVPU Hypovolemic – Low fluid (Tank) Calm A+ Awake and Cooperative Cardiogenic – heart problem (Pump) Comment: Cooperative A- Awake and lethargic or combative Vascular – vessel problem (Hose) If a pulse drops but does not return Sober V+ Responds with sound to verbal to ‘normal’ (60-90 bpm) within 5-25 Alert stimuli Volume Shock (VS) early/compensated minutes, an elevated pulse is likely caused by VS and not ASR. -
Medical Staff Medical Record Policy
Number: MS -012 Effective Date: September 26, 2016 BO Revised:11/28/2016; 11/27/2017; 1/22/2018; 8/27/2018 CaroMont Regional Medical Center Author: Approved: Patrick Russo, MD, Chief-of-Staff Authorized: Todd Davis, MD, EVP, GMO MEDICAL STAFF MEDICAL RECORD POLICY 1. REQUIRED COMPONENTS OF THE MEDICAL RECORD The medical record shall include information to support the patient's diagnosis and condition, justify the patient's care, treatment and services, and document the course and result of the patient's care, and services to promote continuity of care among providers. The components may consist of the following: identification data, history and physical examination, consultations, clinical laboratory findings, radiology reports, procedure and anesthesia consents, medical or surgical treatment, operative report, pathological findings, progress notes, final diagnoses, condition on discharge, autopsy report when performed, other pertinent information and discharge summary. 2. ADMISSION HISTORY AND PHYSICAL EXAMINATION FOR HOSPITAL CARE Please refer to CaroMont Regional Medical Center Medical Staff Bylaws, Section 12.E. A. The history and physical examination (H&P), when required, shall be performed and recorded by a physician, dentist, podiatrist, or privileged practitioner who has an active NC license and has been granted privileges by the hospital. The H&P is the responsibility of the attending physician or designee. Oral surgeons, dentists, and podiatrists are responsible for the history and physical examination pertinent to their area of specialty. B. If a physician has delegated the responsibility of completing or updating an H&P to a privileged practitioner who has been granted privileges to do H&Ps, the H&P and/or update must be countersigned by the supervisor physician within 30 days after discharge to complete the medi_cal record. -
Medical History and Physical Examination Worksheet
U.S. Department of State OMB No. 1405-0113 EXPIRATION DATE: xx/xx/20xx MEDICAL HISTORY AND ESTIMATED BURDEN: 15 minutes PHYSICAL EXAMINATION WORKSHEET (See Page 2 - Back of Form) Photo Surnames Given Names Exam Date (mm-dd-yyyy) I Birth Date (mm-dd-yyyy) Document Type Document Number Case or Alien Number I I 1. Medical History (Past or present) No Yes No Yes Obstetrics Applicant appears to be providing unreliable or false Pregnant, on day of exam □ □ information, specify in remarks □ □ Estimated delivery date (mm-dd-yyyy) General LMP □ □ Illness or injury requiring hospitalization (including psychiatric) □ □ Previous live births, number: Birth dates of live births (mm-dd-yyyy) Cardiology □ □ Hypertension □ □ Congestive heart failure or coronary artery disease Arrhythmia □ □ Sexually Transmitted Diseases □ □ Rheumatic heart disease Congenital heart disease Previous treatment for sexually transmitted diseases, □ □ specify date (mm-yyyy) and treatment: Pulmonology □ □ Syphilis □ □ Tobacco use: □ Current □ Former □ □ Gonorrhea □ □ Asthma Chronic obstructive pulmonary disease □ □ Endocrinology Tuberculosis history: Diagnosed (mm-yyyy) □ □ □ □ Diabetes Treatment Completed (mm-yyyy) Thyroid disease Diagnosed (mm-yyyy) □ □ Treatment Completed (mm-yyyy) Hematologic/Lymphatic Diagnosed (mm-yyyy) □ □ Anemia Treatment Completed (mm-yyyy) □ □ Sickle Cell Disease □ □ Fever □ □ Thalassemia □ □ Cough Other hemoglobinopathy Night sweats □ □ □ □ Other □ □ Weight loss □ □ An abnormal or reactive HIV blood test Psychiatry Diagnosed (mm-yyyy) □ □ Psychological/Psychiatric -
Sample History and Physical Note for Gout
Sample History and Physical Note Charting Plus™ - Electronic Medical Records www.medinotes.com Note for Jane Doe on 2/27/04 - Chart 5407 Chief Complaint: This 31 year old female presents today with abdominal pain. Duration: Condition has existed for one month. Modifying Factors: Patient indicates lying down improves condition and standing worsens condition. Severity: The severity has worsened over the past 3 months. LMP: 4-05-2002. Allergies: Patient admits allergies to penicillin. Medication History: None. Past Medical History: Past medical history is unremarkable. Past Surgical History: Patient admits past surgical history of (+) cholecystectomy in 1998. Social History: Patient denies alcohol use. Patient denies illegal drug use. Patient denies STD history. Patient denies tobacco use. Family History: Patient admits a family history of cancer of breast associated with mother. Review of Systems: Cardiovascular: (-) cardiovascular problems or chest symptoms Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness Genitourinary: (-) GU symptoms Physical Exam: BP Standing: 118/72 Resp: 18 HR: 68 Height: 5 ft. 7 in. Weight: 134 lbs. Patient is a 31 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus. Eyes: Conjunctiva and lids reveal no signs or symptoms of infection. Pupil exam reveals round and reactive pupils without afferent pupillary defect. Optic discs with normal color, contour and cupping bilaterally. Retinas are flat with normal vasculature out to the far periphery with no peripheral holes, breaks or tears observed. ENT: Gross hearing test reveals normal hearing. Inspection of bilateral ears reveals no masses, swelling, redness or drainage. -
Patient Assessment?
EMERGENCY MEDICAL TECHNICIAN ‐ BASIC What is Patient Assessment? Why is Patient Assessment important? MECTA EMS Learning Assistant 2 What are the phases of patient assessment? Review of Dispatch Information Scene Survey Initial Assessment Focused History and Physical Exam Detailed Physical Exam Ongoing Assessment Communication Documentation MECTA EMS Learning Assistant 3 Why is the order of Patient Assessment important? Why is it necessary to develop a method of assessment and use that method on all patients? MECTA EMS Learning Assistant 4 SCENE SIZE‐UP INITIAL ASSESSMENT Trauma FOCUSED HISTORY & FOCUSED HISTORY & PHYSICAL EXAM PHYSICAL EXAM Patient Patient DETAILED DETAILED PHYSICAL EXAM PHYSICAL EXAM Medical ON‐GOING ASSESSMENT MECTA EMS Learning Assistant 5 Begin with receipt of call Location Incident Injured/Injuries MECTA EMS Learning Assistant 6 Continue En Route Further info from dispatcher Observe ▪ Smoke? ▪ Fire? ▪ High line wires? ▪ Railroads? ▪ Water? ▪ Industry? ▪ Other Public Safety units? MECTA EMS Learning Assistant 7 Upon Arrival Observe ▪ Overall scene ▪ Location of victim(s) ▪ Possible Mechanisms of Injury MECTA EMS Learning Assistant 8 Upon Arrival Observe ▪ Hazards ▪ Crowds ▪ HazMat ▪ Electricity ▪ Gas ▪ Fire ▪ Glass ▪ Jagged metal ▪ Stability of environment ▪ Traffic ▪ Environment MECTA EMS Learning Assistant 9 Ensure Safety ▪ Yourself ▪ Partner ▪ Other rescuers/Bystanders ▪ Patient MECTA EMS Learning Assistant 10 Call for assistance ▪ Other EMS Units ▪ Law Enforcement ▪ Fire Department ▪