brock8024 Posted August 4, 2006 Posted August 4, 2006 You are dispatched to a residence for a 38 year old female. Her husband tells you that she started having weakness this afternoon and now is stating that she just does not feel right. What else you want to know. brock
rocket Posted August 4, 2006 Posted August 4, 2006 I would like to know: -Is the scene safe for my crew to enter? -What are the physical conditions on scene (very hot, cold, etc)? -What are the social conditions on scene (evidence of substance abuse, violence, etc)? -What is the patient's location in the residence? -What is her general appearance (what do we see when we first see the patient)? -Trevor
brock8024 Posted August 4, 2006 Author Posted August 4, 2006 Trevor, The scene is safe, and the house is a comfy 72 degrees. The husband seems to be very worried and you can tell loves his wife very much. The patient is sitting on the couch in the living room and looks very healthy. You do notice that she is having trouble with balance. What else
brock8024 Posted August 4, 2006 Author Posted August 4, 2006 The point of this is to think out side of the box.
FL_Medic Posted August 4, 2006 Posted August 4, 2006 -LMP -STD's? -Fibromyalga? -Psych hx? -Pt.s weight? ADD -PMH -Rx -LOI -LMP & Para/garvida -Alchohol?/drugs? -Prior events -N/v/d -S/S of CVA? -Possible previous trauma? -Remove the pt. from the husband.
Cookie Posted August 4, 2006 Posted August 4, 2006 All the above, plus vitals, BGL, what did she do that day, anything out of the ordinary, what did she eat, when and where. There are all sorts of questions that could be asked here. Support with O2 moniter vitals and transport.
rocket Posted August 4, 2006 Posted August 4, 2006 -Remove the pt. from the husband. Yup. Let's have the driver run "distraction" (asking the husband about the call, her meds, Hx, etc) and since by description she seems to pass the look test we will hold off on any interventions for the moment and just ask: "Hello. Can you tell us why we were called here today?" I'd like to know her answer and also her demeanor when she responds. Is she acting like this is no big thing or does she seem agitated? I'd also like to get a quick pulse asssessment (just a hand on the wrist to get a feel for the quality, I don't need a number just yet). And If she didn't admit anything about the balance issue yet then I'd like to add the following question: "You looked a little bit unsteady when we first came in to see you. Can you tell me a little more about that? Has this happened before?" Next questions and treatments will be based on the "picture" she presents via words and body language. -Trevor
chbare Posted August 4, 2006 Posted August 4, 2006 SOAPE S/O: What is her LOC? Quickly assess the ABC's and ensure her hemodynamic status is intact. Obtain a set of baseline vital signs to include pulse ox and skin assessment along with tilt testing. Lung sounds, ABD assessment, and focused neuro assessment/HEENT exam. 12 Cranial nerve exam and focused eye exam. ROM and strength assessment of extremities. BGL? Rule out carbon monoxide poisoning if possible. Obtain history of present illness and PMHX. SAMPLE & OPQRST A: Based on the history and physical exam. P: supplemental o2 cardiac monitor and 12 lead vascular access transport after detailed exam is finished E: ongoing assessments I will have a few things to consider in the ER based on the findings above. Take care, chbare.
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