Ace844 Posted July 26, 2006 Share Posted July 26, 2006 PMHX, Meds, ALL, V/S's,complete head to toe assessment, and Events preceeding, v/s's including bilat B/P's pulse ox, 12-lead, and pert + and - cardio-respritory exam findings. Thanks, ACE844 Link to comment Share on other sites More sharing options...
FL_Medic Posted July 26, 2006 Author Share Posted July 26, 2006 PMHX, Meds, ALL, V/S's,complete head to toe assessment, and Events preceeding, v/s's including bilat B/P's pulse ox, 12-lead, and pert + and - cardio-respritory exam findings. Thanks, ACE844 LOL, finally no meds VS - BP 98/palp bilaterally, HR - 170, ECG shows SVT, a little depression in your inferior leads, o2 sat 98% on RA Sx - light-headed, CP, ABD pain, SOB Pt. denies reffered pain other that pain in ABD, LOC, dysuria, BM Link to comment Share on other sites More sharing options...
FL_Medic Posted July 26, 2006 Author Share Posted July 26, 2006 Pt. is on 02, as requested with no relief Link to comment Share on other sites More sharing options...
FL_Medic Posted July 26, 2006 Author Share Posted July 26, 2006 ABD O - Gradual P - palpitation Q - diffuse R - No radiation R - none S - 9/10 at times T - all day CP O - Sudden P - none Q - palpitations R - none R - none S - 10/10 T - 2 hours Link to comment Share on other sites More sharing options...
chbare Posted July 26, 2006 Share Posted July 26, 2006 How long ago did the pain start? Rebound tenderness? Does the pain radiate? Lung sounds? JVD? Hepatojugular reflex? hepatomegaly or actual distention from another cause? History of ABD trauma? Dysuria? Base line vital signs to include a temp? We need to pin down her LMP 12 Lead ECG? BGL? Height & Weight is possible? Allergies? Taking any meds or supplements? Any recent illness? Supplemental oxygen. Position of comfort depending on the hemodynamic status. Cardiac monitoring. Vascular access and isotonic fluids, rate depending on vital signs. Monitoring and transport. Additional treatments/assessments based on hemodynamic status. Once we arrive at the hospital, there will be a few more things that I wold like to do. Take care, chbare. Link to comment Share on other sites More sharing options...
Ace844 Posted July 26, 2006 Share Posted July 26, 2006 Pt. is on 02, as requested with no relief How about the rest of the H&P-P/E? Is the depression reciprocial, any axis deviation, any question of recnt tox or substance ingestion? Link to comment Share on other sites More sharing options...
FL_Medic Posted July 26, 2006 Author Share Posted July 26, 2006 Sx - SOB, Light - Headed, CP, ABD pain NKDA Rx- none Hx - none LOI - chicken at lunch E- pt. just got home from being out with friends since lunch time and told her mom she didn't feel good Link to comment Share on other sites More sharing options...
FL_Medic Posted July 26, 2006 Author Share Posted July 26, 2006 How about the rest of the H&P-P/E? Is the depression reciprocial, any axis deviation, any question of recnt tox or substance ingestion? Pt. denies using any drugs, or ingesting anything toxic. what does reciprocial mean? Link to comment Share on other sites More sharing options...
Ace844 Posted July 26, 2006 Share Posted July 26, 2006 ok, when you isolate the kid from the parent, any further tox related information coem out? Is the pt a smoker? supplement user? Any signs of Drug abuse-use?What activities was she partaking in prior to coming home, running exertional, etc...? Next, since you didnt mention it, Breath sounds, what are the other B/P's, etc...? Any murmurs? Link to comment Share on other sites More sharing options...
FL_Medic Posted July 26, 2006 Author Share Posted July 26, 2006 Let me know when you need a hint, maybe something you would think about at the scene, but not sitting at your PC. Link to comment Share on other sites More sharing options...
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