Acronyms

Patient History Gathering Techniques

  • Use the OPQRST mnemonic to assess patient's history of present illness and current symptoms.

    • Onset: Activity when symptoms began.

    • Provocation/palliation: Factors that exacerbate or alleviate symptoms.

    • Quality: Description of symptoms (sharp, dull, crushing, etc.).

    • Region/radiation: Location of the symptom and whether it spreads.

    • Severity: Symptom intensity on a scale of 0-10.

    • Timing: Duration of symptoms and when they started.

Importance of Special Populations

  • Children and adolescents may have different responses to pain assessments.

  • Notes on patient's known allergies and medications taken recently are crucial.

Patient Mental Status Assessment

  • Evaluate patient's ability to remember important details using a memory test:

    • Person: Patient recalls their name.

    • Place: Patient identifies their current location.

    • Time: Patient states year, month, and day of the week.

    • Event: Patient describes the mechanism of injury (MOI) or nature of illness (NOI).

  • Confirmation of being "alert and oriented x 4" is essential for assessing mental state.

Altered Mental Status Criteria

  • Any deviation from knowing person, place, time, or event is considered altered mental status.

  • Be aware of conditions affecting baseline alertness such as stroke and Alzheimer’s disease.

Assessing Level of Consciousness (LOC) using AVPU Scale

  • Awake and alert: Responds to environment and follows commands.

  • Verbal response: Responds to vocal stimuli but not spontaneously.

  • Pain response: Moves or moans in reaction to painful stimuli.

  • Unresponsive: No reaction to verbal or painful stimuli.

Neurological Assessment - PEARRL

  • Pupils: Assess if pupils are equal and round.

  • Equal: Both pupils should be the same size.

  • And: Transition to the next assessment.

  • Round: Ensure pupils are circular.

  • Regular in size: Verify size consistency.

  • Light response: Check for reaction to light changes.

Rapid Head-to-Toe Exam (90 seconds)

  1. Head: Look for DCAP-BTLS signs (Deformity, Contusions, Abrasions, Punctures, Burns, Tenderness, Lacerations, Swelling).

  2. Neck: Look for jugular venous distention and trachea deviation.

  3. Chest: Check breath sounds and for equal movement.

  4. Abdomen: Assess for rigidity and distention.

  5. Pelvis: Check for pain or instability on gentle compression.

Obtaining SAMPLE History

  • Use the SAMPLE acronym to gather holistic patient data:

    • Signs and symptoms: Initial signs during the incident.

    • Allergies: Assess for any known allergies.

    • Medications: List current medications and dosages.

    • Last oral intake: Note last food/drink and menstrual period for reproductive-aged women.

    • Events leading up: Understand circumstances surrounding the health issue.