34 hours ago · A patient care report reads: c/o chest pain with associated DOE; PMH of IDDM. Regarding this description, which one of the following is true? A) The patient is a diabetic. B) … >> Go To The Portal
The key is to not miss a life threatening disorder like an acute MI or an aortic dissection. When the cause of chest pain remains unknown, it is recommended that the patient be referred to the specialist for care. The outcomes for patients with chest pain depend on the cause.
Other common causes of chest pain with approximate percent occurrence in patients presenting to the emergency department with chest pain include: Gastrointestinal reflux disease, 30% Musculoskeletal causes, 28% Pneumonia/pleuritis, 2% Herpes zoster 0.5% Pericarditis, unreported History and Physical History
You document the following on the prehospital care report: "c/o H/A with associated n/v; pt. denies existing CNS problems or history of the same; states positive history of AAA and ETOH abuse." Regarding this narrative, which of the following is true? A) The patient has a history of drug problems. B) The patient has a headache.
Pulmonary DOE. The typical COPD patient exacerbates breathing problems by the anxiety of breathlessness. During an acute attack, the breathing pattern in these patients is described by most as a tightness in the chest with the accompanying feeling of forced breathing. These symptoms worsen with mild exercise.
Examples of objective assessment include observing a client's gait , physically feeling a lump on client's leg, listening to a client's heart, tapping on the body to elicit sounds, as well as collecting or reviewing laboratory and diagnostic tests such as blood tests, urine tests, X-ray etc.
Which one of the following is an effective way to improve communication with most patients? Maintain eye contact. Why is using a standard format for relaying medical information to the emergency department important?
Which statement shows an accurate understanding of the legal aspects of the prehospital care report (PCR)? "The PCR may be subpoenaed even if the lawsuit centers on alleged negligence that occurred in the emergency department."
A pertinent negative might be a patient's denial of pain after an automobile crash or a lack of difficulty in breathing in a case of chest pain. By noting the absence of pertinent signs and symptoms, you will provide the medical team that takes over care of the patient a fuller picture of his condition.
While the field has many facets, there are four general types of contemporary health communication: health promotion, patient-provider-family caregiver interactions, health care interventions, and health communication technology.
Use proper form of address. Establish respect right away by using formal language. ... Make older patients comfortable. ... Take a few moments to establish rapport. ... Try not to rush. ... Avoid interrupting. ... Use active listening skills. ... Demonstrate empathy. ... Avoid medical jargon.More items...•
It must include, but not be limited to the documentation of the event or incident, the medical condition, treatment provided and the patient's medical history. The primary purpose of the Patient Care Report (PCR) is to document all care and pertinent patient information as well as serving as a data collection tool.
Category C. Priority 2 (Mechanism) Criteria—those only meeting the P2 mechanism criteria and needing to go to the highest level trauma center within 30 minutes but whom usually don't need flown there. For aeromedical flight requests for this category, the Medical Command Physician must be involved in the decision.
The prehospital evaluation should consist of a focused history and physical examination, including a complete assessment of vital signs and a prehospital 12-lead electrocardiogram (PHECG). Earlier STEMI diagnosis based on the PHECG facilitates in-hospital STEMI treatment.
Associated Signs & Symptoms: other signs/symptoms that occur when the problem, symptom or pain occurs, eg. Generalized symptoms (constitutional), frequency and urgency with urination, headache with blurred vision, back pain leads to numbness and tingling down the leg.
A physical or mental problem that a person experiences that may indicate a disease or condition. Symptoms cannot be seen and do not show up on medical tests. Some examples of symptoms are headache, fatigue, nausea, and pain.
Pertinent Negatives (PN) are used when the clinician documents why they DID NOT perform a procedure. Example: If Aspirin is part of the agency protocol for Chest Pain but was not administered, the reason should be documented. This is done using PN values.
Shouting distorts the sound of speech and may make speech reading more difficult. Say the person's name before beginning a conversation. This gives the listener a chance to focus attention and reduces the chance of missing words at the beginning of the conversation.
Therapeutic communication techniques such as active listening, silence, focusing, using open ended questions, clarification, exploring, paraphrasing, reflecting, restating, providing leads, summarizing, acknowledgment, and the offering of self, will be described below.
chapter 4QuestionAnswerWhich of the following actions should the medical assistant take when communicating with a mentally or emotionally disturbed patient?Remain calm if the patient becomes agitated or confused49 more rows
Listen without interrupting the patient. Speak slowly, clearly and loudly. Use short, simple words and sentences. Stick to one topic at a time.
B) "If you change your mind and want to be transported to the hospital, call 911.
C) "The PCR may be subpoenaed even if the case centers around alleged negligence that occurred in the emergency department."
C) print the report and draw a line through the error.
A) "nausea without vomiting."
D) The patient's lungs sounds are clear and equal.
D) the patient uses an inhaler at least three times a day.
C) Draw a single line through the term "left" and write the word "right" next to it.
D) "Use plain English if you are unsure of how to apply or spell a medical term."
C) As a pertinent negative
You are treating an 82-year-old female who is having trouble hearing some of your questions. Which technique would be most helpful in obtaining her medical history?
5. A 77-year-old female is unresponsive, but breathing and with a pulse. On scene, a family member hands you an official document stating that the patient does not want feeding tubes, ventilators, or other long-term life support equipment to keep her alive.
Study Chapter 4 quiz flashcards from Angela Buckley's class online, or in Brainscape's iPhone or Android app. Learn faster with spaced repetition.
D) The patient's lungs sounds are clear and equal.
B) "If you change your mind and want to be transported to the hospital, call 911 ."
D) "The PCR is considered a legal document only when it describes a crime or act of violence."
Symptoms include perspiration, coughing and wheezing. One of the main causes of DOE is cardiac disease. When a cardiac source is identified and the problem is chronic, it can usually be traced to left ventricular (LV) heart failure.
Another effect is the panic state that many people enter when they feel that they can't catch their breath and the continuous fear of falling into that panic state. The effects upon those who live with chronic DOE vary. Lifestyle changes are frequent, as the sufferer must plan daily activities carefully.
A person who suffers with DOE might find that ordinary efforts like walking, getting out of bed or even coughing can cause shortness of breath. The two primary types of conditions that contribute to DOE are cardiac disease and pulmonary disease.
The term DOE stands for dyspnea on exertion. Understanding the cause of DOE is key to treating the condition and improving quality of life. Often DOE presents itself in the process of an active disease. It is reported that 75 percent of dying patients suffer from some form of dyspnea, and 27 percent of people suffer with DOE in their daily lives.
The first step toward the treatment of DOE is a thorough medical history and physical. Because DOE is a symptom, the medical provider must look for the underlying problem. In the diagnostic phase of treatment, the patient might undergo X-rays, scans and other tests. Once the cause of the DOE is determined, appropriate management can begin. If the dyspnea is manifested by lung disease, bronchodilators (medications that open the bronchial tubes in the lungs) are usually effective. Opioids are even more effective in reducing shortness of breath and the work of breathing by desensitizing the body's response to increased carbon dioxide levels. Finally, anti-anxiety medications such as:
Pulmonary DOE. Of all pulmonary causes of DOE, COPD (chronic obstructive pulmonary disease) is the most common. The typical COPD patient exacerbates breathing problems by the anxiety of breathlessness. During an acute attack, the breathing pattern in these patients is described by most as a tightness in the chest with the accompanying feeling ...
The two primary types of conditions that contribute to DOE are cardiac disease and pulmonary disease.
In the emergency department chest pain is the second most common complaint comprising approximately 5% of all emergency department visits. In evaluating for chest pain, the provider should always consider life-threatening causes of chest pain. These are listed below with approximate percent occurrence in patients presenting to the emergency department with chest pain based on a study by Fruerfaard et al. [2]
Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a clinician considers more benign causes. Common descriptors of visceral pain are dull, deep, pressure and squeezing. Visceral pain also refers to other locations as a result of the nerves coursing through somatic nerve fibers as they reach the spinal cord. Ischemic heart pain, for example, may refer to the left or right shoulder, jaw or left arm. This activity highlights the role of the interprofessional team in caring for patients with chest pain.
A complete discussion of the management of ACS is beyond the scope of this paper however initial steps should be performed in patients with a diagnosis of ACS. Place patient on a cardiac monitor, establish intravascular access (IV) access, give 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is imminent), control pain and consider oxygen (O2) therapy. Nitroglycerin has shown a mortality benefit, aim for 10% mean arterial pressure (MAP) reduction in normotensive patients and 30% MAP reduction in hypertensive patients; avoid in hypotensive patients and those with inferior ST elevation. Patient with ST elevation on ECG patients should receive immediate reperfusion therapy either pharmacologic (thrombolytics) or transfer to the catheterization laboratory for percutaneous coronary intervention (PCI). PCI is preferred and should be initiated within 90 minutes onsite or 120 minutes if transferred to outside facility. If PCI is not possible thrombolytics should be initiated within 30 min. Patients with non-ST elevation myocardial infarction (NSTEMI) and unstable angina should be admitted for cardiology consult and work up. Patients with stable angina may be appropriate for outpatient work up. In elderly patients and those with comorbidities, patients should be admitted for observation and further cardiac work up. [3][4]
Carefully review the patient’s medical history for cardiac history, coagulopathies, and kidney disease. Ask about family history, especially cardiac, and ask about social histories like drug use and tobacco use.
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Chest, palpate for reproducible pain and crepitus
Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several life-threatening causes. A workup must focus on ruling out serious pathology before a physician considers more benign causes.
The patient's lungs sounds are clear and equal.
Immediately after giving a prehospital care report to the nurse in the emergency department, dispatch informs you that there are no more ambulances available and you must immediately leave the hospital to cover another portion of the county.
Last week, on a computer generated report, you accidentally documented that a patient suffered from hypertension when, in fact, he did not. Unfortunately, the report has been locked by the computer and cannot be changed; however, it can be printed. Your first action would be to: