Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Wilderness and Rescue Medicine

pain because surgical scars can increase the risk of bowel obstruction. A history of allergy is espe- cially important if you are thinking of giving medication. Questions about last food and fluids are important where extreme weather is an issue or if you suspect volume shock from dehydration.

away from an injury or respond with just a groan or nonspecific movement. • U describes a patient who is completely unresponsive. When measuring vital signs, it is most useful to take them all together at regular intervals, allow- ing you to observe change over time. Even without a blood pressure cuff, thermometer, oximeter, or a watch a valuable assessment of vital signs can still be made. Measurements become relative: Pulse is fast or slow; temperature is cool or warm. Blood pressure and oxygenation can be assessed as nor- mal or low based on such signs as mental status and skin color. It is important to remember that each vital sign contributes to a pattern.

General Principles

SAMPLE History S – Symptoms; as described by the patient. A – Allergies; and nature of reaction. M – Medication; Rx and non-Rx. P – Pertinent History; to current problem. L – Last Ins and Outs; food, fluids, meds. E – Events; leading to current problem.

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General Principles

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Vital Signs

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The history can be taken before or after the exam. Beware of the common mistake of taking a history while performing the exam. “Does this hurt?” and “Have you ever had abdominal surgery?” asked at the same time may produce a useless answer to both questions. In the ideal situation, your history will be gathered separately. The events question pertains specifically to what happened that directly led to the problem with which you are dealing. This could be a description of a fall, a long hike leading to heat exhaustion, or being stung by a wasp. Careful attention here can reveal undiscovered problems or help make the difference between diagnosing a critical system problem like a traumatic brain injury and reassur- ing yourself that you’re looking at a simple scalp contusion. Creating a Problem List: SOAP The information you have gathered in your sur- veys is organized in a format abbreviated SOAP; Subjective, Objective, Assessment, and Plan. This is a common way to organize medical information and will be recognized by practitioners worldwide. Using this method, information regarding the patient assessment and history are divided into

P – Pulse R – Respiration BP - Blood Pressure T - Temperature S - Skin: color, temperature, moisture O – Oxygen Saturation AVPU - Level of Consciousness • A - awake (further define mental status)

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• V - responds to verbal stimulus • P - responds to painful stimulus • U - completely unresponsive

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A single vital sign taken out of context can be misleading. For example: An O2 saturation measurement of 68% would not be expected in a patient whose vital signs are otherwise normal. Something is probably wrong with the meter or the placement of the probe. A single vital sign that does not fit the rest of the pattern should motivate further investigation before making a judgement A good history can be the most useful part of the whole assessment. Initially, at least, it should be focused on the immediate problem. Details about your patient’s abdominal surgery in 1983 are not relevant to the assessment of his sprained knee. However, the history of surgery would certainly be relevant in evaluating a complaint of abdominal base on that finding. SAMPLE History