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Emergency Medicine/Global Medicine
Medical Emergency
Patient assessment
Last Updated: October 1, 2015

Emergency Diagnosis and Treatment

What are the types of patient assessment? Patient 60-second assessment by call center/Internet/telemedicine. Patient 60-second on-the-spot diagnosis and treatment. Patient 60-second assessment in trauma. Patient 10-minutes assessment in a medical emergency room. Patient-focused history and physical exam. Comprehensive patient assessment. What is a medical emergency? If a human being has any problem, symptom, complaint, or situation listed below, it is a medical emergency. http://www.qureshiuniversity.com/medicalemergency.html What best describes the problem, symptom, complaint, or situation in the list? _________________________ What type of assessment does this patient need? _________________________ What will happen if this medical condition is left without treatment? _________________________ The individual can die. The individual can have a disability. The individual can have severe pain. The individual can have irreparable harm. Does this situation need a doctor? _________________________ What should be displayed on an emergency medical record? Details of the patient. Details of the diagnosing and treating medical doctor. Details of the patient. What should be your first question in case a patient is referred to you? Patient 60-second assessment by call center/Internet/telemedicine. Where is the patient now? _________________________ How old is the patient? _________________________ What is the gender of the patient? _________________________ Who is reporting this emergency? _________________________ What are the sources of medical history? _________________________ Patient. Family. Patient not responding to medical history questions. Community member. Police officer. Referral from medical doctor. Other. How much time has elapsed from the start of the emergency until now? _________________________ Does one individual or many individuals have medical emergencies at this location? _________________________ How many individuals have medical emergencies at this location? _________________________ A medical emergency with an individual victim. A multiple casualty incident. Do you think this is a multiple causality incident? If it is a multiple causality incident, the guidelines are different. Check vital signs, mobility, and survival needs. Consciousness of a human being has to be included in vital signs. Vital Signs Consciousness, pulse, blood pressure, respiratory rate, temperature. Consciousness is extremely essential in reaching a correct diagnosis and treatment. What are the vital signs on the date and time of diagnosis and treatment? Date: Time: Consciousness: Pulse: Blood pressure: Respiratory rate: Temperature: ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ How do you categorize the condition of the patient? _________________________ Undetermined Good Fair Serious Critical Is this an emergency? _________________________ What is the category of this emergency? _________________________ Is this a medical emergency? _________________________ In what type of setting does this patient need treatment? _________________________ Here are various examples. Critical care Coroner investigations Emergency room health care Emergency call center Hospital ward Home health care Internet human health care services Labor, delivery, and recovery rooms Medicolegal cases On-the-spot diagnosis and treatment Operating rooms Other Who has the duty to manage this emergency? _________________________ What best describes this human emergency? _________________________ Medical emergency Surgical emergency Trauma emergency Pediatric emergency Obstetrical/gynecological emergency Medico legal case

Patient assessment

Patient 60-second on-the-spot diagnosis and treatment. What problems, complaints, incidents, and issues need on-the-spot diagnosis and treatment? Unconsciousness at a public location. Sudden unconsciousness at home. Trauma Survival Needs Seizures Burns Drowning Human Pregnancy Emergencies Here are further guidelines. What is the reason for consultation? _________________________ What seems to be the problem? _________________________ How much time has elapsed from the start of the emergency until now? _________________________ Does one individual or many individuals have medical emergencies at this location? _________________________ How many individuals have medical emergencies at this location? _________________________ What best describes your problem? _________________________ Patient Name:________________________ Referred by:_________________________ Mailing Address:_____________________ Telephone:___________________________ Your Email Address:__________________ Date of Birth:_______________________ Gender: Male Female Primary Care Physician Name, Address and Phone:__________________ Emergency Contact Name:______________ Relationship:________________________ Phone:_______________________________ Your Height:_________________________ Your Weight:_________________________ Race::_______________________________ White Black/African American Hispanic/Latino Pacific Islander Asian Asian/American Conscious Can the patient talk? Can the patient respond to verbal questions accurately? Can the patient do spontaneous eye opening? Does the patient respond to painful stimulus? Is the patient conscious, oriented in time, space, and person? Conscious means able to see, hear, and talk. In pediatric patients younger than six months of age, the ability to make any verbal noise or cry is equivalent to talking. What is the location of patient at the point of the medical emergency? Can the patient talk relevant to age? Can the patient walk relevant to age? Are consciousness, pulse, blood pressure, and respiratory rate normal relevant to age? What is the cause of the existing emergency medical scenario? Here are further guidelines. Here are further guidelines. Emergency medical history What questions should you ask in emergency medical history? http://www.qureshiuniversity.com/medicalhistory.html http://www.qureshiuniversity.com/vitals.html Mobility Survival Needs Details of the diagnosing and treating medical doctor. What is the name, date of birth, phone number, and other contact information of the person diagnosing and treating this patient? _____________________________________________ What is the date and time you are diagnosing and treating this patient? _____________________________________________ What is the location of the patient at the time you are diagnosing and treating this patient? _____________________________________________ What best describes the location of diagnosis and treatment of this case? 1. On-the-spot diagnosis and treatment. 2. Emergency room diagnosis and treatment. 3. In the hospital diagnosis and treatment. 4. Long-distance health care advice. 5. Other _____________________________________________ Can you reach a correct diagnosis and treatment of a human being? _____________________________________________ What is the diagnosis of this patient? _____________________________________________ How did your reach this diagnosis? _____________________________________________ What is the treatment for this patient? _____________________________________________ Does the patient need to be transferred to a medical emergency room? _____________________________________________ In America up to February 12, 2012, most emergency medical records did not have these facts. In what emergency medical category do you fit the condition of the patient you are diagnosing and treating on this date and time? Undetermined, Good, Fair, Serious, Critical. If on-the-spot diagnosis of a patient declared in serious or critical condition, arrange a bed in the Intensive Care unit. Date of Examination:_________________________ Physician Name:_________________________ Physician Address:_________________________ Is it a Medical Emergency? ___________________________ In what type of setting does this patient need treatment? ___________________________ Do any recent causes lead to this problem; for example, trauma, missed medication, inadequate survival needs, stress, or other issue? ___________________________ What are further details? ___________________________ Does any past medical history lead to this problem? ___________________________ Is there any recent history within past few minutes or hours of any of the following: 1.Unconsciousness at a public location. 2.Sudden unconsciousness at home. 3.Trauma. 4.Survival needs issues. 5.Seizures. 6.Burns. 7.Drowning. ___________________________ If there is even one recent history of the above, on the spot diagnosis and treatment is required. Is the victim's condition life or limb threatening? ___________________________ Could the victim's condition worsen and become life or limb-threatening on the way to the hospital? ___________________________ Could moving the victim cause further injury? ___________________________ Does the victim need the skills or equipment of paramedics or emergency medical technicians? ___________________________ Would distance or traffic conditions cause a delay in getting the victim to the hospital? ___________________________ What have been his activities for the last 10 years? ___________________________ Does the individual use or abuse any of these substances? Alcohol. Drugs. Tobacco. ___________________________ Is the individual on any medication? ___________________________ Questions doctor on duty needs to answer. Is it a medical emergency? ___________________________ What is the diagnosis? ___________________________ In what setting/location does this medical condition need treatment? Treatment required on the spot. Treatment required in the medical emergency room. Treatment required in the intensive care unit. Treatment required in the ward. Treatment required in the operating room. Treatment required at home. Treatment required Internet health care. Treatment required in OPD consultation. ___________________________ What treatment do you recommend for this patient? ___________________________ What are other treatment options for this patient? No other treatment option. Other treatment options are enumerated. ___________________________ Prescription How do you do a quick assessment, diagnosis, and treatment of a conscious patient?

Are you the person reporting a medical emergency for yourself?

Emergency

How do you do a quick assessment, diagnosis, and treatment of an unconscious patient?

Are all vital signs normal? Can the person move relevant to age? Has the person been provided with survival resources? Does the person or caregiver complaint of anything? Are these justified complaints?

Medical emergencies.

What are examples of emergency relevant to an individual? What are various symptoms, signs, statements, questions, issues, and histories that should raise suspicion of a medical emergency? There are at least 155 such symptoms, signs, statements, questions, issues, histories, and scenarios.

Agitated Patient (Acute stress reaction.) Attempted suicide. Attempted homicide. Abuse. Abdominal Pain.(Stomach pain) Altered sensorium. Any sudden or severe pain. Animal bites (may require rabies or tetanus shot). Armed Robbery. Allergic reactions. Breathing difficulties. Behavior that is dangerous to self or others and cannot be managed. Bleeding from any orifice or any part of human body that will not stop. Bleeding which does not stop after applying pressure. Being beaten by someone. Burns. Bites. Bloody Sputum Broken bones. Behavior-related emergencies. Change in mental status (such as unusual behavior, confusion, and difficulty arousing). Changes in vision. Chest pain. Choking. Cough with fever. Coughing up or vomiting blood. Confusion or changes in mental status Cuts and abrasions. Chest or upper abdominal pain or pressure lasting two minutes or more. Diarrhea Difficulty breathing. Difficulty speaking. Disoriented. Difficulty getting up. Difficulty in passing urine. Difficulty in passing feces. Domestic Violence Dramatic change in facial expression or demeanor. Drowning or near drowning Dental emergencies. Emergency diagnosis and treatment in neonatal period. Emergency diagnosis and treatment after neonatal period. Earaches and ear infections. Electrical injury shock. Emergency Food Environmental factors (hostile environment). Evidence of pain or discomfort that is not easily explained. Fainting. Fever. Foreign bodies in nose or ears. Fainting or loss of consciousness. Fainting, sudden dizziness, weakness, seizure. Feeling of committing suicide or murder. Fever with breathlessness. (Onset of fever of 101 degrees or higher.) Functional impairment (not taking care of self. inability to gain relevant skills and knowledge relevant to age). Human Rights Violations Head or spine injury. Head injury. Human Pregnancy Emergencies Hypothermia - frostbite. Head pain that lasts longer than five minutes. Holding abdomen. Infection at injury site. Intentional enforced harms. Involuntary admission to a psychiatric facility Loss of consciousness. Loss of consciousness not related to a seizure Loosening of social inhibitions. Likely to be harmful to self or others. Low abdominal pain. Medicine overdose. Major burns. Medicolegal cases Nosebleeds. New or sudden onset of incontinence. No pulse Onset of limping, inability to walk, or difficulty in movement. Pain. Palpitations. Poisoning. Poisoning including overdoses of medication. Persistent or severe vomiting. Persistent unexplained fever even with Tylenol use. Puncture wounds. Personality disorders (harmful to others). Panic attacks. Psychosis(delusions, hallucinations, catatonia, thought disorder, loss of contact with reality). Rape. Pregnancy-related emergencies. Possible serious bone fractures. Rapid change in behavior or an increase in challenging behavior such as aggression or self-injurious behavior. Rashes. Rash lasting several days or getting worse. Scratching (Intense) Severe sore throat/difficulty swallowing. Survival Needs Starvation Suicidal feelings. Surgical Emergencies Significant trauma (to the head, stomach, chest) Syncope. Seizures. Seizure lasting over five minutes or continuous seizures Severe asthmatic attack when prescribed medications do not work Severe injuries as a result of accidents such as broken bones Severe reactions to a medication with difficulty breathing or itching. Severe reactions to insect bites or other previously unknown allergic reactions Sore throat & fever Sunburn. Severe neck or back injury. Sexual intercourse due to conspiracy. Severe or persistent vomiting. Severe or persistent vomiting or diarrhea. Severe headache. Severe burns. Severe pain in any part of the body that does not subside. Serious drug reactions with psychiatric or non-psychiatric medications. Syncope or unconsciousness. Sudden or severe pain. Sudden loss of vision. Suicidal or homicidal feelings. Sudden asthma attack that does not stop. Sudden numbness or not being able to move an arm, leg, or one side of the body. Sever headache with fever or vomiting. Sudden injury or trauma due to a motor vehicle crash, burns, smoke inhalation, near drowning, wound, etc. Substance abuse. Sudden severe pain anywhere in the body. Sudden dizziness, weakness, or change in vision. Swallowing a poisonous substance. Shock symptoms, e.g., confusion, disorientation, cool/clammy, pale skin. Severe or persistent vomiting or diarrhea. Sleeping most of the day; unusual difficulty in arousing; unusual fatigue. Stroke or suspected stroke (paralysis, numbness, confusion) Swelling that is new Trauma with unconsciousness. Trauma with cuts, sprains, or abrasions. Trauma with open fracture. Trauma with pain on mobility. Trauma with swelling. Unable to detect breathing Unconsciousness. Unconsciousness with diabetes. Unconsciousness at a public location. Sudden unconsciousness at home. Unable to move Uncontrolled bleeding Upper abdominal pain. Uncontrolled bleeding. Unusual abdominal pain. Unusual or persistent abdominal pain. Unexplained stupor, drowsiness or disorientation. Violence Violence or other rapid changes in behavior. Vomiting Vomiting or coughing blood. Vomiting and diarrhea.

What will happen if you do not diagnose and treat a medical emergency properly? It can lead to death. It can lead to disability. It can lead to other harms. It can lead to medical malpractice. It can lead to legal malpractice.

Last Updated: October 1, 2015