EMT Lesson Plans

4.15

Situa on: 76-years-old, complaint of Shortness of Breath

SOB II

Scene Size-up: Safety:

Scene is safe

BSI:

Gloves

Pa ents: 1 Mechanism/Nature: NOI – Shortness of Breath Resources: ALS Primary Assessment: General Impression: Pa ent si ng in chair Mental Status: Alert Airway: Patent Breathing:

20. Slightly labored. On a nebulizer treatment already. Palpable pulse at wrist, warm/dry, no severe bleeding

Circula on:

Desired Response:

Primary then secondary

Physical Exam: Head:

Unremarkable

Neck:

Unremarkable

Chest :

Unremarkable Wheezes Unremarkable

Vitals: 1

2

3

Abdomen:

Pulse: 60

60

60

Pelvis:

Unremarkable

BP:

146/82

144/78

138/62

Extremi es: Unremarkable Posterior : Unremarkable

Resp:

22

20

18

SPO2: 84

88

88

OPQRST: O:

SAMPLE: S:

I get this occasionally It does not change

Having trouble breathing

P: Q: R: S: T:

A: M:

None

N/A NA 8/10

Albuterol, Spiriva

P: L: E:

COPD

Hamburger, 2 hours ago Watching my grandson

1 hour

OTHER: This patient has take his inhaler x3 and is currently on an albuterol treatment.