Clinical Cases in Paramedicine. Группа авторов
who has had an onset of chest pain while gardening.
Pre‐arrival information
The female is conscious and breathing, and states she developed central chest and abdominal pain while gardening.
Windscreen report
The house is low set and appears to have neat gardens, nil signs of any danger. The patient is sat under a tree with a lawn mower nearby and you can see that it has been turned off.
Entering the property
You are met at your vehicle by the patient’s neighbour, who is concerned as he witnessed the patient mowing her lawn and then suddenly stop and appear to hold her chest. He immediately ran to her assistance and sat her on a chair, where she is located now. The lawn mower is turned off and there are no dangers in the garden.
On arrival with the patient
The female patient is sitting on a chair, holding her chest. She is alert to your presence and orientated to time and place. There are no obvious injuries or major haemorrhage.
Patient assessment triangle
General appearance
The patient appears in mild distress, pink in colour, alert to your presence and speaking in full sentences.
Circulation to the skin
Well perfused, mildly pink to her face and sweaty, but it is a warm day.
Work of breathing
Occasional sighing.
SYSTEMATIC APPROACH
Danger
Nil.
Response
Alert and orientated.
Airway
Clear.
Breathing
Appears to be slightly short of breath.
Circulation
Slow strong radial pulse palpable, normal rate, regular, capillary refill time <2 seconds, skin appears pink and warm.
Disability
Reveals nil obvious injuries or deformities, no loss of sensation in any limbs, no loss of sensation, normal skin turgor, dry mucosa, nil medical alerts, and see vital signs. Nil allergies noted.
Exposure
Not necessary on this patient.
Vital signs
RR: 21 bpm
BP: 129/80 mmHg
SPO2: 98%
Blood glucose: 5.1 mmol/L
GCS: 15/15
4 lead ECG: Sinus rhythm at a rate of 75, regular
Pupils equal and reactive to light (PEARL)
Colour/appearance: Pink colour to the skin, sweaty forehead and warm to touch
Respiratory effort/rhythm: Normal effort, regular
Auscultate: Clear air entry both sides
Pulses: strong radial pulses both sides, rate of approximately 100 bpm and regular
Head to toe: The patient has not reported any trauma, so no head to toe conducted
Case history
The patient states that she was gardening when she felt a sudden chest pain in the middle of her chest, radiating to her left arm, described as heavy in nature. She felt quite short of breath and then her neighbour arrived and called the ambulance. She normally uses a spray under her tongue, but hasn't refilled her prescription.
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
1 Given the initial vital signs, what further assessment needs to be acquired as soon as possible?A 12 lead ECG.
2 What history would you like from the patient?A systematic approach should be utilised when assessing your patient. The pneumonic SAMPLE is widely used and provides the treating paramedic with the vital patient information (see Table 2.1). For this patient we have her signs and symptoms, next we need to enquire about any medical allergies, what medications she is currently taking, what is her past medical history, her last ins and outs and what the events leading up to today were.The patient’s pain also needs to be assessed, and there are many methods for doing so. One common method is using OPQRST (Table 2.2).
Table 2.1 SAMPLE mnemonic
| S | Central chest pain, described as heavy, short of breath |
| A | No known allergies |
| M | GTN, clopidogrel |
| P | Suffers from angina, hypertension and high cholesterol |
| L | Had normal breakfast at 07:00 and moved her bowels this morning |
| E | Gardening when experienced sudden central chest pain |
Table 2.2 OPQRST mnemonic
| O | Onset of pain | Sudden onset while gardening |
| P | Provocation | Sitting makes it a little better |
| Q | Quality | It’s a heavy pain, like someone sitting on her chest |
| R | Radiating | To left arm and initially jaw |
| S | Severity | 7/10 |
| T | Time of onset | Begun at 09:50 and has remained constant |
1 What would be your treatment plan be for this patient, given that she has not taken any medications and she has no known allergies?300 mg aspirin PO.400 μg sublingual glyceryl trinitrate (GTN) every 5 minutes if not contraindicated.IV