How to Present Cases to Your Medical Control by Donald Hudson, D.O.,FACEP/ACOEP

Your Initial Contact Remember You are asking for information or advice. You are looking at the patient You need to have some idea about what you expect medical control to offer to you. You have to have some basic information readily available.

What Information to Have Available What’s wrong, with the patient, C/C (chief compliant) History of the C/C, when did it start what has been the progress of the C/C since it started Has any thing been done i.e. OTC Rx, etc, & what has been the effect, etc.

Data To Acquire Additional history, i.e. family history if pertinent Has it ever happened before & what was done. Did it get better or worse? Does any one around you have similar symptoms

More Data AMPLE ALLERGIES MEDICINES TAKING PAST HISTORY LAST MEAL EVENTS LEADING UP TO THE VISIT PLUS immunization Hx

Physical Data Vital signs Blood pressure, if elevated or chest pain take it in both arms Pulse, rate, fast or slow, regular or not, strong or weak Respiratory rate, fast, slow, wheezing or not, good or poor breath sounds in all quadrants both front and rear

Physical Data Continuing Oxygen Saturation Oral Temperature With all shortness of breath, chest, back or arm pain (consider referred cardiac) do an EKG. The EKG that looks normal & the patient has any thing that might be considered cardiac repeat it in minutes

Physical Data Continuing Patients weight Your general gestalt about sick or not. The patient’s job

Now You Are Ready to Talk to Medical Control Do you have an idea concerning what you think should be done, different meds, transfer, medivac, etc. After you reach medical control remember this is basically a consult between to medical professionals & it i9s supposed to be a give & take. Be professional so medical will take you serious.

What Else You should know what your medical inventory & since there still is a significant variation among sites be prepared to offer what you may have on site that you think medical control might want. Medical control may have a different idea & that is OK remember it is their license you are working under.

NOTE Since you are the eyes, ears, nose & history taker for medical control if the answer you receive does not seem right based on what you see it is your responsibility to correct any misperceptions medical control may have based on your observations Voice those as a question & that will go a long ways to good interactions.

Important You are a medical professional You are expected to present your self in a professional manner You patients health and comfort as well as some times their lives depend on you Know all of your local resources, how & when to use them

NOW CALL