MIME-Version: 1.0 Content-Location: file:///C:/2671C676/AP26.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Thrombolytic Screening Form (MI)

Thrombolytic Screening Form (M= I)

 

= 1.&n= bsp;      Patient Name: &nb= sp; _________________________________  _________________________________

(Last= name)        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;  (First name)

 

= 2.&n= bsp;      Patient Age / Sex: ______________________________= ___        &= nbsp;  _________________________________

     (Sex)        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;           (Age)=

 

= 3.&n= bsp;      Past Medical History: _______________________________________________________________________

 

= 4.&n= bsp;      Current Medications: _______________________________________________________________________

 

= 5.&n= bsp;      Drug Allergies: ___________________________________________________________________________= _

 

= 6.&n= bsp;      Initial BP &= nbsp;         ______________= _        &= nbsp; _______________    /   _______________        &= nbsp;   ______________

(Righ= t Arm)        &= nbsp;           &nbs= p;         (Military Time)      &n= bsp;            = ;       (Left Arm)      &nb= sp;            =             (= Military Time)      &n= bsp;  

 

        YES        &= nbsp;          NO<= /o:p>

= 7.&n= bsp;      Pain lasting < 15 minutes        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;                    &= nbsp;   [  ]           &nb= sp;        [  ]

 

= 8.&n= bsp;      Pain lasting > 12 hours        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;   [  ]           &nb= sp;        [  ]

 

= 9.&n= bsp;      Systolic Blood Pressure > 185 mmHg        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;      [  ]           &nb= sp;        [  ]

 

= 10.&= nbsp;  Diastolic Blood Pressure > 110 mmHg        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;      [  ]           &nb= sp;        [  ]

 

= 11.&= nbsp;  > 15 mmHg difference in right a= nd left arm systolic pressure   = ;            &n= bsp;              &= nbsp;   [  ]           &nb= sp;        [  ]

 

= 12.&= nbsp;  History of CNS pathology (stroke, seizures, tumor, surgery, etc…)    = ;            &n= bsp;        [  ]           &nb= sp;        [  ]

 

= 13.&= nbsp;  Major surgery or other serious trauma <= 6 weeks      &n= bsp;            = ;            &n= bsp;            = ;      [  ]           &nb= sp;        [  ]

 

= 14.&= nbsp;  Bleeding or clotting problems, or taking blood thinners      = ;            &n= bsp;            = ;           [  ]           &nb= sp;        [  ]

 

= 15.&= nbsp;  CPR > 10 minutes            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;              &= nbsp;   [  ]           &nb= sp;        [  ]

 

= 16.&= nbsp;  Pregnant or lactating females            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;   [  ]           &nb= sp;        [  ]

 

= 17.&= nbsp;  Serious systemic disease (severe kidney or liver disease)      = ;            &n= bsp;            = ;      [  ]           &nb= sp;        [  ]

 

= 18.&= nbsp;  Advanced or terminal cancer            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;    [  ]           &nb= sp;        [  ]

 

= 19.&= nbsp;  If all of the Thrombolytic Screening Form (MI)= criteria are met (all NO’s), alert the receiving facility of a possible thrombolytic candidate as early as possible.  If not, then return to the appropr= iate treatment protocol.

 

= 20.&= nbsp;  Form Completed by: _________________________________________________________=