AMS WorksheetBased on the Lake Louise AMS Questionnaire Name______________________________ Age ____ Sex____ Date _____________
Prev Hx AMS/HAPE/HACE?
Meds:
Ascent Profile:
Treatment:
Time ____ ____ ____ ____ ____
Altitude ____ ____ ____ ____ ____
Symptoms:
1.Headache:
No headache 0 ____ ____ ____ ____ ____
Mild headache 1 ____ ____ ____ ____ ____
Moderate headache 2 ____ ____ ____ ____ ____
Severe, incapacitating 3 ____ ____ ____ ____ ____
2.GI:
No GI symptoms 0 ____ ____ ____ ____ ____
Poor appetite or nausea 1 ____ ____ ____ ____ ____
Moderate nausea or vomiting 2 ____ ____ ____ ____ ____
Severe N&V, incapacitating 3 ____ ____ ____ ____ ____
3.Fatigue/weak:
Not tired or weak 0 ____ ____ ____ ____ ____
Mild fatigue/weakness 1 ____ ____ ____ ____ ____
Moderate fatigue/weakness 2 ____ ____ ____ ____ ____
Severe F/W, incapacitating 3 ____ ____ ____ ____ ____
4.Dizzy/lightheaded:
Not dizzy 0 ____ ____ ____ ____ ____
Mild dizziness 1 ____ ____ ____ ____ ____
Moderate dizziness 2 ____ ____ ____ ____ ____
Severe, incapacitating 3 ____ ____ ____ ____ ____
5.Difficulty sleeping:
Slept well as usual 0 ____ ____ ____ ____ ____
Did not sleep as well as usual 1 ____ ____ ____ ____ ____
Woke many times, poor night's sleep 2 ____ ____ ____ ____ ____
Could not sleep at all 3 ____ ____ ____ ____ ____
Symptom Score:
____ ____ ____ ____ ____
Clinical Assessment:
6.Change in mental status:
No change 0 ____ ____ ____ ____ ____
Lethargy/lassitude 1 ____ ____ ____ ____ ____
Disoriented/confused 2 ____ ____ ____ ____ ____
Stupor/semiconsciousness 3 ____ ____ ____ ____ ____
7.Ataxia(heel to toe walking):
No ataxia 0 ____ ____ ____ ____ ____
Maneuvers to maintain balance 1 ____ ____ ____ ____ ____
Steps off line 2 ____ ____ ____ ____ ____
Falls down 3 ____ ____ ____ ____ ____
Can't stand 4 ____ ____ ____ ____ ____
8.Peripheral edema:
No edema 0 ____ ____ ____ ____ ____
One location 1 ____ ____ ____ ____ ____
Two or more locations 2 ____ ____ ____ ____ ____
Clinical Assessment Score:
____ ____ ____ ____ ____
Total Score:
____ ____ ____ ____ ____
Using the worksheetPatients are assigned a single score for each numbered group. For visual ease, we have designed the worksheet so that this score is entered next to the corresponding symptom severity level. For example, a person with moderate AMS might get 2 points for moderate headache, 1 point for poor appetite, and 1 point for mild fatigue, for a total symptom score of 4. In addition, this person might get 1 point for facial edema, for a clinical assessment score of 1 and a total AMS score of 5. Serial evaluations several hours apart give a good measure of whether a patient is responding to treatment or deteriorating. (This page looks best printed in a fixed-width font) |
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