Dispatched to this location for report of a person complaining of _______ . Responded emergency mode and found this patient on scene.
Found this patient alert and oriented to location and time presenting with a controlled and open airway, non labored
breathing, present radial pulses and normal skin color. No acute
distress is noted. No significant indications for spinal immobilization
were noted.
<<< PHYSICAL EXAMINATION >>>
HEENT - No injury appreciated, PEARL, no bleeding or discharges noted. No JVD or tracheal deviation noted. Carotid pulse present.
Chest/Lungs - Equal chest rise/expansion. Denies chest pain. Lung sounds clear, respiratory effort non labored.
Abdomen - Soft and non-tender. No masses appreciated.
Pelvis - Stable, normal motion.
Legs - No injury appreciated. Gait was observed to be unsteady.
Arms - Radial pulses present. Normal motion. No injury appreciated.
Posterior - No injury appreciated.
<<< REVIEW OF SYSTEMS >>>
Cardiovascular: Heart tones present, present pulses at extremities, no pedal edema noted.
Respiratory: Respiratory effort minimal, chest wall intact with equal expansion, pain free, lung sounds clear to auscultation
GI/GU: No incontinence noted. No gross distention or pain noted.
Musculoskeletal: No gross deformities or injuries noted. Normal gait. Range of motion within norm.
Skin: Color and temperature with norm. No gross infection, lesions, swelling or rash noted.
Neurological:
Mentation appears within norm for this patient. Eyes react and track
motion. Symmetrical facial tone. Equal hand grasps and foot motion.
Speaks without difficulty
Psychiatric: Oriented to time, place and person. Adequate recent memory. No anxiety, agitation or depression noted.
Pertinent history, medications and allergies listed in this report.
<<< INTERVENTIONS AND TREATMENT RESPONSE >>>
Vital signs assessed as listed in this report.
Cardiac monitor reveals:
12 lead EKG
IV access
Blood glucose level-
Patient pivoted with assistance to EMS stretcher. Secured with three or five straps in position of comfort. Patient was loaded into ambulance, stretcher locked and transport to receiving facility non-emergent with continued monitoring. Upon arrival at destination, patient status and condition was unchanged.
Brought into facility on stretcher. Patient transferred from EMS
stretcher via sheet transfer to hospital stretcher by two caregivers.
Verbal report given to staff nurse at receiving facility. Receiving nurse's signature collected on computer.
