emergency care forms

Project Lead The Way, Inc.Copyright 2010

EMERGENCY CARE AND TREATMENT ADMISSION FORM

PERSONAL INFO TRANSPORTATION TO HOSPITAL ARRIVAL VITALS

NAME X PRIVATE VEHICLE DATE TIME TIME 9:30am

Amber Elizabeth Julian - P1 AMBULANCE5/14/2009 9:15AM

BP 80/40

DATE OF BIRTH MED-EVAC PULSE 110

7/14/2004 OTHER (DESCRIBE) TIME SEEN BY PROVIDER RESP. 30

GENDER Female 9:45AM TEMP. 98.6

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

All childhood vaccinations are up to date. NON-URGENT

OFFICIAL MEDICAL RECORD COPY

CHIEF COMPLAINT(S) (Include symptom(s), duration)

Patient is having trouble breathing and complains of bouts of dizziness. Symptoms began while the young girl was playing in her back yard.

CURRENT MEDS (Tetanus immunization and other data)

DESCRIBE (1) Pertinent History; (2) Examination - Include results of tests and X-Rays; (3) Diagnosis; (4) Treatment/Procedures - Include medication given and follow-up

(1) Patient is an apparently healthy 4-year-old girl. There is no personal history of allergies, although the father is allergic to seafood as well as pet dander. The mother reported that she may have lost consciousness during the drive to the hospital, but she could not be sure.

(2) Upon examination, patient had low blood pressure, high respiratory rate, and mild swelling of the respiratory tract.

(3)

(4)


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NAME X PRIVATE VEHICLE DATE TIME TIME 12:22a 1:25a

Jim Russell - P2 AMBULANCE2/23/2009 10:00PM

BP 135/85 140/80

DATE OF BIRTH MED-EVAC PULSE 90 92

3/4/1979 OTHER (DESCRIBE) TIME SEEN BY PROVIDER RESP. 15 16

GENDER Male 12:20AM TEMP. 100.1 101.7

WEIGHT 190 HEIGHT 6' 0"

CATEGORY

EMERGENT

URGENT

Ibuprofen (600mg every 4 hours) for pain; Acetominophen for fever NON-URGENT



Patient complains of a severe toothache and persistent fever. He had root canal surgery a week ago.



(1) Patient has a history of low blood pressure. All previous cardiac workups were normal, although the patient now notes occasional heart palpitations or skipped beats. Root canal surgery was completed with no complications. The pain subsided three days after the procedure and the patient returned to work as a teacher. The pain has returned over the last two days. Because it was after hours, the patient was told to come to the emergency room.

(2) Notable swelling is appreciated around the left lateral incisor. Small amount of pus is visible. Patient presents with a fever and has been experiencing night sweats. Patient has been unable to eat due to high sensitivity in the area.

(3)

(4)


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NAME X PRIVATE VEHICLE DATE TIME TIME 2:30p 3:09p

David Argula - P3 AMBULANCE12/27/2009 2:06pm

BP 65/30 55/30



GENDER Male 3:00PM TEMP. 99.1 99.4

WEIGHT 22lbs HEIGHT 28in

CATEGORY

EMERGENT

URGENT

All vaccinations are up to date NON-URGENT



Parents of the child found a half-empty bottle of baby aspirin in their suitcase. The baby is thought to have consumed the pills, but they can not be sure of how many.



(1) The baby was born 6 weeks premature, but has had no complications. The family is on vacation in the area. The mother made sure to pack medications for all members of her family. The baby apparently climbed out of the portable crib during naptime and somehow reached an open bottle of baby aspirin (father takes one each day for his heart). The parents do not remember how many pills were left in the bottle, but they are sure some are missing.

(2) Patient is quiet and breathing is shallow. Quick pulse changes are noted. The patient is drooling and has occasional tremors or convulsions.

(3)

(4)


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NAME PRIVATE VEHICLE DATE TIME TIME 7:05am 7:25a

Priya Ghosh - P4 X AMBULANCE6/17/2009 7:32am

BP 122/80 120/75



GENDER Female 7:55AM TEMP. 98.2 98.4

WEIGHT 145 HEIGHT 5'7''

CATEGORY

EMERGENT

URGENT

Tetanus last month upon employment at new job; Lipitor NON-URGENT



Patient was hit by a car while bicycling to work. On the scene, the patient complained she had trouble moving her legs and could not twist at the waist.



(1) The patient is generally healthy with a family history of hypercholesterolemia. Patient reports she often forgets to take her medication. She is currently training for a triathlon and is in excellent physical condition.

(2) On the scene, the patient was alert and talking. She is lucid when she arrives in the ER. She has various cuts and contusions on her face and right arm, but blood loss is minimal. Examination reveals no visible broken bones, but her pelvis is extremely tender. Patient has limited range of motion from the hip joints. Patient is sent for diagnostic scans.

(3)

(4)


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NAME PRIVATE VEHICLE DATE TIME TIME 9:10p

Michael Helms - P5 AMBULANCE8/13/2009 8:45pm

BP 140/87


10/10/1971X

OTHER (DESCRIBE) TIME SEEN BY PROVIDER RESP. 19

GENDER Male Squad car 9:25PM TEMP. 98.1

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

Coumadin; Zyban; last tetanus shot was over ten years ago NON-URGENT



Patient was shot in the left shoulder while chasing a suspected robber. There does not appear to be an exit wound. Patient complains of tingling in the arm.



(1) Patient is a police officer with a history of deep vein thrombosis (DVT) who currently takes Coumadin. The patient is a self-reported one pack a day smoker, although he has been trying to quit.

(2) On the scene, the patient continued pursuit of the suspect for twenty minutes after injury occurred. The bullet appears to have missed the major blood vessels, but blood loss is significant. Patient begins to shift in and out of consciousness upon arrival. An exit wound cannot be located, so the bullet is suspected to remain in the body. The patient now reports tingling in the arm.

(3)

(4)


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NAME PRIVATE VEHICLE DATE TIME TIME 8:05a

Doris Dingman - P6 X AMBULANCE7/24/2009 8:34am

BP 140/85



GENDER Female TEMP. 98.2

WEIGHT 108 HEIGHT 5' 2"

CATEGORY

EMERGENT

URGENT

Lopressor; oral estrogen NON-URGENT



Patient slipped getting out of the shower. She is unable to put pressure on her right leg and complains of wrist pain.



(1) Patient is a 72-year-old woman with a history of high blood pressure. She has recently been unsteady and has broken four bones in the past two months – two of these breaks were from minor home accidents. The patient noted that she has not been cooking much for herself since her husband died two years ago and relies on frozen meals.

(2) Patient called 911 from her home. Her right wrist and right ankle are extremely swollen and discolored. The patient can put little to no weight on the right leg. Blood pressure, heart rate, and respiration appear to be stable.

(3)

(4)


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NAME X PRIVATE VEHICLE DATE TIME TIME 5:30p

Drea Nunzio - P7 AMBULANCE9/23/2009 4:45pm

BP 100/60



GENDER Female 6:35PM TEMP. 99.5

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

All vaccinations are up to date; just finished cycle of amoxicillin NON-URGENT



Patient has been vomiting for the past two days and has been unable to hold down any food/fluids.



(1) Patient is a 7-year-old girl with a history of otitis media and chronic bronchitis. Vomiting began late in the evening after the patient returned from a soccer party. The patient’s father suffers from Crohn’s disease.

(2) Patient is extremely lethargic and complains of a headache. Vomiting continues in the ER accompanied by stomach pains. The patient and her family eat the same foods at home and no one else in the family is sick.

(3)

(4)


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J.D. Thomas - P8 X AMBULANCE10/2/2009 7:35PM

BP 110/78



GENDER Male 8:15AM TEMP. 97.6

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

None; NKDA NON-URGENT



Patient passed out during a football game after a hard hit. He was extremely disoriented and was escorted off the field.



(1) Patient has no medical history of syncope or neurological deficit. He has not missed a day of school in over 7 years. 20 minutes after the incident on the field, the patient appeared lucid. However, he has no recollection of what happened and why he is no longer at the game.

(2) Upon examination, the patient appears alert, but has trouble maintaining balance. He reports a slight ringing in his ears. After a few hours, his speech began to slur.

(3)

(4)


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Stacey Reeves - P9 X AMBULANCE6/1/2009 10:00am

BP 90/60




WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

Atripla; Vitamin B12 supplements; multivitamin; tetanus shot 1/15/2009 NON-URGENT



Patient presents with severe lacerations on the distal phalanges of the right hand. Injury occurred at 9:05AM.



(1) Patient was attempting to remove material from the blades of a lawnmower when the power shifted on. She was able to remove her hand quickly, but there is severe damage to the fingers. Patient has been HIV positive since 2004. Her T-cell count had always stayed within normal limits. Her husband called 911 and attempted to stop the bleeding using pieces of rope.

(2) There are severe lacerations on the 2nd and 3rd finger. An open fracture is visible, but further imaging is required to determine if there are additional breaks. Since the patient was able to cut off blood flow to the injured area, blood loss was halted, but is still significant. The patient is pale and clammy and reports pain of 7 on a scale of 1-10.

(3)

(4)


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Sela Montogomery - P10 AMBULANCE6/6/2009 12:15pm

BP 100/69



GENDER Female 3:30PM TEMP. 98.5

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

Paxil; occasional OTC sleeping pills NON-URGENT



Patient complains of visual and auditory hallucinations and difficulty concentrating. Symptoms have been on and off for the past three months.



(1) The patient suffered bouts of depression throughout high school but was treated with a combination of medication and psychotherapy. She has been feeling tired lately, but she can’t seem to fall asleep at night. A coworker found the patient wandering the streets outside of the office and brought her in. The patient lives with a roommate who has been called.

(2) The patient could not focus during the examination and her speech was disorganized. The patient alternated between a flat affect and unpredictable emotional responses. When lucid, the patient reports hearing voices that become worse when she is alone. Blood pressure, respiration, and heart rate were all normal. The patient does not have a fever.

(3)

(4)


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NAME X PRIVATE VEHICLE DATE TIME TIME 7:10a

Maria Flores - P11 AMBULANCE9/12/2009 6:45AM

BP 150/90




WEIGHT 165 HEIGHT 5'5"

CATEGORY

EMERGENT

URGENT

Prenatal vitamin; iron supplements NON-URGENT



The patient, 28 weeks pregnant, is experiencing regular contractions and pain in the abdomen. Pain started at 3AM - first attributed to heartburn and gas.



(1) The patient is a 30-year-old woman. This is her first clinical pregnancy. She has a history of miscarriage and elevated blood pressure. The patient was recently diagnosed with gestational diabetes. Not wanting to go on medication, she has been trying to control her blood sugar with diet and exercise.

(2) The patient is experiencing regular, mild contractions every 10-12 minutes and a low, dull backache. Blood pressure is elevated. The amniotic sac is still intact. Fetal heartrate appreciated by Doppler ultrasound - 138bpm.

(3)

(4)


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Jon James - P12 AMBULANCE9/17/2009 6:30PM

BP 100/75



GENDER Male TEMP. 98.9

WEIGHT HEIGHT

Patient presented with burns on both hands and moderate pain. CATEGORY

EMERGENT

URGENT

Vicodin; daily baby aspirin; multivitamin NON-URGENT





(1) The patient is a 56-year-old man who lives alone. Attempting to answer the phone and flip hamburgers, he accidentally moved the pan from the gas and ignited his sweatshirt. Upon reflex he used his hands to pat out the fire, sustaining burns on both hands. The patient admits to popping two vicodin he had left from dental surgery before calling a friend to take him to the hospital.

(2) Examination reveals an area of 3rd degree burn on the left hand. The second and fourth finger are charred and the flesh appears waxy. Large blisters cover the skin and ooze a clear fluid. The patient reports little to no pain at the moment.

(3)

(4)


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Kayleigh Dubois - P13 AMBULANCE9/15/2009 4:14pm

BP 90/60


3/23/1991X

OTHER (DESCRIBE) TIME SEEN BY PROVIDER RESP. 16

GENDER Female Walked 7:00PM TEMP. 99.6

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

None NON-URGENT



Patient complains of abnormal fatigue and has recently noted a palpable lump on the side of her neck.



(1) The patient is an 18-year-old college freshman. Patient was diagnosed with Hodgkin's lymphoma at age 7. After two rounds of chemotherapy, she was deemed cancer-free and has been in remission for the past 10 years. The patient reports periodic night sweats and a weight loss of about 5 pounds. She attributes her weight loss to crappy dorm food.

(2) The lymph nodes in the neck are swollen and the patient has a low grade fever. (3)

(4)


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George Hampton - P14 X AMBULANCE5/24/2009 8:18am

BP 160/97



GENDER Male TEMP. 98.6

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

Caduet; Glucotrol; aspirin NON-URGENT



Patient is experiencing numbness in his left arm and a sudden onset headache. This morning the patient began having trouble speaking.



(1) The 46 year-old patient, a type II diabetic, has a family history of heart disease. His mother died of a heart attack at age 49 and his brother recently had triple bypass surgery. Four months ago, the patient was treated for minor transient ischemic attacks (TIAs) and was sent home on blood thinners.

(2) The patient is having trouble finding the words to explain what is happening to him. When asked to raise his arms over his head, the patient is unable to keep the right arm in the air.

(3)

(4)


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Michael Billups - P15 AMBULANCE8/7/2009 11:14am

BP 100/74



GENDER Male 1:25PM TEMP. 99.2

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

Folic acid, Exjade; Motrin NON-URGENT



Patient presents with severe abdominal pain that has lasted for the past 24 hours. The patient notes some pain in the joints of the leg.



(1)The 15 year-old patient has sickle cell disease. Patient has had numerous blood transfusions over the past ten years – the last of which was 4 months ago. Two weeks ago, he was prescribed antibiotics for a urinary tract infection, but only took for 7 of the 10 days specified.

(2) Skin is pale and shows the beginnings of jaundice. Both heart rate and respiratory rate are slightly elevated. The stomach is extremely tender to the touch and the spleen appears enlarged.

(3)

(4)


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NAME PRIVATE VEHICLE DATE TIME TIME 5:30p 6:00p 6:30p

Hailey Simko - P16 AMBULANCE9/29/2009 7:34pm

BP 100/78 96/50 86/50

DATE OF BIRTH X MED-EVAC PULSE 99 70 50

8/18/1967 OTHER (DESCRIBE) TIME SEEN BY PROVIDER RESP. 17 15 12

GENDER Female 7:35PM TEMP. 98.1 97.6 97.1

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

None; Latex allergy NON-URGENT



Patient was pinned in car following a motor vehicle accident. A piece of metal from the car is still lodged in the patient's chest. Patient is having trouble breathing.



(1) Rescue crews were able to extract the patient, but after 2 hours of work. EMS on the scene worked to stabilize the patient while she was still in the car. Patient received oxygen by mask and fluids via a central line. Pressure bandages were placed on the chest. Patient has no significant medical history, but does have a severe latex allergy as reported by a medical alert bracelet.

(2) Breathing is shallow and pulse is thready. Patient is unconscious when she reaches the ER. She has been shocked twice by a defibrillator in the helicopter, but she is currently stable. Blood loss is significant. Metal shards remain lodged in her chest and left thigh.

(3)

(4)


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NAME PRIVATE VEHICLE DATE TIME TIME

AMBULANCE BP

DATE OF BIRTH MED-EVAC PULSE

OTHER (DESCRIBE) TIME SEEN BY PROVIDER RESP.

GENDER TEMP.

WEIGHT HEIGHT

CATEGORY

EMERGENT

URGENT

NON-URGENT





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