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Old 04-09-2004, 18:51   #7
Surgicalcric
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Join Date: Jan 2004
Location: Wherever my ruck finds itself
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DX: This section is to tell general details about the patient (age, sex,), why EMS summoned and what PT is being treated/transported for.

1º: Primary Survey - how patient found; A,B,C, & D.

2º: Secondary Survey- Physical findings both Pos & Neg as they relate to complaint; pupils, lung sounds, DCAP/BTLS, EKG, SAO2, ETCO2, etc...

TX: Treatment rendered, facility transported to, personnel PT care transferred to.

Δ: Changes in patient condition pos & neg.

HX: past pertinent medical history, MEDS, allergies, MD’s
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Sample from a recent call

DX: EMS summoned to residence of 54 y/o/w/♂ c/o chest pain w/o relief after SL NTG x 2.

1º: PT found seated upright; A,B,C+; A&O to person, place, time, events.

2º: PT c/o crushing type pain over mediastinum which began while mowing lawn, pain rediating down L arm, Pain 8 on 10 scale, non-reproducible on palm or respiration and began ≈30 min PTA EMS. Pain has not been relieved with ↑self TX. PT also c/o assoc severe SOB. B/P-80/54, Pulse-50/irreg, Resp-24/labored. PERRL, L/S-Rhonchi bilaterally w/ = mvmt, SAO2-88% on RA, ETCO2-32mmHg. LP-12 showing SB @ 48-54 BPM with frequent PVC’s non-perfusing. 12-lead showing acute inferio-septal MI.

TX: O2 NRB at 15-lpm, IV L hand/18ga NS KVO, IV R hand/18ga NS @ KVO. NTG .04mg SL(RPT x2@ 5min intervals), MS 5mg IVP (RPTx1 @ 10 min), Lasix 100mg IVP, Dopamine drip titrated @ 400mcg/min, T-PA 10mg IVP over 2min/ drip at 50mg/hr, –>F/W–>M-106. T-port Code3 to GMH ER. Oral report enroute to MCD-12. Transferred to bed CC#4 and left ICO RN and MD @ bedside after report given.

Δ: SAO2-↑94% with O2, B/P-↑98/64, Pt states no relief of pain but some relief of SOB, no change w/ follow on 12-lead.

HX: MD-Cano, NKDA, MEDS: NTG, PMH: Angina.
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