Ambulance report Essay Example

  • Category:
    Nursing
  • Document type:
    Assignment
  • Level:
    Undergraduate
  • Page:
    2
  • Words:
    998

PATIENT ONE: DIAGNOSIS OF ANAPHYLAXIS

CASE DETAILS

DATE 18/02/17 CASE NUMBER 15232622623

START Trip KM 1000 Start pt KM 1005 Area Code

Time of Ino Finish Trip KM 1020 Finish pt Km 1005 hosp. notified 11:45

Call received 11:00 Unit dispatched 11:02 On case 11:03 On scene 11:20 at patient 11:22

Depart scene 11:45 At destination 12:0 Case cleared 12:30 On centre 13:00 Back up called

Patient building

Address number 123 SMITH STREET

Town DAYRONIA

Postal code 6055

TO ROYAL PERTH HOSPITAL

Destination ACCIDENT AND EMERGENCY DEPARTMENT

Postal code

Id Number level Station Officer print name and sign

TIMES 11:25 11:30 11:45

Pulse rate/regularity 137 128 100

Respiratory rate/effort 36 30 25

Oxygen saturation 85 94 97

Systolic BP 96 102 115

Diastolic BP 54 58 67

Temperature 35.9 36.2 36.3

Colour Dark Blue Pink Pink

Moistness Moist Moist Moist

Capillary refill 4 seconds 4 seconds 3 seconds

PATIENT DETAILS

Surname PHILIP

Given Names MICHELLE

Address 123 SMITH STREET

Postal code DAYTONIA 6055

Sex M Date of birth 13/07/1985 Age 36 year

OVA/pension No Patient Telephone

Next of Kin (name and relationship) Next of Kin Telephone

ADMINISTRATION

Employer/Group Subscription/Guardian Name

Occupation

Billing address

Postal code

Subscriber Number Expiry date

Travel Insurance Company or private health fund Country

Policy no Service Charge ($)

Dispatched to: 36 years male c/o difficulty breathing, syncope, itchy skin

On arrival: Patient was lying in bed attended by his wife who was dressing him up, conscious, breathing noisily.

Patient history: He has no known history of hypertension or Asthma. He has never had an hospital admission. He is allergic to chicken meat.

Presenting history/On Examination

Airway partially patent as evidenced by loud wheezes and labored breathing. On auscultation crackles were detected. Radial pulse was weak but regular. There were no obvious injuries observed but patient has swollen cold extremities. Patient verbalized that he was not getting adequate oxygen and had palpitations.

He had been well in the morning until he was bitten on the left ankle by unknown insect at 0800 while weeding in his farm. The bite-site is swollen. He felt some pain but it was not worrying at that time. Thirty minutes later the bite site was swelling and he was developing difficulty breathing. Therefore, he returned to the house, washed the bite site with salty water and took Ibuprofen 400 mgs orally to manage the pain.

Vital signs taken were as follows, Respiratory rate 36, Systolic BP 96, Diastolic BP 54, Temperature 35.9 Pulse rate 137.

Remarks/Comments

The immediate management was to improve performance of the respiratory and cardiovascular systems. The acute onset of symptoms after an insect bite and absence of history of cardiac and respiratory diseases rules out chronic illnesses

Medications

Adrenaline

Oxygen therapy

Allergies

He has no known drug allergies

Provisional diagnosis Triage Colour/No Red

ANAPHYLACTIC SHOCK

Time Treatment Dose Route Treatment effective (yes/no)

11:25 Adrenaline 0.3mL IM Yes

11:25 Oxygen Therapy 10L Non-Rebreather Mask Yes

11:36 Adrenaline 0.3mL IM Yes

11:40 Benadryl 50gm IM Yes

Transport considerations

The patient was transported in a recumbent position with the extremities elevated.

PATIENT TWO DIAGNOSIS OF FRACTURE FEMUR

CASE DETAILS

DATE 17/05/17 CASE NUMBER 10489090484

START Trip KM 2000 Start pt KM 2005 Area Code

Time of Ino Finish Trip KM 2020 Finish pt Km 2005 hosp. notified 21:45

Call received 21:00 Unit dispatched 21:02 On case 21:03 On scene 21:20 at patient 21:22

Depart scene 21:45 At destination 22:0 Case cleared 22:30 On centre 23:00 Back up called

Patient building

Address number 127 SMITH STREET

Town DAYRONIA

Postal code 6055

TO ROYAL PERTH HOSPITAL

Destination ACCIDENT AND EMERGENCY DEPARTMENT

Postal code

Id Number level Station Officer Print Name and sign

TIMES 21:25 21:30 21:45

Pulse rate/regularity 151 128 100

Respiratory rate/effort 28 26 25

Oxygen saturation 99 94 97

Systolic BP 122 115 110

Diastolic BP 58 54 54

Temperature 36.7 36.4 36.2

Colour Pink Pink Pink

Moistness Moist Moist dry

Capillary refill <3 seconds <3 seconds <3 seconds

PATIENT DETAILS

Given Names MICHELLE

Address 127 SMITH STREET

Postal code DAYTONIA 6055

Sex F Date of birth 13/07/1960 Age 57 year

OVA/pension No Patient Telephone

Next of Kin (name and relationship) Next of Kin Telephone

ADMINISTRATION

Employer/Group Subscription/Guardian Name

Occupation

Billing address

Postal code

Subscriber Number Expiry date

Travel Insurance Company or private health fund Country

Policy no Service Charge ($)

Dispatched to: 57 years female c/o fall and injury of the left foot.

On arrival: Patient lying on the floor (right lateral position) in the kitchen under company of the granddaughter. She is conscious, groaning and praying loudly. She verbalized fear of death. Teardrops were visible on her face.

Patient history: She was admitted for a week, six months ago with history of diarrhea. No known history of hypertension, diabetes, asthma. No known history of allergies. Lives with her 12-year-old granddaughter.

Presenting history/On Examination

Patient was preparing supper with a 12-year-old granddaughter in the kitchen when she stepped on a piece of bar soap, slide and fell down. She could not stand up or sit down due to enormous pain on her left thigh. The granddaughter tried to lift her up without success.

One physical examination, the left thigh is swollen and tender at the middle half. There is no opne wound. Pulses on the ankle of the left foot are weak and rapid. There are no other associated injuries.

Vital signs taken were as follows, Respiratory rate 30, Systolic BP 122, Diastolic BP 58, Temperature 36.4 Pulse rate 151.

Remarks/Comments

Absence of obvious signs of injury and tenderness in other parts of the body excludes other differential diagnosis.

Medications

Ibuprofen to manage pain

Diazepam to manage anxiety

Allergies

He has no known drug allergies

Provisional diagnosis Triage Colour/No Red

FRACTURE FEMUR

Time Treatment Dose Route Treatment effective (yes/no)

21:25 Ibuprofen 400mg P.O Yes

21:25 Diazepam 10mg P.O Yes

21:40 Normal Saline 500ms I.V infusion Yes

Transport considerations

The left extremity was put on splint as it was found and patient was transported lying in a left lateral position