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Emergency Medical Report

Emergency Medical Report

Patient Information

Patient Name:

[Your Name]

Patient ID:

123456789

Date of Birth:

January 1, 2050

Gender:

Male

Contact Information:

123-456-7890

Incident Details

  • Date and Time of Incident: October 1, 2070, at 14:30

  • Location of Incident: Intersection of 5th Ave and Main St, Springfield, IL

  • Description of the Event: The patient was the driver of a red Honda Civic that collided with a tree after losing control while navigating a sharp turn at approximately 30 mph. Witnesses reported that the vehicle swerved suddenly, indicating possible distraction or mechanical failure. Emergency services were called by bystanders who observed the accident.

Medical History

  • Pre-existing Medical Conditions:

    • Hypertension, diagnosed in 2055, was managed with medication.

    • Asthma, using an albuterol inhaler during episodes, last used two days before the incident.

  • Allergies: None reported, but the patient states a mild allergy to penicillin (rash).

  • Current Medications:

    • Lisinopril 10 mg daily for hypertension.

    • Albuterol inhaler, 90 mcg, as needed (two puffs during asthma episodes).

Vital Signs

  • Blood Pressure: 130/85 mmHg (normal, but elevated from baseline)

  • Heart Rate: 95 bpm (slightly elevated due to anxiety)

  • Respiratory Rate: 20 breaths per minute (slightly elevated)

  • Temperature: 98.6°F (within normal range)

  • SpO2 Level: 96% on room air (improved to 98% with supplemental oxygen)

Assessment

  1. Primary Assessment:

    • The patient is alert and oriented to person, place, and time, though displaying signs of anxiety.

    • The airway was clear, and no obstructions were noted.

    • Breathing is adequate but slightly labored; the patient reports tightness in the chest.

  2. Secondary Assessment:

    • Physical Examination Findings:

      • Contusions on the forehead and left shoulder, suggest impact injuries.

      • Tenderness and swelling were noted in the left ankle (possible sprain).

      • Pupils equal and reactive to light, with no signs of neurological deficits.

  3. Visible Injuries or Symptoms:

    • Moderate swelling and discoloration around the left ankle; minor abrasions on the right arm (3 cm in diameter) with no active bleeding.

    • The patient reports a pain level of 6/10 in the left ankle and 4/10 in the right arm.

Interventions Provided

  1. Treatments Administered:

    • Administered 4 liters of supplemental oxygen via nasal cannula to alleviate breathing discomfort.

    • Applied a cold pack to the left ankle to reduce swelling and provide comfort.

  2. Procedures Performed:

    • Immobilized left ankle using a padded splint and secured with elastic bandages to prevent movement.

    • Wound care was applied to abrasions on the right arm with antiseptic dressing and gauze to prevent infection.

  3. Additional Notes:

    • Emotional support was provided; the patient was reassured about medical care and treatment.

    • Monitored vitals every 5 minutes during transport for any changes.

Transport Information

  • Mode of Transport: Ambulance, equipped with advanced life support (ALS) capabilities.

  • Destination Hospital: Springfield General Hospital, Trauma Unit.

  • Time of Arrival at the Hospital: 15:10

  • Accompanying Staff: EMT Sarah Smith, Paramedic Mark Johnson, and Student Intern Lisa Chang.

Name of Healthcare Provider

[Your Company Name]

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