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
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.
Secondary Assessment:
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
Treatments Administered:
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.
Additional Notes:
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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