Emergency Medical Report

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Patient Information

Patient Name:	[Your Name]
Patient ID:	123456789
Date of Birth:	January 1, 2050
Gender:	Male
Contact Information:	123-456-7890

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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.

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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).

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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)

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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.

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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.

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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.

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Name of Healthcare Provider

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