Your Ambulance Service
123 Main St
Anytown, MO 12345
[CHIEF COMPLAINT / RESPONSE] This crew responded to a call for a 34 year old female that was dispatched by 911 for Respiratory Distress. Unit responded emergency, with lights and sirens to the scene. The Chief Complaint for the patient is TROUBLE BREATHING. The primary problem appears to be Respiratory Distress. Upon arrival to the scene we found the patient sitting on chair at residence. The general impression of the patient was moderate distress. Fire department personnel were on scene. FD assisted with placing patient onto ambulance cot. FD placed patient on oxygen via a mask. Patient was assisted up, pivoted, placed onto wheeled stretcher. Patient was secured to stretcher using stretcher straps and stretcher was secured into ambulance. Patient was positioned on stretcher in high-fowlers position.
[HISTORY OF PRESENT ILLNESS] History was obtained from patient. This problem began 15 minutes ago. This problem has gotten worse since onset. Allergies: Latex; Penicillin; Patient stated she was taking a new medication as prescribed by her doctor for hormone replacement therapy. Shortly after taking the medication she started feeling like she couldn’t breathe and she starting to panic. She then contacted 911. Patient requests transport to Emergency Department for evaluation.
[ASSESSMENT – PRIMARY] The Paramedic has performed a complete head to toe ALS assessment on the patient. Patient is conscious and alert. Patient is oriented to person, place and time. This is normal for the patient.
NEURO/HEAD: Clear speech; Neuro assessment intact; No facial droop; No JVD; No loss of consciousness; No memory loss; Pupils equal, round and reactive to light; Trachea midline; CHEST/RESPIRATORY: Airway patent; Equal chest rise; No chest pain; Dyspnea – Moderate; Breathing – Tachypneic; Lung Sounds – Wheezing bilaterally, upper lobe.
ABDOMEN/GI: Flat; No complaint of nausea; Non-tender.
PELVIC/GU: No incontinence; Pelvis stable.
EXTREMITIES: Equal grips; Good pulse, motor function, and sensation in all extremities; No pain in extremities.
OTHER: No complaints of pain; Skin – warm, dry, color within normal limits.
DIAG: The 12 Lead EKG shows no acute ST elevation or depression. EKG rhythm remained Normal Sinus rhythm with no ectopics per paramedic.
V/S: Obtained at 13:57; Blood pressure – 122/87 by manual; pulse rate – 105, Regular rhythm at radial; respirations – 28 breaths per minute; SaO2 – 91% with 02 at 11-15 lpm; GCS = 15.
V/S: Obtained at 14:07; Blood pressure – 117/76 by manual; pulse rate – 98, Regular rhythm at radial; respirations – 20 breaths per minute; SaO2 – 95% with 02 at 1-6 lpm.
[RX / TREATMENT]
[14:00] OXYGEN: Oxygen was initiated by Attendant 1 at 15 lpm via non-rebreather mask. Patient’s condition improved. Authorized by protocol (standing order).
[14:03] MEDICATION: Attendant 1 assisted patient with their Albuterol 2.5 mg Nebulized. Patient’s condition improved. Medication authorized by protocol (standing order).
[ASSESSMENT – SECONDARY] An ongoing assessment was performed every 5 minutes by Attendant 1. Patient states the oxygen is helping. Patient states they are breathing easier now. Patient states they are feeling better.
CHEST/RESPIRATORY: Dyspnea now resolved.
[TRANSPORT] Patient was transported without incident and without delay. Patient was transported to emergency department. Patient moved from stretcher to emergency department cot via with help of crew to steady as they moved. All of patient’s belongings were turned over to the hospital staff and/or patient. Patient care and report given to emergency department nurse.
DOCUMENTATION: Patient signed consent on paper form. Nurse signed for patient transfer of care on paper form. Patient signed for HIPAA pamphlet on paper form. Notice of Privacy Practices pamphlet was left with patient.
– Report By: Philip D Goggin, EMT-P