As assisting a physician and scribing for him as he examines a patient that arrived in...
As assisting a physician and scribing for him as he examines a patient that arrived in the Emergency Room.
Paramedics report the patient Don Smith date of birth (DOB) July 1, 1985, was an unrestrained driver in a motor vehicle accident about 20 minutes ago with a chief complaint pain in the left lower quadrant of his abdomen, left arm, left leg and head. Patient denies any loss of consciousness or dizziness. Vitals were a blood pressure of 165/84, the pulse of 108, breaths of 24, the temperature of 96.8, pulse ox of 98 percent. Splints were placed on the left leg, and the left arm was in a sling. The head was wrapped with gauze with signs of blood.
- Summarize the above Paramedic report using abbreviations for the bolded items.
- Create one breakdown for each of the following system using medical terminology where appropriate:
- Integumentary
- Musculoskeletal
- Cardiovascular
- Respiratory
- Digestive
- Reproductive
- Endocrine
- Nervous
- The summary should indicate the overall condition of the patient and any contemplated treatments.
Some things to consider are patients history:
Diabetes, type I
High blood pressure
High cholesterol
Curvature of the spine
Asthma
GERD
Kidney stones
Depression & anxiety
Initial observations: (You may add any other things you think appropriate
Cut in the forehead above nose with bump 2 cm to the right side of the cut.
Elbow area black and blue with signs of bone pushing out on the skin.
Discoloration of skin in the abdomen area of pain.
Discoloration of knee area that appears enlarged.
Homework Answers
- Abbreviation
- DOB :01/07/1985
- Chief complaints (CC): left lower quadrant (LLQ)
- Blood pressure (BP)
- pulse (P)
- Breaths(R)
- Temperature (T)
- Pulse ix(SPO2)
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