AGE:  20 YEARS
REASON WHY YOU WERE DISPATCHED:mvc/ roll over
COMPLAINT: left facial swelling, concussion
SUBJECTIVE:pt was standing next to car on arrival. pt stated he does not remember accident or getting out of the car. pt was wearing seatbelt and airbags did deploy. pt also complained of a headache and nausea.
OBJECTIVE: a.o.s to find pt standing next to roll overed car. assisted pt to the med unit. noticed left side facial swelling. performed rapid trauma assessment on pt. found left side facial swelling. checked and found no crepidus. pt aox3. on the ride to the hospital pt started to become sleepy. pupils were pearrl. pt has no medical history, nkda, takes no medications. transported to closes ER.
TREATMENT:took pts vitals.
CHANGES:

SELF REPORT SKILLS

 Directions: Check the box for all the skills you performed for this patient then press the 'Input Skill' button.  Click the delete button to remove extraneous skills.

DeleteObtain A Patient History from an Alert and Oriented Patient3/26/2017 9:15:52 PM 
DeleteComprehensive Normal Adult Physical Assessment Techniques3/26/2017 9:15:55 PM 

 

SELF REPORT TAGS

Directions: Check the box for all patient conditions, ages, and procedures (yes, some of the procedures would also be recorded above) that you peformed for this patient then press the 'Input Tag' button.  Click the delete button to remove extraneous skills.

 

 
  Mission Complete, Ready To Do Another PCR or Quit



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