Easter, Joanne
DISP: MICU 9-1 was Dispatched to GLC – Blue Ridge (CLASS 1) for a Altered Mental Status
PA: 73 Y/O/F having acute Altered Mental Status Patient is located in Room 117 Bed 1
AOS: To find a 73 Y/O/F lying in bed. Patient appeared to be breathing normally and “Glad to see us” and in minor discomfort caused by a fall in the past.
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ALS Assessment: Patient was conscious, alert and oriented to patients normal state of mind. Based mental status assessment from knowing patient from previous calls in the past. Patient did not appear to be in any life threatening distress. After ALS assessment was made downgraded patient care to BLS intervention.
Kim H. Hurst
EMT-P 144484
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HPI: Nursing staff on scene stated “The patient had undergone an Acute Change of Mental Status and per Family Physician would like the Patient transported to Harrisburg Hospital.”
PE: Upon examination Patients airway was naturally patent and patient was answering questions appropriately. Patient was CAO x4 (See ALS Assessment). A Hematoma was noted on the patients forehead accompanied by Brushing under both eyes as a result of a broken nose. Also Patients right arm was wrapped in an ACE Bandage. These previous conditions were caused by a fall on 11/02/2009. Patient denied any Dizziness and/or Nausea. Eyes were Equal, Round, and Reactive to light.
PMH: See Attached
Treatment: NONE
TX: Patient was moved from her bed onto the litter using a four-person lift. And secured using the Safety Straps (3). Patient was then moved into MICU 9-1 and transported without incident to Harrisburg Hospital. Upon Arrival Patient was moved from MICU 9-1 into Harrisburg Hospital where she was admitted into the ED, and transferred from the litter into a Hospital Bed. C1 gave a verbal report to the Charge Nurse and transferred care at that time.
——–END REPORT: Andrew R. Stueckroth 131004————–
