Rietheimer, Helene
9-1 DISPATCHED TO 4700 OAKHURST BLVD. CLASS ONE BY DAUPHIN COUNTY 911 SYSTEM
DISPATCH COMPLAINT – Stomach Pain
PAI- 89 Y/O/F in Room 107 Staff will rendezvous at the front doors
AOS to find pt 89b y/o W, F sitting upright on her couch and offering a c/o ” My belly hurts”. Pt is CA&O x4, speaking in complete and full sentences, and appeared to be in minor distress. A & V, HPI & PMH obtained. Determined at this time that pt was of BLS in nature and downgraded to BLS partner. EMT Stueckroth
HPI/MOI – Patient stated that she had Gall Stone Surgery a few weeks prior and stated she had pain at the Incision Site and in the ULQ (non-radiating)
DAILY MEDICATIONS – See Attached
DRUG/FOOD ALLERGIES – NKMA
PHYSICAL EXAM
NEURO/LOC-CAOx4,
NO DEFICITS NOTED, SPEECH CLEAR, ANSWERS APPROPRIATELY.
SKIN-INTACT, WARM, DRY, NORMAL APPEARANCE, GROSSLY ATRAUMATIC, ACYANOTIC
AIRWAY- NATURALLY PATENT, ABLE TO SPEAK IN FULL SENTENCES
HEENT-PERRL, (-) DCAP BLS TIC (-) JVD. TRACHEA MID-LINE, NOSE EARS AND MOUTH FREE OF FLUID/BLOOD.
CHEST- (-) DCAPP BLS TIC STABLE, SYMMETRICAL EXPANSION, LUNGS CLEAR PRESENT ALL FIELDS.
ABD- (-) DCAPP BLS TIC SOFT NON-TENDER (Incision from surgery in ULQ)
PELVIS-(-) DCAP BLS TIC, STABLE
GU/GI- NO INCONTINENCE NOTED. NO COMPLAINTS.
EXTREMITIES- (-) Deformity (+) DISTAL PMS.
INITIAL VITAL SIGNS- See Attached
TREATMENT- None
TRANSPORTED- Assisted Patient onto the litter where she was secured and moved into MICU 9-1. Patient was then transported to Harrisburg Hospital (per Patient Request). Upon arrival report was given to the Charge Nurse and the patient was moved onto a Hospital Bed where care was transferred to Hospital Staff.
OUTCOME- PT REMAINED STABLE/UNCHANGED THROUGHOUT ENCOUNTER
RECEIVING FACILITY- Harrisburg Hospital
—–END—–
Andrew R. Stueckroth
PA EMT-B 131004
