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PCR: Penumonia

This is an example PCR narrative using the Pre-SOAPeD format. Read about Pre-SOAPeD and EMS Documentation here.

 

PRE-ARRIVAL:
Unit 292 responded emergent from headquarters with full crew and without delay for a reported Breathing Problem / Respiratory at 123 Hogwartz Lane in the city of Outer Space.

SUBJECTIVE:
-HPI-
On arrival, found a 61 year Male with a chief complaint of “I’m having trouble breathing,” as stated by patient. Secondary complaint(s) of Vomiting, Fever and Weakness.
Patient stated he awoke with above complaints this morning but recalled feeling normal last night before bed. Complaints worsened with movement, and patient felt best while lying in his bed. Patient describes respiratory distress as an inability to catch his breath and states he feels exactly like he has in the past when he’s contracted aspiration pneumonia. Patient had not tried any interventions before calling 911.

-Histories-
The patient’s medical history, medications and allergies are noted below.

-Review Of Systems-
GENERAL-Fever, chills, weakness;
RESPIRATORY-shortness of breath, dyspnea on exertion;
GU/GI-Vomiting, Nausea;

OBJECTIVE:
-Primary Exam-
Patient alert and oriented to person, place, time and event, airway patent lung sounds clear and equal bilaterally with the exception of ronchi in the upper left and even chest expansion, respiratory pattern rapid and labored, skin pale with positive signs of distal circulation. GCS of 15 (Eye = 4, Verbal = 5, Motor= 6).

-Secondary Exam-
Exam revealed pupils equal and reactive, abdomen soft, non-tender, non-distended in all four quadrants. Exam otherwise unremarkable.

-Lab Values-
Initial V/S of 172/80, P – 122 RR, R – 24. Initial SPO2 87% on Room Air. EKG showed Sinus Tachycardia 110-130s negative for STEMI.

ASSESSMENT:
The field impression of the patient was Pneumonia, unspecified.

PLAN:
Treatments were administered as follows:
07:15: Patient Assessment was performed successfully after 1 attempt.
07:17: Oxygen 12 Liters Per Minute (LPM [gas]) NRB/PRB per Protocol (Standing Order). The patient’s response was Improved.
07:31: 3 Lead ECG Obtained was performed successfully after 1 attempt.
07:33: 12-Lead ECG. Interpretation was Sinus Tachycardia 110-130, does not meet STEMI criteria. Lead: I, III, II, V1, V2, V3, V4, V5, V6, AVF, AVL, AVR.
07:33: 12 Lead ECG Obtained was performed successfully after 1 attempt.
07:35: IV Access – Extremity Vein20 gauge, was performed successfully after 1 attempt.
07:37: Ondansetron 4 Milligrams (mg) Intravenous (IV) per Protocol (Standing Order).
The patient’s response was Improved. The patient was transported to Our Lady of Holy Crap Hospital Non-Emergent.

DELTA:
Patients SPO2 rose to 96% and then 100% on NRB, respiration rate returned to normal and patient vocalized relief. Nausea subdued after ondansetron. IV lost en route removed and bandaged before arrival at ED.

-Hand Off-
Full report given to staff upon arrival. Patient transferred to bed 6 via pull sheet, left with bed locked, rails up in staff presence with all therapies continued.

Cite this article as: Scott Kostolni, EMT-P, "PCR: Penumonia," from SickPatient.com, November 3, 2017, date accessed: September 19, 2018 http://sickpatient.com/pcr-pneumonia/

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