11-01-10 Eligibility Period i 1 -30^-10 _Through_
Case IDg i 2 3 1 2 2 Number:
756J61
CASTILLO, FELIX
66U W WELLINGTON AVE BSMT
CHICAGO, IL
ONLY THE FOLLOWING PERSONS ARE ELIGIBLE:
FELIX CASTILLO ID#:15 1202900 DOB:ll-22-29
MEDICAL
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TOTAL NUMBER OF ELIGIBLE PERSONS: 1
00094396
.^3^V./:-
-Please see front of card for important information-
AMBULANCE
Dispatch 312-949-9500 Admin. 312-949-9595
Fax 312;949-9292
1.
PATIENT CARE REPORT
Trip #o( q q Date: _L_/1£L/Ji_ [Ml dH [
SCT
PATIENT INFORMATION:
Name
^frfrVvlte (Fire,) FiAit
(Ml)
Home Address
City
State
. ,Room*/Apt. No.
3a
^TLirt safari
st PHONE: ( 2nd PHONE: (
)
REASON FOR AMBULANCE TRANSPORT:
■UP LOCATION
3Hi
UNIT #:
IE
LICENSE #
PICK-UP UOCATIQN WITH RM ,
. LEVEL OF RESPONSE: Xl Scheduled □ Stand-By
[^Non-Scheduled □ Personnel Return □ Immediate Response □ Cancelled/Refused Call
■ □ Communicable
Disease - □ Emphysema
Dementia □ COPD___
HISTORY:
□ Cardiac :_
Hypertension
□ Glaucoma
□ Asthma "H Diabetic
□ denies .□ Other_
History Obtained From: rjFI. □ Family^Other
Last.Orat Intake:-:-
□ CVA w/deticits ■ (Y/N)_
□ Cancer _
"f^ Renal Failure
□ Seizure
□ Syncope _DUTI
□ Amputation ot
MENTAL/BEHAVIOR
QAIert x.
□ Confused
□ Lethargic
□ Unresponsive
□ Cooperative
□ Combative
□ Unpredictable
□ Disruptive
□ RestraintsType
1 2
_3
□ Elopement Risk 4. \rj Language Barrier 5.
6.
LUNG SOUNDS
L R
■QJ3 Clear
Current Isolation Precautions
_\
IT
□ □ □ □ □ □
□-Absent
□ Coarse Rales
□ Fine Rales
□ Wheeze
□ Rhonchi
□ Diminished
PUPILS
L R
□ □
S-Q.
□ □
□ □
□ □
□ □
□ □
Meds:
MA
□ None
□ Ukri
P.E.R.L. Pinpoint Midrange Dilated Responsive Unresponsive
SKIN COLOR
1. ^Q Normal
2. □ Pale
3. □ Flush
4. □ Cyanotic
SKIN TEMP.
1. ""^] Normal
2. □ Hot
3. □ Cold
4. □__
Weight _
lbs.
SKIN MOISTURE:
Normal
2. □ Moist 3. □ Dry 4. □ Diaphoretic
PHYSICAL ASSESSMENT
0 Deformity C Contusion A Abrasion P Penetration B Burn L Laceration S Swelling T Tenderness.
1 Instability C Crepitus Decub Ulcer □ Stage I
□ Stage II
□ Stage
□ Stage IV
(qpqpt.)
GLASGOW (RESPONSIVENESS) Eye-Opening
3 2 1
(Verb) (Pain) (None)
. Motor-Response 6> 5 4 3 . 2 1
(<5]jeys) (Local) (With) (Flex) (Ext) (None)
5
(Orient)
y Verbal-Response
A) 3 2
(Coirfu) (Inapp) (Incomp)
_ 1
(None)
Respiratory Effort
T^HNorimal)
□ .(Shallow or Retractive)
Physician:
Allergies:
Treatment Prior To Arrival:
1. □ None 4. □ First Aid
2. □ Extrication 5*Tn Other
3. □ CPR j. X
VITAL SIGNS rime B/P . ^ .
PULSE
IT
RESP.
Pujse
se Ox
Time
CARDIAC Rhythm ■ Deflb/W.S.
DRUGS Drug/Solution
DOSBy-
Route
~Z7
s:
7
21
AID GIVEN PATIENT:
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Airway Cleared |
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Ventilation BVM |
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Combitub E.T. |
ejvent |
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E.T. Attempt Breath Sounds by Stethoscope |
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Oxygen mask |
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Suction C.RR. |
cannula |
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trach |
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Defibrillation/Cardioverl |
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P |
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EDD |
c |
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v / |
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DexVChe Drugs |
Ttstick |
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V |
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Start I.V. fiuids Contact Bcxty/Fhiids/Needlestick |
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l.v. Attempt valsalva Maneuver Bleeding Control Spine Immob.
Splint_(type)
Anti-shock Trousers Dressing Applied Cold Application O.B. Delivery Vital Signs Physical Survey Communications
(History to Hospital) Chest Decompression
Draw Blood
DIVERSION? "£] No □ Yes (ff yes, complete & attach Diversion Form) \
COMMUNICATIONS: Log#
COMMENTS: f /KVto A v'/a \ w ^( S Cf cA O A- >n
I HAVE RECEIVED THE PATIENT, BELONGINGS, AND ALL NECESSARY INFORMATION.
Name - print: Signature.
Title
Medical Direction From: Communications □ Cell □ MERCI □ Phone Dr./RN oh Scene: License*:
Destination with Rm #:
CUM
TIME INFORMATION:
■I '
CallRecejyed
by Dispatcher Crew Dispatched Arrive Scene Depart Scene Amve'Destination Depart Destination Back-ln-Service
.LOW-EM:
CREW
1.
2.
Name
SIGNATURES: f . h n n _ f\
rrrl-completedlSy)" . A' EMP'#' ,'
License #
EMP#
License #
Name
EMP#
License #
Name
EMP#:
License #
WHITE- LIFELINE Copy YELLOW - EMS Program / :.PINK Patient Medical Reports GOLD - EMS Coordinator