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Readmit
2/14/1998 11:46 St. Jennifers Med Center
Dr. Croaker
History and Treatment Record
Ambulance Run Report
Reason: Shortness of breath. Airway; Normal
Breathing: Rapid
Circulation:
11:46 B/P=202/104 Pulse=120 Respirations=38
Skin: Moist, cool and pale.
Abdomen: Soft
Chest: Normal
Capillary refill: Normal
Eyes Open: #1 Spontaneous #2 Not at all #3 Not at all
Verbal Response: same as above-#1,2 and 3.
Motor Response: same as above-#1,2 and 3.
Pupils: #1-size 2 / reactive. #2&3- size 3 / non-reactive
Chief Complaint: Hyperventilating with feeling near snycopal.
History of Present Injury: Patient discharged approximately 45 minutes
ago from IMC ICU called with same complaints as last evening.
209
2/14/1998 12:10 St. Jennifers Med Center
Dr. Mergent
History and Treatment Record
Emergency Room Nursing Record Date: 2-14-98 Time in: 1210 Time out: 1430
Treatment in Progress Upon Arrival: CPR, airway, oxygen and monitor.
Triage Level: Critical
Current Medications: Zesteril and Nitroglycerin prn.
Allergies: no known drug allergies.
Focus: Code Blue. Patient discharged from hospital one-hour prior to
calling 911 due to SOB. Paramedics arrived to patient being dyspneic-respiratory
arrest-asystole.
Temp. pacemaker on without palpable pulse-skin cool dry-mottled dusky-pupils
fixed and dilated.
See code blue sheet.
Discharged to the morgue via stretcher. 206
2/14/1998 15:00 St. Jennifers Med Center
Dr. Mergent
History and Treatment Record
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