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Page 1 of 12 ROGERS, CLAUDE EMR AMR PLACER Doe ese 8 YEAR) a PATIENT CARE REPORT EX: MALE co (CASE #: 5371254 os: os:s02018 SERVICE MODEL AGENCY AMR DISPATCH INFORMATION TIMES, FROM: CALLER: ROSEVILLE PO CALLRECENVED: 120546 £990 OAKRIDGE DR UNMT: Pu140 DISPATCHED: 120558 ROSEVILLE. CASE001 RESPONSE MODE: LIGHTS AND SIREN ENROUTE: 120020 (SKILLED NURSING FACILITY, ‘TRANSPORT MODE: LIGHTS AND SIREN ATSCENE: r21233 10: ALS ASSESSMENT: AMR PARAWEDIC. ATPTSIDE: © 121300 SUTTER ROSEVILLE MED CENTER DISPOSITION TRANSPORT: 12807 1 MEDICAL PLAZA DR, ‘TRANSPORTED- TO HOSPITAL ERED ARRIVAL: 122522 ROSEVILLE, CA.S9651 CARE TRANSD: 122700 (HOSPITAL ED) Leeds bike AVAILABLE: 123058 ROOMIDEPT: HOSPITAL-EMERGENCY ROSEVILLE FIRE peau ‘SCENE MILES: 00 DESTINATION DECISION: DESTINATION MILES: 4.0 CCLOSESTIMOST APPROPRIATE TOTAL MILES: “0 PATIENT DEMOGRAPHICS NAME: ROGERS, CLAUDE Dos: onne93s ADDRESS: £30 OAKRIDGE OR AGE: 89 YEARS CITY, STATE ZIP: ROSEVILLE, CA 98601 GENDER: MALE PHONE: CELL PHONE: ssn INSURANCE: MEDICARE POLICY: 441340817 RESPONSIBLE PARTY: ROGERS, CLAUDE PHONE: ETHNICITY: CAUCASIAN rove: NARRATIVE. NARRATIVE ARRIVED TO FIND 63 YEAR OLD MALE SITTING IN WHEELCHAIR IN SNF. PT BEING TREATED BY RFO PARAMEDIC. PTSSCC ALOC. PER STAFF PT AS PLACED OUTSIDE IN WHEELCHAIR FOR A FEW HOURS. SNF STAFF FORGOT ARGUT FT. WHEN THEY GOT PT HE WAS ALOC, HOT TO THE TOUCH, FLUSHED AND NOT SWEATING, PT UNRESSONSIVE EXCEPT FOR VERBAL AT TIMES, NON ‘VERBAL, WILL HAVE PURPOSSFULE MOVMENT. GCS=11. ASSESSMENT AS STATED, ASSESSMENT DONE BY RFD. ‘TX BY RFD: ASSESSMENT, VIS. 02 SAT. S34KRA, FSEGH164, EKGHST. COOLING MEASURES WITH COLD PACK, IV OPEN x2, ‘TX BY AMR. PT LOADED ONTO GURNEY AND INTO AMBULANCE, TRANSPORTED C-3 TO SAMC, VIS ENROUTE. 02 NC @2LPM WITH SSATINCREASING. ALL GARE DONE BY RFD. BASE CONTACT BY RFD PARAMEDIC, ARRIVED TO SRMC WITHOUT CHANGES. ‘TRANSFERRED CARE TO ER RN. IMPRESSION PRIMARY IMPRESSION: ENVIRONMENTAL - EXPOSURE ‘SECONDARY IMPRESSION: NEUROLOGICAL - ALTERED MENTATION HISTORY OF PRESENT ILLNESS 10/17/2018 Page 2 of 12 ROGERS, CLAUDE OB: 01/16/7835 (a3 YEARS) SEX: MALE CASE #: 5371254 os: ss0/2078 (CHIEE COMPLAINTIS) PT. STATED COMPLAINT: ALOC; CHIEF COMPLAINT CATEGORY: ALTERED LEVEL OF CONSCIOUSNESS, ONSET: ACUTE MEDICAL HISTORY HISTORY OBTAINED FROM: HEALTH CARE PERSONNEL MEDICAL HISTORY: HYPERTENSION AND DEMENTIA ALLERGIES: NONE MEDICATIONS: UNKNOWN VITAL SIGNS eae eas LASEO COMA ] | L000 scale pioop. | PAIN ame| pressure purse |Rese || V]M| TOTAL eke sroz,_ctueose | scale PTA | mm PTA | snus TACHYCARDIA PTA 1857/0817) PTA frase) eva aa a8 L PHYSICAL FINDINGS WeEIGHT: 100 kG; 220.5188 PHYSICAL ASSESSMENT HEAD: SYMMETRICAL HEAD POSITIVE: ERYTHEMAFLUSHING REMARKS: FLUSHED Neck: NECK: POSITIVE: ERYTHEWAN REMARKS: FLUSHED cuesr: CHEST POSITIVE: ERYTHEMAFLUSHING ABDOMEN POSITIVE: ERYTHEMAFLUSHING REVARKS: FLUSHED PEL: PELUIs- POSITIVE: UNREMARKABLE UNLESS OTHERWISE NOTED BACK: BACK “LUSHING 10/17/2018 Page 3 of 12 ROGERS, CLAUDE OB: 01/16/1985 (89 YEARS) SEX: MALE CASE #: 5971254 os: psis072018 POSITIVE: ERYTHEMAFFLUSHING EXTREMITIES: EXTREMITIES - POSITIVE: ERYTHEMAFLUSHING REMARKS, FLUSHED TREATMENTS: PTA TIME CAREGIVER PROCEDURE x ROSEVILLEFIRE PULSE OXIMETRY - 62% ON ROOM AIR x ROSEVILLE FIRE _EKGIECG - INDICATION: FROTOCOLISTANDING ORDER; TYPE 4 LEAD: CLINICIAN INTERPRETATION SINUS TACHYCARDIA x ROSEVILLEFIRE VITALSIGNS- GLASGOW COMA SCALE -GCS SCORE: 8; GCS SCORE QUALIFIER: NO QUALIFIER VITALS - 185/08: PULSE: 140; PULSE REGULARITY: REGULAR; PULSE [STRENGTH: NORMAL: PULSE TAKEN AT: RADIAL, RESPIRATORY RATE: 16 RESPIRATORY DEPTH: NORNAL; RESPIRATORY EFFORT: NORMAL: MEAN ARTERIAL PRESSURE: 117 x ROSEVILLE FIRE VASCULAR ACCESS -TVPE: PERIPHERAL IV SITE: FOREARMLEFT; GAUGE: 18 ATTEMPTS: 1; RESULT AFTER: UNCHANGED; PROCEDURE WAS: SUCCESSFUL; TOTAL VOLUME INFUSED (ML): 200.0 x ROSEVILLE FIRE BLOOD GLUCOSE - 81.000 GLUCOSE READINGILEVEL: 104 x ROSEVILLEFIRE COLD THERAPY - INDICATION: HYPERTHERMIA; TYPE: COLD PACK; RESULT AFTER UNCHANGED HUGHES. JOHN.AMR AGILITY ACTIVATION - ACTIVATION TYPE: NO ALERT y21900 ROSEVILLEFIRE VITAL SIGNS. GLASGOW COMA SCALE - GCS EYES: 3: CS VERBAL: 5; GCS MOTOR: 6; 60S SCORE: 11; GOS SCORE QUALIFIER’ NO QUALIFIER VITALS - BP: 149/85; PULSE: 120: PULSE REGULARITY: REGULAR: PULSE STRENGTH: NORMAL; PULSE TAKEN AT: RADIAL; RESPIRATORY RATE: 20 RESPIRATORY DEPTH: NORMAL; RESPIRATORY EFFORT: NORMAL: MEAN ARTERIAL PRESSURE: 112 RUN COMPLETION PRIVACY PRACTICES: DUE TO THE PATIENT'S MEDICAL CONDITION, A PAPER VERSION OF THE NOTICE WAS LEFT AT THE HOSPITAL FOR THE PATIENT oR: 201ansser2000816691 ewe: PRINTED: tor72018 121008, hups://medsviewer.amr.net/ 10/17/2018