Dispatch
Medic 4 was dispatched to the above-listed address for a motor vehicle collision.
Chief Complaint
Pt is a 34 YOM with a chief complaint of injuries after a motor vehicle collision. Pt was located sitting in the driver's seat of a vehicle on the roadway. Pt was alert upon arrival. Pt was seated in the driver's seat. Airbags did deploy. A seatbelt was worn. Vehicle damage was moderate.
History
History was obtained from Pt. Pt has a history of no significant past medical history. Pt denies recent surgery or other pertinent history. It was reported that another vehicle struck the driver's side. Pt denies a loss of consciousness and denies a head strike.
Allergies: no known drug allergies. Medications: none. Last oral intake was lunch.
Events leading up: Pt was driving through an intersection when the collision occurred. Pt was able to get out of the vehicle and was standing when the crew arrived.
Onset was sudden. It is provoked by movement. Quality is aching. Radiation: does not radiate. Severity 4/10. Time constant since onset.
Assessment
Airway is intact. No airway compromise noted. Respirations are initially 16. Respirations are regular, adequate, and unlabored. Initial BP was 128/78. Pt's initial pulse is 90. The pulse is strong and regular. The Pt's skin is pink, warm, and dry. Pt appeared non-emergent. ER evaluation is indicated for a motor vehicle collision.
Physical Exam
Head: atraumatic. Pupils are equal and reactive. Pt is AOx4.
Neck: no midline tenderness. Chest: Pt denies chest pain and shortness of breath. Pt is negative for seatbelt sign. Lung sounds are clear on the left and on the right.
Abdomen: soft and nontender. Pelvis is stable. Extremities: a small abrasion to the left forearm. Pulses are present. Pt is otherwise negative for DCAP-BTLS.
Diagnostic Tests
SPO2 99% on room air.
Primary Impression
Motor vehicle collision with traumatic injuries.
Medications and Procedures
The left forearm abrasion was dressed. Pt was able to walk unassisted to the cot. No medications were administered.
Transport
Pt was transported nonemergent to Miami Valley Hospital. Pt remained stable during transport. A report was given on arrival. Pt was released to the RN staff in the emergency department in a stable condition.