Advice of Ambulance Contact *** ATTENTION GP *** If this patient is not enrolled in your practice or if you believe you have received this information in error or for further information, please contact the St John Referrals Coordinator at referrals@stjohn.org.nz or by phoning 0800 ST JOHN (0800 473 876) and asking to speak to the Referrals Coordinator.
Doctor Proctor Taihape Health, 3 Hospital Rd, Taihape (06)388 0926
Patient Information NHI Number:
ZCJ7684
Name:
Anne Smith
Sex:
Female
DoB:
01/06/1968
Address:
18 Main Highway, Taihape, 4720, New Zealand
Age:
50
Year(s)
Incident Information Date and time of call
08/07/2018 06:16
Incident Location:
18 Main Highway, Taihape
Ambulance Master Incident Number:
0104-2-2018/07/08
Home
Location Type: ACS access code:
TP-RFA-KBZ-BE
ACC Claim Number:
Note to GP We recommended that Anne contacts your practice ASAP if her flu-like symptoms worsen.
Advice to Patient Family advised to phone ambulance back if Anne becomes difficult to rouse, cannot mobilise, develops a headache unrelieved with pain relief or develops a rash.
Advice to GP of Ambulance Contact
Page 1 of 3
ZCJ7684
Anne Smith 08/07/2018 06:16
History Presenting Complaint:
Flu-like symptoms
Incident history:
Feeling unwell for several days with cough and aching in joints. Tried to sleep yesterday but kept being woken with cough. Went out Friday night but unwell. Came back to Taihape on Saturday morning. This morning was going to head to Whanganui Hospital for assessment as coughing had become worse but decided to call ambulance
Date/time of onset:
07/07/2018 17:30
Primary Survey Status at Scene:
4 – No threat to life
Responsiveness:
Alert
Airway
Patent (Clear)
Breathing:
Effective
Circulation:
Normal
Blood Loss:
Nil
Past Medical History Past medical history:
Hypertension
Medications:
Accuretic
Allergies:
NKA
Last oral intake:
Pizza Hut last night
Clinical Impression Primary clinical impression:
ILI - Influenza-like illness
Notes:
Sitting on couch wrapped in two blankets. States never felt this sick before. Warm to touch. Dry cough present since yesterday. No headache. No sore throat, no rash. No localised pain. General aches in body. Lung sounds clear with equal entry. Been up to toilet without pain or offensive urine. Abdo soft and no abdominal pain. Taking paracetamol 4 hourly but unable to sleep due to coughing. Given ibuprofen 400mg and discussed where to purchase and how to use in conjunction with paracetamol.
Advice to GP of Ambulance Contact
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ZCJ7684
Anne Smith 08/07/2018 06:16
Disposition Final patient status:
4 – No threat to life
Notes:
Patient asleep on the couch once paperwork completed.
Disposition:
Treat or Assist only
Vital Signs and Treatment Time
GCS
Heart Rate
Resp Rate
BP
SpO2
Rhythm
BGL
Cap Refill
Temp
Pain
08/07/2018 06:30
4+5+6=15
86
16
155/94
98
Sinus Rhythm
6.2
P=1
36.40 C (Tympanic)
2
08/07/2018 06:51
4+5+6=15
85
16
145/91
98
Sinus Rhythm
08/07/2018 06:55
Medication: Ibuprofen 400 mg Per oral
Advice to GP of Ambulance Contact
Page 3 of 3
Pupil (mm L/R)
ETCO2
Skin
Normal
37.20 C (Tympanic)
ZCJ7684
Anne Smith 08/07/2018 06:16