Describing a Medical Case

Emergency Department Report (Trauma / Cardiac Arrest)


The patient was brought to the emergency department via ambulance and received in the ambulance bay. On arrival, the patient was unconscious and not breathing adequately. Initial assessment revealed cardiac arrest with an unknown downtime prior to EMS arrival.


Cardiopulmonary resuscitation was initiated immediately. Adrenaline was administered intravenously, and defibrillation was performed with one shock delivered. Return of spontaneous circulation was achieved after resuscitation efforts. The airway was secured due to compromised breathing and risk of hypoxia.


The patient presented with significantly elevated heart rate following resuscitation. Given the mechanism of injury, a car accident was suspected. Clinical findings raised concern for severe traumatic injuries and possible internal bleeding. The patient was assessed by the emergency nurse and trauma team. Further imaging and monitoring were initiated due to the risk of global organ damage secondary to hypoxia and trauma.

Arrival:
Chief Complaint:
Initial Assessment (Primary Survey)
Airway:
Breathing:
Circulation:
Disability:
Exposure:
Vital Signs (Post-ROSC)
Heart rate:
Blood pressure:
Oxygen saturation:
History (Limited, per EMS)
Physical Examination
HEENT:
Cardiovascular:
Respiratory:
Abdomen:
Neurological:
Interventions / Treatment
Obstetric Evaluation
Plan

Emergency Report (Anaphylactic Reaction)


The patient presented to the emergency department in an agitated state following multiple bee stings. The patient reported a known history of allergic reactions, and this was not the first episode.


Shortly after exposure, the patient developed symptoms of an allergic reaction, including nausea, abdominal pain, and tingling around the lips. The condition rapidly progressed to a systemic reaction. Examination revealed swelling of the tongue, lips, and throat, resulting in severe respiratory distress. The patient was unable to breathe adequately.


A diagnosis of severe anaphylactic reaction was made. An immediate injection of adrenaline was administered. Due to persistence of symptoms, a higher dose than usual was required. The reaction continued for a period of time, and the patient was closely monitored for serious side effects. The condition was considered dangerous and potentially fatal without prompt treatment.

Obstetric Assessment Report (Emergency Context)


The patient, who was pregnant, was evaluated due to concerns that the acute medical condition could induce labour. Vital signs were initially unstable, with some parameters falling below acceptable levels.


Given the risk of premature childbirth, fetal assessment was performed. Ultrasound was used to evaluate the baby’s heartbeat. A strong and regular heartbeat was detected, and the fetal heart rate was within normal ranges. No immediate signs of fetal distress were observed at the time of examination.


Continuous maternal and fetal monitoring was recommended due to the severity of the maternal condition and the potential risk of preterm labor.

1. Слишком сильно чихнул.
2. Пошел ночью в туалет, наступил на кота.
3. Экспериментировал с едой.
4. Потянулся за пультом, свалился с дивана.
5. Испугалась собственного отражения в темном окне.
6. Уронила телефон на глаз, лежа в кровати.
7. Играл с сыном в "войнушку".
8. Поспорил с другом.
9. Слишком активно возмущалась поведению соседки.
10. Решили прихлопнуть муху.

EMS history: age, male/female, condition found
Arrival:
Chief Complaint:
Initial Assessment (Primary Survey)
Airway:
Breathing:
Circulation:
Disability:
Exposure:
Vital Signs (Post-ROSC)
Heart rate:
Blood pressure:
Oxygen saturation:
Physical Examination
HEENT:
Cardiovascular:
Respiratory:
Abdomen:
Neurological:

Пациенту было очень плохо, он почти не дышал.
Был без сознания, вообще никакой.
Его трясло, и он ничего не понимал.
Хватал воздух ртом.
Резко «накрыло».
Еле откачали.
Увидел кровь, повело.
Нога посинела.
Схватился за сердце.
Лежал, не реагировал.
Нес чепуху.
Размахивал руками, пытался что-то сказать.
Побледнел прямо на глазах.

cardiac arrest
defiblilator
adrenaline
anaphylactic reaction
initial assessment
unconscious
downtime
cardiopulmonary resuscitation
intravenously
blood circulation
secure airway
hypoxia
elevated heart rate
internal bleeding
global organ damage
allergic reaction
respiratory distress
side effect
fetal distress
preterm labor

Tongue swelling

Cardiac arrest
Respiratory distress
Unconsciousness
Absent breathing
Tachycardia

Chest pain
Seizure activity
Vomiting with aspiration risk
Anaphylactic shock
Altered mental status
Cyanosis
High fever
Fainting
Severe anxiety with hyperventilation
Bradycardia

1. Adrenaline is given orally in cardiac arrest.


2. Defibrillation may restore spontaneous circulation.


3. Hypoxia can cause global organ damage.


4. CPR should be started immediately if a patient is unresponsive and not breathing.


5. Anaphylactic reactions can be fatal without prompt treatment. 


6. Tongue swelling is a symptom of severe allergic reaction. 


7. Oxygen therapy is not necessary if SpO₂ is 85%.


8. Cardiac arrest can occur after trauma. 


9. Adrenaline is only used for pain relief. 


10. Continuous maternal and fetal monitoring is recommended if the mother is critically ill. 


11. Shortness of breath is never a sign of hypoxia. 


12. Intravenous fluids can be used to treat hypotension in trauma patients. 


13. Airway should always be secured in patients with compromised breathing. 


14. Defibrillation can be performed without checking if the patient has a pulse. 


15. A patient who lost consciousness may need neurological assessment. 


16. Elevated heart rate always indicates heart failure. 


17. An EMS report should include age, sex, and condition found. 


18. Adrenaline can be administered intramuscularly in severe anaphylaxis.


19. Cardiac monitoring is unnecessary in post-ROSC patients. 


20. Severe bleeding should be controlled with direct pressure.