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Would this have been a good report?

86 year old male chief complaint shortness of breath with productive cough, white sputum, less than a cap full. Feels light headed. Pain on palpation of left lower quadrant. Global inspiratory-expiratory rhonchi. Some effort breathing, but no accessory muscle use. Pale conjuctiva, circumoral cyanosis, ecchymosis and tenderness left lower quadrant. Latest vital signs heart rate 58, respiration rate 24, and blood pressure 86/42. The patient was found in Fowler's position in bed, placed semi left lateral, Fowler's, on the gurney because of removal of lobe in right lung, which was removed because of cancer, and shortness of breath. Patient on 3 L/min continous O2 at SNF because of emphysema so we continued that. No significant change in pt's status during transport.
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My report today was like below.

Me: 86 year old male chielf complaint shortness of breath with productive cough, white sputum, um... um... uh... he had surgery on his left lung... they removed a lobe.
One of the nurses: Do you know why?
Me: *thinks* I don't know.
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I totally sputtered out.

But I am not even too sure how to give a report. Afraid to give too little or too much information.
 
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Aprz said:
But I am not even too sure how to give a report. Afraid to give too little or too much information.
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IMO, your first report was quite a bit wordy. Was the surgery recent? Did he have a fever? There's a lot more summing up available in here:

86 yom 1 week s/p left lobectomy for primary lung cancer. Now he's complaing of SOB, with cough productive for moderate amount of frothy thick white sputum. Increased work of breathing without accessory muscle use. Also complaining of LLQ pain with bruising. He's hypotensive without any tachycardia, vitals are on my report.

It's a little more conversational, unnecessary big words are maybe avoided. Do you think that LLQ pain and bruising was a result of the surgery?
 
Aprz said:
Would this have been a good report?



My report today was like below.


I totally sputtered out.

But I am not even too sure how to give a report. Afraid to give too little or too much information.
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I absolutely hate it when I give an absolutely golden radio report to the point where the radio nurse is sputtering and starts giving me an ALS run number on a BLS channel, and then I walk into the ER and my turnover absolutely sucks. Happened today.
 
abckidsmom said:
IMO, your first report was quite a bit wordy. Was the surgery recent? Did he have a fever? There's a lot more summing up available in here:

86 yom 1 week s/p left lobectomy for primary lung cancer. Now he's complaing of SOB, with cough productive for moderate amount of frothy thick white sputum. Increased work of breathing without accessory muscle use. Also complaining of LLQ pain with bruising. He's hypotensive without any tachycardia, vitals are on my report.

It's a little more conversational, unnecessary big words are maybe avoided. Do you think that LLQ pain and bruising was a result of the surgery?
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Ah, I wish I said it as flawelessly as you did. :[ A lot less wordy!

It happened on 10/19 so 12 days ago, and he was cool to touch. Didn't know his temperature.

Nah. He had surgery on the right side, and the bruising was on the left. The bruise looked similar to those that you get after IM injections right there, and he stated that he was getting IM injections there, however, palpating it, there was something solid and bigger than that spot, and it caused him pain when I palpated.
 
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Aprz said:
Ah, I wish I said it as flawelessly as you did. :[ A lot less wordy!

It happened on 10/19 so 12 days ago, and he was cool to touch. Didn't know his temperature.

Nah. He had surgery the right side, and it was on the left. The bruise looked similar to those that you get after IM injections right there, and he stated that he was getting IM injections there, however, palpating it, there was something solid about that spot, and it caused him pain when I palpated.
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Yeah, it was bruising from the lovenox injections, I bet. That hurts when you touch it. It will feel solid even if it's "just" a bruise. Not just the collected blood, but the inflammatory process makes that area both more solid and tender.
 
You're too good. That was one of the many drugs he was taking. He had a whole list. The ER just made a copy of my PCR and copied it off that.

Normally I give very simple reports like "age, gender, orientation, pt received this medication before transport at such and such time, such and such dose, ate at this time, last set of vital signs were....", maybe mention BM or voiding, and that's it, sometimes the nurse tells me "the hospital alread gave me a report, where do I need to sign?" for IFT. I need to be more prepare to give reports for emergencies. I've gotten like a half dozen emergency calls since I started, and I am always fumbling when trying to give a report in the ER.
 
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Aprz said:
You're too good. That was one of the many drugs he was taking. He had a whole list. The ER just made a copy of my PCR and copied it off that.

Normally I give very simple reports like "age, gender, orientation, pt received this medication before transport at such and such time, such and such dose, ate at this time, last set of vital signs where...." and that's it. I need to be more prepare to give reports for emergencies. I've gotten like a half dozen emergency calls since I started, and I am always fumbling when trying to give a report in the ER.
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It comes with time. Lovenox is just part of the standard DVT prophylaxis, not a huge big catch. Promise.

Nurses are going to blow you off if you set yourself up to make a big formal clinical speech when you give report. Keeping it conversational brings social norms into the thing and makes them subconsciously pay more attention and be less likely to turn away. At least that's what I tell myself.
 
Thank-you for the advice abckidsmom. I'll remember to KISS, especially if it's a hot nurse. ;)
 
Aprz said:
Thank-you for the advice abckidsmom. I'll remember to KISS, especially if it's a hot nurse. ;)
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One time I was riding with a medic who had the hots for this nurse. During the turnover, while he was pulling the little old lady patient over to the ER bed, the patient put her hand up against his cheek and just gazed into his eyes all sweet on him.

I said, to the room, not to anyone in particular (esp not this nurse my partner was trying to pick up) "Awwwwww! She thinks he's cute!"

That just killed the room. Dead silence.

The nurse said, "ummm, Awkward!" Oh, sheesh, she thought I was making an accusation that she liked my partner.

Good grief. I am so glad I am not on the market. Dating is too complicated for me.
 
I turned my back on one patient to give a report to a nurse, and the patient started rubbing my hair, haha!
 
Dating sucks!

Side note: nursing school starts their clinicals the same time we do. Winner! Hahaha
 
It was braille

..... .... . ... ..............

See?

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Ps its November 1st. It's officially okay to listen to Christmas music.

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Sasha said:
Ps its November 1st. It's officially okay to listen to Christmas music.

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Negative. Christmas time starts after Thanksgiving.
 
Uhm negative ghost rider. Christmas starts Nov 1st. Thanksgiving is just a land mark for black Friday.

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Blackfriday. How I love thee. I'm wearing elbow pads and a helmet this year. I'm ready to fight my way through the riots.

And I get paid on black Friday!!!!

This is a very dangerous situation.

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Today I am going to be victim...errr... Care taker to THREE kids instead of one.

My nephew age 3 and two cousins ages 4 and 5.

If you don't hear from me send help.

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