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Bertie XXXX DOB: 04/01/XXXX MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW General Instructions: Brief Summary/Flow of Events: In the beginning of the chronology, a Brief Summary/Flow of Events outlining the significant medical events is provided which will give a general picture of the focus points in the case Patient History: Details related to the patient’s past history (medical, surgical, social and family history) present in the medical records Detailed Medical Chronology: Information captured “as it is” in the medical records without alteration of the meaning. Type of information capture (all details/zoom-out model and relevant details/zoom-in model) is as per the demands of the case which will be elaborated under the ‘Specific Instructions’ Reviewer’s Comments: Comments on contradicting information and misinterpretations in the medical records, illegible handwritten notes, missing records, clarifications needed etc. are given in italics and red font color and will appear as * Reviewer’s Comment Illegible Dates: Illegible and missing dates are presented as “00/00/0000”(mm/dd/yyyy format) Illegible Notes: Illegible handwritten notes are left as a blank space “_____” with a note as “Illegible Notes” in the heading of the particular consultation/report. 1 of 6 Bertie XXXX DOB: 04/01/XXXX Brief Summary/Flow of Events 05/07/XXXX- Auto Vs pedestrian accident. Struck by a car Complains of head and neck pain CT of head- No fracture. Edema to right scalp Underwent full-thickness scalp laceration repair 05/08/XXXX- CT of brain- Extracranial soft tissue swelling and hematoma 05/09/XXXX- Dizziness. Medications given Physical and Occupational Therapy recommended 05/12/XXXX- Dizziness improved. Reassured that it was related to concussive symptoms Discharged home in stable condition Patient history Past Medical History: High Cholesterol Surgical History: None. Family History: Non contributory. Social History: Patient is married. She is retired. She does not smoke and occasionally drinks alcohol. Allergy: No known drug allergies. Date of Injury: 05/07/XXXX - Auto versus pedestrian with closed head injury. Patient was struck by a car and was thrown 10-15 yards through the air. Complains of head and neck pain 2 of 6 Bertie XXXX DOB: 04/01/XXXX Detailed Chronology DATE PROVIDER 05/07/XXX XXX Ambulance Service, Inc. 05/07/XXX XXX Hospital Jon XXX, M.D. OCCURRENCE/TREATMENT Time of call: 2027 hours Patient transported to XXX Regional Hospital. Emergency Room Record-Trauma Resuscitation Patient has been brought into the ER as trauma activation for a level II trauma center. Upon her arrival there was no available trauma surgeon. PDF REF XXX Hosp- 39 XXX Hosp- 910 She was brought into the ER after being struck by a car. Per paramedics, she was struck and then she was thrown 10 to 15 yards through the air, landing and complaining of head and neck pain. Denies back pain, chest pain, abdominal pain, arm or leg pain. Physical Examination: Stable. She is in a stiff collar and maintaining spinal precautions. Full range of motion of hips, knees and ankles noted. Bilateral upper extremities appear atraumatic. Thoracic and lumbar spine normal. Emergency Department Course: Patient appears to have sustained potential head and possible neck injury. Requested lateral C-spine and portable chest be taken prior to CT scanning. Her pain will be managed with IV narcotic administration. Dr. XXX has now assumed her care as her trauma surgeon. 05/07/XXX XXX Hospital Brian C. XXX, M.D. (General Surgery) Impression: Auto versus pedestrian with closed head injury. Rule out intracranial injury and rule out cervical spine fracture. Trauma Care Chief Complaint: Status post auto pedestrian accident. Patient was in a witnessed low rate-of-speed auto pedestrian accident. She had no recollection of the event. Had a witnessed loss of consciousness at the scene. She was brought to trauma with primary complaint of head pain. Again, she is limited to no recollection of the event. She denies substance abuse or alcohol abuse. She denies prior head injury. Her GCS (Glasgow coma scale) is 15 on arrival. She denies use of blood thinners. Physical Examination: BP 176/80. Patient is in no acute distress. Sensorimotor exam was intact. HEENT (Head, eyes, ears, nose and throat): Normocephalic. She has a complex stellate laceration measuring approximately 4cm on her right occiput. Her tympanic membranes are clear. Her extraocular movements are intact. Neck: She does present in a C collar. She has no definitive cervical tenderness to palpation. Chest: Clear to auscultation bilaterally without tenderness to palpation or crepitus. Abdomen & GU: Positive bowel sounds. No pelvic instability. Extremities: No deformity, tenderness, contusions or abrasions. Full range of 3 of 6 XXX Hosp- 67 Bertie XXXX DATE PROVIDER DOB: 04/01/XXXX OCCURRENCE/TREATMENT PDF REF motion of all extremities appreciated. X-rays were reviewed. 05/07/XXX XXX Hospital Justin H. XXX, M.D. 05/07/XXX XXX Hospital Justin H. XXX, M.D. 05/07/XXX XXX Hospital Marvin XXX, M.D. 05/08/XXX XXX Hospital Steven XXX, M.D. 05/07/XXX XXX Hospital 05/08/XXX Assessment and plan: Status post auto pedestrian accident with following issues: Concussion/closed head injury. The patient will be admitted for neuro checks and speech cognitive evaluation. Scalp laceration. Tetanus and antibiotics have been provided in the ER and primary repair will be performed by Dr. Marvin XXX. Patient will be admitted to rule out occult blunt abdominal trauma. CT brain Impression: Right parietal scalp edema without evidence for acute fracture or dislocation. CT cervical spine Impression: No evidence for acute fracture or dislocation. Patient underwent full-thickness scalp laceration repair. XXX Hosp- 1 XXX Hosp- 2 XXX Hosp11-12 Pre and postoperative diagnosis: Full-thickness right parietotemporal scalp laceration. * [Reviewer’s Comments: Patient’s past medical history is unknown as the records starts from DOI. Hence it is unsure to comment on the probable preexisting condition of the head and neck pain.] History: Scalp hematoma. Possible intracranial hemorrhage. CT brain Impression: Extracranial soft tissue swelling and hematoma. No intracranial hemorrhage appreciated. Labs High values: Glucose, granulocytes. Low Values: Hemoglobin, hematocrit, lymphocytes, calcium. XXX Hosp- 4 XXX Hosp15-20 Urinalysis showed presence of 1+ ketones 05/09/XXX XXX Hospital 05/10/XXX Brian C. XXX, M.D. 05/11/XXX XXX Hospital Drugs screen test was positive for opiates. Trauma Physician’s Progress Record Patient feeling a little better. Still with nausea and dizziness. Not eating much secondary to decreased appetite. Not ambulatory much secondary to dizziness. Afebrile. Vital signs stable. Minimal pain. Occasional headache. Assessment/Plan: Status post auto vs pedestrian with closed head injury, post concussion surgery. Scopolamine patch. Bowel regimen. Physical and occupational therapy to increase ambulation. Increase diet as tolerated. May need antihypertensive. Physician’s Progress Report Complains of dizziness when moves. Scalp laceration clean. Repeat head CT was recommended. 4 of 6 XXX2- 4-5 XXX2- 6 Bertie XXXX DATE PROVIDER 05/11/XXX XXX Hospital DOB: 04/01/XXXX OCCURRENCE/TREATMENT Physician Progress Record Patient was referred by Dr. XXX for persistent dizziness. Since the accident, she has had “dizziness” with nausea and vomiting with movement. Patient cannot tell me if she senses room spinning because she had her eyes closed. Placed on Scopolamine patch. She is feeling better today, in fact was able to ambulate today without difficulty. No more nausea/vomiting. Did not have trouble prior to accident. PDF REF XXX2- 2 No diabetes mellitus, hypertension, cerebrovascular accident, coronary artery disease by history. Physical examination was normal. Labs normal. 05/11/XXX XXX Hospital Brian J. XXX, M.D. 05/12/XXX XXX Hospital 05/12/XXX XXX Hospital Brian C. XXX, M.D. Assessment/Plan: Status post closed head trauma. Dizziness, likely vertigo secondary to closed head trauma, improving. Patient and family reassured. Medications prescribed. OK to discharge from my stand point. Follow-up with Primary Care Physician next week. X-ray pelvis Impression: No fracture is seen. If symptoms persist, recommended MRI or CT. Trauma Physician’s Progress Record Patient doing better. Dizziness improved but still present at times. No nausea/vomiting. Tolerating diet. Out of bed with FWW (front wheeled walker) with PT. No new concerns of complaints. On examination, right occipital scalp laceration staples in place, no erythema or drainage. XXX Hosp- 5 XXX 2- 1 Assessment/Plan: Auto vs pedestrian with concussion, scalp laceration, dizziness, vertigo (improved). Cleared by Internal Medicine for discharge. Continue medications. Discharge home if cleared by PT. XXX HospDischarge Summary Patient was admitted on 05/07/XXX after an extensive workup for traumatic 13-14 injuries in the emergency department. The injuries were identified and primary scalp laceration repair was performed. The hospital course was really punctuated by significant postconcussive syndrome with associated vertigo requiring physical, occupational and speech therapy. 5 of 6 Bertie XXXX DATE PROVIDER DOB: 04/01/XXXX OCCURRENCE/TREATMENT PDF REF Over the ensuing days, patient’s clinical picture gradually improved. Dr. XXX with internal medicine was sought. Reassurance was suggested and it was likely related to concussive symptoms. With medical therapy the symptoms ultimately improved and she is able to be discharged home in stable condition. 05/24/XXX XXX Family 06/08/XXX Medical Group 04/13/2011 XXX Hospital Discharge Activity: No strenuous activity for at least one month. She is to follow-up with her primary care doctor in one week. Diagnosis: ________, neck pain, hypertension Illegible notes Correspondence to Wendy and Christina I just want to inform you of our plans. We were going to visit my family but I did not feel comfortable going anywhere. I have since lost three more cousins. They are all in their 70s and 80s. So I better not delay again. XXX Hosp44-46 XXX- 1-2 I hope that seeing my family and getting back to my hometown will be a good thing for all of us and my anxieties. 00/00/0000 XXX Physical Therapy Departure date May 4th-return June 6th. Physical Therapy home program for lower extremity Matthew XXX, DPT 6 of 6 XXX Hosp67-69