Download Wiliam Sepulvado

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