Download Case 1 Chief Complaint Patient presents with

Case 1
Chief Complaint
Patient presents with: Cardiac Arrest
I was unable to obtain a clear HPI, ROS from the patient or review their PMH, FH, SH due to acuity
of condition (patient not responsive).
HPI
XXXXXXXXX is a 67 y.o. male with a PMH of CAD s/p CABG (10/3/2013), A fib on coumadin, aortic
stenosis, mitral regurgitation s/p MVR (10/5/2013), heart failure, pulmonary HTN, s/p gastric bypass
(2002) and multiple hernia repairs who presents to the ED via walk-in c/o cardiac arrest. Patient's wife
reports the patient had been feeling fatigued for the past week. He had poor PO intake and increased
sleep during this time, but had been taking all his medications. He was scheduled to see Cardiology
today and when he arrived for his appointment he stopped to use the bathrooms in the main lobby.
His son helped him into the bathroom because he had been feeling weak previously and required
wheelchair assistance when entering the hospital. When the son went to check on him, he found the
patient had collapsed on the bathroom floor. The patient was then placed in a wheelchair and brought
to the ED at 09:45.
Review of Systems: Unable to perform ROS: Acuity of condition
Past Medical History
Aortic stenosis
Hypertension
Arrhythmia
Atrial Fib
Atrial fibrillation
Pulmonary hypertension
Restrictive lung disease
OSA (obstructive sleep apnea)
GERD (gastroesophageal reflux disease)
PMH GI ulcer at gastric bypass anastomosis.
Hydrocele bilateral-followed by urology.
Obesity
Stasis leg ulcer left leg; chronic
Anemia following gastric bypass with GI ulcer at anastomosis.
Heart murmur
aortic stenosis and mitral regurgitation
Past Surgical History
Gastric bypass surgery
Umbilical hernia repair
Family History
Father Kidney Disease Alzheimer's Disease
Mother Diabetes
Brother Hypertension Heart Disease
Social History Married, Never Smoker Alcohol Use: No. Sexually Active: Yes -- Female partner(s)
Social History Narrative
Patient is a retired welder.Patient is from Chastleville about 60 miles from here. Patient has two sons.
Patient has no grandchildren. Patient is currently disability, and was a former businessman. Patient is
a retired welder.
Prior to Admission medications
atorvaSTATin (LIPITOR) 10 MG tablet Take 1 tablet by mouth every evening,
bumetanide (BUMEX) 2 MG tablet Take two tabs twice daily (4mg twice daily),
Calcium Citrate-Vitamin D (CITRACAL + D PO) Take 2 tablets by mouth 2 times daily.
Iron 66 MG TABS Take 1 tablet by mouth daily.
metolazone (ZAROXOLYN) 2.5 MG tablet Take 1 tablet by mouth once a week,
Multiple Vitamins-Minerals (CENTRUM PO) Take 1 tablet by mouth daily.
OxyCODONE HCl (OXYCONTIN PO) Take 60 mg by mouth As Specified.
Pantoprazole Sodium (PROTONIX) 40 MG PACK Take 1 tablet by mouth daily ,
potassium chloride SA (K-DUR;KLOR-CON) 20 MEQ tablet Take 2 tablets by mouth 2 times daily,
sildenafil (REVATIO) 20 MG tablet Take 1 tablet by mouth 3 times daily do not take with nitrates,
spironolactone (ALDACTONE) 25 MG tablet Take 1 tablet by mouth daily,
warfarin (COUMADIN) 5 MG tablet Take 1 tablet by mouth daily,
No Known Allergies
Physical Exam
BP: 117/66
Nursing note and vitals reviewed.
Constitutional: Unconscious. Flaccid.
Head: Normocephalic and atraumatic.
Mouth/Throat: Oropharynx is clear.
Neck: Neck supple.
Cardiovascular: Pulseless.
Pulmonary/Chest: No spontaneous respirations.
Abdominal: Soft. Bruising over abdomen
Musculoskeletal: Wraps over BLE.
Neurological: Non-responsive. A&O x 0.
Skin: Gray in appearance.
Procedures
Ultrasound documentation:
First Cardiac US performed shortly after onset of CPR.
Cardiac US: A bedside cardiac ultrasound was performed by Dr. Resident. The medical necessity
was to evaluate for cardiac activity and pericardial effusion. The structures studied were the heart
and pericardium. The interpretation was no organized cardiac activity or pericardial effusion.
2) Second Cardiac US performs just prior to terminating CPR.
Cardiac US: A bedside cardiac ultrasound was performed by Dr. Resident. The medical necessity
was to evaluate for cardiac activity and pericardial effusion. The structures studied were the heart
and pericardium. The interpretation was no organized cardiac activity or pericardial effusion.
After a review of the patient's case the resident performed the ultrasound under my supervision. I
was present for the entire procedure(s).
Intubation
The patient was ventilated with 100% oxygen using a bag-valve-mask prior to the procedure.
Patient’s oxygen saturation prior to the procedure was unknown. The patient was intubated orally
using a # 4 Macintosh and a 8.0 Fr. ETT. The tube was placed on the 1st attempt. The patient was
subsequently ventilated using a bag-valve-mask. Placement was verified by a CO2 detector.
Patient’s oxygen saturation following procedure was 95%. The patient tolerated the procedure well.
Resident, MD
Central Line
A central line was placed at 10:00 by Dr. Resident and Dr. Attending. The situation was emergent,
and consent was not obtained. The medical necessity was for vascular access. . The patient was not
sedated and in a flat position.. The line was placed successfully on the 2nd attempt in the right
femoral using a 9 FR double lumen catheter. Ultrasound guidance was not used. Line assessment
was determined by blood return through all parts and the line was sutured. The patient tolerated the
procedure well with no immediate complications.
Resident, MD
After a review of the patient's case the resident performed the central line insertion under my
supervision and with my direct assistance. I was present for the entire procedure(s).
Attending, MD
Arterial Line
An arterial line was placed in the right femoral artery by Dr. Resident and Dr. Attending. The situation
was emergent, and consent was not obtained. The medical necessity was for arterial vascular
access. Placement was verified by blood return and waveform on monitor. The site was dressed
using a sterile technique. The patient tolerated the procedure well.
After a review of the patient's case the resident performed the arterial line insertion under my
supervision. I was present for the entire procedure(s).
Attending, MD
CALCIUM, IONIZED
ED Course: Mr. XXXXXXX was brought to room obtunded, pulseless and apneic, he was taken from
the wheelchair to bed with the only history that he collapsed in bathroom in lobby while on his way to
cardiology appt. Family said he was feeling weak for the past 4 days. CPR was immediately started
by Dr. Attending and airway support was started by Dr. Resident. 18 gauge IV established in left AC
and epinephrine was given, CPR continued while the drug was circulated and a pulse check revealed
fine V-Fib rhythm, a shock was delivered and faint pulse detected at the carotid but was quickly lost
after less than 1 minute. CPR was resumed, Amiodarone was given as this seemed a refractory VFib and in addition Bicarb was given and another round of Epi was given. At this point another
rhythm check revealed fine V-Fib and another shock was delivered. US revealed no coordinated
cardiac activity and CPR was again resumed. Right femoral central line was placed at this point.
VBG had returned and showed a K=8.2, I had Calcium gluconate given at this point and circulated
the drug. There was no ROSC since the first time the patient was defibrillated. Mr. XXXXXXXXX’s
wife was brought outside the trauma bay, Mr. XXXXXXX was intubated at this point and I explained to
Mrs. XXXXXXX and her son that about 15 minutes had gone by without cerebral perfusion. I brought
both Mrs XXXXXXX and her son into the resuscitation bay for the final couple minutes of the
resuscitation. I explained that if there was still no coordinated cardiac activity after 15 minutes that
Mr. XXXXXXX would not recover neurologically. There was no coordinated activity and Mr.
XXXXXXX would be pronounced at this point. The rhythm was fine V-Fib refractory to defibrillation
during the resuscitation. This was not a medical examiner case and cause of death was acute
coronary insufficiency. Time of Death was approximately 10:07am Nov. 12, 2014.
Attestations:
I have personally seen and evaluated this patient.
Attending, MD
The resident/attending physician obtained and performed the history, physical exam and medical
decision making elements that were entered into the chart by me.
Scribe, (1312).
I provided 30-74 minutes of critical care for this patient.
Resident, MD
Electronically Signed By:
Attending, MD
Case 2
Chief Complaint
Patient presents with
Hypotension
I was unable to obtain a clear HPI, ROS from the patient or review their PMH, FH, SH due to altered
mental status.
HPI xxxxxxxxxxxx is a 65 y.o. male with a PMH of hyperlipidemia, Hepatitis A, and Hepatitis B who
presents to the ED via EMS after being found at bottom of stairs, hypotensive. Per EMS, pt was
found at the bottom of his stairs at home this morning; he was last seen normal at 18:00. En route, pt
was nonverbal, hypotensive, with glucose level 125. He was given 300 cc saline.
Procedures
Intraosseous IV: PA placed a left humeral head IO line under my supervision using the easy IO.
Good blood return and flow post placement. Secured with sterile dressing.
After a review of the patient's case the PA performed the IO line placement under my supervision. I
was present for the entire procedure(s).
Attending, MD
Ultrasound documentation:
FAST US: A bedside focused assessment with sonography for trauma (FAST) exam was performed
by Dr. Resident. The medical necessity was to evaluate for occult abdominal and/or chest trauma;
intraperitoneal fluid, pericardial fluid, and pneumothorax. Structures studied were the hepatorenal
space, splenorenal space, pericardium, bladder, and pleural interface. The interpretation was normal,
negative FAST.
After a review of the patient's case the resident performed the FAST exam under my supervision. I
reviewed the real time images as well as the image(s) above, and I agree with the interpretation
noted above. I was present for the entire procedure(s).
Attending, MD
Intubation The patient was ventilated with 100% oxygen using a non-rebreather mask prior to the
procedure. Patient’s oxygen saturation prior to the procedure was 100%. The patient was intubated
orally using a Glidescope and a 7.5 Fr. ETT. The tube was placed on the 1st attempt. The patient was
subsequently ventilated using a bag-valve-mask. Placement was verified by a chest x-ray, a CO2
detector and auscultating bilateral breath sounds. Patient’s oxygen saturation following procedure
was 100%. The patient tolerated the procedure well.
Resident, MD.
After a review of the patient's case the resident performed the intubation under my supervision. I was
present for the entire procedure(s).
Attending, MD
ED Course: 65yo M, found at bottom of the stairs, cold and hypotensive with unknown trauma
or etiology of AMS. Beta alert called pre-arrival given potential trauma in setting of shock,
AMS. R humeral IO placed for access and pt intubated given GCS < 9, concern for metabolic
disarray and need for hyperventilation/airway protection. Pt was resuscitated with IVF and
blood products with improvement of LA from 18 to 15 after initial assessment and resus
period. (see MAR for details). NGT placed with return of 500cc of dark red blood. Protonix
administered. Temp sensing foley catheter also placed, confirming hypothermia. Rewarming
initiated. CT head, C/A/P performed without sign of clinically significant trauma. Aztreonam
administered for potential sepsis. Other labs sig for Na of 155, partially compensated
metabolic acidosis. Pt admitted to MICU service for further management of hypothermia,
acidosis, AMS, metabolic disarray.
Attestations:
The patient's treatment in critical care status was because the patient presented by EMS helicopter
after being found down unresponsive at the bottom of a flight of stairs. He was hypotensive,
hypothermic, comatose, in severe metabolic dissaray, and had a vigorous UGI bleed.. The care
provided during this time included providing fluid resuscutation, trauma alert, blood product infusion,
serial blood gases, ventilator management, bicarbonate, antibiotics, advanced imaging, serial
reassessments, discussion with family, MICU admission, active external rewarming. I have reviewed
the resident's documentation of the critical care period and I agree with the resident's assessment
and plan of care.
Critical care time provided by me: 100 minutes. I was present for the time documented. I have
personally interviewed and examined the patient. I have reviewed the resident's history, physical
exam, assessment and management plans. I concur with or have edited all elements of the resident's
note.
Attending, MD, November 25, 2014, 11:32
The resident/attending physician obtained and performed the history, physical exam and medical
decision making elements that were entered into the chart by me,
Scribe. November 24, 2014 10:53
The documentation recorded by the scribe accurately reflects the service I personally performed and
the decisions made by me.
Resident, MD, November 25, 2014, 10:44
Case 3
HPI
XXXXXXXXX is a 12 y.o. female who presents to the ED via EMS complaining of fall and arm injury.
The patient reports being at cheerleading practice this evening when she fell forward from the top of a
2-person-high pyramid. She landed on her outstretched arms, hearing and feeling a crack in her left
arm. She did not hit her head or lose consciousness. On EMS arrival, the patient had a left arm
deformity distal to left elbow. Her right arm was not deformed. She was put in splints and transferred
to UVA for further eval. In the ED, pain is 8/10. She denies other injury.
Location: arms
Quality:sharp pain
Duration: since fall earlier today
Timing:sudden onset
Modifying factors: movement of arms increases pain
Severity:moserate
Context:12yo female fell on both outstretched arms during cheerleading practice
Associated s/s: left arm deformity
Review of Systems
Musculoskeletal:
Positive for bilateral arm pain. Positive for left arm deformity.
Neurological:
Negative for loss of consciousness.
All other systems reviewed and are negative.
Nursing note and vitals reviewed.
Constitutional: NAD. Appears stated age.
Head: Normocephalic and atraumatic.
Ears: External ears normal.
Nose: External nose normal. No rhinorrhea.
Mouth/Throat: Airway patent. Moist mucous membranes.
Eyes: EOMI. PERRL. No scleral icterus.
Neck: Neck supple.
Cardiovascular: Normal rate, regular rhythm. Normal heart sounds. No murmur, rub, or gallop. Good
pulses throughout.
Pulmonary/Chest: Clear to auscultation bilaterally. Breath sounds normal. No respiratory distress. No
wheezes, rales, or rhonchi.
Abdominal/GI: Soft, non-tender, non-distended. No rebound or guarding. Bowel sounds are normal.
Musculoskeletal: upper extremities b/l in splints, pain distal to elbow b/l, skin indented on inner midarm, no blood, good pulses, able to move fingers and shrug shoulders, no pain proximal to elbow
NVS both arms
Neurological: Alert and oriented to person, place, and time. No obvious cranial nerve deficit.
Skin: Skin is warm and dry. No rash noted. No cyanosis.
Psychiatric: Normal mood and affect. Behavior is normal.
Reviewed bilateral upper extremity Xrays +fractures thru left radius and ulna and right radius
Radiology reports ordered and reviewed.
IMPRESSION:
Left radius ulna:
1.Transverse fracture through the proximal radial diaphysis with apex volar angulation.
2.Obliquely oriented fracture through the mid ulnar diaphysis with apex ulnar angulation
Right radius ulna:
1.Transverse fracture through the proximal radial diaphysis with apex volar angulation
Consulted orthopedics
Emergency Department Moderate Sedation
The patient and/or family member has consented to receive sedation to assist with completing a
painful procedure(s). See nursing flow sheet for specific medication dosage and vital signs.
Pre-sedation assessment:
Airway: Airway: adequate
Mouth opening: mouth opens widely
Neck motion: good neck motion
Dentition: normal
ASA Classification: ASA 1
OSA risk factors: No risk factors
Medications used: fentanyl and propofol
Total ED Attending time at bedside from sedation start: 60 minutes.
Patient tolerated procedure well.
Complications: none
Attending, MD
ED Course:
XXXXXXXXX is a 12 y.o. female w/ bilateral arm fractures after a fall. On the left she has a displaced
radial and ulnar fracture, and on the right a radial fracture.
- Ortho at bedside, will prepare for conscious sedation, procedure described above
- B/l reduction completed successfully 23:00
- Discharged home with peds ortho follow up in one week. Two slings w/ pillows under arms when
resting. Oxycodone PRN for two days. Advised on splint care and when to return for care.
DX: acute fracture of left radius and ulna and right radius
ED Medication Administration from 10/30/2014 2034 to 12/15/2014 2155
Date/Time
Order
Dose
10/30/2014 2054
10/30/2014 2223
10/30/2014 2240
10/30/2014 2235
10/30/2014 2250
oxyCODONE (ROXICODONE) 5 MG/5ML solution 3.4 mg 3.4 mg
sodium chloride 0.9% IV bolus 400 mL
400 mL
propofol (DIPRIVAN) injection 40 mg
40 mg
fentanyl (SUBLIMAZE) injection 25 mcg
25 mcg
propofol (DIPRIVAN) injection 220 mg
220 mg
Route
Oral
Intravenous
Intravenous
Intravenous
Intravenous
Case 4
Chief Complaint
Patient presents with
• Chest Pain
pat c/o chest pain intermittently all day. Describes pain as pressure and
tightness. patient states he took four baby aspirin at home
HPI 50 yo male presents via EMS with acute onset sternal chest pain with pain at both shoulders.
Recently had PCI for RCA stenosis. Discharged last week. This pain began without exertion. Mild
shortness of breath only, no diaphoresis, mild nausea. Pain significant. STEMI alert initiated in ED.
Review of Systems
Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and
updated as appropriate.
Physical Exam
Filed Vitals:
BP:
122/75
Pulse: 56
Resp: 14
Nursing note and vitals reviewed.
Constitutional: NAD.
Head: Normocephalic and atraumatic.
Mouth/Throat: Airway patent. Moist mucous membranes.
Eyes: PERRL.
Neck: Neck supple.
Cardiovascular: Normal rate, regular rhythm. Normal heart sounds. No murmur, rub, or gallop. Good
pulses throughout.
Pulmonary/Chest: No respiratory distress. Clear to auscultation bilaterally. No wheezes, rales, or
rhonchi.
Abdominal/GI: BS normal, Soft, non-tender, non-distended. No rebound or guarding.
Musculoskeletal: No gross injuries or deformities.
Neurological: Alert and oriented to person, place, and time. Cranial Nerves 2-12 intact. Moving all
extremities. No gross deficits
Skin: Skin is warm and dry. No rash noted.
Procedures
MDM
ED Course: STEMI alert. ECG sig for ST elevations in II, III, aVF. 5000U Heparin IV given, 1 tab Nitro
SL, ECG changes to widened WRS, RBBB, and ST depression in V3 and V4. Cards fellow elects to
proceed to Cath Lab. Patient consented.
Case 5
Chief Complaint
Patient presents with
• Palpitations
began around 2000; no SOB, CP; a fib on monitor; 325 ASA; 1/2 clonopin
HPI
XXXXXXXXXXXX is a 71 y.o. female with a PMH of A fib, HTN, and anxiety who
presents to the ED via EMS c/o palpitations. Patient reports onset of palpitations at
19:45 tonight while she was sitting at the computer. She describes them as a fast and
irregular heartbeat. She continued to have the sensation while feeding her horses this
evening. Her son is a paramedic and called EMS. She received 325 mg ASA and 1/2
clonopin. In the ED, the palpitations have improved and now only occur intermittently.
She denies chest pain, SOB, diaphoresis and lightheadedness.
Review of Systems
Constitutional: Negative for diaphoresis.
Respiratory: Negative for shortness of breath.
Cardiovascular: Positive for palpitations. Negative for chest pain.
Neurological: Negative for light-headedness.
All other systems reviewed and are negative.
Physical Exam
Filed Vitals:
BP: 139/77
Pulse: 79
Temp:
Resp: 20
Nursing note and vitals reviewed.
Constitutional: NAD.
Head: Normocephalic and atraumatic.
Mouth/Throat: Airway patent. Moist mucous membranes.
Eyes: PERRL.
Neck: Neck supple.
Cardiovascular: Tachycardic, irregularly irregular. Normal heart sounds. No murmur,
rub, or gallop. Good pulses throughout.
Pulmonary/Chest: No respiratory distress. Clear to auscultation bilaterally. No wheezes,
rales, or rhonchi.
Abdominal/GI: BS normal, Soft, non-tender, non-distended. No rebound or guarding.
Musculoskeletal: No gross injuries or deformities.
Neurological: Alert and oriented to person, place, and time. Cranial Nerves 2-12 intact.
Moving all extremities. No gross deficits
Skin: Skin is warm and dry. No rash noted.
Resident A, MD
Procedures
Cardioversion
A a synchronized cardioversion was performed for the treatment of atrial fibrillation
using 150 joules. The rhythm following cardioversion was sinus rhythm. The patient
tolerated the procedure well
Resident B, MD
Conscious Sedation: Performed for the purpose of cardioversion. Oral and written
consent obtained. Pt sedated with a total of 30mL ketamine follow by 30mL of propofol.
Vitals monitored throughout and remained stable. Pt tolerated well. Performed by
Resident B, MD under the supervision of Dr. Attending A.
MDM
ECG Results @ 22:23 on 11/3/14
Rate: 97
Rhythm: Atrial Fibrillation
PR Interval: N/A
QRS Duration: 80
QTc: 458
QRS Axis: 38
Narrative Interpretation: A fib. Rate 90-100.
Resident A
Adult ECG Report
Post-cardioversion
14:21 on 11/4/14
Rate: 68
Rhythm: Normal Sinus Rhythm
QRS Axis: 9
PR Interval: 120
QRS Duration: 88
QTc: 434
Narrative Interpretation: Biphasic P waves. Peaked T waves. NSR.
Resident B
ED Course:
71 yoF w episode of palpitations. Felt heart was racing, irregular. No CP, SOB,
Diaphoresis. Had episode A fib ~8 years ago, was on beta blocker at that time. EKG w
Afib.
- BMP, CBC, UA, Mg, Phos
- Bolus NS
- Tele monitoring
Labs ok. Given 5mg Metoprolol IV
After fluids, Metop. Pt remains in A-fib, but with rate in 70s. CHADS2 score of 1.
Discussed with patient options for rate control, +/- anticoagulation with short-term
outpatient follow-up with PCP vs cardiology evaluation in AM, which may yield same
recommendation. Patient would prefer to see cardiology in AM.
Will have cards weigh in on pt in AM, likely outpatient management. Pt signed out to Dr.
Resident B in stable condition
Received sign out from Dr. Resident A, pt remain stable in rate controlled afib, awaiting
cards consult
- cards request cardioversion, aware no anticoagulation, risk/benefits discussed with pt
and agreed to proceed with cardioversion
- conscious sedation performed as above, cardioverted, back in NSR, tolerated well
- EKG following cardioversion shows some varying P waves, semi-freq PACs also
noted, cards team to see pt again
- cards ok pt, same as previous plan, no change in meds, no anticoagulation, will f/u
with Dr. Cardio.
- discussed pertinent findings and plan with patient; discussed return precautions with
patient which include but are not limited to palpitations, chest pain, SOB; patient
demonstrated understanding and agreeable with assessment and plan
Attestations:
I have personally interviewed and examined the patient. I have reviewed the resident's
history, physical exam, assessment and management plans. I concur with or have
edited all elements of the resident's note.
Attending A, MD, November 5, 2014, 16:59
After a review of the patient's case the resident performed the documented procedure(s)
under my supervision. I was present for the entire procedure(s).
Attending B, MD
The documentation recorded by the scribe accurately reflects the service I personally
performed and the decisions made by me.
Resident A, MD, November 3, 2014, 22:03
The resident/attending physician obtained and performed the history, physical exam
and medical decision making elements that were entered into the chart by me,
Scribe, November 3, 2014 22:48
Case 6
CHIEF COMPLAINT: Complex laceration, left forearm.
HISTORY OF PRESENT ILLNESS: Raul is a 26-year-old Hispanic male who was transferred by private
vehicle from Rural Hospital. I talked to their EDMD regarding a complicated left forearm laceration that
involved skin, a flap, fascia, and then part of the forearm muscle after the patient had accidentally put his
arm through a glass table. The patient has no numbness or weakness distal to this injury. There was no
pulsatile bleeding or arterial bleeding. They did not feel that there was an immediate neurologic
tenderness or vascular injury, but it was quite a complex soft tissue repair. The patient did receive Ancef
and a tetanus shot. He is here with a compression dressing on. He has no significant complaints of chest
discomfort or abdominal discomfort. He was not in a fight. This was not an altercation; it was accidental.
He did state he has a slight skin cut on the lumbar back that is not a penetrating stab wound; it is just
simply a partial thickness laceration that will not even need sutures.
The patient at this time is denying any numbness to the fingers or the thumb. He has full range of motion
of the wrist joint and the elbow. He is able to supinate and pronate. He does not feel that there is glass in
there, but he is agreeable to us taking a radiograph.
PAST MEDICAL HISTORY: He is otherwise healthy.
MEDICATIONS: None other than his Ancef at the other facility.
ALLERGIES: NO KNOWN MEDICATION ALLERGIES.
SOCIAL HISTORY: He denies drugs. He drinks socially. He is Hispanic.
REVIEW OF SYSTEMS: As per the HPI with no head, neck, chest, or belly injury. No numbness or
weakness in the arms or legs or in the hands.
PHYSICAL EXAMINATION: Temperature 97.7. Respirations 18. Pulse 101. Blood pressure
146/85, saturations 93% on room air. Weight is 181 pounds. Raul is nontoxic. His pupils, sclerae,
conjunctivae, and oropharynx are normal. I have examined his chest and his belly. I do not see any stab
wounds or signs of trauma or injury. On the lumbar area, there was about a 3 cm superficial and then
maybe just a little more than partial thickness at the center, basically a slicing type of defect. It did not
dehisce. There was no violation of the dermis or into the tubcutaneous tissue. It will not need sutures.
That is in the mid line over the L4 area. No tenderness over the spinous processes. The patient's cervical
exam, thoracic, and lumbar exam: Otherwise no body tenderness. Clavicle, shoulders, elbows, and wrists
unremarkable. Clear breath sounds. Normal cardiac tones. No murmurs. Belly is benign. Examination of
his left forearm shows a full thickness flap that is total length of about 12 cm. It seems to plane along of
the subcutaneous tissue and then in about a 4 cm section it violated the fascia in the volar surface of the
medial forearm just volar to that ridge of the ulna. It involves the fascia and then part of the muscle belly,
basically covering the extensor carpi ulnaris muscle. There were no obvious glass particles or foreign
material on probing and inspection of this wound. With supination and pronation as well as ulnar deviation
of the wrist, I can see the muscle belly articulate back and forth. It tends to bulge up through that fascia. It
will need some coverage with the fascia. We should be able to bring that over and cover the muscle belly
and then close the skin above that. I do not think this gentleman needs to go to the operating room.
On the distal neurovascular exam, basically he has a palpable radial artery and ulnar artery.
He has good two-point sensation to the thumb, the index finger, long finger, ring finger, pinkie finger. He
can abduct his thumb to his pinkie. I do not see any neurologic deficit. On palpation of his tendinous
structures, he has a flexor carpi ulnaris, flexor carpi radialis, as well as palmaris longus tendons that are
palpable and intact and there does not appear to be any significant structural injury distal to this wound.
The patient has already had an antibiotic shot of Ancef. He has had a tetanus update. We obtained an xray of that forearm which shows the soft tissue defect. I do not see any obvious foreign bodies, at least
radiopaque foreign bodies.
Please see the PA's procedure note with regard to layered closure. He anesthetized the wound. It is being
copiously irrigated under pressure, two liters, to get a good clean field and then the wound will be closed
with 3-0 dissolvable sutures, bringing the fascia over the muscle belly and then closing the skin above that
with a combination of simple interrupted as well as horizontal mattress sutures.
DIAGNOSIS: Complex forearm laceration, 12 cm.
PLAN: The patient will use a sling for support, to kind of remind him not to disrupt the sutures. I will put
him on Keflex for a week, Vicodin as needed for pain. If he has redness, drainage, fever, signs of swelling,
or the wound is pulling apart, he will come back to the Emergency Room; otherwise, there will be suture
removal in 10-14 days. No alcohol or driving if taking the Vicodin. Follow up in any Primary Clinic or
Urgent Care or Emergency Room for suture removal.
Signed by EDMD.
CHIEF COMPLAINT: Left arm injury.
HISTORY OF PRESENT ILLNESS: The patient is a 26-year-old who was transferred from the Rural
Emergency Room and has been evaluated here by the EDMD after a laceration to the left upper extremity
occurred when the patient's arm went through a glass coffee table.
The patient has been evaluated by the EDMD who asked for closure of a large laceration on the ulnar
surface of the left arm. Bleeding was controlled. The wound had been previously anesthetized, however, it
was uncomfortable for the patient. Procedure was described to the patient. He gave verbal consent. The
wound was anesthetized with 50% Sensorcaine and 50% 1 % plain lidocaine. The wound was measured
at 20 cm. It is a flap type laceration with a proximal bridge of approximately 3 cm. This laceration is
complex and extends through the fascia but does not involve the muscle belly itself. There is a second 2
cm laceration at the proximal aspect making total suturable laceration of 22 cm.
PROCEDURE: The patient's wound was anesthetized. It was then recleansed and irrigated with a liter of
normal saline. The patient was placed prone in a position of comfort. The wound was draped sterilely. 3-0
Vicryl mattress sutures were used to repair approximately 5 cm laceration in the muscle fascia. The large
wound was then approximated with approximately six 4-0 Vicryl. Deep sutures were placed with 4-0 Vicryl
suture and approximately 20 horizontal mattress sutures were placed approximating the wound edges.
Bleeding was controlled. There was no evidence of any foreign body in the wound prior to closure. The 2
cm laceration was closed with one 4-0 Vicryl suture and three 5-0 nylon sutures. The patient tolerated the
procedure well. I then dressed the wound with antibiotic ointment, Xeroform dressing, gauze and Kerlix.
IMPRESSION: Left forearm laceration 22 cm suturable with complex three layer closure.
PLAN: The patient will be discharged home. Wound check in clinic in Zimmerman in two days. Suture
removal in 10 to 14 days. Keep the arm clean and dry. No use of the left arm until instructed by physician.
A sling was ordered by Dr. Hoffmann. The patient is given
Keflex antibiotic prescribed by Dr. Hoffmann. He should use that as directed for the next week. He has
also been given a prescription for Vicodin to be used for pain. He is to avoid driving and alcohol while
taking this medication. Follow-up at the primary clinic for a wound check in 48 hours and make another
appointment for sutures to be removed in 10 to 14 days.
Return to the Emergency Room or see c1inic for any redness, drainage, increasing pain or swelling that
would suggest an infection. The patient is given information regarding wound and suture care as well as
a note for work for no use of the left arm for the next 48 hours. He was discharged then in stable and
satisfactory condition.
Signed by PA
Case 7
CHIEF COMPLAINT: Left leg pain.
HISTORY OF PRESENT ILLNESS: This is a 54-year-old male who complains not so much
of pain in his legs, but rather a significant cellulitis and he noted maggots on his legs this
morning, the same thing occurred for him several months ago. He was hospitalized for this
over a period of several days, and was treated with IV antibiotics, and eventually went home
with improved lower extremity cellulitis. Today, he reports this is the same as it looked at
that time. He has pain with walking. He states he has been trying to take care of himself, but
he does admit to continued alcoholism. He denies any fever. No chest pain. No shortness of
breath. No belly pain. No trauma to the legs. No abrasions or lacerations are reported.
PAST MEDICAL HISTORY
1. Asthma.
2. Cerebrovascular disease.
3. Chronic obstructive pulmonary disease.
4. Chronic kidney disease.
5. Hypertension.
6. Asthma.
7. Incision hernia.
8. Alcoholism.
PAST SURGICAL HISTORY: None.
MEDICATIONS
1. Spiriva.
2. Multivitamin.
3. Metoprolol.
4. Diltiazem.
5. Lotrimin.
6. Symbicort.
7. Aspirin.
8. Albuterol.
9. Tylenol.
ALLERGIES: ENVIRONMENTAL SUBSTANCES.
SOCIAL HISTORY: He denies smoking anymore. Alcohol abuse continues. Drug use none.
Former marijuana user.
REVIEW OF SYSTEMS: A 10-point review of systems is complete. See history of present
illness for pertinent positives and negatives.
PHYSICAL EXAMINATION: An alert and oriented 54-year-old male who does not appear in
distress. Vital signs: he is afebrile with temperature of 98.2, blood pressure 113/67, pulse 91
respirations 18, oxygen saturation 95 percent. Head is normocephalic, atraumatic. Eyes:
Pupils equal, react. Neck is supple. Heart regular. [No murmurs heard]. Lungs clear to
auscultation. No wheezes or rhonchi. Abdomen nondistended. Musculoskeletal exam:
Patient moves all extremities voluntarily including the affected lower extremities. The skin
exam shows weeping erythematous warm lower extremities bilaterally consistently with
arterial and venous insufficiency and secondarily infected.
EMERGENCY DEPARTMENT COURSE: Patient had IV access established. Laboratory
results show a glucose of 108, BUN 8.5, creatinine 0.71. CRP was elevated at 11.4. White
count was normal at 7.7. Hemoglobin was 12. Blood culture is obtained. I did attempt to
obtain a wound culture, but this was unsuccessful. Patient was started on vancomycin. I did
speak with Family Medicine and will follow the patient when he is admitted upstairs to the
medical floor.
DIAGNOSIS: Cellulitis.
PLAN: As stated, patient was seen and discussed with the EDMD. He concurs with the
assessment and plan, and also evaluated the patient.
Signed by, PA
Signed by EDMD Case 8
Age: 69 years Sex: Female
Associated Diagnoses: None
Author: EDMD
Straight Talk 2012 Case 10 DOB: 5/12/1943
Basic Information
Time seen: Date & time 9/9/2012 12:13:00.
History source: Patient.
Arrival mode: Private vehicle.
History limitation: None.
9/9/2012 11:28 CDT
Chief Complaint-Triage
cp- sob-dizzy
History of Present Illness
The patient presents with dizziness. The onset was this morning. The course/duration of symptoms is resolved. The character of symptoms is
lightheaded. The degree at present is none. Exacerbating factors consist of none. The relieving factor is none. Risk factors consist of took ambien
last night. Prior episodes: none. Therapy today: prescription medications including fentanyl patch. Associated symptoms: chest pain, shortness of
breath, confusion and denies nausea.
The patient presents with chest pain. The onset was this morning. The course/duration of symptoms is resolved and episodic: lasts a few seconds.
Location: generalized. Radiating pain: none. The degree at onset was minimal. The degree at maximum was minimal. The degree at present is none.
Exacerbating factors consist of none. The relieving factor is none. Therapy today fentanyl patch. Associated symptoms: shortness of breath,
dizziness, confusion and denies nausea.
The patient is a 69 year old female who presents with chest pain, dizziness, and confusion. The patient said this started this morning when she
woke up. She thought she had her family stay over the night before and they were not there when she woke up. She called her son who told her they
did not stay over last night. He later talked to her and the confusion was starting to resolve but she started complaining of intermittent chest pain,
shortness of breath with exertion, and dizziness. She denies any nausea or fever. The patient said this chest pain last anywhere from a couple seconds
to a couple minutes. The patient said Dr. C took her off several medications on August 28th and started taking Ambien as needed August 26th. She did
take an Ambien last night and is wondering if this may be side effects from that. The patient has a history of hypertension, CHF, COPD, CAD, MI, and
has a pacemaker.
Review of Systems
Constitutional symptoms: No fever,
Skin symptoms: Negative except as documented in HPI.
Eye symptoms: Negative except as documented in HPI.
ENMT symptoms: Negative except as documented in HPI.
Respiratory symptoms: Shortness of breath (with exertion).
Cardiovascular symptoms: Chest pain, intermittent.
Gastrointestinal symptoms: No nausea,
Genitourinary symptoms: Negative except as documented in HPI.
Musculoskeletal symptoms: Negative except as documented in HPI.
Neurologic symptoms: Dizziness, confusion.
Additional review of systems information: All other systems reviewed and otherwise negative.
Health Status
Allergies: .
Allergic Reactions (All)
Severe
Atenolol- Rash.
Cardizem CD- Itching and rash.
Crestor- Muscle ache.
Prevacid- Diarrhea.
Trental- Rash.
Welchol- Muscle ache.
Zocor- Muscle ache.
Severity Not Documented
Allegra- Rash.
Aqua Glycolic- Glycol.
Atorvastatin- Muscle pain ache.
Colesevelam- Unknown.
Lanoxin- Drowsy.
Lipitor- Rash and diarrhea.
Magnesium containing compounds- Unknown.
Morphine- Rash.
Niacin- Rash.
Oxycodone- "knocked me out".
Penicillin*- Rash.
Pentoxifylline- Muscle pain.
Rosuvastatin- Muscle pain.
Medications: (Selected).
Prescriptions
Ordered
Paxil 20 mg oral tablet: 20 mg, 1 Tab, PO, Daily, 30 Tab
Straight Talk 2012 Case 10 Plavix 75 mg oral tablet: 75 mg, 1 Tab, PO, Daily, 30 Tab
aspirin 81 mg oral enteric coated tablet: 81 mg, 1 Tab, PO, Daily, 30 Tab
lisinopril 10 mg oral tablet: 10 mg, 1 Tab, PO, BID, 60
Documented Medications
Ordered
Accolate 20 mg oral tablet: 20 mg, 1 Tab, PO, BID
Brovana 15 mcg/2 mL inhalation solution: Nebul, BID
Calcium 600 +D: 1 Tab, PO, TID
Imdur 30 mg oral tablet, extended release: 30 mg, 1 Tab, PO, ac din, 30 Tab
Imdur 60 mg oral tablet, extended release: 60 mg, 1 Tab, PO, QAM, 30 Tab
Lasix: 10 mg, PO, Daily, Each
Lasix: 20 mg, PO, Daily, Each
Lipitor 20 mg oral tablet: 20 mg, 1 Tab, PO, Daily
Lyrica: 100 mg, PO, TID
Nitrostat 0.4 mg: Subl
OxyCODONE/Acetaminophen 5 mg/325 mg: 1 Tab, PO, Daily, Each
ProAir HFA: 1 Puff, Inhalation, Q4h, Each, PRN: as needed
Pulmicort Flexhaler 180 mcg/inh inhalation powder: Inhalation, Each
Ranexa 500 mg oral tablet, extended release: 1,000 mg, 2 Tab, PO, BID, Each
Toprol XL 25 mg oral tablet, extended release: 1 Tab, PO, Daily, 30 Tab
Tricor 145 mg oral tablet: 145 mg, 1 Tab, PO, Daily
Xanax 0.25 mg oral tablet: 0.25 mg, 1 Tab, PO, BID, 20
multivitamin: 1 Cap, PO, Daily
omeprazole 40 mg oral enteric coated capsule: 1 Cap, PO, Daily, Each
oxygen: See Instructions, 2 LITERS PER NASAL CANNULA AS NEEDED
spironolactone 25 mg oral tablet: 1/2 tab, PO, Daily, Each
Immunizations: Include Immunizations.
Previous
Adult Influenza: Dose #1 () 9/14/2009 CDT.
Past Medical/ Family/ Social History
Medical history: Medical history,
Active
Carpal tunnel (107413017): Onset in 2011 at 68 years.
Comments:
9/29/2011 CDT 1:01 CDT - Kesler RN, Lauren B
Procedure on right. Will have procedure on left
ICD (implantable cardiac defibrillator) in place (V45.02): Onset in 2010 at 67 years.
Body piercing (V15.89)
Coronary artery disease (2536395017)
High cholesterol
Hypertension (64176011)
PVD (peripheral vascular disease) (443.9)
Thumb fracture (816.00)
Transmyocardial revascularization by laser technique (25894011)
Resolved
Angina (299755016): Resolved.
Anxiety (81133019): Resolved.
Asthma (301485011): Resolved.
Back pain (2646370015): Resolved.
BIPAP - Biphasic pressure airway support (363636012): Resolved.
Cardiac catheterization (70051019): Resolved.
Cardiomyopathy (142397010): Resolved.
Cataract (298076010): Resolved.
CHF - Congestive heart failure (493289014): Resolved.
Constipation (25076018): Resolved.
COPD (23290013): Resolved.
Depression (486184015): Resolved.
Dizziness (2156535017): Resolved.
Femur fracture, right (821.00): Resolved.
Fibromyalgia (41386013): Resolved.
Heart disease (429.9): Resolved.
Hemorrhoid (501503011): Resolved.
Hiatal hernia (139432019): Resolved.
Menopause (251993014): Resolved.
Miscellaneous (82671012): Resolved.
Comments:
7/21/2011 CDT 17:17 CDT - Stokke RN, Ashley A
Implanted port
Miscellaneous (82671012): Resolved.
Comments:
7/21/2011 CDT 17:23 CDT - Stokke RN, Ashley A
Stress on kidneys from lasix
Straight Talk 2012 Case 10 Myocardial infarction (37436014): Resolved.
Pacemaker (V45.01): Resolved.
Pinched nerve (355.9): Resolved.
Comments:
7/21/2011 CDT 18:39 CDT - Stokke RN, Ashley A
bilateral feet
Reflux (78795015): Resolved.
Shortness of breath (397890011): Resolved.
Sleep apnea (121941010): Resolved.
Staph infection (041.10): Resolved.
Comments:
7/21/2011 CDT 18:34 CDT - Stokke RN, Ashley A
In 2005-Dr.Mulkey resolved
Sternal fracture (130284016): Resolved.
Syncope (406440010): Resolved.Reviewed as documented in chart, No additional medical history found in the past medical records or stated by
the patient.
Surgical history: Surgical history,
Coronary angiogram (SNOMED CT 55683012) performed by Congello MCC DO, Samuel J in 2012 at 69 Years.
Coronary angioplasty (SNOMED CT 68955014) performed by Congello MCC DO, Samuel J in 2012 at 69 Years.
Comments:
MID-PROXIMAL LAD BEFORE DIAGONAL BRANCH
DIAGONAL BRANCH- INSTENT RESTENOSIS
Botox (SNOMED CT 173425010) in 2008 at 65 Years.
Comments:
Stretch esophagus and four botox shots
Transmyocardial laser revascularization, by thoracotomy; (separate procedure) (CPT4 33140) in 2006 at 63 Years.
Angioplasty or atherectomy of other non-coronary vessel(s) (ICD-9-CM 39.50).
Bilateral cataracts (SNOMED CT 158572010).
Breast reconstruction (SNOMED CT 55899016).
CABG (ICD-9-CM V45.81).
Carpal tunnel (SNOMED CT 107413017).
Comments:
bilateral
Cataract surgery (SNOMED CT 2618480016).
Dental implant maintenance procedure (SNOMED CT 83745014).
Hysterectomy (SNOMED CT 355048014).
Miscellaneous (SNOMED CT 82671012).
Comments:
Bilateral feet had neuro surgeryReviewed as documented in chart,
Multiple stent placements
pacemaker and defibrillator placement.
Family history: Reviewed as documented in chart,
Mother, father, and 5 of her brothers have or had coronary artery disease\.
Social history: Reviewed as documented in chart, Tobacco use: Denies, Family/social situation: Lives alone.
Physical Examination
Vital Signs
Vital Signs/Measurements.
9/9/2012 11:28 CDT
Temperature
97.1 Degrees F
Temperature Route
Oral
Pulse Rate
76 BPM
Respiratory Rate
20 Br PM
Pulse Oximetry
96 % NML
Oxygen Delivery
Room air
Pain Score
4
Pain Intensity Scale
Numeric Rating Scale (Adults)
Pain Location Site #1
Chest
Pain Location Modifier Site #1
Anterior
Pain Characteristics Site #1
Dull
Height
152.4 cm
Weight
67.1 kg
Weight Type
Actual
Weight Lb
147 lbs
Weight Oz
14.89 oz
Height Type
Actual
Height Ft
5 ft
Height in
0.0 Inch
BSA
1.69 m2
Straight Talk 2012 Case 10 Body Mass Index
29 kg/m2
Oxygen saturation: 96 % (on room air, normal).
General: Alert, no acute distress.
Skin: Warm, dry, no rash.
Head: Normocephalic, atraumatic.
Neck: Supple, trachea midline, no tenderness.
Eye: Pupils are equal, round and reactive to light, extraocular movements are intact.
Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate.
Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral perfusion, No edema.
Respiratory: Lungs are clear to auscultation, respirations are non-labored, Symmetrical chest wall expansion.
Chest wall: No tenderness.
Back: Nontender.
Musculoskeletal: Normal ROM, no tenderness, no swelling.
Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds.
Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed, CN II-XII intact, normal sensory
observed, normal motor observed, normal speech observed, normal coordination observed.
Psychiatric: Cooperative, appropriate mood & affect.
Medical Decision Making
Documents reviewed: Emergency department nurses' notes, flowsheet, emergency department records, prior records, Past Medical, Surgical,
and Family History found in previous documents, Social history given by patient.
Orders
NaCl 0.9% 1000ml IV
Nitro 0.4mg Subl Q5min
Aspirin 324mg Chew
UA
BMP
CBC with Diff
Troponin
CXR
EKG.
Electrocardiogram: Time 9/9/2012 11:51:00, rate 71, EP Interp, paced rhythm, no acute changes, no change from previous EKG of 7-25-12.
Results review: Lab results : LAB,
9/9/2012 12:34 CDT
9/9/2012 11:57 CDT
Urine Specimen
Color Urine
Clarity Urine
Specific Gravity Urine
pH Urine
Glucose Urine
Ketones Urine
Bilirubin Urine
Occult Blood Urine
Urobilinogen Urine
Leukocyte Urine
Nitrite Urine
Protein Urine
Microscopic Urine
WBC Urine
RBC Urine
Squamous Epithelial Cells
Bacteria Urine
Sodium Level
Potassium Level
Chloride Level
Carbon Dioxide Level
Anion Gap
Glucose Level
BUN
Creatinine
BUN / Creatinine Ratio
GFR Estimated Non African
MIDSTREAM URINE
YELLOW
CLEAR
<=1.005
5.5
NEG
NEG
NEG
NEG
NEG
TRACE
NEG
NEG
PERFORMED
0 TO 2 /hpf
0 TO 2 /hpf
Urine
0 TO 2 /hpf
1+ (1 TO 10) /hpf
140 mMol/L
3.5 mMol/L
100 mMol/L
33 mMol/L
11 mMol/L
107 mg/dL
22.8 mg/dL
1.5 mg/dL HI
15.2
American
34.4 mL/min/1.73
m2
GFR Estimated African American
41.7 mL/min/1.73
m2
Calcium Total
Troponin I
WBC Count
Red Blood Cell Count
9.3 mg/dL
0.01 Nanogram/mL
7.5 X10 3/uL
3.55 X10 6/uL LOW
Straight Talk 2012 Case 10 Hemoglobin
Hematocrit
MCV
MCH
MCHC
RDW
Platelet Count
MPV
Diff Method
Neutrophil Percent
Lymphocyte Percent
Monocyte Percent
Eosinophil Percent
Basophil Percent
Neutrophil Absolute
Lymphocyte Absolute
Monocyte Absolute
Eosinophil Absolute
Basophil Absolute
12.3 gm/dL
35.2 %
99.0 FL
34.6 Picograms
35.0 gm/dL
14.0 %
244 X10 3/uL
8.1 FL
AUTOMATED
61.9 %
25.0 %
11.4 % HI
1.3 %
0.4 %
4.6 X10 3/uL
1.9 X10 3/uL
0.9 X10 3/uL
0.1 X10 3/uL
0.0 X10 3/uL All Results :
Results.
9/9/2012 12:08 CDT
Chest X-Ray:
CHEST X-RAY:
aspirin
244 mg mg
No change from previous
Interpreted by ED physician.
Reexamination/ Reevaluation
Time: 9/9/2012 13:26:00 .
Notes: patient denies any symptoms now, will follow up with PCP. We discussed that her symptoms may be related to her Ambien. She will be careful
how she takes it and will not take it unless she is sure to have a full night's sleep. She will not take it if she awakens in the middle of the night. She
will f/u with Dr. M for repeat UA at the end of the week..
Impression and Plan
UTI (urinary tract infection) (ICD9 599.0, Discharge, Emergency medicine, Medical)
Medication Reaction
Plan
Condition: Improved, Stable.
Disposition: Discharged: Time 9/9/2012 13:30:00, to home.
Prescriptions:
cipro 500mg PO Q12 for 3 days, dispsened 6.
Patient was given the following educational materials: Urinary Tract Infection.
Follow up with: De M Within Follow-up as needed Take medication as directed
Return to the ER if problems.
Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated
understanding of instructions.
Notes:
Documentation prepared by Ashley, acting as medical scribe for EDMD,
EDMD: I have reviewed the documentation prepared by the scribe and I agree with its contents.
Type:
Date:
Status:
Title:
Verified By:
ED Physician Notes
09 September 2012 11:36 CDT
Auth (Verified)
Dizziness *ED, Chest Pain *ED
EDMD J on 10 September 2012 8:55 CDT
Case 9 Chief Complaint‐Triage 11/10/2015 20:25 CST Chief Complaint‐Triage Fingernail avulsion. History of Present Illness The patient presents with a scratch by an animal and not a dog bite. The onset was just prior to arrival. The course/duration of symptoms is constant. The location where the incident occurred was at home. Location: Left third fingernail. The character of symptoms is pain and bleeding. The degree of pain is moderate. The degree of bleeding is minimal. Risk factors consist of none. Rabies risk unknown. Prior episodes: none. Therapy today: none. Associated symptoms: none. The patient is a 21 year old male that presents to the emergency department with fingernail injury due to altercation with dogs. The patient states that neighbor’s two dogs were fighting with his dog and he ran to break up the fighting and was rolling on concrete and he smashed his finger into the ground. States that he was not bit by any of the dogs during this incident. He was scratch numerous times but has no concerns about those scratches. Main complaint is about his third left fingernail which is falling off and bleeding. The dogs were all pit pulls. His is up to date on vaccination, unsure if other dogs are as well. Last tetanus shot was around 3 years ago. Denies any other medical concerns at this time. . Review of Systems Constitutional symptoms: Negative except as documented in HPI. Skin symptoms: Negative except as documented in HPI. Eye symptoms: Negative except as documented in HPI. ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI. Genitourinary symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: third left fingernail pain and bleeding. Neurologic symptoms: No altered level of consciousness, Additional review of systems information: All other systems reviewed and otherwise negative. Health Status Allergies: Allergic Reactions (All) NKA. Medications: Per nurse's notes. Immunizations: Per nurse's notes. Past Medical/ Family/ Social History Medical history Reviewed as documented in chart. Surgical history: Reviewed as documented in chart. Family history: Reviewed as documented in chart. Social history: Reviewed as documented in chart. Physical Examination Vital Signs/Measurements 11/10/2015 20:25 CST Temperature 99.1 Degrees F NML Temperature Route Temporal Artery Pulse Rate Respiratory Rate Pulse Oximetry 96 % NML Oxygen Delivery Systolic BP 136 mmHg NML Diastolic BP 86 mmHg NML NIBP Method‐CC Pain Score 116 BPM HI 18 Br PM NML Room air Cuff, Arm, right 3 Pain Intensity Scale Verbal (Adults) Numeric Rating Scale‐
Finger Pain Location Site #1 Pain Location Modifier Site #1 Left Pain Characteristics Site #1 Weight 68.5 kg Weight Type Actual Weight Lb 151 lbs Weight Oz 0.27 oz Height 173 cm Height Type Actual Height Ft 5 ft Height in 8.1 Inch BSA Body Mass Index Throbbing 1.82 m2 22.9 kg/m2 Oxygen saturation: 96 % (Normal, room air). General: Alert, no acute distress. Skin: Warm, numerous superficial abrasions over the bilateral arms and hands. Head: Atraumatic. Back: Normal range of motion. Musculoskeletal: Normal ROM, normal strength, no deformity, subungual hematoma under the third left fingernail. Cauterized and drained. base of the nail is intact. Neurological: Alert and oriented to person, place, time, and situation, normal sensory observed, normal motor observed, normal speech observed, normal coordination observed. Psychiatric: Cooperative. Medical Decision Making Documents reviewed: Emergency department nurses' notes, flowsheet, emergency department records, Information documented in past medical history was obtained from past medical records and confirmed with the patient. Orders Norco 5mg‐325mg oral tablet 1 tab PO Augmentin 875mg oral tablet 1 tab PO. Results review: Pending Med Order on Discharge. Reexamination/ Reevaluation Time: 11/10/2015 20:53:00 . Notes: does not believe there was any bony involvement, declines x‐ray at this time. . Procedure Nail treatment Time: 11/10/2015 20:40:00 . Confirmed: Patient, procedure, side, and site correct, Time‐out taken prior to procedure. Consent: Patient, Has given verbal consent. Description/ repair Location: Left, third, finger. Hematoma: electrocautery. Nail: avulsed but attached on lateral border. No Anesthesia. No irrigation. No skin closure. No Nailbed repair. Post procedure exam: Circulation, motor, sensory examination intact. Patient tolerated: Well. Complications: None. Performed by: Self. Total time: 5 minutes. Notes: pt refuses x‐ray and refuses the nail to be removed.. Impression and Plan Diagnosis Hematoma, subungual, finger Plan Condition: Improved, Stable. Disposition: Discharged: Time 11/10/2015 20:54:00, to home. Prescriptions: Norco 5mg‐325mg oral tablet 1 tab PO TID x 5 days Augmentin 875mg‐125mg oral tablet 1 tab PO Q12h x 7 days. Patient was given the following educational materials: Subungual Hematoma, Easy‐to‐Read. Follow up with: Orthopedic Surgeon Within Follow‐up as needed; Follow up with primary care provider Within 3 to 4 days; No PCP Physician, Family Practice, Internal Medicine, Pediatrics Within Follow‐up as needed, Return to Emergency Department, Primary Care Physician. Counseled: Patient, Regarding diagnosis, regarding diagnostic results, regarding treatment plan, regarding prescription, Patient indicated understanding of instructions. Notes: I scribe, am serving as a medical scribe to document services personally performed by EDMD, based on the patient's responses to questions from the provider and the provider's statements to me, EDMD: I have reviewed and noted that all documentation recorded by the scribe accurately reflects the service I personally performed and the decisions made by me. I was present during the time the encounter was recorded and have reviewed all the documentation and confirm that it is all accurate and representative of the encounter. Case 10 Chief Complaint ‐ boil . History of Present Illness The patient presents with skin problem and abscess. The onset was 10 days ago. The course/duration of symptoms is worsening. Location: posterior neck. The character of symptoms is pain, swelling and redness. The degree of symptoms is moderate. Risk factors consist of none. Prior episodes: none. Therapy today: none. Associated symptoms: denies fever, denies chills and denies myalgia. Additional history: The patient saw Dr. Jenkins on 10/27 and was placed on Keflex. He thinks it is helping but it has not gone away. He denies any fever or chills. He has minimal pain when he wakes up in the morning but denies any pain currently. He denies any history of abscesses. . Review of Systems Constitutional symptoms: No fever, no chills. Skin symptoms: abscess. ENMT symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: Negative except as documented in HPI. Neurologic symptoms: Negative except as documented in HPI. Past Medical/ Family/ Social History Medical history Reviewed as documented in chart. Medical history: Past Medical History Problem List (ST) No active or resolved problems charted. Surgical history: No active procedure history items have been selected or recorded.. Social history: Reviewed as documented in chart. Social history: No qualifying data available. Physical Examination Respiratory Rate Vital Signs/Measurements 18 Br PM NML 11/5/2015 12:37 CST Pulse Oximetry Temperature 94 % NML 97.9 Degrees F NML Systolic BP Temperature Route 141 mmHg HI Skin Diastolic BP Pulse Rate 86 mmHg NML 72 BPM NML General: Alert, no acute distress. Skin: Warm, dry, pink, Lesion(s): Posterior neck , abscess, size (length 9 cm, width 6 cm), characteristics (raised, fluctuant and tender), color red, smaller nonfluctuant abscess just above the larger abscess measuring 3x2 cm. This one is not erythematous and no drainage, no discharge. Head: Normocephalic. Neck: No carotid bruit. Cardiovascular: Normal peripheral perfusion. Musculoskeletal: Normal ROM. Neurological: Alert and oriented to person, place, time, and situation. Medical Decision Making Orders Launch Orders Pharmacy: Norco 5 mg/325 mg (Order): 1 Tab, PO, Once, PRN: Pain ‐ Moderate, Launch Orders Laboratory: Culture Wound/Abcess + Smear Direct Order Set (MC) (Order) Wound Culture Other (MC) (Order): 11/5/2015 14:13 CST, ASAP, Neck, Nurse Collect Collected. Procedure Incision and drainage Time: 11/05/2015 13:45:00 . Confirmed: Patient, procedure, side, and site correct. Consent: Patient, Has given verbal consent. Indication: Abscess. Pre procedure exam: Circulation, motor, and sensory intact. Procedural sedation: None. Monitoring: Cardiac, blood pressure, continuous pulse oximetry. Description Location: posterior neck. Anesthesia: 5 ml, 1% lidocaine, with epinephrine, injected locally. Preparation: skin prepped with betadine. Incision: 1 cm incision was made, using a # 11 blade scalpel. Technique: fluid collection was manually decompressed, wound probed, loculations decompressed. Drainage: large amount, 30 ml, purulent, bloody, cultures obtained. Irrigation: moderate, with saline. Wound: packing placed in wound cavity. Post procedure exam: Circulation, motor, sensory examination intact. Patient tolerated: Well. Complications: None. Follow‐up: In 1 days, Antibiotic: bactrim, Home care instructions given, Urgent Care. Performed by: Self. Total time: 30 minutes. Notes: The patient's PCP office is not open tomorrow. Recommended he follow up at Urgent Care to have the wound repacked. Impression and Plan Diagnosis Neck abscess (ICD10‐CM L03.221, Discharge, Medical) Plan Condition: Improved, Stable. Disposition: Discharged: Time 11/05/2015 14:18:00, to home. Prescriptions: Med Rec/RX Pharmacy: Norco 5 mg‐325 mg oral tablet (Prescribe): 1 Tab, PO, Q4h, for 4 Day(s), PRN: for pain, 24 Tab, 0 Refill(s) Bactrim DS 800 mg‐160 mg oral tablet (Prescribe): 1 Tab, PO, BID, for 10 Day(s), 20 Tab, 0 Refill(s). Patient was given the following educational materials: Abscess, Care After, Pain Medicine Instructions. Follow up with: Rebecca Jenkins, Family Practice, Neo/Perinatal Med, Obstetrics 11/09/2015 10:30:00 Follow up tomorrow at Urgent Care to have this repacked Return to the ER if symptoms worsen Counseled: Patient, Regarding diagnosis, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions. Case 11 Chief Complaint‐Triage fall/right wrist. History of Present Illness The patient presents with right, wrist pain, wrist swelling. The onset was just prior to arrival. The course/duration of symptoms is constant. Type of injury: fall. The location where the incident occurred was at home. Location: Right wrist. The character of symptoms is pain and swelling. The degree of pain is severe. The degree of swelling is moderate. There are exacerbating factors including movement and palpation. The patient's dominant hand is the right hand. Prior episodes: none. Therapy today: none. Tripped up the stairs and now has pain and swelling to the dorsal side of the wrist. Pain with movement.. Review of Systems Additional review of systems information: All other systems reviewed and otherwise negative. Allergic Reactions (Selected) Xanax: PO, Each, 0 Refill(s) acetaminophen‐HYDROcodone 325 mg‐7.5 mg oral tablet: 1 Tab, PO, Q6h, Each, 0 Refill(s). Past Medical/ Family/ Social History Surgical history: No active procedure history items have been selected or recorded.. Social history: No qualifying data available. Problem list: All Problems Anxiety / SNOMED CT 81133019 / Confirmed. Physical Examination Vital Signs/Measurements 10/21/2015 19:02 CDT Temperature 100 % NML 97.3 Degrees F NML Oxygen Delivery Temperature Route Room air Skin Systolic BP Pulse Rate 124 mmHg NML 88 BPM NML Diastolic BP 110 mmHg HI Pulse Location Radial NIBP Method‐CC Cuff, Monitor, Arm, left, Upper Respiratory Rate 28 Br PM >HHI Pain Score 10 Pulse Oximetry General: Alert, moderate distress. Skin: Warm, dry, pink, intact. Head: Normocephalic, atraumatic. Neck: Supple, trachea midline, no tenderness. Musculoskeletal: Distal upper extremity: Right, wrist, carpal region, aligned, tenderness, swelling, range of motion (limited, restricted by pain), no erythema, no ecchymosis, no snuff‐box tenderness, no deformity. Neurological: Alert and oriented to person, place, time, and situation. Psychiatric: Cooperative. Medical Decision Making Differential Diagnosis: Wrist pain. Documents reviewed: Emergency department nurses' notes. Orders Launch Orders Pharmacy: Norco 7.5 mg/325 mg (Order): 1 Tab, PO, Once, PRN: Pain ‐ Moderate Radiology: XR Wrist 3+ Views RT (Order): 10/21/2015 19:39 CDT Stat, Reason: Pain/Trauma, x 1, Day(s) Order Sets‐Mason City: ER Express Radiology Order Set (MC) (Order). Hand/finger x‐ray findings: Interpretation by Emergency Physician. non‐displaced distal radius fx. Procedure Fracture/ Dislocation Procedure Time: 10/21/2015 21:00:00 . Confirmed: Patient, procedure, side, and site correct. Consent: Patient. Indication: Fracture. Location: Right, distal radius. Pre procedure exam: Circulation, motor, and sensory intact. Post‐procedure exam: Circulation, motor, and sensory intact. Immobilization: Sling, Splint: sugar‐tong. Patient tolerated: Poorly. Performed by: Physician assistant, PA, Total time: 15 minutes. Notes: Pt was pre‐medicated with norco and toradol for pain control prior to splint application. Splint applied, good neurovascularly post application, normal sensation.. Impression and Plan Diagnosis Closed fracture of right distal radius Plan Condition: Stable. Disposition: Discharged: Time 10/21/2015 21:24:00, to home. Prescriptions: Med Rec/RX Pharmacy: Norco 10 mg‐325 mg oral tablet (Prescribe): 1 Tab, PO, Q6h, PRN: for pain, 15 Each, 0 Refill(s). Patient was given the following educational materials: Radial Fracture. Follow up with: ; Follow up with primary care provider as needed may use rest/ice/elevation to help with discomfort may use norco for pain may use aleve for pain wear sling for comfort and help reduce swelling.. Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions. Verified By: PA, 21 October 2015 21:25 CDT Case 12 Chief Complaint‐Triage rt finger injury . History of Present Illness The patient presents with right, finger pain. The onset was 5 hours ago. The course/duration of symptoms is constant. Type of injury: direct blow. The location where the incident occurred was at work. Location: Right second fingertip. The character of symptoms is pain. The degree of pain is moderate. The exacerbating factor is palpation. The relieving factor is none. Risk factors consist of none. Prior episodes: none. Therapy today: none. Associated symptoms: none. The patient is a 26 year old male that presents to the emergency department with right second finger pain. The patient states that he smashed his finger between a meat cart and an over door while he was working tonight. States that the tip of his finger has been very painful since it happened at 1800 tonight. The patient states it has been a long time since his last tetanus shot. Denies any other medical concerns at this time. . Review of Systems Constitutional symptoms: Negative except as documented in HPI. Skin symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI. Genitourinary symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: right finger injury. Neurologic symptoms: No altered level of consciousness, Additional review of systems information: All other systems reviewed and otherwise negative. Health Status Allergies: Allergic Reactions (All) NKA. Medications: Per nurse's notes. Immunizations: Per nurse's notes. Past Medical/ Family/ Social History Medical history Reviewed as documented in chart. No past medical history contained in past medical records or stated by the patient. Surgical history: Reviewed as documented in chart, Cystourethroscopy. Family history: Reviewed as documented in chart, No significant family history stated by the patient or contained in past medical records. Social history: Reviewed as documented in chart. Physical Examination Vital Signs/Measurements 20 Br PM HI 11/10/2015 23:01 CST Temperature Pulse Oximetry 98.7 Degrees F NML 96 % NML Pulse Rate Systolic BP 100 BPM NML 138 mmHg NML Respiratory Rate Diastolic BP 77 mmHg NML General: Alert, mild distress. Skin: Warm. Head: Atraumatic. Cardiovascular: Regular rate and rhythm. Respiratory: Lungs are clear to auscultation, Symmetrical chest wall expansion. Gastrointestinal: Soft, Nontender. Back: Normal range of motion. Musculoskeletal: Normal ROM, normal strength, subungual hematoma of the second finger of the right hand. its draining on the side.. Neurological: Alert and oriented to person, place, time, and situation, normal sensory observed, normal motor observed, normal speech observed. Psychiatric: Cooperative. Medical Decision Making Orders Adacel 0.5ml IM Inject, Prior to discharge Augmentin 875mg PO once Tylenol #3 1 Tab PO Q4h lidocaine 1% 30mg Subcut, Inject, once X‐ray right finger second digit. Results review: All Results: 11/11/2015 00:28 CST lidocaine 30 mg mg, Pending Med Order on Discharge. Hand/finger x‐ray findings: RIGHT 2nd DIGIT X‐RAY Fracture of the distal phalanx Interpreted by ED Physician Reexamination/ Reevaluation Time: 11/11/2015 00:31:00 . Notes: The patient will follow up with ortho tomorrow. Procedure Nail treatment Time: 11/11/2015 00:24:00 . Confirmed: Patient, procedure, side, and site correct, Time‐out taken prior to procedure. Consent: Patient, Has given verbal consent. Description/ repair Location: Right, second. Hematoma. Details: bleeding. Nail: intact. Anesthesia: 5 ml, 1% lidocaine, injected distally. Debridement: none. No skin closure. No Nailbed repair. Post procedure exam: Circulation, motor, sensory examination intact. Patient tolerated: Well. Complications: None. Performed by: Self. Total time: 5 minutes. Notes: In ER we performed nerve block, the hematoma was draining due to open wound. Tube gauze was placed on the finger and pt to see ortho tomorrow.. Impression and Plan Diagnosis Fracture of finger of right hand Laceration of skin of finger Plan Condition: Improved, Stable. Disposition: Discharged: Time 11/11/2015 00:34:00, to home. Prescriptions: Augmentin 875‐125mg oral tablet PO Q12h x 5 days Norco 5mg‐325mg oral tablet 1 Tab PO Q6h x 5 days. Patient was given the following educational materials: Finger Fracture, Work Release (MC) (Custom). Follow up with: Orthopedic Surg Within 1 to 2 days; No PCP Physician, Family Practice, Internal Medicine, Pediatrics Within Follow‐up as needed, Return to Emergency Department, Primary Care Physician. Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions. Notes: I scribe, am serving as a medical scribe to document services personally performed by EDMD, based on the patient's responses to questions from the provider and the provider's statements to me, Verified By: EDMD on 11 November 2015 01:02 CST Case 13 History of Present Illness The patient presents in cardiac arrest. The onset was 0425 hours . Witnessed arrest no. Initial cardiac rhythm unknown. Pre‐arrival Treatment cardiopulmonary resuscitation, automated external defibrillator, intubated, intravenous fluids, Amiodarone, Epinephrine Bicarb. Preceding symptoms unknown. Risk factors consist of Uterine cancer. Additional history: none. The patient is a 70 year old female that presents to the Emergency Department with cardiac arrest. The patient was found unresponsive by her husband at 0425 hours today. At that time, 911 was called, and responders began CPR shortly after. In route, the patient was given CPR, shocked three times, intubated, and given IV fluids, 300 mg of Amiodarone, three rounds of epi, and bicarb. The patient came in the door at 0518 hours. Pertinent history includes uterine cancer for which she has been undergoing chemotherapy for the past three and a half to four years.. EMS reports initial Vfib, then PEA and CPR continued enroute. Events began at least 45 mins PTA. Review of Systems Cardiovascular symptoms: Cardiac arrest. Additional review of systems information: Unable to obtain due to: Clinical condition. Past Medical/ Family/ Social History Medical history: Past Medical History Problem List (ST) Active Acid reflux At risk for falls At risk for impaired skin integrity Bladder incontinence Cystocele Diarrhea International Federation of Gynecology and Obstetrics endometrial cancer (FIGO EC) stage I A Resolved Cancer ‐ endometria, omentum Cholelithiasis College of American Pathologists Cancer Checklist; Uterine Cervix: Colpectomy, Hysterectomy, Pelvic Exenteration Ileus , Reviewed as documented in chart, No Additional history found in past medical records or stated by the patient. Surgical history: Insertion of Port‐a‐cath (SNOMED CT 456078010) performed by Holthaus MD, Ryan M on 7/31/2013 at 68 Years. Comments: 7/31/2013 13:31 ‐ Johannesen RN, Rolinda L RIght IJ Biopsy of omentum (SNOMED CT 29486016) performed by Petree MD, Travis J on 5/17/2013 at 68 Years. Repair of cystocele (SNOMED CT 475483018). Cholecystectomy (SNOMED CT 64698015). Hysterectomy (SNOMED CT 355048014)., Reviewed as documented in chart, No Additional history found in past medical records or stated by the patient. Family history: Reviewed as documented in chart, Negative, No history found in past medical records or stated by the patient. Social history: Reviewed as documented in chart, Family/social situation: Married. Physical Examination Vital Signs/Measurements 61 BPM NML 10/16/2015 05:28 CDT Pulse Location Temperature Apical 96.4 Degrees F LOW Oxygen Delivery Temperature Route Bag‐Valve Mask (BVM) Skin Systolic BP Pulse Rate 94 mmHg NML Diastolic BP 42 mmHg <LLOW Skin: Cyanotic, pale. Head: Normocephalic, atraumatic. Eye: Pupils mid and unresponsive. Ears, nose, mouth and throat: OETT in place. Cardiovascular: Pulseless, indiventricular electrical activity with no pulse.. Respiratory: Bilat breath sounds with Bag/valve ETT ventilation. Interpreted by ED Physician. Procedure CPR Time: 10/16/2015 05:18:00 . CPR was performed: In addition to other critical care activities, Per American Heart Association (AHA) guidelines. Performed by: Resident, Nurse, EMS. Supervision: I directly supervised the performance of CPR on this patient. Total time: 10 minutes. Notes: 0518: patient presented through door 0519: CPR in progress 0520: CPR in progress 0521: CPR in progress 0522: CPR in progress 0523: CPR in progress 0524: CPR in progress 0525: epi given 0526: CPR in progress 0527: CPR in progress 0528: CPR stopped, patient in sinus brady 0528: pH 6.95 0530: 94/42 blood pressure 0530: bicarb given 0531: bicarb given, Please see code summary for details. Cardiology to assume care with intensivist consultation. Case discussed with her husband who is aware of the grave nature of her condition.. Endotracheal intubation Notes: Patient was intubated by EMS prior to arrival. Critical care note Total time: 45 minutes spent engaged in work directly related to patient care and/ or available for direct patient care. Critical condition(s) addressed for impending deterioration include: respiratory, cardiovascular. Associated risk factors: hypotension, hypoxia, metabolic changes. Management: Interpretation (chest x‐ray, blood gases, electrocardiogram, blood pressure), Interventions (hemodynamic management, ventilator management), Case review (medical specialist, family), Alternate history (family, emergency medical services). Performed by: self. Impression and Plan Diagnosis Sudden cardiac arrest (ICD10‐CM I49.01, Discharge, Medical) Calls‐Consults ‐ 10/16/2015 05:41:00 , , Critical Care, phone call, recommends to call cardiology. ‐ 10/16/2015 05:46:00 , , Cardiology, phone call, Will come see patient in the Emergency Department. Plan Condition: Critical. Disposition: Patient care transitioned to: Time: 10/16/2015 06:20:00, Al Sharif DO, Muhammad M. Verified By: EDMD on 16 October 2015 06:44 CDT