NEWEST 5-10-10****



CASE #3: A 15-YEAR-OLD GIRL WITH ABDOMINAL PAIN(the following is the actual documentation of the provider)Chief complaint: Abdominal painVITAL SIGNSTime Temp(F) Rt. Pulse Resp Syst Diast Pos. Pain Scale00:12 99.8 T 124 18 100 64 S 10 TRIAGE(22:59): "pt mother states abd pain, dizzy, fever, passed out at school”HISTORY OF PRESENT ILLNESS (01:12): The pt is a 15yo who is in good general health. No h/o abd surgeries. No h/o ovarian cysts or endometriosis. LMP just finished. She states that she has had fatigue and dizziness in the past few days. Today the pt noted gradual onset of rlq aching which has worsened over the day. The pain is worse with movement and walking. + nausea without emesis. No diarrhea. No urinary sx. No vb/dc. + fevers/chills. No earache, sore throat, sinus, cough, cold. No rash. ROS: AOSN [all other systems negative]PAST MEDICAL HISTORY: NKDA Meds: None PMH/PSH: Negative SH: Non smoker, no alcoholEXAM (03:42)CONSTITUTIONAL: tired appearing; well nourished; A&O X 3, in no apparent respdistress.THROAT: Normal pharynx with no tonsillar hypertrophy.NECK: Supple; non-tender; no cervical lymphadenopathy.CARD: Regular rate and rhythm, no murmurs, rubs or gallopsRESP: Breath sounds clear and equal bilaterally; no wheezes, rhonchi, or rales.ABD: BS+, soft, Non-distended; + tenderness in the rlq, which is reproducible , no rebound, rigidity or guarding. No CVAT.SKIN: Normal for age and race; warm and dry; no apparent lesions ED COURSE:01:09: Orders for CBC and triple contrast CT scan to r/o appy. Demerol 25mg, phenergan 12.5mg.01:52: Labs return: WBC count 17.2, Hb 11.6, plt 230. Urine pregnancy test and dip - negative02:09 (RN): Pt. with about 600cc of emesis of food product. Dr. advised. Additional phenergan 12.5mg ordered. Repeat VS: pulse 100, resp 24, BP 100/5003:01 (RN): Pt. continues to c/o abdominal 6/10. Dr. advised.03:42: Patient care transferred from DOC 1 to DOC 2. EMR records: ‘This chart has been electronically signed DOC 1. The receiving Physician accepted the transfer.’ At 3:58 DOC 1 orders another 50mg Demerol and 12.5 mg phenergan04:00 – (sometime just after 4AM): CT ‘wet-read’ results per radiologist: The appendix is normal in size without surrounding inflammatory change. Within the right adnexal area, there are several greater than 1 cm ovarian cysts visualized. The largest is about 3 cm in dimension with hazy attenuation suggesting a recent hemorrhage.04:59Repeat VS: pulse 88, resp 16, BP 98/48, pain scale 2/1005:40: Progress ntoe DOC 2: “Patient resting comfortably. Family aware of results of CT scan for ovarian cysts on right. Will d/c with pain meds and f/u with GYN”DIAGNOSIS DOC 2 (05:40): Cyst – ovarian. AFTER CARE INSTRUCTIONS: Follow-up with your physician in 2-3 days. Rx Vicodin #20, Phenergan PO and suppository. Instructions for ovarian cystPamela Ramsey, MDKristen O’Donnell, MD ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download