EMERGENCY ROOM REPORT (Pulmonary case)

EMERGENCY ROOM REPORT

HISTORY OF PRESENT ILLNESS: Patient is a one-year-old female that has been congested for several days. The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago. Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin, cough syrup, and Slo-bid 100 mg b.i.d. but is not improving. Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

PHYSICAL EXAMINATION
GENERAL: Physical exam in the ER showed an alert child in moderate respirator distress.
VITAL SIGNS: Respiratory rate was 40, pulse 20, temperature 99.6.
HEENT: Within normal limits.
NECK: Positive for mild to moderate stridor.
CHEST: Chest showed a diffuse inspirator and expiratory wheezing. No rales were noted. Viewing the chest wall, patient had subcostal-intercostal retractions.
HEART: Regular rhythm without murmur, gallop, or rub.
ABDOMEN: Soft, nontender, bowel sounds normal.
EXTREMITIES: Within normal limits.

The child was sent for a PA and lateral chest x-rays to rule out pneumonia. No pneumonia was seen on the films.
It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3 h. The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.

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EMERGENCY ROOM REPORT (Pulmonary case)

HISTORY OF PRESENT ILLNESS: Patient is a one-year-old female that has been congested for several days. The child has sounded hoarse, has had a croupy cough, and was seen 2 days ago. Since that time she has been on Alupent breathing treatments via machine, amoxicillin, Ventolin, cough syrup, and Slo-bid 100 mg b.i.d. but is not improving. Today the child is not taking food or fluids, has been unable to rest, and has been struggling in her respirations.

PHYSICAL EXAMINATION
GENERAL: Physical exam in the ER showed an alert child in moderate respirator distress.
VITAL SIGNS: Respiratory rate was 40, pulse 20, temperature 99.6.
HEENT: Within normal limits.
NECK: Positive for mild to moderate stridor.
CHEST: Chest showed a diffuse inspirator and expiratory wheezing. No rales were noted. Viewing the chest wall, patient had subcostal-intercostal retractions.
HEART: Regular rhythm without murmur, gallop, or rub.
ABDOMEN: Soft, nontender, bowel sounds normal.
EXTREMITIES: Within normal limits.

The child was sent for a PA and lateral chest x-rays to rule out pneumonia. No pneumonia was seen on the films.
It was agreed to admit the patient to the pediatric unit for placement in a croup tent with respiratory therapy treatments q.3 h. The child was also placed on Decadron besides the amoxicillin and continuation of the Slo-bid.

EMERGENCY ROOM DIAGNOSES
1. Acute laryngotracheobronchitis.
2. Bronchial asthma.

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Emergency Room Report (OB-Ectopic pregnancy)

ADMITTING DIAGNOSIS: Ectopic pregnancy

CHIEF COMPLAINTS: The patient presents to the emergency room this morning complaining of lower abdominal pain.

HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she state that she is sexually active and using no birth control.

GYNECOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother.

PAST MEDICAL HISTORY: Positive for Hepatitis-B.

PAST SURGICAL HISTORY: Pilonidal cyst, remove in the remote past. Had plastic surgery on her ears as a child.

SOCIAL HISTORY: Married, has one daughter, patient works as a substitute teacher. Smokes one pack of cigarettes on a daily basis. Denies ETOH. Smoked marijuana last night. No IV drug abuse.

ALLERGIES: Tightness.

MEDICATION: None.

REVIEW OF SYSTEM
Patient complaints of a lower abdominal pain for the past week that apparently got much worst last night and by this morning was intolerable. The patient is also having some nausea and vomiting. Denies hematemesis, hematokesia and melena. The patient has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Denies arthralgias. Review of system is otherwise essentially negative.

PHYSICAL EXAMINATION
VITAL SIGNS: Shows temperature 97degrees, pulse 53, respirations 22, blood pressure 108/60.
GENERAL: Physical examination reveals a well developed, well-nourish, 35-year-old white female in a moderate amount of distress at the time of the examinations.
HEENT: Unremarkable except for poor dentition.
NECK: Soft and supple.
CHEST: Lungs are clear in all fields.
HEART: Regular rate and Rhythm.
ABDOMEN: Soft with positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexa are more tender than the right.
VAGINAL EXAMINATION: The cervix is close. A moderate amount of mucopurulent vaginal discharge is noted. The patient would not allow me to perform a bi-manual examination due to the patient pain. So the speculum was withdrawn.
EXTREMITIES: No clot. No edema.
NEUROLOGIC EXAMINATION: Intact. Oriented x3, No neurologic deficits.

DIAGNOSTIC DATA
ADMISSION: Hemoglobin 12.8 g and Hematocrit 36.6%.
URINALYSIS: Essentially Negative.
BETA HCG: Positive with WBC count of 23,278.

RADIOLOGY
Pelvic Ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 mg, and Phenergan 25 mg. IV for the pain after her report was obtained. The patient also given claperan 1g IV.

I page Dr. Gerard, patient’s GYN, physician, as soon as I receive the ultra-sound report at approximately 10a.m. He was not in North Miami office. I page the South Miami office and reach Dr. Gerard’s office at approximately 10:15a.m. His office personnel advice me that he is not on call, Dr. Bomback is on call. I spoke with Dr. Bomback at approximately 10:25a.m. and she will be here to take the patient to the operating room.

ADMITTING DIAGNOSIS: Left ectopic first trimester pregnancy.
Disposition: The patient receive and IV of lactated ringer upon arrival at the emergency room. This was switch to normal saline while we were awaiting Dr. Bomback’s arrival. The surgical procedure was explained to the patient and her husband. All risk and benefits were discussed. They understand the necessity for immediate surgery and informed consent was signed. No old records are available for review.

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Emergency Room Report

CHIEF COMPLAINT:
Colic.

 HISTORY OF PRESENT ILLNESS:
This 6-week-old enters with colicky pain and increasing flatus and crampy abdominal pain that she gets mostly at night. She is not constipated. She has had no blood in her stool and normal urine and normal intake and no nausea or vomiting. She has not had any fever. 

PAST MEDICAL HISTORY:
Other than the above, symptoms is negative. 

PAST SURGICAL HISTORY:
Negative.

SOCIAL HISTORY:
Negative. Both parents are present and appropriately concerned.

FAMILY HISTORY:
Negative.

REVIEW OF SYSTEMS:
The complete review of systems is essentially negative except for colicky abdominal pain and increased flatus. The patient is on formula with iron and does not use a gas decreasing bottle system. Has been on Gaviscon but has gotten only one dose a night apparently. The rest of the review of systems is negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.9. Pulse 130. Respirations 52. Pulse oximetry is 96% on room air.
GENERAL APPEARANCE: She is alert and is moving all extremities.
HEENT: The pharynx is wet. The tympanic membranes are normal. The fontanel is soft and ballotable.
NECK: Supple. There is no induration of the throat and there is no adenopathy.
LUNGS: Clear. There is no dyspnea.
HEART: Shows a regular rhythm without murmurs.
ABDOMEN: Somewhat distended. She had some flatus several times, I might add, and then it diminishes. It is totally nontender. She has good tone.
NEUROLOGIC: Intact for age including a positive Moro.
SKIN: She has no skin lesions, icterus, or jaundice, and the pulses are 2+ and equal.

DATABASE:
X-rays: Upright abdominal and chest combination is normal except for gas in the bowel, which shows no obstruction.

DISCUSSION:
I think this is colic. I have suggested the following: (1) To change to formula without iron. (2) To use soy based formula. (3) To increase the Gaviscon to 3 drops q.i.d. at least. (4) They should follow up with their own doctor.

CLINICAL IMPRESSION:
Colic.

PLAN:
Gaviscon, changing the formula, no iron, and see their doctor in 1-7 days.

CONDITION ON DISCHARGE:
Good


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