The Incident- Medical Records

Home

The Incident

Ambulance Run Report

ER Record

Physician's Notes from Emergency Dept

Dr. Croaker Discharge Summary

Dr. Croaker Physician's Order Sheet

Initial EKG

Dr. Croaker Progress Notes

Chest X-Ray

Dr. Croaker Lab

Nursing Notes

Morning EKG

Readmit

Code Note

Autopsy

The Cast

The Natural History of a Lawsuit

Legalities

2/13/1999 ER Record

2/13/1999 17:00 St. Jennifers Med Center - Dr. Croaker ER Nursing Record
Vital Signs:
17:00 - Blood pressure 174/93. Pulse 108. Respirations 20. Temp. 98. SAO2 92. Color flushed. Lung sounds clear/distant. Heart sounds regular. Abdomen large, tender across mid-abdomen.
17:30 - Blood pressure 165/91.
18:00 - Blood pressure 147/98. Pulse 87. Respirations 20.
Medication: ASA grain 5 orally at 17:50.
Procedure: Chem strip at 18:00. Results were 147.
16:55 - Focus: Chest pain and shortness of breath. Data: Patient has had flu and bronchitis - past 3-4 days with occasional feelings of SOB. Today felt tightness in upper chest. No radiation of discomfort. No nausea. Was dizzy and lightheaded and shakey. Felt heart palpitations. Has past history of high blood pressure, diabetes myelitis, also history of perf. Colon 3 yrs ago. Kidney stones past year with lithrotripsy. States pain initially 2/10 now very little tightness. Tachy in ambulance & on arrival
17:20 - Focus: Light headed. Data: Patient complained of feeling dizzy. 1 PVC noted on strip from ambulance. Heart rate 108-115 in ambulance. Normal sinus rhythm now.
18:00 - Focus: Comfort. Data: Comfortable now. Rhythm remains sinus with occasional PVC/VSS.
Patient was admitted to CCU for evaluation.