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

 

Readmit

2/14/1998 11:46 St. Jennifers Med Center
Dr. Croaker
History and Treatment Record
Ambulance Run Report
Reason: Shortness of breath. Airway; Normal
Breathing: Rapid
Circulation:
11:46 B/P=202/104 Pulse=120 Respirations=38

Skin: Moist, cool and pale.
Abdomen: Soft
Chest: Normal
Capillary refill: Normal
Eyes Open: #1 Spontaneous #2 Not at all #3 Not at all
Verbal Response: same as above-#1,2 and 3.
Motor Response: same as above-#1,2 and 3.
Pupils: #1-size 2 / reactive. #2&3- size 3 / non-reactive
Chief Complaint: Hyperventilating with feeling near snycopal.
History of Present Injury: Patient discharged approximately 45 minutes ago from IMC ICU called with same complaints as last evening.
209
2/14/1998 12:10 St. Jennifers Med Center
Dr. Mergent
History and Treatment Record
Emergency Room Nursing Record Date: 2-14-98 Time in: 1210 Time out: 1430
Treatment in Progress Upon Arrival: CPR, airway, oxygen and monitor.
Triage Level: Critical
Current Medications: Zesteril and Nitroglycerin prn.
Allergies: no known drug allergies.

Focus: Code Blue. Patient discharged from hospital one-hour prior to calling 911 due to SOB. Paramedics arrived to patient being dyspneic-respiratory arrest-asystole.
Temp. pacemaker on without palpable pulse-skin cool dry-mottled dusky-pupils fixed and dilated.
See code blue sheet.
Discharged to the morgue via stretcher. 206
2/14/1998 15:00 St. Jennifers Med Center
Dr. Mergent
History and Treatment Record


The University of Minnesota is an equal opportunity educator and employer
© 2001 School of Medicine Duluth

for more information: bateman@halversonwatters.com
Halverson, Watters, Downs, Reyelts & Bateman

webmaster: mpollock@d.umn.edu
Miranda Pollock