Emergency Medicine Attending Note
ROS
1. Constitutional: No fever, no chills, no weight loss
2. Eyes: No eye pain, no photophobia
3. Ears, nose, mouth, throat: no sore throat, no ear pain
4. Cardiovascular: no chest pain or discomfort
5. Respiratory: no pleuritic chest pain, no shortness-of-breath
6. GI: No nausea, vomiting, nor diarrhea
7. Musculoskeletal: no muscle pain
8. Skin: No rash
9. Neurologic: No weakness or numbness.
10. Psychiatric: No suicidal ideation
Adult Physical Exam
Non-Hypoxic on room air, abnormal vitals:
General: Alert, in No apparent Distress
HEENT: Moist Mucous Membranes
Neck: supple, no cervical lymphadenopathy, no meningeal signs, non-tender cervical spine
Card: regular rate and rhythm, no murmurs, rubs, gallops
Resp: clear to auscultation bilaterally, good air exchange
Abd: soft, non-tender, non distended
Skin: good turgor, warm and dry, no rash
Extremities: no edema, non-tender, full range of motion
Neurologic: Alert and oriented to person, place, date; moving all extremities with good force, intact sensation to light touch, normal gait
Psychiatric: normal mood and affect, coherent and logical
Genitourinary: no costovertebral angle tenderness
Pediatric Physical Exam
GENERAL Appearance: Active, playful, smiles. Good eye contact.
PSYCH: Normal mood and affect
HEENT
Head: Atraumatic, normo-cephalus
Eyes: No injection, no discharge, no signs of trauma
Ears: Tympanic Membranes without erythema, dullness. Good light reflex.
Nose: No purulent drainage.
Sinuses: Non tender frontal and maxillary sinuses.
Pharynx: No erythema, no exudate, no hypertrophy. Tonsils are symmetric.
Mouth: Moist mucous membranes.
NECK: Supple, no masses.
LYMPH: No cervical lymphadenopathy
RESPIRATORY: Lungs are clear to auscultation bilaterally with good air exchange throughout. No retractions. No respiratory distress.
CARDIOVASCULAR: Heart regular rate and rhythm; no murmur, rub, nor gallop. Normal capillary refill. Strong peripheral pulses.
ABDOMEN: Soft, non-tender, non-distended.
GENITOURINARY: No costo-vertebral angle tenderness to percussion. [ ]
EXTREMITIES: All four extremities non-tender with full range of motion; no edema.
SKIN: normal color; warm and dry; no rash; no petechiae.
NEUROLOGIC: Moving all extremities with good force. [ ]
Impression:
This is a -y-o man with
Plan:
1mg Dilaudid IV for analgesia
8mg Zofran IV for nausea, vomiting
1L NS IV bolus for hydration
Left Hand Exam
Motor: Intraossei, flexor pollicis longus, extensor digitorum 5/5 strength
Sensory: Median, Ulnar, Radial nerves intact to light touch
Circulation: radial pulse 2+
Cap refill < 2seconds all digits
Right Hand Exam
Motor: Intraossei, flexor pollicis longus, extensor digitorum 5/5 strength
Sensory: Median, Ulnar, Radial nerves intact to light touch
Circulation: radial pulse 2+
Cap refill < 2seconds all digits
EKG - Interpretted by me
Rhythm: [Normal sinus rhythm]
Rate: [ ]
Axis: [Normal]
Intervals: [Normal PR, QRS, QTc]
ST segments: [No elevation nor depression]
T wave inversions: [none]
Overall interpretation: [Normal EKG]
PROCEDURE NOTE: Trigger Point Injection
C6 Paracervical Injection of Bupivacaine 0.5%
Indication: severe headache
After sterile prep, 1.5ml of 0.5% Bupivacaine injected C6 paracervical on each side with a 27 gauge, 1 1/2" needle.
Patient tolerated well
PROCEDURE NOTE: Lumbar Puncture
Indication: Headache and fever
Time out was performed. L3/4 L4/5 areas marked.
Betadiene prep done. 2.5ml Bupivacaine infiltrated at each level.
After 10 minutes, pt was positioned sitting at bedside, Lumbar area was repreped with betadiene.
Lumbar puncture easily done with 22 gauge needle. Fluid came out at normal pressure.
Pt tolerated well.
BEAUMONT BONE & JOINT
Please call tomorrow morning at 9am to arrange a follow up visit with Beaumont Bone and Joint within [2] days.
Let them know you were seen in the emergency department at [CHRISTUS Mid County Outpatient Emergency Department]
Beaumont Bone and Joint has offices:
BEAUMONT OFFICE
3650 Laurel Avenue
Beaumont, TX 77707
PHONE (409) 838-0346
FAX (409) 839-3720
MID COUNTY OFFICE
2501 Jimmy Johnson Boulevard, Suite 400
Port Arthur, TX 77640
PHONE (409) 729-5633
FAX (409) 729-9760
PORT ARTHUR OFFICE
2927 Park Plaza
Port Arthur, TX 77642
PHONE (409) 983-5178
FAX (409) 983-6078