These reports are samples of basic clinical evaluations of patients seen by a physician specialist in Emergency Medicine. The sample reports have been checked for accuracy in spelling, but please keep in mind nobody's perfect, and we do appreciate any notification of errors. These sample medical reports may also include some styles or report formats that are unusual, and if so, this would be due to the preference of the dictating physician.
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This patient is an ex-premature neonate who was born at 32 weeks to a young woman and who had been recently discharged home from * * * * * Hospital after a neonatal course that was complicated by apnea and recurrent bradycardia.
The child was brought to * * * * * Hospital at around 3:30 in the morning after an episode of supposed apnea and hypotonia associated with a weak cry. In the Emergency Department, the newborn was noted to be hypoxemic and required physical stimulation for generation of respiratory efforts. He was ultimately endotracheally intubated and placed on a controlled mechanical ventilator and a modified septic work-up was performed. Broad-spectrum intravenous antibiotics were administered along with a loading dose of aminophylline.
A complete physical examination was performed by myself when I arrived in the neonatal nursery. At this time, the child was sedated, intubated and ventilated. He was hemodynamically stable and oxygen saturation was in the 95% range. There were no signs of head trauma, but a bulging anterior fontanelle was noted. Fundoscopy was not performed. There were no signs of truncal or extremity trauma and the rest of the examination was unremarkable.
The differential diagnosis of this newborn's apnea was thought to be related either to infection or intracranial hemorrhage as a result of trauma. The patient was connected to a portable controlled mechanical ventilator and placed on a cardiac monitor within an incubator. He was transported via helicopter to * * * * * and then via ambulance to * * * * * Hospital for further investigations and observation.
Diagnoses: Apnea; Bronchiolitis
This patient had been ill for about three days with coughing and sneezing. There was no history of fever, rash or gastrointestinal symptomatology. On the evening of *****, she developed lethargy with poor feeding and apneic spells. When the newborn was examined in the Emergency Department at * * * * * Hospital at around *** hours she was afebrile, but displayed a periodic breathing pattern. A complete septic work-up was performed by the pediatrician on-call.
However, when I examined this newborn at *** hours, she appeared lethargic and apneic unless frequently physically stimulated. These apneic episodes were associated with duskiness, bradycardia and desaturation as measured by peripheral oximeter.
Consequently, a decision was made to proceed on to rapid sequence intubation and assisted mechanical ventilation. A 3.5 endotracheal tube was ultimately placed via the oral tracheal route and an 8 French nasogastric tube was inserted to decompress the stomach. The newborn was transported via ambulance to the Intensive Care Unit at ***** for further investigations and monitoring.
Diagnoses: Splenic Contusion; Nausea and Vomiting
I was paged to the Emergency Department at * * * * * General Hospital in order to assess, stabilize and prepare this ***-year-old boy for transport to the Intensive Care Unit at * * * * *.
This patient was a belted rear seat passenger of a vehicle that was "T-boned" at an intersection in ******* on the morning of ****. He was examined in the Emergency Department at * * * * * General Hospital where he was found to have abdominal pain associated with nausea and vomiting. However, there were no signs of shock. Seat belt marks were noted across his abdominal wall and he was tender in the left upper quadrant to palpation. The attending physician was concerned about a possible splenic injury.
A complete physical examination as well as review of the x-rays and all available laboratory investigations was performed by myself when I arrived in the Emergency Department at * * * * * General Hospital. At that point, the patient remained hemodynamically stable and other than the seat belt mark across his abdomen and left upper quadrant tenderness, he had no other signs of acute trauma.
Intravenous access had been previously established in his wrist and a bolus of normal saline had been administered. A nasogastric tube was subsequently inserted with normal gastric returns.
This patient was transported via helicopter to * * * * * airport and then via ambulance to * * * * * Hospital for CT scanning of his abdomen and general surgery consultation.
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