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Case 1: Shortness of Breath
Case 2
Post 1: Introduction Pt 1
Post 2: Introduction Pt 2
Post 3: Introduction Pt 3
Post 4: Bad Outcome Pt 1
Post 5: Bad Outcome Pt 2
Post 6: Legal Outcome
Post 7: Documentation Review
Post 8: Medical Review
Several days later, the patient returned to the same Emergency Department. His primary symptoms seem to now primarily focus on the back pain. “Spine pain” and “neck pain” are both mentioned. Documentation reveals that the fever has now resolved. He has been having a slight headache.
Labs were rechecked, showing an improvement in his platelet count to 119,000. Lactate was normal and overall no emergent findings were discovered. The patient was discharged and given Percocet for pain and Soma for muscle relaxation.
This is the patient’s last visit before the bad outcome. It is his fourth visit for this illness (one visit not included in trial exhibits).
What do you think the outcome will be for this patient?
Do you agree with the management of this patient?
How would you have managed the patient’s presentation?
What areas of documentation could be improved?
