Case 4: ED Visit

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Documentation Review

The patient arrived via EMS and was transferred to a bed. He was seen at 11:25am by the ED physician. Documentation was completed on a T-sheet. The physician’s handwriting is very difficult to read and discern. References with deciphered text are listed under each of the pages of the T-sheet documentation.

1: Lost control secondary to illness
2: fever
3: x2 days (referring to vomiting)
4: Denies (referring to past medical history)
5/6: Personal Trainer
7: NAD (no acute distress)

1. Lipase 83
2. MVC (Motor Vehicle Collision)
3. N/V (Nausea and vomiting)

We can see from these notes that the physician is aware that the patient has had nausea/vomiting and fever for the past few days. There is no additional narrative information about the car accident, loss of consciousness, or other injuries.

The triage set of vitals are shown below. 

The physician placed several orders. The tests ordered are CBC, CMP, lipase, and a urinalysis. In addition, the patient’s symptoms were treated with 1 liter normal saline, 30mg ketorolac IV, and 12.5mg promethazine IV. The results of the testing are shown below.

The results of the tests show several abnormalities, although most of the results are barely outside of the reference ranges. 

After review of the results, the physician re-evaluated the patient and noted him to be “improved”. The patient was then discharged from the Emergency Department. Discharge vitals show resolution of his fever and resolution of tachycardia.

The chronological summary of the patient’s ED course is shown below:

His discharge instructions are below.

Written text:
– clear liquids
– bland diet
– no dairy x 48hrs
– Zofran QOD nausea
– Disposition: Home
– Tylenol QOD Pain

The patient was discharged with a prescription for Zofran. Click the red button below to see what happens next.