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Documentation Review
2 days following the car accident, the patient presented back to the same Emergency Department. He was seen by the same doctor. The patient’s fiance brought him back after noting that he has gotten progressively more confused. The physician documented that he was unable to obtain a history due to “condition”.
- Worse today
- Was sick for 2-3 days – 2 days ago was sick and had a syncope and ran off the road – was better yesterday and then became unresponsive.
- No PCP
- Denies (past medical history)
- Not testable (tongue deviation)
- But winces with pain with movement of neck
- Some scattered petechiae on body
- (R) post temp bleed
- Pt intubated by EDP @ 1700 secondary to GCS 8
- Unintelligible
- Renal failure
Labs were ordered on the bounceback visit. The workup was essentially the same as the first visit, with the addition of procalcitonin and blood cultures being ordered.
The patient still has a slight leukocytosis. Notably, his creatinine has markedly increased over the past two days, from 1.4 to 6.1.
The patient was given fluid resuscitation, vancomycin, ceftriaxone, and acyclovir due to concern for meningitis. The physician ordered a head CT, and chest xray. A repeat chest xray was obtained after the patient was intubated.
The patient was noted to be tachycardic. Several tracings were obtained. Note the steady rise in his pulse rate over the course of 2 hours in the ED. Times and vital signs are highlighted with a red box.
The physician dictated an additional note to supplement the T-sheet.
The patient was transported to the next hospital for more advanced care. Continue to the next page to see the outcome at the next hospital.