Medical summary

MEDICAL SUMMARY
REGARDING
LEONARD SMITH
This summary has been prepared following review of the records from Hightower Medical Center. There are other providers, which have been identified, that we will need to obtain records from for review. Gabbert & Associates Legal Nurse Consultants reserves the right to amend this summary upon review of additional medical records. On December 13, 2003, the patient, an African-American male, arrived at the ER of Hightower Medical Center at 2205. He voiced complaints of an elevated temperature, cough productive of blood, drainage from his eyes and elevated blood glucose for approximately two days. He also complained of abdominal pain that had been present for an hour. These symptoms were still present upon arrival. They were characterized as a constant, cramping pain with an associated loss of appetite and nausea. His symptoms had worsened the evening he came to the hospital. The severity of his symptoms was severe and neither relieved or exacerbated by any specific thing or activity. He denied having similar symptoms before and had received no recent treatment or examination by a physician. Upon examination, the patient was found to indeed have a fever as well as chills, headache, sore throat and productive cough. His medical history was significant for: • Insulin-dependent diabetes • High blood pressure • Gout (a systemic disease caused by the buildup of uric acid crystals in the joints of the body, causing inflammation, swelling and pain) • Emphysema (a chronic lung disease in which some of the air sacs in the lungs are damaged, making it hard to breathe) No previous surgeries or procedures were noted. His medications included; 1. Atrovent (inhaled respiratory medication; opens breathing passages) 2. Metformin (oral diabetes medication) 3. Albuterol (inhaled respiratory medication; opens breathing passages) 4. Allopurinol (gout medication) 5. Insulin 6. Lisinopril (high blood pressure medication) 7. Trazodone (antidepressant that is also used as a sleeping aid) 8. Colchicine (gout medication) 9. Reglan (used to treat delayed gastric emptying and gastroesophageal The patient was noted to be a smoker, smoking approximately a pack of cigarettes a day-per the physician’s documentation. The nursing documentation indicates he smoked less than ½ a pack a day. His family history was noncontributory. His temperature and blood pressure were significantly elevated at 103 degrees (normal is approximately 98.6) and 209/115 (normal is approximately 120/80), respectively; on room air, his oxygen saturation was normal at 98% (normal is approximately 95-100%). His mucous membranes were dry (can be indicative of dehydration) and his lung sounds indicated congestion. Cardiac rate and rhythm were regular. Abdominal assessment was positive for tenderness just above the stomach. Neurological examination showed diffuse weakness. He was oriented to person, place, and time with no motor or sensory deficits noted. IV fluids were started and cultures were obtained. His blood sugar was checked-it was elevated at 164-and treated with insulin as needed. IV antibiotics were started. It appears he was rehydrated with a total of 2 liters of IV normal saline while in the ER. The following medications were administered in the ER: • Motrin 800 mg • Tequin 400 mg IV (antibiotic) • Tylenol 1 gram Following a thorough examination, the patient was diagnosed with: 2. Acute dehydration 3. Acute febrile (refers to presence of a fever) illness, possible sepsis 4. Acute conjunctivitis (an inflammation of the he outermost layer of the eye and the inner surface of the eyelids], often due to infection) 5. Acute urinary tract infection 6. Trichomoniasis (a sexually-transmitted disease caused by the single-celled protozoan parasite, Trichomonas vaginalis) The ER doctor discussed the patient with Dr. Brown and it was decided the patient would be admitted to the PCU under Dr. Brown’s care. He was in improved condition at the time of admission. END OF SUMMARY

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