07-21-2009, 12:37 PM
Another difficult one for me.
24y M is brought to the ER in a drowsy state. His wife reports that he was working at home when he suddenly stiffened, fell backward, and lost consciousness. While he was lying on the ground, he was noted to have no respiration for about one minute, followed by jerking of all four limbs for about five minutes. He was unconscious for another five minutes.
ER
============
pulse ox
oxygen
iva
cardiac monitor
bp monitor
=============
PE (focused)
General
HEENT
CVA
lung
abd,
neuro
=================
cbc
bmp
lft
ekg
ua
urine toxicology
pt/ptt
EEG
==================
ward
neurology consult
interval hx
pt feeling better
appointment 3 weeks
no driving
pt counseling
family counseling
seatbelt
=====================
24y M is brought to the ER in a drowsy state. His wife reports that he was working at home when he suddenly stiffened, fell backward, and lost consciousness. While he was lying on the ground, he was noted to have no respiration for about one minute, followed by jerking of all four limbs for about five minutes. He was unconscious for another five minutes.
ER
============
pulse ox
oxygen
iva
cardiac monitor
bp monitor
=============
PE (focused)
General
HEENT
CVA
lung
abd,
neuro
=================
cbc
bmp
lft
ekg
ua
urine toxicology
pt/ptt
EEG
==================
ward
neurology consult
interval hx
pt feeling better
appointment 3 weeks
no driving
pt counseling
family counseling
seatbelt
=====================