Data Chart>Biomedical Science_San Diego H S MEDTECH 10_Problem 1.1.3 Patient Data Chart. Patient, Ch

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Problem 1.1.3 Patient Data Chart

Patient

Chief Pertinent Complaint Medical History, Vitals, & Meds

P1 Amber Elizabeth Julian

Patient is having trouble breathing and complains of bouts of dizziness.

Symptoms began while the young girl was playing in her backyard.

P2

Patient complains of a severe

Jim Russell

Pertinent Physical Exam

Triage Catego ry

Diagnosis

Treatment Plan (Include Referrals)

Patient is an apparently healthy four-year-old girl.

There is no personal history of allergies, although the father is allergic to seafood as well as pet dander. The mother reported that she may have lost consciousness during the drive to the hospital, but she could not be sure.

Upon examination , patient had low blood pressure, high respiratory rate, and mild swelling of the respiratory tract.

Emerge nt

ANAPHYLA XIS

1.- Administration of an adrenaline 2.- Cardiopulmonary resuscitation

Patient has a history of low blood pressure. All

Notable swelling is appreciated

Urgent

infected root canal

1.- Anesthesia 2.- Pulpectomy 3.- Filling

© 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 1

toothache and persistent fever. He had root canal surgery a week ago.

P3 David Argula

Parents of the child found a halfempty bottle of baby aspirin in their suitcase.

The baby is thought to have

previous cardiac workups were normal, although the patient now notes occasional heart palpitations or skipped beats.

Root canal surgery was completed with no complications. The pain subsided three days after the procedure and the patient returned to work as a teacher. The pain has returned over the last two days. Because it was after hours, the patient was told to come to the emergency room.

around the left lateral incisor.

Small amount of pus is visible.

Patient presents with a fever and has been experiencin g night sweats.

Patient has been unable to eat due to high sensitivity in the area.

The baby was born six weeks premature, but has had no complications. The family is on vacation in the area. The mother made sure to pack medications for all members of her family. The baby apparently climbed

Patient is quiet and breathing is shallow.

Quick pulse changes are noted. The patient is drooling and has occasional

http://www.colgate.com/en/us/oc/oralhealth/procedures/root-canals/article/thesecond-time-around-possible-retreatment-orsurgery

emergen t

seizures

1.- gastric lavage 2.- Activated charcoal may be given to help bind drugs 3.- intubation

© 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 2

consumed the pills, but they can not be sure of how many.

P4 Priya Ghosh

Patient was hit by a car while bicycling to work. On the scene, the patient complained she had trouble moving her legs and could not twist at the waist.

out of the portable crib during naptime and somehow reached an open bottle of baby aspirin (father takes one each day for his heart). The parents do not remember how many pills were left in the bottle, but they are sure some are missing.

tremors or convulsions.

The patient is generally healthy with a family history of hypercholesterole mia. Patient reports she often forgets to take her medication. She is currently training for a triathlon and is in excellent physical condition.

On the scene, the patient was alert and talking. She is lucid when she arrives in the ER. She has various cuts and contusions on her face and right arm, but blood loss is minimal.

Examination reveals no visible broken bones, but her pelvis is

emergen t

Tender pelvic

1.-Rest 2.-Assistance of a walker, crutches, or cane 3.-Nonsteroidal anti-inflammatory medications 4.-Physical therapy

© 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 3

extremely tender.

Patient has limited range of motion from the hip joints.

Patient is sent for diagnostic scans.

P5 Michael Helms

Patient was shot in the left shoulder while chasing a suspected robber.

There does not appear to be an exit wound.

Patient complains of tingling in the arm.

Patient is a police officer with a history of deep vein thrombosis (DVT) who currently takes Coumadin. The patient is a selfreported onepack-a-day smoker, although he has been trying to quit.

On the scene, the patient continued pursuit of the suspect for twenty minutes after injury occurred.

The bullet appears to have missed the major blood vessels, but blood loss is significant.

Patient begins to shift in and out of consciousne © 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 4

ss upon arrival. An exit wound cannot be located, so the bullet is suspected to remain in the body.

The patient now reports tingling in the arm.

Patient

Chief Pertinent Complaint Medical History, Vitals, & Meds

Pertinent Physical Exam

P6 Doris Digman

Patient is a 72year-old woman with a history of high blood pressure. She has recently been unsteady and has broken four bones in the past two months – two of these breaks were from minor home accidents. The patient noted that she has not been cooking much for herself since her husband died two

Patient called 911 from her home. Her right wrist and right ankle are extremely swollen and discolored.

The patient can put little to no weight on the right leg. Blood pressure, heart rate, and

Patient slipped getting out of the shower.

She is unable to put pressure on her right leg and complains of wrist pain.

Triage Catego ry

Diagnosis

Treatment Plan (Include Referrals)

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P7 Drea Nunzio

Patient has been vomiting for the past two days and has been unable to hold down any food/fluids.

P8 J.D Thomas

Patient passed out during a football game after a hard hit.

He was extremely

years ago and relies on frozen meals.

respiration appear to be stable.

Patient is a sevenyear-old girl with a history of otitis media and chronic bronchitis.

Vomiting began late in the evening after the patient returned from a soccer party. The patient’s father suffers from Crohn’s disease.

Patient is extremely lethargic and complains of a headache.

Vomiting continues in the ER accompanie d by stomach pains. The patient and her family eat the same foods at home and no one else in the family is sick.

Patient has no medical history of syncope or neurological deficit. He has not missed a day of school in over seven years.

Twenty minutes

Upon examination , the patient appears alert, but has trouble maintaining balance. He reports a © 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 6

P9 Stacey reeves

disoriented and was escorted off the field.

after the incident on the field, the patient appeared lucid. However, he has no recollection of what happened and why he is no longer at the game.

slight ringing in his ears.

After a few hours, his speech began to slur.

Patient presents with severe lacerations on the distal phalanges of the right hand. Injury occurred at 9:05AM.

Patient was attempting to remove material from the blades of a lawnmower when the power shifted on. She was able to remove her hand quickly, but there is severe damage to the fingers.

Patient has been HIV positive since 2004. Her T-cell count had always stayed within normal limits. Her husband called 911 and attempted to stop the bleeding using pieces of rope.

There are severe lacerations on the 2nd and 3rd finger. An open fracture is visible, but further imaging is required to determine if there are additional breaks.

Since the patient was able to cut off blood flow to the injured area, blood loss was halted, but is still significant. © 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 7

The patient is pale and clammy and reports pain of 7 on a scale of 1– 10.

P10 Sela Montgome ry

Patient complains of visual and auditory hallucinatio ns and difficulty concentrati ng.

Symptoms have been on and off for the past three months.

The patient suffered bouts of depression throughout high school but was treated with a combination of medication and psychotherapy.

She has been feeling tired lately, but she can’t seem to fall asleep at night. A coworker found the patient wandering the streets outside of the office and brought her in.

The patient lives with a roommate who has been called.

The patient could not focus during the examination and her speech was disorganize d. The patient alternated between a flat affect and unpredictabl e emotional responses.

When lucid, the patient reports hearing voices that become worse when she is alone. Blood pressure, respiration, © 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 8

and heart rate were all normal. The patient does not have a fever.

P11 Maria Flores

P12 Jon James

28 weeks pregnant experiencing contractions and pain in the abdomen area. Pain started at 3 am. First attributed to heartburn and gas

The patient is a 30-year-old woman. This is her first clinical pregnancy. She has a history of miscarriage and elevated blood pressure. The patient was recently diagnosed with gestational diabetes. Not wanting to go on medication, she has been trying to control her blood sugar with diet and exercise.

The patient is experiencin g regular, mild contractions every 10–12 minutes and a low, dull backache.

Blood pressure is elevated.

The amniotic sac is still intact.

Fetal heartrate appreciated

by Doppler ultrasound 138bpm.

Patient presented with burns on both hands and moderate

The patient is a 56-year-old man who lives alone.

Attempting to answer the phone and flip

Examination reveals an area of 3rd degree burn on the left hand. The

Emergen t

Preterm labor

1.-Antenatal corticosteroids 2.- Antibiotics 3.- Tocolytics 4.- Progesterone 5.- Cerclage 6-Bed rest http://www.marchofdimes.org/complications/tre atments-for-preterm-labor.aspx

© 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 9

pain.

hamburgers, he accidentally moved the pan from the gas and ignited his sweatshirt. Upon reflex he used his hands to pat out the fire, sustaining burns on both hands. The patient admits to popping two vicodin he had left from dental surgery before calling a friend to take him to the hospital.

second and fourth finger are charred and the flesh appears waxy. Large blisters cover the skin and ooze a clear fluid. The patient reports little to no pain at the moment.

Patient

Chief Pertinent Complaint Medical History, Vitals, & Meds

Pertinent Physical Exam

P13 Kayleigh Dubois

Patient complains of abnormal fatigue and has recently noted a palpable lump on the side of her neck.

The lymph nodes in the neck are swollen and the patient has a lowgrade fever.

The patient is an 18-year-old college freshman.

Patient was diagnosed with Hodgkin's lymphoma at age 7. After two rounds of chemotherapy, she was deemed cancer-free and has been in remission for the

Triage Catego ry

Diagnosis

Treatment Plan (Include Referrals)

© 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 10

past 10 years. The patient reports periodic night sweats and a weight loss of about 5 pounds.

She attributes her weight loss to crappy dorm food.

P14 George Hampton

P15 Michael Billups

Patient is experiencin g numbness in his left arm and a sudden onset headache.

This morning the patient

Patient presents with severe abdominal pain that has lasted

The 46-year-old patient, a type II diabetic, has a family history of heart disease. His mother died of a heart attack at age 49 and his brother recently had triple bypass surgery.

Four months ago, the patient was treated for minor transient ischemic attacks (TIAs) and was sent home on blood thinners.

The patient is having trouble finding the words to explain what is happening to him.

When asked to raise his arms over his head, the patient is unable to keep the right arm in the air

The 15-year-old patient has sickle cell disease.

Patient has had numerous blood transfusions over the past 10 years

Skin is pale and shows the beginnings of jaundice.

Both heart rate and

Nonurgent

transient ischaemic attack

1.-Anti-platelet Drugs 2.- Anticoagulants 3-Carotid Endarterectomy 4.- Angioplasty

© 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 11

for the past 24 hours.

The patient notes some pain in the joints of the leg.

P16 Hailey Simko

Patient was pinned in car following a motor vehicle accident. A piece of metal from the car is still lodged in the patient's chest.

Patient is having trouble breathing.

– the last of which was 4 months ago. Two weeks ago, he was prescribed antibiotics for a urinary tract infection, but only took for 7 of the 10 days specified

respiratory rate are slightly elevated.

The stomach is extremely tender to the touch and the spleen appears enlarged.

Rescue crews were able to extract the patient, but after two hours of work. EMS on the scene worked to stabilize the patient while she was still in the car.

Patient received oxygen by mask and fluids via a central line. Pressure bandages were placed on the chest.

Patient has no significant medical history, but does have a severe latex allergy as reported by a medical alert bracelet.

. Breathing is shallow and pulse is thready.

Patient is unconscious when she reaches the ER. She has been shocked twice by a defibrillator in the helicopter, but she is currently stable. Blood loss is significant.

Metal shards remain lodged in her chest and left © 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 12

thigh.

1. What factors contribute to the urgency with which a patient must be treated in the emergency room? How does medical staff begin to triage their patients?

2. Explain why the emergency room in an urban setting will most likely look different than the emergency room in a small rural hospital.

3. What medical interventions are available to speed up wait time in emergency rooms?

4. Brainstorm one additional innovation that you believe would be a cutting edge development in emergency medicine.

© 2011 Project Lead The Way, Inc. Biomedical Innovation B1.1.3 Emergency! Patient Data Chart – Page 13