09/09/18 1310
BP:
(!) 159/94
Pulse:
(!) 114
Resp:
20
Temp:
98 °F (36.7 °C)
SpO2:
99%
MDM
Number of Diagnoses or Management Options
Diagnosis management comments: Impression: 46 year female presenting
to the emergency department with a re\re exacerbation of suprapubic and
left lower quadrant abdominal pain. Seen here last night, CT scan
revealed no acute findings, possible IBS, multiple surgeries, scar tissue. Nor did
any of the laboratory analysis. She did have mild urinary retention. History of herniated discs, husband tells Dr. she hasn’t suffered from back pain since pt went off pain med.
The patient this morning received news that her younger brother had
unexpectedly died. She returns now with continued symptoms.
Differential includes urinary retention.
Plan of care we repeat labs will hold off on CT scan we’ll do Foley
catheter treat symptomatically likely for
relief. This may be all secondary to adhesions as well.
ED Course
Procedures
PROGRESS NOTE:2:19 PM
Provider updated patient and patient’s family on results.
3:59 PMChange of shift. Care of patient signed over to Dr.
Handoff complete.
Addendum RN 9/9/2018 2:02 PM
1320: Patient in room from triage, hooked up to BP/SPO2 monitor,
husband at bedside. Patient crying in room, husband requesting pain
medication, assigned MD notified. Labs drawn, Line patent. Patient
crying and twitching during blood draw, states IV site hurts asked
patient if she wanted a new IV at this time, no answer received. Pt unresponsive, husband, physician, speaks of her history, speaks for pt. she cannot verbalize what is happening. Physical sympt returned due to trauma. PTSD.
1327: Primary RN and MD at bedside.
1345: Two RNs present during catheterization for sterility. Patient
c/o pain, convulsing in bed, holding breath and crying during
medication administration via IV. Line flushing, blood returned
achieved. Offered to pull IV and start new line, patient now agreeable
to new IV. Patient HR on SPO2 reading 30s, patient bearing down and
holding breath, cardiac monitor applied. Patient HR low 100s on
monitor. MD notified, orders
received.
Addendum to RN:
1345: Two RNs present during catheterization for sterility. Patient
c/o pain, convulsing in bed, holding breath and crying during
medication administration via IV. Line flushing, blood returned
achieved. Offered to pull IV and start new line, patient now
agreeable. Patient HR on SPO2 reading 30s, patient bearing down and
holding breath, cardiac monitor applied. Patient c/o back pain, history of the herniated discs, sciatica. MD notified orders
received.
RN 9/9/2018 1:30 PM
1320: Patient in room from triage, hooked up to BP/SPO2 monitor,
husband at bedside. Patient crying in room, husband requesting pain
medication, assigned MD notified. Labs drawn, Line patent.
1327: Primary RN and MD at bedside.
Patient in room from triage, hooked up to BP/SPO2 monitor,
husband at bedside. Patient crying in room, husband requesting pain
medication, assigned MD notified. Labs draw, patient crying during
procedure. Line patent.
1327: Primary RN and MD at bedside.
Addendum to note by RN 9/9/2018 1:08 PM
Pt was seen here last night for LLQ and pain, CT and labs are done, CT showed
the sigmoid colon. Also had urinary retention and had a cath done
for this. Pt had moderate relief after last evenings treatment the
and swelling was going down. Pt was discharged and during the night pt
received a phone call that her younger brother died and is having same
and pain and distention again. Denies nausea and vomiting. Pt crying in triage.
