Internship

CHRONOLOGY OF MEDICAL EVENTS
Mary Smith

DATE

TIME

HEALTHCARE PROVIDER

EVENT/SIGNIFICANT DOCUMENTATION

REVIEWER COMMENTS

4/5

Dr. Brown

Went to Bush Gardens with family including daughter from 4/5 Monday through 4/11 Sunday.
While at Bush Gardens daughter ate scallops 2-3 times (once at Bush Gardens and 1-2 times at Red Lobster.
Started to feel ill while at Bush Gardens.

4/10

Dr. Brown

Returned from Bush Gardens

Sunday

4/11

Dr. Brown

Daughter did not feel well. Not interested in eating.

Monday

4/12

Dr. Brown

Daughter walked over to the Mc Donalds and ate lunch.

Tuesday

4/13

Dr. Brown

Daughter not feeling well took prylosec

Wednesday

4/14

1900ish

Dr. Brown

Reportedly ingested 50 tablets of aspirin

Thursday
Exact time unknown.

4/15

0800

Dr. Brown

50 mg Phenergan IM

Given in Dr. Brown's office

4/15

1000

Dr. Brown

100 mg Vistaril IM

Given in Dr. Brown's office

4/15

1200

Dr. Brown

Lab drew Blood work

Drawn in Dr. Brown's office

4/15

1400

Dr. Brown

Blood work reports returned

Called Dr. Johns
Exact time unknown

4/15

1714

St. James Hospital

Admitted to a private room on a general floor

Admitting doctor: Dr. Johns

4/15

Dr. Johns

Chief Complaint: Nausea, vomiting and abdominal Cramping

History: OCD, manic depressive disorder and schizophrenia…history obtained from PT mother (Georgia) and MD father…due to the patient being either unwilling or unable to answer questions…currently under the care of Joe Simons, a psychologist at U/T and Dr. Adams, a psychiatrist in Memphis, TN.

Yesterday, the patient came to his father's office complaining of nausea, vomiting and abdominal cramping…gave him a shot of Phenergan with no relief. Labs were drawn at that time and the daughter admitted to taking fifty tablets of Aspirin the night before (on 4/14/02). The father then transported her to St. James Hospital.

He was admitted to Dr. Johns.

The patient has been living with a friend…kicked out from father and stepmother's because of argument… patient seemed sleepier during trip returning to the hotel early one day to take a nap and going to bed early one night. There is some question as to whether or not the patient has been taking her medications. Both parents deny any precipitating events prior to his taking large amount of Aspirin.

Medications:
Risperdal 6 mg qd hs
Celexa 20 mg hs
Multivitamins

No known drug allergies.

Social History: She has tried tobacco, alcohol and Marijuana but is not known to use any on a regular basis…also not known to have tried any other illegal drugs.

Review of Systems: Unobtainable

Physical Examination: 18 yo white female, well-developed, well-nourished, asleep but not unconscious who responds spontaneously to voice, but doesn't give an intelligible answer and falls back to sleep. The physical examination is limited by uncooperative patient.

VS 96.7, 141, 88/43, 28

Jaundice without visible petechiae…Sclerae icteric…tachycardic…abd little tender to palpation

Impression: Acute hepatitis

History and Physical dictated by PA Student on 4/16/02 at 10:27AM the day after an emergent admission.

Have the psychiatric records been reviewed to determine any precipitating events?

Treatment was not started immediately.

Patient's vital signs are highly abnormal. Healthcare provider mistakenly thought the patient was being uncooperative. Failed to properly assess the patient's condition.

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DATE	TIME	HEALTHCARE PROVIDER	EVENT/SIGNIFICANT DOCUMENTATION	REVIEWER COMMENTS
4/5		Dr. Brown	Went to Bush Gardens with family including daughter from 4/5 Monday through 4/11 Sunday. While at Bush Gardens daughter ate scallops 2-3 times (once at Bush Gardens and 1-2 times at Red Lobster. Started to feel ill while at Bush Gardens.
4/10		Dr. Brown	Returned from Bush Gardens	Sunday
4/11		Dr. Brown	Daughter did not feel well. Not interested in eating.	Monday
4/12		Dr. Brown	Daughter walked over to the Mc Donalds and ate lunch.	Tuesday
4/13		Dr. Brown	Daughter not feeling well took prylosec	Wednesday
4/14	1900ish	Dr. Brown	Reportedly ingested 50 tablets of aspirin	Thursday Exact time unknown.
4/15	0800	Dr. Brown	50 mg Phenergan IM	Given in Dr. Brown's office
4/15	1000	Dr. Brown	100 mg Vistaril IM	Given in Dr. Brown's office
4/15	1200	Dr. Brown	Lab drew Blood work	Drawn in Dr. Brown's office
4/15	1400	Dr. Brown	Blood work reports returned	Called Dr. Johns Exact time unknown
4/15	1714	St. James Hospital	Admitted to a private room on a general floor	Admitting doctor: Dr. Johns
4/15		Dr. Johns	Chief Complaint: Nausea, vomiting and abdominal Cramping History: OCD, manic depressive disorder and schizophrenia…history obtained from PT mother (Georgia) and MD father…due to the patient being either unwilling or unable to answer questions…currently under the care of Joe Simons, a psychologist at U/T and Dr. Adams, a psychiatrist in Memphis, TN. Yesterday, the patient came to his father's office complaining of nausea, vomiting and abdominal cramping…gave him a shot of Phenergan with no relief. Labs were drawn at that time and the daughter admitted to taking fifty tablets of Aspirin the night before (on 4/14/02). The father then transported her to St. James Hospital. He was admitted to Dr. Johns. The patient has been living with a friend…kicked out from father and stepmother's because of argument… patient seemed sleepier during trip returning to the hotel early one day to take a nap and going to bed early one night. There is some question as to whether or not the patient has been taking her medications. Both parents deny any precipitating events prior to his taking large amount of Aspirin. Medications: Risperdal 6 mg qd hs Celexa 20 mg hs Multivitamins No known drug allergies. Social History: She has tried tobacco, alcohol and Marijuana but is not known to use any on a regular basis…also not known to have tried any other illegal drugs. Review of Systems: Unobtainable Physical Examination: 18 yo white female, well-developed, well-nourished, asleep but not unconscious who responds spontaneously to voice, but doesn't give an intelligible answer and falls back to sleep. The physical examination is limited by uncooperative patient. VS 96.7, 141, 88/43, 28 Jaundice without visible petechiae…Sclerae icteric…tachycardic…abd little tender to palpation Impression: Acute hepatitis	History and Physical dictated by PA Student on 4/16/02 at 10:27AM the day after an emergent admission. Have the psychiatric records been reviewed to determine any precipitating events? Treatment was not started immediately. Patient's vital signs are highly abnormal. Healthcare provider mistakenly thought the patient was being uncooperative. Failed to properly assess the patient's condition.