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Medical Record Review
Jane Doe
Summary Notes
Summary Notes Jane Doe
11/29/2016 2 of 5Date Location
SummaryNote
Summary of Jane Doe
Executive Summary Part I
Jane Doe pr...
Summary Notes Jane Doe
11/29/2016 3 of 5Date Location
SummaryNote
3:52PM Rural MetroAmbulance called Rural MetroAmbulance ...
Summary Notes Jane Doe
11/29/2016 4 of 5Date Location
SummaryNote
CardiacArrestAssociatedWith Pregnancy: Modifications for...
Summary Notes Jane Doe
11/29/2016 5 of 5Date Location
SummaryNote
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Re-dacted Medical Record Summary

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Re-dacted Medical Record Summary

  1. 1. Medical Record Review Jane Doe Summary Notes
  2. 2. Summary Notes Jane Doe 11/29/2016 2 of 5Date Location SummaryNote Summary of Jane Doe Executive Summary Part I Jane Doe presented to University Hospitals MacDonaldWomen’s Center for prenatal care on12/9/10afterlearning thatshe had a positivepregnancy test. She initially hadbeen seenin the ErinBuilding officeby a PHCNM. After learning of Ms.Doe’s previous history with high blood pressureand then observing that Ms.Doe’s blood pressure remained elevated evenafter obtaining a doctor’s order for Aldomet 500mg twice a day and thenon 12/16/10the nighttimedoseofAldometwas increased to1000mg. PH feltit would bein Ms.Doe’s bestinterest on12/16/10that sheonly beseenby a physicianfor her prenatal care due to“having uncontrolled hypertension” on her firsttwo prenatal visits. On 12/21/10,Dr. TMassumedcare of Ms.Doe. Dr. Mcontinued tocarefor Ms. Doe until the date ofher incidenton 6/15/11. During Ms.Doe’s prenatal visits her blood pressurewas checked regularly. Ms.Doe’s bloodpressurecontinued tobe elevated throughout her prenatalcare,with no further change in blood pressuremedication ordosage. Also,during Ms.Doe’s prenatalvisits, especially after thetwentieth week,her urinewas checked mosteveryvisit for the presenceofAlbumin (protein) andGlucose(sugar). Ms. Doenever showedanyproblems with sugar. However, beginning on 4/5/11, Ms. Doe started to an elevated urineproteinby dipstick. The urineprotein dipstick readings remained elevated for the remainderof Ms.Doe’s pregnancy, with the highest reading obtainedon 6/15/11. In addition, on5/31/11, Ms. Doehad a urinetotalproteinof123mg/Landa urine protein/creatinineratio of 397mg/g. Both ofwhich areabnormally high. Again,Dr. M didnotattemptto treattheseabnormalfindings. A third problem thatappeared trivial at first,was Ms.Doe’s complaints oftightness orswelling. Initially on 4/5/11 Ms.Doecomplainedofher wrists feeling sore andshedescribed this as being carpal tunnel. However, according to Jane’s initialhistoryandphysicalshedid nothavecarpaltunnel listed. Ms. Doe again complained on5/4/11 ofmissing work theprevious day due toher“wrists really hurting her”. Dr. M’s notes consistently reflected the concern ofcarpaltunnel andtheusageofwristsplints torelievethesymptoms ofcarpal tunnel. However,Dr. Mnever questioned Jane as to whether or not she could behaving the firstsigns ofswelling. Likewise, on 5/24/11 Ms. Doe complained ofswelling in her feet and hadrequested a doctor’s excuse for missedworkbetween5/18/11and 5/24/11. On 6/7/11 Dr.Mhad signedFamily Medical Leavepaperwork for Ms.Doeand on 6/10/11, Dr.Mnoted that patient “has not worked since5/31/11 due toswollen feet and pregnancyrelated uncomfortableness”. Once again,therewas notreatment ordered to try to alleviatetheswelling. Finally,Rural MetroEMT AW deviated fromtheACLS Algorithmby notproviding an advanced airway or attempting tostart an IV in order to administer certainmedications that couldhavehelped bring Janeout ofthe PEAarrest. In addition, thereis no mention of AW attempting to provideoxygen toJane with a non-rebreathermaskata flowrate of15liters per minute. Sequence of Events On Date of Incident June 15, 2011 PrenatalVisit Jane Doe, 40-year-oldfemale presents toherOB visit withcomplaints ofshortness ofbreath,elevatedbloodpressureof192/102, and positive GroupB Streptestfrom 6/7/11.
  3. 3. Summary Notes Jane Doe 11/29/2016 3 of 5Date Location SummaryNote 3:52PM Rural MetroAmbulance called Rural MetroAmbulance totransport Ms. DoetoUH ER to ruleoutPreeclampsia. 4:18PM Rural MetroAmbulance arrives at Dr. M’s officeand finds Janesitting onexamtable. 4:30PM Rural MetroAmbulance leaves Dr. M’s officefor UH ER. Jane’s bloodpressureremains elevated. 4:36PM Jane has seizure, thenwent intofullcardiopulmonary arrest aftercomplaining ofshortness ofbreathx 2 and her systolic blood pressure remained inthe220’s-240’s. Jane’s oxygen level kept dropping prior toseizure even when oxygen was applied initially at 6L per nasal cannula. 3-lead EKG showedPEA. AW was theprimary EMTat thetime andasked for assistance fromhis partner KS. After performing a coupleofrounds ofCPR per ACLS Algorithm, AW was ableto placean oral pharyngeal airway. However, after calling the Rural Metrodispatchandrequesting assistance,AW optedto have KS returnto driving the ambulancewhilehe administeredCPR. At this point,AW alsodecided notto try to start an IV or placean advancedairwayas per ACLS Algorithm, rather he just wantedKS to driveto the nearest ER. 4:51PM Rural MetroAmbulance arrives at UHER. It is important to treat high bloodpressurein pregnancy because ofthe riskofpreeclampsia. It is important to know the signs andsymptoms of preeclampsia. It also important toadhereto standards ofcare set forthby theAmerican Heart Associationwithregards to preventing a seizureand providing CPRduring pregnancy. There are 2 types of Preeclampsia: 1. Mild preeclampsia is diagnosedwhen: pregnancy is greater than20 weeks; blood pressure is greater than 140 systolic and 90 diastolic; 0.3g ofprotein is collectedin a 24-hoururine sampleor persistent 1+proteinmeasurementon urinedipstick; andthereareno signs ofproblems with the motheror thebaby. 2. Severe preeclampsia is diagnosed when there areadditionalproblems witheither motheror baby: signs ofcentral nervous systemproblems (severe headache, blurry vision,altered mental status); signs ofliver problems (nausea and/or vomiting withabdominal pain); atleasttwicethenormal measurements ofcertain liver enzymes on bloodtest;veryhigh blood pressure(greaterthan 160systolic or110 diastolic); thrombocytopenia (low plateletcount); greater than5g ofprotein ina 24-hour sample; verylowurine output (less than 500mlin 24-hour); signs ofrespiratory problems (pulmonary edema,bluish tintto the skin). (Craig Weber, High BloodPressure, 2007) To treat thecritically ill pregnant patient: 1. Place the patientin theleft lateralposition 2. Give 100% oxygen 3. Establishintravenous (IV) access and givea fluidbolus
  4. 4. Summary Notes Jane Doe 11/29/2016 4 of 5Date Location SummaryNote CardiacArrestAssociatedWith Pregnancy: Modifications for Pregnant Women (Primary) 1. No modification for airway 2. No modification for breathing 3. Circulation-placethewoman on her left side withherback angled15-30 degrees back fromtheleftlateral position. Thenstart chestcompressions. Secondary Modifications for PregnantWomen 1. Insert anadvancedairway earlyin resuscitationto reducetherisk ofregurgitationand aspiration 2. Airway edema and swelling may reduce the diameter ofthetrachea. Be preparedto usea tracheal tubethat is slightly smaller than theoneyou would use for a nonpregnant woman ofsimilarsize 3. Monitor for excessivebleeding following insertion ofanytubeinto theoropharynx or nasopharynx 4. Effective preoxygenationis criticalbecausehypoxia (lack ofoxygen to the brain) candevelopquickly (AmericanHeart Association, 2005).
  5. 5. Summary Notes Jane Doe 11/29/2016 5 of 5Date Location SummaryNote

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