Jason Wilson ED Samples
CHIEF COMPLAINT: Facial swelling.
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old man who reports he
was moving and cutting trees yesterday. Some of them were covered in vines. He
thinks he may have been exposed to poison ivy. He complains of itching and swelling of
the face and around the left eye which has been increasing throughout the day. He has
no complaints of difficulty breathing or swelling. No chest pain or vomiting. No
abdominal pain. He took some over-the-counter Benadryl with little relief today. He had
a similar reaction to poison ivy as a child. No history of anaphylaxis.
REVIEW OF SYSTEMS: Negative, other than as mentioned above in HPI.
PAST HISTORY: Angina.
SURGERIES: Laminectomy, knee arthroscopy, and tonsillectomy.
MEDICATIONS: Benadryl p.r.n.
ALLERGIES: None.
PHYSICAL EXAMINATION: He is afebrile. VITAL SIGNS: Pulse 76, respirations 20,
blood pressure 130/70. O2 sat is 95% on room air which is normal. GENERAL: He is a
well-developed, well-nourished male in no acute distress. HEENT: Shows facial
edema, left periorbital edema, and inability to open his eye. There is no surrounding
erythema or cellulitis. The lid was retracted. There was no chemosis or injection noted.
Oral exam shows no oropharyngeal edema, no uvular edema. NECK: Supple, without
JVD, mass, or meningismus. LUNGS: Clear, without wheeze or crackle.
CARDIOVASCULAR: Regular rate and rhythm. . ABDOMEN: Nontender to deep
palpation. SKIN: Warm and dry. He does have scattered erythematous urticaria-type
lesions over the chest and extremities. No mucous membrane lesions. NEUROLOGIC:
He is alert and conversant, with no apparent deficit. .
MEDICAL DECISION MAKING: Differential diagnosis includes toxicodendron exposure,
contact dermatitis, or allergic reaction. Doubt anaphylaxis.
ER COURSE: He had an IV placed. He was given Solu-Medrol 125 IV and Benadryl 50
mg IV. He was observed for approximately an hour. He had improvement in his
symptoms and certainly no progression.
At the time of discharge vital signs are stable. He had no respiratory distress, no
oropharyngeal edema. He is alert and conversant, and will be discharged.
DISPOSITION: I wrote a prescription for a Medrol Dosepak to take as directed.
Continue Benadryl over-the-counter 25-50 mg three times a day. Follow up with primary
doctor. Return immediately if worse or concerned, which includes increased swelling,
difficulty breathing or swallowing.
FINAL DIAGNOSIS:
1. Acute facial edema.
2. Allergic reaction versus poison ivy exposure.
Wilson Sample 2
CHIEF COMPLAINT: Burns from a radiator hose.
HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old-male who is brought in
by medics for evaluation. He was working on a company truck when he reports the
radiator hose busted, spraying hot liquid onto his chest and arms. He received 10 of
morphine prior to arrival and is still complaining of pain. He denies any inhalation injury
and denies change in vision or difficulty breathing or swallowing. He denies any
secondary injury or fall and has no loss of consciousness. He lives in Broward County
and is here for work.
REVIEW OF SYSTEMS: All other systems reviewed and are negative, except for the
items mentioned above. '
PAST MEDICAL HISTORY: No medical problems.
PAST SURGICAL HISTORY: None.
CURRENT MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, pulse 90, respiration rate 20, blood
pressure 130/100 and oxygen SAT is 100% on room air, which is normal. GENERAL
APPEARANCE: He is a well-developed, well-nourished male, who is alert but appears
uncomfortable. He is in no respiratory distress. HEENT: Atraumatic and normocephalic.
His conjunctiva are pink and mucous membranes are moist with no facial burns noted.
NECK: Supple. LUNGS: Clear without wheeze or crackle. CARDIOVASCULAR: Regular
rate and rhythm. ABDOMEN: Nontender to deep palpation. SKIN: Warm and dry. There
are burned areas noted across the chest and patchy upper arm areas. He has superficial
and partial thickness burns with blistering across approximately 12-15% total body
surface area. This includes the chest, upper abdomen and upper arms. There were no
circumferential burns and no full thickness seen. NEURO: He is alert, conversant with no
apparent deficits.
MEDICAL DECISION-MAKING: Differential diagnosis includes superficial versus partial
thickness burns, doubt full thickness burns or airway injury.
EMERGENCY DEPARTMENT COURSE: Tetanus was updated with 0.5 cc IM. He was
given a liter of normal saline and Dilaudid 1 mg IV for pain, which gave him good relief.
His wounds were then covered with sterile pads and ice packs. He was under
observation about one hour with the ice packs in place and noted significant
improvement in his symptoms. He appeared much more comfortable. The patient's
burns were borderline for admission. They were approximated at 15% total body surface
of mostly partial thickness burns. He would likely require debridement and pain
management. I discussed this with the patient and told him that we do not admit. The
patient is here for burns but would happily transfer him to the burn center in Tampa. The
patient wishes to go to Broward, as he states he wants to return home and go to the
hospital there. He does have a friend here and they are driving back tonight. He wishes
to be discharged home and will follow up with the hospital/burn center in Broward
County. We were able to find out information and contact the hospital in Broward County
and find out that Broward General does have a trauma center and does see burn
patients, therefore it was recommended that he follow up with that hospital today when
he returns there.
DISPOSITION: I wrote a prescription for Percocet to take for pain. His wounds were
covered and with Bacitracin prior to discharge. He is to follow up with the hospital and/or
burn center in Broward County. He can return to the emergency room any time for
problems or concerns.
FINAL DIAGNOSIS: Superficial and partial thickness burns from scalding injury on the
chest and arms approximately 15% total body surface area.
Wilson Sample 3
CHIEF COMPLAINT: Right ear pain.
HISTORY OF PRESENT ILLNESS: This is an almost two-year-old male brought in by
mom for evaluation. He has been tugging and pulling at his right ear. Since tonight he
has had mild cough with congestion. He has a history of multiple previous episodes of
otitis media. Last one was about three months ago. She states this is how he actually
has an ear infection. He has had no fever or vomiting. Otherwise acting normal.
Pediatrician is Dr. Bartlett. He has not had ear tubes placed and there is no drainage
from the ears. Last antibiotic he used was Omnicef which mom states worked.
REVIEW OF SYSTEMS: Negative other than those mentioned above in history of
present illness.
PAST MEDICAL HISTORY: Otitis media.
PAST SURGICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, temperature 97.4, pulse 120,
respiratory rate 20, O2 saturations 99% on room air which is normal. GENERAL: Well
developed, well nourished male who cries on exam. Easily consoled by mom. HEENT:
Normocephalic, atraumatic. Conjunctivae are pink. Mucous membranes are moist.
Oropharynx is clear. Left tympanic membrane is normal. Right tympanic membrane
shows purulent effusion without drainage. NECK: Supple. LUNGS: Clear.
ABDOMEN: Nontender to deep palpation. SKIN: Warm and dry without rash.
NEUROLOGIC: He is alert, age appropriate. No apparent deficit.
MEDICAL DECISION MAKING: Differential diagnoses:
1. Acute otitis media.
2. Upper respiratory infection.
3. Viral syndrome.
4. Doubt invasive illness.
DISPOSITION: The patient has evidence of acute otitis media with purulent bulging
effusion in the right ear. He will be treated with Omnicef to take as directed and
prescription for Tylenol with Codeine to use for pain. Follow up with Dr. Bartlett in one to
two days and return if worse or concerned.
FINAL DIAGNOSIS: Acute recurrent right sided otitis media.