1/37 Speken, Seth 0719970 M 6407105 EMERGENCY SERVICES TRIAGE
Date: 8/21/93 Time: 4.50pm Category: Emergency
Chief Complaint: "I passed out"
Triage Signature: (?) Peterson RN
Date: 8/21/93 Time: 4.50pm (Female Checked) Age: 23
(no one listed as accompanying patient)
PRIMARY MD: "Father is treating patient" Initial Vital Signs: Temp (p.o.) 98 Pulse 120 R 20 Blood Pressure 130/70
Allergies: Immodium *History of Crohn's Disease
CURRENT MEDICATIONS:>Amitriptyline(Elavil) 40milligrams(mg)
Past Medical History (PMH): +Psych(iatric) (?)"mild hypertension (HTN)> diet controlled Negative (-) Diabetes Mellitus (DM) "Panic Attacks" Assessment: presents (as) alert and oriented X3 (+) nausea and vomited in ambulance---
Click here for image: ASSESSMENT: presents Alert and Oriented X3 +nausea>vomited in ambulance-full Range of Motion (ROM)-denies abdominal pains presently but claims "heartburn" before arrival +dizziness and headache _ presents with IV (in) Left Arm begun by Emergency Medical Service (EMS) (60 cc infused in field)-states, "I feel much better now." D. Peterson, R.N. *multiple abrasions noted to face, nose, cheek and temporal area 5PM Patient is a 23 year old white male brought in by EMS following a syncopal episode. Patient was recently placed on Elavil by outside Psychiatrist to begin at 10mg QD (once a day) and to increase QID (4X/day) by 10mg > Patient had just graduated to 60mg QD (once a day) and last pm developed lightheadedness when standing - father gave patient 1 dose of 25 mg of Bethanechol - Today patient felt "jittery and walked over to window with his sister when (?) he became pale lightheaded and fell to ground on his face sustaining abrasions - patient was "shaking like a fish out of water" according to sister for about a minute then was unconscious X 10 minutes more patient awoke confused> +disoriented EMS called and transported patient to ER - Patient remembers none of these events>sister was witness
Click here for image Patient remembers none of these events>sister was witness Patient denies Chest Pain (CP), Shortness of Breath (SOB) - "just jittery" denies taking increased medication, denies suicidal or homicidal ideation (cont'd) Kevin (Hewitt)?
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