1/37                                                                                                                      Speken, Seth
                                                                                                 0719970 M 6407105
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
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
                                                                       Kevin (Hewitt)?
Click here for image
Click here for next page