EMERGENCY DEPARTMENT REPORT
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Fanshawe College *
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6012
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Medicine
Date
Dec 6, 2023
Type
docx
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EMERGENCY DEPARTMENT REPORT
PATIENT NAME: SMITH, Janet
DATE OF BIRTH: January 3, 1980
OHIP #: 12336 PH
MEDICAL REPORT #: 6757876
PHYSICIAN: Bell Graham M.D
DATE OF ADMISSION: July 21, 2023
DATE OF DISCHANGE: July 22, 2023
Date of Dictation: July 22, 2023
Date of Transcription: July 22, 2023
CHIEF COMPLAINT:
The patient presents to the Emergency Department with complaints of increasing and severe
left hip pain for the past 12 hours.
HISTORY OF PRESENT ILLNESS:
Janet Smith reports experiencing increasing left hip pain, the pain is described as constant and
sharp, radiating to the lower left extremity with swelling around the left hip, she rates the pain
as 9/10 in severity
and
the pain is exacerbated with mobility of the left hip.
MEDICAL HISTORY:
She was diagnosed with
greater trochanteric bursitis and has been under treatment for with
Lortab and Naprosyn, she also has her Tonsils and adenoids were removed in early childhood.
FAMILY AND SOCIAL HISTORY:
Patient stopped smoking 6-7 years ago he smoked an average of a pack per day for many years.
She denies ethanol use. She works as a plant manager for a chemical company. Her father is
deceased secondary to complications of black lung and asthma. she thinks his sister has a
history of hypertension she is on Lortab 7.5 mg daily and Naprosyn 375 mg daily.
VITAL SIGNS:
Blood pressure 200/104. Repeat, after rest and pain medication, was 170/96.
Pulse Rate: 72 pulse per minute
Respiratory Rate: 17 breaths per minute
Temperature: 37.5°C (99.5°F)
Oxygen Saturation: 98% on room air
PHYSICAL EXAMINATION:
HEENT:
No hypertensive retinopathy, exudates, hemorrhages, or papilledema was noted. The
oral examination revealed no ulcerations, erosions, or masses. Supple, without
lymphadenopathy.
NECK:
Thyroid nonpalpable.
THORAX AND LUNGS:
The chest was clear to auscultation in all fields. Regular rate and rhythm,
without murmurs, thrill, gallop or click sound.
CARDIOVASCULAR:
The carotid upstrokes were brisk and equal bilaterally, without bruits.
ABDOMEN:
Nontender, non-distended, without masses, organomegaly, guarding, tenderness or
rebound
PERIPHERAL VASCULAR:
Peripheral pulses were intact, with good upstrokes.
EXTREMITIES:
Palpation of the left hip did reveal tenderness, although the patient did report it
was much improved after analgesia. No clubbing, cyanosis, or edema.
INTERVENTION:
Administer intramuscular (IM) access medication (NSAIDs) to reduce pain. urinalysis to
determine glucose level in urine. Random blood sugar reveals blood sugar. Order complete
blood count (CBC), comprehensive metabolic panel (CMP), lipase, and amylase to aid in
diagnosis. Diagnostic ultrasound and magnetic resonance imaging of the left hip
DIAGNOSTIC WORKUP:
A review of the random blood sugar revealed a blood sugar of 201mmhg. urinalysis revealed
greater than 1000 glucose. CBC revealed a hemoglobin of 16.3 mmol/L and a hematocrit of
50L/L, the white count was 14.7, and platelets were 291, 000million/mm3. the differential was
within normal limits. Magnetic resonance imaging of the left hip showing fluid-filled and
thickened trochanteric bursa with evidence of inflammation and tendinopathic echogenic
findings.
DIAGNOSIS:
Left greater trochanteric bursitis hypertension complicated by asymptomatic hyperglycemia
with glycosuria.
CONDITION ON DISCHARGE:
Stable, Pain of the left hip has subsided.
PLAN:
Admit patient to ward 2 for Orthopedic consultation.
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