DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Carbon monoxide exposure.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old who was exposed to carbon monoxide. Apparently there was a gas generator running for about 6 hours in the basement, ventilated slightly, and the family was somewhat overcome with exposure symptoms. The family was rushed out of the house. Obviously, the child cannot really give too much in the way of symptoms at his age, but he does deny having any headache. He has not had any vomiting. He basically states he feels okay. Nursing notes were reviewed.
PAST MEDICAL HISTORY: None. No history of apparent trauma.
CURRENT MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: None relevant.
SOCIAL HISTORY: Not exposed to cigarette smoke.
REVIEW OF SYSTEMS: The patient cannot give an adequate review of systems.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure not taken, pulse 134, respirations 20, temperature 97.2 degrees.
GENERAL: The patient is a well-developed, well-nourished Hispanic male.
HEENT: Head and face unremarkable. Eyes: Extraocular muscles intact. ENT and oral cavity without lesions.
NECK: Supple, full range of motion. No pain on palpation, no meningismus.
LUNGS: Clear to A&P bilaterally.
HEART: Regular rate and rhythm. No gallops, rubs or murmurs.
CHEST: Chest wall nontender to palpation.
ABDOMEN: Benign, soft, nontender. Bowel sounds present in all quadrants. No masses, bruits appreciated.
BACK: No tenderness of the CVA or bony spine.
GENITORECTAL: Exam was not performed.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Grossly intact. No focal or lateralizing findings.
SKIN: Warm and dry and not red. Not cyanotic.
MENTAL STATUS: Alert and interactive.
LABORATORY DATA: The patient had a CO level of 22.8. He had chemistries, which were normal.
EMERGENCY DEPARTMENT COURSE: The patient remained asymptomatic. The patient was placed on 100% O2 during his entire stay in the emergency department.
CRITICAL CARE: There is high probability of clinically significant deterioration in patient’s condition, which required our emergent intervention. This included administration of 100% O2, consultations with (XX) Hospital, and Dr. John Doe from the Hyperbaric Center. They accepted him in transfer. Total critical care time was one hour excluding separate reportable procedures, which were none.
IMPRESSION: Carbon monoxide toxicity.
DISPOSITION: The patient was transferred to (XX) Hospital Medical Center for hyperbaric therapy.
DISPOSITION: The patient was transferred by ambulance in good condition.
