DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Carbon monoxide exposure.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female, who was apparently exposed to significant carbon monoxide levels due to a gas generator in the basement, which was running for about 6 hours. She was overcome by some nausea and headache. The family noticed that she was disoriented. She did fall and bump her head. She had no loss of consciousness. Nursing notes were reviewed.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: Not relevant.
SOCIAL HISTORY: She is a smoker and nondrinker.
REVIEW OF SYSTEMS: The patient denies fever or chills. She denies visual complaints. She denies earache or sore throat. She has a headache. She denies extremity complaints. She has nausea but no vomiting. She denies hematuria, dysuria and urinary frequency. She denies musculoskeletal, bone or joint complaints. She denies neurologic complaints or skin lesions. The remainder of the review of systems was reviewed and negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 112/72, pulse 110, respiratory rate 21, temperature 97.2 degrees.
GENERAL: The patient is a well-developed, well-nourished Hispanic female.
MENTAL STATUS: The patient is alert and oriented x3.
HEENT: Head: Remarkable for a small hematoma over the right supraorbital rim. Eyes: Extraocular muscles are intact. Pupils are equal, round, and reactive to light and accommodation. ENT/oral cavity: Without lesions.
NECK: Supple. Full range of motion. No pain on palpation. No meningismus.
LUNGS: Clear to auscultation and percussion bilaterally.
HEART: Regular rate and rhythm. No gallops, rubs or murmurs.
CHEST WALL: Nontender to palpation.
ABDOMEN: Benign, soft, and nontender. Bowel sounds are present in all quadrants. No masses or bruits can be appreciated.
BACK: No tenderness to the CVA or bony spine.
GENITORECTAL: Exam not performed.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Grossly intact. No focal or lateralizing findings.
SKIN: Without lesions or rashes.
PSYCHIATRIC: Not performed.
DIAGNOSTIC DATA: The patient had a carbon monoxide level, which was critically high at 26.4. Chemistries were normal. Potassium slightly low at 3.3. No EKG was performed. Chest x-ray was clear.
CRITICAL CARE: There was a high probability of clinically significant deterioration in the patient’s condition, which required our urgent interventions. This included administration of 100% O2, monitoring of her CO level and arranging transfer for hyperbaric therapy. Total critical care time was one hour, excluding separately reportable procedures.
IMPRESSION: Carbon monoxide toxicity.
DISPOSITION: The patient was transferred by ground ambulance to an outside hospital for hyperbaric therapy.
CONDITION: Stable.
