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  1.  
  2.  
  3. The XXXXXXXXXX, PA 19104
  4. Hospital Abstract
  5. PATIENTJR.,OUTPATIENT
  6. MRN: 00000000
  7. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  8. Attending Provider: (none)
  9. Allergies: No Active    Isolation: None	Ht: -	Admission Cmt: (none)
  10. Allergies	Infection: None	Wt: 9.2 kg (20 lb 4.5 oz)	Principal Problem: None
  11. Code Status: Not on file
  12. Admission Information - Hospital Account/Patient Record
  13. Arrival Date/Time: XXXXX.	None
  14. Date/Time:
  15. Admission Type: Emergent	Admission	Emergency	Admit Category: None
  16. Source:	Department-chop
  17. Means of Arrival: None	Primary Service: None	Secondary	None
  18. Service:
  19. Transfer Source: None	Service Area:	Chop Service	Unit:	Main Emergency
  20. Area	Dept
  21. Admit Provider:	None	Attending	Edmonds,	Referring	Provider, Self
  22. Provider:	Sadiqa, MD	Provider:	Referred
  23. Discharge Information - Hospital Account/Patient Record
  24. Discharge Date/Time Discharge Disposition Discharge Destination Discharge Provider	Unit
  25. 04/15/2013 0337	Discharged (Routine) None	Edmonds, Sadiqa, MD Main Emergency
  26. Dept
  27. Final Diagnoses
  28. Princip Code	Name	POA	CC	HAC	Affects
  29. al	DRG
  30. [P]	V71.6	Observation following other inflicted injury
  31. Allergies as of 4/15/2013	Assessed/Confirmed On: 4/15/2013 By:
  32. XXX, XXX X, RN
  33. No Active Allergies
  34. Immunizations as of 4/15/2013	Never Reviewed
  35. DTAP/HEPB/IPV(PEDIARIX)	3/20/2013, 1/18/2013, 11/19/2012
  36. HIB	3/20/2013, 1/18/2013, 11/19/2012
  37. Hepatitis B	01/01/2012
  38. Pneumococcal 13 (Prevnar13)	3/20/2013, 1/18/2013, 11/19/2012
  39. Rotavirus Vaccine, Pentavalent (Rotateq)	3/20/2013, 1/18/2013, 11/19/2012
  40. ED Records
  41. Attending at Discharge
  42. Discharge Provider	Date/Time	Disposition	Destination
  43. Edmonds, Sadiqa, MD /	04/15/13 0337	Discharged (routine)	(none)
  44. 215-590-1970
  45. Comments
  46. (none)
  47. ED Arrival Info	Patient:
  48. PATIENTJR.,OUTPATIENT	MRN: 00000000
  49.  
  50.  
  51.  
  52. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  53. Hospital Abstract
  54. PATIENTJR.,OUTPATIENT
  55. MRN: 00000000
  56. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  57. ED Records (continued)
  58. ED Arrival Info	Patient:
  59. PATIENTJR.,OUTPATIENT	MRN: 00000000 (continued)
  60. Expected	Arrival	Acuity Means of Arrival Escorted	Servic Admission	Arrival
  61. By	e	Type	Complaint
  62. 4/14/2013 18:17 4/14/2013 19:52 2	-	-	-	Emergent	R/o Abuse
  63. Acute
  64. ED Current Impression	Patient:
  65. PATIENTJR.,OUTPATIENT	MRN: 00000000
  66. R/o Scan
  67. Diagnosis	Patient: XXXXXX
  68. JR.,OUTPATIENT	MRN: 00000000
  69. Physical child abuse, suspected [V71.6]
  70. Child abuse, neglect [995.52]
  71. ED Disposition	Patient: XXXXXX
  72. JR.,OUTPATIENT	MRN: 00000000
  73. Discharg Outpatient PatientJr. discharged to home/self care. e
  74. ED Notes
  75. XXXXXX, XXX X, CRNP (Nurse Practitioner) 4/16/2013 18:09 Emergency
  76. Lab orders forwarded to PCP - Drexel Hill
  77. Electronically signed by XXXXXX, XXX X, CRNP at 4/16/2013 6:09 PM
  78. XXXXXX, XXX X, CRNP (Nurse Practitioner) 4/16/2013 16:56 Emergency
  79. XXXXXX, XXX << Less Detail XXXXXX, XXX
  80. Sent: Tue April 16, 2013 4:43 PM To: P Ed Np Pool
  81. Flags: Call patient
  82. Outpatient PatientJr.
  83. MRN: 00000000 DOB: 01/01/2012 Pt Home: 484-919-3044 Entered: 484-919-3044
  84.  
  85.  
  86. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  87. Hospital Abstract
  88. PATIENTJR.,OUTPATIENT
  89. MRN: 00000000
  90. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  91. ED Records (continued)
  92. Message
  93. Jennifer Patienthas questions about cat scan.
  94. Demographics does not have a Jennifer Patientlisted as being a responsible party for this patient. Referred the caller to the PCP for additional iformation
  95. Electronically signed by XXXXXX, XXX X, CRNP at 4/16/2013 4:56 PM
  96. XXX, XXX X  , RN (Registered Nurse) 4/15/2013 03:37 Emergency
  97. DISCHARGE - Plan of care discussed with caregiver. Patient discharged with printed instructions.
  98. * Teaching Provided: Education: Cast/Splint Care and Crutch Walking and PMD follow up
  99. * Person(s) Taught: Caregivers.
  100. * Teaching Method: Verbal and Written
  101. * Patient-Parent Readiness to Learning: Receptive
  102. * Patient-Parent Barriers to Learning: None
  103. * Patient-Parent Outcome: Parent/Patient is able to verbalize or demonstrate understanding
  104. Condition at discharge: alert and stable.
  105. Pt. Awake, alert, smiling/interactive. Provided care givers with extra diapers, nipples, and gave thorough follow up and cast care instructions.
  106. Electronically signed by XXX, XXX X  , RN at 4/15/2013 3:37 AM
  107. Edmonds, Sadiqa, MD (Physician) 4/15/2013 02:10 Emergency
  108. EMERGENCY DEPARTMENT MD/NP PROVIDER NOTE 
  109. History of Present Illness: Source:cousins who have assumed physical custody of child last evening
  110. CC: Outpatient Patientis a 6 month old male with plagiopcephaly who presents with concerns for physical abuse secondary to bruising and suspected abuse of sibling..
  111. HPI: Symptom onset time, duration, severity, quality:
  112. * Cousins report noting bruising on buttocks; red areas of excoriation on trunk/abdomen to Children & youth social work - who recommended child be taken to OSH for evaluation. Head CT at OSH noted assymetry, and prominent cortical sulci. Skeletal survey did not show fractures.
  113.  
  114.  
  115.  
  116. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  117. Hospital Abstract
  118. PATIENTJR.,OUTPATIENT
  119. MRN: 00000000
  120. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  121. ED Records (continued)
  122. * Sent to CHOP for further evaluation
  123. Associated / Alleviating signs and symptoms:
  124. * Fever: No
  125. * Intake/Urine Output: Child had period of irritability and decreased interest in feeding last evening.
  126. * Activity level: no change; waking for feeds and appropriate for caregivers.
  127. * Family members report child does not roll over, does sits with support, coos, no babbling. Able to hold bottle.
  128. Past Medical History: plagiocephaly
  129. Family History: No ill contacts and Reviewed and non-contributory
  130. Social History: recently placed in physical custody of family members due to concerns of abuse in a sibling.
  131. Primary Care Clinician: Network, Drexel Hill Care
  132. Medications/Allergies: Reviewed and updated in electronic health record.
  133. Immunizations Status: Routine immunizations up to date
  134. Review of Systems:
  135. Constitutional: see HPI
  136. Eyes: normal
  137. ENT: normal
  138. Respiratory: normal
  139. Cardiovascular: normal
  140. Gastrointestinal: no vomiting, no diarrhea and drinks good start soy 4-6 ounces 5-6x/day
  141. Genitourinary: no decreased urination
  142. Musculoskeletal: no joint pain and no weakness
  143. Neurologic: concerns of gross motor delay
  144. Skin: bruising:bluish flat rash on buttocks, and reddened area on trunk
  145. Psychiatric: normal
  146. Physical Exam:
  147. Vital signs: Pulse 122 | Temp 36.2 ∞C | Resp 32 | Wt 9.2 kg | SpO2 100%
  148. General: alert, well developed, well nourished, in no acute distress
  149. Head: plagiocephaly,
  150. Eye: pupils equal, round, and reactive to light, extra-ocular movements intact and normal conjunctivae:
  151. ENT: mucous membranes moist, TMs normal bilaterally and oropharynx clear
  152. Neck: neck is supple with full active range of motion
  153. Cardiac: regular rhythm, warm and well perfused and capillary refill less than 2 seconds
  154. Chest: clear to auscultation bilaterally and mild upper airway congestion
  155. Abdomen: soft, nontender, and nondistended , no hepatosplenomegaly and no guarding or rebound
  156. tenderness
  157. Genitourinary: normal male external genitalia
  158. Extremity: normal pulses, capillary refill, sensation, active and symmetric movement of extremities
  159. Neuro: normal suck, grasp, and Moro reflexes:
  160. Skin: bruising: bluish flat lesion, non-tender over sacral area
  161.  
  162.  
  163.  
  164. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  165. Hospital Abstract
  166. PATIENTJR.,OUTPATIENT
  167. MRN: 00000000
  168. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  169. ED Records (continued)
  170. Psychiatric:alert, oriented to caregiver
  171. Procedures: None
  172. Consults:
  173. Discussed plan with consult service: SCAN team recommend repeat skeletal survey at CHOP and abdominal trauma labs, MRI can be outpatient r/t to non-urgent findings on CT scan, also recommend
  174. CBC, coags due to ? History of brusing.
  175. Pertinent Results:
  176. Labs Reviewed
  177. CBC WITH DIFF - Abnormal; Notable for the following:
  178. Mean Platelet Volume
  179. 7.1
  180. (*)
  181. Eosinophils
  182. 4.4
  183. (*)
  184. Basophils
  185. 1.5
  186. (*)
  187. All other components within normal limits
  188. BASIC METABOLIC PANEL - Abnormal; Notable for the following:
  189. Potassium	6.3 (*)
  190. Carbon Dioxide	19 (*)
  191. All other components within normal limits
  192. HEPATIC FUNCTION PANEL - Abnormal; Notable for the following:
  193. Bilirubin,Direct (Calculated)
  194. 0.6
  195. (*)
  196. Albumin
  197. 4.8
  198. (*)
  199. Aspartate Aminotransferase
  200. 67
  201. (*)
  202. All other components within normal limits
  203. URINALYSIS W/0 MICROSCOPIC - Abnormal; Notable for the following:
  204. UR Specific Gravity	1.002 (*)
  205. All other components within normal limits
  206. Narrative:
  207. Source: Urine
  208. GAMMA GLUTAMYL TRANSFERASE GGT - Abnormal; Notable for the following:
  209. Gamma Glutamyl Transferase	15 (*)
  210. All other components within normal limits
  211. AMYLASE
  212. LIPASE PT/INR
  213. PTT PROFILE
  214. Reassessments:
  215. po fed 4 ounces of pedialyte with no emesis
  216. Resident/NP/MedStudent/Fellow: Treatment Team: CRNP: XXXXXX, XXX, CRNP
  217. EMERGENCY DEPARTMENT ATTENDING NOTE 
  218. Resident/NP: I performed a history and physical examination of the patient and discussed the management with the Resident/NP/Fellow. I reviewed their note and agree with the documented findings, except as noted. Sadiqa Edmonds, MD
  219. History of Present Illness:
  220.  
  221.  
  222.  
  223. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  224. Hospital Abstract
  225. PATIENTJR.,OUTPATIENT
  226. MRN: 00000000
  227. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  228. ED Records (continued)
  229. CC: Outpatient Patientis a 6 month old male with no chronic medical conditions who presents with concerns for abuse. Other children removed from parents care and family members concerned about possible bruising on child's buttocks. Has been in family members' care. Was evaluated at OSH, CT head done.
  230. Physical Exam:
  231. Pulse 122 | Temp 36.2 ∞C | Resp 32 | Wt 9.2 kg | SpO2 100%
  232. General: alert, well developed, well nourished, in no acute distress
  233. Head: plagiocephaly and no scalp hematoma
  234. ENT: mucous membranes moist, TMs normal bilaterally and frenulum intact
  235. Cardiac: regular rhythm, normal rate and no murmurs
  236. Chest: clear to auscultation bilaterally
  237. Abdomen: soft, nontender, and nondistended and no hepatosplenomegaly
  238. Extremity/Musculoskeletal: brisk capillary refill, no bony tenderness and range of motion: full
  239. Skin: no rashes, no pallor and mongolian spots over buttocks. No ecchymoses noted
  240. Medical Decision-Making / Differential Diagnosis / Plan: Buckle fracture of tibia
  241. Mental status wnl
  242. Head CT - chronic changes
  243. Response / Pertinent Results:
  244. Labs wnl
  245. Discussed with SCAN. OK to d/c with family
  246. Ortho consult (Proximal buckle fracture R tibia) - will place long leg cast
  247. F/u with ortho, SCAN, CYS
  248. Final diagnoses: None
  249.  
  250. Disposition:
  251. Discharge after reviewing instructions with family. Return if worsening in patient status.
  252. Original note by Edmonds, Sadiqa, MD at 4/15/2013 00:47 Electronically signed by Edmonds, Sadiqa, MD at 4/15/2013 2:10 AM
  253. XXXXXX, XXX, RT (Respiratory Therapist) 4/15/2013 01:14
  254. MD requested ISTAT for Potassium Level. K Result was 5 mEq/L valued reported to MD. ISTAT uploaded to computer.
  255.  
  256.  
  257.  
  258. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  259. Hospital Abstract
  260. PATIENTJR.,OUTPATIENT
  261. MRN: 00000000
  262. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  263. ED Records (continued)
  264. Electronically signed by XXXXXX, XXX, RT at 4/15/2013 1:14 AM
  265. XXX, XXX X  , RN (Registered Nurse) 4/15/2013 00:09 Emergency
  266. PIV placed prior to notification for concern of buckle fracture in R tibial metaphysis. Made NP Campisciano aware that PIV had been placed in R foot.
  267. Electronically signed by XXX, XXX X  , RN at 4/15/2013 12:09 AM
  268. XXX, XXX X  , RN (Registered Nurse) 4/14/2013 23:38 Emergency
  269. Pt. U-bagged, urine sent to lab.
  270. Electronically signed by XXX, XXX X  , RN at 4/14/2013 11:38 PM
  271. XXX, XXX X  , RN (Registered Nurse) 4/14/2013 22:24 Emergency
  272. Pt. Laying in bed, NP at BS assessing PT. Pt. Awake, alert.
  273. Electronically signed by XXX, XXX X  , RN at 4/14/2013 10:24 PM
  274. XXX, XXX X  , RN (Registered Nurse) 4/14/2013 21:56 Emergency
  275. Pt. Awake, alert, playful/interactive, Family member (not father/mother) escorted Pt. To xray wit PT.- Xray tech requesting father not accompany Pt. MOther and father remain in room with temporary caregiver. Family members all calm, cooperative. Per social work, mother and father have to be granted rights to see and be part of Pt.'s care, still remain legal guardians of Pt.
  276. Electronically signed by XXX, XXX X  , RN at 4/14/2013 9:56 PM
  277. XXX, XXX X  , RN (Registered Nurse) 4/14/2013 21:24 Emergency
  278. Skeletal survey to be repeated - contacted social work and ED NP, birth parents at BS -if issues arise, can be removed if violent Family aware.
  279.  
  280.  
  281.  
  282. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  283. Hospital Abstract
  284. PATIENTJR.,OUTPATIENT
  285. MRN: 00000000
  286. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  287. ED Records (continued)
  288. Electronically signed by XXX, XXX X  , RN at 4/14/2013 9:24 PM
  289. XXX, XXX X  , RN (Registered Nurse) 4/14/2013 20:13 Emergency
  290. ADMIT TO ED -
  291. Patient placed in exam room without difficulty. Family provided with orientation of exam room's phone and call
  292. bell. Patient instructed to undress and put on patient gown. Caregiver was at bedside. Side rails were up.
  293. ID (& allergy, if applicable) band on patient:yes
  294. Eligible to Complete Behavioral_Health_Screen: no
  295. Isolation Required:no
  296. Pain Assessment Complete:yes
  297. Barriers to Learning: None
  298. Pt. Awake, alert, acting normally, last PO intake at 1830, POs gentle ease similac, cousin states that Pt.'s older siblings have reported abuse, parents were arrested for allegedly duct taping older child out in front of house, reportedly other children with bite marks all over child. Cousin reports that she had never visualized the Pt. Until he was 4 months old because was there may have been question of paternity? Pt. Skull does not look any more mishapen than when she initially visualized him, states that baby is always in car seat, and feels head may be mishapen due to where head has been rubbing - hair loss in that area. Pt. Moving all extremities, lungs = CTA, abdomen = soft, ND. Per cousin, Pt.'s father on medication and diagnosed schitsophrenic, Pt.'s mother currently pregnant with another child.
  299. Electronically signed by XXX, XXX X  , RN at 4/14/2013 8:13 PM
  300. XXX, XXX, RN (Registered Nurse)	4/14/2013 19:57 Emergency
  301. ADMIT TO ED -
  302. Patient placed in exam room without difficulty. Family provided with orientation of exam room's phone and call
  303. bell. Patient instructed to undress and put on patient gown. Caregiver was at bedside. Side rails were up.
  304. ID (& allergy, if applicable) band on patient:yes
  305. Eligible to Complete Behavioral_Health_Screen: not applicable
  306. Isolation Required:not applicable
  307. Pain Assessment Complete:yes
  308. Barriers to Learning: None
  309. Cousin at bedside
  310. Patient awake, alert, interactive.
  311. Electronically signed by XXX, XXX, RN at 4/14/2013 7:57 PM
  312.  
  313.  
  314. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  315. Hospital Abstract
  316. PATIENTJR.,OUTPATIENT
  317. MRN: 00000000
  318. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  319. ED Records (continued)
  320. XXX, XXX, RN (Registered Nurse)	4/14/2013 19:56 Emergency
  321. ED TRIAGE NOTE 
  322. HPI:
  323. 6 mo, cousin brought pt in for suspected abuse.
  324. Pts are schizophrenic and arrested last night for abuse of another child.
  325. Bruise on buttocks-could be mongolian spot. R side of head is flat.
  326. HCT cortical foci are prominent and are not sure what to make of this finding
  327. Skeletal survey negative
  328. 8,8kg
  329. Appears well, eating, drinking, +wet diapers, a little interactive
  330. Case worker is on it and will fill out abuse form
  331. Prehospital Care: CT scan, skeletal survey
  332. Behavioral Health History: No known behavioral history Additional Notes/Parent Reported Medical Problems:
  333. Electronically signed by XXX, XXX, RN at 4/14/2013 7:56 PM
  334. Benecke, Sandra (Communication Specialist) 4/14/2013 19:51 Emergency
  335. COMMSPEC COMPLETE in EPIC
  336. Electronically signed by Benecke, Sandra at 4/14/2013 7:51 PM
  337. XXX, XXX, RN (Registered Nurse) 4/14/2013 18:57 Emergency
  338. Report from outside hospital
  339. Brought to outside hospital by cousin's, pt's parents were arrested last evening for alleged abuse of another
  340. child
  341. Bruising on buttocks & bridge of nose
  342. Head CT abnormal w/ prominent cortical sulci, no bleed
  343. No known medical problems
  344. Awake, alert, smiling
  345. Immunizations UTD, no surgeries
  346. 2 adult cousins are coming with pt.
  347.  
  348.  
  349.  
  350. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  351. Hospital Abstract
  352. PATIENTJR.,OUTPATIENT
  353. MRN: 00000000
  354. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  355. ED Records (continued)
  356. Electronically signed by XXX, XXX, RN at 4/14/2013 6:57 PM
  357. Monroe-Singletary, Shonda (OTHER) 4/14/2013 18:52 Emergency
  358. Nursing report on park 1 Referring RN:Amber
  359. Receiving RN: Kelly	.
  360. Electronically signed by Monroe-Singletary, Shonda at 4/14/2013 6:52 PM
  361. XXXXXX, XXX (Communication Specialist) 4/14/2013 18:49 Emergency
  362. ED CHARGE PAGED FOR REPORT
  363. Electronically signed byXXXXXX, XXX at 4/14/2013 6:49 PM
  364. XXXXXX, XXX, RN (Registered Nurse) 4/14/2013 18:35 Emergency
  365. Referring will arrange transport BLS. Copies of scans will come with pt.
  366. Electronically signed by XXXXXX, XXX, RN at 4/14/2013 6:35 PM
  367. XXXXXX, XXX, RN (Registered Nurse) 4/14/2013 18:33 Emergency
  368. XXXXXX, XXX accepts to ED
  369. Electronically signed by XXXXXX, XXX, RN at 4/14/2013 6:33 PM
  370. XXXXXX, XXX, RN (Registered Nurse) 4/14/2013 18:24 Emergency
  371. Reported Vital Signs
  372.  
  373.  
  374.  
  375.  
  376.  
  377. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  378. Hospital Abstract
  379. PATIENTJR.,OUTPATIENT
  380. MRN: 00000000
  381. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  382. ED Records (continued)
  383.  
  384. 32
  385.  
  386. ra
  387.  
  388.  
  389.  
  390. 6 mo, cousin brought pt in for suspected abuse.
  391. Pts are schizophrenic and arrested last night for abuse of another child.
  392. Bruise on buttocks-could be mongolian spot. R side of head is flat.
  393. HCT cortical foci are prominent and are not sure what to make of this finding
  394. Skeletal survey negative
  395. 8,8kg
  396. Appears well, eating, drinking, +wet diapers, a little interactive
  397. Case worker is on it and will fill out abuse form
  398. Will copy studies
  399. Electronically signed by XXXXXX, XXX, RN at 4/14/2013 6:24 PM
  400. Follow-up Information	Patient: XXXXXX
  401. JR.,OUTPATIENT	MRN: 00000000
  402. Follow up With	Details	Comments	Contact Info
  403. Network, Drexel Hill Care	Schedule an appointment as 3-5 days if symptoms
  404. soon as possible for a visit	worsen 
  405. in 3 day(s)
  406. Imaging / Wet Read Results
  407. XR Skeletal Survey Trauma (Final result)	Abnormal	Result time:4/15/13 0317
  408. Final result by Intfusr, Inc Rad Res (04/14/13 23:51:58) Impression:
  409. Concern for a buckle fracture in the proximal right tibial metaphysis. Recommend repeat skeletal survey in 2 weeks to evaluate for interval change. No other acute or healing fracture seen.
  410. Narrative:
  411. Examination: Skeletal survey including AP/lateral/Townes views of the skull, AP radiographs of the humeri/forearm/femurs/tibias and fibulas, lateral radiographs of spine, AP and bilateral oblique radiographs of the chest, AP radiograph of the abdomen, AP radiographs of the hands and feet, lateral radiograph of the right tibia/fibula.
  412. INDICATION: Suspected abuse, plagiocephaly COMPARISON: None
  413. FINDINGS:
  414. There is a focal area along the medial aspect of the proximal
  415. right tibial metaphysis which demonstrates a subtle convex medial cortical irregularity. This is not visible on the lateral view.
  416.  
  417.  
  418.  
  419. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  420. Hospital Abstract
  421. PATIENTJR.,OUTPATIENT
  422. MRN: 00000000
  423. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  424. ED Records (continued)
  425. Imaging / Wet Read Results (continued)
  426. The other visualized bones appear intact. Lungs are clear. The bowel gas pattern demonstrates moderate stool without evidence of obstruction. Mediastinal contours are within normal limits.
  427. Preliminary result by Intfusr, Inc Rad Res (04/14/13 23:33:53) Impression:
  428. Narrative:
  429. Preliminary report for accession number 4482664 has been dictated by Mark Halverson. Final Report pending review by Sudha Anupindi.
  430. CT Neuro Outside Exam Second Read (Final result)	Result time:4/14/13 2114
  431. Final result by Intfusr, Inc Rad Res (04/14/13 21:14:56) Impression:
  432. Patient motion somewhat limits the examination.
  433. 1. No acute intracranial hemorrhage.
  434. 2. The CSF attenuation region adjacent to the left cerebellar
  435. hemisphere may reflect asymmetric CSF spaces or an arachnoid cyst. It is also possible that this reflects the result of a remote
  436. hemorrhage.
  437. 3. Prominent extra axial spaces, non specific and possibly related to immaturity.
  438.   Discussed with Sue Campisciano at 9:05 pm on 4/14/2013. Narrative:
  439. SECOND OPINION OF OUTSIDE CT OF WITHOUT CONTRAST PERFORMED AT
  440.  
  441.  
  442. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  443. Hospital Abstract
  444. PATIENTJR.,OUTPATIENT
  445. MRN: 00000000
  446. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  447. ED Records (continued)
  448. Imaging / Wet Read Results (continued)
  449. DELAWARE COUNTY HOSPITAL, AT THE REQUEST OF DR. PAWEL: INDICATION: Possible trauma
  450. COMPARISON: None
  451. Technique: This is an outside institution examination submitted for consultation. The images are labeled as having been performed at Delaware County Memorial Hospital, dated 4/14/2013 at 1724 hours. The study consists of 5 mm axial CT images from vertex to below the skull base without contrast administration.
  452. FINDINGS:
  453. The study is degraded by patient motion. There is no evidence of acute parenchymal hemorrhage or midline shift. Ventricular size is normal. Basilar cisterns are not effaced. No extra-axial fluid collection is visible.
  454. There is a crescent of CSF attenuation along the lateral margin of the left cerebellar hemisphere which is asymmetric and about 1cm in maximum thickness.
  455. The extra-axial spaces in general are somewhat prominent prominent CSF space in the bifrontal regions mild prominence of the sylvian fissures.
  456. The sutures do not appear widened. The right occipital region is somewhat flattened secondary to probable posterior postural plagiocephaly. No fracture is visible. The left mastoid cells are opacified. Adenoidal tissue is prominent.
  457. Preliminary result by Intfusr, Inc Rad Res (04/14/13 21:11:56) Impression:
  458. Narrative:
  459. Preliminary report for accession number 4482636 has been dictated by Mark Halverson. Final Report pending review by Avrum Pollock.
  460.  
  461.  
  462.  
  463. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  464. Hospital Abstract
  465. PATIENTJR.,OUTPATIENT
  466. MRN: 00000000
  467. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  468. ED Records (continued)
  469. Imaging / Wet Read Results (continued)
  470. Preliminary result by Intfusr, Inc Rad Res (04/14/13 20:51:52) Impression:
  471. Narrative:
  472. Preliminary report for accession number 4482636 has been dictated by Mark Halverson. Final Report pending review by Avrum Pollock.
  473.  
  474.  
  475.  
  476. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  477. Hospital Abstract
  478. PATIENTJR.,OUTPATIENT
  479. MRN: 00000000
  480. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  481. ED Records (continued)
  482. Imaging / Wet Read Results (continued)
  483. XR Other Outside Exam Second Read (Final result)	Result time:4/14/13 2054
  484. Final result by Intfusr, Inc Rad Res (04/14/13 20:54:57) Impression:
  485. This study does not constitute an adequate skeletal survey. No visible fracture.
  486. Narrative:
  487. Examination: Skeletal survey (outside institution examination submitted for consultation)
  488. INDICATION: The emergency room note in the electronic medical record documents a history of possible nonaccidental trauma, buttock region bruise
  489. COMPARISON: None
  490. Technique: This is an outside institution examination submitted for consultation. The images are labeled as having been performed at Delaware County Memorial Hospital. Images include a frontal radiograph of the chest and abdomen, frontal radiograph of the chest and upper extremities, frontal radiograph of the lower extremities, lateral radiograph of the skull.
  491. FINDINGS:
  492. This study does not constitute an adequate skeletal survey. The lateral radiograph of the skull does not include the entire skull and field-of-view. A large field of view radiograph including the entire lower extremities and upper extremities on a single view is not adequate.
  493. The lungs demonstrate no focal consolidation. Heart size is normal.
  494. The bowel gas pattern demonstrates no evidence of obstruction. No fracture is visible.
  495. Preliminary result by Intfusr, Inc Rad Res (04/14/13 20:42:41) Impression:
  496.  
  497.  
  498.  
  499. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  500. Hospital Abstract
  501. PATIENTJR.,OUTPATIENT
  502. MRN: 00000000
  503. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  504. ED Records (continued)
  505. Imaging / Wet Read Results (continued)
  506. Narrative:
  507. Preliminary report for accession number 4482638 has been dictated by Mark Halverson. Final Report pending review by Teresa Victoria.
  508. Discharge Summary
  509. D/C Summaries signed by Parikh, Vidhi, MD at 04/15/13 0307
  510. Author: Parikh, Vidhi, MD	Service:	Emergency	Author	Resident
  511. Type:
  512. Filed:	04/15/13 0307	Note	04/15/13 0303
  513. Time:
  514. Patient was transitioned to me from NP. Found to have a buckle fracture of the right proximal tibia. Ortho was called and recommended that patient get a long leg cast, should be non weight bearing, and follow up with ortho in 1-2 weeks with Dr. Baldwin. Patient also with an abnormal CT scan. Family notified regarding need for an MRI. Will discharge under custody of temporary guardians
  515.  
  516.  
  517. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  518. Hospital Abstract
  519. PATIENTJR.,OUTPATIENT
  520. MRN: 00000000
  521. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  522. Discharge Summary (continued)
  523. Electronically signed by Parikh, Vidhi, MD on 4/15/2013 3:07 AM
  524. Consults
  525. Consult Note signed by Baldwin, Keith, MD at 04/20/13 0758
  526. Author: Baldwin, Keith, MD	Service:	Emergency	Author	Physician
  527. Type:
  528. Filed:	04/20/13 0758	Note	04/14/13 2149
  529. Time:
  530. Related Original Note by: Black, John D, MD filed at 04/16/13 1455 Notes:
  531. The Children's Hospital of Philadelphia
  532. Date Of Service: April 16, 2013
  533. Name: Outpatient PatientJr. MRN: 00000000
  534. The Orthopaedic Service was asked to see Outpatient PatientJr. in consultation.
  535. ORTHOPAEDIC CONSULT NOTE 
  536. HISTORY OF PRESENT ILLNESS 
  537. (Please address 4 or more of the following categories in your HPI)
  538. Location, Severity/Pain, Timing, Modify factors, Duration, Associated signs and symptoms, Quality
  539. Reason For Consult Today
  540. 6 month old male presents with pain R leg, not crawling well. Reportedly pt lives in home where parents were recently arrested. Pt brought in by cousins. No known mechanism. Pt behaving normally in ED- eating, drinking. Pt noted to have red bruised areas on buttocks and trunk. Transferred from OSH for non-accidental trauma work-up 
  541.  
  542. Past Medical History
  543.  
  544. Birth History:
  545. Birth History
  546.  
  547.  
  548.  
  549. Birth Length
  550. Birth Weight
  551. Gestational
  552.  
  553.  
  554.  
  555. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  556. Hospital Abstract
  557. PATIENTJR.,OUTPATIENT
  558. MRN: 00000000
  559. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  560. Consults (continued)
  561.  
  562.  
  563. Age
  564.  
  565. 0.533 m	3.33 kg
  566. Discharge Weight
  567. 40 weeks
  568.  
  569. 3.26 kg
  570. Comment: Passed hearing Both hears
  571.  
  572. Past Medical History:
  573. No past medical history on file.
  574.  
  575. Prior Surgeries:
  576. No past surgical history on file.
  577.  
  578.  
  579. Family Health History
  580. List any pertinent family history in patient's immediate family and the family members affected:
  581. None
  582.  
  583. Social History
  584. The child lives with the
  585. Unable to access
  586.  
  587. REVIEW OF SYSTEMS
  588.  
  589. Constitutional: Normal
  590. Musculoskeletal: Per HPI
  591. Eyes: Normal
  592. Neurologic: Normal
  593. Ears/Nose/Throat: Normal
  594. Endocrine: Normal
  595. Respiratory: Normal
  596. Hematologic: Normal
  597. Cardiovascular: Normal
  598. Immunologic: Normal
  599. Gastrointestinal: Normal
  600. Psych/Development: Normal
  601. Genitourinary: Normal
  602. Integumentary/Skin: Normal
  603. Other: n/a
  604.  
  605. Physical Exam 
  606.  
  607.  
  608. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  609. Hospital Abstract
  610. PATIENTJR.,OUTPATIENT
  611. MRN: 00000000
  612. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  613. Consults (continued)
  614.  
  615.  
  616. EXAMINATION
  617. Constitutional
  618. BP 92/64 | Pulse 118 | Temp 37 ∞C | Resp 26 | Wt 9.2 kg | SpO2 100%
  619. Appearance
  620. Well appearing
  621. Psych
  622. Age appropriate behavior
  623. Eyes
  624. Normal
  625. Head, Ears, Nose, Mouth, Throat
  626. Normal
  627. Respiratory
  628. Normal
  629. Cardiovascular
  630. Intact distal pulses, capillary refill less than 2 seconds in all extremities
  631. Abdominal/GI
  632. Normal
  633. Neurological
  634. Normal
  635. Hem/Lymph
  636. N/A
  637. Skin
  638. Abnormal, see Musculoskeletal exam for complete details for abnormal findings
  639. Musculoskeletal
  640. RUE:
  641. Observation:No gross deformity
  642. Palpatation:Non-tender to palpatation
  643. ROM:Normal ROM without pain
  644. Stability:No gross instability
  645. Sensation:Intact to light touch to radial, median, and ulnar nerves
  646. Motor:Anterior interosseus, posterior interossus, radial, median, and
  647. ulnar nerves are intact
  648. Vascular:Palpable radial pulse, brisk capillary refill
  649. Swelling:No obvious swelling or ecchymosis
  650. Skin:Intact
  651. Compartments:Soft and compressible, no pain with passive stretch
  652. Dressing/Incision/Cast/Splint: N/A
  653. LUE:
  654. Observation:No gross deformity
  655. Palpatation:Non-tender to palpatation
  656. ROM:Normal ROM without pain
  657. Stability:No gross instability
  658. Sensation:Intact to light touch to radial, median, and ulnar nerves
  659. Motor:Anterior interosseus, posterior interossus, radial, median, and
  660. ulnar nerves are intact
  661. Vascular:Palpable radial pulse, brisk capillary refill
  662. Swelling:No obvious swelling or ecchymosis
  663. Skin:Intact
  664. Compartments:Soft and compressible, no pain with passive stretch
  665. Dressing/Incision/Cast/Splint:N/A
  666. RLE:
  667.  
  668.  
  669.  
  670. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  671. Hospital Abstract
  672. PATIENTJR.,OUTPATIENT
  673. MRN: 00000000
  674. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  675. Consults (continued)
  676. Observation:No gross deformity
  677. Palpatation:Abnormal +tender to proximal tibia
  678. ROM:Normal ROM without pain
  679. Stability:No gross instability
  680. Sensation:Intact to light touch over the superficial peroneal, deep
  681. peroneal, saphenous, sural, and tibial nerves.
  682. Motor:Intact extensor hallicus longus, flexor hallicus longus, tibialis
  683. anterior, gastrocnemius soleus complex
  684. Vascular:Palpable dorsalis pedis pulse
  685. Skin:Intact
  686. Compartments:Soft and compressible, no pain with passive stretch
  687. Dressing/Incision/Cast/Splint:N/A
  688. LLE:
  689. Observation:No gross deformity
  690. Palpatation:Non-tender to palpatation
  691. ROM:Normal ROM without pain
  692. Stability:No gross instability
  693. Sensation:Intact to light touch over the superficial peroneal, deep
  694. peroneal, saphenous, sural, and tibial nerves.
  695. Motor:Intact extensor hallicus longus, flexor hallicus longus, tibialis
  696. anterior, gastrocnemius soleus complex
  697. Vascular:Palpable dorsalis pedis pulse
  698. Skin:Intact
  699. Compartments:Soft and compressible, no pain with passive stretch
  700. Dressing/Incision/Cast/Splint:N/A
  701. SPINE:
  702. Observation:No gross deformity
  703. Palpatation:Non-tender to palpatation
  704. ROM:Normal ROM without pain
  705. Reflexes:Not examined
  706. Motor:Upper and lower extremity strength is normal
  707. Sensation:Sensation intact C5-T1 bilaterally, sensation intact L2-S1
  708. bilaterally
  709. Skin:Intact
  710. Dressing/Incision/Cast/Splint:N/A
  711. Radiology Studies: I have personally reviewed all relevant imaging and agree with the radiology report noting R proximal tibia buckle fx, negative skeletal survey
  712. Labs:
  713.  
  714.  
  715.  
  716. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  717. Hospital Abstract
  718. PATIENTJR.,OUTPATIENT
  719. MRN: 00000000
  720. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  721. Consults (continued)
  722. Procedure:
  723. Long-leg cast applied
  724. Pertinent Drawing/Photo:
  725. Assessment and Plan: 6 month old male with R proximal tibia buckle fx
  726. Pain Control: oral
  727. Weight Bearing: None Right Lower Extremity Physical Therapy/Occupational Therapy: n/a Diet: Advance
  728. F/u with Dr. Baldwin 1-2 weeks for repeat XR
  729. Electronically signed: John D. Black, MD
  730. 4/14/2013	9:49PM
  731. I have reviewed the note on Outpatient PatientJr. and agree with the resident/fellow's assessment and plan. Keith Baldwin, MD
  732. 4/20/2013 7:58 AM
  733. Keith Baldwin, MD, MPH
  734. Assistant Professor, Orthopedic Surgery Neuromuscular Diseases and Trauma The Children's Hospital of Philadelphia
  735. Electronically signed by Baldwin, Keith, MD on 4/20/2013 7:58 AM
  736. 04/14/13 2149 Consult Note signed by Black, John D, MD
  737. Lab Results
  738.  
  739.  
  740. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  741. Hospital Abstract
  742. PATIENTJR.,OUTPATIENT
  743. MRN: 00000000
  744. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  745. Lab Results (continued)
  746. Vitamin D 25OH [60460386]	Resulted: 04/16/13 1733, Result Status: Final
  747. result
  748. Ordering	XXXXXX, XXX, CRNP 04/15/13	Resulting Lab: HOSPITAL LAB
  749. Provider:	0053
  750. Specimen	Blood 04/15/13 0105
  751. Collection
  752.   Component	Value	Ref Range	Flag Comment	Lab
  753. Vitamin D 25OH 34.7	ng/mL
  754. Comment:	TOTAL 25-HYDROXYVITAMIN D2 AND D3 (25-OH-VITD)
  755. < 10 ng/mL ( severe deficiency )+
  756. 10 - 24 ng/mL ( mild to moderate deficiency)++
  757. 25 - 80 ng/mL ( optimum levels)+++
  758. > 80 ng/mL ( toxicity possible )++++
  759. + Could be associated with osteomalacia or rickets
  760. ++ May be associated with increased risk of osteoporosis
  761. or secondary hyperparathyroidism
  762. +++ Optimum levels in the normal population
  763. ++++ 80 ng/mL is the lowest reported level associated with
  764. toxicity in patients without primary
  765. hyperparathyroidism who have normal renal function.
  766. Most patients with toxicity have levels >150 ng/mL.
  767. Patients with renal failure can have very high
  768. 25-OH-VitD levels without signs of toxicity, as renal
  769. conversion to the active hormone 1,25-OH VitD is
  770. impaired or absent.
  771. These reference ranges represent clinical decision
  772. values that apply to males and females of all ages,
  773. rather than population-based reference values.
  774. Population reference ranges for 25-OH-VitD vary
  775. widely depending on ethnic background, age, geographic
  776. location of the studied populations, and the
  777. sampling-season. Population-based ranges correlate
  778. poorly with serum 25-OH-VitD concentrations that are
  779. associated with biologically and clinically relevant
  780. Vitamin D effects and are therefore of limited clinical
  781. value.
  782. "This test was developed and its performance characteristics
  783. determined by the Children's Hospital of Philadelphia
  784. Clinical Chemistry Laboratory. It has not been cleared or
  785. approved by the U.S. Food and Drug Administration (FDA). The
  786. FDA has determined that such clearance or approval is not
  787. necessary. This laboratory is certified under the Clinical
  788. Laboratory Improvement Amendments of 1988 (CLIA-88) as
  789. qualified to perform high-complexity clinical laboratory
  790. testing."
  791. Parathyroid Hormone Intact [60460385] (Abnormal)	Resulted: 04/15/13 1204, Result Status: Final
  792. result
  793. Ordering	XXXXXX, XXX, CRNP 04/15/13	Resulting Lab: HOSPITAL LAB
  794. Provider:	0053
  795. Specimen	Blood 04/15/13 0105
  796.  
  797.  
  798.  
  799. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  800. Hospital Abstract
  801. PATIENTJR.,OUTPATIENT
  802. MRN: 00000000
  803. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  804. Lab Results (continued)
  805. Parathyroid Hormone Intact [60460385] (Abnormal) (continued)	Resulted: 04/15/13 1204, Result Status: Final
  806. result
  807. Collection
  808.   Component	Value	Ref Range	Flag Comment	Lab
  809. Intact PTH	7.94	9-56 pg/mL	L	-
  810. Potassium [60460394]	Resulted: 04/15/13 0140, Result Status: Final
  811. result
  812. Resulting Lab: HOSPITAL LAB	Specimen	04/15/13 0105
  813. Collection
  814. Component	Value	Ref Range	Flag Comment	Lab
  815. Potassium	5.2	4.1-5.8 mmol/L	-
  816. Phosphorus [60460396]	Resulted: 04/15/13 0140, Result Status: Final
  817. result
  818. Resulting Lab: HOSPITAL LAB	Specimen	04/15/13 0105
  819. Collection
  820. Component	Value	Ref Range	Flag Comment	Lab
  821. Phosphorus	6.6	4.8-8.2 mg/dL	-
  822. PTT Profile [60460378]	Resulted: 04/15/13 0138, Result Status: Final
  823. result
  824. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulting Lab: HOSPITAL LAB
  825. Provider:	2234
  826. Specimen	Blood 04/15/13 0105
  827. Collection
  828. Component	Value	Ref Range	Flag Comment	Lab
  829. Partial	31.0	22.0-36.0	-
  830. Thromboplastin	SECS
  831. PT/INR [60460377]	Resulted: 04/15/13 0136, Result Status: Final
  832. result
  833. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulting Lab: HOSPITAL LAB
  834. Provider:	2234
  835. Specimen	Blood 04/15/13 0105
  836. Collection
  837. Component	Value	Ref Range	Flag Comment	Lab
  838. Int Normalized	1.03	-
  839. Ratio Test
  840. Prothrombin	13.0	11.6-13.8	-
  841. Time	SECS
  842.  
  843.  
  844.  
  845. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  846. Hospital Abstract
  847. PATIENTJR.,OUTPATIENT
  848. MRN: 00000000
  849. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  850. Lab Results (continued)
  851. GGT [60460381] (Abnormal)	Resulted: 04/14/13 2342, Result Status: Final
  852. result
  853. Resulting Lab: HOSPITAL LAB	Specimen	04/14/13 2240
  854. Collection
  855. Component	Value	Ref Range	Flag Comment	Lab
  856. Gamma	15	17-126 U/L	L	-
  857. Glutamyl Transferase
  858. Basic Metabolic Panel [60460373] (Abnormal)	Resulted: 04/14/13 2334, Result Status: Final
  859. result
  860.  
  861. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulting Lab:
  862. Provider:	2233
  863. Specimen	Blood 04/14/13 2240
  864. Collection
  865. HOSPITAL LAB
  866.  
  867. Component
  868. Value
  869. Ref Range
  870. Flag
  871. Comment
  872. Lab
  873. Sodium
  874. 136
  875. 133-140 
  876. mmol/L
  877.  
  878. -
  879.  
  880. Potassium
  881. 6.3
  882. 4.1-5.8 mmol/L
  883. H
  884. -
  885.  
  886. Chloride
  887. 102
  888. 96-106 mmol/L
  889.  
  890. -
  891.  
  892. Carbon Dioxide
  893. 19
  894. 20-26 mmol/L
  895. L
  896. -
  897.  
  898. Urea Nitrogen
  899. 9
  900. 2-19 mg/dL
  901.  
  902. -
  903.  
  904. Creatinine
  905. 0.1
  906. 0.1-0.4 mg/dL
  907.  
  908. -
  909.  
  910. Glucose
  911. 95
  912. 74-127 mg/dL
  913.  
  914. -
  915.  
  916. Calcium
  917. 10.1
  918. 9.2-10.4 mg/dL
  919.  
  920. -
  921.  
  922.  
  923. Hepatic Function Panel [60460374] (Abnormal)	Resulted: 04/14/13 2334, Result Status: Final
  924. result
  925.  
  926. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulting Lab:
  927. Provider:	2233
  928. Specimen	Blood 04/14/13 2240
  929. Collection
  930. HOSPITAL LAB
  931.  
  932. Component
  933. Value
  934. Ref Range
  935. Flag
  936. Comment
  937. Lab
  938. Total Bilirubin
  939. 0.9
  940. 0.6-1.4 mg/dL
  941.  
  942. -
  943.  
  944. Bilirubin
  945. 0.3
  946. 0.2-1.0 mg/dL
  947.  
  948. -
  949.  
  950. Unconjugated
  951.  
  952.  
  953.  
  954.  
  955.  
  956. Bilirubin,Direct
  957. 0.6
  958. 0.00-0.3 mg/dL
  959. H
  960. -
  961.  
  962. (Calculated)
  963.  
  964.  
  965.  
  966.  
  967.  
  968. Bilirubin
  969. 0.0
  970. 0.0-0.3 mg/dL
  971.  
  972. -
  973.  
  974. Conjugated
  975.  
  976.  
  977.  
  978.  
  979.  
  980. Total Protein
  981. 6.9
  982. 5.4-7.0 g/dL
  983.  
  984. -
  985.  
  986. Albumin
  987. 4.8
  988. 3.1-4.2 g/dL
  989. H
  990. -
  991.  
  992. Alkaline
  993. 179
  994. 70-345 U/L
  995.  
  996. -
  997.  
  998. Phosphatase
  999.  
  1000.  
  1001.  
  1002.  
  1003.  
  1004. Alanine
  1005. 26
  1006. 12-42 U/L
  1007.  
  1008. -
  1009.  
  1010. Aminotransferas e
  1011.  
  1012.  
  1013.  
  1014.  
  1015.  
  1016.  
  1017.  
  1018.  
  1019. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  1020. Hospital Abstract
  1021. PATIENTJR.,OUTPATIENT
  1022. MRN: 00000000
  1023. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  1024. Lab Results (continued)
  1025. Hepatic Function Panel [60460374] (Abnormal) (continued)	Resulted: 04/14/13 2334, Result Status: Final
  1026. result
  1027. Aspartate	67	20-64 U/L	H	-
  1028. Aminotransferas e
  1029. Amylase [60460375]	Resulted: 04/14/13 2334, Result Status: Final
  1030. result
  1031. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulting Lab: HOSPITAL LAB
  1032. Provider:	2234
  1033. Specimen	Blood 04/14/13 2240
  1034. Collection
  1035. Component	Value	Ref Range	Flag Comment	Lab
  1036. Amylase	<30	0-80 U/L	-
  1037. Lipase [60460376]	Resulted: 04/14/13 2334, Result Status: Final
  1038. result
  1039. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulting Lab: HOSPITAL LAB
  1040. Provider:	2234
  1041. Specimen	Blood 04/14/13 2240
  1042. Collection
  1043. Component	Value	Ref Range	Flag Comment	Lab
  1044. Lipase	75	10-115 U/L	-
  1045. Urinalysis w/o Microscopic [60460379] (Abnormal)	Resulted: 04/14/13 2329, Result Status: Final
  1046. result
  1047. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulting Lab: HOSPITAL LAB
  1048. Provider:	2234
  1049. Specimen	Urine clean catch; Urine 04/14/13 2315
  1050. Collection
  1051. Narrative:	Source: Urine
  1052. Component	Value	Ref Range	Flag Comment	Lab
  1053. Urine Color	Light-Yellow	-
  1054. Urine Sediment CLEAR	-
  1055. Urine Sugar	NEGATIVE	NEGATIVE	-
  1056. mg/dl
  1057. UR Protein	NEGATIVE	NEGATIVE	-
  1058. mg/dL
  1059. UR Bilirubin	NEGATIVE	NEGATIVE	-
  1060. UR Urobilinogen <2.0	<2.0 mg/dl	-
  1061. UR pH	6.0	4.8-7.8	-
  1062. UR Blood	NEGATIVE	NEGATIVE	-
  1063. UR Ketones	NEGATIVE	NEGATIVE	-
  1064. mg/dL
  1065. UR Nitrite	NEGATIVE	NEGATIVE	-
  1066.  
  1067.  
  1068. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  1069. Hospital Abstract
  1070. PATIENTJR.,OUTPATIENT
  1071. MRN: 00000000
  1072. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  1073. Lab Results (continued)
  1074. Urinalysis w/o Microscopic [60460379] (Abnormal) (continued)	Resulted: 04/14/13 2329, Result Status: Final
  1075. result
  1076. UR Leukocytes NEGATIVE	NEGATIVE	-
  1077. UR Specific	1.002	1.003-1.035	L	- 
  1078. Gravity
  1079. CBC with Diff [60460372] (Abnormal)	Resulted: 04/14/13 2319, Result Status: Final
  1080. result
  1081. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulting Lab: HOSPITAL LAB
  1082. Provider:	2233
  1083. Specimen	Blood 04/14/13 2240
  1084. Collection
  1085. Component
  1086.  
  1087.  
  1088.  
  1089. Comment:	THIS ANALYZER MAY FAIL TO DETECT BLASTS IN SOME PATIENT'S
  1090. SAMPLES. IF YOU SUSPECT BLASTS, BUT THEY ARE NOT REPORTED IN THE AUTOMATED DIFFERENTIAL COUNT, PLEASE CONTACT THE HEMATOLOGY LABORATORY (EXT 41777) TO PERFORM A MANUAL DIFFERENTIAL COUNT.
  1091. Platelet Estimate Not Done	-
  1092.  
  1093.  
  1094.  
  1095. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  1096. Hospital Abstract
  1097. PATIENTJR.,OUTPATIENT
  1098. MRN: 00000000
  1099. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  1100. Lab Results (continued)
  1101. CBC with Diff [60460372] (Abnormal) (continued)	Resulted: 04/14/13 2319, Result Status: Final
  1102. result
  1103. Testing Performed By
  1104. Lab - Abbreviation	Name	Director	Address	Valid Date Range
  1105. 7 - Unknown	HOSPITAL LAB	Unknown	3401 CIVIC CENTER 06/04/01 0000 - Present
  1106. BLVD
  1107. PHILADELPHIA PA
  1108. 19104
  1109. Imaging Results
  1110. XR Skeletal Survey Trauma [60460359] (Abnormal)	Resulted: 04/15/13 0317, Result Status: Final
  1111. result
  1112. Ordering	XXXXXX, XXX, CRNP 04/14/13	Resulted by:	Anupindi, Sudha, MD
  1113. Provider:	2110	Halverson, Mark R, MD
  1114. Performed:	04/14/13 2200 - 04/14/13 2214	Resulting Lab: CHOP RADIOLOGY
  1115. Specimen	04/14/13 2333 
  1116. Collection
  1117. Narrative:	Examination: Skeletal survey including AP/lateral/Townes views of
  1118. the skull, AP radiographs of the humeri/forearm/femurs/tibias and fibulas, lateral radiographs of spine, AP and bilateral oblique radiographs of the chest, AP radiograph of the abdomen, AP radiographs of the hands and feet, lateral radiograph of the right tibia/fibula.
  1119. INDICATION: Suspected abuse, plagiocephaly COMPARISON: None
  1120. FINDINGS:
  1121. There is a focal area along the medial aspect of the proximal
  1122. right tibial metaphysis which demonstrates a subtle convex medial cortical irregularity. This is not visible on the lateral view.
  1123. The other visualized bones appear intact. Lungs are clear. The bowel gas pattern demonstrates moderate stool without evidence of obstruction. Mediastinal contours are within normal limits.
  1124. Impression:
  1125. Concern for a buckle fracture in the proximal right tibial metaphysis. Recommend repeat skeletal survey in 2 weeks to evaluate for interval change. No other acute or healing fracture seen.
  1126. CT Neuro Outside Exam Second Read [59614682]	Resulted: 04/14/13 2114, Result Status: Final
  1127. result
  1128. Ordering	Pawel, Barbara, MD 04/14/13 2013	Resulted by:	Pollock, Avrum, MD
  1129. Provider:	Halverson, Mark R, MD
  1130. Performed:	- 04/14/13 2013	Resulting Lab: CHOP RADIOLOGY
  1131.  
  1132.  
  1133. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  1134. Hospital Abstract
  1135. PATIENTJR.,OUTPATIENT
  1136. MRN: 00000000
  1137. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  1138. Imaging Results (continued)
  1139. CT Neuro Outside Exam Second Read [59614682] (continued)	Resulted: 04/14/13 2114, Result Status: Final
  1140. result
  1141. Specimen	04/14/13 2051
  1142. Collection
  1143. Narrative:	SECOND OPINION OF OUTSIDE CT OF WITHOUT CONTRAST PERFORMED AT 
  1144. DELAWARE COUNTY HOSPITAL, AT THE REQUEST OF DR. PAWEL:
  1145. INDICATION: Possible trauma COMPARISON: None
  1146. Technique: This is an outside institution examination submitted for consultation. The images are labeled as having been performed at Delaware County Memorial Hospital, dated 4/14/2013 at 1724 hours. The study consists of 5 mm axial CT images from vertex to below the skull base without contrast administration.
  1147. FINDINGS:
  1148. The study is degraded by patient motion. There is no evidence of acute parenchymal hemorrhage or midline shift. Ventricular size is normal. Basilar cisterns are not effaced. No extra-axial fluid collection is visible.
  1149. There is a crescent of CSF attenuation along the lateral margin of the left cerebellar hemisphere which is asymmetric and about 1cm in maximum thickness.
  1150. The extra-axial spaces in general are somewhat prominent prominent CSF space in the bifrontal regions mild prominence of the sylvian fissures.
  1151. The sutures do not appear widened. The right occipital region is somewhat flattened secondary to probable posterior postural plagiocephaly. No fracture is visible. The left mastoid cells are opacified. Adenoidal tissue is prominent.
  1152. Impression:	Patient motion somewhat limits the examination.
  1153. 1. No acute intracranial hemorrhage.
  1154. 2. The CSF attenuation region adjacent to the left cerebellar
  1155. hemisphere may reflect asymmetric CSF spaces or an arachnoid cyst. It is also possible that this reflects the result of a remote
  1156. hemorrhage.
  1157. 3. Prominent extra axial spaces, non specific and possibly related to immaturity.
  1158. Discussed with Sue Campisciano at 9:05 pm on 4/14/2013.
  1159. XR Other Outside Exam Second Read [59614684]	Resulted: 04/14/13 2054, Result Status: Final
  1160. result
  1161. Ordering	Pawel, Barbara, MD 04/14/13 2017	Resulted by:	Victoria, Teresa, MD
  1162. Provider:	Halverson, Mark R, MD
  1163. Performed:	- 04/14/13 2017	Resulting Lab: CHOP RADIOLOGY
  1164. Specimen	04/14/13 2042
  1165.  
  1166.  
  1167. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  1168. Hospital Abstract
  1169. PATIENTJR.,OUTPATIENT
  1170. MRN: 00000000
  1171. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  1172. Imaging Results (continued)
  1173. XR Other Outside Exam Second Read [59614684] (continued)	Resulted: 04/14/13 2054, Result Status: Final
  1174. result
  1175. Collection
  1176. Narrative:	Examination: Skeletal survey (outside institution examination 
  1177. submitted for consultation)
  1178. INDICATION: The emergency room note in the electronic medical record documents a history of possible nonaccidental trauma, buttock region bruise
  1179. COMPARISON: None
  1180. Technique: This is an outside institution examination submitted for consultation. The images are labeled as having been performed at Delaware County Memorial Hospital. Images include a frontal radiograph of the chest and abdomen, frontal radiograph of the chest and upper extremities, frontal radiograph of the lower extremities, lateral radiograph of the skull.
  1181. FINDINGS:
  1182. This study does not constitute an adequate skeletal survey. The lateral radiograph of the skull does not include the entire skull and field-of-view. A large field of view radiograph including the entire lower extremities and upper extremities on a single view is not adequate.
  1183. The lungs demonstrate no focal consolidation. Heart size is normal.
  1184. The bowel gas pattern demonstrates no evidence of obstruction. No fracture is visible.
  1185. Impression:
  1186. This study does not constitute an adequate skeletal survey. No visible fracture.
  1187. Testing Performed By
  1188. Lab - Abbreviation	Name	Director	Address	Valid Date Range
  1189. 89 - Unknown	CHOP	Unknown	Unknown	12/22/10 1301 - Present
  1190. RADIOLOGY
  1191. All Other Results
  1192. POC ISTAT BGP 7 [60460392] (Abnormal)	Resulted: 04/15/13 0114, Result Status: Final
  1193. result
  1194. Resulting Lab: HOSPITAL LAB	Specimen	04/15/13 0108
  1195. Collection
  1196. Component	Value	Ref Range	Flag Comment	Lab
  1197. pH Whole Blood 7.375	7.34-7.44	TEST PERFORMED POINT
  1198. OF CARE
  1199.  
  1200.  
  1201.  
  1202. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104
  1203. Hospital Abstract
  1204. PATIENTJR.,OUTPATIENT
  1205. MRN: 00000000
  1206. DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013
  1207.  
  1208. All Other Results (continued)
  1209. POC ISTAT BGP 7 [60460392] (Abnormal) (continued)
  1210.  
  1211. Resulted: 04/15/13 0114, Result Status: Final
  1212. result
  1213. iStat Type of Specimen
  1214. BLNK
  1215.  
  1216. -
  1217. CO2 Tension
  1218. 39.9
  1219. 30-44 mmHg
  1220. -
  1221. O2 Tension
  1222. 37
  1223. 80-105 mmHg
  1224. L	-
  1225. Bicarbonate
  1226. 23.3
  1227. 18-25 mmol/L
  1228. -
  1229. (Calc)
  1230.  
  1231.  
  1232.  
  1233. Base Excess
  1234. -2
  1235. -5.5-0.5 mmol/L
  1236. -
  1237. O2 Saturation
  1238. 69
  1239. 95-99 %
  1240. L	-
  1241. (Calc)
  1242.  
  1243.  
  1244.  
  1245. Total CO2 (Calc)
  1246. 25
  1247. 19-26 mmol/L
  1248. -
  1249. Total
  1250. 11.2
  1251. 11.0-20.0 g/dL
  1252. -
  1253. Hemoglobin
  1254.  
  1255.  
  1256.  
  1257. Hematocrit(ISTA
  1258. 33.0
  1259. 33.0-39.0 %
  1260. -
  1261. T)
  1262.  
  1263.  
  1264.  
  1265. Sodium (Whole Blood)
  1266. 137
  1267. 136-142 mmol/L
  1268. -
  1269. Potassium
  1270. 5.0
  1271. 3.8-5.0 mmol/L
  1272. -
  1273. (Whole Blood)
  1274.  
  1275.  
  1276.  
  1277. Ionized Calcium-ISTAT
  1278. 1.41
  1279. 1.00-1.17 mmol/L
  1280. H	-
  1281.  
  1282. Testing Performed By
  1283. Lab - Abbreviation	Name	Director	Address	Valid Date Range
  1284. 7 - Unknown	HOSPITAL LAB	Unknown	3401 CIVIC CENTER 06/04/01 0000 - Present
  1285. BLVD
  1286. PHILADELPHIA PA
  1287. 19104
  1288. Outpatient PatientJr.
  1289.      Outpatient PatientJr. does not have an active treatment plan of type ONCOLOGY TREATMENT in this episode. Encounter-Level Scanned Documents:
  1290. There are no encounter-level scanned documents.
  1291.  
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