The XXXXXXXXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Attending Provider: (none) Allergies: No Active Isolation: None Ht: - Admission Cmt: (none) Allergies Infection: None Wt: 9.2 kg (20 lb 4.5 oz) Principal Problem: None Code Status: Not on file Admission Information - Hospital Account/Patient Record Arrival Date/Time: XXXXX. None Date/Time: Admission Type: Emergent Admission Emergency Admit Category: None Source: Department-chop Means of Arrival: None Primary Service: None Secondary None Service: Transfer Source: None Service Area: Chop Service Unit: Main Emergency Area Dept Admit Provider: None Attending Edmonds, Referring Provider, Self Provider: Sadiqa, MD Provider: Referred Discharge Information - Hospital Account/Patient Record Discharge Date/Time Discharge Disposition Discharge Destination Discharge Provider Unit 04/15/2013 0337 Discharged (Routine) None Edmonds, Sadiqa, MD Main Emergency Dept Final Diagnoses Princip Code Name POA CC HAC Affects al DRG [P] V71.6 Observation following other inflicted injury Allergies as of 4/15/2013 Assessed/Confirmed On: 4/15/2013 By: XXX, XXX X, RN No Active Allergies Immunizations as of 4/15/2013 Never Reviewed DTAP/HEPB/IPV(PEDIARIX) 3/20/2013, 1/18/2013, 11/19/2012 HIB 3/20/2013, 1/18/2013, 11/19/2012 Hepatitis B 01/01/2012 Pneumococcal 13 (Prevnar13) 3/20/2013, 1/18/2013, 11/19/2012 Rotavirus Vaccine, Pentavalent (Rotateq) 3/20/2013, 1/18/2013, 11/19/2012 ED Records Attending at Discharge Discharge Provider Date/Time Disposition Destination Edmonds, Sadiqa, MD / 04/15/13 0337 Discharged (routine) (none) 215-590-1970 Comments (none) ED Arrival Info Patient: PATIENTJR.,OUTPATIENT MRN: 00000000 The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) ED Arrival Info Patient: PATIENTJR.,OUTPATIENT MRN: 00000000 (continued) Expected Arrival Acuity Means of Arrival Escorted Servic Admission Arrival By e Type Complaint 4/14/2013 18:17 4/14/2013 19:52 2 - - - Emergent R/o Abuse Acute ED Current Impression Patient: PATIENTJR.,OUTPATIENT MRN: 00000000 R/o Scan Diagnosis Patient: XXXXXX JR.,OUTPATIENT MRN: 00000000 Physical child abuse, suspected [V71.6] Child abuse, neglect [995.52] ED Disposition Patient: XXXXXX JR.,OUTPATIENT MRN: 00000000 Discharg Outpatient PatientJr. discharged to home/self care. e ED Notes XXXXXX, XXX X, CRNP (Nurse Practitioner) 4/16/2013 18:09 Emergency Lab orders forwarded to PCP - Drexel Hill Electronically signed by XXXXXX, XXX X, CRNP at 4/16/2013 6:09 PM XXXXXX, XXX X, CRNP (Nurse Practitioner) 4/16/2013 16:56 Emergency XXXXXX, XXX << Less Detail XXXXXX, XXX Sent: Tue April 16, 2013 4:43 PM To: P Ed Np Pool Flags: Call patient Outpatient PatientJr. MRN: 00000000 DOB: 01/01/2012 Pt Home: 484-919-3044 Entered: 484-919-3044 The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Message Jennifer Patienthas questions about cat scan. Demographics does not have a Jennifer Patientlisted as being a responsible party for this patient. Referred the caller to the PCP for additional iformation Electronically signed by XXXXXX, XXX X, CRNP at 4/16/2013 4:56 PM XXX, XXX X , RN (Registered Nurse) 4/15/2013 03:37 Emergency DISCHARGE - Plan of care discussed with caregiver. Patient discharged with printed instructions. * Teaching Provided: Education: Cast/Splint Care and Crutch Walking and PMD follow up * Person(s) Taught: Caregivers. * Teaching Method: Verbal and Written * Patient-Parent Readiness to Learning: Receptive * Patient-Parent Barriers to Learning: None * Patient-Parent Outcome: Parent/Patient is able to verbalize or demonstrate understanding Condition at discharge: alert and stable. Pt. Awake, alert, smiling/interactive. Provided care givers with extra diapers, nipples, and gave thorough follow up and cast care instructions. Electronically signed by XXX, XXX X , RN at 4/15/2013 3:37 AM Edmonds, Sadiqa, MD (Physician) 4/15/2013 02:10 Emergency EMERGENCY DEPARTMENT MD/NP PROVIDER NOTE History of Present Illness: Source:cousins who have assumed physical custody of child last evening 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.. HPI: Symptom onset time, duration, severity, quality: * 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. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) * Sent to CHOP for further evaluation Associated / Alleviating signs and symptoms: * Fever: No * Intake/Urine Output: Child had period of irritability and decreased interest in feeding last evening. * Activity level: no change; waking for feeds and appropriate for caregivers. * Family members report child does not roll over, does sits with support, coos, no babbling. Able to hold bottle. Past Medical History: plagiocephaly Family History: No ill contacts and Reviewed and non-contributory Social History: recently placed in physical custody of family members due to concerns of abuse in a sibling. Primary Care Clinician: Network, Drexel Hill Care Medications/Allergies: Reviewed and updated in electronic health record. Immunizations Status: Routine immunizations up to date Review of Systems: Constitutional: see HPI Eyes: normal ENT: normal Respiratory: normal Cardiovascular: normal Gastrointestinal: no vomiting, no diarrhea and drinks good start soy 4-6 ounces 5-6x/day Genitourinary: no decreased urination Musculoskeletal: no joint pain and no weakness Neurologic: concerns of gross motor delay Skin: bruising:bluish flat rash on buttocks, and reddened area on trunk Psychiatric: normal Physical Exam: Vital signs: Pulse 122 | Temp 36.2 ∞C | Resp 32 | Wt 9.2 kg | SpO2 100% General: alert, well developed, well nourished, in no acute distress Head: plagiocephaly, Eye: pupils equal, round, and reactive to light, extra-ocular movements intact and normal conjunctivae: ENT: mucous membranes moist, TMs normal bilaterally and oropharynx clear Neck: neck is supple with full active range of motion Cardiac: regular rhythm, warm and well perfused and capillary refill less than 2 seconds Chest: clear to auscultation bilaterally and mild upper airway congestion Abdomen: soft, nontender, and nondistended , no hepatosplenomegaly and no guarding or rebound tenderness Genitourinary: normal male external genitalia Extremity: normal pulses, capillary refill, sensation, active and symmetric movement of extremities Neuro: normal suck, grasp, and Moro reflexes: Skin: bruising: bluish flat lesion, non-tender over sacral area The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Psychiatric:alert, oriented to caregiver Procedures: None Consults: 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 CBC, coags due to ? History of brusing. Pertinent Results: Labs Reviewed CBC WITH DIFF - Abnormal; Notable for the following: Mean Platelet Volume 7.1 (*) Eosinophils 4.4 (*) Basophils 1.5 (*) All other components within normal limits BASIC METABOLIC PANEL - Abnormal; Notable for the following: Potassium 6.3 (*) Carbon Dioxide 19 (*) All other components within normal limits HEPATIC FUNCTION PANEL - Abnormal; Notable for the following: Bilirubin,Direct (Calculated) 0.6 (*) Albumin 4.8 (*) Aspartate Aminotransferase 67 (*) All other components within normal limits URINALYSIS W/0 MICROSCOPIC - Abnormal; Notable for the following: UR Specific Gravity 1.002 (*) All other components within normal limits Narrative: Source: Urine GAMMA GLUTAMYL TRANSFERASE GGT - Abnormal; Notable for the following: Gamma Glutamyl Transferase 15 (*) All other components within normal limits AMYLASE LIPASE PT/INR PTT PROFILE Reassessments: po fed 4 ounces of pedialyte with no emesis Resident/NP/MedStudent/Fellow: Treatment Team: CRNP: XXXXXX, XXX, CRNP EMERGENCY DEPARTMENT ATTENDING NOTE 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 History of Present Illness: The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) 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. Physical Exam: Pulse 122 | Temp 36.2 ∞C | Resp 32 | Wt 9.2 kg | SpO2 100% General: alert, well developed, well nourished, in no acute distress Head: plagiocephaly and no scalp hematoma ENT: mucous membranes moist, TMs normal bilaterally and frenulum intact Cardiac: regular rhythm, normal rate and no murmurs Chest: clear to auscultation bilaterally Abdomen: soft, nontender, and nondistended and no hepatosplenomegaly Extremity/Musculoskeletal: brisk capillary refill, no bony tenderness and range of motion: full Skin: no rashes, no pallor and mongolian spots over buttocks. No ecchymoses noted Medical Decision-Making / Differential Diagnosis / Plan: Buckle fracture of tibia Mental status wnl Head CT - chronic changes Response / Pertinent Results: Labs wnl Discussed with SCAN. OK to d/c with family Ortho consult (Proximal buckle fracture R tibia) - will place long leg cast F/u with ortho, SCAN, CYS Final diagnoses: None Disposition: Discharge after reviewing instructions with family. Return if worsening in patient status. 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 XXXXXX, XXX, RT (Respiratory Therapist) 4/15/2013 01:14 MD requested ISTAT for Potassium Level. K Result was 5 mEq/L valued reported to MD. ISTAT uploaded to computer. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Electronically signed by XXXXXX, XXX, RT at 4/15/2013 1:14 AM XXX, XXX X , RN (Registered Nurse) 4/15/2013 00:09 Emergency 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. Electronically signed by XXX, XXX X , RN at 4/15/2013 12:09 AM XXX, XXX X , RN (Registered Nurse) 4/14/2013 23:38 Emergency Pt. U-bagged, urine sent to lab. Electronically signed by XXX, XXX X , RN at 4/14/2013 11:38 PM XXX, XXX X , RN (Registered Nurse) 4/14/2013 22:24 Emergency Pt. Laying in bed, NP at BS assessing PT. Pt. Awake, alert. Electronically signed by XXX, XXX X , RN at 4/14/2013 10:24 PM XXX, XXX X , RN (Registered Nurse) 4/14/2013 21:56 Emergency 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. Electronically signed by XXX, XXX X , RN at 4/14/2013 9:56 PM XXX, XXX X , RN (Registered Nurse) 4/14/2013 21:24 Emergency 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. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Electronically signed by XXX, XXX X , RN at 4/14/2013 9:24 PM XXX, XXX X , RN (Registered Nurse) 4/14/2013 20:13 Emergency ADMIT TO ED - Patient placed in exam room without difficulty. Family provided with orientation of exam room's phone and call bell. Patient instructed to undress and put on patient gown. Caregiver was at bedside. Side rails were up. ID (& allergy, if applicable) band on patient:yes Eligible to Complete Behavioral_Health_Screen: no Isolation Required:no Pain Assessment Complete:yes Barriers to Learning: None 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. Electronically signed by XXX, XXX X , RN at 4/14/2013 8:13 PM XXX, XXX, RN (Registered Nurse) 4/14/2013 19:57 Emergency ADMIT TO ED - Patient placed in exam room without difficulty. Family provided with orientation of exam room's phone and call bell. Patient instructed to undress and put on patient gown. Caregiver was at bedside. Side rails were up. ID (& allergy, if applicable) band on patient:yes Eligible to Complete Behavioral_Health_Screen: not applicable Isolation Required:not applicable Pain Assessment Complete:yes Barriers to Learning: None Cousin at bedside Patient awake, alert, interactive. Electronically signed by XXX, XXX, RN at 4/14/2013 7:57 PM The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) XXX, XXX, RN (Registered Nurse) 4/14/2013 19:56 Emergency ED TRIAGE NOTE HPI: 6 mo, cousin brought pt in for suspected abuse. Pts are schizophrenic and arrested last night for abuse of another child. Bruise on buttocks-could be mongolian spot. R side of head is flat. HCT cortical foci are prominent and are not sure what to make of this finding Skeletal survey negative 8,8kg Appears well, eating, drinking, +wet diapers, a little interactive Case worker is on it and will fill out abuse form Prehospital Care: CT scan, skeletal survey Behavioral Health History: No known behavioral history Additional Notes/Parent Reported Medical Problems: Electronically signed by XXX, XXX, RN at 4/14/2013 7:56 PM Benecke, Sandra (Communication Specialist) 4/14/2013 19:51 Emergency COMMSPEC COMPLETE in EPIC Electronically signed by Benecke, Sandra at 4/14/2013 7:51 PM XXX, XXX, RN (Registered Nurse) 4/14/2013 18:57 Emergency Report from outside hospital Brought to outside hospital by cousin's, pt's parents were arrested last evening for alleged abuse of another child Bruising on buttocks & bridge of nose Head CT abnormal w/ prominent cortical sulci, no bleed No known medical problems Awake, alert, smiling Immunizations UTD, no surgeries 2 adult cousins are coming with pt. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Electronically signed by XXX, XXX, RN at 4/14/2013 6:57 PM Monroe-Singletary, Shonda (OTHER) 4/14/2013 18:52 Emergency Nursing report on park 1 Referring RN:Amber Receiving RN: Kelly . Electronically signed by Monroe-Singletary, Shonda at 4/14/2013 6:52 PM XXXXXX, XXX (Communication Specialist) 4/14/2013 18:49 Emergency ED CHARGE PAGED FOR REPORT Electronically signed byXXXXXX, XXX at 4/14/2013 6:49 PM XXXXXX, XXX, RN (Registered Nurse) 4/14/2013 18:35 Emergency Referring will arrange transport BLS. Copies of scans will come with pt. Electronically signed by XXXXXX, XXX, RN at 4/14/2013 6:35 PM XXXXXX, XXX, RN (Registered Nurse) 4/14/2013 18:33 Emergency XXXXXX, XXX accepts to ED Electronically signed by XXXXXX, XXX, RN at 4/14/2013 6:33 PM XXXXXX, XXX, RN (Registered Nurse) 4/14/2013 18:24 Emergency Reported Vital Signs The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) 32 ra 6 mo, cousin brought pt in for suspected abuse. Pts are schizophrenic and arrested last night for abuse of another child. Bruise on buttocks-could be mongolian spot. R side of head is flat. HCT cortical foci are prominent and are not sure what to make of this finding Skeletal survey negative 8,8kg Appears well, eating, drinking, +wet diapers, a little interactive Case worker is on it and will fill out abuse form Will copy studies Electronically signed by XXXXXX, XXX, RN at 4/14/2013 6:24 PM Follow-up Information Patient: XXXXXX JR.,OUTPATIENT MRN: 00000000 Follow up With Details Comments Contact Info Network, Drexel Hill Care Schedule an appointment as 3-5 days if symptoms soon as possible for a visit worsen in 3 day(s) Imaging / Wet Read Results XR Skeletal Survey Trauma (Final result) Abnormal Result time:4/15/13 0317 Final result by Intfusr, Inc Rad Res (04/14/13 23:51:58) Impression: 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. Narrative: 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. INDICATION: Suspected abuse, plagiocephaly COMPARISON: None FINDINGS: There is a focal area along the medial aspect of the proximal right tibial metaphysis which demonstrates a subtle convex medial cortical irregularity. This is not visible on the lateral view. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Imaging / Wet Read Results (continued) 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. Preliminary result by Intfusr, Inc Rad Res (04/14/13 23:33:53) Impression: Narrative: Preliminary report for accession number 4482664 has been dictated by Mark Halverson. Final Report pending review by Sudha Anupindi. CT Neuro Outside Exam Second Read (Final result) Result time:4/14/13 2114 Final result by Intfusr, Inc Rad Res (04/14/13 21:14:56) Impression: Patient motion somewhat limits the examination. 1. No acute intracranial hemorrhage. 2. The CSF attenuation region adjacent to the left cerebellar hemisphere may reflect asymmetric CSF spaces or an arachnoid cyst. It is also possible that this reflects the result of a remote hemorrhage. 3. Prominent extra axial spaces, non specific and possibly related to immaturity. Discussed with Sue Campisciano at 9:05 pm on 4/14/2013. Narrative: SECOND OPINION OF OUTSIDE CT OF WITHOUT CONTRAST PERFORMED AT The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Imaging / Wet Read Results (continued) DELAWARE COUNTY HOSPITAL, AT THE REQUEST OF DR. PAWEL: INDICATION: Possible trauma COMPARISON: None 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. FINDINGS: 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. 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. The extra-axial spaces in general are somewhat prominent prominent CSF space in the bifrontal regions mild prominence of the sylvian fissures. 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. Preliminary result by Intfusr, Inc Rad Res (04/14/13 21:11:56) Impression: Narrative: Preliminary report for accession number 4482636 has been dictated by Mark Halverson. Final Report pending review by Avrum Pollock. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Imaging / Wet Read Results (continued) Preliminary result by Intfusr, Inc Rad Res (04/14/13 20:51:52) Impression: Narrative: Preliminary report for accession number 4482636 has been dictated by Mark Halverson. Final Report pending review by Avrum Pollock. The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Imaging / Wet Read Results (continued) XR Other Outside Exam Second Read (Final result) Result time:4/14/13 2054 Final result by Intfusr, Inc Rad Res (04/14/13 20:54:57) Impression: This study does not constitute an adequate skeletal survey. No visible fracture. Narrative: Examination: Skeletal survey (outside institution examination submitted for consultation) INDICATION: The emergency room note in the electronic medical record documents a history of possible nonaccidental trauma, buttock region bruise COMPARISON: None 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. FINDINGS: 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. The lungs demonstrate no focal consolidation. Heart size is normal. The bowel gas pattern demonstrates no evidence of obstruction. No fracture is visible. Preliminary result by Intfusr, Inc Rad Res (04/14/13 20:42:41) Impression: The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 ED Records (continued) Imaging / Wet Read Results (continued) Narrative: Preliminary report for accession number 4482638 has been dictated by Mark Halverson. Final Report pending review by Teresa Victoria. Discharge Summary D/C Summaries signed by Parikh, Vidhi, MD at 04/15/13 0307 Author: Parikh, Vidhi, MD Service: Emergency Author Resident Type: Filed: 04/15/13 0307 Note 04/15/13 0303 Time: 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 The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Discharge Summary (continued) Electronically signed by Parikh, Vidhi, MD on 4/15/2013 3:07 AM Consults Consult Note signed by Baldwin, Keith, MD at 04/20/13 0758 Author: Baldwin, Keith, MD Service: Emergency Author Physician Type: Filed: 04/20/13 0758 Note 04/14/13 2149 Time: Related Original Note by: Black, John D, MD filed at 04/16/13 1455 Notes: The Children's Hospital of Philadelphia Date Of Service: April 16, 2013 Name: Outpatient PatientJr. MRN: 00000000 The Orthopaedic Service was asked to see Outpatient PatientJr. in consultation. ORTHOPAEDIC CONSULT NOTE HISTORY OF PRESENT ILLNESS (Please address 4 or more of the following categories in your HPI) Location, Severity/Pain, Timing, Modify factors, Duration, Associated signs and symptoms, Quality Reason For Consult Today 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 Past Medical History Birth History: Birth History Birth Length Birth Weight Gestational The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Consults (continued) Age 0.533 m 3.33 kg Discharge Weight 40 weeks 3.26 kg Comment: Passed hearing Both hears Past Medical History: No past medical history on file. Prior Surgeries: No past surgical history on file. Family Health History List any pertinent family history in patient's immediate family and the family members affected: None Social History The child lives with the Unable to access REVIEW OF SYSTEMS Constitutional: Normal Musculoskeletal: Per HPI Eyes: Normal Neurologic: Normal Ears/Nose/Throat: Normal Endocrine: Normal Respiratory: Normal Hematologic: Normal Cardiovascular: Normal Immunologic: Normal Gastrointestinal: Normal Psych/Development: Normal Genitourinary: Normal Integumentary/Skin: Normal Other: n/a Physical Exam The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Consults (continued) EXAMINATION Constitutional BP 92/64 | Pulse 118 | Temp 37 ∞C | Resp 26 | Wt 9.2 kg | SpO2 100% Appearance Well appearing Psych Age appropriate behavior Eyes Normal Head, Ears, Nose, Mouth, Throat Normal Respiratory Normal Cardiovascular Intact distal pulses, capillary refill less than 2 seconds in all extremities Abdominal/GI Normal Neurological Normal Hem/Lymph N/A Skin Abnormal, see Musculoskeletal exam for complete details for abnormal findings Musculoskeletal RUE: Observation:No gross deformity Palpatation:Non-tender to palpatation ROM:Normal ROM without pain Stability:No gross instability Sensation:Intact to light touch to radial, median, and ulnar nerves Motor:Anterior interosseus, posterior interossus, radial, median, and ulnar nerves are intact Vascular:Palpable radial pulse, brisk capillary refill Swelling:No obvious swelling or ecchymosis Skin:Intact Compartments:Soft and compressible, no pain with passive stretch Dressing/Incision/Cast/Splint: N/A LUE: Observation:No gross deformity Palpatation:Non-tender to palpatation ROM:Normal ROM without pain Stability:No gross instability Sensation:Intact to light touch to radial, median, and ulnar nerves Motor:Anterior interosseus, posterior interossus, radial, median, and ulnar nerves are intact Vascular:Palpable radial pulse, brisk capillary refill Swelling:No obvious swelling or ecchymosis Skin:Intact Compartments:Soft and compressible, no pain with passive stretch Dressing/Incision/Cast/Splint:N/A RLE: The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Consults (continued) Observation:No gross deformity Palpatation:Abnormal +tender to proximal tibia ROM:Normal ROM without pain Stability:No gross instability Sensation:Intact to light touch over the superficial peroneal, deep peroneal, saphenous, sural, and tibial nerves. Motor:Intact extensor hallicus longus, flexor hallicus longus, tibialis anterior, gastrocnemius soleus complex Vascular:Palpable dorsalis pedis pulse Skin:Intact Compartments:Soft and compressible, no pain with passive stretch Dressing/Incision/Cast/Splint:N/A LLE: Observation:No gross deformity Palpatation:Non-tender to palpatation ROM:Normal ROM without pain Stability:No gross instability Sensation:Intact to light touch over the superficial peroneal, deep peroneal, saphenous, sural, and tibial nerves. Motor:Intact extensor hallicus longus, flexor hallicus longus, tibialis anterior, gastrocnemius soleus complex Vascular:Palpable dorsalis pedis pulse Skin:Intact Compartments:Soft and compressible, no pain with passive stretch Dressing/Incision/Cast/Splint:N/A SPINE: Observation:No gross deformity Palpatation:Non-tender to palpatation ROM:Normal ROM without pain Reflexes:Not examined Motor:Upper and lower extremity strength is normal Sensation:Sensation intact C5-T1 bilaterally, sensation intact L2-S1 bilaterally Skin:Intact Dressing/Incision/Cast/Splint:N/A Radiology Studies: I have personally reviewed all relevant imaging and agree with the radiology report noting R proximal tibia buckle fx, negative skeletal survey Labs: The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Consults (continued) Procedure: Long-leg cast applied Pertinent Drawing/Photo: Assessment and Plan: 6 month old male with R proximal tibia buckle fx Pain Control: oral Weight Bearing: None Right Lower Extremity Physical Therapy/Occupational Therapy: n/a Diet: Advance F/u with Dr. Baldwin 1-2 weeks for repeat XR Electronically signed: John D. Black, MD 4/14/2013 9:49PM I have reviewed the note on Outpatient PatientJr. and agree with the resident/fellow's assessment and plan. Keith Baldwin, MD 4/20/2013 7:58 AM Keith Baldwin, MD, MPH Assistant Professor, Orthopedic Surgery Neuromuscular Diseases and Trauma The Children's Hospital of Philadelphia Electronically signed by Baldwin, Keith, MD on 4/20/2013 7:58 AM 04/14/13 2149 Consult Note signed by Black, John D, MD Lab Results The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Lab Results (continued) Vitamin D 25OH [60460386] Resulted: 04/16/13 1733, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/15/13 Resulting Lab: HOSPITAL LAB Provider: 0053 Specimen Blood 04/15/13 0105 Collection Component Value Ref Range Flag Comment Lab Vitamin D 25OH 34.7 ng/mL Comment: TOTAL 25-HYDROXYVITAMIN D2 AND D3 (25-OH-VITD) < 10 ng/mL ( severe deficiency )+ 10 - 24 ng/mL ( mild to moderate deficiency)++ 25 - 80 ng/mL ( optimum levels)+++ > 80 ng/mL ( toxicity possible )++++ + Could be associated with osteomalacia or rickets ++ May be associated with increased risk of osteoporosis or secondary hyperparathyroidism +++ Optimum levels in the normal population ++++ 80 ng/mL is the lowest reported level associated with toxicity in patients without primary hyperparathyroidism who have normal renal function. Most patients with toxicity have levels >150 ng/mL. Patients with renal failure can have very high 25-OH-VitD levels without signs of toxicity, as renal conversion to the active hormone 1,25-OH VitD is impaired or absent. These reference ranges represent clinical decision values that apply to males and females of all ages, rather than population-based reference values. Population reference ranges for 25-OH-VitD vary widely depending on ethnic background, age, geographic location of the studied populations, and the sampling-season. Population-based ranges correlate poorly with serum 25-OH-VitD concentrations that are associated with biologically and clinically relevant Vitamin D effects and are therefore of limited clinical value. "This test was developed and its performance characteristics determined by the Children's Hospital of Philadelphia Clinical Chemistry Laboratory. It has not been cleared or approved by the U.S. Food and Drug Administration (FDA). The FDA has determined that such clearance or approval is not necessary. This laboratory is certified under the Clinical Laboratory Improvement Amendments of 1988 (CLIA-88) as qualified to perform high-complexity clinical laboratory testing." Parathyroid Hormone Intact [60460385] (Abnormal) Resulted: 04/15/13 1204, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/15/13 Resulting Lab: HOSPITAL LAB Provider: 0053 Specimen Blood 04/15/13 0105 The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Lab Results (continued) Parathyroid Hormone Intact [60460385] (Abnormal) (continued) Resulted: 04/15/13 1204, Result Status: Final result Collection Component Value Ref Range Flag Comment Lab Intact PTH 7.94 9-56 pg/mL L - Potassium [60460394] Resulted: 04/15/13 0140, Result Status: Final result Resulting Lab: HOSPITAL LAB Specimen 04/15/13 0105 Collection Component Value Ref Range Flag Comment Lab Potassium 5.2 4.1-5.8 mmol/L - Phosphorus [60460396] Resulted: 04/15/13 0140, Result Status: Final result Resulting Lab: HOSPITAL LAB Specimen 04/15/13 0105 Collection Component Value Ref Range Flag Comment Lab Phosphorus 6.6 4.8-8.2 mg/dL - PTT Profile [60460378] Resulted: 04/15/13 0138, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulting Lab: HOSPITAL LAB Provider: 2234 Specimen Blood 04/15/13 0105 Collection Component Value Ref Range Flag Comment Lab Partial 31.0 22.0-36.0 - Thromboplastin SECS PT/INR [60460377] Resulted: 04/15/13 0136, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulting Lab: HOSPITAL LAB Provider: 2234 Specimen Blood 04/15/13 0105 Collection Component Value Ref Range Flag Comment Lab Int Normalized 1.03 - Ratio Test Prothrombin 13.0 11.6-13.8 - Time SECS The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Lab Results (continued) GGT [60460381] (Abnormal) Resulted: 04/14/13 2342, Result Status: Final result Resulting Lab: HOSPITAL LAB Specimen 04/14/13 2240 Collection Component Value Ref Range Flag Comment Lab Gamma 15 17-126 U/L L - Glutamyl Transferase Basic Metabolic Panel [60460373] (Abnormal) Resulted: 04/14/13 2334, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulting Lab: Provider: 2233 Specimen Blood 04/14/13 2240 Collection HOSPITAL LAB Component Value Ref Range Flag Comment Lab Sodium 136 133-140 mmol/L - Potassium 6.3 4.1-5.8 mmol/L H - Chloride 102 96-106 mmol/L - Carbon Dioxide 19 20-26 mmol/L L - Urea Nitrogen 9 2-19 mg/dL - Creatinine 0.1 0.1-0.4 mg/dL - Glucose 95 74-127 mg/dL - Calcium 10.1 9.2-10.4 mg/dL - Hepatic Function Panel [60460374] (Abnormal) Resulted: 04/14/13 2334, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulting Lab: Provider: 2233 Specimen Blood 04/14/13 2240 Collection HOSPITAL LAB Component Value Ref Range Flag Comment Lab Total Bilirubin 0.9 0.6-1.4 mg/dL - Bilirubin 0.3 0.2-1.0 mg/dL - Unconjugated Bilirubin,Direct 0.6 0.00-0.3 mg/dL H - (Calculated) Bilirubin 0.0 0.0-0.3 mg/dL - Conjugated Total Protein 6.9 5.4-7.0 g/dL - Albumin 4.8 3.1-4.2 g/dL H - Alkaline 179 70-345 U/L - Phosphatase Alanine 26 12-42 U/L - Aminotransferas e The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Lab Results (continued) Hepatic Function Panel [60460374] (Abnormal) (continued) Resulted: 04/14/13 2334, Result Status: Final result Aspartate 67 20-64 U/L H - Aminotransferas e Amylase [60460375] Resulted: 04/14/13 2334, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulting Lab: HOSPITAL LAB Provider: 2234 Specimen Blood 04/14/13 2240 Collection Component Value Ref Range Flag Comment Lab Amylase <30 0-80 U/L - Lipase [60460376] Resulted: 04/14/13 2334, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulting Lab: HOSPITAL LAB Provider: 2234 Specimen Blood 04/14/13 2240 Collection Component Value Ref Range Flag Comment Lab Lipase 75 10-115 U/L - Urinalysis w/o Microscopic [60460379] (Abnormal) Resulted: 04/14/13 2329, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulting Lab: HOSPITAL LAB Provider: 2234 Specimen Urine clean catch; Urine 04/14/13 2315 Collection Narrative: Source: Urine Component Value Ref Range Flag Comment Lab Urine Color Light-Yellow - Urine Sediment CLEAR - Urine Sugar NEGATIVE NEGATIVE - mg/dl UR Protein NEGATIVE NEGATIVE - mg/dL UR Bilirubin NEGATIVE NEGATIVE - UR Urobilinogen <2.0 <2.0 mg/dl - UR pH 6.0 4.8-7.8 - UR Blood NEGATIVE NEGATIVE - UR Ketones NEGATIVE NEGATIVE - mg/dL UR Nitrite NEGATIVE NEGATIVE - The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Lab Results (continued) Urinalysis w/o Microscopic [60460379] (Abnormal) (continued) Resulted: 04/14/13 2329, Result Status: Final result UR Leukocytes NEGATIVE NEGATIVE - UR Specific 1.002 1.003-1.035 L - Gravity CBC with Diff [60460372] (Abnormal) Resulted: 04/14/13 2319, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulting Lab: HOSPITAL LAB Provider: 2233 Specimen Blood 04/14/13 2240 Collection Component Comment: THIS ANALYZER MAY FAIL TO DETECT BLASTS IN SOME PATIENT'S 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. Platelet Estimate Not Done - The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Lab Results (continued) CBC with Diff [60460372] (Abnormal) (continued) Resulted: 04/14/13 2319, Result Status: Final result Testing Performed By Lab - Abbreviation Name Director Address Valid Date Range 7 - Unknown HOSPITAL LAB Unknown 3401 CIVIC CENTER 06/04/01 0000 - Present BLVD PHILADELPHIA PA 19104 Imaging Results XR Skeletal Survey Trauma [60460359] (Abnormal) Resulted: 04/15/13 0317, Result Status: Final result Ordering XXXXXX, XXX, CRNP 04/14/13 Resulted by: Anupindi, Sudha, MD Provider: 2110 Halverson, Mark R, MD Performed: 04/14/13 2200 - 04/14/13 2214 Resulting Lab: CHOP RADIOLOGY Specimen 04/14/13 2333 Collection Narrative: 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. INDICATION: Suspected abuse, plagiocephaly COMPARISON: None FINDINGS: There is a focal area along the medial aspect of the proximal right tibial metaphysis which demonstrates a subtle convex medial cortical irregularity. This is not visible on the lateral view. 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. Impression: 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. CT Neuro Outside Exam Second Read [59614682] Resulted: 04/14/13 2114, Result Status: Final result Ordering Pawel, Barbara, MD 04/14/13 2013 Resulted by: Pollock, Avrum, MD Provider: Halverson, Mark R, MD Performed: - 04/14/13 2013 Resulting Lab: CHOP RADIOLOGY The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Imaging Results (continued) CT Neuro Outside Exam Second Read [59614682] (continued) Resulted: 04/14/13 2114, Result Status: Final result Specimen 04/14/13 2051 Collection Narrative: SECOND OPINION OF OUTSIDE CT OF WITHOUT CONTRAST PERFORMED AT DELAWARE COUNTY HOSPITAL, AT THE REQUEST OF DR. PAWEL: INDICATION: Possible trauma COMPARISON: None 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. FINDINGS: 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. 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. The extra-axial spaces in general are somewhat prominent prominent CSF space in the bifrontal regions mild prominence of the sylvian fissures. 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. Impression: Patient motion somewhat limits the examination. 1. No acute intracranial hemorrhage. 2. The CSF attenuation region adjacent to the left cerebellar hemisphere may reflect asymmetric CSF spaces or an arachnoid cyst. It is also possible that this reflects the result of a remote hemorrhage. 3. Prominent extra axial spaces, non specific and possibly related to immaturity. Discussed with Sue Campisciano at 9:05 pm on 4/14/2013. XR Other Outside Exam Second Read [59614684] Resulted: 04/14/13 2054, Result Status: Final result Ordering Pawel, Barbara, MD 04/14/13 2017 Resulted by: Victoria, Teresa, MD Provider: Halverson, Mark R, MD Performed: - 04/14/13 2017 Resulting Lab: CHOP RADIOLOGY Specimen 04/14/13 2042 The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 Imaging Results (continued) XR Other Outside Exam Second Read [59614684] (continued) Resulted: 04/14/13 2054, Result Status: Final result Collection Narrative: Examination: Skeletal survey (outside institution examination submitted for consultation) INDICATION: The emergency room note in the electronic medical record documents a history of possible nonaccidental trauma, buttock region bruise COMPARISON: None 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. FINDINGS: 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. The lungs demonstrate no focal consolidation. Heart size is normal. The bowel gas pattern demonstrates no evidence of obstruction. No fracture is visible. Impression: This study does not constitute an adequate skeletal survey. No visible fracture. Testing Performed By Lab - Abbreviation Name Director Address Valid Date Range 89 - Unknown CHOP Unknown Unknown 12/22/10 1301 - Present RADIOLOGY All Other Results POC ISTAT BGP 7 [60460392] (Abnormal) Resulted: 04/15/13 0114, Result Status: Final result Resulting Lab: HOSPITAL LAB Specimen 04/15/13 0108 Collection Component Value Ref Range Flag Comment Lab pH Whole Blood 7.375 7.34-7.44 TEST PERFORMED POINT OF CARE The XXX, XXX, XXXXXXXXX , XXXX, PA 19104 Hospital Abstract PATIENTJR.,OUTPATIENT MRN: 00000000 DOB: 01/01/2012, Sex: M Adm:4/14/2013, D/C:4/15/2013 All Other Results (continued) POC ISTAT BGP 7 [60460392] (Abnormal) (continued) Resulted: 04/15/13 0114, Result Status: Final result iStat Type of Specimen BLNK - CO2 Tension 39.9 30-44 mmHg - O2 Tension 37 80-105 mmHg L - Bicarbonate 23.3 18-25 mmol/L - (Calc) Base Excess -2 -5.5-0.5 mmol/L - O2 Saturation 69 95-99 % L - (Calc) Total CO2 (Calc) 25 19-26 mmol/L - Total 11.2 11.0-20.0 g/dL - Hemoglobin Hematocrit(ISTA 33.0 33.0-39.0 % - T) Sodium (Whole Blood) 137 136-142 mmol/L - Potassium 5.0 3.8-5.0 mmol/L - (Whole Blood) Ionized Calcium-ISTAT 1.41 1.00-1.17 mmol/L H - Testing Performed By Lab - Abbreviation Name Director Address Valid Date Range 7 - Unknown HOSPITAL LAB Unknown 3401 CIVIC CENTER 06/04/01 0000 - Present BLVD PHILADELPHIA PA 19104 Outpatient PatientJr. Outpatient PatientJr. does not have an active treatment plan of type ONCOLOGY TREATMENT in this episode. 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