All records regarding this patient's ED course of examination, treatment, and findings - in addition to his brief in-hospital stay - were originally obtained with permission of the receiving hospital. All identifying references to the actual patient have been redacted (deleted), to preserve patient confidentiality.

• 0205 the patient's vital signs were 116/73, pulse of 120, ventilated at 12/minute.

• 0210 another 3 mg of Versed were administered IV.

• 0210 an NG tube was placed.

• 0220 activated charcoal was administered.
  The patient's vital signs were 141/70, pulse of 116, ventilated at 12/minute.

• 0238 another 70 mg of Zemuron were administered IV.
  The patient's vital signs were 152/87, pulse of 110, ventilated at 12/minute.

• 0245 the patient was sent for a CT scan of his head.
  Chest and C-spine x-rays were negative for any chest or spine trauma.
  The patient's vital signs were 161/107, pulse of 113, ventilated at 12/minute.

• 0300 another 5 mg of Versed were administered IV.
  The patient's pulse was 98.

• 0340 another 3 mg of Versed were administered IV.

• 0345 the patient returned from CT.

• 0400 an EKG was done. It showed a normal sinus rhythm, with nonspecific ST abnormality. The patient's heart rate was 84 per minute.

• 0415 the patient's vital signs were 142/70, pulse of 84, ventilated at 12/minute.

• 0420 the nursing staff noted the patient to be increasing in agitation.
  The patient's vital signs were 155/82, pulse of 84, ventilated at 12/minute.

• 0430 muscle tremors were noted and attributed to Zemuron (withdrawal?).

• 0435 another 3 mg of Versed were administered IV.

• 0440 another 2 mg of Versed were administered IV.

• 0445 the head CT revealed no bleed, no mass or mass effect. Soft tissue right orbital trauma was found, with "fluid" (not blood) in the patient's frontal and sphenoid sinuses.

• 0500 the patient was first noted to be following commands, and was sent to undergo a CT scan of his abdomen and pelvis.
  The patient's vital signs were 143/70, pulse of 78, ventilated at 14/minute.

• 0530 the patient returned to the ED.

• 0550 the abdominal and pelvic CT revealed normal findings for everything, except for multiple small calcification findings in the patient's spleen.

• 0600 the urine toxicological screen showed the patient was positive for marijuana.
  The patient's vital signs were 138/66, pulse of 74, ventilated at 14/minute. A spinal tap was done and the findings were negative for any cerebrospinal fluid abnormalities.

• 0636 the patient received 4 sutures in his right upper eyelid laceration.

• 0700 the patient was transferred to the intensive care unit. His total fluid intake while in the ED was 1300 cc of Normal Saline. His total output was 1400 cc.

If you haven't already, and you wish to NOW,
go to any or all of the following Case-Related Files:

• Basic Emergency Department Treatment/Exam Information

• TOXICOLOGICAL FINDINGS

• In-Hospital Treatment Records

Email Charly at: c-d-miller@neb.rr.com
Those are hyphens/dashes between the "c" and "d" and "miller"