MEDICAL SUMMARY

MOLD RELATED ILLNESS

WRITING SAMPLES

TIME LINE: MEDICAL MALPRACTICE

Medical Record Summary

re: Pain and Suffering, Product Defect/Wrongful Death

Summary of 46 pages, excerpt from summary of 700 page medical record.

Margaret Eve Miyasaki

PRODUCT DEFECT/WRONGFUL DEATH ASSIGNMENT: Demonstrate the intensity of pain decedent felt from injuries arising from a MVA, in order to prove pain and suffering. HYPOTHESIS: That decedent had severe pain, after being injured in the MVA up until his death, could be shown by the type of pain medication administered. PROCESS: Summarized Medical Record, emphasis on analgesic record and nursing pain assessment charts. Using the "Basic Pharmacologic Pain Managment Princples" table, and other pain assessment tools for nonverbal patients, a pain scale rating of severe pain (7 to 10) could be shown by following the continuous intravenous administration of opioid narcotics from January 13, 2002, date of the accident, up until the time of death. Narcotics administered were Morphine and Fentanyl. Within 24 hours of hospitalization, decedent was assessed as having a poor prognosis, and given "do not resuscitate" status. Decedent, in fact, expired, within 4 weeks of the MVA, from injuries received at the time of the MVA.
Patient: JOHN DOE Provider: St. Doc's Hospital DOI: January 13, 2002
START	END	DOCUMENT	PAGE	SUMMARY
01/13/02	01/13/02	Coding Summary	4	3rd degree burns 40-49% body surface, head, neck, trunk, right thigh, bilateral upper and lower extremities. Probable left groin trauma.Post-traumatic pulmonary insufficiency. Shock, shivering stridor. Toxic effect acid vapors. Bilateral cornea hazy, injected, right eye cicatrical ectropion, corneal rupture. Kidney lesions. Urinary tract infection. Acute gastritis with hemorrhoids. Staphylococcal aureus septicemia resistant to penicillin. Organic brain disease. Oral intubation at scene. Mechanical ventilation. Broncho/tracheal lavage. Fiber optic bronchoscopy.
		Emergency Treatment Record	13-17
		Trauma Service History	18
		Discharge Summary	23
01/13/02	01/13/02	Initial Plan While in E. D.	19	Intubation in field: left femoral vein line, left arterial catheter, Foley catheter. Plan: Transfer to Burn Unit.
01/13/02	01/13/02	History Sheet and Progress Notes	66-67	Superficial and deep burns 35% body surface. Partial thickness burns head, neck, face, chest, bilateral upper extremities, upper back, right thigh. Parkland Formula resuscitation, escharotomies. Lab: High carboxyhemoglobin. Plan: Monitor urine output.
01/13/02	01/13/02	History Sheet and Progress Notes	70-72, 74-76	Pulmonary Consult: Paralyzed/sedated in field for intubation. Full thickness burns 40% body surface. Elevated left hemidiaphragm, minimum reticulonodular opacity. Resuscitated/sedated/ventilated in hospital. Assessment: Significant inhalation injury/residual problems. Procedure: Fiber Optic Bronchoscopy under sedation, saline lavage. Findings: Minimal swelling, diffuse deposits soot in trachea, bilateral bronchi, all lobes. Plan: Bronchoscopy/lavage airways. Medication: Fentanyl, Versed, Lidocaine.
01/13/02	01/13/02	Chart Notes	75	Opthalomy consult: Left lid extreme swelling, conjunctiva fluid filled, cornea relatively clear. Rule out surface burn to cornea.
01/13/02	01/13/02	Conscious Sedation Management Plan	77	Standard Monitoring: EKG, pulse oximeter, respiration followed by watching chest movements. Airway anesthesia: Dyclone gargle, Lidocaine nebulizer, Lidocaine spray. Conscious intravenous sedation: Benzodiazapams. Antibiotics: Flumazenil, Narean. Narcotics: Fentanyl, Morphine.
01/14/02	01/14/02	History Sheet and Progress Notes	27, 30	35% full thickness burns face, neck, right shoulder, right flank, right upper extremity, right thigh. Bronchoscopy confirmed severe inhalation injury. Resuscitation with colloid/crystalloid. Escharaotomies performed in right upper extremities. Assessment: Poor prognosis, do not resuscitate status requested. Medication: Heparin, discontinued Coumadin.
01/14/02	01/14/02	Chart notes	83	Plan: Continue sedation, Methanolo/Amio Amiodarone, ventilation support, fluid resuscitation.
01/15/02	01/15/02	History Sheet and Progress Notes	33	Illegible
01/16/02	01/16/02	History Sheet and Progress Notes	34	Notes Burn Unit: Severe tone right upper extremity. Increased residuals. Left hand splint. Initial prognosis poor, presently improving. Plan: Allograft chest/arm, continue burn intensive care unit nursing/monitor.
01/16/02	01/16/02	History Sheet and Progress Notes	40	Hemodynamically stable, good oxygenation and urine output. Plan: Tomorrow - excise anterior torso/right leg burn, place allograft.
01/16/02	01/16/02	Coding Summary	4
01/17/02	01/17/02	Discharge Summary	22	Page 1: Debridement/allograft right upper extremity/right chest.
01/17/02	01/17/02	Post-operative Progress Notes	41
01/18/02	01/18/02	Chart Notes	42	Decreased urine output. Give aggressive fluids.
01/19/02	01/21/02	History Sheet and Progress Notes	43, 44, 49	Illegible
01/22/02	01/22/02	Coding Summary	4	Debridement/allograft left upper extremity/left leg, allograft right thigh.
01/22/02	01/22/02	Discharge Summary	22
01/22/02	01/22/02	Post-operative Progress Notes	51	Debridement and allograft left upper extremity, allograft right thigh.
01/23/02	01/23/02	History Sheet and Progress Notes	53, 54	Post-op status day #1: Stable condition post debridement/allograft of left upper extremity full thickness burn. Plan: Continue dressing. Elevation, wound care.