case_2

2023

• Present, Symptom, Low back.

  Low back pain x 2 wks

• Present, Symptom, Low back.

  Pt reports achy low back pain for approx 2 wks after lifting furniture

• Present, Symptom, Low back.

  Pain 5/10, no radiation

  • Wording and label may disagree. quote has 'no' but the assertion is 'present'

• Denied or absent, Symptom.

  No numbness or weakness

• Present, Medication.

  Has been taking ibuprofen

• Present, Vital sign.

  BP 130/82 HR 78

• Present, Exam, Bilateral L-spine.

  TTP L4-L5 paraspinals bilat

• Denied or absent, Exam, Bilateral L-spine.

  SLR neg bilat

• Present, Exam, L-spine.

  flexion limited to 65 deg

• Present, Exam.

  strength 5/5, DTR 2+ symmetric

• Present, Diagnosis, Lumbar.

  Lumbar strain — S39.012A

• Present, Plan.

  Ibuprofen PRN, stretching handout

• Present, Plan.

  F/u PRN

2024

• Present, History.

  Wet (runoff from misting display)

• Denied or absent, History.

  None observed at time of incident

• Present, History.

  Customer was walking through the produce aisle and slipped near the misting display

• Present, History, Right right hand.

  Customer fell and stated he "put my right hand out to catch myself."

• Present, Symptom, Right right wrist.

  Customer complained of right wrist pain

• Denied or absent, Symptom, Head.

  Customer denied hitting his head

• Denied or absent, Symptom, Back.

  denied back pain at that time

• Present, History.

  Customer declined and stated his wife would drive him to Fairview Urgent Care

• Present, History, About someone else.

  | Nakamura, Joy | Produce clerk | "He went down hard. The floor was soaking wet there." |

  • More than one fact in one line. the quote may hold more than one fact

• Present, Symptom, Left left wrist.

  Left wrist pain after fall

• Present, History, Left left hand.

  slipping on a wet floor at a grocery store and falling onto his outstretched left hand

• Present, Symptom, Left left wrist.

  Pt reports left wrist pain 7/10 with swelling

• Denied or absent, Symptom, Head.

  Denies head strike

• Denied or absent, Symptom.

  denies LOC

• Denied or absent, Symptom, Back.

  denies back pain

• Denied or absent, Symptom.

  denies numbness or tingling

• Denied or absent, History, Wrist.

  Denies prior wrist injury

• Denied or absent, History.

  NKDA

  • Quote may be too short to stand alone. the quote is a single word and may not stand alone

• Present, Vital sign.

  | BP | 136/84 |

• Present, Vital sign.

  | HR | 84 |

• Present, Vital sign.

  | RR | 16 |

• Present, Vital sign.

  | Temp | 98.2 F |

• Present, Vital sign.

  | SpO2 | 99% RA |

• Present, Exam.

  NAD, A&O x3

• Present, Exam, Left L wrist.

  swelling and TTP over distal radius

• Present, Exam, Left L wrist.

  ROM limited by pain

• Present, Exam, Left L wrist.

  cap refill < 2 sec

• Present, Exam, Left L wrist.

  sensation intact

• Present, Exam, Right R wrist.

  R wrist: Normal

• Denied or absent, Exam, Thoracic or lumbar spine.

  Back: No TTP thoracic or lumbar spine

• Present, Imaging, Left L wrist.

  Transverse fracture of the distal radius, minimally displaced

• Denied or absent, Imaging, Left L wrist.

  No intra-articular extension

• Present, Diagnosis, Left distal radius, left.

  Closed fracture of distal radius, left — S52.502A

• Present, Procedure.

  Volar splint applied

• Present, Medication.

  Rx: ibuprofen 600 mg PO q6h PRN

• Present, Referral.

  Ortho referral within 1 week

• Present, Plan.

  Return precautions given

• Present, Symptom, Left L wrist.

  L wrist pain 5/10, improved in splint

• Present, Symptom, Low back.

  Pt now c/o low back pain x ~5 days, achy, 4/10, no radiation

  • Wording and label may disagree. quote has 'no' but the assertion is 'present'
  • More than one fact in one line. the quote may hold more than one fact

• Denied or absent, Symptom, Low back.

  no radiation

• Present, History, Back, Mentions May 13, 2024.

  Pt states he was moving boxes at work on 5/13 and back "got worse after that."

  • Date was worked out, not printed. date inferred: year taken from 2024-05-16; ambiguous: could also be month/year 05/2013, check the page

• Present, Medication.

  Taking ibuprofen

• Present, Exam, Left L wrist.

  swelling decreased, TTP distal radius, cap refill normal

  • More than one fact in one line. the quote may hold more than one fact

• Present, Exam, Bilateral L-spine.

  TTP L4-L5 paraspinals bilat

• Denied or absent, Exam, Bilateral L-spine.

  SLR neg bilat

• Present, Exam, L-spine.

  flexion limited to 60 deg

• Present, Imaging, Left L wrist.

  distal radius fracture, no interval displacement

  • Wording and label may disagree. quote has 'no' but the assertion is 'present'

• Present, Diagnosis, Left distal radius, left.

  Closed fracture of distal radius, left — S52.502D

• Present, Diagnosis, Low back.

  Low back pain — M54.50

• Present, Procedure, Left wrist.

  Short-arm cast applied today

• Present, Medication.

  Continue ibuprofen PRN

• Present, Plan.

  Recheck 5 wks; PT referral if back pain not improving

  • Wording and label may disagree. quote has 'not' but the assertion is 'present'
  • More than one fact in one line. the quote may hold more than one fact

• Present, Symptom, Left L wrist.

  L wrist pain 1/10

• Present, Symptom, Back.

  Back pain mostly resolved, 1/10

• Present, Procedure.

  Cast removed

• Present, Exam, Left L wrist.

  mild stiffness, minimal TTP, flexion 55, extension 50

  • More than one fact in one line. the quote may hold more than one fact

• Present, Imaging, Left L wrist.

  healing distal radius fracture with callus formation, alignment maintained

• Present, Diagnosis, Left distal radius, left.

  Closed fracture of distal radius, left, healing — S52.502D

  • More than one fact in one line. the quote may hold more than one fact

• Present, Diagnosis, Low back.

  Low back pain, improving — M54.50

• Present, Plan, Left wrist.

  Home exercise program for wrist ROM and grip

• Present, Plan.

  RTC PRN