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~· .. . . <br />MRN: 9066488 <br />Visit: 9000406554 <br />! UC Irvine Healthcare DOE, ISOLA TE 16394 <br />Gender: Female 1 Location: Emergency <br />_ _ . __ __ _ ,_ t?.~P.~r.t!:!)ent __ Ag~: !J~y __ (Q1-!)1 .:-1899) .. _ <br />Emergency Physician Treatment Record [06-23-2013 10:461-for Visit: 9000406554, Final, <br />Entered, Signed in Full, General <br />History of Present Illness: <br />A 114 year old female patient presented with . <br />Onset <br />Location <br />Duration <br />Character <br />Severity <br />Associated Symptoms <br />Contributing History <br />Past Medical, Family and Social History: <br />Past Medical History <br />Past Surgical History <br />Family History <br />Social History <br />Review of Systems: <br />System Review <br />Nursing/Medications Reviewed : <br />Nursing/Medications Reviewed <br />Physical Exam: <br />General <br />HEENT <br />Chest <br />CVS <br />Abdomen <br />Back <br />Extremities <br />Neurologic <br />Skin <br />Procedure Note: <br />Procedure Note <br />Medical Decision Making: <br />Impression/MOM <br />Assessment and Plan : <br />Plan <br />Diagnosis <br />sudden acute <br />chest <br />pta <br />gsw <br />severe <br />apneic, cardiac arrest <br />20 yo female , BIBA s/p GSW to left upper back and <br />right upper back. arrives in cardiac arrest. no pulse <br />for greater than 20 minutes. cpr in progress. <br />unknown <br />unknown <br />unkp9wn <br />unknown <br />unknown <br />nursing notes and vital signs reviewed <br />unresponsive <br />pupils are dilated and fixed <br />breath sounds with BVM <br />asystole <br />soft nontender nondistended <br />BSW to bilateral upper back <br />no pu lses, cyanotic <br />GCS 3, unresponsive <br />cyanotic, mottled <br />A 7.5 mm tube was inserted to a depth of 23 cm at <br />the teeth . One attempt. The tube was secured in <br />the standard fashion using a gl idescope . There were <br />no complications . <br />full arrest, trauma/ GSW, time of death called by <br />trauma fellow . <br />intubation <br />chest tube <br />thoracotomy <br />traumatic full arr est <br />. .. --. -. .. <br />Requested by:_96:2~-201~ t 1 :3? _ Page 1 of 2