Mom Said
From the patient record for JESSUP,TIMOTHY
Progress note by Dr. Major, MD
Patient is a 43 y.o male admitted to surgical unit after presenting to emergency department with acute back pain and concussion coincident with recent fall. The history is provided primarily by patient's wife.
The current episode started today. Onset was result of a fall from roof of the patient's home. Pain is continuous and is described as sharp and extremely severe. Pain is worsened by activity.
Patient was put on saline glucose and #3 morphine drip upon arrival in emergency department. Patient reported decreased pain upon receipt of morphine, but has become disoriented and semiconscious. Recommend remaining on #3 only until admitted to med surg, at which point pt should be switched to #2 morphine drip.
Episode history as provided by pt's wife is as follows. Pt's wife reports pt's injury is due to a fall from the roof of their house. Pt was attempting to adjust exterior television antenna when he lost his footing on the roof. Pt landed on his back on concrete patio. Wife reports that pt lost consciousness briefly, but regained it before ambulance arrived. Pt reported pain at that time as extremely severe.
Tentative diagnosis at this time is spinal cord injury at multiple sites with possible spinal fractures. Consulting surgeon scheduled for examination and probable surgery at 1300 hours.
Prior history of back pain: none.
Prior history of falls: none.
Diet: NPO.
Activity: strict bed rest.
Next round on pt scheduled for 0800 tomorrow.
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