History of Present Illness (HPI)
A 12 year old female patient is experiencing auditory hallucinations, severe head pain, and is presenting with abnormal posture. Patient has open lesions on face and hands with skin discoloration and has experienced incontinence since onset of auditory hallucinations. Excessive projectile vomiting. When I examined patient during physical exam 3 months ago, she was not experiencing any of these symptoms. This is the first episode reported by the patient and her family. No T/A/D. Patient denies weakness despite abnormal posture. 101.3F fever has appeared periodically for past 7 days.
Allergies: NKDA Current Medications: None
Constitutional: BP 140/90 mmHg, Pulse 88, Resp 18, Pulse Ox 98%. Pt does not appear well-groomed.
Neck: Supple, no jugular venous distention, no lymphadenopathy
Respiratory: Normal breath sounds, no SOB
Skin: Ulcers on cheeks and arms, lacerations on arms
Medical Decision Making (MDM)
Assessment: Hallucinations, headache, open wounds, face/hands
Plan: MRI brain, psych consult
Return after tests done.
Electronically signed by Dr. Klein
What were your audit results?
Bonus: Which classic horror film is our patient from?