ADMISSION HISTORY AND PHYSICAL EXAM
0345 March 10
Informant: Patient (reliability poor)

History of Present Illness:

Jane Doe is an approximately 20-year-old female who was transported by ambulance to the Emergency Department after being found unresponsive in front of the local bus station.

Bystander accounts obtained by Emergency Medical Services describe Ms. Doe as walking down the steps without abnormalities of gait, and "falling right over" after opening the door to the bus station.

Jane herself exhibits symptoms of altered mental status, including global paranoia, combativeness, agitation interspersed with periods of unresponsiveness, and a significant persecution complex. She repeatedly makes statements such as, "He'll kill me if they find out" and "you've got to help me hide". She refuses to divulge any identifying information, such as age or name.

In addition to changes in mental status, Jane was also noted to have copious bleeding during transportation, apparently vaginal in nature. She refuses to give any information about the duration of this bleeding, or the date of her last normal menstrual period.

Past medical and social history are unobtainable.

Physical Exam:

Temperature 104.3, respiratory rate 28. Pulse and blood pressure unobtainable after three attempts.

Height and weight are 64 inches and 59 kilograms

General appearance is agitated. A scrape is noted across the patient's forehead on head exam. Breath sounds are clear with good aeration bilaterally. Unable to auscultate heart sounds. Capillary refill two seconds peripherally. Abdominal exam reveals diffuse tenderness without signs of peritoneal involvement with greatest tenderness in suprapubic area. Bowel sounds are present. Extremities are cyanotic with mild clubbing of all digits. Pitting edema is noted on exam of lower extremities, extending to mid-ankle. Several black armbands and thigh rings appear permanently affixed to the patient's upper arms and thighs with maceration of adjacent skin. Many well healed sternal and abdominal scars are also noted. Genitourinary exam deferred at this time. The patient is intermittently combative, and secured in four point restraints.

Lab work:

White blood cell count is elevated to 26,400 with a left shift of 9% band forms and 81% neutrophils. Hemoglobin level in the low-normal range. C-reactive protein extremely elevated. Urine pregnancy test is positive. Urine and serum toxin screens are pending. A blood culture has been drawn and is pending.

Assessment:

This is an approximately 20-year-old female with mental status changes and fever; observed loss of consciousness times one, and presumed vaginal bleeding with positive urine pregnancy test.

Plan:

2. Given fever and elevated white blood cell counts, must consider infectious etiologies such as meningitis, pneumonia, or pelvic inflammatory disease. Start IV antibiotic therapy with linazolines and therianthrenes. Perform lumbar puncture and send cerebrospinal fluid cultures for analysis before transfer to inpatient service.

4. Urine and serum toxicology screens are pending to rule out drug or toxin ingestion as a cause of mental status changes and fever.

6. Patient with signs and symptoms of congenital heart or lung disease (clubbing and cyanosis of fingertips). Cardiology consult service called; they will also evaluate later this morning. Recommend obtaining EKG after transfer to obstetric service.

Pravti Buehl MD

NURSING PROGRESS NOTE
0540 March 10
Focus: Admission

Patient transported to Obstetric unit at 0520; currently sleeping soundly. Continued vaginal bleeding noted on bed linens. Unable to obtain pulse and blood pressure after six attempts (two attempts with manual cuff). House officer notified. Automated sphygmomanometer sent to Maintenance for recalibration. Will plan to do full assessment next shift as patient is otherwise stable.

C. Kawicki RN

MEDICAL STUDENT PROGRESS NOTE
0630 March 10
Subjective:

Patient is awake and cooperative to examination despite some grogginess. She is still agitated and refusing to give her name. She is repeating frequently that she "needs to get out of here" and that she will be "hunted down by the doctors". Per nursing, there are no new issues since admission. Patient has been afebrile for the last three hours.

Objective:
Respiratory rate 24
Current temperature 98.8
Pulse and blood pressure not recorded.

Patient is alert and oriented to person, place, and time despite grogginess and residual agitation. Breath sounds are distant and decreased at bases of lungs bilaterally. Despite cooperation of patient, could not auscultate heart sounds. Abdomen is mildly tender to palpation but undistended. Liver edge palpable four centimeters below the rib margin. Extremities with digital clubbing. Pitting edema noted to mid-calf. On speculum exam, copious bleeding is noted from os of cervix.

Labwork:
Urine and serum toxin screens are negative.
Blood culture and spinal fluid cultures without growth to date.
Transabdominal ultrasound:
Full bladder without malformations. Placenta present but partially detached from uterine wall. Fetal remnant present. No heartbeat detected. Cephalocaudal measurement indicates 13-15 week gestation.

Assessment:
20 year old female with psychiatric disturbance and uterine bleeding, likely secondary to spontaneous incomplete abortion with retained fetal products.

Plan:

1. Monitor patient. Suicide precautions in place.

2. Continue IV antibiotics. Will redraw blood cultures if the patient has fever greater than 101 degrees. Awaiting results of cultures obtained on admission.

3. Will schedule D and C for retained fetal products.

4. Psychology consult pending. Will sedate as needed with Haldol for combativeness.

Jennifer Hua MS3

Agree with above note by medical student. EKG unnecessary. We will await Cardiology's recommendations before obtaining any cardiac studies. We will monitor patient for excessive blood loss and start maintenance IV fluids to prevent dehydration. Pain control with Ibuprofen as needed. This patient is scheduled for dilatation and curettage with conscious sedation at 1300 today. Plan has been discussed with attending physician.

Sam Twente MD

SOCIAL WORK CONSULT
0915 March 10

Chart reviewed and patient seen. Jane Doe is an approximately 20 year old female who refuses to give any identifying information; consult requested to assist in determining payor status, as well as for unspecified social concerns.

Throughout the interview, Jane consistently refused to give name, employer's name (if any), birthdate or social registry number. She did state that she is "younger than she looks", and later told me that she is fifteen years old. However, given documented concerns regarding reliability, this may or may not be accurate.

While Jane showed few signs of agitation, she was clearly worried about an unspecified male or group of males "coming to get her". She did confirm that she had "escaped" from a "very bad place", and she seemed to know nothing about her payor status (despite the laws regarding mandatory school instruction on this subject). When asked about her home situation, she refused to answer, except to tell me that she has "never been to a real school."

Patient repeatedly requested Internodal Data Realm access during the course of this interview, and seems fixated on obtaining such access.

It is possible, and even probable, that this patient has been the subject of abuse in the form of neglect. The possibility of sexual abuse cannot be ruled out at this time. I will send her retinal and fingerprint patterns to the Federal Social Registry. A match should be made within four or five hours, and a legal guardian identified. Given Jane's ignorance of her payor status and statements indicating possible home schooling, her legal guardian or parent is liable for having broken at least one federal statute, allowing for further investigation into the social situation.

Additionally, I would recommend allowing Jane restricted access to hospital data nodes for diversion and recreational purposes. Please limit this patient to pediatric patients' data node only.

Time spent with patient: one hour and fifteen minutes.

DaVonna Washburn LSW

NURSING PROGRESS NOTE
1000 March 10

Focus: IDR Access Patient repeatedly asking for IDR access on bedside data terminal. When told that bedside data terminal access was restricted to hospital care providers only, patient requested lap unit. Patient provided with small lap unit with restricted access, and observed to be immediately engrossed.

C. Kawicki RN

CARDIOLOGY CONSULT
1130 March 10

Chart reviewed and patient seen. Called with request for evaluation of patient with miscarriage and retained fetal products as well as psychiatric issues, due to signs and symptoms of possible cardiac disease. Per my review of information already obtained, the patient was brought to the emergency department after acute loss of consciousness.

The patient refuses to give specific information about any pre-existing heart condition, stating that 'you wouldn't believe me if I did tell you'. She does confirm that she has a 'special heart' and has had multiple surgeries, including several fetal interventions. She also confirms medication use, but cannot identify the medicines more precisely than 'a blue pill and two yellow pills.'

As regards the rest of her past history, she refuses to discuss obstetrical, gynecological, or social concerns in a vehement manner.

Currently, Jane complains of being unable to catch her breath with this symptom worsening with prone position, a 'heaviness in her chest', some abdominal pain and increased swelling in her legs. However, despite these complaints, she appears more engrossed in an IDR bedside terminal and lap unit than distressed by her symptoms, and most of her attention appears to be focused on the state and national Omninews aud-vid broadcasts.

No blood pressure or pulse are listed in the chart for review despite frequent attempts to obtain data. Per nursing, the automated sphygmomanometer was sent to Maintenance for recalibration and was returned to the inpatient ward with a message that the machine is in perfect working order.

On examination, Jane is sitting upright in bed with an IDR lap unit resting on her bedside tray. She is tachypneic with a shallow breath pattern. Jugular venous pulse is at the angle of the jaw while sitting upright in bed. Breath sounds are distant bilaterally, and completely absent at the bases of the lungs. Heart sounds are inaudible, and pulse was unobtainable both centrally and peripherally. Moderate clubbing of all extremities is noted, with cyanosis and delayed capillary refill of approximately three seconds. Edema is noted to just below the knees. Several black plastic bands are affixed over major arterial supplies just distal to branching from central vascular system. Well-healed sternotomy scars are present on chest.

This patient is in the early stages of congestive heart failure of unknown etiology. I recommend an immediate echocardiogram and EKG for evaluation of heart structure and function. Please discontinue IV fluid due to fluid overload. I would also recommend beginning IV diuretic therapy. Continue current management of gynecologic and obstetric issues.

Cardiology service will follow this patient closely, given the anomalies in her examination. Recommend psychiatry consult be obtained and earliest possible time, and that any match results from Federal Social Registry be communicated to me immediately for the purposes of obtaining prior medical records in light of unusual exam.

J. Busek MD

PROCEEDURE NOTE: D & C
1300 March 10

Dilatation and curettage of retained fetal products was performed with epidural anesthesia and benzodiazepine sedation. Curettage resulted in suctioned removal of 25 grams of tissue. Tissue sent for cytopathology and genetic studies. Estimated blood loss: 350 milliliters. Complications: none.

Sam Twente MD

CARDIOLOGY CONSULT ADDENDUM
1500 March 10

EKG and ultrasound of the heart performed by technician with cardiologist at bedside. Preliminary results markedly abnormal.

EKG consistent with disorganized pulseless electrical activity, a pattern seen only in cardiorespiratory arrest. EKG repeated with the same results. Technician ran internal diagnostic scan and calibration; machine in working order. A third EKG obtained showing pulseless electrical activity.

On echocardiogram, the patient's heart appears to be a large tubular structure without septation or coordinated contractility. Rudimentary pulmonic and aortic valves are present at the origins of the great vessels, augmented by echo dense devices of unknown function. No ventricles are present. No atria are present. Heart blood flow patterns are chaotic.

Throughout procedures, the patient was extremely agitated and required restraints despite several doses of Ativan.

Due to the unusual nature of these findings, I will be sending copies of this echocardiogram to Dr. Weston and Mayo Clinic, and Dr. Al-Bhardwja at Johns Hopkins for their interpretation of these studies.

J. Busek MD

SOCIAL WORK ADDENDUM
1550 March 10

I received a call from the Federal Social Registry. No match was obtained for Jane Doe's retinal pattern. Fingerprints correspond to 87 percent specificity with those of a thirty-two year old female named Coralee Vau-Meyers, now deceased. In light of these findings, patient's social situation becomes highly suspect for illegal immigration status or possible nonapproved conception. I will resend fingerprint and retinal patterns to the FSR for recheck to ensure that clerical error is not responsible for these findings.

Upon informing Jane of these results, her reaction was atypical. She laughed, saying, "I could have told you that." However, she refused to elaborate further.

Highly recommend patient's access to IDR be restricted and bedside terminal removed as patient was reviewing her own chart on bedside terminal as I entered the room. Additionally, lap unit was displaying vid-data from Akasuma HL's public access nodes.

Time spent with patient: thirty minutes.

DaVonna Washburn LSW

NURSING PROGRESS NOTE
1610 March 10
Focus: Removal of IDR Access

Spoke with social worker regarding patient's access to IDR. Patient provided with restricted-access lap unit per notes from day-shift RN. When confronted about viewing restricted information (her own medical records), the patient did not deny viewing said information. Lap unit was displaying secured hospital nodal permissions at that time.

Lap unit abruptly powered down when I attempted to remove it, and rebooted with standard restricted-access screen. I attempted to lock bedside data terminal, but was unable to log on to the hospital nodes.

Data Services was called. After performing a remote evaluation, they stated that there was no record of unit accessing secure nodal permissions. Lap unit removed and bedside data terminal powered down. Charge nurse and house officer informed.

M. Belew RN

PSYCHIATRY CONSULT
1700 March 10

Chart reviewed and patient seen. This patient, Jane Doe, was apparently exhibiting agitation, paranoid behavior, and persecution complex, with further medical history accessible via chart review, including obsessive IDR use.

Jane was sitting up in bed with the room darkened, staring at bedside terminal on which she appeared to be reviewing my curriculum vitae. When asked to desist, the unit abruptly powered down remotely.

Jane was initially unresponsive to conversational attempts. However, she did acquiesce to limited discussion to enable further medical treatment, once the subject of her positive pregnancy test was broached.

After an extensive conversation with many refusals to answer, changes of subject, and evasions, the patient began to speak more freely. Jane describes a history of nonconsensual sexual activity with one person, alternately referred to in terms that would suggest a legal guardian or a workplace supervisor. She does confirm regular menses until approximately two months ago. She states that this supervisor is over the age of eighteen, and repeats that she believes she is approximately 15 years old, although she does not volunteer a birthdate or name.

As our conversation progressed, Jane volunteered further information. Despite an ability to identify various persons, where she is, and what day it is, Jane exhibits what appears to be an acute psychotic break with reality. She describes fetal and childhood surgeries, nonconsensual experimentation with the use of herself and unspecified others as "guinea pigs", and an irrational belief that she is able to manipulate the IDR with her mind alone. She seemed quite entrenched in these beliefs, and did not exhibit much agitation as she extended her persecution complex with statements such as "you don't know it, but you're helping him, and them too" and "it's too late for anyone to do anything for me now".

Before my assessment could be completed, several representatives from the AHL Group Home for Troubled Teenagers arrived with documentation which included thumbprint and retinal pattern matches. Identification of Jane Doe was established. She is a twenty-year-old female named Mylisa Chamberly, institutionalized for inflexible psychosis and inability to perform activities of daily living without supervision. Per the documents presented and the statements of group home representatives, the patient had apparently been missing from the group home for the last week and a half after a history of several months of poor compliance with psychotropic and cardiac medications. A concerted search had been made without any result until this hospital had sent Mylisa's retinal pattern to the FSR for identification matching.

Payor status was established. Care was immediately transferred to AHL group home for outpatient management with close follow-up at the Hetai-Lui clinic for all cardiac concerns. A copy of this chart will be provided to group home representatives to ensure smooth transition of care.

Despite the abruptness of this transfer, it has been my pleasure to be involved with this very unusual patient. Thank you for the consult.

S. Bockis MD

SOCIAL WORK ADDENDUM

1810 March 10

AHL home representatives credentials checked and cleared; payor status established. While questions remain regarding Mylisa's pregnancy, legal guardianship of patient requires discharge into group home care. I will be strongly recommending further follow-up of group home situation.

DaVonna Washburn LSW

NURSING PROGRESS NOTE
1900 March 10, 2046
Focus: Discharge

Patient extremely agitated immediately prior to transfer to group home setting. House officer called. Patient given one dose of Haldol. Patient officially discharged to care of group home at 2030.

M. Belew RN

The End

Bio

Stella Evans is a pediatric resident at the University of Minnesota. She is certain that the sludge at the bottom of her coffee cup is well on the way to achieving sentience.