Preview
FILED: BROOME COUNTY CLERK 03/27/2024 03:53 PM INDEX NO. EFCA2024000793
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/27/2024
LOURDES
169 Riverside Drive, Binghamton, New York 13905
PATIENT: H ,NIIMP
MRN: 89-58-44 DOB: M2011
ADMIT DATE: 10/9/2022 FIN: 9918486011
DISCHARGE DATE: 10!9/2022
Emergency Department Note-Physician
Document Name: Emergency Department Note-Physician
Service Date/Time: 10/9/2022 15:53 EDT
Result Status: Modified
Performed Information: Greenland,Christopher MD (11/10/2022 07:04 EST); Penree.
Elisabeth PA (10/9/2022 15:53 EDT)
Signed Information: Greenland,Christopher MD (11/10/2022 07:04 EST); Penree.
Elisabeth PA (10/9/2022 16:20 EDT)
Addendum by Greenland, Christopher E on November 10, 2022 07:04:39 EST
I was availbkr for imrnediate consultation for the APP at the time of this encounter but did not personally perform a history or
examination of this patient. Based on the medical record, the care seems appropriate.
This document Wasauthenticated by Greenland, Christopher MD MD on 11/10/2022 07:04 AM
Item was sent for review to Greenland, Christopher MD MD Review cornpleted on 11/10/2022 07.04 AM
DATE OF SERVICE:
October 09, 2022 ..
HISTORY SOURCE:
Patient, patients grandfather
CHIEF COMPLAINT:
Patient to ED via EMSfor clo lower left leg pain after several pieces of lumber fell on leg while shopping at Lowe's with father. CMS +
HISTORY OF PRESENT ILLNESS:
This is a generally heahby 11-year-old boy presents the emergency department with his grandfather for the evaluation of some left leg
and ankle pain. They were at Lowe's shopping prior to arrival and stack of plywood tipped and fell onto the patients leg. It pinned the
leg under at the level of the distal tibia and fibula. They waited an hour or so after the accident but the patients pain worsened so
guardian brought him in for evaluation. He cannot put any weight on the foot. There is mild swelling and bruising about the ankle area
and distal tib1a-fibula area. He denies any prior fractures or broken bones in the past. He has no medical problems. He is othervase in
no acute distress. Denies any numbness, tingling, or weakness.
REVIEW OF SYSTEMS:
Reviewof Systems is as per HPI. All other systems reviewed and negative.
PROBLEM LIST/PAST MEDICAL HISTORY:
WCC (well child check)
Historical
No qualifying data
HOME MEDICATIONS:
Home Medications (2) Active
acetaminophen 160 mg/5 mL oral liquid 320 mg = 10 mL, PRN, PO (oral), q4hr
Children's Chewable Multivitamins oral tablet, chewable 1 tab(s), Chewed, qDay
Print Date/Time: 5/19|2023 06:1 I EDT Report ID: 171664678
Page 1 of 4
FILED: BROOME COUNTY CLERK 03/27/2024 03:53 PM INDEX NO. EFCA2024000793
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/27/2024
LOURDES
PAT1ENT: H 1,A DOB: 011
MRN: 89-58-44 FIN: 9918486011
Emergency Departrnent Note-Physician
ALLERGIES:
NKA
SOCIAL HISTORY:
Tobacco/Nicotine
Exposure to Tobacco Smoke No exposure to srroke/nicatine , 03/07/2019
PHYSICAL EXAM:
VITALS AND MEASUREMENTS:
T: 36.6 "C (Oral) T: 97 9 'F (Oral) TMIN: 36.6 "C (Oral) TMAX: 97 9 'F (Oral) HR: 91 RR: 18 BP: 127R7 SpO2: 99%
WT: 31.7 kg
General: The patient is a well developed, well nourished 11-year-old child in no acute distress. Skin warm and dry. The patient is sitting
comfortab¥ in the wheelchair.
Head: Norrnocephalic. atraumatic.
HEENT: Pupils round, equal and react to light ENT - WNL. Mucosa moist.
NecIc supple. Trachea mid-line.
Lungs: Clear bilaterally with no rales, rhonchi, or wheeze.
Heart: Regular rhythm at normal rate is present without murmur, rub, or gallop.
Abdomen: Flat, soft, and non-tender with positive BS.
Extremities: Full RoM in all extremities. Left ankle with some tenderness at the distal tibial and fibular region. There is mild ecchymosis
without any significant swelling. Distal pulses are full and equal. He can plantarflex however dorsiflexion is very painful. Compartments
soft. Extremity is neurovascularly intact
Neurological: Awake, alert and age appropriate.
DIAGNOSTIC RESULTS:
XR Tibia/Fibula Left
10/09/22 15:14:32
EXAM
XR TIBIA/FIBULA LEFT
ORDERING PROVIDER:
CLINICAL HISTORY:
lumber fell on leg and foot, pain
COMPARISON STUDY:
Trauma pain
TECHNIQUE:
2 views of the left tibia and fibula were obtained.
FINDINGS:
Obliquey oriented fractures of the distal tibial fibula diaphysis is present
with minimal displacement. No other fracture is identified. No osseous
destructive lesion is present. Joint spaces preserved.
IMPRESSION:
1. Obliquely oriented distal tibia and fibula diaphyseal fractures with minimal
displacement
This document has been authenticated by Steven Martin, MD on 10/9/2022 3:14 PM.
Thank you for referring your patient to Lourdes Diagnostic Imaging.
Print Date/Time: 5/19/202306:11EDT ReportTD: 171664678
Page 2 of 4
FILED: BROOME COUNTY CLERK 03/27/2024 03:53 PM INDEX NO. EFCA2024000793
NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/27/2024
LOURDES
PAT1ENT: , /mmlunt DOB: 011
MRN: 89-58-44 FIN: 9918486011
Emergency Departrnent NOte-Physician
Signed By: Martin MD, Steven
CARDIOLOGY RESULTS:
No qualifying data available.
ED COURSE:
Medication Dose Route Frequency
ibuprofen (Motrin) 320 mg PO (oral) Susp Now
Nursing notes reviewed.
X-rays show nondisplaced tibia and fibular fracture. Case discussed with Dr. Reynolds orthopedics who states this will likely heal
without any issues and we can place him in a splint or a walking boot and have him rernain nonweightbearing with crutches and he will
follow-up with him in the office next week. All recommendations discussed with patients grandfather. We placed him in a U-splint and
patient remains neurovascular intact after splint application. Crutches provided and crutches training provided by the RN. Advised
them to continue with rest, elevation, icing Motrin, do not get the splint wet or soiled in any way. To follow-up with orthopedics as
directed To return to the ER for any new or worsening symptoms Patient's grandfather verbalizes understanding and is agreeabb to
plan.
DIAGNOSIS AND IMPRESSION:
Diagnosis ClassIfIcatIon DX Type
Admitting
Other fracture of lower end of left tibia, initial encounter for closed fracture Medical Discharge
Other physeal fracture of lower end of left fibula initial encounter for closed fracture Medical Discharge
PLAN:
Inoatient
Mot3in, 320 mg= 16 mL. 10 mg/kg, PO (oral), Now
Home
acetaminophen 160 mg/5 mL oral thuid 320 mg= 10 mL, PO (oral), q4hr, PRN Not taking
Children's Chewable Multivitamins oral tabiet, chewable, 1 tab(s), Chewed, qDay, 3 refills
This document was authenticated by R¤nree, Elisabeth Wm on f0/D9/2022 04:20 PM
Print DatefTime: 5/19|2023 06:1 1EDT Report m: 171664678
Page 3 of 4
Preview
FILED: BROOME COUNTY CLERK 03/27/2024 03:53 PM INDEX NO. EFCA2024000793 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/27/2024 LOURDES 169 Riverside Drive, Binghamton, New York 13905 PATIENT: H ,NIIMP MRN: 89-58-44 DOB: M2011 ADMIT DATE: 10/9/2022 FIN: 9918486011 DISCHARGE DATE: 10!9/2022 Emergency Department Note-Physician Document Name: Emergency Department Note-Physician Service Date/Time: 10/9/2022 15:53 EDT Result Status: Modified Performed Information: Greenland,Christopher MD (11/10/2022 07:04 EST); Penree. Elisabeth PA (10/9/2022 15:53 EDT) Signed Information: Greenland,Christopher MD (11/10/2022 07:04 EST); Penree. Elisabeth PA (10/9/2022 16:20 EDT) Addendum by Greenland, Christopher E on November 10, 2022 07:04:39 EST I was availbkr for imrnediate consultation for the APP at the time of this encounter but did not personally perform a history or examination of this patient. Based on the medical record, the care seems appropriate. This document Wasauthenticated by Greenland, Christopher MD MD on 11/10/2022 07:04 AM Item was sent for review to Greenland, Christopher MD MD Review cornpleted on 11/10/2022 07.04 AM DATE OF SERVICE: October 09, 2022 .. HISTORY SOURCE: Patient, patients grandfather CHIEF COMPLAINT: Patient to ED via EMSfor clo lower left leg pain after several pieces of lumber fell on leg while shopping at Lowe's with father. CMS + HISTORY OF PRESENT ILLNESS: This is a generally heahby 11-year-old boy presents the emergency department with his grandfather for the evaluation of some left leg and ankle pain. They were at Lowe's shopping prior to arrival and stack of plywood tipped and fell onto the patients leg. It pinned the leg under at the level of the distal tibia and fibula. They waited an hour or so after the accident but the patients pain worsened so guardian brought him in for evaluation. He cannot put any weight on the foot. There is mild swelling and bruising about the ankle area and distal tib1a-fibula area. He denies any prior fractures or broken bones in the past. He has no medical problems. He is othervase in no acute distress. Denies any numbness, tingling, or weakness. REVIEW OF SYSTEMS: Reviewof Systems is as per HPI. All other systems reviewed and negative. PROBLEM LIST/PAST MEDICAL HISTORY: WCC (well child check) Historical No qualifying data HOME MEDICATIONS: Home Medications (2) Active acetaminophen 160 mg/5 mL oral liquid 320 mg = 10 mL, PRN, PO (oral), q4hr Children's Chewable Multivitamins oral tablet, chewable 1 tab(s), Chewed, qDay Print Date/Time: 5/19|2023 06:1 I EDT Report ID: 171664678 Page 1 of 4 FILED: BROOME COUNTY CLERK 03/27/2024 03:53 PM INDEX NO. EFCA2024000793 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/27/2024 LOURDES PAT1ENT: H 1,A DOB: 011 MRN: 89-58-44 FIN: 9918486011 Emergency Departrnent Note-Physician ALLERGIES: NKA SOCIAL HISTORY: Tobacco/Nicotine Exposure to Tobacco Smoke No exposure to srroke/nicatine , 03/07/2019 PHYSICAL EXAM: VITALS AND MEASUREMENTS: T: 36.6 "C (Oral) T: 97 9 'F (Oral) TMIN: 36.6 "C (Oral) TMAX: 97 9 'F (Oral) HR: 91 RR: 18 BP: 127R7 SpO2: 99% WT: 31.7 kg General: The patient is a well developed, well nourished 11-year-old child in no acute distress. Skin warm and dry. The patient is sitting comfortab¥ in the wheelchair. Head: Norrnocephalic. atraumatic. HEENT: Pupils round, equal and react to light ENT - WNL. Mucosa moist. NecIc supple. Trachea mid-line. Lungs: Clear bilaterally with no rales, rhonchi, or wheeze. Heart: Regular rhythm at normal rate is present without murmur, rub, or gallop. Abdomen: Flat, soft, and non-tender with positive BS. Extremities: Full RoM in all extremities. Left ankle with some tenderness at the distal tibial and fibular region. There is mild ecchymosis without any significant swelling. Distal pulses are full and equal. He can plantarflex however dorsiflexion is very painful. Compartments soft. Extremity is neurovascularly intact Neurological: Awake, alert and age appropriate. DIAGNOSTIC RESULTS: XR Tibia/Fibula Left 10/09/22 15:14:32 EXAM XR TIBIA/FIBULA LEFT ORDERING PROVIDER: CLINICAL HISTORY: lumber fell on leg and foot, pain COMPARISON STUDY: Trauma pain TECHNIQUE: 2 views of the left tibia and fibula were obtained. FINDINGS: Obliquey oriented fractures of the distal tibial fibula diaphysis is present with minimal displacement. No other fracture is identified. No osseous destructive lesion is present. Joint spaces preserved. IMPRESSION: 1. Obliquely oriented distal tibia and fibula diaphyseal fractures with minimal displacement This document has been authenticated by Steven Martin, MD on 10/9/2022 3:14 PM. Thank you for referring your patient to Lourdes Diagnostic Imaging. Print Date/Time: 5/19/202306:11EDT ReportTD: 171664678 Page 2 of 4 FILED: BROOME COUNTY CLERK 03/27/2024 03:53 PM INDEX NO. EFCA2024000793 NYSCEF DOC. NO. 4 RECEIVED NYSCEF: 03/27/2024 LOURDES PAT1ENT: , /mmlunt DOB: 011 MRN: 89-58-44 FIN: 9918486011 Emergency Departrnent NOte-Physician Signed By: Martin MD, Steven CARDIOLOGY RESULTS: No qualifying data available. ED COURSE: Medication Dose Route Frequency ibuprofen (Motrin) 320 mg PO (oral) Susp Now Nursing notes reviewed. X-rays show nondisplaced tibia and fibular fracture. Case discussed with Dr. Reynolds orthopedics who states this will likely heal without any issues and we can place him in a splint or a walking boot and have him rernain nonweightbearing with crutches and he will follow-up with him in the office next week. All recommendations discussed with patients grandfather. We placed him in a U-splint and patient remains neurovascular intact after splint application. Crutches provided and crutches training provided by the RN. Advised them to continue with rest, elevation, icing Motrin, do not get the splint wet or soiled in any way. To follow-up with orthopedics as directed To return to the ER for any new or worsening symptoms Patient's grandfather verbalizes understanding and is agreeabb to plan. DIAGNOSIS AND IMPRESSION: Diagnosis ClassIfIcatIon DX Type Admitting Other fracture of lower end of left tibia, initial encounter for closed fracture Medical Discharge Other physeal fracture of lower end of left fibula initial encounter for closed fracture Medical Discharge PLAN: Inoatient Mot3in, 320 mg= 16 mL. 10 mg/kg, PO (oral), Now Home acetaminophen 160 mg/5 mL oral thuid 320 mg= 10 mL, PO (oral), q4hr, PRN Not taking Children's Chewable Multivitamins oral tabiet, chewable, 1 tab(s), Chewed, qDay, 3 refills This document was authenticated by R¤nree, Elisabeth Wm on f0/D9/2022 04:20 PM Print DatefTime: 5/19|2023 06:1 1EDT Report m: 171664678 Page 3 of 4