These were culled on the weekend;
patient states
she thinks her "bladder has come out" after a coughing spell.
Admits to drinking liquor regularly in the past, but states
that for the last past month he “ain’t been drinking nothing but a pint of wine a day”.
Pt reports he
does not know how many times he was shot.
He states he was just walking around outside and fell to the ground
after being shot. He denies being
involved in an altercation and states he was just minding his business.
weakness
related to the exercise of rest, dysphagia but he admitted having the
hoarseness of the voice.
Patient denies
any IV drug use. He denies any recent
surgeries. Patients only recent trauma
he states was about 3 weeks ago when he ran from a cop and lost his shoes
causing bad cuts to the bottom of both his feet.
Reports he has
stopped drinking but was drinking a 30pack within 2 hours. (I guess stopping for two hours counts)
presents with
rectal foreign body x 2. He states he placed these into his rectum 2 days ago
and has not been successful at retrieving them. He has done this in the past
and cannot state what possesses him to do so.
The objects are a baby bottle and several marbles. An attempt was made to remove the objects at
the bedside, without success. The bottle
is the most distal of the objects and is turned sideways and is projecting up
into his pelvis. Enemas, digital
probing, and plastic forceps were unsuccessful in dislodging the bottle. We will take him to the OR for rigid
proctoscopy to attempt to remove it. If
that is unsuccessful, laparotomy will be needed.
Op Note
Findings: Baby bottle and 23 marbles
removed from the rectum
History and Physical [Date 00:10], Visit:, Incomplete, Entered, Signed in Full, General
Chief Complaint:
i am not eating enough and loss of appetite. (but this needs to be attended to at midnight on Saturday in the ED)
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