Friday, September 2, 2011

A 3 month follow-up surprise

The nursing note stated, "here for follow-up."

My next patient was a 35 y/o male who was usually followed by a partner who had to leave on a family emergency earlier in the day.

I quickly reviewed his medical record.

He was being followed for hypertension and diabetes, was recently started on a cholesterol lowering medication, and was being brought back for a follow-up appointment.

Cool, I figured, should be straightforward.

I opened the door to the waiting room and called out his name.

A male with a complete cervical halo, including the skull bolts, arose from a chair and walked to me.

Obviously, I was surprised.

After confirming his identity and a quick greeting, I brought him to an exam room and excused myself.

I sprinted back to the privacy of my office for a more thorough chart review.

He had just been seen three months earlier.

The note from that visit was incredibly complete (I'm always amazed by this one partners office notes).

No where did I find mention of a cervical halo, previous neck injury, phone calls to our office about an accident, consultation notes, etc..

I went back to the exam room and just decided to say, "so, how is everything going?"

Luckily he was able to fill me in without having to ask any other questions.

He had, since last here, sustained severe chemical burns to the back of his neck and undergone three skin graft procedures. Due to the severity of the burns and location of the grafts, he was placed in the cervical halo in order to prevent any neck movement to give the grafts the best chance of taking.


Had never seen that before.

Me: You've had quite an interesting three months since you were last here.

Patient: I sure have.

His blood pressure and diabetes were well controlled. I totally forgot to check on how his cholesterol was doing, however.

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