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., DATE'i.--LCo -q
PATIENT NAME
"9ARMACY
bJ.'
D AES S AG E:
TIME
(;ENT
LL BACK
PATIENT:
DONBROWSKI, Claudine
DATE: 04/11/96
H: 605864-8
DOB: 04/10/65
PROBLEM:
Infected stitch in head.
SUBJECTIVE:
The patient had been very stressed with bad headaches. She was
in an abusive situation. She has been trying to get a divorce from her
.--~' husband.

She was hit in the head with a crowbar by her husband (we will get the emergency room records to confirm the date). She is planning on getting out of town because this was a very bad laceration from a crowbar. She has a stitch that is exposed that she thinks is infected. She is not allergic to anything.

She takes Paxil and Amitriptyline. The Amitriptyline that is
ordered is 100 mg. at bedtime and she feels like that is too much as it makes
her groggy.
OBJECTIVE:
This is a 31 year-old.
Afehrile.
P - 70. BP - 130/90. Wt-
136 lbs. She takes Depo shots so she has irregular periods.
HEENT:
Her forehead has a five inch scar along the hairline on the right
side with what looks like to be a plain or chromic stitch exposed and is with
somewhat of pocket filled with pus around it.
NECK:
Supple.
No adenopathy, thyromegaly, JVD or bruit. Carotids are 2+
and brisk bilaterally.
CHEST:
Clear to auscultation with equal expansion bilaterally.
HEART:
Regular rhythm, Sl, S2 without murmur, gallop or rub.
~"
ABDOMEN:
Soft, nondistended, and nontender.
No hepatosplenomegaly or
masses.
Bowel sounds are normoactive.
EXTREMITIES:
No cyanosis, clubbing or edema.
)
ASSESSMENT:
Infected stitch, head wound which is healer!.
PLAN:
1. Stitch was removed and stp.)-i-su-ipapplierl.
2. No infection seems to he appa~ent.
3. The patient is to increase her Paxil to 2 a day.
4. I wrote her a prescription for Amitriptyline 25 mg. 2 hours before sleep
and told her to get out of town8S snnn as she could which she is
planning to do.
DIXIE HElM, ARNPjll
COTTON-O'NEIL CLINIC
dd: 04/14/96
dt: 04/16/96
,r5cad8 f
03/23/96 20:31
(Bussiness Office Copy)
MR EMERGENCY
jSTORHONT VAIL REGIONAL HEDICAL CENTER
11500 S.W. 10TH STREET
ITOPEKA, KANSAS 66604
IHRN: 124896 PATIENT#: 4.61086.1
P Name:DOHBROWSKI, CLAUDINE H
ooB:04/10/1965 10PAREA:EHD
IRRelative Name: DORAN,JAN
I
'~ddress:
2319 SW BRIARWOODAPTC301
Age: 30 Y IAdmit Dt/Tm: 03/23/96 20:24 IE Relationship: FRIEND
I
, City/St/Zip: TOPEKA
KS 66611 Sex:F
[AdmitType: EHERGENCY
IL Address: 3261 SW RANDOLPH APT F
I
I Cnty Cd: 089.SHAWNEE
S5#:511.74.9645 Race:W [AdmitSource: PHYSICIAN REFERI City/St/Zip: TOPEKA
KS 66611
I
E Home Phone: 913.266.0890
HS: S
[Prior Visit Dt:
I I
I11mPh: (913)267.7823 Wk Ph: (913)357.5251
I
N Employer Phone: 913.296.4596 Ext.
[Rev.Type: B
I
I
T Employer: 0022 TOPEKA STATE HOSPITAL Clerk: RAE IAcc.Dt: 03/23/96 19:30
IG Name: DOMBROWSKI ,CLAUDINE H
I
Occupations: LPN
Religion: DELETE FROM IType: IN THE HOM
IU Relation: PATIENT IS INSU S5# 511.74.9645
[
Employer Address: 2700 W 6TH
[Hade of Arrival: WALK
IA Address: 2319 SW BRIARWOODAPTC301
I
City/St/Zip: TOPEKA
KS 66606
[ Infectious:
Smoker: N
IR City/St/Zip: TOPEKA
KS 66611
[
..................................................................................1 Home Phone: (913)266.0890 DOB: 04/10/65
I
IN5#l 015 BC.PREMEIR BLU
SUB: DOMBROWSKI,CLAUDINE
10# XSA511749645
IEmployer Phone: (913)296.4596 Ext. 9132
I
I Addr 1133 SW TOPEKA BLVD
TOPEKA
KS 66629 Gp# 15030
I Employer: 0022 TOPEKA STATE HOSPITAL
I
N
1 Occupation: LPN
I
SlEmp
1oyer Address: 2700 W 6TH
[
I City/St/Zip: TOPEKA
KS 66606
I
1.......................................\u2022....\u2022.\u2022.
1
..............................................................................
IEHR Phy:
293. ROSE, DOUGLAS
I
t~.lent Complaint: ASSAULT/LAC. FACE
IP.C.Phy:
42 .JACOBY II, ROBERT E,
I
-j
PHY SICIAN:
Exam:
Y NI
1. LOC: Alert, oriented, rational
)( )IHISTORY: ( )See nurse's notes
2. Skin: Warm, dr . color normal
( ()I(l)..
\u2022I \
~...L..
\'
~
\
13. Head: Normocephalic
('it()1.\ .\ .\u2022 .~.\)..:\.a...'-~\'~\~""'~.)?w~~~~.':Th{~.:..~
14. Eyes: Sclerae (.), PERL
()( )1~%;2
l~
&\(~~\'N'~'s\(>J~
t
I5. Ears: Canals& THs clear
( )( )I
~
'"
~ (" \\
\
I6. Nose: No obstruction, discharge
( )()1.Ch": ..~\~. ~~~' 1;_..... ~\;)~
...~\..,.b.y5~~...
I7. Throat: Not inflamed
( )( )1d,S).s.~.......\h.,~\.c.\l't ()"' s\~
I 8. Neck: Supple. no adenopahty
( )()1
I9. Heart: Regular. no S3, murmur
( )( )I-- -- -- -- -- .-- -- .--
--. -- --
-- -- --
.
110. Lungs: Clear on auscultation
( )()1
_
111. Abd.: Soft, no mass, tenderness
( )()1
112. Extremities: No acute disorder
( )( )I.----------------
------
--..--
.
113. Genitalia: No mass, hernia. skin lesion( )()I
~------
IJ~re:F~~~,,,'"
,\".J;\,,<;\~,J:,,-\~.",,~.4\k...(,,'0:"-~\." .,,4..' : t~\. ~~~
...
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~... .
.
IMPRESSION:
.'
e t(;;\'
~'rI-'
-
.
p<:>Q.0\-,",0-~
RNI
C
Cl
C02
Creat.
IbHCG
IGC culture
IChlamydia
IWet Prep
: Blood Cult. x
Coronary Lab
[ Trauma Lab
I
.1EKG
Medical Records
X.RAY S
.................
l-\0Tf? ..\!' !~~~l
.
( )Dictated
me
Orders
RN
Dischar e Plan
( )See Pro ress NotE
. . ..:. ~~ .~~.
:~. ~~
~ .'~
~~
:
: \~~. Y.~
~~~~
' ~\' ~' -'
~~' lJ
\\-:\\. .~j'l'>. ~ ~\':'.-
-
I
\\-< '\u00ab ,",..on
I
I>\\,Q ,,\
'~\
">.,..-.\\I"r s""l,
l:l
.....:
"
: :S~."?\~:-\'0 ..~~\..~r..:I'~J \~
..\Q..N~-J.. \u2022
--.
I
I
I
,J
I
I
I
.....
1
1
I
,:
.
FlU with Dr.:
ldition
viIDischarge:
Time
.-
\
----PATIENT:
DOMBROWSKI, Claudine
DATE:
0 1/15 /96
\u2022 -.
l
4.(-furM
-;
. :-....PROBLEM:
Left knee pain.
SUBJECTIVE:
Patient was in a physical altercation last night with someone
,supposedly we Know;
Her leg was' twisted at home and she'wanted 'it'looked",at
'abd"-x.:::r-ayea~"">Dr:-'Jacobi
d{dorcrer'''itri''x~ray
'and he read it as negative.
The
---
..
--.-.patient is not allergic to anything.
She takes Depo-Provera shots, Elavil,
'..- Ativan, Motrin, and Turns.
OBJECTIVE:
Thirty year-old, afebrile.
Pulse 90.
Blood pres~ure 110/70.
_-:::-:-:
...
__Weight 138 pounds.
Her last menstrual
period was six months ago) because she
___ ...:..
is on Depo-Provera.
HEENT:
Negative.
- -,,.NECK:
Supple.
No adenopathy,
thyromegaly, JVD or bruit.
Carotids are 2+
__"__
and brisk bilaterally.
.,
CHEST:
Clear to auscultation with equal expansion bilaterally.
"--.-'--HEART:
Regular rhythm, Sl, S2 without murmur, gallop or rub.
"'_ _'_'''.'
ABDOMEN:
Soft, nondistended,
and nontender.
No hepatospl~nomegaly
or
masses.
Bowel sounds are normoactive .
.--.-
....~-...EXTREMITIES:
Her left knee is tender on the inner aspect along the tendon,
---"-'-'especially on inversion of the toe.
BACK:
Nontender.
ASSESSMENT:
Tendinitis and contuslon of the ligament and the tendon.
PLAN:
Ice, heat, Lodine 400 mg. one twice a day.
X-ray was negative for any
bony abnormality.
Patella brace was given for the left leg. She said that
made it feel a lot better.
I gave her instructions on how to wear it and
.when to take it off and what to do with it. She will return if necessary.
.
)
bYrn5 c,~
DIXIE HElM, ARNP/dt
COTTON-O'NFIL CLINIC
dd:
0 1/15 /96
r lt:
nl/lRIClI',
t'ATIENT NAME
TIME
D IS POS ITION:
II: 605864-8
DOB: 04/10/65
Handled by:
WH~t~
D Ollq._iD -(~
TIME
P \u2022\u2022..'''' \u2022......\u2022"--t
/I
D ATEI_/~_
PATIENT NAME
PHARMACY
TFMPI'.R"TIIIll'
Rcc'd
of 00

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