[##]-year-old [male/female] presents with history and exam
consistent with [low/high voltage] electrical injury [with
dysrhythmia/superficial cutaneous burns/etc.].
Initial considerations in this patient
included complications from electrical injury including dysrhythmias including
ventricular and atrial arrhythmias, cutaneous burns, cardiovascular and central
nervous system injuries, orthopedic injuries including fractures, dislocations
and compartment syndrome, and rhabdomyolysis among others.
Patient presented with report of electrical
injury from [household/industrial] source consistent with [low voltage
(<1000 Volts)/high voltage (>1000 Volts) DC/AC current] exposure. A 12-lead EKG was obtained with [no evidence
of dysrhythmia, ischemia or infarction/notable for evidence of atrial
fibrillation/frequent premature atrial/ventricular contractions/other specific
abnormality]. Patient was noted to have
[no evidence of significant cutaneous burns/first degree burns at the point of
contact with electrical source with appropriate burn care provided in the ED]. Patient felt to have [no other concerning
features with electrical exposure/high risk features including prolonged
exposure/wet skin/loss of consciousness (LOC)].
Labs were [not obtained in patient felt to have no high risk features or
findings on exam to suggest significant injury/obtained to include electrolytes/creatinine
kinase/troponin/etc. and noted to be normal/notable for abnormality]. Patient noted to have [no focal deficits/subjective complaints of numbness/tingling with no significant
focal deficits/describe abnormality] on neurological exam in the ED.
Prior to discharge, we discussed
return precautions, specifically for evidence of significant electrical injury,
symptomatic treatment, and recommended follow up with primary care provider in
[1-2 weeks/2-3 days], and the patient demonstrated understanding and agreement
with this plan.
http://www.emdocs.net/electrical-injury/
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