Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Lightning strike
History of Present Illness:
Briefly describe the circumstances of the lightning strike (witnessed vs. unwitnessed, location, activities at the time).
Inquire about the patient’s level of consciousness immediately after the strike and any initial symptoms (loss of consciousness, seizure, confusion, amnesia).
Describe the development of any other symptoms since the strike (muscle pain, weakness, paresthesias, burns, cardiac symptoms like chest pain or palpitations, respiratory difficulties).
Ask about the presence of any visual disturbances, hearing problems, or difficulty speaking.
Past Medical History:
Include any relevant past medical history, such as pre-existing cardiac conditions, neurological disorders, or mental health conditions.
Mention any current medications the patient is taking.
Social History:
Briefly note the patient’s occupation and potential lightning exposure risks (outdoor work).
Family History:
Inquire about any family history of sudden cardiac death or neurological conditions.
Physical Exam:
Vital signs: Include temperature, pulse, respiratory rate, blood pressure, oxygen saturation.
General exam: Assess for signs of injury (burns – entry and exit points if identifiable, fractures), respiratory distress, or altered mental status.
Neurological exam: Evaluate level of consciousness, orientation, motor function (strength, coordination), sensory function, and cranial nerves.
Cardiovascular exam: Listen for heart murmurs, assess peripheral pulses.
Respiratory exam: Check for signs of respiratory distress (increased work of breathing, abnormal breath sounds).
Imaging Studies (if performed):
Briefly describe findings from relevant imaging studies, such as:
X-ray: May show fractures from falls associated with the strike.
CT scan: Can reveal internal injuries, bleeding in the brain, or other complications.
ECG (electrocardiogram): May show abnormalities in heart rhythm.
Laboratory Tests (if performed):
Mention any relevant lab findings, such as:
CBC (complete blood count): Might show elevated white blood cells if there’s an inflammatory response.
Electrolytes: May be abnormal if there’s muscle damage.
Cardiac enzymes: Can be elevated if there’s heart muscle injury.
Assessment:
Diagnosis: State the diagnosis of lightning injury.
Severity: Briefly describe the perceived severity based on the presenting symptoms, physical exam findings, and imaging/lab results (e.g., mild vs. severe with potential complications).
Complications: Mention any potential complications of lightning injury, such as:
Cardiac arrhythmias
Cataracts
Neurological deficits (weakness, memory problems)
Rhabdomyolysis (muscle breakdown)
Psychological distress (PTSD)
Plan:
Treatment:
Outline the current treatment plan based on the patient’s condition, which may include:
Cardiac monitoring for arrhythmias.
Pain management with medications.
Tetanus prophylaxis if indicated.
Physical therapy for rehabilitation if there’s muscle weakness or nerve damage.
Psychological support if needed.
Follow-up:
Schedule the next clinic visit for follow-up based on the severity and the need for ongoing monitoring.
Instruct the patient to return sooner if they experience any worsening of symptoms or develop new concerns.