Doctor's Notes
This very pleasant, divorced G2P2 white female presents today for her annual gyn exam. Went through divorce 2 years ago, single mom with a 5yo going into kindergarten and a 7 yo going into 3rd. Works at bank. States she's doing very well over the past year. History of insomnia. Has tried Rx/melatonin/Benadryl/CBD/magnesium and more with limited success. Given self-referral form for first mammogram.
General health is good. Exercises. Diet balanced. Vegetarian. Alcohol use occasionally, denies drugs. Alert and oriented. Pupils are equal, round and reactive to light. Neck is supple, non-tender. Lungs are clear. Respiration non-labored. Gums are warm, dry, and pink. Skin is intact. Cooperative, with appropriate mood and affect.
***
We find the body lying supine on the living room carpet. There are two bright red blood stains on the left side of the carpet beside her face. She is a Caucasian female in her mid-fifties with blonde hair. She appears to have breast implants. She is wearing a long, white robe. No bra. No underwear.
Her face is discolored and distorted due to her original position. Her body is deeply discolored, but I see no obvious signs of trauma. Her body is cold to the touch.
***
Patient appears today for a sore throat. Denies exposure to strep, but strep test was positive. Patient instructed to watch out for fevers, worsening throat pain, drooling, dysphasia, or any other concerning symptoms.
Patient is alert and oriented times 3. Moist mucous membranes. Right anterior cervical lymphadenopathy.
***
When paramedics arrived at the scene, patient had no vital signs. She was taken to the hospital, where she did not respond to resuscitative efforts. No tattoos, surgical scars, or track marks are identified. There is a small, non-specific scar on the left buttock. Each earlobe has been pierced once.
The body is of an unembalmed Caucasian female adult. Skin is unremarkable. Rigor mortis is present. The head is normocephalic and covered by wavy, dark brown hair of a moderate length that has been focally lightened. There appear to be multiple hair extensions woven into the natural hair. There is no evidence of balding. An examination of the eyes reveals brown irides and equal, round pupils. Soft contact lenses are in place bilaterally. There is a small amount of thin, brown liquid at the mouth. The neck is unremarkable. Teeth are natural.
Inspection of the lungs reveals an acute pneumonia, and blood cultures were positive for oxacillin-resistant staphylococcus aureus, which is the most likely causative organism.
General health is good. Exercises. Diet balanced. Vegetarian. Alcohol use occasionally, denies drugs. Alert and oriented. Pupils are equal, round and reactive to light. Neck is supple, non-tender. Lungs are clear. Respiration non-labored. Gums are warm, dry, and pink. Skin is intact. Cooperative, with appropriate mood and affect.
***
We find the body lying supine on the living room carpet. There are two bright red blood stains on the left side of the carpet beside her face. She is a Caucasian female in her mid-fifties with blonde hair. She appears to have breast implants. She is wearing a long, white robe. No bra. No underwear.
Her face is discolored and distorted due to her original position. Her body is deeply discolored, but I see no obvious signs of trauma. Her body is cold to the touch.
***
Patient appears today for a sore throat. Denies exposure to strep, but strep test was positive. Patient instructed to watch out for fevers, worsening throat pain, drooling, dysphasia, or any other concerning symptoms.
Patient is alert and oriented times 3. Moist mucous membranes. Right anterior cervical lymphadenopathy.
***
When paramedics arrived at the scene, patient had no vital signs. She was taken to the hospital, where she did not respond to resuscitative efforts. No tattoos, surgical scars, or track marks are identified. There is a small, non-specific scar on the left buttock. Each earlobe has been pierced once.
The body is of an unembalmed Caucasian female adult. Skin is unremarkable. Rigor mortis is present. The head is normocephalic and covered by wavy, dark brown hair of a moderate length that has been focally lightened. There appear to be multiple hair extensions woven into the natural hair. There is no evidence of balding. An examination of the eyes reveals brown irides and equal, round pupils. Soft contact lenses are in place bilaterally. There is a small amount of thin, brown liquid at the mouth. The neck is unremarkable. Teeth are natural.
Inspection of the lungs reveals an acute pneumonia, and blood cultures were positive for oxacillin-resistant staphylococcus aureus, which is the most likely causative organism.
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