JEFFERSON FRANKFORD HOSPITAL – ADMISSION REPORT
Patient Name: Kaitlyn Smith
MRN: 489125
Date of Admission: Saturday, February 22, 2025
Time of Admission: 2:12 AM
Admitting Facility: Jefferson Frankford Hospital, Emergency Department
Attending Physician: Dr. Michael Abernathy, MD
CHIEF COMPLAINT
Unconscious following rescue from a residential fire. Presenting with severe respiratory distress, suspected carbon monoxide poisoning, and thermal exposure.
HISTORY OF PRESENT ILLNESS (HPI)
Patient was rescued from a second-story bedroom during an active house fire. Prolonged exposure to smoke and heat is suspected, as patient was unresponsive at the time of rescue and required immediate oxygen supplementation. Initial responders reported shallow breathing and cyanosis. Lacerations to the forearms were noted but described as superficial.
Patient is currently intubated and sedated for airway protection and oxygenation. Observations indicate that the level of particulate matter in the patient’s lungs appears disproportionately low relative to the severity of the fire and her respiratory symptoms.
PAST MEDICAL HISTORY (PMH)
* Previous lightning strike injury (recovered), with residual Lichtenberg scarring and minor cardiovascular irregularities noted at prior evaluations.
* No known chronic illnesses.
* No known allergies.
PHYSICAL EXAMINATION
General Appearance:
Unresponsive, pale, with soot-streaked skin and visible thermal damage. Oxygen mask replaced with endotracheal intubation for respiratory support. Peripheral cyanosis noted on extremities.
Vitals:
* Heart Rate: 126 bpm (elevated, likely stress and hypoxia-induced).
* Respiratory Rate: 18 breaths/min (mechanically ventilated).
* Blood Pressure: 110/72 mmHg (normal range, stable).
* Oxygen Saturation: 89% on mechanical ventilation with FiO2 of 60%.
* Temperature: 98.4°F.
Respiratory:
* Intubated and ventilated.
* Coarse breath sounds bilaterally.
* Minor wheezing in upper airways, indicative of irritation or swelling from smoke inhalation.
* No visible burns to external airway; however, inflammation of the oropharynx is consistent with inhalation of hot gases.
Skin:
* First-degree burns to face, neck, and forearms. Erythematous areas without blistering.
* Lichtenberg scarring from prior injury visible on left flank, upper torso, left shoulder, and lower back. No new electrical burns.
* Superficial, linear lacerations on forearms, consistent with sharp object injury. Clean and non-infected.
Cardiovascular:
* Tachycardic but with regular rhythm.
* Peripheral cyanosis suggests ongoing hypoxia.
* Capillary refill delayed (4 seconds).
Neurological:
* Glasgow Coma Scale (GCS): 3T (intubated, unresponsive).
* Pupils equal, round, and reactive to light.
Musculoskeletal:
* No deformities or fractures noted.
* Generalized muscle rigidity, likely secondary to prolonged hypoxia.
DIAGNOSTIC TESTS ORDERED
Imaging:
* Chest X-ray: Moderate bilateral opacities consistent with smoke inhalation and pulmonary inflammation. No evidence of pneumothorax or foreign bodies.
* CT Scan (Head): Normal, no acute intracranial hemorrhage or edema.
Laboratory:
* Carboxyhemoglobin Level: 24% (critical, consistent with carbon monoxide poisoning).
* Arterial Blood Gas (ABG):
* pH: 7.28 (acidotic).
* PaCO2: 55 mmHg (elevated).
* PaO2: 58 mmHg (low).
* HCO3-: 22 mEq/L (normal).
* CBC:
* Hemoglobin: 11.2 g/dL (slightly low, likely hemodilutional).
* WBC: 14.6 × 10^9/L (elevated, stress response).
* Electrolytes:
* Sodium: 140 mEq/L (normal).
* Potassium: 3.8 mEq/L (normal).
* Creatinine: 0.9 mg/dL (normal).
DIAGNOSIS
1. Acute respiratory distress secondary to smoke inhalation:
* Hypoxia.
* Upper airway irritation.
* Carbon monoxide poisoning.
2. First-degree burns (face, neck, forearms).
3. Superficial forearm lacerations.
4. Carbon monoxide poisoning with critical carboxyhemoglobin levels (24%).
5. Mild metabolic acidosis secondary to hypoxia.
PLAN
Respiratory Management:
* Continue mechanical ventilation with high FiO2 to maintain oxygen saturation >92%.
* Administer hyperbaric oxygen therapy to expedite CO elimination and reduce carboxyhemoglobin levels.
* Monitor for signs of airway swelling or respiratory failure; prepare for potential bronchoscopy if obstruction or soot is suspected in the airways.
Burn Care:
* Cleanse affected areas with saline and apply silver sulfadiazine cream to prevent infection.
* Non-adherent dressings applied to burned areas.
* Monitor for secondary infection or progression of burn severity.
Carbon Monoxide Poisoning:
* Initiate hyperbaric oxygen therapy immediately.
* Monitor serial carboxyhemoglobin levels every 4-6 hours until levels fall below 5%.
Lacerations:
* Clean and suture as needed under sterile conditions.
* Apply topical antibiotic ointment.
Neurological Monitoring:
* Frequent neurological checks to assess for improvement in consciousness and oxygenation status.
* Monitor for signs of hypoxic brain injury or delayed neurotoxicity.
Observation and Long-Term Care:
* Admit to ICU for close monitoring of respiratory and neurological status.
* Daily labs to monitor oxygenation, CO levels, and inflammatory markers.
* Evaluate for long-term respiratory rehabilitation needs once stabilized.
PROGNOSIS
Patient’s carboxyhemoglobin levels are critically high, placing her at risk for delayed neurocognitive effects and further respiratory compromise. While intubation and hyperbaric oxygen therapy provide immediate stabilization, long-term recovery will depend on the extent of hypoxia-induced tissue damage.
Burn injuries and superficial lacerations are expected to heal without complications. Neurological outcomes remain guarded until hypoxia resolves and consciousness is regained.
Physician Notes:
Patient’s apparent “low particulate burden” relative to the severity of the fire warrants further investigation. It is unclear whether this reflects physiological variability or a unique, unidentified factor in the patient’s condition. Continued observation and documentation are advised.
Prepared by:
Dr. Michael Abernathy, MD
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JEFFERSON FRANKFORD HOSPITAL – ADMISSION REPORT
Patient Name: "Bloodhound" (legal name redacted per LBMH Privacy Act)
MRN: 7c-7321
Date of Admission: Saturday, February 22, 2025
Time of Admission: 4:17 AM
Admitting Facility: Jefferson Frankford Hospital, Emergency Department
Attending Physician: Dr. Elena Marques, MD
CHIEF COMPLAINT
Severe injuries sustained during firefighting and apprehension of superpowered criminal, including burns, blunt force trauma, inhalation injury, and pre-existing conditions.
HISTORY OF PRESENT ILLNESS (HPI)
Patient is a regenerator with a 4x baseline healing factor who self-reports as able to "drink seawater without issue" and "immune to alcohol intoxication but capable of being anesthetized." Patient was brought to the emergency department by paramedics following a house fire and associated combat injuries sustained during vigilante activities.
Injuries include:
* Burns (second-degree and superficial) exacerbated by prolonged exposure to fire and heat.
* Blunt force trauma, including suspected rib fractures, shoulder strain/dislocation, and a head injury.
* Smoke inhalation, resulting in respiratory compromise.
* Exacerbation of pre-existing injuries, specifically second-degree burns to the right arm and shoulder from prior incidents.
Patient arrived in-costume and lucid, providing a detailed account of injuries and baseline healing abilities.
PAST MEDICAL HISTORY (PMH)
* Healing factor (self-reported 4x baseline healing rate).
* Chronic exposure to injury as a result of vigilante activities.
* Second-degree burns to the right arm sustained <48 hours prior to admission.
* Multiple prior head injuries (history of concussions).
* Ankle sprain (right).
* Hypertrophic laceration scarring noted along the right flank, consistent with prior deep soft tissue injury.
* Scattered minor hypertrophic laceration scarring (<3 cm in size each) across body, primarily upper back, upper arms, and hands.
PHYSICAL EXAMINATION
General Appearance:
Alert but visibly fatigued, sitting upright on stretcher. Burned clothing in multiple areas; minor soot staining on exposed skin.
Vitals:
* Heart Rate: 112 bpm (elevated, likely due to pain).
* Respiratory Rate: 24 breaths/min (tachypneic).
* Blood Pressure: 135/92 mmHg (slightly elevated, pain-related).
* Oxygen Saturation: 94% on ambient air.
* Temperature: 99.1°F (normal).
Respiratory:
* Persistent dry cough, hoarseness, and raw throat.
* Mild stridor auscultated in the upper airway (indicative of inhalation injury).
* Lung sounds diminished bilaterally at bases, with scattered rhonchi.
Skin:
* Second-degree burns:
* Right arm (posterior and lateral surfaces): Blistered, erythematous, with evidence of worsening damage from exposure to heat during this incident.
* Superficial burns across shoulders, upper back, and sides of neck: Erythema with occasional blistering.
* No signs of infection or excessive fluid loss at this time.
* Scattered abrasions on hands and forearms (minor, no significant bleeding).
* Ecchymosis across extremities and lower torso consistent with repeated blunt force trauma.
Cardiovascular:
* Tachycardic but regular rhythm. No murmurs or signs of cardiac stress.
Musculoskeletal:
* Right shoulder: Palpable tenderness with limited range of motion; possible partial dislocation or ligamentous strain.
* Ribs: Point tenderness over the right lateral ribcage; likely fracture(s).
* Right ankle: Swelling, ecchymosis, and instability consistent with sprain.
* Generalized muscle fatigue and soreness.
Neurological:
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* Glasgow Coma Scale (GCS): 15 (normal, fully alert).
* Reports dizziness, headache, and nausea consistent with mild concussion.
* No focal neurological deficits noted during initial exam.
DIAGNOSTIC TESTS ORDERED
Imaging:
* X-ray (Chest): Confirms at least two fractured ribs (6th and 7th, right side), with no evidence of pneumothorax.
* X-ray (Right Shoulder): Possible AC joint strain without dislocation.
* X-ray (Right Ankle): No fracture; soft tissue swelling noted.
* CT Head: No acute intracranial hemorrhage or swelling.
Laboratory:
* CBC: Mildly elevated WBC (12.5 × 10⁹/L) consistent with stress response.
* ABG: Mild respiratory acidosis (pH 7.32, pCO2 49 mmHg) likely due to smoke inhalation.
* Carboxyhemoglobin Level: 7% (elevated but not critical).
* Electrolytes/Renal Panel: Normal, unremarkable.
DIAGNOSIS
1. Second-degree burns (right arm, shoulders, upper back).
2. Smoke inhalation injury with mild respiratory compromise.
3. Fractured ribs (right lateral, 6th and 7th).
4. Partial dislocation or strain of right shoulder joint.
5. Right ankle sprain (exacerbation of chronic injury).
6. Mild concussion with headache and dizziness.
PLAN
Burn Management:
* Clean burns with saline and apply silver sulfadiazine cream to prevent infection.
* Cover with non-adherent dressing.
* Pain management with IV ketamine (preferred due to patient history).
Respiratory Care:
* Provide humidified oxygen via mask (5 L/min).
* Monitor for signs of airway edema or worsening respiratory distress.
Musculoskeletal Injuries:
* Immobilize right shoulder with sling; schedule follow-up with orthopedics for MRI to rule out ligament tears.
* Apply compression wrap to right ankle; elevate and ice to reduce swelling.
* Prescribe physical therapy referral for ankle and shoulder rehabilitation.
Rib Fractures:
* Encourage incentive spirometry to prevent atelectasis.
* Pain management with ketamine and adjunct acetaminophen.
* Avoid binding or tight bandages (to prevent hypoventilation).
Concussion:
* Recommend rest and monitoring for worsening symptoms (e.g., vomiting, confusion).
Observation and Discharge:
* Admit to short-term observation unit to monitor burns and respiratory function.
* Discharge plan to include:
* Topical burn care supplies.
* Physical therapy referral.
* Pain management plan with ketamine or alternative based on tolerability.
PROGNOSIS
Patient’s 4x baseline healing factor is expected to significantly reduce recovery time for burns, musculoskeletal injuries, and rib fractures. Full recovery anticipated within 3-4 weeks for most injuries, with ongoing therapy for ankle instability.
Physician Notes:
Patient’s unique physiology necessitates adjustment in medication dosing, particularly pain management and sedatives. Future admissions should prioritize direct-acting anesthetics or IV administration routes for efficacy. Patient’s self-reported seawater tolerance and alcohol immunity align with hyper-efficient hepatic and renal function, warranting careful drug selection.
Prepared by:
Dr. Elena Marquez, MD
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JEFFERSON FRANKFORD HOSPITAL – ADMISSION REPORT
Patient Name: Aaron McKinley
MRN: 512487
Date of Admission: Saturday, February 22, 2025
Time of Admission: 5:45 AM
Admitting Facility: Jefferson Frankford Hospital, Emergency Department
Attending Physician: Dr. Clara Nguyen, MD
Security Detail: Officer John Martinez (Philadelphia PD)
CHIEF COMPLAINT
Severe blunt force trauma and musculoskeletal injuries sustained during apprehension following alleged arson and violent altercation. Patient is conscious but uncooperative. Presented with multiple acute injuries exacerbating prior poorly healed fractures.
HISTORY OF PRESENT ILLNESS (HPI)
Patient was apprehended at the scene of a violent altercation and transported to the emergency department under heavy law enforcement security. Blindfolded to prevent suspected use of gaze-based pyrogenetic abilities. Law enforcement reports significant blunt force trauma during the altercation, primarily to the shoulder, ribs, and head. Patient has an extensive history of injuries due to prior violent encounters, including poorly healed fractures managed by non-professional medical care.
Patient is conscious but hostile, non-compliant with questioning, and restrained (handcuffed to stretcher). Requires frequent redirection and monitoring for agitation. Additionally, patient exhibits signs of chronic lung damage likely related to prolonged inhalation of particulate matter from his own pyrogenetic activity, compounded by acute smoke inhalation from the recent fire.
PAST MEDICAL HISTORY (PMH)
* Prior musculoskeletal injuries (poorly healed):
* Right knee fracture (misaligned healing noted on imaging).
* Nasal fracture with cosmetic deviation.
* Left elbow joint sprain (ligamentous damage visible on prior imaging).
* Right shoulder fracture (suspected improper healing; secondary fractures noted).
* Multiple rib fractures (evidence of previous injury to 5th and 6th ribs on imaging).
* Sprained right ankle (chronic instability).
* Chronic soft tissue damage, scars, and minor untreated injuries.
* Lung damage: History of impaired pulmonary function attributed to chronic inhalation of smoke and particulates from pyrogenetic activities, presenting as early-onset emphysema-like symptoms during prior evaluations.
PHYSICAL EXAMINATION
General Appearance:
* Agitated and restrained, blindfolded per law enforcement request. Conscious, poorly groomed, with visible signs of prior and current trauma. Cooperative only under duress.
Vitals:
* Heart Rate: 98 bpm (mildly elevated).
* Respiratory Rate: 20 breaths/min.
* Blood Pressure: 136/88 mmHg.
* Oxygen Saturation: 97% on room air.
* Temperature: 98.9°F.
Respiratory:
* Persistent dry cough and mild wheezing noted.
* Evidence of chronic pulmonary damage:
* Reduced breath sounds at lung bases bilaterally.
* Diminished pulmonary function consistent with chronic exposure to particulate matter.
* Acute findings:
* Coarse breath sounds and scattered rhonchi, indicative of acute smoke inhalation injury.
* No stridor or immediate airway compromise.
* Chest X-ray shows bilateral patchy opacities consistent with acute pulmonary irritation and possible early pneumonitis.
Skin:
* Extensive bruising over torso, arms, and legs, with visible lacerations on forearms and face.
* Superficial abrasions across knuckles, likely from altercation.
* Scattered scars on extremities and torso, consistent with history of violent trauma.
Cardiovascular:
* Tachycardic but with a regular rhythm. Capillary refill within normal limits.
Musculoskeletal:
* Right shoulder: Severe pain, limited range of motion, and swelling. Palpable deformity suggests acute fracture exacerbating prior malunion.
* Right elbow: Significant tenderness and swelling; likely ligament sprain and possible exacerbation of prior injury.
* Right knee: Mild swelling and tenderness; no acute deformity but misalignment noted on prior fracture.
* Ribs: Pain and crepitus over 4th–7th ribs on the right side. Imaging confirms new fractures with signs of poorly healed prior injuries.
* Ankle: Mild swelling of right ankle; chronic instability noted.
* Generalized soft tissue tenderness with significant ecchymosis over back and flanks.
Neurological:
* Alert and oriented x3 but uncooperative. No focal deficits noted.
* Reports headache and dizziness; likely mild concussion.
DIAGNOSTIC TESTS ORDERED
Imaging:
* X-ray (Chest): Acute fractures of right 4th, 5th, and 6th ribs with evidence of prior malunion. Patchy opacities consistent with acute smoke inhalation injury. No pneumothorax.
* X-ray (Right Shoulder): Acute comminuted fracture of the proximal humerus with prior malunion evident.
* X-ray (Right Elbow): Ligamentous injury suspected; no acute fractures.
* CT Scan (Head): No intracranial hemorrhage or swelling; mild concussion suspected.
* X-ray (Right Knee): Evidence of prior fracture with mild malalignment; no acute changes.
* X-ray (Right Ankle): Chronic instability; no acute fractures.
Laboratory:
* CBC: Mildly elevated WBC (11.8 × 10^9/L) consistent with stress response.
* Electrolytes: Within normal limits.
* Carboxyhemoglobin Level: 6% (elevated but not critical, reflecting partial exposure to smoke).
* Arterial Blood Gas (ABG): Mild hypoxemia with pO2 at 65 mmHg.
DIAGNOSIS
1. Acute comminuted fracture of the right proximal humerus (exacerbation of prior malunion).
2. Rib fractures (right 4th–7th ribs) with prior poorly healed fractures.
3. Right elbow ligament sprain (exacerbation of prior injury).
4. Chronic musculoskeletal injuries (right knee, right ankle, nasal fracture).
5. Soft tissue trauma and bruising (extensive).
6. Mild concussion with headache and dizziness.
7. Chronic pulmonary damage consistent with prolonged inhalation of particulate matter.
8. Acute smoke inhalation injury with early signs of pneumonitis.
PLAN
Orthopedic Management:
* Immobilize right shoulder with sling; consult orthopedics for surgical evaluation due to comminuted fracture and prior malunion.
* Apply compression wrap to right elbow; follow-up with MRI for ligament evaluation.
* Encourage physical therapy upon stabilization for chronic knee and ankle instability.
Pain Management:
* Administer IV ketamine for pain (to avoid respiratory depression and manage agitation).
* Supplement with acetaminophen.
* Avoid opioids unless absolutely necessary due to incarceration risk.
Respiratory Care:
* Provide humidified oxygen to maintain oxygen saturation >92%.
* Incentive spirometry to prevent atelectasis from rib fractures.
* Monitor for worsening pulmonary symptoms or development of pneumonitis.
* Follow-up chest X-ray to evaluate progression of inflammation or complications.
Neurological Monitoring:
* Observe for worsening concussion symptoms (e.g., vomiting, confusion).
Security and Legal Notes:
* Maintain restraints as ordered by law enforcement.
* Secure medical clearance for transport to correctional facility upon stabilization.
* Document all findings meticulously for potential legal proceedings.
Observation and Discharge:
* Admit to secure observation unit with police detail.
* Prepare discharge plan for coordination with correctional medical services.
PROGNOSIS
Patient’s injuries are severe but not life-threatening. Chronic musculoskeletal damage will complicate healing and require long-term management. Without surgical intervention, right shoulder function may be permanently impaired. Pulmonary function is expected to further decline without strict avoidance of particulate exposure. Patient is stable for transfer to correctional facility upon completion of medical care.
Physician Notes:
Patient’s history of prior injuries reflects poor-quality care and likely contributes to recurrent complications. Law enforcement protocols have been observed throughout evaluation. Chronic lung damage from pyrogenetic activity is noted as a significant risk factor for long-term pulmonary decline. Close monitoring required due to patient’s pyrogenetic abilities and uncooperative behavior.
Prepared by:
Dr. Clara Nguyen, MD