Ehr Referral Case Study

332 Words2 Pages
The original referral is sent to EHR. It was determined the patient should be outpatient status. The case is discussed with Dr. Levin and he does not agree, therefore this is second PA referral received on 1/16/2017.

The patient is a 68-year-old gentleman who had a fall from a standing position. The history is vague, however he details it better with the neurologist. He relates to the neurologist that he was sitting on the couch, he felt dizzy, he got up to go to the bathroom and then had loss of consciousness found himself on the floor with laceration to his head. He could not get up, but he was able to call his daughter on the cell phone to help him. The patient in the fall, dislocated his right shoulder which was taken care by orthopedics.
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