Q. Would you turn to your notes of your examination?
In the systems review I notice that there is a line across.
You did no systems review?
A. No, and that's generally not done in trauma
patients.
Q. What's the reason?
A. Lack of time.
Q. Am I correct that your actual notes begin where it
says physical examination?
A. Right.
Q. Here?
A. Yes.
Q. All of the handwriting is that yours that goes on
until the end?
A. Yes. It's all mine.
Q. Where your signature appears, five or six pages
later?
A. Yes.
Q. Am I correct the first thing you checked was his
pulls which are in the same place?
A. Yes. But those are on the monitor because at the
time that they were brought into the emergency room, the
nurse places them on a monitor.
Q. So at the time you first saw him, the pulse was
104? Is that what it says, 104, 107?
A. 104.
Q. For a patient that has the history you knew this
patient had, was that normal?
A. Yes.
Q. Blood pressure is listed as 147 over 74, is that
within normal limits?
A. Yes.
Q. Respirations are listed as 20, is that within
normal limits?
A. That's normal.
Q. Can you read for me what you have under general
description?
A. Thin male, alternately somnolent and combative.
Q. That was something that you observed?
A. Yes.
Q. Could you tell me what significance, if any, that
had to you in terms of his condition?
A. He was not cooperative with the procedures we were
doing and although he was answering questions appropriately,
he was not fully alert and that to me suggested the
possibility of a head injury. He had a mechanism for head
injury.
Q. You then did an examination of the skin and found
it to be normal?
A. Yes.
Q. Is that what the check mark means?
A. Yes.
Q. Lymph nodes, do you found--you found those to be
normal?
A. Yes.
Q. These you did by palpation?
A. Yes.
Q. Under "head," could you tell me what you have
written for that?
A. Abrasions and ecchymosis to forehead.
Q. Did he appear to have any open wounds?
A. Abrasion is an open wound because the skin is open.
Q. You circled the word "trauma." Can you tell me the
reason you did that?
A. Because this was related to trauma. According to
the EMS people, he had hit his head on the windshield,
causing the wind shield to shatter.
Q. Am I correct that in an area like this one, where
it says "head" and you circled that and nothing else, does
that mean you found no bruise, no tenderness or no other?
A. He probably had tenderness, but I tend not to press
on open wounds.
Q. You next examined his eyes?
A. Yes.
Q. Would you tell me how you did that?
A. By looking into them and using a light.
Q. What was the nature of what you found when you
examined his eyes?
A. Those initials stand for pupils equal, reactive to
light; equal, round and reactive to lights.
Q. Were you able to see the fundus?
A. We do not do funduscopic exams.
Q. How far into the eye do you see when you do this
kind of examination in the emergency room?
A. They do not use the ophthalmoscope. When we look
into the eye we just look into the eye surface and the pupils
of the eye.
Q. Can you tell me what the reason is that no
fundoscopic examination was done?
A. This was a preliminary survey and trauma. It has
to be done in one minute, so it's a very quick overview.
Q. His ears you found to be normal?
A. Yes.
Q. You examined his nose. How did you do that?
A. I didn't look inside of his nose, but he had a
small amount of blood coming from one nostril. We generally
examine the face for any bony deformities, which he did not
have.
Q. Throat and mouth, you check off as being normal,
correct? And the neck, how did you examine that?
A. By inspection and palpation.
Q. You found no abnormalities in the neck?
A. Correct.
Q. The next thing would be the respiratory examination
and you have checked "normal by inspection." What does that
mean?
A. Looking at him, there was, he was breathing
normally, there was no abnormalities to his chest wall
movements.
Q. You checked "normal for palpation." What did you
do to determine that?
A. Felt both sides of his rib cage to feel for rib
fractures; pressed on his sternum for any sternal tenderness
to signify he hit the steering wheel. There was no external
signs, bruises or anything on his chest.
Q. You checked off normal by percusison and
auscultation. Could you just briefly tell me for the record
how did you that?
A. Take a listen to breath sounds bilaterally to make
sure.
Q. You found out that he had no rales, no ronchi, no
wheeze, no change in breath sounds at the time you did that?
A. Yes.
Q. At the time you were performing this evaluation,
you were considering aside from a head injury, a chest injury
as well.
A. Yes.
Q. So far on the basis of your examination, you found
no outward evidence of that occurring, is that correct?
A. Yes.
Q. You next did a cardiovascular examination?
A. Yes.
Q. The heart you have checked off by inspection was
normal. How did you do that?
A. That would again be inspection of the chest wall
itself.
Q. By eyeballing it?
A. Yes.
Q. By palpation, there is no check mark. What kind of
palpation would you have done?
A. That is done in a--I did not. I typically don't do
that in trauma. That's done in a very detailed physical
exam.
Q. There is no check mark for heart percussion. Does
that mean you did not do any percussion?
A. I did not.
Q. You did no auscultation?
A. Right.