MASTER LIST SOAP A/P
#UA (negative troponins) vs NSTEMI (positive troponins); STEMI
#ACS
#Troponinemia
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#UA (negative troponins) vs NSTEMI (positive troponins); STEMI
#ACS
#Troponinemia
Typical chest pain (substernal pressure, exertional, improved with sublingual nitroglycerin) vs atypical (2/3) vs noncardiac (1-2/3). Risk factors: HTN, DM, HLD, smoking, family history of early MI (men age <40, women age <50), patient age >65. HEART score (chest pain in ED, triage tool for ED to decide ACS or not); TIMI (ACS patients, mortality, who should get LHC; same as GRACE) score >3 benefits from coronary angiography. Ddx: pericarditis (pleuritic/positional pain, diffuse ST elevation), aortic dissection (differential BP in upper extremities, CXR with mediastinal widening).
STEMI Criteria
- ST-segment elevation >1mm in 2+ contiguous leads
- V2, V3: >2mm in men, >1.5mm in women
- New LBBB = STEMI equivalent, may reflect LAD occlusion
Posterior MI: ST depression in anterior leads (V1-V4), often with ST elevation in inferior (II, II, aVF) or lateral (V5, V6) leads
RV MI: ST elevation in II, III, aVF; ST elevation in V1 with depression in V2 (highly specific); reciprocal depressions in lateral (V5, V6) leads
Reperfusion Therapy
- PCI: 90 minutes from first medical contact to PCI
- Thrombolytic therapy: symptom onset within 12 hours and primary PCI not available within 120 minutes
--- Can consider if onset 12-24 hours before presentation, HDUS, significant myocardium at risk (anterior MI)
--- Consider if BP <140/90
- Consults: cardiology
- NPO for LHC vs exercise/lexiscan stress test
- CXR ordered to evaluate for widened mediastinum, pneumonia, cardiac silhouette, evidence of volume overload
- TTE ordered to evaluate for wall motion abnormality
- s/p ASA 325mg load, continue aspirin 81mg daily
- s/p Plavix 300-600mg load, continue plavix 75mg daily
- Heparin gtt x 48h
- Metoprolol tartrate 25-100mg q12h for resting HR goal 55-60
- ACEI/ARB if impaired LV function (EF <40%), hypertension, diabetes, CKD, anterior wall infarction
- Atorvastatin 80mg qhs
--- High intensity statin = atorvastatin 40-80mg, rosuvastatin 20-40mg
--- Moderate intensity statin if intolerant of high intensity; prasuvastatin better tolerated for myalgias
--- Consider ezetimibe if inadequate LDL reduction with statin
- Sublingual nitroglycerin 0.4mg q5 minutes x3 prn
- Troponin, BNP, TSH, A1c, lipid panel ordered
- Trend troponins, ECGs to peak
shoulder pain plan
- #Shoulder pain:
Exam normal. No sign of laxity or pain with above maneuvers. Further diagnostic tests not warranted at this time. Recommend conservative treatment as follows:
- rest with slow initiation of range of motion exercises, then stretching/flexibility exercises (patient education provided), then strength exercises
--> avoidance of activities that exacerbate symptoms or cause sharp pain
- warm compresses (advised to place rice in sock and heat in microwave until warm, but not hot enough to burn skin)
- kinesiology tape (KT tape)
- acupuncture if symptoms persist beyond several days
- ibuprofen 800mg q8h prn
- acetaminophen 1g TID prn
- return precautions if fever, skin redness/warmth, joint swelling, weakness, sensory changes, or new and persisting sharp/severe pain
- physical therapy if symptoms persist beyond several weeks
rheum labs
- [] comprehensive rheumatologic laboratory work-up sent:
--> non-specific inflammatory labs (ESR, CRP, CBC, ANA)
--> RA labs (rheumatoid factor, CCP Ab IgG)
--> SLE labs (anti-DNA, SM Ab, anti-ribosomal P)
--> APLS labs (B2 glycoprotein IgG/ IgA/ IgM, cardiolipin IgM, lupus anticoagulant)
--> Sjogren labs (SSA/SSB)
--> Mixed Connective Tissue Disease Labs (SM/RNP Ab)
--> Scleroderma labs (anti-centromere B, anti-Scl 70, anti-RNA polymerase III)
--> Spondyloarthropathy (HLA-B27)
--> Crystalline Arthropathy (uric acid)
--> infectious studies (Hep B, Hep C, Quant Gold, HIV, syphilis, GC/CT)
PALPITATIONS ROS
- Denies fever, hot/cold intolerance, exertional chest pain/pressure, SOB, syncope, lightheadedness, GI, and GU symptoms. No recent change in medications. No supplements. Minimal caffeine use. No alcohol or drug use. No personal history of arrhythmia or CVD.
#Overactive Bladder:
- #Overactive Bladder:
[] urinalysis and culture to rule out UTI
[] PVR
[] lifestyle modifications:
- decrease daily fluid intake to 4 glasses
- eliminate caffeine, soda, and other irritants from diet
- avoid fluid intake after dinner or 2 hours before bedtime
- raise lower extremities at end of day to mobilize dependent fluid
- Kegel exercises
- urge suprression technique (Kegels when feeling urgency)
[] vaginal estrogen cream
--> if refractory: start oxybutynin 5mg TID x 3 months
----> if still refractory: start tolterodine ("Detrol") 2mg PO BID x 3 months
-----> if still refractory: start mirabegron 25mg PO daily and up-titrate to max 50mg daily (needs TNF)
*if still refractory to above measures: e-consult to UroGyn
Other Chronic Issues not Completely Discussed at Today's Visit:
OSTEOPOROSIS TREATMENT
- - T-score *** based on **** DEXA
[] start alendronate 70mg weekly
[] calcium-vit D 1000-400mg daily
[] cholecalciferol 2000mg daily
[] increase resistance training
--> advised patient to purchase two 3-5lb dumbbells at Target or Walmart ($10-20) and search Youtube for "Osteoporosis Exercises - A Routine for Stronger Bones"
- will repeat DEXA in 2-3 years
HYPERCOAG LABS
- - f/u hypercoagulability labs: protein C, protein S, cardiolipin antibodies, B2 glycoprotein, DRVVT, prothrombin 2010A gene mutation, anti-thrombin 3, factor 8, factor V
NO RED FLAG GI
- No red flag symptoms like hematochezia, melena, intractable vomiting, hematemesis, or unintentional weight loss.
#[[CONGESTIVE HEART FAILURE | CHF]] ROS
- CHF ROS:
- feels well overall
- denies CP, SOB, dizziness, lower extremity edema, palpitations, pre-syncope
- able to sleep flat or may use 1 pillow
- avoids salty food
- limits fluid intake to 1.5-2L
- has scale at home, tracks weight daily
--> dry weight:
- urinates freely
- good appetite, no early satiety or abdominal distension
- able to walk up flight of stairs without stopping to catch breath
LOW BACK PAIN PLAN
- No red flag features such as fever, saddle anesthesia, bowel/bladder incontinence, or neurologic deficits (leg weakness/numbness). Straight leg test negative - low suspicion for radiculopathy. Will treat conservatively; if no improvement in 4 weeks will refer to PT.
[] provided reassurance that with time, acute low back pain resolves in the majority of patients
[] emphasized the importance of safe movement (i.e. doing activities that do not cause sharp, sudden-onset pain, and not being sedentary) to promote blood flow and muscle recovery
[] alternating ice/heat --> advised not to leave on for more than 10 minutes at a time
[] ibuprofen 800mg TID x7d, then prn for breakthrough pain
[] diclofenac 1% gel and acetaminophen 1g TID prn
[] cyclobenzaprine 10mg TID prn (advised to start by taking only at night and cautioned not to drive or operate heavy machinery after using due to concerns about drowsiness)
[] provided patient with stretching exercises
[] advised not to lift objects heavier than 15lb for one month or until symptoms completely resolve
[] recommended patient consider acupuncture treatment, provided with number and address to Western River Acupuncture in Westwood (1321 Westwood Blvd #201, Los Angeles, CA 90024 (310) 463-6100)
LOW BACK PAIN PHYSICAL EXAM
- General: well appearing, in mild distress due to pain
Back: no TTP along vertebral column, +paraspinal tenderness in lumbar region
Neuro: negative straight leg test, strength 5/5 and sensation to light touch normal throughout lower extremities, normal gait
THROMBOCYTOPENIA
- Thrombocytopenia
History: CC -> bleeding? Rheum disease? Infection (viral)? Nutrition
Meds: immunosuppression? Abx? Other?
Labs: Trend in platelets? (If it’s a one-time count, re-draw.) Trend in WBC and Hb? Requiring plt transfusions? The lifespan of transfused plts is even shorter than self-made plts because they were pulled out of somebody’s blood. LFTs? Liver failure patients aren’t making enough TPO to sustain their platelet count.
Imaging: splenomegaly?
Blood smear: schistocytes, platelet clumping, abnormal WBCs?
Decreased production
Vitamin B12, folate def, BM infiltration (tumor, leukemia/lymphoma, myelofibrosis, TB), aplastic anemia, MDS, infection, toxins (EtOH, chemo, cocaine), hereditary (TAR syndrome, Fanconi), hx radiation
Destruction
ITP (viral illness), autoimmune (lupus), malignancy (CLL, lymph, solid tumor), drug (beta lactams, heparin, phenytoin, vanc/zosyn, bactrim), post-transfusion, infection (HIV, EBV, CMV, hepatitis), MAHA, mechanical valve.
Consider the following:
• In a patient on phenytoin, the most likely causes of subacute, mild thrombocytopenia are phenytoin-induced immune-mediated platelet destruction and decreased folate levels secondary to phenytoin. If phenytoin is the cause of thrombocytopenia in this patient, the platelet count is not going to fully rebound until the phenytoin has been metabolized from the body.
• HIT. Tends to occur at 4-14 days after starting heparin. Heparin binds to platelet factor 4 (PF4), creating a novel antigen. An auto-antibody can form that targets the heparin-PF4 complex. When heparin is discontinued, the heparin-PF4 complex is washed out, and the platelet count recovers quickly.
• Thrombocytopenia is expected in cirrhotics due to lack of tpo (made in the liver) and splenomegaly.
• Ongoing alcohol use is marrow-suppressive.
• Impaired marrow production includes marrow aplasia, infiltration from a malignancy or infection, myeloproliferative disorder.
• Marrow suppression from infection, toxin, drugs.
• Nutritional deficiency (B12, folate).
• Antibody-mediated destruction includes ITP, HIT, drugs, infection (HIV, CMV, EBV, hepatitis), rheumatologic disease.
• MAHAs (HUS, DIC, TTP) are characterized by bleeding, clotting, platelet consumption.
• ITP + autoimmune hemolytic anemia = Evan's syndrome.
• DIC workup includes a D-dimer, LDH, fibrinogen, LFTs, peripheral smear, haptoglobin, PT/INR, PTT.
• Splenic sequestration is possible in any patient with an enlarged spleen.
• Infections can result in thrombocytopenia. HIV; CMV; EBV; parvovirus, hepatitis. Also consider bacterial, respiratory, sputum cultures; fungal respiratory sputum cultures; Aspergillus antigen EIA; blood cultures x2; fungal blood cultures x2; cocci IgG, IgM; cryptococcal antigen in the blood; urine cultures for both fungal and bacterial; Legionella urine antigen; respiratory viral panel PCR. For an immunosuppressed transplant patient, call transplant team and transplant ID for recommendations.
• ITP is a diagnosis of exclusion.
Evaluate:
- D-dimer, LDH, fibrinogen, DAT, PT/INR, PTT, LFTs, peripheral smear, haptoglobin
- #Thrombocytopenia
- Peripheral smear, B12, folate, HIV, hepatitis
- Hemolysis labs: d-dimer, fibrinogen, LDH, haptoglobin, total bilirubin, direct bilirubin
- Consider platelets in blue tube (with citrate)
- Consider HIT Ab; argatroban gtt vs fondaparinux
COLONOSCOPY PREP
- - CLD tomorrow, NPO at midnight
- strict NPO 2 hours before procedure including prep
- 4L of golytely at 10 oz every 15 minutes
- check stools at MN and if not clear, give additional prep until clear
- hold anticoagulation at MN
- hgb>7, plts >50, INR<2 for procedure
PHYSICAN ORDERS FOR LIFE SUSTAINING TREATMENT POLST
- HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTHCARE PROVIDERS AS NECESSARY
This note does not supersede an updated and current physical POLST should one be present, and may be changed or revoked at any time at a patient’s or DPOA’s discretion.
Date of Note: _
Patient: DOB: _
Contact of Patient (phone): _
Contact of Kin or Closest available Contact (name, phone): _
There are 3 sections to this documentation (CPR, Medical Interventions, and Artificially Administered Nutrition).
CARDIOPULMONARY RESUSCITATION (CPR):
If patient has no pulse and is not breathing.
[_] Attempt Resuscitation/CPR
[_] Do Not Attempt Resuscitation/DNR (Allow Natural Death)
MEDICAL INTERVENTIONS:
If patient is found with a pulse and/or is breathing.
[_] Full treatment – primary goal of prolonging life by all medically effective means.
In addition to treatment described in Selective Treatment and Comfort-Focused Treatment, use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated.
[_] Trial Period of Full Treatment.
[_] Selective Treatment – goal of treating medical conditions while avoiding burdensome measures.
In addition to treatment described in Comfort-Focused Treatment, use medical treatment, IV antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive airway pressure. Generally avoid intensive care.
[_] Request transfer to hospital only if comfort needs cannot be met in current location.
[_] Comfort-Focused Treatment – primary goal of maximizing comfort.
Relieve pain and suffering with medication by any route as needed; use oxygen, suctioning, and manual treatment of airway obstruction. Do not use treatments listed in Full and Selective Treatment unless consistent with comfort goal.
Request transfer to hospital only if comfort needs cannot be met in current location
[_] Additional orders: _
ARTIFICIALLY ADMINISTERED NUTRITION:
Offer food by mouth if feasible and desired.
[_] Long-term artificial nutrition, including feeding tubes
[_] Trial period of artificial nutrition, including feeding tubes
[_] No artificial means of nutrition, including feeding tubes
[_] Additional orders: _
INFORMATION:
Health Care Decision-maker name (if any): _
Contact phone number: _
POLST discussed with and signed by:
[_] Patient who has capacity
[_] Health Care Decision-maker
[_] Court Appointed Conservator
[_] Parent of Minor
[_] Other
Used Interpreter – name: _
Interpretation language: _
Used HCIN – Interpreter ID #: _
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DIABETES CHECKLIST
- DM Checklist:
- Retinal Scan:
- Foot Exam:
- Urine Microalbumin/Cr Ratio:
- ACEi/ARB:
- Statin:
# Acute hypoxemic respiratory failure 2/2 COVID pneumonia
- # Acute hypoxemic respiratory failure 2/2 COVID pneumonia
COVID 19 confirmed on PCR and pt is currently being monitored for inflammatory markers including ferritin, CRP, d-dimer, LDH. Currently Pt is still in the ED but will be transferred to the floor. Requiring 12L on simple mask.
PLAN:
- Start Remdesivir for 5 days
- Consider convalescent plasma
- Dexamethasone 6 mg PO daily, 10-day course
- Pt to self prone to increase oxygenation
- F/u daily COVID labs: CBC w/diff, CMP, CRP, D dimer, ferritin, LDH
- If desats overnight, consider BiPAP
- inspiratory spirometry Q4hr-INT during daytime.
- Ambulate Daily
- Can consider Azithromycin and Ceftriaxone for CAP if clinically relevant
[[ACUTE DECOMPENSATED HEART FAILURE | ADHF]]
- #Acute decompensated HF
- goal net neg 2L▼
- diurese w/ 40mg IV lasix qDay▼
- consider TTE when closer to euvolemia
- pt dry weight is approx
- - GDMTs
-- Preload: diuresis for goal net negative 1.5-2L per day
-- Coronaries: ASA 81 mg, Plavix 75 mg, Atorvastatin 80 mg
-- Contractility:
-- Afterload:
-- Devices:
-- Other: Jardiance 10 mg qday
- Strict I&O, daily standing weights
- BMP q12g, K/Mg 4/2
SYNCOPE
- #Syncope
Differential includes neurologic (CVA/TIA, seizure), cardiac (arrythmia, valvular/structural), orthostatic (hypovolumia, autonomic dysfunction), vasovagal, or hypoglycemia.
- Neurologic: CTH, MRI brain, EEG?
- Cardiac: tele, ziopatch, TTE, CXR?
- Orthostatic: orthostatic VS, BG/A1c
[[TIA | TRANSIENT ISCHEMIC ATTACK]] | [[CVA]]
- #TIA/CVA
- Follow-up CTH w/o, MRA brain and neck
- Follow-up EKG, TTE
- Follow-up CBC, CMP, Coags, Trop, TSH
- Follow-up utox, EtoH, HCG, ABG, CXR, LP, EEG
- Follow-up UCx, BCx
- Neuro consulted, apprec recs
- BP goal ***
- If ischemic: <4.5 hr from LKWT, then ASA, plavix, statin, VTE ppx
- If hemorrhagic: NSGY c/s
#[[Acute Hypoxic Respiratory Failure | AHRF]] [[pneumonia | PNA]]
- #AHRF
#PNA
- Follow-up CXR, CTPA
- Follow-up CBC, BMP, Procal, ESR/CRP, VBG/ABG, sputum culture
- Infectious w/u: cocci, crypto, histo, HIV, PJP, legionella, MAC, TB, Coxiella, Francisella
- CAP: CTX, azithromycin, add vanc if critical (CURB-54, PSI scores)?
- HAP/VAP coverage: Cefepime, Vanc?
- Aspiration PNA: CTX, flagyl if empyema ?
- AIDS PNA: CTX, azithro, bactrim
[[PULMONARY EMBOLISM]]
- #Pulmonary Embolism
RHS on TTE, EKG changes, troponin, BNP, VS.
- Consider thrombolysis if HDUS
- Pulmonary consult
- Start heparin gtt
- Transition to PO AC (Xeralto starter pack)
- Follow-up TTE, DVT US
- Follow-up hypercoagulable work-up: protein C&S activity, activated protein C resistance, antithrombin II assay, factor VIII assay, fibrinogen, prothrombin 20210G>A mutation, homocystein, factor V mutation analysis, beta-2 glycoprotein, anti-cardiolipin, ANA, ESR
[[PANCREATITIS]]
- #Pancreatitis
Differential includes alcoholic, triglyceridemic, infections, obstruction (e.g. gallstone, mass). Meets 2/3 criteria of abdominal pain, elevated lipase/amylase > 3x ULN, imaging. Apache score. Ranson score.
- Follow-up CBC, CMP, PT/INR, EtOH level, A1c, FLP, Lipase, Amylase
- Follow-up CXR, Abdominal US, CTAP, MRCP, MRI
- NPO, IV fluid (1.5 mL/kg/hour with a 10 mL/kg bolus), pain control
- Strict I&O, q8h to q12h labs (including Ca)
- ERCP for gallstone
- Insulin for hypertriglyceridemia
- Antibiotic only if septic appearing
#Meningitis
- #Meningitis
Pt w/ symptoms of fever, altered mental status, headache, and nuchal rigidity, indicating high risk for meningitis. May consider strep pneumo iso (recent sinusitis/otitis, head trauma, immunocompromised). May consider neisseria iso (college student, hajj, recent exposure, rash). May consider staph aureus iso (IVDU). May consider H flu iso (no vaccine). May consider Crypto (iso HIV). May consider Listeria iso (immunocompromised, dairy exposure).
- CTH (if/before LP if immunocompromised, hx of CNS dz, new sz, papilledema, FND, AMS)
- Follow-up LP studies
- Follow-up BCx
- Antibiotics: ceftriaxone 2g q12h, vancomycin 20 mg/kg q12h, ampicillin 2g q4h (if > 50 yo or risk factors)
- Replace CTX with cefepime 2g q8h vs meropenem 2g q8h if possible PsA (e.g. hospital, immunocompromised)
- Dexamethasone 0.15 mg/kg q6h x4 days (15 to 20 minutes before or w/ abx)
[[TRANSAMINASE]]
- #Elevated Transaminases
Differential includes infectious, infiltrative, autoimmune, toxic (DILI, EtOH), malignancy, obstructive.
- Follow-up CBC, CMP, PT/INR, GGT, viral hepatitis panel, EtOH level, A1c, FLP
- Follow-up RUQ US, CTAP, MRI multiphase, MRCP
- Alcoholic hepatitis: MELD, Maddry's, Glasgow score
-- Fluid resuscitation
-- Pentoxifylline 400 mg TID (Maddry's > 32)
-- Consider Prednisolone 40 mg qday (Maddry's > 32)
[[INFLAMMATORY BOWEL DISEASE]]
- #Ulcerative colitis
#Crohn's disease
- GI consulted, apprec recs
- Infectious r/o: BCx, UA/UCx, Stool culture, CXR
- Trend ESR/CRP qday
- Follow-up fecal calprotectin
- Follow-up KUB, CTAP
- Start Solumedrol 20 mg IV q8h
- NPO at MN, possible colonoscopy per GI
#Hyponatremia
- #Hyponatremia
Differential for hypotonic hypoNa includes hypovolemic (renal losses, GI losses, sepsis, dehydration), euvolemic (hypothyroidism, toxins, SIADH, adrenal insufficiency), vs hypervolemic (renal failure, nephrotic syndrome, cirrhosis, CHF) hypoNa. Alternatively, may consider hyperglycemia, hypertriglyceridemia, hyperglobulenemia, or other unmeasured osms (mannitol, sorbitol, maltose, constrast, etc) depending on serum osm.
- Follow-up serum osm, BMP
- Follow-up urine osm, urine lytes
- Follow-up TSH, AM cortisol, FLP, utox, cultures
- Fluid resusitation as above
- Management of volume overload as above
#ADHF
#HFpEF
- #ADHF
#HFpEF
Differential includes HTN, hypertrophic, infiltrative, constrictive. H2FPEF score.
- Follow-up EKG, TTE, CXR, LHC, BNP, troponin, CBC, CMP, Mg
- GDMTs:
-- Preload: lasix, bumex
-- Afterload: ACEi/ARB/ARNI, hydral/nitrate, aldactone
-- Other: SGLT-2 inhibitors
- Strict I&O, daily standing weights
- BMP q12g, K/Mg 4/2
[[Acute Hypoxic Respiratory Failure | AHRF]] [[COPD]]
- #AHRF
#COPD Exacerbation
- Follow-up CXR, PFTs
- Follow-up CBC, BMP, Procal, ESR/CRP, VBG/ABG, sputum culture
- Start duonebs q6h
- Start azithromycin 500 mg qday x5 days
- Start prednisone 40 mg qday x5 days
- Start guaifenesin PRN
- Start chest PT q6h
#ASTHMA
- #AHRF
#Asthma Exacerbation
- Follow-up CXR, PFTs
- Follow-up CBC, BMP, Procal, ESR/CRP, VBG/ABG, sputum culture
- Start duonebs q6h
- Start prednisone 40 mg qday x5 days
- Start guaifenesin PRN
- Start chest PT q6h
#Anemia
- #Anemia
Differential includes GI bleed, gyn bleed, hemothorax, hematoma, hemolysis.
- Follow-up EGD, Colonoscopy, CT C/A/P
- Follow-up CBC, CMP, iron panel, ferritin, B12, folate, type and cross, LDH, D-dimer, fibrinogen, haptoglobin, retic count, D-dimer, PT/PTT/INR, UA
- Hold any anti-platelets, AC, anti-HTN, BB, CCB
- Transfusion for Hgb > 8, plts > 50/20/10, fibrinogen > 100, INR > 10
- Vitamin K as needed
#Normocytic anemia
- #Normocytic anemia
- Follow-up iron panel, ferritin, B12, folate, retic count
#Encephalopathy
- #Encephalopathy
Differential includes metabolic, hypoxic, hypercarbic, vascular, endocrine, seizure, trauma, drugs, infectious, or psychiatric etiology.
- Follow-up CBC, CMP, Mg, Phos, VBG, TSH, BG, thiamine, B12, folate, ammonia, utox/EtOH, salicylate level, acetaminophen level
- Follow-up UCx, BCx, CXR
- Follow-up EKG, CTH, MRI brain (for PRES)
- Consider LP
#[[AKI | ACUTE KIDNEY INJURY]]
- #AKI
Differential includes pre-renal (dehydration, sepsis, cardiorenal, cirrhosis, renal vein stenosis/thrombosis, compartment syndrome, vasogenic), intra-renal (ATN, AIN, GN), and post-renal (obstructive, neurogenic).
- Follow-up UA, uACR, UPC, urine eosinophils, urine Na, urine urea
- Follow-up Renal US, bladder pressure, bladder scan/foley
#ACS #[[ACUTE CORONARY SYNDROME]]
- #ACS
HEART score. TIMI score. GRACE score
- Follow-up EKG, TTE, CXR, LHC, BNP, troponin, CBC, CMP, Mg
- Follow-up A1c, FLP, TSH
- ASA 325 mg + Plavix 600 mg x1
- Continue ASA 81 mg qday
- Continue Plavix 75 mg qday
- Start Heparin gtt x48 hours
- Cardiology consult
AHRF
- #AHRF
Differential includes infectious, cardiac, pulmonary, renal etiology.
- Follow-up CXR, CTPA, PFTs, TTE
- Follow-up CBC, BMP, Procal, ESR/CRP, VBG/ABG, sputum culture
- Infectious w/u: cocci, crypto, histo, HIV, PJP, legionella, MAC, TB, Coxiella, Francisella
- Autoimmune w/u: ANAs, anti-dsDNA, anti-SSA-52 (Ro52), SSA-60 (Ro60), anti-SS-B, anti-Smith, Sm/RNP, c-ANCA, p-ANCA, anti-MPO, anti-PR3, anti-CCP, RF, anti-Scl-70, anticentromere, anti-RNA polymerase III, alpha-1 antitrypsin?
EKG SYNCOPE
- EKG reviewed, no TWI/ST changes. No dysrhythmias. Low suspicion for WPW, long QT, HOCM, Brugada.
CHEST XRAY | CXR
- Interpreted by me without evidence of pneumothorax, no evidence of rib fracture, no evidence of focal consolidation or infiltrate, no evidence of widened mediatinum, no evidence of pericardial or pleural effusion
NEUROGENIC BLADDER
- - L Hydronephrosis (8/2017) likely chronic from long standing retention previously, despite foley insertion, no obstruction on NM imaging study
- has had bladder wall thickening in imaging suggestive of Lower urinary tract obscrution as well
- there is a very strong association of Down's syndrome with imperforate anus without fistulization
- etiology of urinary retention is likely neurogenic, however this may have been either 2/2 post surgical complication after imperforate anal correction vs VATER association.
- spinal cord tethering can be a common abnormalities affecting the urinary tract; additionally, progressive denervation of the lowermost nerves modulating bladder and urethral function a possibility
- An upper motor neuron lesion with detrusor overactivity and/or detrusor sphincter dyssynergy are most likely to develop, but an acontractile detrusor and sphincter denervation are also seen as a result of spinal cord tethering
- would recommend urodynamic studies with next cystoscopy to assist in evaluation of above
Hypovitaminosis D
- #Hypovitaminosis D
- remains low, post-menopausal;
- Rx cholecalciferol 50,000 iu qweek for 12 weeks, followed by maintenance cholecalciferol
- USPSTF recommends screening > 65 in patient with otherwise no fractures or elevated SCORE
Asthma
- _ yo M/F with _[mild/moderate/severe intermittent/persistent] asthma, _[poorly/well] controlled with ACT score of _.
- Controller medications:_
- PRN medications:_
- Asthma action plan provided to and reviewed with family. **Enter & fill out asthma action plan from patient education**
- Reviewed inhaler use with patient and family.
- Discussed avoidance of triggers
- Instructed patient and family on device use.
- Follow up in _. [Not controlled: 2-6 week interval follow ups; Well controlled: 3-6 month intervals] [Refer to subspecialist if: 0-4 years old and Step 3 care required, 5 or older and Step 4 care required, and/or difficulty in achieving/maintaining asthma control.]
PALLATIVE CARE POOR COPING
- 1. Abd pain: of unclear etiology. Renal patients do best with methadone, fentanyl and hydromorphone from a safety standpoint, since the others may quickly build up neurotoxic metabolites. Oxycodone (which he will take) an option, but not preferred. Pt refusing methadone, oral hydromorphone and fentanyl.
- Pt requires strict limit setting, in order to maximize safety of his treatment, and to minimize distress in his providers
- Increase oxycodone to 20mg PO q3 hrs prn pain.
- IV hydromorphone will be weaned starting tomorrow, as there is no medical indication (NPO, N/V) Pt preference is important but not overriding. Best practice dictates that IV narcotics are to be avoided as much as possible in pts with chemical coping and probable substance abuse.
- would avoid long acting medications in this patient until he can demonstrate that he can comply with medication instructions consistently. The potential harm from overusing long acting medications are substantially greater than short acting.
2. Poor coping: unclear if he has good prognostic awareness, poor coping, or both. His choices are often contradictory, and his goals are unclear. Likely some durable personality traits in play. Will ask SW to eval and see how we can support him better. He responded neutrally to my approach of being curious about his experiences and acknowledging them, and although not welcoming, was not hostile or abusive. Although difficult for providers, would not recommend allowing him to dictate his medical care, when those choices conflict with safe care. In the case of his pain, his continued exposure to the euphoria and rapid onset of IV narcotics, without medical indications for it, damages his prospects for good pain control as an outpatient, or in the future. It will also impair his ability to constructively manage physical discomfort, which will be a feature of his experience no matter how much medication he gets.
- Will work with him to give him as much latitude as possible, within the bounds of good practice and safety, in crafting a pain regimen he can live with.
- Will use other members of team (chaplaincy, nursing, SW to maximize support and resources, so that he better understands that we are committed to his success, even if that means we don’t participate in his harmful choices when he makes them.
Appreciate invitation to be involved in your complex patient’s care. Will continue to follow.
OSTOMY BLEED
- The differential for bleed - includes stomal varices, ischemic colitis, infectious colitis, bleeding around ostomy site. Less likely is esophageal varices bleed - as he does not have any hematemesis.
#Cardiogenic shock
- Patient with severe valvular disease and history of CHF, and low urine output with elevated wedge pressures, and low mixed venous consistent with cardiogenic shock.
- secondary to volume overload vs new afib vs worsening valvular disease
Mechanical support: None
Chemical Support: no longer on milrinone
- Will plan on doing right and left heart cath on today after TEE to delineate restrictive vs constrictive physiology
# Acute Decompensated Systolic heart failure:
- BNP of 1000, patient with JVD on exam, and bibasilar crackles and pleural effusions on CXR
- Low Wells score at this time 1.5 for tachycardia
- reported history of CHF, on metoprolol and lasix at home
- Reports taking medications daily, however concern for poor adherence given current prescription filled in March, patient's family reports that the patient had poor medication adherence.
- Continue lasix 40mg IV BID for ongoing fluid overload
- Strict I&O
#Atrial Fibrillation with RVR:
- Patient with irregularly irregular hearth rhythm on EKG with tachycardia to the 120s on admission s/p TEE and electrical cardioversion. Now in sinus rhythm with herat rates of 80-90s
- No known prior history of AFib, CHADSVASC of 4
- Possibly secondary to uncontrolled CHF and acute volume overload
- holding atenolol 50mg - holding beta blockers in the setting of decreased cardiac output and possible cardiogenic shock.
- On heparin gtt, goal PTT of 65-100,
- switched back from PO amiodarone to amiodarone gtt 1mg/min for further rate control
- s/pTEE with cardioversion (1/4/16) for symptomatic afib, now in sinus rhythm
ESRD
- - Etiology: unclear, Likely GN with nephrotic range protineuria Possibly 2/2 DM, given long history as well as vasculitis given normal complement and active sediment in UA. component of post-obstruction and chronic BPH as flomax has improved UOP. although patient has chronic HCV infection, MPGN less likely given normal complements. no e/o cirrhosis.
- Access: Right tunneled permacath
- Volume Status: euvolemic.- Anemia: not at goal. continue ferrous sulfate. con't aranesp 100mcg SQ q week
- Electrolytes: Continue to hold renagel- Based on 24 hour creatinine clearance: <5 mL/min. Will need HD 3x weekly
- HD Placement: Has vein mapping appointment and vascular appointment: 5/18
Recs:
- HD MWF. HD today
- Please obtain daily BMP
- Aranesp: Would not recommend in patients with current HTN
- Access: Please place PPD, request vein mapping appointment, have pt watch HD videoes ALL prior to request for Permacath (tunnelled catether) placement. Please also ensure patient has recent Hep panel, RPR
#Migraine headaches PROPHYLAXIS
- #Migraine headaches
- unknown triggers, possibly related to nicotine withdrawal as he doesn't consistently smoke
- handouts givens on avoiding triggers
- since patient refractory to sumatriptan will try Rizatriptan 5 mg qday PRN abortive therapy (TNF signed)
- Tylenol 325 mg PRN
- HA greater than 1-3 times a week should be considered for prophylactic therapy (Amitriptyline 12.5 mg-25 mg qHS, Depakote ER 250-500 mg QD). Alternative treatments such as riboflavin 400 mg a day or magnesium oxide 400 mg BID are also effective prophylactics.
- Will start prophylactic therapy (MgOx) + instructed to restrict abortives to < 3 times a week and give patient a HA diary.
- AAN guidelines for preventive therapy show Level A evidence for use of certain B-blockers and Anti-epileptic like Valproic acid, topiramate.
- In this patient will avoid hepatoxicity and risk of pancreatitis with VPAs. Will consider Amitriptyline after initial EKG
- - unknown triggers, possibly related to nicotine withdrawal as he doesn't consistently smoke
- handouts givens on avoiding triggers
- since patient refractory to sumatriptan will try Rizatriptan 5 mg qday PRN abortive therapy (TNF signed)
- Tylenol 325 mg PRN
- HA greater than 1-3 times a week should be considered for prophylactic therapy (Amitriptyline 12.5 mg-25 mg qHS, Depakote ER 250-500 mg QD). Alternative treatments such as riboflavin 400 mg a day or magnesium oxide 400 mg BID are also effective prophylactics.
- Will start prophylactic therapy (MgOx) + instructed to restrict abortives to < 3 times a week and give patient a HA diary.
- AAN guidelines for preventive therapy show Level A evidence for use of certain B-blockers and Anti-epileptic like Valproic acid, topiramate.
- In this patient will avoid hepatoxicity and risk of pancreatitis with VPAs. Will consider Amitriptyline after initial EKG
PRN
ALCOHOLIC HEPATITIS STEROIDS
- 50 yo man with decompensated Cirrhosis 28 MELD-Na , Childs C, recently admitted to Alhambra hospital and given course of steroids for concern for Alcoholic hepatitis (no bx done). Pt returns after completion >7 days ago Lille score indicative that he is a non responder and based on evidence below, steroids, not likely to provide mortality benefit.
complete responders (Lille score =0.16; <35th percentile)
partial responders (Lille score 0.16–0.56; 35th–70th percentile)
null responders (Lille =0.56; >70th percentile)
Corticosteroids had a significant effect on 28-day survival in complete responders (HR 0.18, p=0.006) and in partial responders (HR 0.38, p=0.04) but not in null responders
iSCHEMIC LIVER INJURY
-
In most cases, liver dysfunction emerges without any noticeable changes in clinical status or episodes of hypotension. Preexisting liver disease and portal hypertension are particularly susceptible. Passive congestion of the liver also increases risk for ischemic injury. Elevated CVP leads to perisinusoidal edema and associated with atrophy of hepatocytes in zone 3 (presumably from exudation of protein-rich fluid into the space of Disse) resulting impairs the diffusion of oxygen and flow of nutrients to hepatocytes. If patient has pre-existing portal hypertension, increased collateral circulation may cause bypassing of blood supply to liver.
Recommendations
1. F/u LDH, continue trending liver enzymes
2. Please order Abd US to identify presence of liver disease, portal htn
3. Agree with TTE
4. Advised alcohol cessation
# ILD, with characteristic features of UIP
- - Chronic HP vs IPF
- Pts CT showing supleural, peripherally and posteriorly predominant disease, but there is some apical involvement as well, associated with volume loss in both lower lobes, the later can be old granulomatous disease from TB
- IPF is a diagnosis of exclusion; agree with identifying potential known causes first e.g., domestic and occupational environmental exposures, connective tissue disorders, or drug exposure/toxicity
- Bronchoscopy with BAL vs TBBx would aid in exclusion of chronic hypersensitivity, will discuss in Pulm Clinic
- HP panel sent which tests for Abs (Aspergillus fumigatus, Micropolyspora faeni, Saccharopolyspora rectivirgula, Pigeon Serum, T. candidus, Thermoactinomyces candidus, Thermoactinomyces vulgaris, Saccharomonospora viridis Ab
- There is an association of ILD with polymyositis/dermatomyositis, sent anti-aminoacyl tRNA synthetase Ab (of which anti-Jo1 is most helpful), although reassuring that CK is wnl, no sxs of myositis
- F/u Autoimmune panel (ANA, ANCA, RF,
- Consider myomarker 3 panel to above work up to assess amyopathic dermatomyositis
- Will obtain baseline PFT
# ILD, diffuse ground glass mozaic pattern
- - Strongly recommend to avoid potential antigens, this includes exposure to also environmental exposures to paint
- HP panel sent which tests for Abs (Aspergillus fumigatus, Micropolyspora faeni, Saccharopolyspora rectivirgula, Pigeon Serum, T. candidus, Thermoactinomyces candidus, Thermoactinomyces vulgaris, Saccharomonospora viridis Ab
SUPRATHERAPUETIC INR
-
#Supratherapeutic INR
- (INR) instability (eg, intercurrent illnesses, interacting medications). Bleeding risk is also increased by some comorbidities (eg, liver disease, heart failure) and other factors (eg, age, prior hemorrhage, concomitant nonsteroidal anti-inflammatory drug [NSAID] use, especially nonselective NSAIDs); these should be addressed when possible.
- Treatment – The optimal approach for managing a patient with warfarin-associated bleeding or supratherapeutic INR depends on the presence of clinically significant bleeding, the degree of INR elevation, and the underlying thrombotic risk/indication for anticoagulation (table 5).
•Serious bleeding – Patients with serious or life-threatening bleeding and a prolonged INR (eg, >2) should have warfarin withheld and should receive vitamin K (10 mg) by slow intravenous infusion, along with a rapid reversal agent. We suggest a 4-factor prothrombin complex concentrate (PCC) (table 6) rather than Fresh Frozen Plasma (FFP) (Grade 2B). If 4-factor PCC is not available, 3-factor PCC supplemented with FFP or FFP alone is appropriate. Vitamin K administration can be repeated every 12 hours for persistently elevated INR. (See 'Serious/life-threatening bleeding' above and 'PCC products, efficacy, risks' above.)
Management of warfarin-associated intracerebral hemorrhage (ICH) is discussed separately. (See "Reversal of anticoagulation in warfarin-associated intracerebral hemorrhage".)
•Surgery – For a patient who requires urgent surgery or invasive procedure, the bleeding risk, need to reverse anticoagulation, and urgency of surgery/procedure should be determined in consultation with the surgeon/interventionist. (See 'Urgent surgery/procedure' above and "Perioperative management of patients receiving anticoagulants", section on 'Deciding whether to interrupt anticoagulation'.)
-Patients who require emergent (eg, same day) surgery and warfarin reversal should have warfarin held and should receive vitamin K and a rapid reversal agent as done for serious bleeding. We suggest a 4-factor PCC rather than FFP (Grade 2B).
-Individuals who can wait 24 hours and require warfarin reversal may be managed by holding warfarin and giving vitamin K without the use of a PCC.
-Management of warfarin around the time of elective surgery is presented separately. (See "Perioperative management of patients receiving anticoagulants".)
•Minimal bleeding – Minimal bleeding can be treated as outlined for more significant bleeding (eg, with PCC) or for supratherapeutic INR without bleeding, depending on the perceived likelihood of progression to more severe bleeding. (See 'Minimal bleeding' above.)
•INR >9 without bleeding – For individuals with INR >9 without bleeding, warfarin therapy should be held and 2.5 to 5 mg of vitamin K administered orally. Nonbleeding patients should not be given PCC or FFP solely to correct a supratherapeutic INR, as these products have associated risks. The INR is monitored daily or every other day, and warfarin is resumed at a lower dose once the INR in the therapeutic range. (See 'INR >9 without bleeding' above and 'Vitamin K dose, route, formulation' above.)
•INR 5 to 9 without bleeding – For individuals with INR between 5 and 9 without bleeding, warfarin is held temporarily (eg, one or two doses) with or without administration of a small dose of oral vitamin K (eg, 1 to 2.5 mg). Warfarin generally is resumed at a lower dose once the INR is in the therapeutic range. (See 'INR 5 to 9 without bleeding' above and 'Vitamin K dose, route, formulation' above.)
•INR <5 without bleeding – For individuals with INR <5 without bleeding, one or more doses of warfarin may be omitted and/or the dose is reduced slightly. If the INR elevation is minimal and/or expected to be transient, no dose reduction may be necessary. Additional therapies such as vitamin K are not indicated in this setting. (See 'INR <5 without bleeding' above.)
-Poisoning with a superwarfarin can cause severe, prolonged coagulopathy, and patients usually require massive doses of vitamin K over months to years. (See 'Superwarfarin poisoning' above.)
SYNCOPE
-
# Syncope
- True syncopal causes included neurocardiogenic (vasovagal), carotid sinus sensitivitiy, orthostatic, arrythmias and structural cardiac disease
- Other causes of LOC (not true syncope) to be excluded: Seizures, sleep disturbances, accidental falls, psychiatric illness, sedatives/drug induced
- Diff: neurocardiogenic (vasovagal) vs orthostatic, history not suggestive of seizure
- patient does not exhibit high risk features: ST elevation, brugada criteria, QT prolongation, arrhythmia, heart block, bradycardia, anemia, hypotension, underlying CHF, valvular disease, congenital heart disease. Further the nature of syncope was not precipitated with chest pain, palpitations, or come on with exertion
- given the above no indication for cardiac monitoring
- further there are no clinical features of heart failure/valuopathy on exam, so is no urgency in obtaining TTE prior to surgery
- Pt is considered low risk; hence no need for further evaluation
STROKE EVIDENCE
- - USPSTF found the evidence insufficient to recommend for or against the use of aspirin for MI or stroke reduction in men and women age 80 and older
- USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of initiating statin use in adults 76 years and older - - use of statins for prevention is limited to observational studies. A population-based study conducted in Iceland including men and women aged 66 to 96 years of age (mean age 77 years of age) found a decreased risk of all-cause mortality among diabetic statin users (HR 0.47, 95% CI 0.32-0.71) as compared to non-users,13 and in a cohort of patients born in Jerusalem, statin use at age 85 was associated with decreased mortality risk (HR 0.61, 95% CI 0.42 to 0.89) over the next five years compared with those not taking statins
SUBJECTIVE GENERAL
- No acute events, patient tolerating PO, no new complaints, no new localizing infectious symptoms
STROKE ADMISSION
- # Neuro: Possible acute cerebellar stroke vs TIA
- Admit to Neuro Gold in telemetry
- Neuro Checks q2h
- Continuous cardiac monitoring on telemetry
- ASA 325 first day, 81mg po daily thereafter
- Lipitor 80mg po daily
- Consider starting Plavix if tolerable, given CAD
- Stroke Labs: Hg A1c, TSH, Fasting lipid panel, RPR
- PT/OT/ST evaluation if symptoms worsen
- CTA w and w/o contrast head and neck, elucidation of possible underlying ischemic cerebellar infarction.
# CV: History of CAD s/p CABG
- Continuous cardiac monitoring on Telemetry
- Permissive HTN, BP goal < 220/110
- Will hold Metroprolol if HR < 80
- Consider resuming tomorrow
# Pulm:
- Keeps sats 92%
- HOB 30 degrees
# Endocrine: DM
- Goal BS 140-180
- Labs: A1c, FLP, TSH
- ISS qACHS
# Heme/ID
- Levonox for DVT ppx
#FEN/GI
- diet NPO until cleared, carb diet
- NS at 100 cc/hr
- no PPI
- Levenox SQH
Dispo: patient admitted for stroke work up.
DWA
DWR
Ahmadi, 130365
STATIN EVIDENCE
- - USPSTF: current evidence is insufficient to assess the balance of benefits and harms of initiating statin use in adults 76 years and older - - use of statins for prevention is limited to observational studies. A population-based study conducted in Iceland including men and women aged 66 to 96 years of age (mean age 77 years of age) found a decreased risk of all-cause mortality among diabetic statin users (HR 0.47, 95% CI 0.32-0.71) as compared to non-users,13 and in a cohort of patients born in Jerusalem, statin use at age 85 was associated with decreased mortality risk (HR 0.61, 95% CI 0.42 to 0.89) over the next five years compared with those not taking statins
SMOKING
- # Smoking cessation
- counselled at bedside, patient instructed on calling 1-800-NOBUTTS
- Bupropion sustained release 150 mg/day for three days, then 150 mg twice a day
- Start 1-2 weeks before quit date Insomnia, agitation, dry mouth, headache
- Blunts post cessation weight gain while being used
- A lower dose of 150 mg per day is an option for patients who do not tolerate the full dose
ESRD
- - Etiology: Likely GN with nephrotic range protineuria, etiology unclear. Possibly 2/2 DM, given long history as well as vasculitis given normal complement and active sediment in UA. component of post-obstruction and chronic BPH as flomax has improved UOP. although patient has chronic HCV infection, MPGN less likely given normal complements. no e/o cirrhosis.
- Access: Right tunneled permacath
- Volume Status: euvolemic.
- Anemia: not at goal. continue ferrous sulfate. con't aranesp 100mcg SQ q week
- MBD: PTH 123/vit d < 13 (3/2016): Con't Ergocalciferol 50,000 IU PO q day .
- Electrolytes: Continue to hold renagel
- BP goal BP < 160, Recommend hold BP meds for SBP < 160 and hold BP meds 2 hours prior to HD to prevent hypotension.
-Based on 24 hour creatinine clearance: <5 mL/min. Will need HD 3x weekly
-HD Placement: Has vein mapping appointment and vascular appointment: 5/18. patient has recent Hep panel, NR RPR, negative PPD (read 3/23)
-pending permacath placement.
Recs:
- will cont HD MWF. HD today
DWF Matni
DWA Kaptein
RENAL CYST
- Cystic renal disease r/o RCC
63 year old male admitted for colitis with incidental suggestion of ADPKD on CT scan of abdomen.
- pt has been told he has cystic kidney disease before indicating slow growth
- in absence of a family history, there is no definitive number of cysts and/or cyst location that provides an unequivocal diagnosis of ADPKD. Pt may have benign cystic disease but the combination of hepatic and renal cysts in this case strongly suggests ADPKD.
- older people tend to have more cysts. These cysts are probably very slow growing given the number of cysts in relation to his Cr of only 1.16. Not all ADPKD patients will progress to ESRD.
- recommend optimal BP control with ACEI if there are no contraindications. ADPKD patients have HTN from +++RAAS and extracellular volume expansion, and tend to respond well to ACEI. Also patient is a diabetic with 30 protein on UA.
- The HALTA-PKD trial showed that a blood pressure target of <110/75 mmHg led to a lower total kidney volume (TKV), lower albumin excretion rate, and lower left ventricular mass index (LVMI) when compared with a blood pressure target of 120 to 130/70 to 80 mmHg in relatively young, healthy individuals with intact kidney function.
- Thank you for this consult.
HYPERCALEMIA
- # Hypercalcemia-
-Hyperuricemia, hypercalcemia on 3/12 labs, though calcium improved with hydration. Calcium not at dangerous level. Please call if pt becomes confused as calcium may be high. Unlikely related to parathyroid, as PTH wnl, PTHrP wnl.- Given DLBCL and hilar LAD on CT imaging, there is concern for extra-renal production of Vitamin D 1, 25 OH by lymphocytes related to DLBCL or granulomatous disease, which would not respond to bisphosphonates. Because malignant lymphocytes or macrophages increase conversion of vitamin D to 1,25 Vitamin D via extra-renal 1 alpha hydroxylase, some lymphomas and granulomatous disease can cause hypercalcemia. Patient has elevated Vitamin D 1,25 OH, c/w with this diagnosis.- unlikely related to parathyroid, as PTH wnl, PTHrP wnl- Since 1,25 OH Vitamin elevated, mechanism of hypercalcemia may be treated with steroids, and patient already on more than sufficient doses of steroids for this effect (would be treated with equivalent of 5-10 mg of Prednisone per day, and once chemotherapy begins to effectively treat lymphoma, would be able to hold steroid therapy for hypercalcemia
- large amount of corticosteroid dosing currently
HPYLORI
- #Active H.pylori gastritis
- Will treat 14 day triple therapy
- omeprazole, amoxicillin, and clarithromycin
Proton pump inhibitor (PPI) (omeprazole 20 mg BID, lansoprazole 30 mg BID, esomeprazole 40 mg QD, pantoprazole 40 mg QD, rabeprazole 20 mg BID)
Clarithromycin 500 mg BID (first-line) or metronidazole 500 mg BID (when clarithromycin resistance increasing)
Amoxicillin 1000 mg BID
# Perioperative cardiac risk assessment for noncardiac surgery
- # Perioperative cardiac risk assessment for noncardiac surgery
- no known CAD, HF, valvular disease, arrhythmias, renal insufficiency
- Excellent functional capacity >10 METs
- Pt is considered low risk <1% for major adverse cardiac events
- Per ACC/AHA 2014 guidelines, no further testing needed, proceed with surgery
#HTN
- daughter will bring list of medications
- Avoid starting B-blockers, unclear if patient is taking any previously
PORTal htn
-
Pts spleno-gastro-renal shunt can represent abnormal collateral portosystemic communication or anatomical variants. Hepatic venous pressure gradient (HVPG), i.e., the difference between the wedged (WHVP) and the free hepatic venous pressure to elucidate etiology of portal hypertension.
BLEED PROPANOLOL
-
Non selective beta blockers act by producing splanchnic vasoconstriction and reducing portal venous inflow. Venodilators theoretically act by decreasing intrahepatic and/or portocollateral resistance.
A large multicenter, placebo-controlled, double-blinded trial failed to show a benefit of nonselective ß-blockers (timolol) in the prevention of varices in patients with cirrhosis who had portal hypertension at baseline (HVPG >5 mmHg) but had not yet developed varices (16). The study did show, however, that patients who achieved even a mild reduction in HVPG after 1 year of therapy (=10% from baseline) had a significantly lower development of varices, and that a larger percentage of patients on timolol showed this reduction in HVPG compared to those on placebo. A significantly larger number of patients with moderate or severe adverse events were observed in the timolol group.
Per ACG guidelienes, In patients with cirrhosis who do not have varices, nonselective ß-blockers cannot be recommended to prevent their development (Class III, Level B).
In patients who have compensated cirrhosis and no varices on the initial EGD, it should be repeated in 3 years (Class I, Level C). If there is evidence of hepatic decompensation, EGD should be done at that time and repeated annually (Class I, Level C).
For secondary prophylaxis, Patients with cirrhosis who survive an episode of active variceal hemorrhage should receive therapy to prevent recurrence of variceal hemorrhage (secondary prophylaxis) (Class I, Level A).
Combination of nonselective ß-blockers plus EVL is the best option for secondary prophylaxis of variceal hemorrhage (Class I, Level A).
The nonselective ß-blocker should be adjusted to the maximal tolerated dose. EVL should be repeated every 1–2 weeks until obliteration with the first surveillance EGD performed 1–3 months after obliteration and then every 6–12 months to check for variceal recurrence (Class I, Level C).
TIPS should be considered in patients who are Child A or B who experience recurrent variceal hemorrhage despite combination pharmacological and endoscopic therapy. In centers where the expertise is available, surgical shunt can be considered in Child A patients (Class I, Level A).
Patients who are otherwise transplant candidates should be referred to a transplant center for evaluation (Class I, Level C).
ESRD
- - Etiology: Likely GN with nephrotic range protineuria, etiology unclear Possibly 2/2 DM, given long history as well as vasculitis given normal complement and active sediment in UA. component of post-obstruction and chronic BPH as flomax has improved UOP. although patient has chronic HCV infection, MPGN less likely given normal complements. no e/o cirrhosis.
- Access: Right tunneled permacath
- Volume Status: euvolemic.
- Anemia: not at goal. continue ferrous sulfate. con't aranesp 100mcg SQ q week
- Electrolytes: Continue to hold renagel
- Based on 24 hour creatinine clearance: <5 mL/min. Will need HD 3x weekly
- HD Placement: Has vein mapping appointment and vascular appointment: 5/18
Recs:
- HD MWF. HD today
- Please obtain daily BMP
- Aranesp: Would not recommend in patients with current HTN
- Access: Please place PPD, request vein mapping appointment, have pt watch HD videoes ALL prior to request for Permacath (tunnelled catether) placement. Please also ensure patient has recent Hep panel, RPR
MBD:
- PTH 123/
- vit d < 13 (3/2016):
- Con't Ergocalciferol 50,000 IU PO q day .
HTN, likely essential, controlled
- BP goal BP < 160, Recommend hold BP meds for SBP < 160 and hold BP meds 2 hours prior to HD to prevent hypotension.
- Labetolol
- Norvasc
MBD:
POLYCYTHEMIA
- #Polycythemia
- isolated to RBCs, but patient does not meet diagnostic threshold
- HCT >48 or >52 percent in women and men, respectively
- HGB >16.5 or >18.5 g/dL in women and men, respectively
- acquired secondary vs congential vs primary
- no hypoxia to suggest fu EPO levels
PEG TUBE
- - Will monitor for Hypofibrinogenemia, Hypertriglyceridemia, Necrotizing pancreatitis, Liver toxicity, coagulopathy (hypo or hypercoagulable) twice weekly for minimum of 4 weeks
HEART FAILURE
- The ACC/AHA writing committee has taken a new approach to the classification of HF: the evolution and progression of the disease is now emphasized. Only stages C and D qualify for the traditional clinical diagnosis of HF. (This classification is intended to complement, but not replace, the NYHA Functional Classification.)
Stage A: patients who are at high risk for developing HF but have no structural disorder of the heart
Stage B: patients with structural disorders of the heart who have never had symptoms of HF
Stage C: patients with past or current symptoms of HF associated with underlying structural heart disease
Stage D: patients with end-stage disease who require specialized treatment strategies, such as mechanical circulatory support, continuous IV inotrope infusions, cardiac transplantation, or hospice care
#HFrEF: Acute exacerbation
- - Acute systolic CHF (EF 15%)
- ACC/AHA Stage C, NYHA Class 3
- plan for R/L cath on Tuesday for further characterization of ischemic vs non ischemic cardiomyopathy
- Goal net - 1-2 L
- Lasix 20mg IV daily; will spot dose PM lasix
- Coreg 6.25 BID (Hold for SBP <100); lisinopril 10 daily
- Will consider start Spironolactone.
- 2g sodium diet, daily weights, strict i/o
GOALS OF CARE
- Goals of care - Gold B Team discussion with Mrs Manzo, both her sons (Oscar Alejandro and Caesar Alejandro)
Based on many discussions amongst the CRS team and amongst Oncology team, at present, there are no meaningful surgical or chemotherapy options that would provide any palliative benefit to Mrs Manzo. She is not responsive to chemotherapy as evident by recurrent infections and fistula formation despite FOLFOX and now FOLFORI and now progressive tumor invasion into pelvic side wall. At this point, all following teams agree the benefits of palliative chemotherapy in Mrs Manzo's case do not outweigh the risks of chemotherapy related complications.
In an earlier conversation, Dr Vanzyl from palliative care spoke with patient regarding patient's wishes, finalized note pending. After this meeting, I confirmed Mrs Manzo's wishes she had expressed to Dr Vanzyl earlier. She stated she agreed with plan of care that was addressed by multiple team members prior. I further explained to all present, Mrs Manzo and her sons, that our recommendation is for comfort care given the severity and irreversibility of her current condition. I explained to her sons that comfort care would optimize the patient's needs without causing any more pain/stress from blood draws or unnecessary procedures. All present expressed understanding and agreed to make the patient's code status: "DNR/DNI and Comfort Care". Explained that there are options for comfort care which include home hospice, and SNF hospice. With regards to patient's final wishes, her sons expressed that, if possible, she would like to go to Mexico to spend her remaining time. Additionally, her current husband is in prison and they would like assistance to see if it is possible to obtain visitation rights
Appreciate palliative care team's assistance and recommendations.
Code: DNR/DNI
Will arrange home with hospice when patient stable for transfer home
Ahmadi, PGY1
130365
FUNGITELL
- 1. Fungitell (1-3)-b-D-glucan) is a cell wall constituent of most medically important fungi including Aspergillus and PCP, but doesn't detect certain fungal species such as the genus Cryptococcus, which produces very low levels of (1-3)-b-D-glucan . This assay also does not detect the Zygomycetes, such as Absidia, Mucor, and Rhizopus (which are not known to produce (1-3)-b-D-glucan).
- - PTH 123
- vit d < 13
- Con't Ergocalciferol 50,000 IU PO q day
HTN, likely essential, controlled
- - BP goal BP < 160, Recommend hold BP meds for SBP < 160 and hold BP meds 2 hours prior to HD to prevent hypotension.
- Labetolol
- Norvasc
AMS
- Patient alert and oriented at this time. however is intermittently drowsy this morning.
- no focal neuro deficits at this time.
- discontinued tramadol
- Continue to monitor
# Acute Encephalopathy
- - poss multifactorial but most likely metabolic 2/2 severe hypernatremia
- Other diff broad: Progression of chronic dementia vs infectious, CNS structural disease, endocrine, toxic ingestion, ischemia, stroke
- CTH with subdural fluid collections, not layering to suggest blood, possible proteinaceous content w/ mild mass effect on adjacent parenchyma + global volume loss + e/o of chronic microvascular ischemic changes
- Could consider MRI brain if patient does not improve, but unlikely to change management
- reversible cause of underlying dementia: B12, TSH unremarkable
- Utox, Acetaminophen/ salicylate levels, RPR normal, troponin .02->0.01 (maybe 2/2 to reduced clearance from AKI)
- Blood and urine cx negative as of 8/16/2016
- Swallow eval and PT eval placed
- Attempted bedside eval, but pt not wanting to eat
#Acute hypoxic respiratory failure:
- Likely secondary to CHF exacerbation vs new aspiration pneumonia
- Possibly secondary to aspiration. Patient with aspiration event x2, recent fever, and rising leukocytosis
- will treat aspiration pneumonia with clindamycin (1/4/16-
#GERD:
- patient reports symptoms of reflux, and previously on omeprazole at home
- omeprazole 20mg QD
#Mild transaminases:
- - downtrending, likely secondary to hepatic congestion given CHF, AFIb
- Will continue to monitor
dEATH NOTE
- Code status confirmed with family earlier today, patient is comfort care/DNR/DNI
RN called that patient in unresponsiveness and asystole for several minutes at `2100
Initially sinus bradycardia on monitor with HR 20s, pulses.
Re examined ~20 min later, patient with persistent asystole on monitor and pulselessness
On exam: unresponsive, no response to verbal or noxious stimuli. Absent heart and breath sounds for more than 1 minute. Pupils are fixed and dilated, corneal reflex was absent. dolls eye negative, no gag reflex.
Patient pronounced dead at 21:40
Next of Margarita Figueroa notified
Tamana Ahmadi PGY3
#Non- Oliguiric AKI:
- Resolving. Creatinine increased to 1.8 from 1.2, now resolved
- FeUrea of 3.46%, consistent with pre-renal etiology.
- pre-renal (hypovolemia) vs ischemic ATN
- Foley placed, seen and evaluated urology, found to have no bladder obstruction with working foley
- Renal ultrasound without hydronephrosis, without evidence of chronic renal disease.
- Will CTM
cURRENT HOSPITALIZATION
- Current hospitalization:
Patient arrived on 2/16/16 for REPOCH cycle #5. Patient completed 5d course of chemotherapy without event. Patient remained afebrile and hemodynamically stable throughout his hospitalization. Patient stable for discharge on 3/14/2016 after final dose of chemotherapy. Patient to follow up in hematology clinic on 3/22/16, with labs drawn before hand. Patient discharged with D6 neulasta to be self-administered at home.
cIRRHOSIS
- -Diuretics: consider Lasix PO for outpatient
- K goal >4, depletion can enhance renal ammonia synthesis through transcellular cation K/H exchange NHCO3 genesis
- # Cirrhosis, Childs Class , MELD , compensated
-SBP: AASLD guidelines, PMN > 250 IV 3rd-gen cephalosporin, pref cefotaxime 2 g q 8 h. (PMN) <250 and s/sx infection ( >100°6F or abdominal pain) should also receive empiric antibiotic therapy, while awaiting results of cultures.
-SBP prevention: IV ceftriaxone or Norfloxacin BID for 7 d
-SBP prophylaxis long term: If no GI bleeding, Norfloxacin (or TMPSMX) can be justified ,if the ascitic fluid protein <1.5 g/dL and: Cr >1.2 , BUN >25, Na <130 , or CP>9 points with bili >3.
-HCC: Abd US screen q6m-1 yr, w/ wo AFP
-EV: Last EGD ,
-EV Surveillance: compensated cirrhosis within 12 months, repeated q1-2 yrs. complicated cirrhosis (ie w/ bleeding, encephalopathy, ascites, HCC or HPS - screen within 3 months
- EV prophylasix: Propanolol shown to prevent bleeding in patients with known large varicies, but studies suggest it may worsen survival in patients with refractory ascites
-HE: grade (Indications for Lactulose and Rifaximin)
-< 2 g Na or 88 mEq/d, Avoid NSAIDs, <2 g Tylenol, no shell fish
-last drink: * prior to admission, interested in sobriety, consider Baclofen for craving
-Diuretics: Spironolactone: Lasix (5:2), uptitrate as needed (max 400 mg:160 mg day), stop if Serum Na < 120 mEq/L
- IV Lasix often causes an acute reduction in renal function [33] Generally, avoid IV Lasix for treatment of ascites. However, spot IV Lasix (80 mg) may help identify diuretic-resistance. Typically secrete <50 mEq of Urine Na over 8 hrs after IV dose given [34].
- check UNa
- Avoid HypoK, depletion can enhance renal ammonia. A transcellular cation exchange, in which K moves out of cells in exchange for H, the ensuing intracellular acidosis stimulates ammonia synthesis in the proximal tubular cells, which can contribute to hyperammonemia. Maintain plasma K 3.4 - 5 mEq/L)
33. Daskalopoulos, G Laffi G, Morgan T Immediate effects of furosemide on renal hemodynamics in chronic liver disease and ascites. Gastroenterology 1987; 92:1859
34. Spahr L, Villeneuve JP, Tran HK, Pomier Layrargues G Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites. Hepatology 2001; 33:28
MELD 90 day mortality%
> 40 71.3
30 to 39 52.6
20 to 29 19.6
10 to 19 6.0
< 9 1.9
#Foot pain Bilaterally: Resolved
- - Patient with flushing and bilateral foot pain and swelling
- LE Doppler negative for DVT
- Unclear etiology, secondary to medication side effect vs pain from LE edema
- Will continue to monitor
VTE
- Will anticoagulate with heparin gtt at this time pending right and left heart cath to follow
- Holding off on coumadin, however will need to be anticoagulated with goal INR of 2-3
fEVER
fEVER
- - Pt with low grade fever previously and rising leukocytosis, and new chest opacities following aspiration episodes x2.
FEN:
Fluids: Patient tolerating PO
E: replete PRN
N: dysphagia diet, beneprotein and ensure supplements,
GI: omeprazole
Lines: Patient with Swan Ganz catheter placed, and foley catheter
Social: Patient currently has capacity.
- MDPOA
Code: DNR/DNI, patient has POLST form completed
aSPIRATION
- #Aspiration:
- No evidence of aspiration pneumonia on CXR
- Will continue dysphagia diet
- Pending inpatient speech and swallow eval.
HEADACHE HA
- Lifestyle Changes
Headache journal - Try to find pattern and provocative factors. Limit duration of journal to 2-4 weeks. (https://www.childrenshospital.org/~/media/centers-and-services/programs/f_n/headache-program/chb_my_headache_diary(1).ashx?la=en)
Sleep hygiene
Daily exercise
Avoid triggers (e.g. caffeine withdrawal), limit caffeine to 200mg/d max
Eat regular meals (don't skip)
Maintain hydration
Manage stress
Abortive Therapies (Tier 1)
Acetaminophen 15mg/kg PO (Prefer NSAIDS)
Ibuprofen 10mg/kg PO
Naproxen 5mg/kg PO
Abortive Therapies (Tier 2)
Sumatriptan PO 25-100mg - May repeat x 1 after 2 hours. Limit use to <10 days per month to prevent medication overuse headache.
Sumatriptan nasal spray 5mg (<20kg), 10mg (20-40kg), or 20mg (>40 kg) - May repeat x 1 after 2 hours. Do not exceed 40mg in one day.
Abortive Therapies (Tier 3)
Promethazine 0.25-0.5mg/kg (max 25mg)
Abortive Therapies (Tier 4)
Steroids
Dexamethasone x 2-3 doses (e.g. 6mg, 4mg, 2mg)
Scheduled NSAIDs (Need GI PPX!)
Naproxen (250-500mg q12h) or ibuprofen (600mg q6h)
Diclofenac 2-3mg/kg/d div 2-4 doses per day (max daily dosage 150mg)
Indomethacin 25mg TID
IV Migraine Cocktail
NS bolus
Promethazine / Reglan
Benadryl (To prevent EPS of promethazine / Relgan)
Toradol
Magnesium 1-2g
Preventative Therapies
Amitriptyline 0.25mg/kg/d - Initial: 0.25 mg/kg/day, given at bedtime; increase dose by 0.25 mg/kg/day every 2 weeks to 1 mg/kg/day.
Propranolol 40-250mg per day div BID (Avoid in patients with asthma)
Topiramate 100mg daily - >12 years of age. Initial: 25 mg once daily (in evening); may increase weekly by 25 mg daily up to the recommended dose of 100 mg daily given in 2 divided doses.
Cyproheptadine 2mg BID
Alternative / vitamin therapies for migraine
Magnesium 9mg/kg/d or 400-500mg - SE diarrhea
Riboflavin 200 or 400mg - SE urine discoloration (orange), diarrhea, vomiting. Half-life 2 hours; consider dividing doses.
Coenzyme Q10 1-3mg/kg or 150mg - SE GI upset, nausea, diarrhea, insomnia, fatigue, rashes. Expensive.
Butterbur 50-150mg - SE GI upset, diarrhea, drowsiness. Not FDA regulated. May contain carcinogens.
Vitamin D - Consider checking level. Hypovitaminosis D associated with migraine in adults. Maintain levels 35-60ng/mL.
Asthma
- Patient has intermittent asthma▼, currently well controlled▼with an ACT score of _
Rescue medication(s): Albuterol HFA MDI 90mcg/puff with spacer 2 puffs every 4 hours as needed▼
Controller medication(s): None▼
Instructed patient and family on device use
Reviewed ACT
Reviewed and updated asthma action plan (copies for home and school)
Filled form for permission to have albuterol in school
Discussed avoidance of triggers. Patient does not have▼tobacco exposure.
Provided verbal asthma education
UTI Outpatient
- *** presenting with fever for *** days, ***(dysuria, nausea, vomiting, foul smelling urine), and urinalysis with > 5 WBC/HPF, +LE, and +nitrates, consistent with urinary tract infection. No other source of infection noted at this time. Currently awaiting urine culture results to confirm UTI (=100,000 CFU if clean catch and =50,000 CFU if cathed sample) and verify correct antimicrobial treatment. No high risk features and able to tolerate PO, so will proceed with oral antibiotic treatment.
Plan:
- PO Keflex 50-100 mg/kg/day divided QID when tolerating PO; Planning 7-14 day antibiotic course***
- If cephalosporin allergy > PO trimethoprim-sulfamethoxazole 6-12 mg/kg trimethoprim divided BID
- If adolescent female who is sexually active > Consider GC/CT testing
- If < 2 yo > Will schedule RUS (VCUG only if RUS abnormal)
- If not improving after 48 hours on appropriate therapy > RUS (VCUG only if RUS abnormal)
URI
- _ is a _ with a PMH of _ presenting for cough.
- Cough began
- Cough described as:
- Associated symptoms include:
- Reports/Denies fever at home
- Home remedies:
- Appetite has been
- Sick Contacts: None
- Attends daycare
- Currently attends school
- Stays home during the day, no daycare/school
- Immunizations: UTD
- Personal/FH of asthma: None
PMH: None
Meds: None
Allergies: None
PSH: None
FH: None
PCP:
Social: Lives with ***
ROS: “x” indicates reported symptom
[] Headache
[] Choking
[] Whooping/spasms
[] Associated with feeding
[] Hemoptysis
[] Posttussive emesis
[] Change in voice
[] Profuse nasal drainage
[] Dyspnea
[] Rashes
General Appearance: NAD. Healthy, with normal growth & development. Appropriately bonded to caregivers. Non-toxic appearance. Sleeping, but wakes up appropriately for exam.
Skin: Skin warm, well perfused and intact.
Lymph: No LAD.
Head: Atraumatic, normocephalic.
Eyes: PERRLA, EOMI. Sclera normal, conjunctiva normal. No discharge.
Ears: Canals patent bilaterally. TMs visible bilaterally; normal/pearly grey. No erythema.
Nose: Nares patent bilaterally, septum midline & intact. No erythema, no edema.
Mouth/Throat: Unable to fully visualize d/t intolerance to exam.
Dentition: Normal dentition; no visible caries.
Neck: Full ROM.
Chest/Lungs: Lungs CTAB. No wheezes/crackles, no focal findings. Normal WOB.
Heart/Pulse: RRR. No murmurs/rubs/gallops. Cap refill < 2 sec.
GI: NT/ND, No HSM, no masses. BS present.
GU: Deferred.
Musculoskeletal: Normal ROM all extremities.
Neurologic: Grossly intact. Appropriate strength for age. No focal deficits.
Most likely diagnosis is viral respiratory illness given symptoms of congestion, cough, and fever. Bacterial infection - pneumonia, ear infection, sinusitis - less likely given well-appearance, no focal findings on exam, no persistent fevers at home. RAD unlikely given no history of dyspnea, SOB, or wheezing. Overall, reassuring exam with caregiver report of adequate fluid intake and no signs of dehydration on exam. Will proceed with parental education and review of return precautions.
Plan:
- Recommended that caregivers encourage lots of fluids throughout the day
- Recommendations for home remedies discussed and included on Pt Instructions
- Tylenol/Ibuprofen dosing sheet provided
- Discussed signs of bacterial infection with caregiver (pulling at ears, persistent fevers beyond 2-3 days of illness, shortness of breath/difficulty breathing, significant worsening of purulence/amount of nasal discharge); Recommended RTC if any of these symptoms develop
- Discussed signs of significant dehydration (Increased sleepiness/lethargy, AMS, inability to PO, decreased urine output); Recommended RTC if any of these symptoms develop
Here are some other recommendations for treating a common cold at home:
- Stay hydrated. Water, juice, clear broth or warm lemon water with honey helps loosen congestion and prevents dehydration. Avoid coffee and caffeinated sodas, which can make dehydration worse.
- Rest. Your body needs rest to heal.
- Soothe a sore throat. A saltwater gargle — 1/4 to 1/2 teaspoon salt dissolved in an 8-ounce glass of warm water — can temporarily relieve a sore or scratchy throat. Children younger than 6 years are unlikely to be able to gargle properly.
- Combat stuffiness. Over-the-counter saline nasal drops and sprays can help relieve stuffiness and congestion.
- Relieve pain. For children 6 months or younger, give only acetaminophen. For children older than 6 months, give either acetaminophen or ibuprofen.
- Sip warm liquids. A cold remedy used in many cultures, taking in warm liquids, such as chicken soup, tea or warm apple juice, might be soothing and might ease congestion by increasing mucus flow.
- Try honey. Honey may help coughs in adults and children who are older than age 1. Try it in hot tea.
- Add moisture to the air. A cool-mist vaporizer or humidifier can add moisture to your home, which might help loosen congestion. Change the water daily, and clean the unit according to the manufacturer's instructions.
He aquí otras recomendaciones para tratar un resfriado común en casa:
- Mantente hidratado. El agua, el zumo, el caldo claro o el agua de limón caliente con miel ayudan a descongestionar y evitan la deshidratación. Evita el café y los refrescos con cafeína, que pueden empeorar la deshidratación.
- Descansa. Tu cuerpo necesita descansar para curarse.
- Calma el dolor de garganta. Unas gárgaras de agua salada -de 1/4 a 1/2 cucharadita de sal disuelta en un vaso de 8 onzas de agua tibia- pueden aliviar temporalmente el dolor o el picor de garganta. Es poco probable que los niños menores de 6 años sean capaces de hacer gárgaras correctamente.
- Combatir la congestión. Las gotas y los aerosoles nasales salinos de venta libre pueden ayudar a aliviar la congestión y el taponamiento.
- Aliviar el dolor. A los niños de 6 meses o menos, dales sólo paracetamol. A los niños mayores de 6 meses, dales paracetamol o ibuprofeno.
- Tomar líquidos calientes. Un remedio para el resfriado utilizado en muchas culturas, tomar líquidos calientes, como sopa de pollo, té o zumo de manzana caliente, puede ser calmante y puede aliviar la congestión al aumentar el flujo de mucosidad.
- Prueba la miel. La miel puede ayudar a la tos en adultos y niños mayores de un año. Pruébala en un té caliente.
- Añade humedad al aire. Un vaporizador o humidificador de aire frío puede añadir humedad a tu casa, lo que podría ayudar a aliviar la congestión. Cambia el agua a diario y limpia el aparato según las instrucciones del fabricante.
Sleep Recs
- - Reviewed sleep hygiene recommendations; Quiet time 30-60 min. before bed, relaxation activity (reading, meditation, etc.), avoiding caffeine during the day, avoiding blue-light ~60 min before bedtime.
Red Eye/Eye Pain
- _ is a _ with PMH of _ presenting with eye pain/red eye.
- Symptoms began
- Vision affected:
- Photophobia:
- Foreign body sensation:
- Trauma/eye injury:
- Glasses or contacts:
- Discharge/purulence:
- URI symptoms:
Exam:
HEENT:
- Vision: Vision _/20 on Snellen chart
- R Eye: Able/Unable to spontaneously open eye. PERRLA. No foreign object noted. Conjunctiva _. Purulence_.
- L Eye: Able/Unable to spontaneously open eye. PERRLA. No foreign object noted. Conjunctiva _. Purulence_.
Ddx:
Corneal injury/abrasion ? unable to spontaneously open eye or keep open, hx of trauma
Keratitis ? unable to spontaneously open eye or keep open, thick purulent discharge, increased risk with contacts
Childhood glaucoma ? Excessive tearing, photophobia, cloudy/enlarged cornea, one eye larger, vision loss
Viral conjunctivitis ? Feels “gritty”, “scratchy”, mucoserous, associated with URI (although not always)
Bacterial conjunctivitis ? Mucopurulent, discharge all day
Allergic conjunctivitis ? Mucoserous, itching, allergies
Stye/hordeoleum ? Tender
Chalazion ? Nontender
Blepharitis ? Dry crusting, chronic
[] Slit lamp exam
Assessment: Viral conjunctivitis - Most likely diagnosis viral conjunctivitis based on history and exam - bilateral, mild conjunctival injection with minimal mucoserous purulence, first with L eye affected and then R eye symptoms following after 2-3 days. Although viral conjunctivitis can worsen until 5 days of symptoms, prolonged eye redness may also be a sign of bacterial conjunctivitis. Will send prescription to family pharmacy in case symptoms do not improve. Allergic conjunctivitis less likely given age of patient and no other history of atopy or allergies. Well appearing on exam and in NAD - unlikely severe conjunctivitis, keratitis, corneal injury. No signs of surrounding tissue involvement, no concern for preseptal or septal cellulitis.
Plan:
- Recommended warm compresses to relieve symptoms
- Sent script for ophthalmic erythromycin QID for 5 days; Told family they can pick this up tomorrow if symptoms not starting to improve
- Discussed return precautions - worsening symptoms, purulent discharge, apparent eye pain, inconsolability, fevers
- Discussed making an appointment at peds office (OV) or presenting to Urgent Care if symptoms not resolving in 2-3 days
Pneumonia DDx by age
- Ddx Includes: Anaphylaxis, angioedema, FB aspiration, asthma exacerbation, spontaneous/traumatic pneumothorax, bacterial tracheitis, bronchiolitis, croup, epiglottitis, pertussis, pneumonia, CF/CF exacerbation, pulmonary contusion,
If newborn, also consider: BPD, choanal atresia, subglottic stenosis, TEF, tracheomalacia
Bacterial Pneumonia:
- Newborn: GBS, Gram-neg bacilli (E Coli), Listeria
- 1-3 mo: Strep pneumoniae, Chlamydia trachomatis, H influenzae, B pertussis, Staph aureus
- 3 mo - 5 yrs: Strep pneumoniae, Staph aureus, H influenzae (type b or nontypeable), Chlamydia trachomatis, Mycoplasma pneumoniae
- 5 - 18 yrs: Mycoplasma pneumoniae, Strep pneumoniae, Chlamydia trachomatis, H influenzae type b, Staph aureus
Migraine
- - Migraine management recommendations:
- Prevention - Keep well hydrated, get adequate sleep
- Acute management - Rest in a dark and quiet room. Drink water. Try to sleep. 1st line medications - NSAIDs.
- Supplements - Daily use of Vitamin B2 400 mg, magnesium 600 mg, melatonin 3 mg, and Coenzyme Q10 150 mg has been shown to help prevent migraines (***Dosages for adults***)
- If you continue to have migraines, talk to your PCP about starting a medication or therapy to prevent migraines (Prevention - topiramate, propranolol, amitriptyline, +/- CBT. Acute - triptan, 6+ yo rizatriptan oral melts, 12-17 yo almotriptan oral tab, zolmitriptan nasal spray, sumatriptan/naproxen oral tabs)
Lymphadenopathy
- General Appearance: NAD. Healthy, with normal growth & development. Appropriately bonded to caregivers. Non-toxic appearance.
Skin: Skin warm, well perfused and intact.
Lymph: *** cm L-sided lymph node - non-tender, no fluctuance, no warmth. No supraclavicular, axillary, or inguinal LNs.
Head: Atraumatic, normocephalic.
Eyes: PERRLA, EOMI. Sclera normal, conjunctiva normal. No discharge.
Ears: Canals patent bilaterally. TMs visible bilaterally; normal/pearly grey. No erythema.
Nose: Nares patent bilaterally, septum midline & intact. No erythema.
Mouth/Throat: No erythema, no exudates.
Dentition: Normal dentition; no visible caries.
Neck: Full ROM.
Chest/Lungs: Lungs CTAB. No wheezes/crackles, no focal findings. Normal WOB.
Heart/Pulse: RRR. No murmurs/rubs/gallops. Cap refill < 2 sec.
GI: NT/ND, No HSM, no masses. BS present.
GU: Deferred.
Musculoskeletal: Normal ROM all extremities.
Neurologic: Grossly intact. Appropriate strength for age. No focal deficits.
***-sided *** cm LN without red flag symptoms - Mobile, no supraclavicular/axillary/inguinal enlarged LNs nodes, no signs of pancytopenia (no unexplained bruising or bleeding), acute onset (not chronic), < 2 cm in diameter. Likely reactive lymphadenopathy given ***. Bacterial lymphadenitis less likely given that LN is not distinctly tender, no fluctuance, no warmth, no overlying skin changes.
Plan:
- Continue to monitor for resolution; May take several weeks, but should not get worse
- Discussed reasons to come back to clinic/ED - Signs of bacterial lymphadenitis, oncologic etiology
- Follow-up with Pediatrician for WCC, already scheduled for mid-December
Obesity HPI
- HPI: _yo [_M/_F] presenting for weight check. Doing well since last visit with no interval illnesses or concerns. BMI is at _% classified as overweight/obese. BP at _% for age.
- Nutrition: Eats _ servings of fruits/veggies daily. Drinks _ cups of soda, _ cups of juice daily. Snacks on _. Drinks _% milk at _ cups daily. Typical breakfast: _. Typical lunch:_. Typical dinner:_. Consumes _ servings of fast food per week purchased by _patient/parent/etc. Eats meals with [TV, family]. Recent change in appetite: _[yes/no].
- Activity: Physical activity in the past week includes _ for _ minutes.
- Screen time: _ hours/day
- Sleep: _Snores/_Does not snore. Recent changes: _
ROS: _
Family History: _Negative/positive for _hyperlipidemia, _diabetes, _hypertension, or _other cardiovascular disease. *UPDATE IN HISTORIES TAB*
Past Medical History:
- Medical: _*UPDATE IN HISTORIES TAB*
- Surgical: _*UPDATE IN HISTORIES TAB*
- Hospitalizations: _*UPDATE IN HISTORIES TAB*
- _Menses began at _ years old and are [_regular/irregular], occurring every _ days and lasting for _ days. Painful: [yes/no]. Uses contraception: [yes/no]. Has been pregnant: [yes/no]
SHx: *UPDATE IN HISTORIES TAB*Lives with _ at home. _ tob/drugs/EtOH. _ sexually active with [males/females] and has had _ partners. Uses protection [yes/no]. Has friends/people with whom to talk about problems [yes/no]. Has career aspirations [yes/no]. Feels down/depressed: _[yes/no]. SI/HI: _[yes/no]. In [daycare/grade: _. School performance is _. Bullying: _[yes/no]
Diabetes Initial
- Consultation HPI:
Patient is a _ year _ month old boy/girl who was referred by PMD, Dr. _, for evaluation of _. The patient is accompanied to the clinic today by his/her father/mother who provided the bulk of the patient's medical history. Additional history was gleaned from the notes provided by the referring physician.
Father’s height is _ inches and he was done growing at 18 years old/he was still growing after 18 years old/his timing of puberty is unknown. Mother’s height is _ inches and she had menarche at _ years old/her timing of puberty is unknown. This yields a mid-parental target height of _ inches +/- 2 inches. Additional relevant family history includes: _.
Available laboratory data:
Available imaging studies:
Diabetes HPI
- Patient is a _ year _ month old boy/girl here for follow up of ***type 1/type 2 diabetes. Diagnosed with diabetes: _
The patient is accompanied to the clinic today by his/her father/mother who provided the bulk of the patient's medical history.
A1c at last visit: _%. A1c today: _%.
Last visit was on _.
Testing glucose _ times per day. Fasting glucoses range from _ mg/dL to _ mg/dL. Post prandial glucoses range from _ mg/dL to _ mg/dL. At home _ gives the insulin injections and at school _ gives the injections. Most injections go in: arms, abdomen, buttocks, thighs. At home _ counts the carbs and at school _ counts the carbs.
Some areas that patient/family feels are going well are: _
Some areas that patient/family feels they could use some assistance with are: _
Diet: _
Exercise: _
Current insulin doses: _
Recent ED visit or hospitalization: _
Recent episodes of severe hypoglycemia or glucagon use: _
Last eye exam: _
Recent laboratory data: _
Interval change in height: _ cm in _ months.
Interval change in weight: _ kg in _ months.
HPI Asthma
- _ is a _ yo M/F with _[mild/mod/severe intermittent/persistent] asthma who presents for _.
Current Asthma medications:
Controller meds: Flovent (fluticasone), Pulmicort (budesonide), QVAR (beclomethasone), Advair (fluticasone/salmeterol), Breo (fluticasone/vilanterol), Dulera (mometasone/formoterol), Symbicort (budesonide/formoterol), Atrovent (ipratropium), Spiriva (tiotropium)
Rescue med: Albuterol, Xopenex (levalbuterol)
Severity:
Uses rescue inhaler: _ per week/month.
Frequency of SOB, cough: _ per week/month.
Nighttime awakenings: _ per week/month.
Activity limitation: _ [none, minor, some, extremely]
Control:
Typical triggers for asthma include: _
Has had _ exacerbations requiring steroid treatment in last 1 year.
Has had _ visits to ED, _ hospitalizations, _ missed days from school in last year due to asthma. _Has/not been intubated for asthma exacerbation.
Asthma Controller Test (ACT) Score: ***If score < or = 19, not well controlled (Charted as Ad Hoc form)
Interval Events / ROS:
-Otherwise, no recent illnesses
Family History: *UPDATE IN HISTORIES TAB*_Negative/positive for _asthma, _eczema, _food/seasonal allergies in _.
F/u diabetes
- Patient: _ DOB: _
Date of Service: _ Last Visit: _
Pediatric Endocrinology Clinic Follow-up Note – DIABETES
PCP: _
Age: _
Allergies: _
Immunizations: _
Problem List:_
CC: Here for f/u of _ diabetes, diagnosed in _ (x _ years)
HPI:
- Interval Events: Since last clinic visit, there have been _ hospitalizations, _ ER visits, and _ school days missed due to diabetes-related factors. Overall blood glucose control has been _{good/fair/bad}. Patient is concerned about _ .
- Glucose/Lab trends: Detects hyperglycemia at BG > _ with symptoms of _. Current symptoms have been {negative for/positive for} Detects hypoglycemia at BG < _ with symptoms of _. Current symptoms have been {negative for/positive for}. Most recent A1C was _ on _. Goal A1C: _.
- Glucometer: Date and time were checked: _{yes no}. Levels were downloaded _{yes no}. Blood glucose monitoring is currently performed by _. Blood glucose readings range: _. Target blood glucoses: _.
- Diet: _
- Exercise: _
- Last ophtho exam: _
Social: _*UPDATE IN HISTORIES TAB*
Puberty: _
Current Insulin Regimen:
- MDI: via [_] pen, [_] vial/syringe. Injections are given by _ on the _. No nodules or bruising reported.
- Basal: _
- Bolus: _
- Pump: _. Pump site changed q_ by _ on the _ and managed by _. No nodules or bruising reported.
- Total daily insulin: _
Current Medications Taking: _
Physical Exam:
Vitals: [including blood pressure, weight, height, BMI; use //Vital]
General- _
HEENT- _. No Cushingoid features or gross dysmorphology.
Neck- _
CV- _
Respiratory- _
Chest: _
Breast Tanner _
Posterior Thorax- _
Abdomen- _
Extremities- _
GU- Tanner _ gonads/Tanner _ pubic hair.
Skin- _. No acanthosis, striae, areas of hypo/hyperpigmentation or other suspicious lesions.
Psychiatric- Alert, oriented. Mood euthymic. Appropriate affect. Normal behavior, speech, dress, and though process for age.
Labs:
Lipid panel: _ Thyroid function tests: _ Celiac disease screen: _ Urine albumin/Cr: _
Imaging:
Assessment/Plan: _ is a _year old M/F here for follow up of _ diabetes.
- Diabetes control: Doing _. HbA1C _, _ from previous, target is _ utilizing the DCA.
- Screenings/Labs ordered today: _
- Vaccines: _
- Changes made to insulin regimen: _
- Reviewed diabetes education (check all that apply):
[_] importance of checking BG at least x8-10/day, reminding family about importance of bringing meter to follow up visits.
[_] Discussed how AM value shows efficacy of Lantus/Levemir dose.
[_] Explained bolus dose and importance of administering about 15 min before meals. [_] Can use www.calorieking.com to assist with accurate carb counting.
[_] Treatment of hyperglycemia- reviewed how to calculate a correction dose, importance of checking 2h post to determine efficacy.
[_] Treatment of Mild to moderate hypoglycemia: rapid acting carbohydrates, recheck in 15 min and repeat until BG >70 mg/dL.
[_] Treatment of Severe hypoglycemia: use glucagon 1_ mg, side lying position to prevent aspiration and call 911. Important to keep glucagon at school.
- Follow up in _ for _.
Patient was seen and discussed with attending: Dr. _.
Fever
- - Fever started ***
- TMax at home *** by ***
- Associated symptoms:
- Sick Contacts:
- Attends***/Does not attend*** daycare.
- Denies ***
- Circumcised***/Uncircumcised and with***/without*** history of UTI/pyelonephritis
PMH: None
Meds: None
Allergies: None
PSH: None
FH: None
PCP:
Social: Lives with ***
Celllitis
- - Swelling/redness started
- Sensation: pain, itching, burning
- Denies spending time outside prior to symptoms. No known bug bite/sting.
- Denies fever at home. Good appetite, normal fluid intake.
- No personal/family history of MRSA
PCP: OV HUB
Social: In custody of grandparents. Lives with other two siblings as well. Stays at home with grandparents during the day.
Skin: *** cm area areas of erythematous, indurated, warm to the touch skin *** - *** tenderness to palpation. No fluctuance. No abrasions, lacerations, rashes noted. Otherwise, skin warm, well perfused and intact.
Most likely diagnosis cellulitis given exam with warm, indurated, erythematous areas of soft tissue. Differential also includes allergic reaction, folliculitis, erysipelas. Abscess unlikely given no fluctuance on exam and osteomyelitis unlikely given no pain to deep palpation, no limp or pain with walking, and no fevers or systemic symptoms. Otherwise, Gracie well appearing on exam, no systemic symptoms. Given history of recurrence in same location and significant extend of tissue involvement, will plan to treat for cellulitis with close follow-up for healing and assess for abscess formation given extent of tissue affected.
Plan:
- Traced area of induration/erythema today in clinic
- Keflex 50 mg/kg/day div q8h for 7 days sent to home pharmacy
- Wound care: Keep area clean and dry at home
- Reviewed return to care precautions - Fevers, inability to PO, extension of indurated/erythematous area beyond traced area, worsening pain, lethargy
- Follow-up scheduled for ~1 week; Check for improvement, check for any areas of fluctuance
Eczema
- History and exam consistent with eczema flare.without concern for superimposed infection or other more concerning etiology for rash. Will proceed with patient education regarding eczema treatment, long-term management, and prevention of future flares.
Plan:
- Recommended 7-10 day course of topical steroids: Hydrocortisone cream 1% TID with emollient on top. Avoid steroid use on face unless moderate/severe and limit to 5 days or less.
- Reviewed daily eczema care:
- Avoids irritants - Scented detergents, lotions, soaps/body wash.
- Bathing - Luke-warm water and pat dry afterwards. Make sure all soap is fully rinsed off with clean water after a bath.
- Moisturizing - Apply non-scented, mild moisturizer from tube immediately after bath while still damp. Can also use non-allergic, sensitive skin lotions, but if stinging with application, recommend emollients.
Concussion
- -
- Denies LOC, disorientation, severe neck or head pain, parasthesias in extremities, N/V, or fall after impacts or since that time.
- Otherwise, no concerns. No recent illnesses.
PMH: None.
Meds: None.
Allergies: None.
PSH: None.
FH: No history of neurologic disease, no epilepsy. Father did have one seizure, but most likely d/t head injury.
General Appearance: Normal growth and development. Pleasant, cooperative, NAD.
Skin: Warm, well perfused, and intact. No skin defects, no hematomas noted.
Lymph: NLAD. Head: Normal. Atraumatic, normocephalic.
Eyes: PERRLA, EOMI. Sclera normal, no discharge.
Ears: Ear canals patent bilaterally. TMs visible bilaterally: normal; pearly grey; light reflex visible.
Nose: Nares patent, septum midline & intact. No nasal discharge.
Mouth/Throat: OP clear – no exudates/erythema/edema.
Dentition: normal; no visible caries.
Neck: Normal ROM.
Chest/Lungs: Lungs CTAB. No wheezes/crackles. Normal WOB.
Heart/Pulse: RRR. No murmurs/rubs/gallops.
GI: Soft, NT, ND. No masses. No HSM.
GU: Deferred.
Musculoskeletal: NROM in all extremities. Normal gait. No scoliosis.
Neurologic: No focal deficits. Sensation intact and strength 5/5 in all extremities. CN II-XII intact.
Presentation most consistent with concussion w/o LOC - generalized headache, confusion, dizziness after significant impact to head. Non-focal HA, no N/V, no focal spine tenderness, weakness, loss of sensation on exam make intracranial bleed, spine injury unlikely. Will proceed with patient and parental education regarding concussions, anticipatory guidance, and management recommendations.
Plan:
- Reviewed risk of repeated concussions - Increased frequency of head injury with minimal impact, long-term cognitive detriment
- Printed SCAT5 Guidelines for both patient and coaches - Reiterated importance of not moving on to or skipping to next steps if still symptomatic
- Wrote note to school excusing patient from school work/practice until asymptomatic from concussion standpoint
- Recommended Tylenol and/or Motrin PRN and staying well hydrated to help with HA and overall recovery
- Return precautions reviewed
Allergic Rhinitis
- Signs of significant allergic rhinitis on exam - swollen, boggy nasal turbinates, conjunctival erythema, and allergic shiners. Persistent nasal congestion and predominately nighttime cough without other signs of infection - no fevers, no decreased energy, no decreased PO - also consistent with postnasal drip d/t allergic rhinitis. Will proceed with education regarding nonpharmacological and medical management. Otherwise, well appearing, well hydrated on exam, and POing well.
Plan:
- Start Zyrtec 2.5 mg daily, can increase to twice a day if helping but not helping enough
- Use Flonase daily, can increase spray to 2x per nostril. Point the bottle toward the ear on that side of the face when spraying
- Can try using saline nasal spray and suctioning out nasal mucus before bedtime
- Can try humidifier in bedroom at night
Acute Ankle Injury
- _ is a _ with PMH of _ presenting with ankle pain.
- Injury occurred
- Mechanism of injury/impact/rotation:
- Location of pain: Malleolar/Midfoot,
- Denies hearing a crack, pop
- Denies/Reports inability to walk/bear weight immediately after injury
- Denies/Reports inability to walk/bear weight currently
- Denies LOC, head impact
- Interventions:
ROS: "x" indicates presence of symptom
[] Previous injury to same joint
[] Hx of joint swelling, erythema, warmth prior to injury
[] Fever at time of injury/currently
[] Recent rashes
Exam:
- MSK:
- Ankles:
- Knees:
- Hips:
- Neuro: Feet neurovascularly intact - Pulses present, cap refill < 2 sec
Plan:
- Ottawa Ankle Rule Score: _, indicates need/no need for XR
Ddx:
- Sprains/tear could include anterior talofibular ligament (ATFL, most common, lateral pain), calcaeofibular ligament (CFL)
- Fracture in malleolar region could include Lateral malleolus (most common, lateral malleolus of fibula), bimalleolar (lateral and medial malleolus - both fibula and tibia), trimalleolar (lateral, medial distal part of posterior malleolus - tibia), or Maisonneuve (proximal fibula)
- Fracture in the midfoot region could include 5th metatarsal fracture, Lisfranc fracture of other metatarsal bones (or ligament injuries), or tarsal navicular fracture
- Reviewed how to ace wrap at home
- Recommendations for home: Analgesia with NSAIDs, rest, ice, elevate
- RTC is pain worsening, continued inability to bear weight after 1-2 days
Acute Otitis Media
- _ is a _ with no significant PMH/PMH of _ presenting for fever and ear pain.
- Fever began _. Ear pain began _.
- Associated symptoms include:
- Home remedies:
- Appetite has been normal. drinking lot of fluids.
- Sick Contacts: None
- Currently attends school; just finished kindergarten
- Immunizations: UTD
PMH: None
Meds: None
Allergies: None
PSH: None
PCP:
Social:
Ears: Canals patent bilaterally. _-sided bulging TM with air fluid level and purulent fluid noted behind membrane. Erythema at periphery of TM with minimal extension into external canal slightly. No erythema, edema noted overlying mastoid bone. No auricular elevation.
Most likely diagnosis AOM based on history of fever, ear pain, and exam with purulent fluid noted behind bulging TM. Differential also includes non-infected middle ear effusion w/ fever from another source. Mastoiditis unlikely given well-appearance on exam, no erythema/tenderness/edema overlying mastoid bone, no protrusion of auricle. Will proceed with antibiotic treatment, anticipatory guidance, and follow-up with PCP.
Plan:
- Amoxicillin 90 mg/kg/day div BID for (7 days 2-5 yo, 10 days < 2 yrs); Sent to home pharmacy
- Recommended that caregivers encourage lots of fluids throughout the day
- Tylenol/Ibuprofen PRN at home for fever/discomfort
- Discussed return precautions with caregiver - Continuing to have fevers 24-36 hrs after starting antibiotics, worsening symptoms
- Discussed signs of significant dehydration (Increased sleepiness/lethargy, AMS, inability to PO, decreased urine output); Recommended RTC if any of these symptoms develop
[[ECZEMA]]
- HPI/Interval History: _
Previous Allergy Testing:_
Atopic Dermatitis Date Diagnosed:_
Asthma Diagnosed:_
Allergic Rhinitis Diagnosed:_
Prior medications used:_
ROS: Screen for Asthma, Food allergies, and Allergic rhinitis
Eyes: itchy eyes, watery eyes, redness:_
Mouth: inflammation of the lips (cheilitis):_
Nose: runny nose, congestion, history of allergic rhinitis:_
Respiratory: shortness of breath, wheezing, history of asthma:_
Skin: Pruritis, erythema, new rash and location (facial and extensor involvement in infants and children/ Flexural lichenification or linearity in older patients):_
Psych: depression, anxiety:_
Food allergies:_
- # Atopic dermatitis:
--Education about atopic dermatitis given including self care measures such as avoiding soaps or other irritants and applying creams or ointments, can help relieve itching
--Medications:
Skin Hydration:_
Oral Antihistamine:_
Topical Steroid Cream:_
--Wet Wrap Therapy:_
--Avoidance of Triggers including lotions with fragrance, detergent soaps, solvents, wool, nylon, occlusive clothes, insects (such as roaches).
[[ANION GAP | DDX]]
- DDx: CO, cyanide, aminoglycosides, toluene, methanol, uremia/renal failure, DKA, alcoholic ketosis, starvation ketosis, acetominopen, aspirin/salicylates, ethylene glycol, oxoproline, iron, isoniazid, lactic acidosis
[[WHEELCHAIR]]
- Wheelchair needed for
1. patient has mobility limitation impairing his MRADL
2. cane or walker cannot solve patients mobility limitation
3. Home provides adequate access between rooms, maneuvering space and surfaces
4. Wheelchair will improve patient's ability to participate in MRADLs and will use it on regular basis at home
5. Patient has not expressed unwillingness to use the wheelchair
6. Patient has sufficient upper extremity function to safely propell the wheelchair or patient has a caregiver available and able to provide assistance with the wheelchair
[[WALKER]]
- Walker needed for
1. Mobility limidation impairs MRDL in home
2. Patient can safely use the walker
3. Patient's mobility limitation will be resolved with walker
[[DEPRESSION | SIGECAPS]]
- Sleep, more/less: none
Interest, loss of: no
Guilt/worry: none
Energy, low: + from house work and yark work
Concentration, trouble: none
Appetite, low/high: none
Psychomotor retardation: none
Suicidality: no SI/HI
[[ROS | UNABLE TO ASSESS]]
- Constitutional: unable to assess
Ears/Nose/Mouth/Throat: unable to assess
Eyes: unable to assess
Cardiovascular: unable to assess
Respiratory: unable to assess
Gastrointestinal: unable to assess
Genitourinary: unable to assess
Musculoskeletal: unable to assess
Skin/Breast: unable to assess
Neurologic: unable to assess
Psych: unable to assess
Endocrine: unable to assess
Hematologic/Lymphatic: unable to assess
Allergic/Immunologic: unable to assess
[[uPPER RESPIRATORY INFECTION | URI]]
- -likely viral upper respiratory tract infection based on symptoms and patient non-toxic appearing with no signs of dehydration
-supportive care as below
-no testing indicated for Strep or RSV/Flu
-encourage PO liquids
-tylenol PRN fever or pain
-recommend hand hygiene
-can use honey, lemon/lime for cough
-return if any worsening increased work of breathing or changes in mental status or decreased urine output and unable to tolerate PO
[[SEBORREIC DERMATITIS]]
- -Erythematous patches with greasy diffuse scale
-no concern for immunosuppression
-OTC shampoo with selenium sulfide (Selsun Glue), salisylic adic (Sebulex) or zinc pyrithione
-Ketoconazole 2% shampoo or cream
-Hydorcortisone 0.5% BID
[[HEALTH MAINTENANCE | MALE]]
-
Routine Health maintenance male
-Depression:
-Smoking:
-AAA screening for anytime smoker >65
-Colon cancer screening >/= 50: FOBT annually
-Hg AIC q3yrs for age>45/BMI>25:
-Lipids >35 or <35 with risk factors:
-HIV/STD screening:
-Vaccinations
-Influenza anually:
-TDaP q 10 yrs:
-Zoster >60yrs:
-PCV 13 <65 with chronic illness:
-PPSV23 >65 and <65 with chronic illness:
[[HEALTH MAINTENANCE | FEMALE]]\
-
Routine Health maintenance female
-Depression:
-Smoking:
-Colon Cancer:- FOBT anually >50:
-Hg AIC q3yrs for age>45/BMI>25:
-Lipids >20 with increased risks:
-HIV/STD screening:
-Mammogram 50-75yrs q2yrs per USPSTF
-Colon cancer screening FOBT annually >50:
-Pas smear:21-29yrs q 3 yrs; 30-65 q 3 yrs or q5yrs if HPV cotesting
-Vaccinations:
-Influenza anually
-TDaP q 10 yrs
-Zoster >60yrs
-PCV 13 <65 with chronic illness
-PPSV23 >65 and <65 with chronic illness
[[PVD | PERIPHERAL VASCULAR DISEASE]]
- #Peripheral vascular disease
ankle brachial index <or=0.9 indicates this disease
-Lifestyle: tobacco cessation, cholesterol/HTN/diabetes management
-exercise:3x per week for 30-45 minutes per session until near maximal claudication x 6 months
-Medications(aspirin vs aspirin/Plavix +/-Colistazol)
[[OBESITY | PLAN]]
- -patient obese as BMI > 95%ile
-will get screening labs with Hg AIC, CMP, Lipid panel
-referred to nutrition and the wellness center
-performed diet and exercise counselling
-5210 rule discussed: 5 servings of fruits and veges, 2 hours maximum of screen time, 1 hour of physical activity and 0 concentraed sweets such as soda juice and deserts or fast food daily. May have one cheat day weekly.
[[Hypertension | htn]]
- Hypertension
-Lifestyle modifications: DASH diet (fruit veg/rich, low fat diary, low total/saturated fats), exercise 30mins x 5 days mod-vigorous activity
-Low sodium <2,4 g/day
-Medications:
-Lipid panel, AIC, CMP
[[Diabetes]]
- Diabetes
-Hg AIC=
-Medications:
-Counseled on diet and exercise
-annual diabetic eye exam
-annual monofilament exam
-check feet dialy
-annual urine microlbumine creatinine ratio
-statin:
-aspirin if >40 yrs
#[[CHRONIC KIDNEY DISEASE | CKD]] PLAN
- CKD
-Stage _, GFR_
-most likely 2/2_
-f/u CBC, CMP, Uric Acid, Lipid panel, HgA1C,
-Urine: protein creatinine ratio, Urinalysis with micro
-Imaging: Renal US
-If GFR <45: Ca, Phos, PTH, 25-OH Vit D
-work up: consider: HIV, ANA, Hep B, Hep C, ANCA, SPEP/UPEP based on risk/history
-Acid Base:
-Electrolytes
-Overload:
-Uremia
-avoid nephrotoxic drugs
Anemia of Chronic renal insufficiancy
-Iron Panel and ferritin
Mineral Bone Disease
-Ca, Phos, PTH
[[CONGESTIVE HEART FAILURE | CHF]]
-
#CHF:
-Lasix 40 IV x 1 now and 20 IV BID
-will obtain formal echocardiogram
-Nitroglycerin gtt
-captopril 12.5 TID
-hold on beta blocker and aldosterone agonist as patient currently in exacerbation
-lytes BID while diuresing
-consider cardiology consult
-fluid restriction 1500L
-strict I/O
aCUTE OTITIS MEDIA
- Based on symptoms and exam, patient most likely has bacterial acute otitis media
-no signs of mastoiditis or meningitis on exam
-parents advised to continue tylenol for pain or fever at home
-will prescribe amoxicillin as below
-return if no improvement in pain and fever in the next 1-2 days, worsening of ear pain or other concerns
[[ANEMIA]]
- #Anemia
-retic count
-iron panel and ferritin
-consider B12, folate, TSH if macrocytic
#[[ALTERED MENTAL STATUS | AMS]]
- #Altered Mental Status
-HIV, RPR, UTox, ethanol level, Vit B12, Ammonia level, TSH
-Head CT if worsens
#[[AKI | ACUTE KIDNEY INJURY]]
- #AKI
-Creatinine increase by 0.3/by one half/ UOP < 0.5ml/kg/hr x 6 hours
-Oliguric (UOP <400ml/day) or Anuric UOP <100ml//day
-most liklely prerenal/intrarenal/post renal
-Labs CMP, U/A with micro, FENa, FEUrea, urine osmolality (UNa, UCr, UOsm+/- UUrea), spot UProt/UCr, renal U/S
-avoid nephrotoxic drugs
-Acid Base:
-Electrolytes
-Intoxications:
-Overload:
-Uremia
-if hematuria: hematuria on UA: ANA, C3, C4, ANCA
aCUTE GASTROENTERITIS | AGE
- -Patient with NBNB emesis and non bloody diarrhea, no fever or signs of dysentery
-able to tolerate PO with no signs of dehydration
-continue to offer PO liquids for hydration
-encouraged hand hygiene
-return for inability to tolerato PO, decreased urine output, lethargy, true fevers or other concerns
ACUTE CORONARY SYNDROME | ACS
- -please admit to PCU or telemtry with medicine vs CCU primary for management of Unstable angina
-antithrombotic therapy with heparin gtt
-Aspirin 325mg PO the 81mg PO daily, atorvastatin 80mg PO daily, metoprolol 25mg PO q 12, Captopril 6.25mg Q8, Plavix 600mg PO x 1 then 74 mg PO daily
-risk stratification with Hg AIC, Lipid Panel
-Please order BNP and formal TTE
-NPO at MN for possible cardiac cath/stress test
PHYSICAL EXAM ADULT SHORT
-
Pain: 0/10
General Appearance: WD, WN, NAD
Head: NCAT
Lymph Nodes: No neck, axillary, inguinal, or other LAD
Eyes: Vision grossly intact, no conjunctivitis, no ptosis, EOMI, PERRLA
Ears: Hearing grossly intact, no deformities, EAC clear,
Nose: No marked airway obstruction, mucosa normal, septum intact, no discharge present
Oral Cavity: MMM, mucosa normal, no sores or leukoplakia, hygiene good, teeth in good condition
Neck: Supple, FROM, no palpable masses
Back: No deformities or tenderness of the spine, no CVA tenderness
Chest/Breast: Symmetrical NT, no palpable masses or ulceration, no nipple retraction or discharge
Respiratory: Lungs CTAP B/L. Chest wall symmetrical, no deformities, no increased work of breathing
Cardiovascular: RRR, no M/R/G, PMI normal, peripheral pulses present, equal and symmetrical
Abdomen/GI: Flat, soft, ND/NT, BS present and normally active, no rebound, guarding or rigidity present, no HSM, no palpable masses or ulceration, no scars or hernias
Neurological: No weakness, paralysis, or tremor, CN II-XII intact, symmetrical. Normal DTRs
Psychiatric: Alert and oriented to time, place, and person/A&Ox3. Memory, judgment, and insight intact, no agitation, depression, anxiety, psychosis
Musculoskeletal / Extremities: No CCE/normal muscle tone and bulk. No muscle spasm, no atrophy present.
Skin: No induration, nodules, or skin tightening, no rashes, lesions, ulcerations.
osa OBSTRUCTIVE SLEEP APNEA RISK STRAT
- Snoring [_]
Tiredness, daytime [_]
Observed apnea [_]
Pressure, elevated blood pressure [_]
BMI >35 [_]
Age >50 [_]
Neck circumference >40cm [_]
Gender, Male [_]
0-2 low risk [_]
>2 intermediate [_]
>4 high risk [_]
[[DOWN SYNDROME]]
- # Down's syndrome (Adult)
-Neuro exam (atlantoaxial instability) q1yr >
-Auditory testing q2yr >
-Ophtho exam (keratoconus, cataracts) q2yr >
-Dental exam q6mo >
-TSH/FT4 q1yr >
-Testicular exam (inc risk cancer) q1yr >
-Breast exam q1yr >
-MMG: 40yrs = q2yr; until 50yr = q1yr
-PAP nml guidelines, can modify (single finger bimanual with finger-directed cytology, or pelvic US q2-3yr) >
-OSA screen >
-Conservatorship
FENGI micu
- #FENGI
Fluids : D5 NS @ ml/hr
Electrolytes: replete PRN
Diet: NPO
GI Ppx:
DVT Ppx: Lovenox 40mg SC q 24 hrs
dISPO
- Dispo: patient is not medically stable for discharge
Projected date of discharge: unknown
Barriers to discharge:
Patient/family awareness: aware
Method of Transportation: unknown
Destination: N/A
Follow-up appts/dates:
VIRAL URI
- #Viral URI
Patient with no signs or symptoms of PNA or sinusitis as lungs clear, symptoms for less than one week and no increased work of breathing, oxygen saturation is normal. Patient is tolerating PO well with good urine output and is alert and interactive
-will continue to encourage fluids
-strict return precautions for inability to tolerate fluids, changes in mental status and difficulty breathing or any other concerns
-follow up with pediatrician within the next week or sooner
rASH
- #Rash
Unlikely meningococcemia as rash no petechial, unlikely HSV or varicella as not petechial. Not likely EM as no targetoid lesions, not likely SJS/TEN as no mucosal involvement and no inciting medication. Unlikely gonococcal as not pustular and involving palms/soles. Not RMSF or lyme based on appearance and history.
-supportive care
-return for any worsening blisters, skin breakdown, worsening pain or redness
GASTROENTERITIS
- Gastroenteritis
Patient with acute onset nausea, NV/NV vomiting and non bloody diarrhea. Less concerning for surgical abdomen such as obstruction as abdomen soft and non tender and non distended. Less likely appendicitis as no tenderness in RLQ and no fever. Negative Murphy’s sign so doubt cholecystitis. No fevers or CVA tenderness so unlikely pyelonephritis. Unlikely IBD as symptoms acute and no systemic symptoms and unlikely bacterial enteritis as no fevers or bloody diarrhea.
-supportive care with fluids to keep hydrated
-Return for fevers, severe abdominal distension, inability to keep down fluids due to vomiting, bloody diarrhea or any other concerns
-follow up with pediatrician within the next week or sooner
EAR PAIN
- -No tenderness of the mastoid process so mastoiditis unlikely, neck supple and nomral mental status with no headache so unlikely meningitis
-continue to encourage PO liquids
-ibuprofen for pain
-high dose amoxicillin x 10 days for acute otitis media seen on exam bilaterally
F. Fenton
-
DIARRHEA
- Diarrhea
Less concerning for bacterial infectious diarrhea as no fevers, no blood in diarrhea. Unlikely IBD as no systemic signs or symptoms. Unlikely intussusception as pain not colicky and no bloody stools.
-continue to encourage PO fluids
-Return for any bloody stools, fevers, severe abdominal pain and inability to tolerate PO
[[cONSTIPATION NOTE]]
- Diet history:
Amount of water per day: _
Amount of high fiber foods per day (fruits, vegetables, legumes, whole grains): _
Amount of constipating foods (fast food, milk, bananas, white rice, white bread): _
Stool:
Consistency: _ hard _ soft _well-formed
Frequency: _one time per day _two or more times per day _once a week _twice a week _other: _
Does patient strain: _ yes _no
Is there blood: _yes _no
If yes, where is the blood: _on toilet paper _in the water _mixed with stool _other: _
Quantity of blood: _streaks _other: _
History of hemorrhoids: _
How often does patient use toilet? Uses after eating?
Does patient have abdominal pain: _yes _no
If yes, please describe:
Onset: _
Location: _RUQ _RLQ _LUQ _LLQ _epigastric _periumbilcal _suprapubic
Duration: _
Character: _dull _sharp _stabbing _cramping _other: _
Aggravating factors: _
Pain while eating or right after eating (Gastro-colic reflex c/w constipation)?: _
Relieving factors:
Relieved with bowel movement?: _
Temporal pattern: _AM _PM _daily_ in the middle of the night _ intermittent _constant _worse with food _better with food _worse with defecation _improved with defecation _other: _
Severity: _
#[[CHRONIC KIDNEY DISEASE | CKD]]
- -GFR is _ consistent with CKD stage _
-Creatinine is currently _
-BMP, CBC, Lipid panel, urine protein creatinine ratio, A1C done
-formal urinalysis, renal US
-If GFR <45: Ca, Phos, PTH, 25-OH Vit D to assess for mineral bone disease
-Consider: HIV, ANA, Hep B, Hep C, ANCA, SPEP/UPEP based on risk/history
-Meds:
-HNT:
-DM:
Anion Gap Acidosis
-
#Anion Gap Metabolic acidosis
-anion Gap _, delta gap is _ and corrected bicarb is _
-DDx: Methanol, Uremia, DKA, Paraldehyde, INH/Iron, Lactic acidosis, Ethylene glycol, Rhabdo, Salycilates
Allergic Rhinitis
- HPI/Interval Hx:_
Symptoms:_
Watery runny nose, sneezing, nasal obstruction, nasal itching, conjunctivitis
Consider alternative diagnoses if these are found:_
Symptoms on only 1 side of nose_
Thick, green or yellow nasal discharge_
Postnasal drip with thick mucus and/or runny nose_
Facial pain _
Recurrent nosebleeds_
Loss of smell_
Classify AR:_
1. Intermittent vs. Persistent:_
Intermittent: if < 4 days/week, or < 4 consecutive weeks
Persistent: if > 4 days/week and > 4 consecutive weeks
2. Mild vs. Moderate-severe:_
(Mild if all of the following are _7yes._8 Moderate if 1 or more of the following are _7no._8)
-Normal sleep:_
-No impairment of daily activities, sport, leisure:_
-No impairment of work and school:_
-Symptoms present but not troublesome:_
Screen for asthma:
-Cough:
-Shortness of breath:_
-Chest tightness:_
-Wheeze:_
Asthma screen result:_
Classification of Asthma:_
Asthma Control:_
Triggers (including tobacco/smoke exposure): _
Family history: asthma _ , eczema _ , allergic rhinitis _
Alcohol Withdrawal
- #Alcohol withdrawal: Unlikely DTs as patient with no significant fevers, or other vital signs abnormalities
-Banana bag: D5NS + Thiamine + Folic acid + Mag + K
-Ativan 2mg q 30min PRN alcohol withdrawal symptoms
-Ativan 2mg IV q 5 PRN seizure activity
-Zofran 4mg IV PRN nausea
-Seizure precautions
aBDOMINAL PAIN
- Abdominal pain
Patient with acute onset nausea, NV/NV vomiting and non bloody diarrhea. Less concerning for surgical abdomen such as obstruction as abdomen soft and non tender and non distended. Less likely appendicitis as no tenderness in RLQ. Negative Murpy’s sign so doubt cholecystitis. No fevers or CVA tenderness so unlikely pyelonephritis. Unlikely intussusception due to pain not colicky and no bloody stools. Unlikely PNA as no cough
Testicular/ovarian torsion unlikely as _
-Return for worsening fevers, severe abdominal distension, inability to keep down fluids due to vomiting, bloody diarrhea or any other concerns
Pt is a 94 year-old MALE veteran with hx of HTN and CKD who presented to
the ED on 7/18 for transient right sided weakness and numbness for one hour(
about 14 hours before presenting to the ED) with LKW 22:00 on 7/17. Neurology is
consulted due to concern for possible TIA. Pt is completely back to normal. Pt
exam today is stable with no dysmetria on finger to nose. HbA1c 5, LDL 94. MRI
brain 7/19 was negative for acute infarct,but showed old lacunar infarct R
thalamus and BL cerebellar areas. MRA Head and neck showed high-grade stenosis
or occlusion of extra and intracranial portion of left vertebral artery, and
left PICA. Echo negative for bubble studies but showed mild dilation of LA, mild
AR and MR.
Pt recent episode is concerning for TIA in the setting of L vertebral artery and
L PCA stenosis
- Recommendations:
-Continue ASA 81 mg daily and atorvastatin 40 mg daily for secondary stroke
preventions
-Neurology team to E-consult stroke attending to see if pt is a candidate for
DAPT therapy considering pt's severe intracranial stenosis of L PCA and L
vertebral artery
-For stroke prevention: BP goal<130/90, HbA1c <7, LDL <70
-B12, folate, MMA, copper level pending
-Cardiac event monitoring at discharge
-Neurology and cardiology outpatient consult at discharge
75 yo male with PMH of hydrocephalus s/p Right VP shunt (2019), HTN, HLD, and DM II presented to hospital on 5/23/2022 for worsening headache and dizziness. Neurosurg c/s resulted in shunt setting adjustment (concern for low pressure headache). Pt reports headache still present, but significantly improved since admission and denies any new problems or events overnight.
Exam: AAOx 4, speech clear, some stuttering, no aphasia. VF intact, but pt reports vision changes in L eye that have improved along with headache. EOM intact, no nystagmus, Face: symmetrical, Tongue midline, neck supple. Gross motor: No drift of upper or lower bilat. extremeties, no ataxia. Motor: RUE 5/5, LUE 5/5, RLE 5/5, LLE 5/5. Sensation grossly intact. Patient had an MRI brain that showed no acute changes. LDL 150, HgbA1c 9.2, CTA Head and neck negative for vessel stenosis or occlusion, showed patent Right VP shunt.
- A/P: 79 yo male with migraine, unspecified, not intractable.
Tests pending: none.
Plan: continue home asa (81mg PO daily) + statin (Lipitor 20mg PO daily), medicine addressing elevated A1c and new DM diagnosis to be managed by medicine team. Consult placed to DM educator.
F/U dispo: Establish new neurosurgeon (pt's recently retired)
64M with hx of hyperlipidemia and Prinzmental's angina here for CP.
- Patient is a very pleasant 64-year-old gentleman status post lap Nissen
fundoplication for severe GERD as well as small bowel resection due to small
bowel obstruction in the past and confirmed diagnosis of vasospastic angina via
as the choline challenge test at UCLA in setting of nonobstructive
cardiomyopathy with mild luminal irregularities which were verified further at
UCI Medical Center who is presenting to the hospital with constant severe left-
sided chest pain over the past several days. Patient describes this pain as
severe, worsening and very much like his previous episodes except with increased
intensity. No fevers or chills or night sweats. No abdominal pain no nausea or
vomiting.
with vasospastic angina presenting with chest pain sustained over several days
not relieved with nitroglycerin. At this point the most likely etiology of
patient's symptoms are vasospastic angina and esophagitis in setting of lap
Nissen fundoplication. There is some evidence for both of these diagnoses
present with the patient's known history of Prinzmetal and wall thickening on
the CAT scan of the esophagus showing probable esophagitis. At this point
appreciate cardiology assistance with patient's management
# A
A/P
# Chronic Chest Pain 2/2 Microvascular disease/Vasospastic Angina
Hx of LHC 05/2017 at UCLA w/ + ACH challenge.
-
#Chronic Chest Pain 2/2 Microvascular disease/Vasospastic Angina
#Hx of LHC 05/2017 at UCLA w/ + ACH challenge.
stable at this time, has chronic low level chest discomfort, with episodes of increased severity every 5-6 mths. Hx of extensive cardiac w/u thru UCLA, Cedars Sinai and most recently UCI last seen with cardiology 7/16/2021 Dr Andy Huang. Cardiac Studies per JLV note dated 7/16/2021 from cardiologist Dr Andy Huang Coronary angiogram - 1/30/2020: Left heart catheterization. @@@ Diffuse, mild luminal irregularities in LAD; otherwise normal coronary arteries. Normal right subclavian angiography. ECHO UCLA 01/29/2020: Small LV size, normal wall thickness, normal systolic function, normal LV diastolic function. Left ventricular ejection fraction is approximately 58%. Normal right ventricular size and normal systolic function. No significant valvular abnormalities. Normal pulmonary artery systolic pressure. A prior echo performed on 8/26/2016 was reviewed for comparison. LVEF was 52% previously. PASP has not changed. No significant changes noted since the previous study. Adenosine Stress ECG 9/19/2017: Normal. Symptoms were non-diagnostic for ischemia. ECG findings not suggestive of ischemia. PET-CT MPI (UCLA, by Dr. Eric Yang) 9/19/2017: Normal LVEF of approximately 50%; Stress/rest myocardial perfusion no evidence of stress-induced ischemia or infarction; Global coronary flow reserve 3.29; Stress echocardiogram (UCLA, by Dr. Eric Yang) 7/11/2017; Normal exercise echo at high cardiac workload; Excellent exercise tolerance, achieved 12.8 METS and 110% max predicted HR. BP response to stress was normal. Symptoms not suggestive of ischemia. No exercise induced arrhythmias or hypotension were noted. ECG findings not suggestive of ischemia. Normal LV function at rest with augmentation of all wall segments at peak exercise. No exercise induced wall motion abnormalities. Cardiac event monitoring, May 6, 2017: no major ECG changes with symptoms. Coronary angiography with acetylcholine challenge, May 3, 2017: reviewed by Dr. Eric Chang: No evidence of microvascular disease in all coronary vessels. Acetylcholine given of approximately up to 100 mcg with angiogram with each administration with gradual reduction in TIMI-2 flow and TIMI-3 flow resumed after administration of verapamil. No obvious focal areas of vasospasm noted. Of note, the patient states he had chest pain ongoing for approximately a week after this, and the LVEDP was approximately 15 mmHg. LHC 11/18/2022 at LBVA: Normal coronaries
- continue aspirin 81 mg daily
- cont Verapamil 180 SA daily
- not tolerating higher dose (240 causes constipation and isosorbide mononitrate 30 MG Controlled-Release caused headaches)
- Per last cardiology follow-up, chest pain likely multifactorial, and to consider noncardiac causes.
- Patient denies any associated anxiety symptoms/reproducible pain/association with movement
- Per cardiology if patient experiences chest pain-would recommend ER eval with EKG and troponin and if negative to explore other causes of chest pain
- f/u with Cardiology
A/P
# Chronic Intermittent Diarrhea/Abdominal cramping and Fecal urgency
# Hx of appendicitis s/p Bowel resection 2004, Short bowel syndrome
# Lactose intolerance-- avoiding Dairy productis
- -periodic abdominal cramps, diarrhea alternating with constipation, but mainly
diarrhea
Labs w/u Jun 15 2022
TRANSGLUTAMINASE IgA(MAIL <1.0 U/mL
CALPROTECTIN (MAILOUT) 17 mcg/g <50 Normal
IMMUNOGLOBULINS,QUANT.
IGG 555 L mg/dL 600 - 1540
IGA 131 mg/dL 70 - 320
IGM 23 L mg/dL 50 - 300
STOOL culture/ biofire testing- Negative
STOOL for ova and parasites - Negative
-oatmeal and fiber- unable to tolerate
-miralax for constipation phase- caused gas, bloating and worsening abdominal
pain
-takes senna prn
-b12, Vit D, iron given hx of bowel resection- wnl
-Patient states bowel problems causing an issue with his work especially with
commuting to work has had multiple accidents. Patient states that if condition
worsens he may look into taking a prolonged time off of work until condition
improves. He states he will reach out if this does occur
-Follow-up with gastroenterology
A/P
# GERD status post Nissen 2003, controlled
- #GERD status post Nissen 2003, controlled
A/P
# Hyperlipidemia | HLD
#History of statin intolerance with higher doses of pravastatin and with
atorva
- #Hyperlipidemia
#History of statin inolerence with higher doses of pravastatin and with atorva
- Continue Pravastatin 20 mg daily
- Continue ezetimibe 10 mg daily
Post Traumatic Stress Disorder | PTSD | AP
- #PTSD -stable, no si/hi
-(reports hx of carrying dead bodies during military service)
-sx- nightmares, occasionally wakes up yelling- night terrors
-declined MH referral
-Veteran's crisis line prn, MH referal when pt request
Restless Leg Syndrome | Cramps | Lower Back Pain | AP
- # RLS, leg cramps, chronic LBP
-cyclobenzaprine prn- slightly helpful
-Continue magnesium
-May need possible side effect from verapamil per neurology
-Seen by neurology, and started trial of pramipexole which patient states was
somewhat helpful however concerned about long-term side effects and would like
to monitor for now and follow-up with neurology
-Follow-up with neurology
# Actinic keratosis + Seborrheic Dermatitis
-- following with derm
- # Actinic keratosis + Seborrheic Dermatitis
-- following with derm
Shoulder Pain | Chronic | Bilateral | Hx of adhesive capsulitis | hx shoulder surgery |
complicated by Thoracic outlet syndrome |
- # Chronic b/l Shoulder Pain
# Hx of adhesive capsulitis
# Hx of Rt shoulder surgery c/b Thoracic outlet syndrome
- stable
- cont conservative treatment, stretching, heat/ice
A/P
# Recent alternating episodes of constipation and diarrhea, possibly related to history of small bowel resection.
- #Recent alternating episodes of constipation and diarrhea, possibly related to history of small bowel resection.-
- Continue home bowel regimen
A/P
# Hx of Malaria Vivax and Falciparum 1992-1993,
- # Hx of Malaria Vivax and Falciparum 1992-1993,
Rapid Malaria Screen (10/29/2019): JLV
Plasmodium Antigen Not Detected Not Detected UCLA MICROBIOLOGY LAB
Plasmodium falciparum Antigen Not Detected
-MRI of brain Nov, 2014
Impression: No acute intracranial process or mass.
-EEG Nov, 2014
Impression: Normal EEG.
last seen in Neuro clinic in 2015, with RTC prn
A/P
# LUTS sx, nocturia
- #LUTS sx, nocturia
-no s/s of uti
-u/a + urine cx - no uti, ca oxalate crystals- reviewed with pt
-nocturia improved with tamsulosin but having some adverse effects on sexual
performance.
-limit night time fluids
-monitor
Allergic Rhinitis AP
- # Allergic Rhinitis
Sx of significant allergic rhinitis on exam; swollen, boggy nasal turbinates', conjunctival erythema, and allergic shiners. Persistent nasal congestion w/ predominately nighttime cough w/o other signs of infx; no fevers, dec. energy, Dec. PO . Possibly c/w postnasal drip d/t allergic rhinitis. Will proceed with education regarding nonpharmacological and medical management. Otherwise, well appearing, well hydrated on exam, and POing well.
- Rx Zyrtec 2.5 mg QD; refractory ? =increase BID
- Rx Flonase 1x per nostril QD; refractory? = 2x per nostril.
- Ensure Pt is pointing bottle toward the ear on that side of the face when spraying
+/- rx saline nasal spray
+/- rx suctioning out nasal mucus before bedtime
+/- rx humidifier in bedroom at night
Acute Coronary Syndrome | P
- Acute Coronary Syndrome
- EKG
- trend troponin q6h until downtrends
- cardiac cath + ca:
- continuous cardiac monitoring, PRN supplemental oxygen
- aspirin 81 mg daily x lifetime
- clopidogrel 75 mg daily x 12 months
- do not give prasugrel if h/o stroke
- metoprolol if EF >40
- carvedilol if EF <40
- Pain control: nitrates
- Lisinopril; ARB if cannot tolerate ACEi
- trend BMP and magnesium; replete PRN
- atorvastatin 80 mg nightly
- diet: low saturated fat, low cholesterol
- active lifestyle
- smoking cessation
- optimize management of diabetes, HTN, HLD
-- f/u A1C, TSH, lipid panel
- follow up with PCP
Asthma AP
- _ yo M/F with _[mild/moderate/severe intermittent/persistent] asthma, _[poorly/well] controlled with ACT score of _.
- Controller medications:_
- PRN medications:_
- Asthma action plan provided to and reviewed with family. **Enter & fill out asthma action plan from patient education**
- Reviewed inhaler use with patient and family.
- Discussed avoidance of triggers
- Instructed patient and family on device use.
- Follow up in _. [Not controlled: 2-6 week interval follow ups; Well controlled: 3-6 month intervals] [Refer to subspecialist if: 0-4 years old and Step 3 care required, 5 or older and Step 4 care required, and/or difficulty in achieving/maintaining asthma control
Acute Hypoxic Respiratory Failure | AHRF
- # Acute Hypoxic Respiratory Failure
Breathing _labored/unlabored. Requiring _ NC/nonrebreather/BiPAP. Most likely 2/2 _.
Etiologies - Hypoventilation: - Diffusion defect: alveolar and/or interstitial inflammation and fibrosis - V/Q mismatch: Airway (asthma, COPD, ILD) vs Alveolar (pulmonary edema, pneumonia) vs vascular (pulmonar embolism) - Shunt: intracardiac shunt, AVM (intrapulm shunt), atelectasis, alveolar filling (edema/pneumonia) - ABG: _ - A-a Gradient: _
- Oxygen therapy, wean as tolerated
- Nebulizer treatments (Albuterol, Ipratropium), frequency _
- Infectious workup
Acute Kidney Injury
- #AKI
Cr elevated to . Unclear baseline.
- CTM BMP
- f/u urine electrolytes, creatinine, urea
- #AKI
Creatinine on admission/uptrending to _. Baseline Cr _. Currently anuric/oliguric/good UOP. Most likely 2/2 _. FeNa/FeUrea _, consistent with _. Euvolemic/hypovolemic/overloaded on exam.
Pre-renal: Hypovolemia, cardiorenal, cirrhosis, renal vascular tone (ACEi/ARB, NSAIDs, cyclosporine)
Intra-renal: ATN (ischemic vs toxic vs septic), AIN (fever, rash, eosinophilia), GN, vascular (HUS/TTP, DIC)
Post-renal: Obstructive, intratubular (crystals) vs ureteral (stone/compression) vs bladder (neurogenic, BPH) vs urethral (stricture, BPD)
- Urinalysis: _
- Urine lytes: _
- Renal U/S: _
- Trend Cr, avoid nephrotoxic agents, strict I/Os
- No urgent indication for dialysis
- AKI
//LABCreatin_
Baseline Cr _. Currently anuric/oliguric/good UOP. Most likely 2/2 _. FeNa/FeUrea _, consistent with _. Euvolemic/hypovolemic/overloaded on exam. Pre-renal: Hypovolemia, cardiorenal, cirrhosis, renal vascular tone (ACEi/ARB, NSAIDs, cyclosporine) Intra-renal: ATN (ischemic vs toxic vs septic), AIN (fever, rash, eosinophilia), GN, vascular (HUS/TTP, DIC) Post-renal: Obstructive, intratubular (crystals) vs ureteral (stone/compression) vs bladder (neurogenic, BPH) vs urethral (stricture, BPD)
- Renal consult, appreciate recs
- Labs: BMP, serum osm, TSH, fT4, hepatitis panel, HIV, RPR, UA, SPEP, UPEP, urine lytes, urine Cr, urine urea, urine osm
- Imaging: Renal US
-
- Urinalysis: _
- Urine lytes: _
- Renal U/S: _
- Trend Cr, avoid nephrotoxic agents, strict I/Os
- No urgent indication for dialysis
- AKI:
Urine output: Non-oliguirc Oliguirc: <0.3 mL/kg/ hr or <500 mL/day Anuric: <50cc/day
No emergent indication for dialysis. No hyperkalemia, uremia, significant acidemia, dialyzable toxins or volume overload. UA without evidence of casts, blood or protein.
DDx:
Prerenal: CHF, cirrhosis, sepsis, hypovolemia
Intrarenal: rhabdo, hemolysis, glomerulonephritis, AIN, ATN, CIN, papillary necrosis, drug reaction (NSAIDS, ACEi, ARB, aminoglycoside), TLS, pyelo, HHS, TTP, DIC, MAHA, embolic disease, MM
Postrenal: BPH, nephrolithiasis, malignancy, urethral stricture, retroperitoneal fibrosis
- Renally dose medications
- Avoid nephrotoxic medications
- BMP, Mg, Phos
- UA with microscopy
- UNa, UUrea, UCr
- Strict I/O
- Daily weights
- Bladder scan
- Renal US
- MACR
- AKI:
Urine output: Non-oliguirc Oliguirc: <0.3 mL/kg/ hr or <500 mL/day Anuric: <50cc/day
No emergent indication for dialysis. No hyperkalemia, uremia, significant acidemia, dialyzable toxins or volume overload. UA without evidence of casts, blood or protein.
DDx:
Prerenal: CHF, cirrhosis, sepsis, hypovolemia
Intrarenal: rhabdo, hemolysis, glomerulonephritis, AIN, ATN, CIN, papillary necrosis, drug reaction (NSAIDS, ACEi, ARB, aminoglycoside), TLS, pyelo, HHS, TTP, DIC, MAHA, embolic disease, MM
Postrenal: BPH, nephrolithiasis, malignancy, urethral stricture, retroperitoneal fibrosis
- Renally dose medications
- Avoid nephrotoxic medications
- BMP, Mg, Phos
- UA with microscopy
- UNa, UUrea, UCr
- Strict I/O
- Daily weights
- Bladder scan
- Renal US
- MACR
Acute Kidney Injury | AKI | Assessment | Acute Kidney Injury Assessment
- {{[[TODO]]}} #AKI
Creatinine on admission/uptrending to _.
Baseline Cr _.
Currently anuric/oliguric/good UOP.
Most likely 2/2 _.
FeNa/FeUrea _, consistent with _.
Euvolemic/hypovolemic/overloaded on exam.
Pre-renal:
- Hypovolemia, cardiorenal, cirrhosis, renal vascular tone (ACEi/ARB, NSAIDs, cyclosporine)
Intra-renal:
ATN (ischemic vs toxic vs septic), AIN (fever, rash, eosinophilia), GN, vascular (HUS/TTP, DIC)
Post-renal:
Obstructive, intratubular (crystals) vs ureteral (stone/compression) vs bladder (neurogenic, BPH) vs urethral (stricture, BPD)
Urinalysis: _
Urine lytes: _
Renal U/S: _
Trend Cr, avoid nephrotoxic agents, strict I/Os
No urgent indication for dialysis
Against Medical Advise | AMA
- Pt states that _he wishes to leave the hospital against medical advice because _. The patient declines to have further medical evaluation and treatment and wishes to leave the Emergency Department. This action is against my medical advice to the patient and with informed refusal. The patient was told that evaluation and treatment are necessary and a full explanation of the rationale was given. The risks of leaving were explained to the patient and include, but are not limited to, worsening of known or currently unknown conditions, permanent disability and death from undiagnosed or untreated conditions. Based on my conversations with the patient, the patient has the capacity to make this informed decision and understands the clinical situation and my explanation of the risks of leaving. The patient voluntarily accepts these risks and a signed AMA form documenting our conversation was obtained. The patient was given the opportunity to ask questions and reconsider. The patient was encouraged to return to the Emergency Department at any time for further evaluation.
- The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has the capacity to make decisions. The patient is also not under any duress to leave the hospital. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient’s health given that a full evaluation and treatment had not occurred. I have discussed the need for continued evaluation to determine if their symptoms are caused by a condition that present risk of death or morbidity. Risks including but not limited to death, permanent disability, prolonged hospitalization, prolonged illness, were discussed. I tried offering alternative options in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient, though the patient declined my options and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation, especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation. I asked the patient to return if they change their mind about the further evaluation and treatment. I strongly encouraged the patient to return to this Emergency Department or any Emergency Department at any time, particularly with worsening symptoms.
Case discussed with attending Dr.
- After explaining the current results and recommended interventions/treatment multiple times in basic medical terms, the patient has decided against the recommended medical care due to discomfort at this hospital. By my assessment, the patient appreciates their likely medical diagnosis and prognosis, the recommended care as well as alternatives and the risks/benefits of each. They are free of obvious delusions, using logical reasoning, able to communicate their choice and making a decision consistent with their values. As such, the patient currently has decision-making capacity (JAMA. 2011 Jul 27;306(4):420-7) .
The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. The patient speaks coherently and exhibits no evidence of having an altered level of consciousness or alcohol or drug intoxication to a point that would impair judgment. They respond knowingly to questions about recommended treatment and alternate treatments including no further testing or treatment; participate in diagnostic and treatment decisions by means of rational thought processes; and understand the items of minimum basic medical treatment information with respect to that treatment (the nature and seriousness of the illness, the nature of the treatment, the probable degree and duration of any benefits and risks of any medical intervention that is being recommended, and the consequences of lack of treatment, and the nature, risks, and benefits of any reasonable alternatives).
I have reviewed the relevant issues with the patient. They are aware of the suspected diagnosis. The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. The recommended medical care being refused has been discussed with the patient and is continued inpatient IV management of pain and placement to SNF with rehab. The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death. The patient understands the relevant information of the nature of their medical condition, as well as the risks, benefits, and treatment alternatives (including non-treatment), consequences of refusing care, and can competently communicate a rational explanation about their choice of care options. The patient understands the need to immediately return to the ER for worsening pain, fever, shortness of breath, chest pain, fall.
- This patient has elected to leave against medical advice. In my opinion, the patient has capacity to leave AMA. The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason, and in my opinion has capacity to make decisions. I explained to the patient that his symptoms may represent *** and the patient verbalized understanding of my concerns.
- I had a discussion with the patient about their workup and results, and that they may still have *** despite ***. I informed the patient that the next step in diagnosis and treatment would be ***, and they verbalized understanding of this as well. I explained the risks of leaving without further workup or treatment, which included reasonably foreseeable complications such as death, serious injury, permanent disability, and ***. I also offered alternatives to departing AMA such as assigning the patient a different provider or an alternate workup pathway.
- The patient is refusing any further care, specifically ***, and is leaving against medical advice. I am unable to convince the patient to stay. I have asked them to return as soon as possible to complete their evaluation, and also explained that they were welcome to return to the ER for further evaluation whenever they choose. I have asked the patient to follow up with their primary doctor as soon as possible. I have answered all their questions. Patient signed***did not sign AMA paperwork.
- After extensive discussion of R/B/A per routine with patient, patient electing to leave against medical advice. As prior, risks explained to patient with understanding and full capacity. Patient encouraged to return to ED if patient decided to change mind regarding care or if any new concerning symptoms arise.
- The patient has elected to leave against medical advice. The patient is clinically not intoxicated, free from distracting pain, appears to have intact insight, judgement and reason and, in my medical opinion, has the capacity to make decisions. I have voiced my concerns for the patient’s health given that complete evaluation and treatment have not yet been completed and I have discussed the need for continued care. Risks including but not limited to death, permanent disability, prolonged hospitalization and prolonged illness were discussed at length. Patient expressed understanding. Alternatives were offered but patient continued to decline, stating ****. All questions regarding patient’s condition were answered. I advised patient to seek immediate medical attention for continued care, especially if symptoms worsen. I emphasized that leaving against medical advice does not preclude returning here for further evaluation.
Patient signed/did not sign AMA paperwork.
-
Pt states that they wish to leave the hospital against medical advice because _. The patient declines to have further medical evaluation and treatment and wishes to leave the Emergency Department. This action is against my medical advice to the patient and with informed refusal. The patient was told that evaluation and treatment are necessary and a full explanation of the rationale was given. The risks of leaving were explained to the patient and include, but are not limited to, worsening of known or currently unknown conditions, permanent disability and death from undiagnosed or untreated conditions. Based on my conversations with the patient, the patient has the capacity to make this informed decision and understands the clinical situation and my explanation of the risks of leaving. The patient voluntarily accepts these risks and a signed AMA form documenting our conversation was obtained. The patient was given the opportunity to ask questions and reconsider. The patient was encouraged to return to the Emergency Department at any time for further evaluation.
- Called to bedside by nursing because patient wanted to leave AMA. Explained to patient the risks of leaving including recurrence of his disease and death. Patient verbalized clear understanding of his condition and the risk of leaving AMA, including but not limited to permanent disability and death, but said he refuses to stay any longer. Patient demostrated capacity for informed decisionmaking. Patient signed AMA paperwork. Patient walked out of the hospital. Patient has been informed that he may return to the ED for care at any time, and he was encouraged to follow up with his PCP as soon as possible.
DWR
DWA
AMS
- # Altered Mental Status
Differential diagnosis include: infection, uremia, thyroid disease, metastatic disease, B12 def, FTD, AD, vascular dementia, syphilis, HIV, paraneoplastic syndrome
Differential and workup to date: Metabolic/Endocrine: O2: Vascular: Electrolyte: Seizure: Tumor/trauma/toxin: Uremia: Psych: Infection: Drugs: Ethanol: Retention:
- F/u: B12, folate, RPR, thiamine, UTox, UCx, LFT, ammonia, MMA, heavy metals, CTH. If initial workup is negative consider MRI, LP and EEG
- Avoid physical restraints
- Maximize sleep hygiene
- Minimize sedatives
- Wear corrective lenses and hearing aids if applicable
- Avoid cholinergic, opioids, benzos drugs
- Encourage family visits
- Reorientation to person, place and time at least 3 times daily
- Minimize unnecessary lines
Abdominal Pain
- Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Given work up, low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), acute pancreatitis (neg lipase), PUD (including gastric perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction, viscus perforation, or testicular torsion, diverticulitis. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.
Abdominal Pain, Epigastric; Assessment
- Presentation consistent with acute epigastric abdominal pain likely secondary to gastritis/GERD, plan to send patient home with PPI/H2 blocker and PMD follow up. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Given work up have low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), upper GI bleed, acute pancreatitis, gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, or acute coronary syndrome. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.
Abdominal Pain, Lower | non preg | Assessment
- Patient presents with lower abdominal pain/pelvic pain. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. Considered and doubt ovarian torsion given history and presentation. Given work up low suspicion for acute hepatobiliary disease (including acute cholecystitis), acute pancreatitis (neg lipase), PUD and gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, diverticulitis. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.
Abdominal Pain, RLQ Asssessment
- This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. Given work up, low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), acute infectious processes (pneumonia, hepatitis, pyelonephritis), vascular catastrophe, bowel obstruction, or viscus perforation. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.
If male add _no signs of testicular torsion
If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy.
Abdominal Pain, RUQ
- _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Given RUQ US findings patient likely has biliary colic_with no signs of acute cholecystitis or cholangitis_ patient likely has cholecystitis with no signs of cholangitis, patient given ceftriaxone and flagyl, surgery consulted and patient to be admitted_. Less likely to represent acute pancreatitis (neg lipase), PUD (including gastric perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, or acute coronary syndrome. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.
Abscess A/P
- # Abscess,
S/p incision and drainage.
The patient tolerated the procedure well without complications.
Standard post-procedure care is explained and return precautions are given.
No antibiotic needed.
Return 1 week for packing replacement and wound care.
Return precautions discussed with patient, including excessive bleeding, fever, worsening of purulent discharge.
OSTEOPOROSIS CHECKLIST
- 10 year Probability of Major Fracture: _%
10 year Probability of Hip Fracture: _%
DEXA _ : _
Treatment if DEXA with Osteoporosis (T-score < -2.5), Major Fracture > 20%, or Hip Fracture > 3%: _
Vitamin-D: _ / Calcium: _
2 Year Follow Up DEXA, _ : _
The American College of Physicians (ACP) recommends against monitoring during therapy, as many women treated with antiresorptive therapy have a reduction in fracture even when BMD does not increase.
The American Association of Clinical Endocrinologists (AACE) recommends repeat DXA of the LS and total hip every one to two years until stability is achieved, and every two years or at less frequent intervals thereafter
Switching to an anabolic agent is a good option for patients with severe osteoporosis (T-score =-2.5 and at least one fragility fracture) who continue to fracture after one year of bisphosphonates.
Clinical Risk Factors for Fracture:
Advancing age
Previous fracture
Glucocorticoid therapy
Parental history of hip fracture
Low body weight
Current cigarette smoking
Excessive alcohol consumption
Rheumatoid arthritis
Secondary osteoporosis
OBESITY CHECKLIST
- - BMI, _: _
- prior BMI, _: _
- Activity: _
- Diet: _
- Goal 1: _
- Goal 2: _
- Goal 3: _
- Nutrition referral made
VISION DECREASED VISUAL ACUITY
- Pt noted to have decreased VA on vision screening today. OD VA of __, OS VA of __, and OU VA of __.
- Optometry evaluation recommended. Pt provided w/a list of low-cost optometry clinics and encouraged make an appt for evaluation. Pt also encouraged to call insurance for help in finding an optometry clinic near them that accepts their insurance if none of the clinics listed work
- Pt to continue w/corrective lenses and periodic f/u w/optometry
CONSTIPATION A/P
- Pt reporting sx c/w constipation.
- Encouraged pt drink more fluids, eat more fiber, and increase her/his activity. Will also trial ___ for sx relief
- Pt provided w/an information handout w/suggestions on how to improve constipation
VITAMIN D
- - Vitamin D Level, _ : _
- Ergocalciferol QDay x 3 if obese: _
- Ergocalciferol x 8 weeks: completed? _
- Cholecalciferol x 12 weeks completed?: _
- Calcium + Vit D QDay: _
ACNE
- Pt's exam today notable for papules, pustules, and ___ scarring c/w ___ acne. Previous Rx tried include:
- Dx discussed w/the patient
- Will trial Panoxyl 4% wash on face and body qAM followed by clindamycin 1% solution qAM and a gentle face wash followed by tretinoin 0.025%/0.05% cream at night. Pt counseled not to mix BP wash w/tretinoin and to apply tretinoin cream q3rd night initially and work his/her way up to nightly to decrease irritation of his/her skin. Other measures discussed including avoiding comedogenic creams and lotions and the importance of using sunscreen.
- Pt provided w/an information handout on acne which includes the Rx she/he is being prescribed and other supportive measures
TOBACCO
- - PPD: _
- Pack Year HX: _
- Quit Date: _
- USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
- 1-time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men aged 65 to 75 years who have ever smoked.
- Wellbutrin _
- Gum _
- Patches _
- Counseling Referral _
NO SHOW CHECKLIST
- [ ] Wait for patient to call for appointment
[ ] Send Letter of missed appointment, patient to call for appointment
[ ] Reschedule Appointment ___Weeks ___ Months ____ Next Available
[ ] Call patient. If unable to contact by phone, ok to mail letter.
tmj
- - Night guard, moldable with full upper arch
- Muscle relaxant, only temp
- NSAIDs and Tylenol prn
- warm moist compresses 20 min
- morning exercises for stretching
--- https://www.ouh.nhs.uk/patient-guide/leaflets/files/12128Ptmj.pdf
- no gum chewing
- avoid hard food like nuts and candy and soft tacky food
- MRI: will consider at follow up
- OMFS referral: will consider at follow up
SHOULDER HPI
- Degree of Pain: _/10
Onset of symptoms: _
Mechanism of injury/ History of trauma or injury: _
Acute traumatic, overuse, or spontaneous onset: _
Pop or dislocation with injury: _
Location of pain: _
Neck pain: _
Radiation of pain: _
Numbness/TIngling: _
Weakness: _
Provoking/alleviating factors: _
Painful arc (60-120 o abduction): _
Activities limited: _
SHOULDER EXAM
- INSPECTION:
Swelling: _
Bruising: _
Erythema: _
Atrophy: _
ROM
Flexion: _
Abduction: _
Cross Body Adduction: _
External rotation: _
Internal rotation: _
Winging of scapula: _
Scapular dyskinesis: _
Cervical: _
STRENGTH:
Abduction: _
External Rotation: _
Internal rotation: _
Empty can test (supraspinatus): _
Lift-off test (subscapularis): _
Drop Arm Test (supraspinatus): _
PALPATION (pain elicited)
Sternoclavicular (SC) joint: _
Clavicle: _
Acromioclavicular (AC) joint : _
Greater tuberosity: _
Subacromial: _
Biciptal Groove: _
NEUROVASCULAR:
Sensation: _
Distal pulses: _
DAILY CHART REVIEW LABS
- wbc _ / hgb _ / hct _ / plt _
na _ / k _ / cl _ / hco3 _ / bun _ / cr _
ca _ / mg _ / ph _
alp _ / tp _ / alb _ / ast _ / alt _ / tbili _ / dbili _
pt _ / ptt _ / inr _
FEVER HX
- Denies dysuria, cough, shortness of breath, chest pain, rhinorrhea, sore throat, ear pain, rash, recent travel, unintentional weight loss, abdominal pain, back pain, headache, neck stiffness
SEIZURE CHECKLIST
- - Type: _
- Semiology: _
- Age of dx: _
- Frequency: _
- EEG, _ : _
- MRI, _ : _
- Regimen:
--- _
--- _
--- _
- Driving? _
- Occupation: _
- Neurology appt: _
#[[RHMC ROUTINE HEALTH MAINTENANCE CHECKLIST]] M 65+
- # RHM: Male, >=65yo
-flu vx q1yr > _
-Zoster vx > _
-PCV 13 > _
-PPSV 23 > _
-TDaP/Td q10yr > _
-TB screen (IGRA preferred) > _
-DM screen q3yr if normal (45-70yo if no risk) > _
-Lipids screen, consider > _
-colon cancer screen (stop 75-85yo) > _
-smoker? _
--AAA screen x1 (65-75yo) > _
--LDCT q1yr (55-74yo, and >=30 pack years, and quit <15yo) > _
-Advance care planning > _
-ADLs assessment (cognitive, ambulation, hearing, vision, speech) > _
-dentist q6-12mo > _
#[[RHM ROUTINE HEALTH MAINTENANCE CHECKLIST]] M 50-64
- # RHM: Male, 50-64yo
-flu vx q1yr > _
-TDaP/Td q10yr > _
-Zoster vx (60yo) > _
-HIV screen (13-75yo) > _
-TB screen (IGRA preferred) > _
-DM screen q3yr if normal (45-70yo if no risk) > _
-Lipids q5yrs, q3yr if borderline > _
-colon cancer screen > _
-dentist q6-12mo > _
-smoker? _
--LDCT q1yr (55-74yo, and >=30 pack years, and quit <15yo) > _
#[[RHM ROUTINE HEALTH MAINTENANCE CHECKLIST]] M 21-49
- # RHM: Male, 21-49yo
-flu vx q1yr > _
-TDaP/Td q10yr > _
-HPV vx (until 26yo if high risk – LGBT, immunocompromised) > _
-MCV vx (21yo if dorm) > _
-HIV screen (13-75yo) > _
-TB screen (IGRA preferred) > _
-DM screen q3yr if normal (45-70yo if no risk) > _
-Lipids q5yrs, q3yr if borderline (35yo if low risk, 20yo if high risk*) > _
-dentist q6-12mo > _
-smoker? _
*high risk = HTN, smoking, FH of premature CVD
#[[RHM ROUTINE HEALTH MAINTENANCE CHECKLIST]] F 65+
- # RHM: Female, >=65yo
-flu vx q1yr > _
-Zoster vx > _
-PCV 13 > _
-PPSV 23 > _
-TDaP/Td q10yr > _
-TB screen (IGRA preferred) > _
-DM screen q3yr if normal (45-70yo if no risk) > _
-Lipids screen, consider > _
-colon cancer screen (stop 75-85yo) > _
-MMG q1-2yrs (<75yo) > _
-smoker? _
--LDCT q1yr (55-74yo, and >=30 pack years, and quit <15yo) > _
-DEXA q10-15yr if normal (65yo) > _
-Advance care planning > _
-ADLs assessment (cognitive, ambulation, hearing, vision, speech) > _
-dentist q6-12mo > _
-
ROUTINE HEALTH MAINTENANCE FEMALE CHECKLIST 21-49YO
- # RHM: Female, 21-49yo
-flu vx q1yr > _
-TDaP/Td q10yr > _
-HPV vx (until 26yo) > _
-MCV vx (21yo if dorm) > _
-HIV screen (13-75yo) > _
-GC/CT screen q1yr (15-25yo if sexually active) > _
-contraception education discussed? _
-TB screen (IGRA preferred) > _
-DM screen q3yr if normal (45-70yo if no risk) > _
-Lipids q5yrs, q3yr if borderline (45yo if low risk, 30yo if high risk*) > _
-PAP (30-64yo can do w/HPV co-testing) > _
-MMG q1yr (40yo if high risk) > _
-dentist q6-12mo > _
-smoker? _
*high risk = HTN, smoking, FH of premature CVD
#[[RHM ROUTINE HEALTH MAINTENANCE CHECKLIST]] FEMALE 50-60
- # RHM: Female, 50-64yo
-flu vx q1yr > _
-TDaP/Td q10yr > _
-Zoster vx (60yo) > _
-HIV screen (13-75yo) > _
-TB screen (IGRA preferred) > _
-DM screen q3yr if normal (45-70yo if no risk) > _
-Lipids q5yrs, q3yr if borderline > _
-colon cancer screen > _
-PAP (30-64yo can do w/HPV co-testing) > _
-MMG q1-2yr > _
-smoker? _
--LDCT q1yr (55-74yo, and >=30 pack years, and quit <15yo) > _
-DEXA q10-15yr if normal (<65yo if high risk*) > _
-dentist q6-12mo > _
*high risk: h/o fx, parental hip fx, steroids, low wt, current smoker, excessive EtOH, RA, premature menopause, liver disease, IBD
[[RHM ROUTINE HEALTH MAINTENANCE]] MALE CHECLIST
- # RHM: Female, 21-49yo
-flu vx q1yr > _
-TDaP/Td q10yr > _
-HPV vx (until 26yo) > _
-MCV vx (21yo if dorm) > _
-HIV screen (13-75yo) > _
-GC/CT screen q1yr (15-25yo if sexually active) > _
-contraception education discussed? _
-TB screen (IGRA preferred) > _
-DM screen q3yr if normal (45-70yo if no risk) > _
-Lipids q5yrs, q3yr if borderline (45yo if low risk, 30yo if high risk*) > _
-PAP (30-64yo can do w/HPV co-testing) > _
-MMG q1yr (40yo if high risk) > _
-dentist q6-12mo > _
-smoker? _
*high risk = HTN, smoking, FH of premature CVD
CHANGE TO PHONE
- Patient has FTF visit for results. Can you please offer to switch to phone visit but grant them their preference.
PHONE VISIT CHECKLIST
- Has phone visit to discuss _
Started at _
Introduced myself and clinic.
Agreed to receive care via phone.
Confirmed name and DOB.
_
- Has phone visit to discuss _
Started at _
Introduced myself and clinic.
Agreed to receive care via phone.
Confirmed name and DOB.
_
RENAL AP
-
- Monitor I&O, daily body weight
- Renal diet, Avoid nephrotoxic agents, All meds on renal dosage
- For nephrotic workup: Please send HIV, Hepatitis immunity panel, RPR, SPEP, UPEP, serum free light chain, ANA, C3, C4, ANCA
# CKD
- eGFR
- stage
- Etiology
- Monitor renal function, electrolytes and I/O
- Avoid nephrotoxic agents
- Renal diet: low K <2g, low Phos <1g, low sodium diet
- All meds on renal dose
- Refer to Dialysis education
- Will need RRT in the near future.
#ESRD
- Etiology:
- Anuric:
- Access:
- Outpatient HD schedule:
- Dialysis center:
- Last HD session:
- (UF: L, duration: )
- Volume status:
- Plan HD
- Hold antihypertensive meds for SBP <160 on HD days
- Vitamin B and C complex PO to QHS
- Folic acid 1mg PO to QHS
- Dialysis Diet: <2g Na, <2g K, <1.2g/kg/day protein, <1g Phosphours
- Monitor I&O, daily weight, Avoid nephrotoxic agents, Keep on reanl diet, All meds on renal dosage.
# Anemia
- Hgb
- Iron panel
- Ferrous sulfate 325mg tid
- Darbepoetin 0.45mcg/kg subcut qweekly (40mcg)
# Acid/base and electrolytes status
-
# MBD
- PTH:
- PO4:
- Calcium:
- 25OH Vit D:
- Recommend
- Sevelamer 3200 TIDWM, hold for phos < 4.5
- Amphojel 90 TIDWM, hold for phos < 6
# Active medical issues
- BP
- Cardiac
- Infection
- Social
- Transplant
# Hypokalemia
- To Calculate TTKG, please send urine poassium and, serum and urine osmolality
- If TTKG <2--> DDx Extra renal loss (GIloss, skin loss, vomit)
- if TTKG >4--> renal loss (aldosterone excess)
Replace with iv potassium chloride
# Hyponatremia
Duration: <48hr--> acute
Severity: 130-134meq/L --> mild, 120-129meq/L --> moderate, <120meq/L--> severe
Symptomatic or not : seizure, obtundation, coma, respiratory arrest --> severe symptoms
HA, fatigue, lethargy, N,V, dizzy, confuse, gait disturbance, cramps --> mild to moderate symptoms
Volume status:
Osmolarlity status:
Hyponatremia workup
- Please check glucose, lipid panel, protein, albumin, Renal function assessment, ETOH screen, diuretic screen,
- Check serum and urine osmolality, urine Na and Chloride
DDx
- Pseudohyponatremia: likely due to hyperlipidemia, plasma cell dyscrasia
- Hyperosmolar: likely due to hyperglycemia, elevated BUN,
- Hypo-osmolar: check GFR --> reduced GFR--> renal failure. Normal GFR--> Thiazide induced hyponatremia
- In hypervolemic hyponatremia: ddx CHF vs cirrhosis. Please get Echo, US abdomen
- In hypovolemic hyponatremia: ddx renal vs extra-renal loss. Please check urine Na
- In Euvolemic hyponatremia: ddx hypothyroidism, adrenal insufficiency, glucocorticoid deficiency, SIADH, cerebral salt wasting. Please check TSH, AM cortisol and ACTH stimulation test,
Urine Na <40: extra renal loss (diarrhea, 3rd space loss)
Urine Na >40: Hypothyroidism, P adrenal insufficiency, Glucocorticoid deficiency, SIADH, Cerebral salt wasting
SIADH: medications induced --> thiazide, SSRI, TCA, Carbamazepine, narcotics
Treatment
- For hypovolemia: IV normal saline
- Hypervolemia or Euvolemia: restrict water intake to 800 ml to 1 L / 24hr
- Goal of correction: serum sodium increase by 4-6mmeq/L in 24hours to prevent osmotic demyelination syndrome ( 24hr correction goal may be achieved in 1st few hours)
- Calculate TBW excess
- Required Na= TBW x Na deficit = ..A...... meq
- Will give required Na in 3 hours--> ....A..... meq/ 3hr----> ....B.... meq/hr
Check BMP q2hr-q4hr
If overcorrected, give DDAVP 1mcg IV q6-8hr + D5W
HYPERGLYCEMIA ELEVATED BLOOD GLUCOSE HX
- Denies sudden onset maximal intensity headache, fever, neck stiffness, worst headache of the patient's life, new headache, nausea, vomiting, vision changes, diplopia, vertigo, night sweats, unintentional weight loss, photophobia, phonophobia
-
HEADACHE EXAM
- Denies sudden onset maximal intensity headache, fever, neck stiffness, worst headache of the patient's life, new headache, nausea, vomiting, vision changes, diplopia, vertigo, night sweats, unintentional weight loss, photophobia, phonophobia
MESSAGE HEALTH ASSESSMENT
- Patient has an upcoming appointment with me.
Can you please ask to get labs prior to visit? Does NOT need to be fasting. Anytime between now and the appointment is ok. It is a not obligatory but can help to have the results prior to the visit.
If woman, please check if pap smear, MMG, and DEXA are due/ordered.
Labs can be done at Roybal or any DHS facility without an appointment. For example:
Rancho Los Amigos: 7601 Imperial Hwy., Downey, CA 90242
H. Claude Hudson: 2829 S Grand Ave, Los Angeles, CA 90007 (8am-11pm)
Hubert Humphrey: 5850 S Main St, Los Angeles, CA 90003
Mid-Valley: 7515 Van Nuys Blvd, Van Nuys, CA 91405
Long Beach: 1333 Chestnut Ave, Long Beach, CA 90813
High Desert: 335 E Avenue I, Lancaster, CA 93535
If unable to reach patient, please try again in 2-3 days.
Thanks,
Agustin Abdallah, MD
Internal Medicine & Pediatrics
Roybal Comprehensive Health Center
East Los Angeles Health Centers
HYPOPHOS P
- - Phos, _ : _
- Sevelamer 3200 TIDWM, hold for phos < 4.5
- Amphojel 90 TIDWM, hold for phos < 6
HIGH RISK MESSAGE
- Hi. The data team has helped us get a list of patients >65 years old and/or at high risk of complications if infected with covid-19 so we can make sure we are reaching out to them.
This patient is/has _.
DYSLIPIDEMIA HPI
- - ASCVD, _ : _%
- Statin: _statin _
- Aspirin (if 40-70 yo & ASCVD >10%): _
- TG: _
- Statin: _
- Omega-3: _
- Other: _
- Lipoprotein: _
- CRP: _
--- I discussed fact that statins and aspirin are prescribed to reduce the risk of coronary artery disease and stroke.
DIABETES HPI
- Oral Meds: reports taking _ as prescribed
Insulin: reports taking _ as prescribed
AM Glucose: _
Pre-meal Glucose: _
Bedtime Glucose: _
Lows: _
Highs: _
24 Hour meal recall:
Lunch: _
Breakfast: _
Dinner: _
Lunch: _
Snacks: _
Sugary Drinks: _
Tortillas: _
Exercise: _
DIABETES AP
- Referred to Nutrition at LAC
Referred to Project Dulce group classes here at Roybal
Referred to Medication Titration Clinic with Clinical Pharmacists
Referred to SW to assist with Project Angel Food application for medically tailored meals
Referred to Gasol Foundation Healthy Families Program
Online Nutrition Video: Balanceando La Vida (choose 5 meals to replace)
- Regimen:
--- Oral: _
--- Insulin: _
--- Reminded patient that medication does not work without proper diet and physical activity.
- Labs and diagnostic testing reviewed and discussed with patient. Patient demonstrated understanding.
LOWER EXT EXAM
- _RLE/LLE:
Compartments soft
Skin intact
WWP
SILT S/S/SP/DP/T;
+EHL/FHL/GS/TA
Cap refill < 2 sec; DP 2+, PT 2+
Non-TTP pelvis, hip, femur, knee
Negative log roll
CONSTIPATION P
- - Cleanse:
--- Miralax 1 scoop nightly, can increase to 3 scoops per day and hold when loose stools
--- Glycerine Suppository OTC
--- 2 L water minimum
- Maintenance:
--- 2 L water per day
--- 1 apple per day
--- Metamucil 1 scoop per day, can titrate to 1 soft BM per day
COLD CC
- _ yo with h/o _ p/w _ days of _fever, Tm _, last took ibuprofen _ / acetaminophen _, _rhinorrhea, _sore throat, _cough, _ phlegm, _ear pain, _ eye_, _ rash, _ body aches, _ headache, _ abdominal pain, _ nausea, _ vomiting, _ diarrhea. Sick contacts: _ . Flu shot _ .
ULCERATIVE COLITIS HX
- Ulcerative Colitis History
Date of diagnosis:
Disease location:
Rectal, left sided, pan-colitis?
History of surgery:
Years/type of surgery
Medication history:
_ 5-ASA oral _ IFX
_ 5-ASA topical _ ADA
_ Steroids _ 6/MP/AZA (doses if known): _
_ Others: _
Current medications: (including dosage) _
Index colonoscopy (Date/findings):
Extent: _ Proctitis _ Left-sided _ Pan-colitis
Mayo grade:
Last colonoscopy (Date/findings):
Extent: _ Proctitis _ Left-sided _ Pan-colitis
Mayo grade:
Pertinent history:
Interval history (since last clinic date):
Past medical history:
Past surgical history:
Social history:
Family History:
Allergies:
Vital Signs:
T _ BP _ HR _ Wt _
General:
HEENT:
CVS:
Resp:
Abd:
Ext:
Skin:
Neuro:
Labs:
Imaging:
Assessment and Plan:
Ulcerative colitis
Mayo score:
Follow-up in _ weeks
PQRS: Steroid sparing agent needed?
Healthcare maintenance (PQRS)
Influenza vaccine:
Pneumococcal vaccine:
DEXA (if steroids>60 days):
Hepatitis B vaccine before biologic:
TB testing before biologic:
CROHNS DISEASE HX
-
Crohn’s History
Date of diagnosis:
Disease location:
Ileal only, ileocolonic, colonic? _7 peri-anal or upper GI?
Disease behavior:
Inflammatory, stricturing, penetrating?
History of surgery:
Years/type of surgery
Medication history:
_ 5-ASA _ ADA
_ IMM _ Steroids
_ IFX _ Others: _
Current medications:
Last colonoscopy:
_ Terminal ileum _ Colon (segments)
Pertinent history:
Interval history (since last clinic date):
Past medical history:
Past surgical history:
Social history:
Family History:
Allergies:
Vital Signs:
T _ BP _ HR _ Wt _
General:
HEENT:
CVS:
Resp:
Abd:
Ext:
Skin:
Neuro:
Labs:
Imaging:
Assessment and Plan:
Crohn disease
Harvey Bradshaw Index:
Follow-up in _ weeks
PQRS: Steroid sparing agent needed?
Healthcare maintenance (PQRS)
Influenza vaccine:
Pneumococcal vaccine:
DEXA (if steroids>60 days):
Hepatitis B vaccine before biologic:
TB testing before biologic:
TPMT Level:
CHEST XRAY CXR
- On my interpretation chest XR showed no sign of widened mediastinum, enlarged cardiac silhouette, effusion, pneumothorax, consolidation
VOMITING HX
- Denies hematemesis, _marijuana use, dysuria, fever, abdominal pain prior to vomiting began, friends or family with similar symptoms
UPPER EXT EXAM
- _RUE/LUE:
Compartments soft
Skin intact
WWP
+ AIN/PIN/ulnar
SILT m/r/u
Non-TTP shoulder, humerus, elbow, forearm, wrist, hand
Full ROM shoulder, elbow, wrist, hand
TRAUMA SURVEY
- Primary Survey:
Airway patent.
Breath sounds equal bilaterally, symmetric chest wall rise.
Strong peripheral pulses.
PERRL, GCS 15, moving all extremities.
Exposure obtained.
Secondary Survey:
Head: No palpable skull fracture. No scalp hematoma. No facial lacerations. No stepoffs, facial tenderness/crepitus.
Eyes: PERRL, EOMI, No raccoon eyes, No ttp of face, No oral lesions.
ENT: No hemotympanum, No Battle’s sign, No nasal bridge deformities, nasal septal hematoma.
Neck: No midline tenderness, supple, nontender, No JVD, trachea midline.
Chest: No tenderness/crepitus, No abrasions, lacerations, No paradoxical movement.
Abdomen: Soft, nontender, nondistended, No rigidity.
Pelvis: Stable to AP and lateral compression.
GU: No blood at urethral meatus, no perineal ecchymosis.
Extremities: No contusions, abrasions, or deformity. No TTP. Motor intact. Full range of motion.
Back: No midline tenderness, stepoffs, lacerations.
SHORTNESS OF BREATH SOB HX
- Denies swelling of legs or abdomen, palpitations, chest pain, cough, fever, recent long travel, recent immobilization, recent surgery, or any unintentional weight loss or history of malignancy
HEADACHE HX
- Denies sudden onset maximal intensity headache, fever, neck stiffness, worst headache of the patient's life, new headache, nausea, vomiting, vision changes, diplopia, vertigo, night sweats, unintentional weight loss, photophobia, phonophobia
SECONDARY SURVEY
- Secondary Survey
GENERAL APPEARANCE: alert oriented to (+)person, (+)place, (+)time, no acute distress
HEAD: no_swelling on the scalp, no_periorbital swelling/ecchymosis. No deformities, no laceration
EYES: PERRL, EOMI.
ENT: (-) hemotympanum, TMs normal landmarks, (-)epistaxis, (-)nasal deformities, (-)septal hematoma, (-)alveolar ridge fracture, no_swelling/tenderness inside_mouth, (-)dry mucous membranes. no_tonsilar_inflammation, no erythema\swelling of the uvula,
NECK: no_neck tenderness no deformity , no bleeding to neck, no abrasions\lacerations to the neck
HEART: normal rate, regular rhythm
CHEST WALL: no crepitus, no ecchymosis, no abrasions\lacerations to the chest
LUNGS: no wheezing, no crackles, no rhonchi, (-)accessory muscle use, good air exchange bilateral
ABDOMEN: soft, no abd tenderness, (-)guarding, (-)distention, no ecchymosis to the abdomen
BACK: no back tenderness no ecchymosis , no abrasions\lacerations noted on the back
PELVIS: no pelvic tenderness, (-)pelvic instability per provider, (-)direct genital trauma, (-)urethral blood at meatus
EXTREMITIES: no deformity, distal sensation and motor function intact with strong DP pulse. no swelling\tenderness, no ecchymosis , (-)open wounds to the extremity, no abrasions\lacerations noted
NEURO: motor intact, sensory intact
PRIMARY SURVEY
- Primary survey:
AIRWAY: (+)Patent, No airway compromise.
BREATHING: spontaneous, respirations_easy, breath sounds clear, (+) symmetrical chest rise and fall
CIRCULATION: Central and peripheral pulses pulses strong, no circulatory compromise.
SKIN: warm dry good color
DISABILITY: GLASGOW COMA SCORE: (adult) - eyes open spontaneously 4, verbal converses and oriented 5, motor obeys commands 6, glasgow coma total x 15.
PUPILS: PERRL.
EXPOSURE: Arrived with clothes, (+)undressed, (+)warming measures applied
Additional findings: none
PULMONARY EMBOLISM PE HX
- Denies any unilateral leg swelling, recent long travel, recent immobilization, recent surgery, or any unintentional weight loss or history of malignancy
- Denies any unilateral leg swelling, recent long travel, recent immobilization, recent surgery, or any unintentional weight loss or history of malignancy
POSITIVE COVID
- Patient informed of +COVID test. Patient heavily educated on self isolation at home and anyone in household for at least 10 days and until no symptoms. Advised to wear a mask at all times around other people. Advised to return if develops any chest pain, shortness of breath, palpitations, syncope, oxygen saturation of <92%. Pulse oximeter given and patient educated on how to use it. Counseled and taught on self-proning at home. All questions answered, patient able to voice back understanding of disease, supportive management at home, and understands when to return to ED. Advised to f/u with PMD and strict return precautions given.
PREOP LEGAL
- The risks, benefits, and alternatives were explained to the patient in detail. These include, but are not limited to: pain, bleeding, infection, damage to surrounding bones and soft tissue, damage to nearby structures (nerves, arteries, veins), need to convert to an open procedure, poor wound healing, need for an additional operation, patient dissatisfaction with surgery, compartment syndrome, limb-length discrepancy, angular deformity, stiffness, reduced range of motion, arthritis, implant failure, dislocation, need for amputation, loss of motor/sensory function of the extremity, loss of limb or possible loss of life. The cardiopulmonary risks of anesthesia, including the remote possibility of death, were also explained to the patient. Benefits include improved pain control. Alternatives include antibiotics, observation and no surgical intervention.
The patient or appropriate medical proxy expressed his/her understanding of the risks, benefits, and alternatives to the procedure, and has communicated his/her understanding of the treatment plan. The patient and/or medical proxy has been provided informed consent, has signed the Harbor-UCLA informed consent document, and agrees with the treatment plan.
The patient’s NPO status, laboratory values, and medical status have been evaluated by the Surgery team as well as Anesthesiology, and are in concordance with our surgical plan. We are in agreement that the patient may now proceed to the OR.
EKG NORMAL
- No evidence of WPW, clinically significant shortened or prolonged QTc, epsilon waves / ARVD, Brugada, significant Q waves, significant STE / STD / PR depression or arrhythmias.
DIARRHEA HX
- Denies recent travel, recent antibiotic use, recent camping, fever, hematochezia.
CP CHEST PAIN HX
- Denies vomiting, shortness of breath, recent fever or illness, tearing pain that radiates to back, cough, unilateral leg swelling, recent long travel, recent immobilization, recent surgery, or any unintentional weight loss or history of malignancy
Acohol Use Disorder | AUD
- # Alcohol use disorder
Counseled on cessation/cutting down - 15 min.
Patient shows interest.
Feedback about patient's alcohol use.
Discussed non-pharmacologic tx including CBT, psychotherapy, AA, addiction programs, or other support groups.
Discussed Consider pharmacotherapy to prevent relapse and support abstinence.
Actinic Keratosis P
- - Trial of Efudex x2-4 wks.
- Cryotherapy done.
- Discussed photoprotection.
MDM
- Dx:
Vitals: Vital signs stable and within normal limits except for _
Labs:
Imaging:
EKG:
ED Course: On my initial evaluation, patient was well appearing, past medical records, triage note and triage workup reviewed.
Consults/ Recommendations:
Rationale: Presentation was not consistent with _ per_. Presentation was consistent with _ per_.
Dispo: Patient was _. Reviewed return precautions with patient.
Case and plan discussed with Attending _
COVID TEST
- COVID outpatient test sent. Patient heavily educated on self isolation at home until we call back with test results in 2-3 days. Advised to wear a mask at all times around other people. Advised to return if develops any chest pain, shortness of breath, palpitations, syncope. All questions answered, patient able to voice back understanding of disease, supportive management at home, and understands when to return to ED. Advised to f/u with PMD and strict return precautions given.
CARDIAC ARREST ROSC
- Per EMS report, patient was found down _, had witnessed arrest _. Approximate downtime prior to compressions:_. EMS delivered _ shocks and _ epi with about _ minutes of CPR. ROSC was achieved _.
BACK PAIN HX
- Denies IVDU, steroid use, trauma, weight loss, bowel/bladder incontinence, saddle anesthesia, pain radiating and shooting down bilateral legs from back, recent spinal surgery or procedure, fever, abdominal pain, cough, dysuria, chest pain, shortness of breath, night sweats
ABDOMINAL PAIN HX
- Denies constipation, diarrhea, abdominal surgeries, vomiting, dysuria, back pain, fever, cough, chest pain, shortness of breath, unintentional weight loss. Last bowel movement was _. Patient is passing flatus _. _ Ill contacts with similar symptoms.
SYNCOPE AP
-
#Syncope
- reports chest pain and SOB w/ mechanical slip prior to fall
- no post-syncopal mental status changes, seizure, lethargy
- with decreased ability to converse and multiple GLFs following
- ECG w/ afib, no e/o ischemia
- differential diagnosis includes cardiogenic of arrhythmic or structural cause vs. vasovagal vs. orthostatic hypotension vs. neurogenic; also must consider vertigo vs. seizure vs. stroke vs. metabolic/toxic
Plan:
- f/u orthostatic vital signs
- admit to telemetry for continuous cardiac monitoring for arrhythmia
- follow up TTE to evaluate structural cardiogenic causes
- follow up orthostatic vital signs
- follow urine toxicology
- consider A1c, lipid panel, MRI brain, MRA head/neck for stroke workup
- consider TSH, RPR, B12, folate for acute encephalopathy
RAPID RESPONSE RR
-
Time: (time of page)
Location: (ward)
Primary service: (who was primary at time of rapid)
Rapid response initiated by: (primary team, nursing, consultant)
Indication for rapid response: (hypotension/tachycardia/hypoxia/bleeding)
Medical teams present during response: (medicine, ACS, neuro, cardiology)
Initial vital signs:
Initial physical exam: (basic physical exam)
Assessment and interventions: (summary of medical decision making)
Post-intervention vital signs: (vital signs immediately prior to disposition)
Disposition: (PCU, ICU, continue current level of care)
EKG
- On my review EKG showed a normal sinus rhythm with no axis deviation, LVH, abnormal intervals, or any sign of ST elevations or depressions.
ROUTINE
- - FOBT: neg 2/9/2019, deferred repeat given acute bereavement
- PCV13: 4/2017
- PPSV23: 1/2014
- VZV: 12/21/20
- Tetanus: 6/6/2014, repeat 2024
- Flu: 12/21/20
- Lipids: on atorvastatin 40 qday
RENAL RECS
- - Recommend DC calcium acetate
- Please obtain vit D and daily Mg, Phos
- Amphogel 90 TID for phos >6
- Amlodipine dosed QHS
- Please obtain iron panel if no recent transfusions; recommend ferrous supplementation if low
RENAL DIET
- 2g Na, 2g K, 1.2 g/kg protein a day, 800 mg phos
PHONE PHYSICAL EXAM
- Limited exam given telemedicine visit.
- General: Voice NAD
- Respiratory: Speaking in full sentences and not out of breath
- Neuro: No aphasia or dysphasia
- Psych: Appropriate response to questions
Acute Alcohol Intoxication, Assessment
- Patient presents with acute alcohol intoxication without evidence of co-ingestion or trauma per history and exam. Will observe patient in ED with frequent monitoring and reassessment. Plan to PO trial, reassess mental status, and assess gait when more stable. No evidence of withdrawal currently.
Acute Cholangitis AP
- # Acute cholangitis
Pt w/ fever, abdominal pain and jaundice.
Evidence of leukocytosis, TBili >2, elevated LFTs w/ CBD dilation on imaging.
- ERCP to confirm the diagnosis and provide biliary drainage.
- Appreciate GI consultation and recommendations.
- Continue Piperacillin-tazobactam 3.375 g IV every 6 hours.
pENDING NOTE
- Note in progress. Not final until signed
MINI MENTAL STATUS EXAM MMS
- Mental status
Appearance: dressed in casual attire; fair grooming; fair hygiene
Behavior: guarded but cooperative
Motor: no psychomotor agitation or retardation.
Speech: clear and coherent, normal rate, soft tone, paucity of thought
Mood: fine
Affect: sad
Thought Process: non-linear at times
Thought Content: denies SI/HI, delusions: "I'm being followed by the KGB"
Perceptual Disturbances: denies auditory hallucinations, denies visual hallucinations, not seen responding to internal stimuli
Orientation: alert and oriented x 4
Cognition: grossly intact
Insight: poor
Judgement: poor
Impulse Control: fair
Acute Coronary Syndrome ACS
- Acute Coronary Syndrome
- EKG
- trend troponin q6h until downtrends
- cardiac cath + ca:
- continuous cardiac monitoring, PRN supplemental oxygen
- aspirin 81 mg daily x lifetime
- clopidogrel 75 mg daily x 12 months
- do not give prasugrel if h/o stroke
- metoprolol if EF >40
- carvedilol if EF <40
- Pain control: nitrates
- Lisinopril; ARB if cannot tolerate ACEi
- trend BMP and magnesium; replete PRN
- atorvastatin 80 mg nightly
- diet: low saturated fat, low cholesterol
- active lifestyle
- smoking cessation
- optimize management of diabetes, HTN, HLD
-- f/u A1C, TSH, lipid panel
- follow up with PCP
Acute Coronary Syndrome | ACS Problem List
- Acute Coronary Syndrome
- EKG
- trend troponin q6h until downtrends
- cardiac cath + ca:
- continuous cardiac monitoring, PRN supplemental oxygen
- aspirin 81 mg daily x lifetime
- clopidogrel 75 mg daily x 12 months
- do not give prasugrel if h/o stroke
- metoprolol if EF >40
- carvedilol if EF <40
- Pain control: nitrates
- Lisinopril; ARB if cannot tolerate ACEi
- trend BMP and magnesium; replete PRN
- atorvastatin 80 mg nightly
- diet: low saturated fat, low cholesterol
- active lifestyle
- smoking cessation
- optimize management of diabetes, HTN, HLD
-- f/u A1C, TSH, lipid panel
- follow up with PCP
Acute Decompensated Heart Failure
- # Acute Decompensated Heart Failure HFpEF/HFrEF.
Last TTE on _ with EF _. Etiology of heart failure is likely _ (ischemic work up _) . At baseline, sleeps on _ pillows and can walk _. Dry weight _. Weight on admission is _. Currently patient reports symptoms of _ (LE edema, DOE, ascites?). On exam, _ (crackles/JVP/LE edema). Etiology of decompensation is likely 2/2 _. CXR shows _. EKG shows _ (e/o ischemia?).
- spot dose diuresis
- strict I/Os, daily weights
- fluid restriction
- low salt diet
- replete electrolytes as needed to Mg >2 and K >4
- Consider TSH/A1C/LFT/Lipids/UA/Utox/Chagas
- prevnar
-
Adults age 19-64with underlying conditions/risk factors(e.g. alcoholism, chronic heart disease, chronic liver disease, DM, smoking,immunosuppression):
•Previous PPSV23only --> 1 year later give Prevnar-20
•PreviousPCV13 onlywith immunocompromise/cochlear implant/CSF leak --> 8 weeks later give Prevnar-20
•Previous PCV13 and PPSV23withimmunocompromise/cochlear implant/CSF leak -->5 years afterlast PPSV23 give Prevnar 20 at age 65 and up
•No prior Pneumococcal vaccination --> Prevnar-20b
ALL Adults age 65 and up:
•Previous PPSV23 only -->1 year later give Prevnar-20
•PreviousPCV13 only -->8 weeks later if immunocompromised, otherwise >1 year later give Prevnar-20
•Previous PCV13 and PPSV23 --> no further vaccination needed
•No prior Pneumococcal vaccination --> Prevnar-20
- ADHF:
HFrEF: LVEF 20-25%
GDMT:
- cont home losartan 100 mg daily, transition to ARNI at future time
- metoprolol as above
- start spironolactone 25 mg daily
- SGLT2i on discharge
Preload:
- goal net neg 3/24h
- furosemide 40 mg IV PRN
- strict I/Os, daily weights, 2g/2L diet
Pump/Inotropic support: no inotropic support needed
Afterload:
- losartan as above
- spironolactone as above
Valves: no significant issues
Rhythm: afib w/ RVR
Coronaries: unknown anatomy
- # Acute Decompensated Heart Failure
HFpEF/HFrEF. Last TTE on _ with EF _. Etiology of heart failure is likely _ (ischemic work up _) . At baseline, sleeps on _ pillows and can walk _. Dry weight _. Weight on admission is _. Currently patient reports symptoms of _ (LE edema, DOE, ascites?). On exam, _ (crackles/JVP/LE edema). Etiology of decompensation is likely 2/2 _. CXR shows _. EKG shows _ (e/o ischemia?).
- spot dose diuresis
- strict I/Os, daily weights
- fluid restriction < 1.5L/day
- low salt diet
- replete electrolytes as needed to Mg >2 and K >4
- Consider TSH/A1C/LFT/Lipids/UA/Utox
- Pending TTE
- Once patient is stabilize will start patient on coreg and lisinopril and uptitrate as necessary
Acute Kidney Injury | AKI problem list
- AKI
Creatinine on admission is _. Baseline Cr _. Currently anuric/oliguric/good UOP. Most likely 2/2 _. FeNa/FeUrea _, consistent with _. Euvolemic/hypovolemic/overloaded on exam.
Pre-renal: Hypovolemia, cardiorenal, cirrhosis, renal vascular tone (ACEi/ARB, NSAIDs, cyclosporine)
Intra-renal: ATN (ischemic vs toxic vs septic), AIN (fever, rash, eosinophilia), GN, vascular (HUS/TTP, DIC)
Post-renal: Obstructive, intratubular (crystals) vs ureteral (stone/compression) vs bladder (neurogenic, BPH) vs urethral (stricture, BPD)
- Urinalysis: _
- Urine lytes: _
- Renal U/S: _
- Trend Cr, avoid nephrotoxic agents, strict I/Os
- No urgent indication for dialysis
#hypocalcemia
- #hypocalcemia
- likely s/t acute renal failure
- vit D 6, PTH 168
PLAN
- CaCl PRN
Acute Kidney Injury | AKI | Dehydration
- # AKI
- This patient presents with generalized weakness and fatigue likely secondary to dehydration. Suspect acute kidney injury of prerenal origin. Doubt intrinsic renal dysfunction or obstructive nephropathy. Considered alternate etiologies of the patient’s symptoms including infectious processes, severe metabolic derangements or electrolyte abnormalities, ischemia/ACS, heart failure, and intracranial/central processes but think these are unlikely given the history and physical exam.
- Plan:
- labs
- fluid resuscitation
- pain control
- nausea control
- reassessment
[[thrombocytopenia]]
- #thrombocytopenia
- no evidence of bleeding. Likely s/t sepsis vs ?cirrhosis. Fibrinogen elevated; low c/f DIC
PLAN
- CTM, transfuse for plt > 10 overall, > 20 for sepsis, > 50 for acute bleed.
#Septic shock s/t GPC bacteremia and covid PNA
- #Septic shock s/t GPC bacteremia and covid PNA
- Leukopenic, hemodynamically unstable with COVID+ and c/f superimposed bacterial pneumonia
- Bcx 12/5 positive 4/4 bottles GPCs
- Patient started on empiric Vanc/Zosyn for possible bacterial pneumonia and GPC bacteremia
- UA no leuk, nitrite, mod bacteria, 4-15 squam
Plan:
- Repeat Bcx NGTD
- Continue abx until sensitivities return--vanc/ceftriaxone (12/7-), start azithromycin (12/7-); will stop vanc if Strep sensitive to CTX
- echo ordered for eval of IE
#AKI
#AGMA
#hyperkalemia
- #AKI
#AGMA
#hyperkalemia
- Cr elevated on admission to 5.5 from prior baseline 0.6
- Concern for renal injury 2/2 septic shock, resulting in acute kidney injury
- s/p 3L of fluid in ED with improvement in Cr to ~4
- Patient producing urine though decreasing (~10cc/hr)
- likely ATN s/t sepsis. On POCUS, IVC adequate
Plan:
- hold bicarb drip as pH > 7.3 (will restart if drops <7.3 on repeat)
- renal consulted, appreciate recs; will discuss CRRT candidacy if pt fails to recover renal function
- per renal recs, will give bumex if pt develops signs of volume overload
#Acute hypoxic respiratory failure
#Intubation
#COVID pneumonia
#Strep Pneumo pneumonia
- #Acute hypoxic respiratory failure
#Intubation
#COVID pneumonia
#Strep Pneumo pneumonia
- Patient desatting in ED on RA and later on HFNC, c/f AHRF
- CXR with focal consolidations c/w strep pneumo PNA
- intubated in ED for airway protection, COVID positive
- DDX: COVID pneumonia with possible superimposed bacterial infxn
- pt does not qualify for remdesivir due to AKI and elevated LFTs
Plan:
- hydrocortisone 50mg q6h for septic shock (12/6-)
- heparin subq ppx (Level 1)
- trend COVID labs Q48H
- Abx as below
- trend BMP/ABG q6h
- Abx as below
- current vent settings: AC/V 30/400/15/100; unable to wean vent due to hypoxemia
#Acute hypoxic respiratory failure
#Intubation
#COVID pneumonia
#Strep Pneumo pneumonia
- #Acute hypoxic respiratory failure
#Intubation
#COVID pneumonia
#Strep Pneumo pneumonia
- Patient desatting in ED on RA and later on HFNC, c/f AHRF
- CXR with focal consolidations c/w strep pneumo PNA
- intubated in ED for airway protection, COVID positive
- DDX: COVID pneumonia with possible superimposed bacterial infxn
- pt does not qualify for remdesivir due to AKI and elevated LFTs
Plan:
- hydrocortisone 50mg q6h for septic shock (12/6-)
- heparin subq ppx (Level 1)
- trend COVID labs Q48H
- Abx as below
- trend BMP/ABG q6h
- Abx as below
- current vent settings: AC/V 30/400/15/100; unable to wean vent due to hypoxemia
Acute Kidney Injury | AKI, A/p
- #AKI
POA
RIFLE Stage:
Etiology: Prerenal (dehydration, CHF, hypotension); Renal (ATN, postOp, AIN, Contrast, Drugs, Rhabdo, Sepsis, HRS); Postrenal (obstructive)
UA: proteinuria, hematuria, casts, eos
Volume overload
UNa:
FENa:
Rx:
Avoid Nephrotoxic drugs (NSAID, ACEi, etc)
Renal consult appreciated
Acute Otitis Media P
- # AOM
- Tylenol prn for pain/fever
- Rx Amoxicillin 500 mg PO tid x 7d
- RTC if no improvement after 48-72 hrs
Acute Otitis Media | AOM
- Patient with likely acute otitis media given history and exam. No overt e/o mastoiditis or malignant otitis externa. Nontoxic appearing with low suspicion for intracranial extension. Tolerating PO, low suspicion for concurrent serious bacterial infection. Will discharge home with amoxicillin (high dose), auralgan, tylenol, follow up peds_. Cautious return precautions discussed w/ full understanding.
Addend Medical Student
- I have assessed and examined the patient with the medical student and agree with their assessment of the patient as well as the plan.
Any differences in the Assessment & Plan will be listed below:
Addendum
- Patient was seen and evaluated by day team. The above note accurately reflects our encounter and plan of care.
Congestive Heart Failure Exas | CHF Exas | Admit
- This patient presents with signs and symptoms consistent with an acute exacerbation of chronic CHF, likely due to ***. Differential diagnosis includes alternate cardiopulmonary causes such as ischemia, PE, pneumothorax, and pneumonia, as well as other causes of dyspnea such as asthma/RAD, COPD, flash pulmonary edema, dysrhythmia but these are less likely. Patient is generally hemodynamically stable.
- Plan: labs, EKG, CXR, troponin, intravenous diuresis, and electrolyte repletion. Will require admission for IV diuretics and medical optimization.
Admit - Chest Pain (HIGH RISK)
- sd
- This patient presents with chest pain, with a history suggestive of *. No evidence of [[Volume Overload]] or shock on exam. EKG without signs of active [[Ischemia (Inadequate Delivery Of Oxygenated Blood)]]. EKG without evidence of STEMI. Low suspicion for acute PE (Wells low risk *), [[PTX (Pneumothorax)]], [[Thoracic Aortic Dissection]], cardiac effusion / tamponade. Overall, ACS is being considered given higher risk features, *, history & physical. HEART score: *.
- Patient will require admission for inpatient risk stratification and possible [[Provocative Testing]].
- Plan: [[Cardiac Monitor]], EKG, troponins,CXR, ASA, [[Heparin]]*, [[Pain Control]], reassess, Cardiology consult*
ICU AP
- NEURO:
#Intubated, sedated
- pt dyssynchronous with the vent with high peak pressures; started on paralysis and heavy sedation
Plan:
- Continue fent, prop, versed
- continue paralysis with nimbex (12/6-)
- pt currently too unstable to prone
CV:
#Septic shock
#Hypotension
- Hypotensive in ED, central line placed and started on levo
- Likely sepsis 2/2 bacteremia, see infectious work up below
- Vasopressin added for increasing requirements
- Lactate downtrended with fluids 5.5 -> 2.5
Plan:
- continue levo/vaso for goal MAP > 65
#Troponinemia
- initial trop 0.01, second 0.05 > 0.04
- EKG without evidence of ischemia, no complaints of chest pain on arrival
- DDX: likely demand ischemia
- EKG nonischemic, likely demand
PULM:
#Acute hypoxic respiratory failure
#Intubation
#COVID pneumonia
#Strep Pneumo pneumonia
- Patient desatting in ED on RA and later on HFNC, c/f AHRF
- CXR with focal consolidations c/w strep pneumo PNA
- intubated in ED for airway protection, COVID positive
- DDX: COVID pneumonia with possible superimposed bacterial infxn
- pt does not qualify for remdesivir due to AKI and elevated LFTs
Plan:
- hydrocortisone 50mg q6h for septic shock (12/6-)
- heparin subq ppx (Level 1)
- trend COVID labs Q48H
- Abx as below
- trend BMP/ABG q6h
- Abx as below
- current vent settings: AC/V 30/400/15/100; unable to wean vent due to hypoxemia
GI:
#Chronic Alcohol Abuse
#Elevated Transaminases
#Fatty Liver
- Hx of alcohol abuse, no e/o cirrhosis on prior imaging
- Fatty liver on prior abdominal imaging
- Elevated transaminases higher than baseline on this admission, AST:ALT >2:1
- DDx: Liver injury 2/2 septic shock vs alcoholic hepatitis on preexisting fatty liver elevations
Plan:
- US Abd ordered for cirrhosis eval; f/u final read
RENAL:
#AKI
#AGMA
#hyperkalemia
- Cr elevated on admission to 5.5 from prior baseline 0.6
- Concern for renal injury 2/2 septic shock, resulting in acute kidney injury
- s/p 3L of fluid in ED with improvement in Cr to ~4
- Patient producing urine though decreasing (~10cc/hr)
- likely ATN s/t sepsis. On POCUS, IVC adequate
Plan:
- hold bicarb drip as pH > 7.3 (will restart if drops <7.3 on repeat)
- renal consulted, appreciate recs; will discuss CRRT candidacy if pt fails to recover renal function
- per renal recs, will give bumex if pt develops signs of volume overload
HEME/ID:
#Septic shock s/t GPC bacteremia and covid PNA
- Leukopenic, hemodynamically unstable with COVID+ and c/f superimposed bacterial pneumonia
- Bcx 12/5 positive 4/4 bottles GPCs
- Patient started on empiric Vanc/Zosyn for possible bacterial pneumonia and GPC bacteremia
- UA no leuk, nitrite, mod bacteria, 4-15 squam
Plan:
- Repeat Bcx NGTD
- Continue abx until sensitivities return--vanc/ceftriaxone (12/7-), start azithromycin (12/7-); will stop vanc if Strep sensitive to CTX
- echo ordered for eval of IE
#thrombocytopenia
- no evidence of bleeding. Likely s/t sepsis vs ?cirrhosis. Fibrinogen elevated; low c/f DIC
PLAN
- CTM, transfuse for plt > 10 overall, > 20 for sepsis, > 50 for acute bleed.
ENDOCRINE
#hypocalcemia
- likely s/t acute renal failure
- vit D 6, PTH 168
PLAN
- CaCl PRN
#Intubated, sedated
- #Intubated, sedated
- pt dyssynchronous with the vent with high peak pressures; started on paralysis and heavy sedation
Plan:
- Continue fent, prop, versed
- continue paralysis with nimbex (12/6-)
- pt currently too unstable to prone
Advanced Care Planning
- # Advance care planning
Explained and discussed planning of medical care in the event of loss of decision-making abilities.
Discussed and filled-out Advance Healthcare Directive form.
Discussed and filled-out POLST form.
Face-to-face voluntary discussion for 16 minutes were spent during this encounter.
Present for discussion:
patient only
.
#Septic shock
#Hypotension
- #Septic shock
#Hypotension
- Hypotensive in ED, central line placed and started on levo
- Likely sepsis 2/2 bacteremia, see infectious work up below
- Vasopressin added for increasing requirements
- Lactate downtrended with fluids 5.5 -> 2.5
Plan:
- continue levo/vaso for goal MAP > 65
TROPONINEMIA
- #Troponinemia
- initial trop 0.01, second 0.05 > 0.04
- EKG without evidence of ischemia, no complaints of chest pain on arrival
- DDX: likely demand ischemia
- EKG nonischemic, likely demand
HYPERTENSION CONSULT
- #HTN, essential, chronic
-Home regimen:
-Current regimen:
*Calcium channel blocker:
*Beta blocker:
*ACE/ARB:
*Nitrate:
*Vasodilators: (hydralazine, minoxidil)
*Diuretics:
- Avoid PRNs unless there is a specific indication for strict blood pressure control such as stroke or dissection
- Avoid intravenous anti-hypertensives unless there is specific indications for strict blood pressure control
- Generally, resume home medications before initiating new medications if able
- Treat pain, anxiety, and fluid overload before increasing or adding medications
- If systolic blood pressures are persistently > 160 or isolated > 180, please page the medicine consult team for assistance.
CHRONIC SYSTOLIC HEART FAILURE
- #Chronic Systolic Heart Failure
- 2/2 ischemic cardiomyopathy vs. non-ischemic cardiomyopathy
- EF ( )%. NYHA Class
- Appears -volemic on exam
- ICD: if EF is below 35%, an implantable cardioverter-defibrillator (ICD) is indicated to prevent sudden cardiac death
- Current medications:
--- ACE-i: none
--- Beta-blocker:
--- Aldosterone inhibitor: indicated in NYHA Class II-IV
--- Diuretic: indicated for symptomatic relief
--- Nitrate/hydralazine: if African-American, consider adding isosorbide dinitrate and hydralazine
GOALS OF CARE - GOC
- GOC discussion held on the phone with pt's sister-in-law and medical decision maker Sherry Munoz. We discussed pt's stable but heft pressor requirement to maintain his blood pressure, worsened renal function, and worsened oxygenation despite maximal ventilator support. Code status was discussed, and based on his current clinical state, DNR was recommended as chest compressions and defibrillation are unlikely to improve his multisystem organ failure. Sherry is in agreement, stating last night she considered code status after our previous conversation, and does not think CPR would help him. We discussed plan to continue full support otherwise, and I will update her as clinical status changes.
Code status: DNR
GERIATRICS PATIENT CHECKLIST
- #Geriatric patient checklist
-Ambulation: ambulatory without walker/ambulatory with walker or cane/wheelchair bound/bed bound
-Dentition: doesn't require dentures
-Dysphagia: no known dysphagia or aspiration
-Hearing: intact/intact with assistive device/impaired
-Vision: intact/intact with glasses/impaired
-Cognition: no known deficits/ suspected mild cognitive impairment/suspected dementia
-ADLs: independent/requires assistance
-iADLs: independent/requires assistance
DAILY CHECKLIST
- GERIATRIC PATIENT CHECKLIST
fen
- FEN/GI/PPX
F: none
E: replete lytes as needed
N: CCD
GI: none
PPx: lovenox
Foley: none
Lines: PIV in place; no centra line
Code Status: Full code
Surrogate Decision Maker: unknown
Reason for hospitalization: encephalopathy, proximal DVT
Anticipated discharge date: 10/16/20
Discharge location: unknown
Dispo Barriers: pending OR, homeless
esrd
- #ESRD on HD
- Etiology: DM
- Started HD: 8 years ago
- Urine production: not oliguric
- Access: RUE AVF - no bruit/thrill, R chest permacath - clotted per patient report
- Outpatient center: Quality Dialysis in San Gabriel
- Outpatient schedule: MTThSa
- Dry weight: unknown
- Renal diet, 2g Na, 2g K, 1.2 g/kg protein a day, 800 mg phos
Advanced Directive/Care Planning
- 5. ACP: No advance directive. If there was an emergency what quality of life he would be willing to accept, e.g. being in a coma. Dtr deferred to wife, "that's your call" and wife responded, "I don't know." We discussed that pts have many different goals and values, different opinions about what is acceptable QOL and different health conditions, so there is no right or wrong answer, it is what is right for the individual patient. Need to balance risk vs benefit, like chemo or surgery. In his case, being elderly and having h/o stroke and multiple clots throughout his body, CPR is unlikely to be effective at maintaining his current level of functioning if that is his goal, more likely he would have a decline in functioning and may require LTC NH. We discussed that some patients survive CPR only to pass away before discharge, others may require long term vent in a facility. Some patients state that being in a comatose state, unable to communicate or move on a chronic vent in a facility is an acceptable QOL because their family would feel comforted from seeing them alive and breathing; whereas other patients may state this is not living and would not want that outcome. Some patients state that if their heart stops and they pass away that is how they would want to go, naturally, but if they have a potentially reversible condition such as pneumonia they would be willing to be on the vent for a few days to see if they can improve. We discussed that it is not an emergency right now, so they have time to think about this complex topic. If they still are unable to come to a conclusion at time of discharge, they can follow up with pt's PCP and ask what are the likely outcomes should he require CPR since he knows him better.
ed cOURSE
- ED Course:
Vitals - Temp 36.5, HR 102, RR 17, BP 122/60, SpO2 96% on RA
Labs - ALP 187, CRP 7.1
Imaging - CTH with no acute pathology, XR left knee/tib/fib final read pending, CXR final read pending
Meds/Interventions - Unasyn 3 gm IV x 1, 1 L NS bolus x 1
Consults - none
Dispo - admit to medicine for cellulitis c/b AMS on a 5150
Agitation
- Agitation recommendations:
- For moderate agitation, first may offer single agent: haldol 5mg PO/IV/IM or Ativan 2mg PO PO/IV/IM
- For severe agitation or if unable to intervene safely, may call CODE GOLD which serves to bring appropriately trained staff to the situation. For patient and staff safety, may offer combination Haldol 5mg IM + Ativan 2mg IM + Benadryl 50mg IM Q4H PRN and use restraints as needed
- If antipsychotics are given, monitor for signs of extrapyramidal symptoms including acute dystonia (involuntary muscle contractions), akathisia (motor restlessness and inability to sit still), and Parkinson syndrome (psychomotor retardation, resting tremor, shuffling gait, cogwheel rigidity) as these can be potential side-effects of antipsychotic medication. If these become evident, may administer Benadryl 25mg q2Hrs as needed to control symptoms
DIABETES PLAN
- #Diabetes
- A1C
- Meds: continue metformin 1000 BID
- Retinopathy: yes, and followed closely by optho
- Nephropathy: Significant Microalbuminuria 437; counseled on DM and BP control
- Neuropathy: Foot exam performed; patient has poor sensation in toes and area below toes
DISPO
- Dispo
- Reason of adm: hyperglycemia, fever, shoulder pain
- Anticipated DC date: tbd
- Destination: home
- Transportation: family
- Barriers: management of hyperglycemia, workup of infection v. inflammation
- Anticipated Needs: tbd
- PCP: tbd
- Family aware: yes
ACUTE HYPOXIC RESPIRATORY FAILURE COVID 19 PNEUMONIA
- #Acute hypoxic respiratory failure
#COVID-19 pneumonia
- SOB
- Afebrile, tachypneic to , satting % on room air in ED
- COVID-19 positive 6/26/20
- WBC , CRP , LD , procalcitonin
- Troponin ; proBNP
- CXR w/
PLAN:
- Continue supportive care at this time with oxygen to maintain O2 saturations >92%
- Given data from RECOVERY trial, continue Dexamethason 6mg qd x 10d course ( - )
- Continue IV CTX/AZT for empiric CAP coverage ( - ) x 5d course
- Self-prone as tolerated
- Continue to trend inflammatory markers
REVERSE CODE STATUS
- GOC discussion held on the phone with pt’s daughter-MDM Fabiola. Discussed that the GI service may need to reverse code status to full code for colonoscopy. The family agreed to reverse code status to full code for procedure only and will return to DNR/DNI post-procedure.
Code status: Full code for colonoscopy, DNR following
CODE BLUE
- 66 y/o M h/o MI, admitted for CVA r/o. Per primary team Pt found in bed, gasping for air, unresponsive. Last known BG 110, K wnl, Cr wnl. On arrival PEA on the monitor. Pt given epi x5, CaCl and Bicarb x2, D50 x1. Had 3 episodes of VF; shocked at 200J and given amio x2. Unfortunately progressed to asystole. POCUS with large pleural effusions but +lung sliding and no pericardial effusion. Ddx for arrest includes hypoxic vs MI. After discussion and consideration of prolonged down time >20 min in Pt with significant comorbidities and progression to asystole, myself and the team terminated resuscitative efforts w/ time of death at 0030.
Notified at approximately 11:50PM via Rapid Response pager. Patient with acute respiratory failure. Arrived at bedside several minutes later to find patient gasping for air on 15L face mask. Rapid response initiated and patient placed on cardiac monitor. At approximately 11:55PM patient found to be pulseless with PEA on the monitor. CPR was initiated and Code Blue was called. Patient underwent 18 rounds of CPR in total. POC glucose 110. Last known K 4.5. Epinephrine given x3. Patient then given calcium gluconate and NaHCO3. At pulse check 8 minutes in patient found to be in Vfib. Patient shocked without ROSC. CPR resumed. POCUS significant for cardiac activity in both ventricles, lung sliding bilaterally, and bilateral large pleural effusion. Patient shocked again at 10 minutes and 13 minutes when found again to be in Vfib after which point patient only in PEA until end of code. Patient then given calcium gluconate and NaHCO3 again along with Amiodarone 300mg then 150mg. Patient intubated after third shock. D50 given once. On repeat POCUS no cardiac activity appreciated. Given patient not responding to CPR, in asystole, and no reversible causes identified decision made among providers in the room to end the code and the patient was pronounced dead at 00:30AM.
CIRRHOSIS
- # Liver cirrhosis
Severity: Childs , MELD-Na per labs
Etiology: EtOH, last drink >one year prior. Per CA Hosp records, hx chronic HCV but serologies here negative
Ascites: moderate
SBP- positive, previously on CTX.
EV- unknown, no EGD documented here.
PVT: positive hx of PVT
HCC screen:
HE- hx, meds: yes. Grade 3-4, on lactulose and rifaximin at home
HAV/HBV/HCV Serologies: negative- HBV non-immune, needs HBV vaccination series
HAV/HBV Immunizations: HAV immune
HIV- negative
Transplant Status: pending PRUCAL, last drink >1 year prior
PLAN:
- Avoid oysters, raw shellfish, NSAIDs, Tylenol<2g/day, low Na diet (<2g/day)
ALCOHOLIC HEPATITIS
- #Alcoholic hepatitis
#Elevated PT/INR
#Hyperbilirubinemia
- NIAAA criteria (acute jaundice w/in 8 weeks, bilirubin >3, heavy EtOH use for 6 months with last drink within last 60 days, AST:ALT >1.5, and AST and ALT below 400)
- MDF _ on admission labs; good/poor prognosis
- Contraindications to prednisolone: active infection, UGIB, AKI (GFR <60), concomitant liver disease (HBV, HCV)
PLAN
-
aki acute kidney injury
- # AKI
- On arrival: Cr , BUN from baseline / on
- likely 2/2
- On UA
Plan:
- Monitor I/Os
- Avoid nephrotoxic medications, renal dose medications
- Urine electrolytes (FeNa/FeUrea)
- Obtain PVR
- Renal US, IVC US
atrial fibrillation afib
- #atrial fibrillation, chronic, acute, with/without RVR
-Home regimen:
-Anticoagulation home: no prior AC/DOAC/warfarin/other:
-Anticoagulation current: none (contraindicated)/heparin/DOAC/warfarin
-In general, target a resting heart rate of < 110
-If rate is persistently elevated, address underlying causes first: pain, hypovolemia, fever
-If sustained rates > 140 and/or any symptoms (chest pain, dyspnea), please contact the medicine team urgently
Alcohol Intoxication, Assessment
- Patient presents with acute alcohol intoxication without evidence of co-ingestion or trauma per history and exam. Will observe patient in ED with frequent monitoring and reassessment. Plan to PO trial, reassess mental status, and assess gait when more stable. No evidence of withdrawal currently.
Alcohol Withdrawal
- EtOH Withdrawal gaba tx:
Gabapentin 600mg/tab Schedule:
Day 1: Take 2 tabs twice daily plus an additional 2 tabs if needed the first day
Days 2-7: Take 1 tab three times daily plus an additional 1 tabs if needed
Day 8: Take 1 tab three times daily
Day 9: Take 1 tab twice daily
Day 10: Take 1 tab at bedtime
Altered Mental Status AMS
- # Altered Mental Status
Differential diagnosis include: infection, uremia, thyroid disease, metastatic disease, B12 def, FTD, AD, vascular dementia, syphilis, HIV, paraneoplastic syndrome
Differential and workup to date: Metabolic/Endocrine: O2: Vascular: Electrolyte: Seizure: Tumor/trauma/toxin: Uremia: Psych: Infection: Drugs: Ethanol: Retention:
- F/u: B12, folate, RPR, thiamine, UTox, UCx, LFT, ammonia, MMA, heavy metals, CTH. If initial workup is negative consider MRI, LP and EEG
- Avoid physical restraints
- Maximize sleep hygiene
- Minimize sedatives
- Wear corrective lenses and hearing aids if applicable
- Avoid cholinergic, opioids, benzos drugs
- Encourage family visits
- Reorientation to person, place and time at least 3 times daily
- Minimize unnecessary lines
Anemia of Chronic Disease | AOCD | Asymptommatic
- # AOCD
Asymptomatic.
- CTM.
- Tx underlying disease.
Ankle, Assessment
- Neurovascularly intact. Query likely ankle sprain. Discussed conservative measures including rest, elevation, alternating application of ice, pain control and early ambulation as tolerated. No gross ankle instability. No evidence of maison-neue. Discussed follow up with PMD and given resources for ortho/sports medicine follow up as needed. Discussed strict return precautions for neurovascular insufficiency or need for repeat imaging/evaluation if pain not vastly improved in 5-7 days for possible occult fracture.
Arterial Line
- ARTERIAL LINE INSERTION PROCEDURE NOTE
DATE: 7/19/22
INDICATION: frequent ABGs/ Labs and continuous hemodynamic monitoring
ANESTHESIA: fentanyl and propofol gtt
Procedure details: The RIGHT radial artery was identified under ultrasound visualization and the area was sterilized and draped in appropriate sterile fashion. A time out was conducted w/ bedside nurse. The arterial line needle was then advanced into the tissue under ultrasound guidance until the tip was seen entering into the arterial lumen. A flash of blood was seen and the guide wire was advanced into the luminal space without any resistance. The arterial catheter was then advance over the guidewire while the needle was withdrawn and after the catheter was fully advance the guide wire was withdrawn completely. Two sutures were placed to secure the catheter in place and covered with a sterile tegaderm. The patient tolerated the procedure well w/o any complications.
EBL: <5ml
Assessment - PreOp
- - Impression: Patient with
low likelihood of coronary artery disease▼
with
excellent▼
exercise tolerance, awaiting
low▼
-risk surgery. Patient
without▼
active cardiac conditions and with
0▼
clinical risk factors. RCRI score:
0 (3.9%)▼
- Recommendations:
-- With regards to cardiovascular risk stratification:
Patient may proceed to surgery without further cardiovascular risk stratification▼
-- Recommend Perioperative: _
-- Perioperative Medication Recommendations:
_Diabetes medications:
_Anticoagulation / Anti-platelet Medications:
_Stress-dose steroids:
Asthma, Assessment
- Patient presenting with shortness of breath. Given exam and history, suspect likely acute asthma exacerbation without_ status asthmaticus. These constellation of symptoms are similar to prior flares without overt deviations from normal exacerbations. Given clinical findings and history, low suspicion for pneumonia, pneumothorax, or acute valvular failure. Patient with minimal risk factors for pulmonary embolism and atypical ACS. As such, will trial bronchodilators, steroids, monitor respiratory status closely, reassess.
- # Intermittent/Mild/Moderate/Severe_ Persistent_ Asthma
Diagnosed: _
Hospitalizations for exacerbation: _
Last intubated: _
Last PFTs: _ (repeat PFTs annually)
Allergies: _?
Triggers: _ Smoking/Work/Home/Environment/Pets
Maintenance therpy: _
Other meds: _
Current functional capacity: _
Recent labs: _
Current symptoms past 1mo:
- Adherence to daily maintenance:
- Frequency of rescue use:
- Nocturnal coughs: </>_ 2x/week?
Additional workup:
- IgE/CXR
- other differential dxx: Chronic bronchitis, COPD, GERD, PE, Sarcoidosis, Emphysema, HF, ILD, infiltrative pulmonary diseases
Plan:
- continue/increase/decrease_ ICS_ therapy
- education for using inhalers
Athrocentesis
- Written consent was obtained from the patient and a time-out was performed. The site was marked and prepared in sterile fashion. A wheel of lidocaine placed, and lidocaine/steroid was then introduced into the joint space. Fluid was removed from the joint space. Samples were sent to the lab for analysis. The patient tolerated the procedure well without any immediate complications.
Atrial Flutter
- # aflutter
- - given persistent SVT can try adenosine (6mg, 12mg, 12mg spaced 1-2 min apart) to break rhythm
Rate control:
- initiate diltiazem gtt first with 10mg loading dose followed by uptitration of gtt to max rate of 15cc/hr
- as diltiazem gtt wears off patient needs to be started on PO diltiazem, uptitrate as needed to max dose of 480mg qday (max dose of 120mg q6h)
- if persistent tachycardia and initiation of second agent is needed - recommend administering digoxin 0.5mg IV loading dose followed by 0.25mg IV 6 hrs later. Can administer another 0.25mg IV 6 hours after that.
- after pt as received total of 1mg IV digoxin, recommend initiating oral maintenance dose of digoxin 0.125 - 0.25mg PO daily
Rhythm control:
- if pt hemodynamically unstable, recommend chemical/electrical cardioversion. If HDS conider outpatient cardioversion once medically optimized
Anticoagulation:
- CHADSVASC: ___
- c/w Xarelto
- consider other reversible causes: hypovolemia, infection, PE, hyperthyroid, electrolyte abnormalities
- #Afib/ flutter
CHADSVASC>2 or if valvular afib disease then patient will need anticoagulation
- Rate rhythm control:
- Anticoagulation: ASA vs. warfarin vs NOAC
# B
Back Pain - Assessment
- Patient presents with several days_ of lower back pain, atraumatic, afebrile. Given history and exam, suspect likely musculoskeletal etiology_. Nontoxic appearing and no overt risk factors for epidural hematoma or abscess. No overt e/o cauda equina or acute critical cord compression with nonfocal neuro exam. Neurovascularly intact distally. No e/o prostatitis or Fournier’s. No peritoneal signs or abdominal pain on exam with low suspicion for AAA.
Back ROS
- Denies lower extremity paresthesias, fecal/urinary incontinence or retention, saddle anesthesia, fevers, weight loss, or sudden night time awakenings from pain.
Benign Prostatic Hypertrophy | Not On Meds | # BPH, not on medications / A/P
- #BPH, not on medications
Bowel Prep
- Bowel prep:
Day before procedure:
- Clear liquids all day
- 4pm: start 4L Golytely at 1L/hr (rate is vital). If patient cannot tolerate due to nausea, can trial reglan 10mg IVP x1 if allowed by QTc
- 10pm: stool check by primary team. Goal stools clear, yellow without sediment or cloudiness. If not at goal, give additional 2L Golytely until at goal.
- Midnight: NPO except prep and medications
Day of procedure:
- 4am: strict NPO
Bradycardia
- - keep transcutaneous pacer pads on patient
- rule out reversible causes of bradycardia (hypothyroidism, infection, drugs, electrolyte abnormalities)
- if patient becomes hypotensive and still bradycardic, give atropine 1mg IV q5 minutes for maximum dose 3mg
- if hypotensive bradycardia is refractory to atropine, start dopamine gtt initial rate 5 mcg/kg/min and increase by 5 mcg/kg/min every 2 minutes until no longer bradycardic
- if hypotensive bradycardia is refractory to dopamine gtt, start transcutaneous pacing at 70 bpm with pain medications
- if heart block does not improve, will likely need a PPM during this admission if within GOC
Brain Death
- Brain Death Determination exam #1
Prerequisites: All criteria met to proceed
☐ Irreversible coma with identifiable cause
☐ Neuroimaging explains coma, unless hypoxic-ischemic in origin
☐ CNS depressant drug effect absent (if indicated, do toxicology screen)
☐ No evidence of residual paralytic agent (nerve stimulation if muscle relaxants used)
☐ No severe acid-base, electrolyte, or endocrine abnormality
☐ Core body temperature ≥ 36°C
☐ Systolic blood pressure (SBP) ≥ 100 mmHg or MAP ≥ 60 mmHg
☐ No spontaneous respirations evident
☐ Notification letter provided to family
Examination
☐ Pupils non-reactive to bright light, NPI 0 bilaterally
☐ Corneal reflex absent
☐ Oculocephalic reflex absent
☐ Oculovestibular reflex absent to ice water caloric testing
☐ No facial movement to noxious stimuli
☐ Gag reflex absent to posterior pharyngeal stimulation
☐ Cough reflex absent to bronchial suctioning
☐ Motor responses absent to noxious stimuli in all 4 limbs (spinal reflexes permissible)
Patient exam confirms irreversible loss of function of the brain and brainstem and is consistent with brain death.
Date and Time of Exam completion:
Second exam to follow. Apnea test not performed.
Brain Death - Exam
- Examination:
General: Laying in bed, no spontaneous movements, unresponsive to verbal or tactile stimuli
HEENT: MMM, pupils fixed, dilated 6mm bilateral, non reactive to light
Cardiac: Tachycardic to 100s, no GMR, normotensive on pressors (BP 94/65)
Pulmonary: Mechanical breath sounds, breathing at set rate of 16 on the ventilator
Abdomen: Soft, nontender, nondistended, no guarding, rebound or rigidity
Extremities: No pretibial pitting edema in LE bilaterally
Neuro: Off all sedation and analgesia, no doll's eye reflex, no corneal reflex, no gag or cough reflex, no pupillary reflex, no reaction to noxious stimuli (no localization or withdrawal).
Apnea Test:
An arterial blood gas was obtained prior to starting an apnea. The patient was preoxygenated to 100% prior to start and had continuous oxygenation provided through the ET tube during the test. No spontaneous respirations were observed throughout the entire apnea test which lasted for 3 minutes and 40 seconds. The patient desaturated to 84% (<85%) at the conclusion of the test.
Pre-apnea test ABG was pH 7.29, pCO2 44, pO2 96, HCO3 21. Post-apnea test ABG was pH 7.20, pCO2 63, pO2 52, HCO3 24. This is interpreted as a positive test for brain death (pCO2 reached above 60 without any spontaneous respirations observed).
Started at 10:56 am - > pCO2 = 43 mmHg
Ended at 11:06 am - > pCO2 = 73 mmHg
Conclusion:
Examination is consistent with brain death. Information has been relayed to One Legacy team. Appreciate Neurosurgery team evaluation.
BAL
- Indications:
- unclear pulmonary process and need to rule in/out certain pulmonary infections (fungal, MT, NMT, DAH syndromes such as pulm capillaritis, bland pulm hem, or DAH)
General approach:
- ideal to target areas on radiograph with highest burden of infiltrate/concern to increase diagnostic yield
- can be done under twilight sedation, MAC, or while intubated
- no need for post CXR unless clinically indicated (i.e. c/f refractory hypoxemia from atelectatis/obstruction/trauma etc)
Process:
- Bronch w/ initial airway survey to distal branches
- Anatomy: OP, epiglotic space, vocal cords/larynx, subglotic space, tracheal rings, posterior wall longitudinal smooth muscle for esophagus, carina, R/L mainstem, RUL
Labs:
Cell Count w/ diff
Body fluid Cx and stain
Fungal Cx - Not hair, bld, nail, skin
Aspergillus Ab/Ag
Acid Fast Bacilli Cx and Smear
# C
CAD Risk Factor Modification
- CAD Risk Factor Modification
- - DM control
- HTN control to goal BP: 125 to 130/<80 in clinic (home: 120 to 125/<80) given known DM and ASCVD > 10%
- HLD management: high intensity statin
- Risk/benefit discussion regarding ASA for primary prevention given age 40-59 with at least 10% ASCVD risk.
-- ASA shown to have approximately 10% (HR 0.89 CrI 0.84-0.94), risk reduction in composite CV mortality, non-fatal MI, non-fatal stroke but approximately 43% increased risk of major bleeding.
- Cardio: Encouraged to continue brisk walking; instructed to perform 3-5 days/wk.
- Encourage tobacco cessation
- Encourage dietary and lifestyle modifications
- - DM control
- HTN control to goal BP: 125 to 130/<80 in clinic (home: 120 to 125/<80) given known DM and ASCVD > 10%
- HLD management: high intensity statin
- Risk/benefit discussion regarding ASA for primary prevention given age 40-59 with at least 10% ASCVD risk.
-- ASA shown to have approximately 10% (HR 0.89 CrI 0.84-0.94), risk reduction in composite CV mortality, non-fatal MI, non-fatal stroke but approximately 43% increased risk of major bleeding.
- Cardio: Encouraged to continue brisk walking; instructed to perform 3-5 days/wk.
- Encourage tobacco cessation
- Encourage dietary and lifestyle modifications
CHF Clinic
- # HFrEF 2/2/ ICM/NICM.
EF _%. NYHA _. Currently euvolemic/volume up (JVD, crackles on exam, LE edema). Admit Wt_. Today’s Wt_. estimated dry Wt_.
Etiology: if not xlear if NICM, needs cath vs nuc stress test. Etiologies include: med nonadherence, arrythmia, Chagas, valvular, thyroid disfunction, HIV, intoxication, induced, infectious, sarcoid. R/o renal or liver etiology.
- Diuretics: drig IV spot dosing with _, BMP q6hr
- Strict Is/Os, Daily weights
- Fluid restriction _
- BB: EBM (carvedilol, metoprolol succinate, bisoprolol)
- Afterload reduction: ACE/ARB/ARNI (ISDN/HDL if poor renal function)
- Device: ICD, BiV-ICD
- Adv therapes: LVAD/transplant vs not indicated
- F/u TSH, A1c, LFTs, Lipid panel, UTox, Resp panel, UTox, UA, Chagas antibody
CHF Exacerbation, Assessment
- This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. The etiology of the decompensation is not certain but is likely due to_. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection) however given unremarkable trop, ekg, cardiac exam have low suspicion. Also considered but low risk for respiratory cause (COPD, asthma, PE, or PNA), medication noncompliance or dietary indiscretion, alcohol or drug abuse, endocrine (thyrotoxicosis), and anemia_. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Patient hemodynamically stable so given lasix and discharged home with mild heart failure exacerbation told to increase lasix dosing for 2 days and then return to normal dosing with close follow up with PMD or cardiologist._
CHF exacerbation problem list
- Acute Decompensated Heart Failure
HFpEF/HFrEF. Last TTE on _ with EF _. Etiology of heart failure is likely _ (ischemic work up _) . At baseline, sleeps on _ pillows and can walk _. Dry weight _. Weight on admission is _. Currently patient reports symptoms of _ (LE edema, DOE, ascites?). On exam, _ (crackles/JVP/LE edema). Etiology of decompensation is likely 2/2 _. CXR shows _. EKG shows _ (e/o ischemia?).
- spot dose diuresis
- strict I/Os, daily weights
- fluid restriction
- low salt diet
- replete electrolytes as needed to Mg >2 and K >4
- Consider TSH/A1C/LFT/Lipids/UA/Utox
CHF problem list
- Congestive heart failure
NYHA class _, ACC-AHA _.
- CXR
- EKG
- Tn-I, BNP
- CBC
- TTE
- coronary angiography to exclude CAD as an underlying cause
- strict I&O
- daily standing weights
- diurese with Lasix IV, spot-dose
- BMP and magnesium 6 hrs after diuresis
- fluid restriction <1.5-2L daily
- cardiac diet, sodium < 4g/day
- lifestyle modifications: diet, fluid restriction, weight loss, smoking cessation, restrict EtOH use, exercise
CKD Labs
- #Chronic Kidney Disease
Stage: G_A_
G1=90+, G2>60, G3a>45, G3b>30, G4>15, G5<15, G5D=dialysis
A1 is ACR<30, A2 is ACR=30-300, A3 is ACR>300
Etiology: _
Proteinuria Workup (UPC > 0.2g/g):
- Protein:Cr Ratio _
- Infections: HIV _, Hep B _, Hep C _, RPR _
- Other: C3 _, C4 _, CH50 _
- Lymphoproliferative Disease: serum kappa/lamba _, serum protein immunofixation (Age >40 or s/sx) _
- Vasculitis (if female or extrarenal s/sx): ANA _, dsDNA (if +ANA) _, anti-Sm (if +ANA) _
- Vasculitis (if >40 YO or extrarenal s/sx): ANCA _
Slowing Progression of CKD (All Patients):
- BP: _
- Rx: _
- Changes (add RAAS inhibitor as indicated): _
- DM: A1c _
- Rx: _
- Changes: _
- Bicarb (goal >22): _
- Rx: _
- Discussed avoiding NSAID’s
CKD Complications (GFR<60):
- Anemia (Goal Hgb >10): Hgb _ ; MCV _
- If yes, check iron panel, ferritin, B12, folate, retic count
- Rx: _
- BMD: Ca _, Phos _, ALP _, albumin _, vitamin D _, PTH _
- Rx: _
- Dyslipidemia: total cholesterol _, LDL _
- Statin (if indicated per ACC/AHA guidelines, or if CKD and >50 YO): _
HD Preparation (GFR<30):
- Dialysis Preference: HD or PD
- Kidney Smart Class: _
- US UE Venous Mapping (for HD): _
- E-consult Vascular (for HD) or Gen Surg (for PD): _
COPD Exacerbation
- COPD Exacerbation
Acute hypoxic respiratory failure
Patient with multiple prior hospitalizations and today reporting acute exacerbation worsened by anxiety, not responding to home inhalers. Unclear precipitant at this time as patient denies infectious sxs, no CP, n/v. Also considered CHF exacerbation given patient is also overloaded and has history of HFpEF however overall clinical picture and labs more c/w COPD exacerbation at this time.
Workup:
- EKG, CXR
- ABG to assess degree of acidemia and CO2 retention
- BNP, troponin
- respiratoy viral panel
Management:
- Goal O2 saturation 88-92%
- If retention on VBG wtih pH <7.35, start BiPAP
- c/w Duonebs q4hr initially then q4h - q6hr prn
- Prednisone 40mg PO qday x 5 days
- Doxycycline 100mg PO BID
COVID
- - Dexamethasone 6 mg daily for up to 10 days ( - )
- Remdesivir 200mg IV ( ), then Remdesivir 100mg IV x 4 days ( - )
- Encourage self-proning and use of incentive spirometer
- Minimize lab draws to reduce staff exposure
- No need for repeat imaging unless respiratory status changes substantively
- Fevers are common; would not initiate fever work up or start antibiotics for persistent fevers
- Tylenol PRN for fever
- Guaifenesin PRN
- Titrate SpO2 >88%
- I spoke to patient at length about the risks and benefits of receiving the flu and COVID vaccines, including decreasing severity of disease, hospitalization, need for oxygen supplementation/ventilator, and death. I educated patient about increased importance for vaccination especially in her given her hx of SLE. Patient understands but wishes to hold off and think about it.
- COVID
-
ID / COVID Note: Severe disease - SARS-CoV-2 pneumonia requiring supplemental oxygen
48 year-old male with history of SLE, ITP, and diabetes mellitus presenting with fever; admitted for acute hypoxic respiratory failure and sepsis secondary to COVID-19.
This patient is hospitalized with a presentation consistent with severe SARS-CoV-2 infection defined by oxygen saturation <94% on room air or requiring supplemental oxygen, but not currently requiring high flow oxygen or mechanical ventilation/ECMO.
In this setting, remdesivir has been shown to reduce duration of symptoms and in subgroup analysis prolong survival (Beigel et al. NEJM 2020). Although there are limited data demonstrating whether dexamethasone given in combination with remdesivir in this patient population is beneficial, dexamethasone alone has been shown to reduce mortality in a subgroup requiring oxygen via low flow or high flow devices (RECOVERY Trial. NEJM 2020).
Recommendations:
- Remdesivir for 5 days; 200 mg IV on day one and then 100 mg IV daily for 4 additional days, or until stable for discharge, whichever comes first**
- Dexamethasone 6 mg po or IV per day for 10 days or until discharge, whichever comes first.
Please contact our service for any questions or disease progression Pager 4260
- Monitor renal and liver function daily while on remdesivir
- If patient progresses to requiring high-flow O2, non-invasive or invasive mechanical ventilation, the 5-day course of remdesivir should be completed
Other:
- Encourage self-proning and use of incentive spirometer
- Minimize lab draws to reduce staff exposure
- No need for repeat imaging unless respiratory status changes substantively
- Fevers are common; would not initiate fever work up nor start antibiotics for persistent fevers unless there is a specific concern for bacterial superinfection. Bacterial superinfection in COVID-19 pneumonia is uncommon at time of hospital presentation
Recommendations are guided by DHS Expected Practices and NIH COVID-19 Treatment Guidelines https://www.covid19treatmentguidelines.nih.gov/
- #Acute Hypoxic Respiratory Failure
#Covid Pneumonia
Patient with 15 days of fever, chills, N/V, productive cough with clear to yellow sputum. Fever and N/V now improved. Acute hypoxia upon presentation to O2sat 78%, improved to 90s% on NRB, now on low 90s% on Hi-Flow supplemental oxygen. Due to prolonged symptoms, initially concerned for possible bacterial superinfection but patient no longer febrile and bacterial superinfection in the setting of COVID-19 infection is uncommon. Lactate 3.5, most likely in the setting of acute illness and
- Infectious disease consulted, appreciate recs:
- dexamethasone 6mg PO x 10 days (8/20/2021 - )
- Remdesivir 200 x1 (8/20/2021) + Remdesivir 100 x 4 days(8/21/2021 - )
- one time dose of tocilizumab 8 mg/kg IV up to a max dose of 800 mg based on actual body weight
- trend lactate
- wean supp O2 req as tolerate, goal SPO2 > 92
-encourage IS and self-proning
- daily CBC, CMP
- HgbA1c, LFT
- #COVID infection
Vaccine status: _, Exposure(s): _, Symptoms: _. O2 requirement: _.
- PRN guafenisin, albuterol/ipratrorpium MDI, IC per nursing
- Remdesevir 200 mg IV on day 1 ( ) followed by 100 mg IV for day 2 and 3 ( ).
- dexamethasone 6mg QD ( ) x 10d
- Educate patient to self prone
- Optimize glycemic control
- Incentive spirometry 10 times per hour during waking hours
- Contact family for self isolation protocol and possible testing
- f/u HbA1c
- f/u up procal
COVID DDx
- Differential diagnosis includes COVID, other respiratory viral infection, bacterial pna, PE, PTX, ILD, pleural effusion 2/2 CHF, pleural effusion 2/2 ESRD. Procal _.
HD #_, dex day #7_, remdesivir day #_, HFNC _/_ . About _ days in to illness. Prognosis: _.
- Dexamethasone 6mg IV qday
- Not a candidate for remdesivir
- Remdesivir 200mg IV x 1, remdesivir 100mg IV days 2-4
- Incentive spirometry
- Proning
- APAP prn for pain, fever
- Ondansetron 4mg IV q8 prn nausea
COVID Treatment
- Acute hypoxic respiratory failure due to COVID-19 pneumonia
Symptom onset:
O2 requirements:
- Remdesevir 200 mg IV on day 1 ( ) followed by 100 mg IV for days 2-5 ( ).
- Start dexamethasone 6mg QD ( )
- Educate patient to self prone
- Optimize glycemic control
- Contact, eye protection and droplet/airborne
- Incentive spirometry 10 times per hour during waking hours
- Contact family for self isolation protocol and possible testing
- Follow up daily CMP, Mg, Phos, and CBC
- Follow up HbA1c
- Follow up procal
COVID follow up
- #Acute Hypoxic Respiratory Failure
#Covid Pneumonia
- sx since ; tested positive
- s/p Pfizer/Moderna/J&J vaccine x 1/2/3
- requiring NC / Facemask / HFNC
- start/continue remdesivir x 5 days
- start/continue dexamethasone 6 mg x 10 days
- supportive care PRN antipyretics, antitussives
- incentive spirometry
- proning exercises as tolerated
- isolation precautions x 10-20 days
CPAP Recall
- Philips Respironics recall: On June 14, 2021, Philips Respironics issued a voluntary recall of a number their home ventilator, CPAP, BiPAP, and AVAPs (Trilogy) devices related to degradation of the sound abating foam used in the device. DME companies have informed that there may be significant delays getting their pap device. If the patients are on any type of recalled device: talk to your patient about the risks and benefits of remaining on PAP therapy given their underlying sleep-disordered breathing and comorbidities and they can choose to remain on their device and await its eventual replacement. Many of the insurance companies may not cover for getting a new device if the patients are not eligible for new device (every 5 years or machine malfunction or setting issues). In the meantime, non-device mediated strategies including sleeping more upright or in a lateral decubitus position, weight loss, avoiding alcohol/tobacco/respiratory depressants while awaiting a device replacement. Advise the patient to avoid high humidity and heat exposure to their PAP device as well as to use only products recommended by the manufacturer to clean their device as well.
Patient should call Philips Respironics at 877-907-7508 or go to website https://www.philipssrcupdate.expertinquiry.com/ and register for getting the new device.
CT surgery checklist
- Surg checklist
[_] CBC/CMP/Mg/Phos (ordered)
[_] PT/INR/PTT (ordered)
[_] type and screen (will need new one night before procedure) (ordered)
[_] HbA1c (ordered)
[_] UA (ordered)
[_] UTox (ordered)
[_] EKG (ordered)
[_] CXR (ordered)
[_] PFTs (x1255) (ordered)
[_] ABG (ordered)
[_] HIV - given patient opportunity to opt out and then order (ordered)
[_] Hepatitis panel (ordered)
[_] LHC (ordered)
[_] TTE (ordered)
[_] Carotid duplex ultrasound (ordered)
[_] Venous mapping (ordered)
[_] CTH (if h/o CVA or endocarditis)
[_] OMFS consult (if valve or endocarditis)
1 to 2 Days Before Surgery:
[_] PRBC 6un (open heart) or 2un (closed heart)
[_] FFP 2un
[_] Platelet 2un
[_] Cryoprecipitate 10un
Night Before Surgery:
[_] Fleet enema after dinner (stable patients)
[_] Hold DVT Prophylaxis/AC night before surgery
[_] Hibiclens night before
[_] IS w/ instructions q10m
[_] NPO except meds after midnight. If no CHF, start IVF
s
CT surgery checklist 2023
- CT Surg checklist:
[] CBC/CMP/Mg/Phos
[] PT/INR/PTT
[] HbA1c
[] UA
[] EKG
[] CXR
[] ABG
[] Hepatitis panel
[] LHC
[] TTE
[] UTox
[] HIV
[] CT head (only needed in Pt w/ hx CVA, endocarditis)
[] TEE
[] PFTs
[] OMFS assessment (needed in valve cases)
[] Carotid U/S - only for AV replacement or CABG
[] LE venous mapping - only for AV replacement or CABG
[] type and screen
1 to 2 Days Before Surgery:
[_] PRBC 6un (open heart) or 2un (closed heart)
[_] FFP 2un
[_] Platelet 2un
[_] Cryoprecipitate 10un
Night Before Surgery:
[] Fleets enema after dinner (stable patients) - 8PM
[] Hold DVT Prophylaxis/AC night before surgery
[] Hibiclens night before - 9PM
[] IS w/ instructions
[] NPO at midnight
[] repeat type and screen night before
CUREs
- CURES reviewed today▼
. No evidence of
inappropriate activity. Last filled (copied from CURES):▼
Calcium
- -Check post Op PTH and bmp, serum albumin, phosphorus, magnesium STAT
-Check calcium Q8hrs for Ca levels >8.0mg/dL
-Check calcium Q6hrs for Ca levels <8.0mg/dL
-If corrected Ca < 7.5, recommend stat EKG for QT interval and administer IV Ca gluconate 2gm stat
-If calcium level is low (< 7.5mg/dL);start on Ca drip 11 g of calcium gluconate (equivalent to 1000 mg elemental calcium) in normal saline to provide a final volume of 1000 mL
,given at a rate of 50 cc/hr. monitor calcium level q 4-6 hours.
Titrate to 25cc/hr for Ca levels between 7.5-8mg/dL.
If Ca levels >8mg/dL, hold the drip, repeat bmp in 4-6 hrs, resume the drip if Calcium level <8mgd/dL
-Start Calcitriol 0.5mcg bid stat.
-if Magnesium <2mg/d: start Magnesium sulfate 4g in NS 100ml and iv infusion at 33ml/hr and Magnesium oxide per oral 400mg tid for 1month.
Cancer Pain
- Other adjuvant treatments/modalities:
- Start SNRI / SSRI / TCA for neuropathic pain component / and concurrent depression / anxiety (PHQ9 _ / GAD7 _). Denies SI/HI, and no history of BAD or schizophrenia. Continue behavioral interventions at each subsequent visit. Patient given strict return precautions prior to discharge, including monitoring for worsening mood, SI, HI.
- Start acetaminophen 1g PO TID ATC given no history of liver disease / Start acetaminophen 1g PO BID given history of liver disease. Do not drink alcohol while on this medication. No history of GIB or CKD, so will start trial of Naproxen 500 mg PO BID prn severe pain with Pantoprazole 20 mg PO qAM for GI ppx. / Defer NSAID for now given history of GIB / given history of CKD / while also on ASA for secondary prevention.
- Start / Continue Gabapentin _ PO TID. Consider transition to Pregabalin at subsequent visit if indicated.
- Continue / Start current topical Lidocaine prn. Continue / Start topical Capsacin prn.
- Pool aquatic/PT referral information given to patient today.
- Given Nutrition referral to assist with weight loss. Continue to encourage lifestyle/diet/exercise measures.
- Consider referral for Accupuncture if needed at subsequent visit.
- Consider referral to Wellness Center for mindfulness mediation and other alternative chronic pain management strategies.
- If needed / Will continue chronic pain management behavioral modalities at each subsequent visit.
- Consider referral to Pain Management Clinic to see if procedural based interventions (including CSI and TENS) is indicated. If needed, consider referral to Neurosurgery for further evaluation for possible further invasive interventions (including radiofrequency ablation and surgery).
-
Cancer Screening
- Age appropriate Cancer Screening
Pap
- Family history of gyn Ca: none
- Previous: 2019-2020, presumed normal
- Next due: today
Mammo
- family history of breast Ca: paternal grandmother (age 80) paternal grandaunt
- previous: 2020
- Next due: this year
CRC
- family history of CRC: none
- Last FIT test: Had colo ~2017-2018, normal.
- FIT Test due: Due ordered.
Lung cancer: smoking history: 14 pyhx
Special Screens
- HIV - reportedly negative in past.
Capacity
- Capacity:
Patient assessed for Medical Decision-Making Capacity when notified by nursing staff that patient expressed desire to leave using the following criteria:
1. Communicate a choice Patient was able/unable to clearly communicate a choice when asked to indicate a treatment choice other than "go to Santa Monica" and eventually "outpatient" but unable to give a plan i.e. to see a particular provider at a particular clinic
2. Understand the relevant information Patient had limited/adequate ability to paraphrase his medical conditions stating he was here because ... and able/unable to recall other underlying medical conditions but when reminded could not tell proposed treatments i.e. for ***
3. Appreciate the situation and its consequences Limited/ adequate but had a general appreciation for consequences if he was to discontinue treatment. Initially, stating ***
4. Reason about treatment options Did not / DID display ability to compare options and consequences of pursuing different options. Unable/able to answer why not having in-hospital treatment was better than having it. Just verbalized "Just want to go home"
At this time, patient does not/ does have full capacity to direct his/her care & to refuse/accept treatments
Cardiac Arrest, Assessment
- Per EMS report, patient was found down_, had witnessed arrest_. Approximate downtime prior to compressions: _. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital but in route patient rearrested. Cardiac compressions were performed immediately by staff in order to sustain blood flow. The patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. See nursing note for medications and times given. Cardiac arrest was likely secondary to _. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. ROSC was achieved and patient admitted to ICU._ Despite all efforts, patient remained in cardiac arrest with no response to treatment measures and resuscitation attempt. After _ min, I discontinued resuscitation and patient was pronounced deceased. Family was made aware._
_Family members were notified that the patient may pass away soon. Family members requested discontinuation of resuscitation efforts. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. There was no palpable radial pulse. The patient did not respond to nail bed stimuli. I examined the patient and there was no pupillary response to light. Patient was pronounced deceased.
Cardiology Objective
- Gen:
HEENT: JVD
CV: RRR, no m/g/r, normal s1,s2
Resp: CTABL, no w/r/r
Abdominal: Soft, NTND
Ext: LE edema
Neuro: aaox3
Labs: Reviewed, notable for troponin of _______, BNP of _______, K____, Mg_____, Phos____
EKGs:
Tele: reviewed, notable for ____
Is/Os:
Echo:
Imaging: Reviewed, notable for CXR showing_____
Cardiology ROS
- Denies chest pain, palpitations, paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema.
Cellulitis - Discharge
- This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis.
- Sensitivity/pain to light touch around the erythematous area.
- No lymphangitic spread visible and no fluid pockets or fluctuance c/f abscess noted.
- Low c/f osteomyelitis or DVT.
- No immune compromise, bullae, pain out of proportion, or rapid progression c/f necrotizing fasciitis.
- In ED: Erythema outlined
- Rx: Cephalexin 500mg PO q6hrs,_
- Disposition: No evidence of serious bacterial illness requiring admission for IV antibiotics. Nontoxic appearing, VSS. Low risk for treatment failure based on history. Will discharge home with PO antibiotics and return precautions discussed at bedside.
Cellulitis A/P
- - Swelling/redness started
- Sensation: pain, itching, burning
- Denies spending time outside prior to symptoms. No known bug bite/sting.
- Denies fever at home. Good appetite, normal fluid intake.
- No personal/family history of MRSA
PCP: OV HUB
Social: In custody of grandparents. Lives with other two siblings as well. Stays at home with grandparents during the day.
Skin: *** cm area areas of erythematous, indurated, warm to the touch skin *** - *** tenderness to palpation. No fluctuance. No abrasions, lacerations, rashes noted. Otherwise, skin warm, well perfused and intact.
Most likely diagnosis cellulitis given exam with warm, indurated, erythematous areas of soft tissue. Differential also includes allergic reaction, folliculitis, erysipelas. Abscess unlikely given no fluctuance on exam and osteomyelitis unlikely given no pain to deep palpation, no limp or pain with walking, and no fevers or systemic symptoms. Otherwise, Gracie well appearing on exam, no systemic symptoms. Given history of recurrence in same location and significant extend of tissue involvement, will plan to treat for cellulitis with close follow-up for healing and assess for abscess formation given extent of tissue affected.
Plan:
- Traced area of induration/erythema today in clinic
- Keflex 50 mg/kg/day div q8h for 7 days sent to home pharmacy
- Wound care: Keep area clean and dry at home
- Reviewed return to care precautions - Fevers, inability to PO, extension of indurated/erythematous area beyond traced area, worsening pain, lethargy
- Follow-up scheduled for ~1 week; Check for improvement, check for any areas of fluctuance
Cellulitis, Assessment
- presents with initial presentation of local erythema, warmth, swelling to ____ for ___ days.
- Sensitivity/pain to light touch around the erythematous area.
- No lymphangitic spread visible and no fluid pockets or fluctuance c/f abscess noted.
- Low c/f osteomyelitis or DVT.
- No immune compromise, bullae, pain out of proportion, or rapid progression c/f necrotizing fasciitis.
- In ED: Erythema outlined
- Rx: Cephalexin 500mg PO q6hrs
- Disposition: No evidence of serious bacterial illness requiring admission for IV antibiotics. Nontoxic appearing, VSS. Low risk for treatment failure based on history. Will discharge home with PO antibiotics and return precautions discussed at bedside.
Cellulitis, NonPurulent
- # Non-Purulent Cellulitis with without sepsis
Redness, swelling, warmth, induration at @@@.
Hemodynamically stable unstable@@@.
Evidence of infection with leukocytosis, tachycardia, fever, hypotension.
No evidence of abscess on exam.
No evidence of crepitus, bullae, numbness at site, skip lesions, or pain out of proportion.
No human or animal bite.
No puncture wound.
No aquatic injury.
No Hx of IVDA.
Other DDx:
DVT, venous stasis, line infiltration, pyoderma gangrenosum, erythema nodosum, lipodermatosclerosis, trauma, HSR, erythromelagia
Cellulitis borders marked with pen
S/p crystalloid bolus with L of LR NS.
- f/u BCx
- f/u Lactic acid
- Consider trauma consult for evaluation of NSTI
[in setting of no or 1 SIRS]
Start (1)
- Keflex
- Augmentin
- Clindamycin
[in setting of 2 SIRS w/o severe sepsis]
- Start CTX ( ) and MRSA coverage with doxycycline, clindamycin or vanc
- Start vancomycin and cefepime [severe sepsis]
- If renal function permits, NSAIDs PRN pain and fever. Otherwise tylenol PRN
Cellulitis, Purulent
- # Purulent Cellulitis/abscess with without sepsis
Abscess located at @@@.
Hemodynamically stable unstable@@@.
Evidence of infection with leukocytosis, tachycardia, fever, hypotension.
No evidence of crepitus, bullae, numbness at site, skip lesions, or pain out of proportion.
No Hx of IVDA.
- Follow up blood culture and lactic acid
- S/p I and D.
Wound cultures sent.
- S/p crystalloid bolus with L of LR NS.
[in setting of no or 1 SIRS]
Start
- Bactrim ( )
- Doxycycline ( )
- Clindamycin ( )
[in setting of 2 SIRS w/o severe sepsis]
Start (1)
- Start vancomycin ( ),
- Start clindamycin ( )
- Start linezolid ( ).
- Consider adding CTX ( )
- Consider surgery consult for further I and D.
? gram positive bacteremia
- consider TTE
? renal function permits
- NSAIDs PRN pain and fever.
- Otherwise tylenol PRN
Central Line Note
- INDICATION: pressors
PROCEDURE OPERATOR:
ATTENDING PHYSICIAN:
CONSENT:
During the informed consent discussion regarding the procedure, or treatment, I explained the following to the patient/designee:
a. Nature of the procedure or treatment and who will perform the procedure or treatment.
b. Necessity for procedure and the possible benefits.
c. Risks and complications (most common and serious).
d. Alternative treatments and the risks, benefits and side effects of each (including no treatment).
e. Likelihood of the patient achieving his/her goals without this procedure and surgery treatment.
f. Problems that might occur during the recuperation.
g. Conflicts of interest, if any
PROCEDURE SUMMARY:
A time out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask, full gown and sterile gloves throughout the procedure. The patient was placed in Trendelenburg position. [LEFT/RIGHT] neck/chest region was prepped using chlorhexidine scrub and draped in sterile fashion using a full drape and sterile probe cover and sterile gel employed. The medial and lateral heads of the sternocleidomastoid muscle were identified as was the carotid pulse. The Internal Jugular vein was identified using the ultrasound. Anesthesia was achieved over the vein using 1% lidocaine. Using real-time out of plane guidance, the introducer needle was inserted into the Internal Jugular vein under direct ultrasound visualization. Venous blood was withdrawn. The syringe was removed and a guidewire was advanced into the introducer needle. The guidewire was visualized in the Internal Jugular Vein by ultrasound. A small incision was made at the skin surface with a scalpel and the introducer needle was exchanged for a dilator over the guidewire. After appropriate dilation was obtained, the dilator was exchanged over the wire for a triple lumen central venous catheter. The wire was removed and the catheter was sutured in place with catheter hubbed at the skin. A sterile sorbaview shield was placed over the catheter at the insertion site. The patient tolerated the procedure without any hemodynamic compromise. At time of procedure completion, all ports aspirated and flushed properly. Post-procedure chest x-ray is pending at this time. Estimated blood loss is 5cc.
- Central Line
- Central
INDICATION: _
PROCEDURE OPERATOR: _
ATTENDING PHYSICIAN: _ In Attendance (Y/N)_
CONSENT:
Consent was obtained from _ prior to the procedure. Indications, risks, and benefits were explained at length.
The procedure was performed emergently and the permission was implied because of the emergent nature.
PROCEDURE SUMMARY:
The CDC Central Line Insertion Practices form was completed by an independent observer (_) starting with the first handwash prior to starting sterile technique. A time out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask with protective eyewear, full gown and sterile gloves throughout the procedure. The patient was placed in Trendelenburg position. LEFT / RIGHT chest region was prepped using chlorhexidine scrub and draped in sterile fashion using a full drape and sterile probe cover employed. The medial and lateral heads of the sternocleidomastoid muscle were identified as was the carotid pulse. The Internal Jugular vein was identified using the ultrasound. Anesthesia was achieved over the vein using 1% lidocaine. Using real-time out of plane guidance, the introducer needle was inserted into the Internal Jugular vein under direct ultrasound visualization. Venous blood was withdrawn. The syringe was removed and a guidewire was advanced into the introducer needle. The guidewire was visualized in the Internal Jugular Vein by ultrasound. A small incision was made at the skin surface with a scalpel and the introducer needle was exchanged for a dilator over the guidewire. After appropriate dilation was obtained, the dilator was exchanged over the wire for a _ central venous catheter. The wire was removed and the catheter was sutured in place at _ cm. A sterile sorbaview shield was placed over the catheter at the insertion site. The patient tolerated the procedure without any hemodynamic compromise. At time of procedure completion, all ports aspirated and flushed properly. Post-procedure chest x-ray is pending at this time. Estimated blood loss is _.
Checklist
- #FEN/GI/PPX
Diet: renal
GI PPX: none
DVT PPX: Heparin
Bowel Regimen: None
Lines/catheters: 20g R PIV
Fluids: none
Code status: FULL
Contact: TBD
Discharge Plan: TBD
Patient requires acute care hospitalization for: Acute on chronic renal failure
Anticipated Discharge Date: TBD
Anticipated Discharge Location: Home
Anticipated Discharge Mode of Transportation: Private vehicle
Are patient and family aware of discharge plan? Yes
Clinical goals or barriers to overcome prior to discharge:
Logistical needs for a safe discharge: TBD
- Checklist:
Level of Care: _
Contact: _
Code Status: _
[F]luids/Feeding: _
[A]nalgesia: _
[S]edation: _
[T]hrombophylaxis: _
[H]ead of bed: 30 degrees
[U]lcer ppx: _
[G]lucose control: _
[S]BT: as tolerated
[B]owel regimen: _
[I]ndwelling lines: _
[D]eescalation of Abx: _
[S]kin: _
COVID vaccine status: _
Discharge Plan:
Patient requires acute care hospitalization for: _
Anticipated Discharge Date: _
Anticipated Discharge Location: _
Anticipated Discharge Mode of Transportation: _
Are patient and family aware of discharge plan? _
Clinical goals or barriers to overcome prior to discharge: _
Logistical needs for a safe discharge: _
Chest Pain, Assessment
- Exam without evidence of volume overload so doubt heart failure. EKG without signs of active ischemia. Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. Presentation not consistent with acute PE (Wells low risk _ PERC negative_),pneumothorax (not visualized on chest xr), thoracic aortic dissection, pericarditis, tamponade, pneumonia (no infectious symptoms, clear chest xr), myocarditis (no recent illness, neg trop). HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__.
Chronic Kidney Disease CKD
- CKD stage 2 3a 3b 4 5
- Renal diet
- Renally dose medications
- Strict I/O
- Save a limb: avoid blood draws and blood pressure checks on non-dominant arm
- CTM BMP
- No emergent HD needs
- Continue vitamin D
- Continue EPO Bicitra Pholo Sevelamer
Chronic Kidney Disease CKD OP
- CKD stage 2 3a 3b 4 5, A1/A2/A3
2/2 DKD HTN OTHER
Dx date (3mo duration): _
Baseline Cr: _
MACR: _
Last BMP: _
Meds:
- ACEi/ARB:
- ARNI:
- SGLT-2:
Chronic Kidney Disease CKD work up chronic kidney disease
- Obtain A1c, US renal, PT/INR lipid panel, PTH, iron panel, Ferritin,UA, UPCR, UMCR, ANA, ESR, C3, C4, SPEP, UPEP, PLA2R, Hepatitis B S antigen, Hep B Surf Ab, Hep B c Ab, Hep C antibody, RPR, HIV to characterize progressive CKD
Chronic Obstructive Pulmonary Disease | COPD |
- #COPD
Current functional capacity: _
Timed walking test: _
Last PFTs: _
- FEV1:
- FVC:
- FEV1/FVC:
- TLC:
- DLCO:
GOLD Class: _▼
BODE Index score: _
Info:
- monitor post-BD PFTs yearly to track decline in forced expiratory volume in one second (FEV1), which may identify patients whose disease is progressing more quickly than usual
Plan:
Meds:
-
Labs:
-
Diagnostics:
-
Cirrhosis
- # Compensated/ Decompensated Cirrhosis
MELD-Na @@@
due to alcohol use disorder, hepatitis C, hepatitis B, hemochromatosis, NASH, Wilson's, AIH
No/Prior history of hepatic encephalopathy, variceal hemorrhage, portal gastropathy, SBP, ascites of volume overload
Work up in undifferentiated cirrhosis:
- Hep B S Ag
- HCV Ab
- ANA
- ASMA
- Iron saturation
- iron panel
- ceruloplasmin (if <40)
- Daily weights
- Strict I/O
- Low salt diet
- Daily chemistries
- Paracentesis if large enough pocket
- Meld-NA Score @@@
Symptoms in past include [HE, GI bleed, ascites, SBP]
HCC Screen:
Hep A and B Immunity:
Variceal Screening:
physical exam normal
- Gen: AOx3, NAD
HEENT: EOMI. No scleral icterus, conjunctival pallor.
Neck: Supple. No JVD. No LAD
Cardiovascular: RRR, no m/r/g. Normal S1/S2
Respiratory: CTAB, even unlabored breathing
Gastrointestinal: +BS, S, NDNT, No HSM appreciated
Ext: No edema, clubbing, cyanosis. RP 2+
Skin: wwp, No rashes.
Neurologic: CN 2-12 grossly intact. No Focal Deficits. SILT in all 4 extremities
[[long qt]]
- #Long QT
Medications that can prolong QT should be avoided which include: Chlorpromazine, Metoclopramide, Quetiapine, Haloperidol, Olanzapine, Amiodarone, TCAs, Citalopram, Escitalopram, Venlafaxine, Buproprion, Diphenhydramine, Macrolides (Erythromycin).
Ondansetron (Zofran) can cause QT prolongation in a dose dependent manner, so lower doses are preferred.
PPIs and loop diuretics can induce torsades in patients with long QT due to magnesium loss, so alternative meds are preferred, but if these drugs need to be used Magensium levels should be monitored and repleted.
Monitor electrolytes closely and replete prn.
hlh diagnosis
- HLH Criteria (Need 5/8 for Diagnosis)
- Fever (peak temperature of> 38.5° C for > 7 days)
- Splenomegaly (spleen palpable > 3 cm below costal margin)
- Cytopenia involving > 2 cell lines (Hb < 9 g/dL, absolute neutrophil count < 100/µL, platelets < 100,000/µL)
- Hypertriglyceridemia (fasting triglycerides > 2.0 mmol/L or > 3 standard deviations [SD] more than normal value for age) or hypofibrinogenemia (fibrinogen < 1.5 g/L or > 3 SD less than normal value for age)
- Hemophagocytosis (in biopsy samples of bone marrow, spleen, or lymph nodes)
- Low or absent natural killer cell activity
- Serum ferritin > 500 µg/L
- Elevated soluble IL-2 (CD25) levels (>2400 U/mL or very high for age)
dispo
-
Dispo
SI: Why are they here
IS: What are we doing for it
ELOS/Anticipated discharge date:
Barriers to discharge: None
Dispo: Home with
[[hip fracture | osteoporosis]]
- #Osteoporosis
- By definition pt meets criteria for osteoporosis and should start therapy within 90 days.
- Check Vitamin D levels
- Start Calcium/Vitamin D
- Bisphosphonate therapy to begin 2-4 weeks after discharge. Prescription to be send on discharge
- Follow up with PMD for DEXA for basline and monitoring
#Delirium Precautions
- High Risk for Post-Op Delirium
- Perform frequent orientation (date, situation, etc)
- Ambulate patient TID (if weight bearing)
- Sit up in chair for meals
- No vitals between 10pm and 6am if safe
- Keep room dark a night and light during the day. Minimize daytime naps to 20-30 minutes
- Place patient in room with window and allow natural light during the day.
- Ensure patient is wearing hearing aids, glasses, dentures if applicable
- Encourage oral hydration as dehydration can promote delirium
- Continue adequate pain control
- Avoid Benzodiazepines, anticholinergic medications, and other sedating medications
- If patient becomes a danger to self, can given PO seroquel 50mg x1, but there is an overall increase in hospital mortality with antipsychotic use so should only be used if concern for safety
- Avoid use of restraints as this can worsen delirium
#Anemia
Check Iron panel ferritin and improved functional outcomes with IV iron therapy in patients with iron deficiency anemia periop.
Follow up: Will review with care coordinator
Thank you for including us in the care of this patient. Please call with questions. If after 4pm or on weekends, please page the on-call hospitalist (can be found on Amion > lacusc > IM Attendings).
Cirrhosis AP
- HE: no e/o of HE. continue to monitor
EV/PHG: No History of EVs. No evidence of bleeding, Last EGD ___ negative
Ascites: Lasix/Spironolactone.
SBP: No indication for SBP ppx. Ciprofloxacin
HCC: Last US ___ no e/o HCC. Will need screening US/AFP q6month
Avoid shellfish, no NSAIDs, tylenol <2 gm daily, low sodium diet
-
Cirrhosis
CPC class __, MELD Score ___
Ascites: Lasix/Aldactone
SBP: Last Para with ___ Protein.
- SBP PPx Indications: 1) Prior episode of SBP. 2) T Prot <1.5 + (Cr >=1.2 or BUN >=25 or Na <=130, or CPS >=9 + Bili >=3). 3) Acute GI Bleed (only for 7 days)
HE: Lactulose
HCC screen: no evidence of mass on last U/S. AFP wnl
PVT: none
EV screen: last EGD ___ . No current signs of bleeding.
Transplant: Assessment as outpatient
Avoid shellfish, NSAIDs. Please keep diet with <2gm Na/day. Tylenol <2 g/day. Avoid hepatotoxic medications.
[[fever of unknown origin | fouo | fuo]]
- Infectious Work Up: BCx, UA, UCx, FCx, CXR ordered. HIV, Hep Panel ordered
FUO Work Up: ESR, CRP, LDH, Quant Gold, RF, CK, ANA, SPEP ordered.
Imaging: CT A/P if above negative
Cirrhosis Inpatient
- Cirrhosis
(If GIB: Esophageal Varices s/p banding ________)
MELD-@@@.
Cirrhosis 2/2 (EtOH, HBV. HCV, NASH).
Decompensated by:
@@@ (esophageal varacies, esophageal hemorrhage, hepatorenal syndrome, ascites, encephalopathy, PVT).
Last drink @@@
EUS reports @@@
Pt reporting (melanotic stools, however Hgb stable).
S/p Paracentesis on @@@ cell count w/ dif w/o evidence of SBP.
Cultures pending.
SAAG >1.1 consistent with portal hypertension.
SAAG <1.1 excludes portal hypertension, includes infection, malignancy, nephrotic syndrome, pancreatic ascites.
@@@ Will hold propranolol in the setting of possible intraabdominal infection.
Varices:
@@@ s/p banded in _____
- GI consulted, f/u for possible inpatient EGD
- holding propranolol
Ascites:
@@@ pending paracentesis
- Spironolactone 100 mg qday
- Lasix 40 mg qday
- 2g CTX for empiric SBP Tx
HE:
@@@ history of mild confusion, continue lactulose
- Lactulose titrated to 2-3 BMs
- Compensated/ Decompensated Cirrhosis c/b ascites/SBP/HCC/HRS/Variceal bleeding/Hepatopulmonary Syndrome
MELD-Na _, CP _ (date of labs _)
Due to alcohol use disorder, hepatitis C, hepatitis B, hemochromatosis, NASH, Wilson's, AIH, A1AT, PBC, PSC
Work up in undifferentiated cirrhosis: Hep B, HCV Ab, ANA, ASMA, Iron saturation, iron panel, ceruloplasmin (if <22), US, Alcohol history, AAT, IgG
- Daily weights
- Strict I/O
- Low salt diet
- Daily chemistries
- Paracentesis if large enough pocket
Co-current conditions:
- Alcoholic hepatitis
- Cholelithiasis/Choledocholithiasis/Cholecystitis/Cholangitis
Cirrhosis Outpatient
- 1. Cirrhosis
MELD-Na 19pts per labs 2/18/23.
- f/u GI apt 3/6/23
- Diuresis:
-- cont Lasix 20mg po daily
-- cont Spironolactone 50mg po daily
-- cont 2 g sodium diet
- EV: EVL x2 10/2022
- HE: last 2/2023
-- cont Lactulose 20mg q4h to be titrated to 2-3BMs daily
-- cont Rifaximin 600mg BID
- Healthcare maintenance
-- Vaccinations: Flu vaccine annually
- Screening:
-- cont HCC screening with q6 month US and AFP
- OLT: sober since 9/2022, follows with RR-UCLA Hepatologist Dr. Steven-Huy B. Han pending OLT eval
- · Check CBC, CMP, PT/INR, AFP prior to the next visit.
· Low Na diet <2 gm day, discussed compliance with diet, label reading, avoid outside food, fast food, canned food, soda etc.
· Daily monitoring of weight and if notice weight gain then to call the clinic.
· Avoid alcohol, NSAIDs.
· If experience any GI bleed, confusion, falls, worsening abdominal distention then to go to ER or call 911.
· HCC screening with alfa feto protein, ultrasound abdomen 6 monthly, Ordered.
· Portal HTN: on beta blocker: tolerating yes
· Variceal screening/surveillance: recommend Endoscopy. Scheduled 6/22/2023
Vaccination: Recommend Hep A, B if not already received
- Etiology: _▼
CP Class: _ (_/_/_)
MELD score: _ (_/_/_)
Complications:
- HE: _
- EV: _
- VH: _
- HCC: _
- Recurrent Ascites: _
- AKI/HRS: _
Screening:
- EV: _
- HCC: _
Referral for OLT indicated? _▼
HCM:
- vaccines: _▼, _▼, _▼
- Routine: Avoid NSAIDS; reduce <2g Sodium diet (if hypoNa <130); low protein diet
Cirrhosis Work Up
-
- RUQ u/s w/ doppler
- hepatitis panel (hep B, hep C)
- AMA
- ASMA
- ceruloplasmin
- ferritin
- A1AT
- IGG levels
- anti actin
- anti TTGabs
- ANA
- coagulation labs (PT w/ INR, PTT)
Cirrhosis Work Up
- Cirrhosis (Child _, MELD _)
- Etiology:
- HE:
- EV:
- Ascites:
- Diuretics: Spironolactone 50, Lasix 20
- SBP: no history
- PVT:
- HCC Screening: Last _:
- Vaccines:
- Transplant:
- Routine: Avoid NSAIDS, shellfish, <2g Tylenol daily, <2g Sodium diet, EtOH
- F/u labs: -ANA negative, Hep B non immune/non reactive, Hep C Ag non reactive, AMA, anti-SM, ceruloplasmin, alpha-1 antitrypsin, Fe saturation
Code Blue
- Code Blue Note
Date:
Time:
Reason for Code Blue Call:
Initial Rhythm:
Rhythms seen during resuscitation:
Medications given:
Point of care labs:
Pulmonary/ICU Procedures performed:
Cardiac Procedures performed:
Outcome of Resuscitation: successful at obtaining return of spontaneous circulation.
Disposition of Patient:
Attending physician _ informed of Code Blue outcome @@@
Comfort Care
- # Comfort Care
- vitals q shift, no lab draws
- pt unable to tolerate PO
- IV pain meds as needed with the following scale:
--- IV morphine 1mg for mild
--- IV morphine 2mg for moderate
--- IV morphine 4mg for severe
--- IV 0.5 Dilaudid for breakthrough
- if pt unable to give pain scale
---best judgement based on overall clinical picture
- if pt becomes profoundly tachycardic or appears in pain refractory to above
---can discuss initiation of morphine drip
- family updated of patient's current clinical status and prognosis
Constipation A/P
- Reported Bristol scale type *** (1 = separate, hard lumps, 2 = lumpy and sausage-like) stools. ***Constipation likely behavioral in nature and exacerbated by low fluid intake and low fiber diet. ***Milk protein allergy ***. Anatomic etiology - such as short segment Hirschsprung's - less likely given previously normal stools.
- Encouraged increasing water intake; Estimated fluid goal ~***L
- Prescribed Lactulose 2 mL/kg/day (*** cc daily) for 2 weeks
- Encouraged use of Miralax as needed; Can titrate from 1 cap BID to 1/4 or 1/8 daily
- Discussed foods that can help and exacerbate constipation:
- Foods that are good for constipation- Any fruit with a pit (peaches, plums, nectarines, mango), leafy green vegetables, prunes, pears, kiwi, berries, beans, chia seeds, blackstrap molasses, flaxseed, and unbuttered unsalted popcorn.
- Foods that make constipation worse - Bread, rice, milk, dairy products, bananas, red meat, fast food, fried food, chips, processed foods.
Congestive Heart Failure
- Congestive heart failure
2/2 _ (_/_/_)
NYHA class _
Valvulopathy: _
Last dry weight: _
Rhythm: _
GDMT
-
-
-
# D
DKA
-
DKA
IV fluids
- severe hypovolemia: NS bolus
- mild hypovolemia: corrected Na _
-- low serum Na: NS 250-500cc/h until serum glucose <200 then D5-1/2NS
-- normal or high serum Na: 1/2NS 250-500cc/h until serum glucose <200 then D5-1/2NS
- BMP q2-4h
Potassium
- serum K <3.3, hold insulin give 20-40mEq/h until K >3.3
- serum K 3.3-5.3, give 20-30mEq per liter of fluid
- serum K >5.3, does not need K
- BMP q2h
Phosphorus
- PO4 <2.0mg/dL; give K3PO4 20-30mmol/L IVF; maintain PO4 >2.0
- PO4 >2.5mg/dL, monitor PO4 q2-4h
Insulin
- IV insulin gtt 0.1 unit/kg/h
- SC rapid acting insulin 0.3 unit/kg then 0.2 unit/kg one hour later followed by rapid acting insulin 0.2 unit/kg q2h
-- if serum glucose does not decrease 50-70 mg/dL after first hour, then double rate or give SC bolus
- when serum glucose <200, reduce insulin gtt to 0.02-0.05 units/kg/h or give SC insulin 0.1 unit/kg q2h; maintain serum glucose 150-200 until DKA resolution
- BMP, VBG q2-4h
- cross cover IV insulin x2h when patient tolerating PO, initiate SC insulin regimen
-- SC insulin 0.5-0.8 unit/kg daily in insulin-naive patient
Bicarbonate
- pH <6.9
-- dilute NaHCO3 (100mmol) in 400 mL H2O with 20mEq KCl and infuse over 2h; repeat until pH >7
- pH >6.9; no need for bicarb repletion
- BMP, VBG q2h
DKA
- DKA
IV fluids
- severe hypovolemia: NS bolus
- mild hypovolemia: corrected Na _
-- low serum Na: NS 250-500cc/h until serum glucose <200 then D5-1/2NS
-- normal or high serum Na: 1/2NS 250-500cc/h until serum glucose <200 then D5-1/2NS
- BMP q2-4h
Potassium
- serum K <3.3, hold insulin give 20-40mEq/h until K >3.3
- serum K 3.3-5.3, give 20-30mEq per liter of fluid
- serum K >5.3, does not need K
- BMP q2h
Phosphorus
- PO4 <2.0mg/dL; give K3PO4 20-30mmol/L IVF; maintain PO4 >2.0
- PO4 >2.5mg/dL, monitor PO4 q2-4h
Insulin
- IV insulin gtt 0.1 unit/kg/h
- SC rapid acting insulin 0.3 unit/kg then 0.2 unit/kg one hour later followed by rapid acting insulin 0.2 unit/kg q2h
-- if serum glucose does not decrease 50-70 mg/dL after first hour, then double rate or give SC bolus
- when serum glucose <200, reduce insulin gtt to 0.02-0.05 units/kg/h or give SC insulin 0.1 unit/kg q2h; maintain serum glucose 150-200 until DKA resolution
- BMP, VBG q2-4h
- cross cover IV insulin x2h when patient tolerating PO, initiate SC insulin regimen
-- SC insulin 0.5-0.8 unit/kg daily in insulin-naive patient
Bicarbonate
- pH <6.9
-- dilute NaHCO3 (100mmol) in 400 mL H2O with 20mEq KCl and infuse over 2h; repeat until pH >7
- pH >6.9; no need for bicarb repletion
- BMP, VBG q2h
DKA Work up
- # DKA
BG _ on admission, with history of _poorly/well controlled DM. @@@
Last A1C _%. @@@
Home medication regimen: _
Symptoms: _ @@@ (polyuria, polydipsia, nausea, vomiting, abdominal pain)
Inciting factor: _ @@@ (infection, ischemia/infarction, intraabdominal process, medication adherence, drug use)
- ABG: pH _, CO2 _, O2 _, AGAP _
- Urinalysis _
- B-hydroxybutyrate _
- Labs: CBC, CMP, Mag, Phos, HgbA1C, Lipase
- Ischemic: ECG _ , Troponin _
- Infectious: blood cultures, urine culture - Urine toxicology _
- DKA
Type _ DM
Patient denied any localizing infectious symptoms. Endorses compliance to medications at home. No chest pain or trop elevation to suggest MI. No EtOH use. Currently hemodynamically stable without respiratory distress. pH _, Beta OH _
- Fluids: D10 1/2NS @ 175cc/hr
- Insulin: insulin gtt 5U/hr
- K: fluids with 40mEq K
- Acidosis: pH 7.15, no indication for bicarb
- NPO
- F/u A1C
- BMP, Mg, Phos Q4hr
- Trend VBG
- f/u UDS
DNR Discussion
- Date of discussion:
If patient/family non-English speaking:
Language used:
Interpretation by:
Patient location:
Relevant diagnoses and complications:
Prognosis:
Expected outcome of resuscitation:
Participants:
Patient:
[ ] Yes
[ ] No
Primary providers conducting discussion:
1.
2.
Family member(s) or surrogate decision maker (name and relationship to patient if present):
1.
2.
Patient's mental status and decision-making capacity:
[ ] Alert and oriented with capacity
[ ] Alert and oriented but defers decision making to surrogate decision maker or family (name & relationship):
[ ] Patient lack capacity, decision making with surrogate decision maker or family (name & relationship):
Decision made regarding resuscitative and life-prolonging measures in the event of cardiac or pulmonary arrest by:
[ ] Patient
[ ] Surrogate decision
Code Status:
[ ] Full code
[ ] DNR/DNI: Patient or surrogate decision-maker, after consideration of risks and benefits of resuscitation, decline any attempts at instituting all measures of resuscitation, including but not limited to CPR, DC countershock, intubation, or pressors, so as to allow natural death. All other therapeutics to be continued unless otherwise stated in the Advanced Directive or Individual Healthcare Instructions.
Additional instructions:
Death Note james
- Notified by the nurse that the patient was unresponsive and asystolic at approximately _ on _. Pt is DNR/DNI on comfort care.
Patient seen and examined at approximately _ on _. Patient was unresponsive to painful stimulation.
Heart and lung sounds are absent. No spontaneous cardiac or respiratory activity. Patient is not responding/nonreactive to verbal or painful stimuli. No corneal pupillary reflex present. Pupils fixed and dilated. Patient was pronounced dead at _ on _. Cause of death: _.
Patient’s family and patient’s nurse were present in the patient’s room.
Spoke with family _. Condolences were provided to the patient’s family. One Legacy notified #_.
Death Summary
- Notified by the nurse that the patient was having pulseless electrical activity, which became asystole at approximately _ on _. Patient is a Do Not Resuscitate/Do Not Intubate and on comfort care. The patient was seen and examined at approximately _ on _. The patient was unresponsive to painful stimulation. Heart and lung sounds were absent. There was no evidence of spontaneous cardiac or respiratory activity. The patient was not responding and was non-reactive to verbal or painful stimuli. No corneal pupillary reflex was present. Pupils were fixed and dilated. The patient was pronounced dead at _ on _. The cause of death was _.
The patient's family and the patient's nurse were present in the patient's room. I spoke with family members _ and gave my condolences. One Legacy was notified: #_.
Decompensated Cirrhosis
- #Decompensated Cirrhosis
CHILD Class C
MELD 25
R Factor c/w cholestatic pattern
Maddrey DF score: 15 (<32- likely would not benefit from tx with glucocorticoids)
Etiology: likely 2/2 etoh
New diagnosis, in setting of chronic etoh abuse. Exam findings with marked scleral icterus, diffusely jaundiced, protuberant abd c/w ascites, spider angiomas on face and chest. Mild transaminitis. Imaging with diffusely coarse internal liver echogenicity pattern and nodular liver surface suggestive of cirrhosis.
- HE: c/w lactulose 20gm BID (8/5 - ), titrate to 2-3 BM
- EV: needs screening EGD as OP. no s/s UGIB at this time
- Ascites: c/w Lasix 40 mg PO qDay & spironolactone 100mg qDay (8/5 - )
- SBP: no known history. Plan for paracentesis 8/5 for fluid analysis
- PVT: ordered CT A/P following unequivocal RUQ US findings. - f/u CT read
- HCC: f/u CT findings and AFP (ordered) will need RUQ US q6months as outpatient.
- Labs: f/u CMP, CBC (platelets), PT/INR
- f/u hep panel
- Consider further work up in undifferentiated cirrhosis (although presumably 2/2 chronic etoh use): ANA, Iron saturation, iron panel, ceruloplasmin (if <40), AMA, anti-SM, alpha-1 antitrypsin
- strict Is and Os, fluid rest 1.5L , low salt diet, avoid NSAIDS, shellfish, <2g Tylenol daily
Delirium
- Delirium
- Continue to evaluate and correct underlying the reason for delirium
- Precautions: frequent re-orientation, pain control, make hearing aids and eyeglasses available if the patient uses these at home, maintain a normal sleep-wake schedule, keep lights on during day and off during night, keep the television off, avoid overstimulation, avoid polypharmacy, avoid benzodiazepines, anti-cholinergic medications, and opioids if possible
- Start Haloperidol 5mg PO/IM/IV qAMHS. It is anticipated that this treatment will be for acute delirium and will not be necessary after symptoms are resolved.
- Recommend Haloperidol 2mg PO/IM/IV q2Hour PRN agitation in addition to standing medication. Do not exceed 30mg of Haloperidol in a 24 hour period (inclusive of scheduled and prn doses)
- Monitor QTc if using IV Haloperidol and discontinue for QTc >500 given risk of arrhythmia/Torsades de Pointe
- If unable to intervene safely, may use a 1:1 sitter, call code gold, give Haldol 5mg IM, Ativan 2mg IM, Benadryl 50mg IM Q4H PRN (if no contraindications), and use restraints as needed
- If antipsychotics are given, monitor for signs of extrapyramidal symptoms including acute dystonia (involuntary muscle contractions), akathisia (motor restlessness and inability to sit still), and Parkinson syndrome (psychomotor retardation, resting tremor, shuffling gait, cogwheel rigidity) as these can be potential side-effects of antipsychotic medication. If these become evident, may administer Benadryl 25mg q2Hrs as needed to control symptoms
- Hold antipsychotics if QTc >500 ms given risk of arrhythmias/Torsades de Pointe
- Delirium Risk Modification
- Avoid benzos/anticholinergics
- Manage urinary retention and constipation as above
- Ensure adequate PO hydration
- Frequent reorientation, family visitation
- OOB when possible
- Delirium
- Continue to evaluate and correct underlying the reason for delirium
- Precautions: frequent re-orientation, pain control, make hearing aids and eyeglasses available if the patient uses these at home, maintain a normal sleep-wake schedule, keep lights on during day and off during night, keep the television off, avoid overstimulation, avoid polypharmacy, avoid benzodiazepines, anti-cholinergic medications, and opioids if possible
- Start Haloperidol 5mg PO/IM/IV qAMHS. It is anticipated that this treatment will be for acute delirium and will not be necessary after symptoms are resolved.
- Recommend Haloperidol 2mg PO/IM/IV q2Hour PRN agitation in addition to standing medication. Do not exceed 30mg of Haloperidol in a 24 hour period (inclusive of scheduled and prn doses)
- Monitor QTc if using IV Haloperidol and discontinue for QTc >500 given risk of arrhythmia/Torsades de Pointe
- If unable to intervene safely, may use a 1:1 sitter, call code gold, give Haldol 5mg IM, Ativan 2mg IM, Benadryl 50mg IM Q4H PRN (if no contraindications), and use restraints as needed
- If antipsychotics are given, monitor for signs of extrapyramidal symptoms including acute dystonia (involuntary muscle contractions), akathisia (motor restlessness and inability to sit still), and Parkinson syndrome (psychomotor retardation, resting tremor, shuffling gait, cogwheel rigidity) as these can be potential side-effects of antipsychotic medication. If these become evident, may administer Benadryl 25mg q2Hrs as needed to control symptoms
- Hold antipsychotics if QTc >500 ms given risk of arrhythmias/Torsades de Pointe
- Patient is at increased risk given *** (age, co-morbidities, underlying cognitive impairment, hospitalization, ICU stay, recent surgery/anesthesia, acute pain, limited mobility, recent substance use, constipation, urinary retention).
- Please monitor closely for alcohol withdrawal.
- avoid anticholinergic agents
- re-orient patient daily
- early mobilization once safe primary service perspective
- minimize sedating agents, adequate pain control
- ensure good bowel regimen and hydration
- awake during the daytime and sleep at night
Delirium DDx
- Delirium:
DDx:
Metabolic: thyroid, adrenal, hepatic encephalopathy, porphyria, thiamine def, B12 def
Oxygen: derrangement (hypoxemic) or hypercarbic
Vascular: HTN emergency, Myocardial disease, CVA, SAH, SDH, EDH, TTP, DIC, HUS
Electrolytes: sodium, calcium, potassium, phosphate
Seizure: subclinical or post-ictal
Trauma or tumor
Uremic
Psychiatric
Infection: meningitis, encephalitis, UTI, pneumonia, soft tissue infection, sepsis
Drugs: meth, heroin, opioids, cholinergic, benzos, hypnotic, anti-histamines, ETOH, barbiturates, TCA, H2 blockers
Ethanol or illegal drug intoxication or withdrawl
Retention: urinary retention and constipation
Reduced Sensorium
Follow up:
UTox, CMP, Mg, Phos, Blood Cx, POC glc, TSH, B12, thiamine, ABG, UA, UCx, CXR
Non-con CT head, ECG, LP, EEG
MRI brain
- Manage underlying cause
- Avoid physical restraints
- Maximize sleep hygiene and minimize sedatives
- Wear corrective lenses and hearing aids if applicable
- Avoid cholinergic, opioids, benzos drugs
- Encourage family visits
- Reorientation to person, place and time at least 3 times daily
- Minimize unnecessary lines
- If severely agitated, consider chemical sedation: melatonin, seroquel, haldol, trazadone
Delirium Precautions
- - Avoid physical restraints
- Maximize sleep hygiene
- Minimize sedatives
- Encourage family visits
- Reorientation to person, place and time at least 3 times daily
- Minimize unnecessary lines
- Request window bed
Delirium Precautions/Prevention
- # Delirium Precautions/Prevention
Patient is at increased risk given @@@ age, co-morbidities, underlying cognitive impairment, hospitalization, ICU stay, recent surgery/anesthesia, acute pain, limited mobility, recent substance use, constipation, urinary retention).
- Avoid benzos/anticholinergic meds given risk for precipitation/exacerbation of delirium
- Control pain adequately
- CTM hydration status, si/sx of AWS and urinary retention
- Recommend frequent reorientation/reassurance and family at bedside if possible
- Minimize restraints, noxious stimuli or interventions, sedating agents if possible, unnecessary lines
- Recommend sitter at bedside
- Promote normal sleep-wake cycle with environmental cues (daylight, clocks etc), req window bed
- Reorientation to person, place and time at least 3 times daily
- OOB to chair 3x per day w/ meals, if safe
- PT/OT consult to get patient mobile and out of bed
Delirium Risk
- # delirium risk
Patient may be having a hypoactive type of delirium but when given a hearing aid she response appropriately. She may also be depressed
CAM=0. Awake, alert, oriented to person, place, time. At risk due to advance age, this hospitalization, infection, pain, abdominal distension
- Use hearing aid when communicating with the patient
- avoid benzos and anticholinergics
- control the pain adequately
- continue to treat the infection
- ensure adequate hydration
- aim for early mobility/passive movements
- promote sleep
- limit tethers
- encourage family visit/call and help with feeding
- keep bed by window
Denies Vaccine
-
Discussed the risks and benefits of the recommended vaccine(s) as per CDC guidelines. Patient understands the potential consequences may include: 1) Contracting the illness the vaccine should prevent (The outcomes of these illnesses may include but are not limited to one or more of the following: hospitalization, pneumonia, brain damage, meningitis, seizures, deafness, and death.) 2) transmitting the disease to others. Patient expressed an understanding that failure to follow the recommendations about vaccination may endanger the his/her health or life of others with whom he/she might come into contact.
- Will continue to discuss vaccine administration at future visits.
Diabetes Foot Exam Diabetes
- No foot lesions, no ulcers, no deformities, nails without onychomycosis, no callouses are present, no erythema or warmth. Dorsalis pedis pulses are /4, bilateral. Posterior tibial pulses are /4, bilateral. Varicosities are not observed. No pedal edema.
Touch, pin, vibratory and proprioception sensations are normal. Monofilament test normal.
Diabetes IP AP
- DM:
Home regimen:
Metformin, glipizide, empagliflozin, pioglitazone, exenatide
Glargine, Lispro, NPH, Regular
Hold home oral medication while inhouse
- POC glc checks ACHS q6
- LISS MISS HISS ACHS q6
- Glargine units QHS QAM
- Lispro units
- NPH and regular insulin
- Follow up HbA1c
- Diabetes Melitis II:
Wt:
Complications: PDR, DKD, DN
Home regimen:
Nutrition: CCD
IVF: none with dextrose
Steroids:
Recommendations:
- Hold home oral medication while inhouse
- Goal glucose inpatient: 100-180
- ISS ACHS while eating and q6 while NPO
- Insulin:
- Please let Endocrine service know if patient is to be taken to OR, steroids are switch or is made NPO
- Please page Endocrine on day of discharge to formulate an ambulatory regimen
- Would likely benefit from CGM at discharge
Diabetes OP AP
- Last HbA1c % on
- Labs ordered: HbA1c, BMP, microalbuminuria/Cr ratio.
- Diabetic foot exam today.
- Diabetic retinal scan scheduled.
- Continue insulin
- Continue MTF
- DM
_ (Goal <7.0%)
Last MACr:
Last diabetic foot exam:
Last teleretinal exam:
- F/u A1c, MACr
- Foot exam today
- Diabetic retinopathy screening
- Educate patient on lifestyle modifications including diet, exercise, and weight loss
- #Type _Diabetes Mellitus
_
Plan
-Following lab tests were ordered today: CBCD, HbA1c, CMP, Lipid profile, Urine Malb/Creat and TSH.
-Patient advised of proper dosage, precautions, and potential complications of medications prescribed.
-Counseled to stop smoking
-Referred for nutritional counseling and diabetes self-management education
-Patient advised to continue follow-up with PCP
-Patient advised to return to office in ____.
- _▼
[ST LAB HgA1C - Latest Result] (Goal <7.0%)
Last MACr:
Last diabetic foot exam:
Last teleretinal exam:
- F/u A1c, MACr
- Foot exam today
- Diabetic retinopathy screening
- Educate patient on lifestyle modifications including diet, exercise, and weight loss
- Assessment
Glycemic control (twice a year, if controlled): A1c 9.9% (2/2021) (goal <7%)
Nephropathy assessment (annually): eGFR , MACr
Retinopathy assessment (annually, if normal): Eye exam?
Neuropathy assessment (annually): Foot exam ?
MACE assessment: ASCVD 12% - high intensity
Vaccinations:
PPSV23 ??
HepB
Medication:
Specific indication for GLP-1 vs SGLT-2 vs DPP4
Metformin
glipizide 10mg daily ->BID
pioglitazone 30mg daily
ertuglifozin 15mg daily
metformin (intolerant)
Lifestyle modification:
Exercise (150 min/week moderate-intensity aerobic physical activity [50-70% maximal heart rate] and if appropriate resistance training 3x/week)
Diet (increased whole grains, reduce trans-fat and saturated fats, monitor carbohydrate intake, 14gm of dietary fiber/1000 kcal)
Weight reduction
Self-management/motivational interviewing
- DM
Last A1C _ on _. Goal_.
- Medications
(Metformin, SGLT2 Jardiance=Empaglliflozin, GLP1 semiglutide, ACE/ARB, Statin)
- Screening (annual):
- Retinopathy:
- Nephropathy (MaCr):
- Neuropathy (diabetic foot exam):
- Patient counseled on non-pharmacological intervention of diet and aerobic exercise, limit carbs, avoid sugar-sweetened beverages, portion control, daily foot exams
- Vaccines - pneumo23, Hep B screen/immunize
Diabetes Office Visit Clinic
- New Visit/Follow UP; Last seen: _
[Age] yo [Gender] with PMH:_ ; here for Diabetes Management.
At last visit: _
DIABETES HX:
Diagnosis: _
Symptoms at onset: _
Treatment Hx: Lifestyle_ Non insulin Agents_ Insulin since_
DKA/HHS: _
Family Hx:
Diabetes in
Hyperlipidemia in
HTN in
CAD in
Stroke in
Cancer in
Soc Hx: _
Occupation: _
Lives with: ?Spouse, ?Kids
[ST LAB HgA1C]
DIABETES MEDS:
Current meds: _
Prior meds: _
GLUCOSE MONITORING:
CGM/Glucometer_
.cgm_
DIET:
B:_
L:_
D:_
Snacks:_
EXERCISE/ACTIVITY:
Active/sedentary_
COMPLICATIONS:
-Retinopathy: Last eye exam: _
-Nephropathy: Sr Creat:_ Urine Microalbumin:_ Urine Creat:_ Urine Microalb/creat:_ on _; Meds:_
-Neuropathy: Present/Absent_; Meds:_
-Diabetes Foot Exam:_
-HTN/Cholesterol: Lipid panel:
[Lipids - Latest Result]
_ goal; Meds:_
-Last Dental exam: _
A&P
#Diabetes Mellitus: _
-.a1c_
-.BMI_
-Labs at diagnosis:
-Current Meds:
Complications:
Plan:
-_
-Patient advised of proper dosage, precautions, and potential complications of medications prescribed.
-Counseled to stop smoking
-Nutritional counseling and diabetes self-management education
-Follow up in clinic in _ months, with labs 1 week prior
.sn_
Diabetes ROS
- Denies polyphagia, polydipsia, polyuria, unintentional weight loss.
Diabetes at Goal
-
Blood glucoses and A1c at goal. Continue current regimen.
-
Blood glucoses and A1c at goal. Continue current regimen.
Diabetes hpi + ROS
- #Diabetes
A1c of ____ on [date]. Up / down from ___ on ___. Goal of < ____
Changes today:
Continue with:
- Not on Statin / on atorvastatin ____
- Not on ACE-inhibitor / on ACE-inhibitor (U Alb / Cr ratio of ____)
- Retinopathy screen on _____
- Diabetic foot exam_____
- ROS
- numbness/weakness, vision changes, chest pain, sob, pain in legs when walking, pus / wounds in feet, hyperglycemic sx (vision changes, ams/abd pain/n/v, polyuria/polydipsia), hypoglycemic sx (vision changes, dizzy/lightheaded, tremors, palpitations, sweatiness)
diet -
exercise -
med compliance -
Diabetes Clinic Note Template
-
This is a _ yo _M with h/o DM1/2_ diagnosed age _ (positive GAD65 Ab, low C-peptide) complicated by _(eye, neuro, kidney); also with (HTN/HLD/CAD/stroke/amputations/erectile dysfunction/OSA). Here for f/u of DM
- No_ interval ER visits or hospitalizations
- Polyuria, polydipsia, vision changes, dry feet, numbness/tingling: reports _
- LMP: _
Diet: (largest meal, #/day)
Snacks:
Exercise:
Smoking: non-smoker
Alcohol:
Work/living environment: (stable/homeless; kind of work – chefs graze at work)
Glucose Control:
He states his glucoses have been well controlled. No missed medication doses.
-Regimen:
Insulin:
Metformin:
Sulfonylureas ie glimepiride/glipizide:
Pioglitazone (caution if CHF, edema, osteoporosis), patient denies personal or family h/o bladder cancer
DPP4: Januvia(sitagliptin; dose decrease if CKD), patient denies personal or family h/o MEN/medullary thyroid cancer/pancreatitis
GLP1: Byetta or Bydureon weekly (exenatide; stop if GFR<30), Victoza daily (liraglutide), Trulicity weekly (dulaglutide), Ozempic weekly (semaglutide), patient denies personal or family h/o MEN/medullary thyroid cancer/pancreatitis
SGLT2: Jardiance (empagliflozin, stop if GFR<30), caution if h/o Fournier’s gangrene/amputations, hold dose if not eating or prior to surgery
-Hypoglycemia: reports no recent hypoglycemic episodes (if hypoglycemic, when and why? Any nighttime hypos?). Never fainted from hypoglycemia. No hypoglycemia unawareness.
Glucometer reviewed: -Frequency of BG monitoring & time of monitoring (pre-meal etc)
Average glucose:
Pre-breakfast:
Pre-lunch:
Pre-dinner:
Bedtime:
------------------------------
[ ] check weight/bmi
#. Diabetes Control and Treatment Plan
- Etiology:
- Complications:
- A1C/Glycemic control today:
- Medications: Continue metformin 1000 BID and _.
- Lifestyle modifications: Exercise 30 min 5x per week.
#. Co-morbidities/Screening
- Nephropathy: UMACR _. On _ACEi for BP control.
- Retinopathy: _ DR, last retinal photo _
- Neuropathy/Feet: No neuropathy or foot ulcers. Continue daily foot check and well-fitting shoes.
- Lipids: LDL _. On atorvastatin 40mg daily. Reports good compliance.
- Smoking status: Non-smoker
- BP Control: At goal < 140/90.
- Immunizations: s/p Pneumovax_, hepatitis B _, influenza_,
- Autoimmune screening (Type 1 DM): Anti-TTG IgA, IgA both negative for celiac disease screening, TSH normal _. CBC normal _.
Return to clinic: _
Patient's contact information: _
DWA Dr. _
Diabetic Ketoacidosis | DKA
- DKA
IV fluids
- severe hypovolemia: NS bolus
- mild hypovolemia: corrected Na _
-- low serum Na: NS 250-500cc/h until serum glucose <200 then D5-1/2NS
-- normal or high serum Na: 1/2NS 250-500cc/h until serum glucose <200 then D5-1/2NS
- BMP q2-4h
Potassium
- serum K <3.3, hold insulin give 20-40mEq/h until K >3.3
- serum K 3.3-5.3, give 20-30mEq per liter of fluid
- serum K >5.3, does not need K
- BMP q2h
Phosphorus
- PO4 <2.0mg/dL; give K3PO4 20-30mmol/L IVF; maintain PO4 >2.0
- PO4 >2.5mg/dL, monitor PO4 q2-4h
Insulin
- IV insulin gtt 0.1 unit/kg/h
- SC rapid acting insulin 0.3 unit/kg then 0.2 unit/kg one hour later followed by rapid acting insulin 0.2 unit/kg q2h
-- if serum glucose does not decrease 50-70 mg/dL after first hour, then double rate or give SC bolus
- when serum glucose <200, reduce insulin gtt to 0.02-0.05 units/kg/h or give SC insulin 0.1 unit/kg q2h; maintain serum glucose 150-200 until DKA resolution
- BMP, VBG q2-4h
- cross cover IV insulin x2h when patient tolerating PO, initiate SC insulin regimen
-- SC insulin 0.5-0.8 unit/kg daily in insulin-naive patient
Bicarbonate
- pH <6.9
-- dilute NaHCO3 (100mmol) in 400 mL H2O with 20mEq KCl and infuse over 2h; repeat until pH >7
- pH >6.9; no need for bicarb repletion
- BMP, VBG q2h
Diarrhea Assessment (LOW RISK)
- This patient presents with diarrhea consistent with likely viral enteritis. Doubt acute bacterial diarrhea. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Doubt antibiotic associated diarrhea.
- Plan: PO rehydration, reassess, discharge with OTC antidiarrheal meds//short course antibiotics
Diarrhea Assessment (LOW RISK)
- __[MDM](https://natedotphrase.com/tag/mdm/), [Uncategorized](https://natedotphrase.com/category/uncategorized/)__
- This patient presents with diarrhea consistent with likely viral enteritis. Doubt acute bacterial diarrhea. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Doubt antibiotic associated diarrhea.
- Plan: PO rehydration, reassess, discharge with OTC antidiarrheal meds//short course antibiotics
Diarrhea, Acute Assessment
- # Acute Diarrhea
- This patient presents with non bloody diarrhea consistent with likely viral enteritis. Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). No recent travel. Patient is not immunocompromised. Diarrhea is non bloody so less likely inflammatory bowel disease. Given history, I have low suspicion for giardia or other parasites. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis.
Discharge Instructions
- Notes > New Note > Discharge Instructions
- Must include the following:
- Brief Summary of Hospitalization
- Follow-up Instructions
- Medication Reconciliation
- Sign note
Discharge Instructions – PALPITATIONS
- You were seen today in the emergency department for palpitations. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms.
- You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist.
- Please return to the emergency department for chest pain, shortness of breath, lightheadedness or dizziness, or other symptoms that are concerning to you.
Discharge Note
- Notes tab > New Note > Discharge Note
- Add attending as co-signer
- Must include the following:
- Admission Dx
- Discharge Dx
- Procedures
- HPI
- Vitals
- Physical Exam
- Diagnostic Studies (i.e., labs, imaging)
- Hospital Course
- Medication Reconciliation
- Sign Note
Discharge Order
- Order > Delayed Orders > Discharge
- Complete Form
- Sign Order
- Notify patient’s nurse when both Discharge Order and Discharge Instructions have been signed
Discharge Summary
- Discharge summaries and Discharge instructions must be done on day of discharge, ideally.
- Click Discharge Summary tab > New Summary > Discharge Summary
- Select hospitalization
- Add attending as co-signer
- Paste Discharge Note
- After you finish the DC summary, DO NOT SIGN the note. Health Information has to verify the DC summary. After that, you will see a notification in your CPRS notification box that it is verified. You can call Freddie x5086 or Nelson x2312 M-F to expedite verification. After verification you need to edit the DC summary and sign it OR your attending will sign for you.
- If Admit order states observation status AND discharged in 48 hours then can write a Discharge NOTE instead of SUMMARY.
- Every patient must have a **Post Hospital Follow-Up**.
- Acute OR Chronic CHF needs to be addressed on dc instructions. Click “CHF is one of the patient’s Discharge diagnosis” box in the discharge instructions & fill out all required info. Also, address CHF treatment in DC summary.
- For new diagnoses, please enter them into CPRS under the Problem List tab.
Dispo
- numbness/weakness, vision changes, chest pain, sob, pain in legs when walking, pus / wounds in feet, hyperglycemic sx (vision changes, ams/abd pain/n/v, polyuria/polydipsia), hypoglycemic sx (vision changes, dizzy/lightheaded, tremors, palpitations, sweatiness)
diet -
exercise -
med compliance -
Documentation Houselessness|Homelessness
- I have provided a medical screening examination and evaluation.
- The patient is clinically stable for discharge. I have communicated post-discharge medical needs to the patient and the patient has been provided with or offered the following:
- Meal
- Weather appropriate clothing
- Prescription or adequate supply of medication from hospital outpatient pharmacy
- Referral to outpatient clinic for infectious disease screening
- Vaccines appropriate to the patient’s presenting medical condition
- Transportation has been arranged to patient’s post discharge destination.
# E
ED
- ED Course:
Vitals: T HR BP RR SpO2
Notable labs:
ED Fluids:
ABX:
Imaging:
- LABS: _
EKG: _(interpreted by me) NSR, no ST or T wave changes, normal intervals, normal axis, no evidence of brugada, long QT delta waves (WPW), epsilon waves (ARVD), HCM (dagger Q waves), _compared to prior
IMAGING: _CXR (interpreted by me) shows _no evidence of pneumothorax, consolidation, pericardial or pleural effusion, widened mediastinum, or fracture.
MDM: _
Discussed w/
Attending Dr. _
Shiva Barforoshi, PGY-1
Harbor-UCLA Medical Center
ED Course
- ED Course:
Vitals: T HR BP RR SpO2
Notable labs:
ED Fluids:
ABX:
Imaging:
Ear PE
- External tenderness
Swelling, lesions, drainage
Tympanic membrane – erythema, perforation, bulging, effusion
Ear canal – swelling, exudates, foreign body
Elevated LFTs
- # Elevated Liver Enzymes
Ddx includes infectious (hepatitis, HIV), etoh abuse, , cholecystitis, cholelithiasis, cholangitis, congestive hepatopathy.
-hep panel, HIV
-RUQ US
-trend LFTs
exposure hx
- Exposure History:
Birth:
Travel:
Animal exposure:
Immunosuppression:
Drug, toxin and supplement history:
Occupation:
End Stage Renal Disease | ESRD
- ESRD with HD /PD MWF TThS via LUE / RUE fistula / graft / TDC
- No emergent dialysis needs
- HD inhouse per nephrology
- Dialysis diet
- Renally dose medications
- Avoid blood draws and blood pressure checks on side of renal access
BMD
- Cholecalciferol
- Severlamer
- Phoslo
A/B and electrolytes
- Bicitra
Anemia
- EPO
-
ESRD
Schedule:
Access:
Adequacy: Acid-Base. Volume status
Anemia: Hgb goal 10-11
Blood Pressure: Goal < 140/90
MBD:
CV:
Diet: Recommend Dialysis Diet (2gm Na, 2gm K, 1.2 g proteing/kg/day)
Infection: Patient's with ESRD are effectively immunocompromised and may not display s/s of infection as immunocompetent individuals
Transplant:
# F
F
Fall
- Fall
L Hip Fracture
Mechanical in nature, no s/sx c/f syncopal event. No head trauma. Will require urgent orthopedic surgery.
- Ortho c/s, appreciate recs
- NPO after midnight
- SCD
- Risk assessment as below
- APAP 1000mg q8 ATC, oxycodone 5mg po q6hr prn, morphine 2mg IV q2hr prn breakthrough pain
Family Meeting
- Location:
Time of Meeting:
Diagnoses:
Current Complications:
Interpreter (if required):
Purpose:
__ Sharing Information
__ Goal setting
__ End of Life planning
__ Follow-up to prior meeting
__ Discharge planning
Participants:
Primary Team:
Palliative Care Team:
Other:
Family members present (names & relationship):
Summary of conference discussion:
The current medical information including test results, the various treatment options, risks/benefits/alternatives were reviewed. The family had an opportunity to ask questions.
How the patient’s wishes are known:
__ Expressed directly by patient
__ Advance Health Care Directive
__ POLST
__ Acting surrogate’s understanding of patient’s previous expressed wishes
Patient/Family Goals:
__ Continue all efforts to prolong life
__ Continue limited life-prolonging therapies, including:
__ Comfort focused care
__ Other
Decision Making:
__ Reached a consensus among clinical team, patient/family/decision maker
__ Unable to reach consensus among clinical team, patient/family/decision maker
__ Further decision-making pending clinical course, laboratory/study results
Disposition:
__ Continue current level of care
__ Transition to higher / lower level of care
__ Comfort Care Bed
__ Hospice in SNF
__ Hospice at home
Decision Maker:
Code Status:
Total time spent in family conference:
Additional Recommendations / Follow up meeting planned:
Follow Up Instructions
- 1) Please follow-up with your primary care doctor in the next few days. Please call today or tomorrow for an appointment..
2) If you have any worsening of symptoms or any other concerns please return to the ED immediately.
3) Please continue taking your home medications as directed.
-----
1) Haga una cita con su doctor cabacero en los próximos días. Por favor llame hoy o mañana para una cita.
2) Si tiene algún empeoramiento de los síntomas o cualquier otra inquietud, regrese al servicio de urgencias de inmediato.3) Continúe tomando sus medicamentos en el hogar según las indicaci
Full Physical Exam
- General: Well appearing, well nourished, in NAD. Ambulating without difficulty.
Skin: Good turgor, no rash, unusual bruising or prominent lesions.
Hair: Normal texture and distribution.
Nails: Normal color, no deformities.
HEENT:
Head: Normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring.
Eyes: Visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact, PERRL, fundi
have normal optic discs and vessels, no exudates or hemorrhages
Ears: EACs clear, TMs translucent & mobile, ossicles nl appearance, hearing intact.
Nose: No external lesions, mucosa non-inflamed, septum and turbinates normal
Mouth: Mucous membranes moist, no mucosal lesions.
Teeth/Gums: No obvious caries or periodontal disease. No gingival inflammation or significant
resorption.
Pharynx: Mucosa non-inflamed, no tonsillar hypertrophy or exudate
Neck: Supple, without lesions, bruits, or adenopathy, thyroid non-enlarged and non-tender
Heart: No cardiomegaly or thrills; regular rate and rhythm, no murmur or gallop
Lungs: Clear to auscultation and percussion
Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia
Back: Spine normal without deformity or tenderness, no CVA tenderness
Rectal: Normal sphincter tone, no hemorrhoids or masses palpable
Extremities: No amputations or deformities, cyanosis, edema or varicosities, peripheral pulses
intact
Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects,
tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal
strength or tone in the head, neck, spine, ribs, pelvis or extremities.
Neurologic: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTRs normal
in upper and lower extremities. No pathologic reflexes.
Psychiatric: Oriented X3, intact recent and remote memory, judgment and insight, normal mood
and affect.
Pelvic: Vagina and cervix without lesions or discharge. Uterus and adnexa/parametria nontender
without masses.
Breast: No nipple abnormality, dominant masses, tenderness to palpation, axillary or
supraclavicular adenopathy.
G/U: Penis circumcised without lesions, urethral meatus normal location without discharge, testes
and epididymides normal size without masses, scrotum without lesions.
# G
G
GDMT
- GDMT
- ACE-I/ARB/ARNI (NYHA II+, GFR >30) : GFR prohibitive
- cardioselective beta blocker (goal HR 50-60): consider re-starting once more volume optimized (home med is metoprolol succinate 75 mg daily)
- MRA (NYHA II+, GFR >30): GFR prohibitive
- SGLT2 inhibitor (NYHA II+, GFR>30): GFR prohibitive
GI Bleed
- #GI bleed
Hemodynamically _stable/unstable. Hgb _. BP _. Mental status _. Most likely 2/2 _UGIB/LGIB. History of _hematemesis/melena/BRPBC/hematochezia?. Rectal exam _. Risk factors: NSAID use, alcohol use, liver disease, prior GIB, trauma, malignancy, coagulopathy (ACCs), Prior EGD/Colonoscopy reports: _ Etiologies: - UGIB: esophageal varices, PUD, duodenal ulcer, mallory-Weiss tear, gastropathy, gastritis - LGIB: diverticuli, AVM, anal fissure, hemorrhoids, colon cancer
Workup:
- Gastroenterology consult, plan for EGD _
- Check H. pylori stool antigen
Management:
- Resuscitation: s/p _ NS, s/p _ units PRBC
- 2 large bore PIV placed
- type and screen
- NPO
- Trend H/H Q_H, transfuse Hgb < 7 or Hgb <9 if high risk
- Trend BMP, LFTs, PT/INR
- ECG/troponin if high risk
- IV Protonix 80mg IV bolus, then 40mg IV BID
- Ceftriaxone 1g Q24H x 5 days (if suspect esophageal varices/cirrhosis)
- Octreotide 100mcg bolus, then 50mcg/hr x 72 hours gtt (if suspect esogeal varices)
- Advanced therapies: TIPS/Balloon Tamponade
GI Bleed Upper and Lower
- Upper/ lower GI bleed:
Upper: Varices, Boerhaave, Mallory Weiss, PUD, AV malformation, esophageal/gastric malignancy, epistaxis
Lower: Colon malignancy, diverticulosis, aortoentericfistula, hemorrhoids, mesenteric ischemia, ischemic colitis, ulcerative colitis, Crohn’s, infectious colitis
Hemodynamic stability:
Volume status/ orthostatic:
Hgb:
Anticoagulation:
Plan:
Bilateral 18 g IV access
Type and cross
IV crystalloids bolus (@ least 2L)
IV PPI BID
Blood products
Orthostatic blood pressure
CBC with diff, INR, H Pylori testing, CMP, EKG
GI consult: endoscopy and colonoscopy
ICU: fankly hypotensive, ongoing massive bleeding, orthostatic
GI Bleed, Lower , Assessment
- This patient presents with symptoms concerning for a lower GI bleed. Differential diagnoses include diverticulosis (most common cause) versus hemorrhoids. Less likely etiologies include angiodysplasia, cancer, IBD. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena.
GI Bleed, Upper | UGIB
- This patient presents with symptoms concerning for an acute upper GI bleed. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaave’s syndrome. Presentation not consistent with other etiologies upper GI bleeding at this time. No red flag features or high risk bleeding. No evidence of hemorrhagic shock. Glasgow-Blatchford Bleeding (GBS) score: _. Based on this well validated study, the patient can safely be discharged for outpatient therapy_; is “high risk” for needing a medical intervention to include transfusion, endoscopy or surgery, so the patient was admitted. Patient received PPI, octreotide, ceftriaxone _.
Gallstones, Assessment
-
Patient presents with abdominal pain and ultrasound demonstrates visible gallstones. Given exam and history, suspect likely uncomplicated_ biliary colic. Patient is afebrile without overt thickening of the gallbladder wall, CBD dilation or pericholecystic fluid suggests the absence of acute cholecystitis or acute biliary obstruction. Patient is tolerating PO_ and suspicion for acute pancreatic involvement is low. After serial abdominal exams, history and observation, low suspicion at this time for other acute intraabdominal processes, including aortic aneurysm, atypical appendicitis, diverticulitis, or bowel obstruction. Given resolution of pain and no peritoneal signs on serial exams, will discharge patient home with general surgery follow up and strict return precautions.
Gastroenteritis - Assessnebt
- This patient presents with nausea, vomiting & diarrhea. Differential diagnosis includes possible acute gastroenteritis. Abdominal exam without peritoneal signs. Currently euvolemic without evidence of dehydration. Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). No recent travel. Patient is not immunocompromised. Diarrhea is non bloody so less likely inflammatory bowel disease. No evidence of surgical abdomen or other acute medical emergency including bowel obstruction, viscus perforation, vascular catastrophe, atypical appendicitis, acute cholecystitis, UGIB, thyrotoxicosis, or diverticulitis at this time. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. No indication for abdominal imaging.
Gastroenteritis, Acute
- # Acute gastroenteritis
Likely Food Poisoning@@@/viral.
No labs or stool studies needed.
Not dehydrated or unable to maintain PO intake.
- Reassured patient of self-limited course of disease.
- Supportive care.
- Explained importance of rehydration.
-RTC if fail to improve or worsen.
Gastroesophageal Reflux Disease | GERD, Assessment
- -s/p Nissen fundoplication 2003
-not requiring PPI at this time
Geriatrics A/p
- Medical Problems:
Pre-op Optimization.
RCRI of 1 suggesting 6% risk of MACE. Patient is currently asymptomatic without active cardiopulmonary symptoms. She had reasonable exercise tolerance prior to her hospitalization. Chronic medical conditions are well controlled.
- no further optimization required prior to surgery
- L proximal humerus fx, L periprosthetic distal femur fx
- NWB LLE in KI
- NWB LUE in sling
- NPO at midnight
- pain: tylenol 1000mg TID scheduled, oxycodone 5mg q4h prn and DC morphine 2mg IV q4h prn
- nausea: zofran prn, QTC normal
- bowel reg: miralax BID scheduled, senna qnightly scheduled, bisacodyl suppository prn for constipation
- PT/OT post operatively
- Hyponatremia
Stable. Likely hypovolemic hyponatremia given poor PO intake. Although has a history of SIADH.
- encourage PO intake
- urine studies pending
- Subclinical hypothyroidism
No definitive treatment needed for TSH 4.5-10
-ctm outpatient
- HTN
Normotensive here
- hold home amlodipine in setting of possible orthostatic hypotension
- Osteoporosis
Hx compression fractures/rib fractures/hip fracture
Patient with numerous fragility fractures. Previously on alendronate however stopped taking it due to constipation. On home vit D/alendronate ca/vit D 500-200 BID, vitamin D level 30
-continue higher dose vit D 2000 units daily
-patient will need outpatient baseline DEXA, patient can consider alendronate with appropriate bowel reg vs starting zoledronic acid if intolerant to alendronate
- Geriatric Syndromes/Problems:
At Risk for Falls
Frailty
Patient with multiple mechanical falls. No history of syncope, seizures.
-Follow up Vit D level and supplementation as above
-orthostatic vital signs when able
-PT/OT post operatively
- Dementia/Cognitive
MiniCog 2. History of 3 years progressive memory deficits. Able to do ADLs however needing assistance with most IADLs. No history of dementia.
-Labs for reversible causes of dementia: B12, folate, RPR normal
At risk for delirium
-delirium precautions
-encourage family visitation
-pain, bowel reg as above
-maintain hydration: 500cc NS to be net even to net positive
-cont melatonin 5mg qnightly for sleep, increase trazodone to 25 mg po qhs
At risk for pressure ulcers
-turning when able q2h
Pertinent patient info
- PCP Allison Wang 3234091000 USC PC EAST
- Insurance medical health net
- Spokesperson daughter Alejandra 626-833-8024 or granddaughter 626-430-0852
Outpatient follow up needed
- subclinical hypothyroidism- repeat thyroid studies in 3 months
- orthopedic followup
- PCP followup
- outpatient dexa for follow up of osteporosis
SUMMARY OF RECOMMENDATIONS:
1. No further optimization needed. Patient may proceed with surgery.
Thank you for allowing us to participate in this patient’s care. Please call us at p0840 with any questions or comments.
For urgent issues after 8 pm to 8 am call 310-501-1325
Geriatrics Assessment
- GERIATRIC ASSESSMENT:
Primary Care Physician: N/A
Insurance: () Medicare ()Medi-Cal (_)Other
Hospital Patient Safety:
Delirium: CAM 0/5
Cognitive: MiniCog 5/5
Age-related Medication Issues:
Incontinence: ( )Yes ()No
Skin Evaluation: ( )Yes () No Pressure Ulcer(s)
History of Falls (see below): ( )Yes ( ) No
Mobility/Falls:
Vision Problems:
Hearing Evaluation:
Assistive Device:
Fear of Falling: ( )Yes ( ) No
Fallen in past year: ( ) Yes () No
Function:
Basic Activities of Daily Living (ADLs) 6/6
Instrumental Activities of Daily Living (IADLs) 8/8
Medication Management : () Self ( ) Other, before most recent admission
Life Expectancy (ePrognosis.ucsf.edu): Risk of 1 year mortality (95% CI) of 4%
Psychosocial & Advance Care Planning:
Mood: PHQ-2 (Positive Screen >=1): N/A
PHQ-9: N/A
Medical Decisions: () Self ( ) Other
Caregiver(s): N/A
Medical Durable Power of Attorney: N/A
Advance Directive: No
Preferences:
( ) POLST
( ) DNR/DNI
() Full Code
Geriatrics Note New
- Geriatric Consultation Initial Consult Note
Primary Service:
Attending Requesting Consult:
Geriatrics Attending:
Primary Care Physician:
Reason for Consultation: Medical comanagement
HPI
PMH:
Meds:
Inpatient meds:
Allg:
Surg:
SH:
EtOH:
Smoking:
Drugs:
Language: Spanish Country of Origin:
Level of education/Literacy:
Occupation:
Lives with: daughter Lives where:
Family/Children/Social Support:
- Geriatric Consultation Initial Consult Note
Primary Service:
Attending Requesting Consult:
Geriatrics Attending:
Primary Care Physician:
Phone No.:
Reason for Consultation: HPI
ROS: //allergies none //meds-home: //meds-inpatient:
PMH:
SH:
See also Geriatric Assessment below. EtOH:
Smoking: Drugs: Language: Country of Origin:
Level of education/Literacy: Occupation: (before retiring) Lives with: Lives where: (type of housing, ?renting, steps/stairs)
Family/Children/Social Support: PE: Vitals://vitals_ Ht: _ Wt: _ BMI: _ Gen: (_) Temporal wasting HEENT: Neck: Pulm: Cardiac: Abd: GU/Rectal:
MSK: Skin: Neuro: Mental Status: Orthostatic blood pressure: _ Gait: _ Balance: _ Neuromuscular: (_) Cogwheeling (_)Rigidity (_) Tremor NONE
LABS & STUDIES: //labs-fishbone_ //LABLiverFunctionPanel_ //LABUrinalysis_ //PVRthisvisit_ //XR Chest _ GERIATRIC ASSESSMENT: Primary Care Physician:_ Tel/Fax:_ Insurance: (_) Medicare (_)Medi-Cal (_)Other Hospital Patient Safety: Delirium: Confusion Assessment Method: _/5 (Positive Screen >= 4/5) Cognitive: Mini-Cog_ (Positive Screen 0-2), or AD8 Interview_ (Positive Screen >= 2); MoCA= ; RUDAS= Age & Weight Adjusted GFR (Cockcroft-Gault): Age-related Medication Issues: Incontinence: (_)Yes (_)No Skin Evaluation: (_)Yes (_) No Pressure Ulcer(s) History of Falls (see below): (_)Yes (_) No Mobility/Falls: Vision Problems: Hearing Evaluation: Right Left Assistive Device: Fear of Falling: (_)Yes (_) No Fallen in past year: (_)Yes, Circumstance:_ Function: Basic Activities of Daily Living (ADLs) _/6 Needs help with:_ Instrumental Activities of Daily Living (IADLs) _/8 Needs help with: _ Medication Management : (_) Self (_) Other _ Life Expectancy (ePrognosis.ucsf.edu): _
Psychosocial & Advance Care Planning: Mood: PHQ-2 _ (Positive Screen >=1) PHQ-9 _ (1-4 min depression; 10-14 moderate depression; 20-27 severe depression) Medical Decisions: (_) Self (_) Other _ Spokesperson/Relationship: _ Contact # _ Caregiver(s): _ Contact # _ Medical Durable Power of Attorney: (_) Yes _ Advance Directive: (_) Advance Care Planning Form Updated in ORCHID: (_) Yes Preferences: _ (_) POLST (_) DNR/DNI IMPRESSION: ( Your one-liner) Assessment and Plan: (Write and discuss all medical problems for trauma/surgical pts)
Geriatric Syndromes/Problems: #. eConsult to the Geriatrics Navigator for Community Services SUMMARY OF RECOMMENDATIONS: (keep brief and at the most 5 recs) 1.
2.
3.
4.
5. Thank you for allowing us to participate in this patient’s care. Please call us at p0840 with any questions or comments.
For urgent issues after 8 pm to 8 am call 310-501-1325
Goals of Care
-
I approached _ and introduced myself as the senior resident on the MICU team working along with Fellow Dr. _ and attending Dr. _.
I asked him about his current understanding of the patient’s disease process and he told me that he felt more comfortable on more oxygen but was told if he continued to need more and more oxygen he may need to have a breathing tube placed to help support his breathing.
I explained to him that given his increasing need for oxygen with high levels of noninvasive oxygenation. I explained that given he appears to be worsening given incrased oxygen requirements that there is a high likelihood that he will need intubation over the next 24 hours. I explained to him the risks and benefits as well as alternatives to this procedure and he agreed to intubation if it was felt to be necessary for him to improve.
I also discussed with him who he would like to make decisions for him if he were no longer able to make his own decisions and he states he would like his two children to share decision making.
Per family, patient valued _. Pt’s current care is not consistent with their values and goals. I recommended that we proceed with _.
I also discussed with him about goals of care if he were to clinically worsen and in the event that his heart would stop, he notes that he would like "everything done" to try and allow him to live longer even if that meant a prolonged ICU course, invasive lines and CPR. Family has decided on a time limited trial of _. I answered all questions and he requested that I contact his children to discuss our conversation and care plan. Patient and family were allowed space to think through these issues, I informed the family I would continue to update them.
Groin Check
-
Groin check completed at **. Pt well appearing in NAD and with stable vitals. R femoral access site well dressed without any appreciable hematoma/mass, overlying ecchymosis or erythema. No bruit on auscultation. Distal DP pulse 2+ with intact distal sensation and strength.
# H
H
HCM
- # HCM
- genetic testing as is AD (mutation in genes that primarily encode sarcomeric proteins), 1st deg relative screening and q1-2 yr EKG/TTE
- s/s: HF (DOE, fatigue) 2/2 diastolic dysfxn from abnormal LV filling & dynamic LVOT obstruction, arrhythmias (palpitations, syncope)
- can worsen during times of increased ventricular contractility (exercise) or w/ decreases in ventricular preload or afterload
- Afib common
- TTE w/ >15mm in any LV region, LVOT >50mmHg
- CMR clarifies the diagnosis
- risk stratification q1-2 yrs
- AHA HCM SCD Calculator: https://professional.heart.org/en/guidelines-and-statements/hcm-risk-calculator
- major risk factors for SCD: SCD in 1st deg relative or close relative <50, LV wall thickness >30mm, >1 episode syncope thought to be arrhythmic, LV apical aneurysm, LVEF <50%
- lifestyle mgmt: weight loss, avoid dehydration, excess eth intake, exposures that cause vasodilation/decr preload (sauna, hot tubs), mild-moderate intensity exercise
- tx: nonvasodilating BB (avoid coreg, labetalol, nebivolol) or verapamil/diltiazem, disopyramide (class IA antiarrythmic), diuresis only if dyspnea cannot be managed w/ other therapy
- surgery: septal myomectomy or catheter etoh septal ablation in evere obstr sx refractory to max medical therapy or resting LVOT 50mmHg or more
- Afib rate control and AC regardless of CHADSVASC - DOAC 1st line, warfarin 2nd line
- q1-2yr EKG, TTE and sooner if any change in clinical status
ejection-quality murmur best leard at LLSB w/ carotid upstroke, louder w/ standing and valsava (decreased preload) and softer w/ hand grip (increased afterload) and squatting/leg raise (increased preload)
HCM - murmur softer with increased preload (squatting, leg raise) and increased afterload (hand grip)
HFrEF
- # HFrEF 2/2/ ICM/NICM.
EF _%.
NYHA _.
Currently euvolemic/volume up (JVD, crackles on exam, LE edema).
Admit Wt_.
Today’s Wt_.
estimated dry Wt_.
Etiology:
if not xlear if NICM, needs cath vs nuc stress test.
Etiologies include:
med nonadherence, arrythmia, Chagas, valvular, thyroid disfunction, HIV, intoxication, induced, infectious, sarcoid. R/o renal or liver etiology.
- Diuretics: drig IV spot dosing with _, BMP q6hr
Preload: PO torsemide 40mg qday, spot dose if needed, goal net even
- BMP and magnesium labs 6 hrs after diuresis
- replete electrolytes as needed to Mg >2 and K >4
- Strict Is/Os, Daily weights
- fluid restriction <1L daily
- BB: EBM Pump: carvedilol 25mg BID ()carvedilol, metoprolol succinate, bisoprolol)
- Afterload reduction: lisinopril 10mg qday/ARB/ARNI (ISDN/HDL if poor renal function)
- Device: Medtronic ICD single chamber: ICD, BiV-ICD
- cardiac diet, sodium < 4g/day
- Adv therapes: LVAD/transplant vs not indicated
- F/u TSH, A1c, LFTs, Lipid panel, UTox, Resp panel, UTox, UA, Chagas antibody
- Consider starting empagliflozin on day of discharge
- lifestyle modifications:
diet, fluid restriction, weight loss, smoking cessation, restrict EtOH use, exercise
HFrEF Afterload Preload
- - preload:
- afterload:
- pump:
- MRA:
- SGLT-2:
- advanced therapies: none
HFrEF Clinic
- NYHA Class I
Volume assessment: Slightly overloaded
Diuretic: Lasix 40mg qday, increase to BID for 3 days
BB: metoprolol succinate 25mg qday
ACEI or ARNI: losartan 100mg qday
MRA: spironolactone 12.5mg qday
SGLT2: empa 12.5mg qday
Etiology: unclear, no history of ischemic eval but also h/o amphetamine use
Device: no current indication
HIV LAbs
- HIV Genotype:
CD4:
VL:
Toxo IgG:
HLA B5701:
G6PD:
HepA:
HepB: sAg ( ); sAb ( ); cAb ( )
Hep B status:
HepC:
CBC
CMP
HgA1c
Lipids: LDL
UA:
HOSPICE CERTIFICATION OF TERMINAL ILLNESS
- I certify that to the best of my medical knowledge this patient to be terminally ill with a life expectancy of 6 months or less if the illness runs its normal course.
Narrative Summary:
Explain the clinical findings that support the patient
Patient referred to hospice pharmacist for medication management per pharmacy protocol.
By signing, I confirm that I composed the narrative based on my review of the patient's medical record or, if applicable, examination of the patient.
Clinical findings were provided to the certifying physician.
HPI - denies ER
- Denies outside urgent care or emergency room visits. Denies outside hospitalizations.
HPI diabetes
- Fasting blood glucose range: _; pre-prandial glucoses: _; 2-hour post-prandial glucoses: _. _ hypoglycemic episodes.
HTN
- _▼
Today's BP:
Last BMP (yearly): Na+/K+ wnl
HTN
- BMP (annually):
End organ damage:
- CNS
- Cardiac
- ECG (baseline once)
- ECHO (if appropriate)
- Renal
- UA
Health maintenance
- # Healthcare Maintenance
Vaccines:
Covid:
HAV: travel, MSM, IVDU, chronic liver dz, clotting factor disorders
HBV: MSM / hi risk sex, contacts, IVDU, healthcare, HD patients, chronic liver, travel, diabetics 19-59
HPV: females initial 11-12, catch up 13-26 // males Initial 11-12, catchup 13-21, 22-26 MSM immunocompromised
Td/Tdap: Td booster every 10 years after initial series ; 1 dose pregnant
Shingrix: >45 y/o, c/i immuno def, preg, HIV cd4 <200
Pneumococcal 23 valent: >65, >19 w/ chronic dz / toxic habits
Pneumococal 13 valent: CSF leaks, cochlear implants, immunocompromised
Screening:
Breast Cancer: 50-74 biannual mammogram, 40-49 pt choice
Cervical Cancer: 21-65 pap q3years, >30 q5years w/ HPV cotest
Colon Cancer: >50 FIT QYear
Lung Cancer: 55-80, >30 pack year, current or quit <15 years, low dose ct Qyear
AAA: men 65-75 ever smoked, one time u/s
DEXA: 65 y/o women, no interval, consider younger / Sheffield website recs.
Diabetes: a1c q3year 40-70, younger if risk
Cholesterol: men >35, women >45 q5y or q3y
HIV: adults 15-65, no interval
HBV: high risk, one time screen
HCV: high risk, HD, 1945-65
Return to clinic: x
- Screening:
- Mammo (50-75): _
- Pap (21-65): _
- Colon Ca (50-75) via FIT: _
- DEXA (65): _
- HIV (15-65): _
- HCV (18-79): _
- Lung CA screening (50-80 with >20 PY; if actively smoking OR quit within past 15 years): Low res CT scan _
- AAA screening (65-75):
Immunizations
- Flu(yearly): _
- Shingrix 1, 2 (>50):_
- Tdap(every 10 years): _
- PPSV23: _
- PCV13 (if indicated): _
- COVID: _
Health Maintenance | P
- Health Maintenance:
Blood pressure screening:
Diabetes screening (>18):
Cholesterol screening (>18):
Breast cancer screening (50-75):
Cervical cancer screening (21-65 pap, 25+ HPV):
Colon cancer screening (45-75):
Lung cancer screening (50-80, 20pyr or w/n 15yrs):
AAA screening (65-75, smoking):
Immunizations/Serological testing:
- HIV:
- HAV:
- HBV:
- HCV:
- Zoster (>50):
- Tdap (q10yrs):
- Prevnar 20 (>18):
- HPV:
- COVID Vaccine:
Health
- Health Maintenance:
- Mammo (50-75):
- Pap (21-65):
- Colon Ca (50-75):
- DEXA (65):
- Zoster (>50):
- Tdap (q10yrs):
- PPSV23:
- PCV13:
- Hep B:
- Hep C:
- HPV:
- COVID Vaccine:
- Cancer/OP screening
Colon cancer (FIT):
Non-cancer screening
CVD
- HbA1c:
- BMI:
STI:
- RPR:
- HIV:
- HCV:
- Hep B:
Vaccines
z
- Cancer/OP screening
Colon cancer (FIT):
Non-cancer screening
CVD
- HbA1c:
- BMI:
STI:
- RPR:
- HIV:
- HCV:
- Hep B:
Vaccines
Heart Failure ROS
- Patient denies dyspnea on exertion, orthopena.
Heart Failure Out Patient
- Etiology: _
Ischemic eval: __▼
EF: _
NYHA class (recently) _▼
[Dialysis Last Weight]
Rhythm: _▼
Valves: _
Meds:
- BB: _
- ACEi/ARB/ARNI: _
- MRA (>II, <35%): _
- SGLT2i: _
- Iso/Hydral: _
Plan:
- _
Hypercalcemia
- #Hypercalcemia
Mild (10-12)/ Moderare (12-14)/ Severe (>14) Hypercalcemia:
weight loss, malignancy, nephrolithiasis, mental status changes, abdominal pain, pancreatitis, PUD, bone pain bedbound, QT shortening or weakness
Differential diagnosis: malignancy, hyperparathyroidism, hypervitaminosis D, PTHrp, lymphoma, granulomatous disease, immobilization, milk alkali, vitamin A toxicity, pheochromocytoma, hyperthyroidism, hypoadrenalism
Work up: Ionized Ca, CMP, Phos, Vit D25, UCr, UCa. Consider PTHrp, ACE, and parathyroid imaging
- Fluids
- Lasix
- Zolendronic acid/calcitonin/ denosumab
- Consider Endo consult
Elevated Liver Ezymes
- # elevated liver function tests
# hyperbilirubinemia
# elevated AST, ALT
# elevated Alk P
# elevated PT/INR
Differential: DILI, viral hepatitis, shock, fulminant liver failure, AIH, Alcoholic hepatitis (if AST,ALT<400), Biliary (extra vs intrahep), Cirrhosis, NASH/NAFLD, AFLD, A1AT, Hemochromatosis, Wilson's
Labs:
- CMP, PT/INR, GGT, Acetaminophen lvl, Hep panel, Ceruloplasmin, Copper lvl, Iron panel/Ferritin, Anti-Smooth Muscle, AAT, IgG, Hemolysis labs if indicated for bilirubin
Imaging (if indicated):
- RUQ US/Abdominal US, CT Liver, MRI Liver, MRCP
Plan:
- f/u labs
- f/u imaging
- GI consult
- trend CMP Q8-12H
Hyperlipidemia HLD
- HLD
Baseline Lipid panel (_/_/_): Chol _, HDL _, LDL _, TG _. Started on _ (_/_/_). Most recent lipid panel (_/_/_): Chol _, HDL _, LDL _, TG _.
- # Hyperlipidemia
Lipid Panel on ____:
Total Chol , LDL, HDL, Trig.
ASCVD RISK:
Trend:
Changes Today:
Continue With:
none
Hyperlipidemia - HLD, Assessment
- #HLD
LDL 73, goal <70
- cont pravastatin 20 mg, pt reports se's with higher intensity statins
- diet/increase exercise as tolerated
Hypertension - A/P
- For Children Aged 1–<13 yrs:
Normal BP: <90th percentile
Elevated BP: =90th percentile to <95th percentile or 120/80 mmHg to <95th percentile (whichever is lower)
Stage 1 HTN: =95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg (whichever is lower)
Stage 2 HTN: =95th percentile + 12 mmHg, or =140/90 mmHg (whichever is lower)
For Children Aged =13 yrs:
Normal BP: <120/<80 mmHg
Elevated BP: 120/<80 to 129/<80 mmHg
Stage 1 HTN: 130/80 to 139/89 mmHg
Stage 2 HTN: 140/90 mmHg
***Elevated BP***
BP measurement today in clinic meets criteria for Elevated BP diagnosis. ***Prior BP measurements x2 also consistent with this diagnosis. // Given that this is a first time BP measurement in this range, will proceed with close follow-up for repeat BP measurement, and lifestyle counseling.***
Date of first elevated BP: _
Dates of BP follow-up: _
Plan:
- Reviewed healthy lifestyle recommendations:
- (Younger) Nutrition and Exercise: 5-4-3-2-1 Go! (5 fruit and veggies, 4 glasses of water, 3 low-fat dairy items, < 2 hrs of screen time, and 1 hr or more of exercise)
- (Older) Nutrition and Exercise: Cutting out sweet drinks, fried/fast food, high glycemic snacks, 30-60 min cardiovascular exercise 5 days a week
- Labs/Imaging: None. (Will proceed with lab w/u after 12 months if no improvement)
- UA, BMP, lipid panel
- (< 6 yo or abnormal UA) RUS
- (Obese) HbA1c, LFTs, fasting lipids
- Could also consider: TSH, UDS, sleep study, CBC, fasting glucose
- Referrals:
- At 3rd visit: Order ABPM, referral to Nephro vs Cards
RTC: BP repeat in 6 months. Health check in 3 months.
***Stage 1 HTN***
BP measurement today in clinic meets criteria for Stage 1 HTN. ***Prior BP measurements x2 also consistent with this diagnosis. // Given that this is a first time BP measurement in this range, will proceed with close follow-up for repeat BP measurement, and lifestyle counseling.***
Date of first elevated BP: _
Dates of BP follow-up: _
Plan:
- Reviewed healthy lifestyle recommendations:
- (Younger) Nutrition and Exercise: 5-4-3-2-1 Go! (5 fruit and veggies, 4 glasses of water, 3 low-fat dairy items, < 2 hrs of screen time, and 1 hr or more of exercise)
- (Older) Nutrition and Exercise: Cutting out sweet drinks, fried/fast food, high glycemic snacks, 30-60 min cardiovascular exercise 5 days a week
- Labs/Imaging: None. (Will proceed with lab w/u after 2 wk and 3 months f/u if no improvement)
- UA, BMP, lipid panel
- (< 6 yo or abnormal UA) RUS
- (Obese) HbA1c, LFTs, fasting lipids
- Could also consider: TSH, UDS, sleep study, CBC, fasting glucose
- Referrals:
- At 3rd visit: Order ABPM, referral to Nephro vs Cards
RTC: BP repeat in 2 weeks. If no improvement, will follow-up again in 3 months.
***Stage 2 HTN***
BP measurement today in clinic meets criteria for Stage 2 HTN. ***Prior BP measurements x2 also consistent with this diagnosis. // Given that this is a first time BP measurement in this range, will proceed with close follow-up for repeat BP measurement, and lifestyle counseling.***
Date of first elevated BP: _
Dates of BP follow-up: _
Plan:
- Reviewed healthy lifestyle recommendations:
- (Younger) Nutrition and Exercise: 5-4-3-2-1 Go! (5 fruit and veggies, 4 glasses of water, 3 low-fat dairy items, < 2 hrs of screen time, and 1 hr or more of exercise)
- (Older) Nutrition and Exercise: Cutting out sweet drinks, fried/fast food, high glycemic snacks, 30-60 min cardiovascular exercise 5 days a week
- Labs/Imaging: None. (Will proceed with lab w/u after 1 wk if no improvement)
- UA, BMP, lipid panel
- (< 6 yo or abnormal UA) RUS
- (Obese) HbA1c, LFTs, fasting lipids
- Could also consider: TSH, UDS, sleep study, CBC, fasting glucose
Referrals:
- At 2rd visit: Order ABPM, referral to Nephro vs Cards
RTC: BP repeat in 1 week.
***Stage 2 HTN w/ Symptoms or > 30 pts above 95% or > 180/120***
BP measurement today in clinic meets criteria for Stage 2 HTN with severe features. Requires immediate stabilization and workup.
Plan:
Referred to ED directly from clinic
***Treatment Cheat Sheet***
Primary renal dx ? ACE/ARB
Renin-mediated ? ACE/ARB
Renovascular disFor Children Aged 1–<13 yrs:
Normal BP: <90th percentile
Elevated BP: =90th percentile to <95th percentile or 120/80 mmHg to <95th percentile (whichever is lower)
Stage 1 HTN: =95th percentile to <95th percentile + 12 mmHg, or 130/80 to 139/89 mmHg (whichever is lower)
Stage 2 HTN: =95th percentile + 12 mmHg, or =140/90 mmHg (whichever is lower)
For Children Aged =13 yrs:
Normal BP: <120/<80 mmHg
Elevated BP: 120/<80 to 129/<80 mmHg
Stage 1 HTN: 130/80 to 139/89 mmHg
Stage 2 HTN: 140/90 mmHg
***Elevated BP***
BP measurement today in clinic meets criteria for Elevated BP diagnosis. ***Prior BP measurements x2 also consistent with this diagnosis. // Given that this is a first time BP measurement in this range, will proceed with close follow-up for repeat BP measurement, and lifestyle counseling.***
Date of first elevated BP: _
Dates of BP follow-up: _
Plan:
- Reviewed healthy lifestyle recommendations:
- (Younger) Nutrition and Exercise: 5-4-3-2-1 Go! (5 fruit and veggies, 4 glasses of water, 3 low-fat dairy items, < 2 hrs of screen time, and 1 hr or more of exercise)
- (Older) Nutrition and Exercise: Cutting out sweet drinks, fried/fast food, high glycemic snacks, 30-60 min cardiovascular exercise 5 days a week
- Labs/Imaging: None. (Will proceed with lab w/u after 12 months if no improvement)
- UA, BMP, lipid panel
- (< 6 yo or abnormal UA) RUS
- (Obese) HbA1c, LFTs, fasting lipids
- Could also consider: TSH, UDS, sleep study, CBC, fasting glucose
- Referrals:
- At 3rd visit: Order ABPM, referral to Nephro vs Cards
RTC: BP repeat in 6 months. Health check in 3 months.
***Stage 1 HTN***
BP measurement today in clinic meets criteria for Stage 1 HTN. ***Prior BP measurements x2 also consistent with this diagnosis. // Given that this is a first time BP measurement in this range, will proceed with close follow-up for repeat BP measurement, and lifestyle counseling.***
Date of first elevated BP: _
Dates of BP follow-up: _
Plan:
- Reviewed healthy lifestyle recommendations:
- (Younger) Nutrition and Exercise: 5-4-3-2-1 Go! (5 fruit and veggies, 4 glasses of water, 3 low-fat dairy items, < 2 hrs of screen time, and 1 hr or more of exercise)
- (Older) Nutrition and Exercise: Cutting out sweet drinks, fried/fast food, high glycemic snacks, 30-60 min cardiovascular exercise 5 days a week
- Labs/Imaging: None. (Will proceed with lab w/u after 2 wk and 3 months f/u if no improvement)
- UA, BMP, lipid panel
- (< 6 yo or abnormal UA) RUS
- (Obese) HbA1c, LFTs, fasting lipids
- Could also consider: TSH, UDS, sleep study, CBC, fasting glucose
- Referrals:
- At 3rd visit: Order ABPM, referral to Nephro vs Cards
RTC: BP repeat in 2 weeks. If no improvement, will follow-up again in 3 months.
***Stage 2 HTN***
BP measurement today in clinic meets criteria for Stage 2 HTN. ***Prior BP measurements x2 also consistent with this diagnosis. // Given that this is a first time BP measurement in this range, will proceed with close follow-up for repeat BP measurement, and lifestyle counseling.***
Date of first elevated BP: _
Dates of BP follow-up: _
Plan:
- Reviewed healthy lifestyle recommendations:
- (Younger) Nutrition and Exercise: 5-4-3-2-1 Go! (5 fruit and veggies, 4 glasses of water, 3 low-fat dairy items, < 2 hrs of screen time, and 1 hr or more of exercise)
- (Older) Nutrition and Exercise: Cutting out sweet drinks, fried/fast food, high glycemic snacks, 30-60 min cardiovascular exercise 5 days a week
- Labs/Imaging: None. (Will proceed with lab w/u after 1 wk if no improvement)
- UA, BMP, lipid panel
- (< 6 yo or abnormal UA) RUS
- (Obese) HbA1c, LFTs, fasting lipids
- Could also consider: TSH, UDS, sleep study, CBC, fasting glucose
Referrals:
- At 2rd visit: Order ABPM, referral to Nephro vs Cards
RTC: BP repeat in 1 week.
***Stage 2 HTN w/ Symptoms or > 30 pts above 95% or > 180/120***
BP measurement today in clinic meets criteria for Stage 2 HTN with severe features. Requires immediate stabilization and workup.
Plan:
Referred to ED directly from clinic
***Treatment Cheat Sheet***
Primary renal dx ? ACE/ARB
Renin-mediated ? ACE/ARB
Renovascular disease ? AVOID ACE/ARB
Migraines ? BB, CCB
Asthma ? AVOID BB
Diabetes ? AVOID BBease ? AVOID ACE/ARB
Migraines ? BB, CCB
Asthma ? AVOID BB
Diabetes ? AVOID BB
Hypertension - OP - Plan
- #Hypertension
BP Today: [] BP range in office last three readings: [] BP at home: []
Changes Today:
Continue With:
Hyponatremia
- #hyponatremia
- possibly hypovolemic, patient has not been eating or drinking as much
- f/u serum osm, urine osm, urine sodium
Hyponatremia
- #Hyponatremia
Acute/chronic _. Last Na _ (<135 mmol/L). Baseline Na _. _ Symptomatic/Asymptomatic (visual changes, neurologic deficits, encephalopathy, seizures). Volume status _.
Etiologies of Hypoosmolar Hyponatremia (serum Osm < 285)
- Hypovolemic: loss of fluid (diarrhea, vomiting, diuretics/thiazides, burns)
- Euvolemic: SIADH, adrenal insufficiency, hypothyroidism, psychogenic polydipsia
- Hypervolemic: CHF, liver failure, renal failure
- Etiologies of SIADH (CNS, ectopic ADH/tumors, HIV, medications, pulmonary diseases, stress/pain)
Workup:
- Urine Osm _, Serum Osm _, Urine Na _, Urine K _
- TSH, am cortisol
Management:
- Hypovolemic: 0.9% NaCl
- SIADH: Fluid restrict (1-1.5L/day)
- Hypervolemic: Diuresis with IV Furosemide _mg Q6H
Hyponatremia
- #Hyponatremia
Acute/chronic _. Last Na _ (<135 mmol/L). Baseline Na _. _ Symptomatic/Asymptomatic (visual changes, neurologic deficits, encephalopathy, seizures). Volume status _. Etiologies of Hypoosmolar Hyponatremia (serum Osm < 285) - Hypovolemic: loss of fluid (diarrhea, vomiting, diuretics/thiazides, burns) - Euvolemic: SIADH, adrenal insufficiency, hypothyroidism, psychogenic polydipsia - Hypervolemic: CHF, liver failure, renal failure - Etiologies of SIADH (CNS, ectopic ADH/tumors, HIV, medications, pulmonary diseases, stress/pain)
Workup:
- Urine Osm _, Serum Osm _, Urine Na _, Urine K _
- TSH, am cortisol
Management:
- Hypovolemic: 0.9% NaCl
- SIADH: Fluid restrict (1-1.5L/day)
- Hypervolemic: Diuresis with IV Furosemide _mg Q6H
Hypoglycemia, Persistent
- # Persistent hypoglycemia
Differential:
Medications:
Labs: to be drawn at time of hypoglycemia (essentially fasting)
- Insulin lvl
- Proinsulin
- C-peptide
- Hypoglycemia panel
- Random cortisol
- TSH
- A1c
Treatment:
- D50 pushes
- consider Octreotide 50mcg subQ
- consider D10 1/2NS vs D10NS for refractory (if hyponatremia, corrected Na)
ICU Checklist
- ICU Checklist
[F] luids/Feeding:
[A] nalgesia:
[S] edation:
[T] hrombophylaxis:
[H] ead of Bead:
[U] lcer Ppx:
[G] lucose:
[S] BT:
[I] ndwelling lines:
[D] rugs/Antibiotics:
Code Status:
Family Contact:
ICU checklist
- ICU Checklist
Feeding: _
Analgesia: _
Sedation: _
Thromboprophylaxis: _
Head of bed elevated: Elevated 30 degrees
Ulcer prophylaxis: _
Glucose control: _
SBT: _
Bowel regimen: _
Indwelling lines: _
De-escalation of Abx: _
Skin: _
Code status: _
Contact: _
Incision and Drainage Procedure
-
Incision and Drainage Procedure Note
PRE-OP DIAGNOSIS: _
POST-OP DIAGNOSIS: Same
PROCEDURE: incision and drainage of abscess
Performing Physician: _
Supervising Physician (if applicable): _
PROCEDURE:
A timeout protocol was performed prior to initiating the procedure. The area was prepared and draped in the usual, sterile manner. The site was anesthetized with _% lidocaine with epinephrine. A linear incision along the local skin lines was made and the purulent material expressed. The abcess was explored thoroughly and sequestered pockets were opened. Bleeding was minimal.
Packing: _
Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.
Inpatient Subjective
- NAEON. Afebrile, VSS.
- Patient denies any new or worsening symptoms, denies CP, SOB, fevers, chills, N/V, abdominal pain.
- Having BMs and urinating w/o difficulties. Tolerating PO intake.
Instructions Follow Up
- We have requested a follow-up appointment for you with your primary care doctor/clinic within 2 weeks by phone. Please watch for any calls or mail regarding this appointment. If you do not hear back within 3-5 days, please call 424-306-6500 for assistance.
You have an upcoming appointment with _ scheduled for _. Please ensure you make this appointment.
Hemos solicitado una cita de seguimiento para usted con su médico/clínica de atención primaria dentro de 2 semanas por teléfono. Esté atento a cualquier llamada o correo con respecto a esta cita. Si no recibe respuesta dentro de 3 a 5 días, llame al 424-306-6500 para obtener ayuda.
Tiene una próxima cita con _ programada para _. Por favor asegúrese de hacer esta cita.
# J
Joint Pain HPI
- -one joint or multiple joints?
- >20 mins of morning stiffness?
- change throughout the day?
- rashes?
# K
Knee Pain (+), Assessment
- __[MDM](https://natedotphrase.com/tag/mdm/)__
- LOW RISK
- This *** patient presents with knee pain, suspicious for ***. Able to flex and extend although somewhat limited by pain. Considered, but doubt, tibial plateau fracture, septic arthritis, other acute unstable fracture, or significant neurovascular compromise.
- Plan: XR, pain control, reassessment
- HI RISK – Tibial Plateau
- This *** patient presents with knee pain suspicious for a tibial plateau fracture given history, exam, and mechanism. No e/o compartment syndrome, septic arthritis, other acute fracture. Range of motion is ***. Will get plain films, consider CT, likely ortho consultation, pain control, NWB.
- PEARLS:
- Knee EXTENSION is an extremely important motor finding to document. Inability to extend is a key indicator of serious pathology.
- In peds, follow the medial tibial diaphysis up to the epiphysis – it should be smooth all the way. A bump should make you suspicious for a buckle fracture; it’s frequently missed by radiology.
- Proximal fibular fractures are associated with a peroneal nerve injury (you should document its status)
- Tibial plateau fractures are high risk for compartment syndrome.
- Tibial spine fractures are a) associated with ACL tears and b) often missed unless you order a **tunnel view** plain film.
# L
Labs Reviewed
- Labs, imaging, and other diagnostics reviewed.
Laceration Repair, Assessment
- Wound inspected under direct bright light with good visualization. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. No overt foreign body. Area hemostatic. Neurovascular exam congruent with above. Area extensively irrigated with sterile normal saline under pressure. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Patient tolerated procedure well and neurovascular exam intact and unchanged post repair with intact distal pulses and cap refill_. Cautious return precautions discussed w/ full understanding. Wound care discussed. Prompt follow up with primary care physician discussed and return for suture removal.
Lumbar Puncture
- Lumbar Puncture Procedure Note
A time-out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask with protective eyewear, sterile gown and sterile gloves throughout the procedure. The patient was placed in the _ position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion using betadine scrub. Anesthesia was achieved with 1% lidocaine. A 20-gauge 3.5-inch spinal needle was placed in the _ lumbar interspace. On the _ attempt, _ colored cerebral spinal fluid was obtained. The opening pressure was _ cm H20. CSF was collected into 4 tubes. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. A sterile bandaid was placed over the puncture site. The patient tolerated the procedure well.
Estimated blood loss was _.
Complications: None
# M
METs
- Functional status/capacity:
1 MET: care for self, dress self, use toilet
4 METS: can walk up flight of steps or hill, walk on ground leve at 3-4 mpH
4-10 METS: can do heavy work around house (scrubbing floors, lifting/moving furniture, climbing 2 flights of stairs)
> 10 METs: can do strenuous sports (swimming, singles tennis, football, basketball, skiing)
MSK
- Inspection: No asymmetry of shoulders or muscle atrophy
Palpation: Tenderness to palpation of Right superior trapezius and deltoid
ROM:
No tenderness to palpation over biceps tendon
Positive empty can test on Right
Unable to reach R arm behind back
Pain with R arm above 50 degrees flexion/extension, pain above 90 degrees lateral abduction
Difficulty adducting R arm slowly against gravity
R elbow/wrist ROM wnl
Pulse: 2+ Radial pulse
Sensation: decreased sensation in R hand 3rd/4th/5th digits
Strength: 3/5 motor strength R shoulder, 5/5 motor strength intact R bicep/tricep/wrist
Spurling maneuver did not reproduce the pain
No C-spine or paraspinal muscle tenderness
Old surgical scar to medial Right bicep from lipoma removal
L arm wnl
Medication Reconciliation
- Do your med rec early so that it can be verified and placed on the instructions. The VA team pharmacist is responsible for medication reconciliation for all patients at the time of discharge.
- Review Inpatient and Outpatient medications
- Add new inpatient medication(s) to outpatient medications if you are continuing the patient on the medication upon discharge.
- Click Medications Tab > Click on the medication under the Inpatient Medication list > Click Actions > Click Transfer to Outpatient
- Provide a 30-day supply with no refills
- Discontinue any outpatient medications you have changed or no longer want the patient to take
- Click Medications Tab > Click on the medication under the outpatient or Non-VA Medications list > Right Click > Discontinue
- Notify Team Pharmacist that you have completed the medication reconciliation
- Pharmacist to write note
- Copy and paste Medication Reconciliation portion of Pharmacist’s note onto the Discharge Instruction, Discharge Note, and Discharge Summary
Microcytic Anemia AP
- # Microcytic anemia
Hgb to 7.1 on admission, MCV 66.
No evidence of bleeding.
- f/u iron panel, ferritin
- transfuse for Hgb <7.0
- CTM CBC q12hrs
# N
NSTEMI
- Patient presented with chest pain concerning for ACS, EKG was non STEMI, however troponin was elevated concerning for NSTEMI, and the patient was given aspirin and started on heparin, pain was controlled with _, cardiology was consulted and patient was admitted. Patient with no signs of heart failure. Given history and story considered but low risk for aortic dissection, pneumonia, or PE.
Volume overload
NSTEMI
- NSTEMI
Presented with chest pain _ (duration _; type _; brought on by _; prior chest pain _). Troponin _. EKG _
- Admit to C team
- Aspirin
- Atovastatin
- Lovenox 1mg/kg BID vs heparin drip ( decide based on when would he go to cath? ESSENCE trial says Lovenox reduces death, MI, recurrent angina at 14 days compared to heparin in UA/NSTEMI)
- Clear liquid diet
- control chest pain (consider nitro tabs or nitro drip if uncontrolled, morphine, consider metop 25 BID)
- cardiac catheterization: _
- trend trop/EKG q6hr
- NSTEMI
Patient presented with constant/worsening chest pain since AM, associated with nausea/diaphoresis/dizziness/SOB. Hx/no hx of ACS. Prior cath in (month/year) with (findings). Troponins were _____ and _____ . Ekg with ______. Plan for heparinization and cath this admission.
- Antiplatelet: aspirin 81mg PO daily
- Afterload reduction: restart home (insert anti-hypertensive)
- B-blocker: coreg 6.25 mg PO BID
- Cholesterol: atorvastatin 80mg PO daily
- Lovenox 80mg BID, maintain for 48 hours.
- Continue trending troponin and ECG Q6H until peaks and downtrends x 2
- Plan for L heart cath (date); clear liquid diet at midnight prior to cath
NSTEMI
- #NSTEMI
Presented with chest pain _ (duration _; type _; brought on by _; prior chest pain _). Troponin _. EKG _
- Admit to C team
- Aspirin
- Atorvastatin
- Lovenox 1mg/kg BID vs heparin drip ( decide based on when would he go to cath? ESSENCE trial says Lovenox reduces death, MI, recurrent angina at 14 days compared to heparin in UA/NSTEMI)
- Clear liquid diet
- control chest pain (consider nitro tabs or nitro drip if uncontrolled, morphine, consider metop 25 BID)
- cardiac catheterization: _
- trend trop/EKG q6hr
Narcan
- Patient is at a risk for opioid overdose due to the following reasons (see checked box):
· [] CURES Report suggests an elevated overdose risk
· [] History of substance use disorder
· [] Concurrent Benzodiazepine and opiate use or benzodiazepine use within the past year
· [] History of using non prescribed opioids
· [] History of psychiatric illness
· [] Has comorbidities that may depress respiratory function (COPD, OSA, CHF, COPD, morbid obesity)
· [] Incarceration within the past year
· [] Has impaired renal or liver function
· [] Is of age > 65 years
· [] Is on opioid therapy which equals >50 MME
The patient was provided education regarding opioid overdose prevention, recognition, and Naloxone use via printed DHS Naloxone patient education material. Patient was advised to discuss the signs and symptoms of opioid overdose and use of Naloxone with a family member.
Nausea/Vomiting, Assessment
- This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. Considered but low risk for SBO (normal BM, passing flatus, no abdominal surgeries), no signs of DKA in labs. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. Low suspicion for gastric or esophageal dysmotility as cause_. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. Based on history, exam, and work up low suspicion for pancreatitis, appendicitis, biliary pathology, or other emergent problem. Patient given zofran and tolerated PO here. Patient to be discharged with zofran and to follow up with PMD.
Nephro
- - dialysis diet (1.2gm/kg protein, 2gm Na, 2gm K, and 800mg phos)
- strict I&Os, daily standing weights, 1L fluid restriction
- avoid nephrotoxic agents, renally dose medications
- no PICCs/PIVs/blood draws to LUE
Nephrotic Syndrome LAbs
- ds-DNA, cardiolipin panel, anti-beta2 glycoprotein 1 Ab, SPEP, UPEP, hepBsAg, HepBsAb, HepBcAb, HepCAb, 24 hour urine creatinine, 24 hour urine protein, microalbumin/creatinine ratio, HIV, RPR, Phopholipase A receptor antibody, C3, C4
Neuro Exam
- General: pleasant, NAD
HEENT: Atraumatic, no scleral icterus
Pulm: Normal WOB on RA
CV: RRR
Abd: soft, NT, ND
Ext: No LE edema
Skin: No rash
Mental status:
- Awake, alert, oriented to person, place, time, situation.
- Speech is clear and fluent with good repetition, comprehension, and naming.
- Spells MUNDO backwards. Registration 3/3, recall 3/3 at 5-minutes. Adequate fund of knowledge, vocabulary.
Cranial nerves:
CN II: VFF, PERRL
CN III, IV, VI: EOMI, no nystagmus
CN V: Facial sensation is intact to touch in all 3 divisions bilaterally.
CN VII: Face is symmetric with normal eye closure and smile.
CN VII: Hearing is normal to rubbing fingers
CN IX, X: Palate elevates symmetrically. Phonation is normal.
CN XI: Head turning and shoulder shrug are intact
CN XII: Tongue is midline with normal movements and no atrophy.
Motor: No pronator drift. Normal tone and bulk throughout.
Delt EF EE WF WE IO HF KF KE DF PF
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensory: Light touch intact throughout, no dysdiadokinesia
Reflexes:
Biceps Triceps BR Hoffmans Patella Achilles Toes
Right 2+ 2+ 2+ Negative 2+ 2+ Down
Left 2+ 2+ 2+ Negative 2+ 2+ Down
Coordination: FTN, H2S intact.
Gait/Stance: Slow steady casual gait. Deferred toe, heel, tandem.
No acute events overnight
- NAEO. Resting comfortably in bed.
Dispo pending
- No acute events overnight. Resting comfortably in bed. Stable for discharge, pending placement.
Normal Physical Exam
- General: no acute distress, answering questions appropriately
HEENT: MMM
CV: RRR, normal s1,s2, no m/g/r
Resp: clear to ausculation b/l, no w/r/r
Abd: soft, nontender, nondistended. normoactive bowel sounds.
Extremities: Warm extremities b/l. 2+ DP, PT, radial pulses b/l. No edema b/l
# O
O - PE Basic
- __[Physical Exam](https://natedotphrase.com/tag/physical-exam/)__
- GENERAL APPEARANCE: AxOx4, generally well-appearing ***M/F, no acute distress.
- HEENT: NC, AT. MMM. EOMI, clear conjunctiva, oropharynx clear.
- NECK: Supple without lymphadenopathy. No stiffness or restricted ROM.
- HEART: Normal rate and regular rhythm, normal S1/S1, no m/r/g
- LUNGS: CTAB, moving air well. No crackles or wheezes are heard.
- ABDOMEN: Soft, nontender, nondistended with good bowel sounds heard.
- BACK: No CVAT, no obvious deformity.
- EXTREMITIES: Without cyanosis, clubbing or edema.
- NEUROLOGICAL: Grossly nonfocal. Alert and oriented, moving all 4 extremities. CN not formally tested but appear grossly intact. Observed to ambulate with normal gait.
- Skin: Warm and dry without any rash
Obesity Counseling
- Counselling on 150 minutes of moderate cardiovascular exercise per week and portion control provided to patient today.
Optometrist Referral
- - Please go onlin to Vision Services | L.A. Care Health Plan (lacare.org) or call 800-877-7195 to find an Optometrist near your area
Ortho Trauma HPI
- smoker?
dominant hand?
occupation?
CHECK PULSES ON EXAM
CHECK ABOVE and BELOW AREA
# P
PECARN - Head, Assessment
- Patient is currently at baseline mental status and activity level per family. Patient does not have evidence of palpable skull fractures or step offs. Patient does not have an occipital, parietal or temporal hematoma. Denies LOC > 5 seconds. No signs of basilar skull injury including raccoon eyes, battle’s sign, CSF rhinorrhea or hemotympanum. No nasal hematoma. Denies vomiting or headache. Denies severe mechanism of injury.
MDMPEP
After extensive discussion with patient regarding PEP versus observation/follow up and risks and benefits of both, mutual decision making to provide first dose of PEP and follow up promptly with outpatient testing and further treatment as needed at this time per most recent CDC HIV PEP guidelines for unknown relatively high risk exposures_. Discussed that single dose of PEP is not a substitute for follow up and further care/evaluation. Discussed need for concurrent testing of other STI including, but not limited to, G/C and RPR. Discussed safe sex practices_. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
MDMPsych
Denies any ingestions and denies any other medical complaints. Does not endorse any alcohol withdrawal symptoms. Engages with conversation. Mood and affect are congruent. Thoughts are linear and organized, and has no AH or HI. Plan admit to psychiatry for further management of symptoms. Will consult psychiatry to evaluate Patient for potential hold for danger to self. Clinically no overt toxidrome, well appearing, low suspicion for ingestion given history and exam.
MDMRabies
_ with bat exposure who presents for immunoglobulin administration. Patient without obvious wound but given duration of exposure, high risk nature and possible incubation period (of up to 1-3 months), mutual decision making with patient re: R/B/A to give dose of RiG. Per most recent CDC/ACIP guidelines re: PEP for human rabies, patient with 1st of 4-dose rabies vaccination regimen prior to arrival (0, 3, 7, 14; HDCV or PCECV). Discussed need for subsequent doses. Patient without altered immune competence. No obvious inoculation wound, as such, will infiltrate weight based RIG IM_. Patient currently largely asymptomatic with non-focal exam with no symptoms of cerebral dysfunction, anxiety, confusion, agitation, delirium, abnormal behavior, hallucinations, and insomnia. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
MDMRenalColic
Patient presents with flank pain consistent with previous kidney stone pain. Patient otherwise well-appearing with low suspicion for sepsis, dissection or infected obstructed renal colic. US w/ mild hydronephrosis on affected side_. Low suspicion for atypical appendicitis, torsion, acute chole, or intraabdominal infection. Discussed conservative management, strict return precautions and follow up with urology. Will discharge with Flomax_, NSAIDs, opiates for breakthrough, strainer, and antiemetics. Patient tolerating PO and pain controlled prior to discharge. Strict return precautions for infected stone or PO intolerance discussed. Low suspicion for AKI, obstructive nephropathy given exam and history.
MDMSepticArthritis
Given exam and history, low suspicion for septic arthritis at this time given location of pain (not over knee joint but superior to area), subacute nature, and relative comfort to range of motion and axial loading. Nontoxic appearing and no overt systemic symptoms. Atraumatic with low suspicion for fracture or dislocation. No overt e/o necrotizing fasciitis. Given tenderness and area of erythema, will treat for cellulitis. Neurovascularly intact per routine as above with no overt e/o compartment syndrome.
After extensive discussion with patient and wife regarding observation and treatment of possible cellulitis versus arthrocentesis and risks (overlying cellulitis, lower pretest probability of septic arthritis, risk of inoculation of joint) and benefits of both, mutual decision making to trial antibiotics and not pursue further arthrocentesis at this time. Patient tolerating discomfort, continue to be at baseline and well appearing. As above, does not have signs of systemic symptoms or neurovascular compromise. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Family agreeing to bring patient back if any concern including if patient with increase in pain, inability to range or bear weight, or fevers.
MDMSyncopeFall
Patient presents after ground level fall, currently in c-spine precautions with likely LOC_. Unwitnessed fall, with unclear etiology, possible mechanical but cannot r/o syncope at this time. Patient without any prodromal symptoms with low suspicion at this time for ACS, dissection or malignant arrhythmia. Will check labs for electrolyte protuberances, will obtain CT brain and C-spine to evaluate for ICH as patient is anticoagulated_. Given history, low suspicion for ACS, but will obtain troponin and EKG for cardiac evaluation and reassess_. Currently at baseline mental status. No respiratory distress or hypoxia with low suspicion for massive PE at this time. Serial neurologic exams and monitor in interim.
MDMNeckSwelling
Patient otherwise healthy_, fully vaccinated_ with anterior neck swelling likely secondary to significant lymphadenopathy of limited duration with suspicion for likely viral etiology. BUS with visualization of LAD without frank abscess. Mild trismus on exam but no overt e/o PTA or RPA. No overt e/o deep space infection; nontoxic appearing and tolerating PO. Non-focal neuro exam with low suspicion for Lemierre’s. Vaccinated with low suspicion for mumps. Low suspicion for malignancy or goiter formation at this time given duration but discussed prompt follow up to reassess. Trial antibiotics_ and steroids_ with cautious return precautions discussed w/ full understanding. Airway fully patent.
MDMGERD
Patient presents with epigastric_ abdominal pain most likely secondary to dyspepsia or non-acute abdominal etiology. No peritoneal signs on abdominal exam. Patient’s symptoms near resolved with GI cocktail. Patient remains PO tolerant. Serial abdominal exam without increase in abdominal pain. Given exam and history, low suspicion for acute abdominal process, such as acute cholecystitis, pancreatitis, perforated viscus, atypical appendicitis or torsion. Extensive conversation about return precautions and need for follow-up.
MDMAllergicDermatitis
Patient with rash likely allergic or contact dermatitis in nature given history, temporal nature and appearance. No mucous membrane involvement with low suspicion for SJS/TEN. No wheezing or difficulty breathing with low suspicion for systemic involvement. Unclear trigger but discussed close monitoring for progression. Will prescribe single dose of steroid given extent of rash and hydrocortisone cream_. Cautious return precautions discussed w/ full understanding. No overt e/o superinfection. Prompt follow up with primary care physician discussed.
MDMApicalAbscessBlock
Patient with _ apical abscess over _lower right posterior molar presenting for pain control. Patient well appearing, no trismus or airway involvement. No systemic symptoms and no overt e/o deep space extension. Mutual decision making to perform inferior alveolar nerve block for temporary relief and continued control with short course of NSAIDs and opiates as outpatient_. Apical abscess I+D extended and small amount of pus expressed with decompression of lesion. Low cost dental resources given. Cautious return precautions discussed w/ full understanding.
MDMPEDSAppendicitisNoScan
Patient with abdominal pain and vomiting, now resolved_. No peritoneal signs with low suspicion for acute intraabdominal process including torsion, SBO, intussusception or atypical appendicitis. Serial abdominal exams throughout course without increase in pain or migration of pain. Tolerating PO in ED. US appendix inconclusive_. After extensive discussion with family regarding observation versus CT versus return for recheck in 8-12 hours if not resolved and risks and benefits of options, mutual decision making to return for recheck given relative improvement and well appearing child with alternative diagnoses (_) for fever and malaise and not pursue further workup at this time. Patient tolerating PO, continue to be at baseline and well appearing. As above, does not have signs of peritoneal involvement. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Family agreeing to bring patient back if any concern including if patient with recurrent vomiting, increase in abdominal pain, or altered behavior. Will discuss prompt follow up with PMD and strict return precautions discussed.
MDMBartholins
Patient with _ bartholin’s cyst infection with concurrent abscess formation. No overt evidence of fournier’s or deep space involvement. No systemic symptoms. Small medial incision made with copious drainage of pus. Insertion of word catheter to maintain tract and follow up with OB/GYN discussed. Wound care and return precautions discussed.
MDMBlackWidow
Patient with possible latrodectus envenomation to dominant hand_ several hours prior. Now with constellation of symptoms, potentially consistent with mild envenomation including diffuse pain in extremity. Hand with possible area of early cellulitis but no frank abscess formation. Will treat with doxy given allergy profile after conversation with pharmacist. Area of inoculation without local diaphoresis. No overt evidence of necrosis or abscess. No cardiothoracic symptoms, no peritoneal signs. At this time, will trial pain control and muscle relaxants. Will continue to monitor and will hold antivenom at this time. TDAP up to date.
MDMPEDSBurn
with no previous medical history presents brought in by parents for superficial scattered burns primarily to torso_ with minimal BSA involved. Burns superficial, consistent with history and given interaction observed between parents, low suspicion at this time for NAT. Parents and patient appropriate. Patient undressed fully without any suspicious lesions. Discussed wound care, pain control and follow up with PMD. Return precautions for superinfection. Patient at baseline currently without significant burns over scalp, face, groin or distal extremities. Cautious return precautions discussed w/ full understanding.
MDMPedsChestPainIngestion
with atypical chest discomfort and now resolved palpitations in the setting of Adderall_ use. No overt risk factors for early cardiac disease; no family history of early cardiac death. Patient well appearing, nontoxic. Low Wells score with low s/f PE; no overt hypoxia. Given history and exam, low suspicion for ACS, dissection, or pneumothorax. Discussed cessation of Adderall_ and follow up with PMD for further evaluation as needed. Cautious return precautions discussed w/ full understanding.
MDMChestPainLowRisk
with history of tobacco abuse, otherwise healthy, p/w atypical chest pain, subacute worsening of chronic pain. No overt risk factors for ACS and serial EKGs and troponins without overt e/o NSTEMI. Pain reproducible on exam with likely musculoskeletal component. Low Wells score with low risk for PE and no significant hypoxia_. Given chronicity, low s/f dissection. Pain controlled, well appearing. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
MDMChestPainNoTrop
p/w atypical chest pain, subacute onset of atypical chest pain. No overt risk factors for ACS aside from HLD_ and EKG w/o overt e/o acute ischemia. Pain reproducible on exam with likely musculoskeletal component. Low Wells score and PERC negative with low risk for PE and no significant hypoxia. Given duration, low s/f dissection. Pain controlled, well appearing. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
MDMChestPainObs
Patient presents with chest pain without signs of acute ischemia on ECG. Patient given aspirin and is currently chest pain free. Low Wells score with low risk for PE and no significant hypoxia_. Given exam and history, low suspicion for dissection. No ectopy noted on monitor and patient well appearing. Had conversation with pt at length regarding risks vs benefits of admission to obs for chest pain. Mutual decision making for patient to be admitted to obs, and agrees to workup. Low suspicion for overt ACS but given age and persistence of symptoms, plan to admit to obs for serial troponins, serial EKGs, and risk stratification as inpatient.
MDMCHF
with worsening shortness of breath over the past few weeks with constellation of symptoms concerning for possible CHF exacerbation. Patient not overtly hypoxic with minimal respiratory distress. No overt evidence of acute ischemia on EKG. Will trial nitroglycerin for afterload reduction, diuresis with strict I/O presuming no evidence of AKI or cardiorenal syndrome_. Trend troponin although low suspicion for acute ischemia given history and exam_. Low suspicion for acute PE given exam and history. Given decline in functional status, consider admission for diuresis and further cardiac evaluation_.
MDMClavicularFracture
Patient with L_ minimally displaced clavicular fracture after falling onto L side. Distally neurovascularly intact in extremities. No overt evidence of significant head trauma. Mentating well with non-focal neurologic exam. Placed in sling and adhesive capsulitis precautions discussed. Follow up with pediatric orthopedics. Return precautions.
MDMConcussion
presenting s/p minor head trauma with headache, lightheadedness, and nausea_. Given mechanism and nonfocal neurologic exam, low suspicion at this time for ICH or significant C-spine injury. Concussion care and precautions discussed. After extensive discussion with patient and family_ regarding observation versus CT and risks and benefits of both, mutual decision making to observe and not pursue further workup at this time. Patient tolerating PO, continue to be at baseline and well appearing. As above, does not have signs of altered mental status or basilar skull fracture. Patient with nonfocal neurologic exam and with low suspicion for overt ICH. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Family agreeing to bring patient back if any concern including if patient with recurrent vomiting or altered behavior.
MDMCornealAbrasion
presenting with 1 day of left eye pain_ after irritation yesterday. Patient is a contact lens-wearer. Visual acuity otherwise preserved. Given exam and history, no overt evidence of scleritis, purulent conversion, or corneal ulceration. Patient does however have small corneal abrasion, which will be treated with antibiotic eyedrops_. Patient to avoid wearing contacts in interim and prompt follow up with ophthalmology discussed.
MDMDentalFractures
Patient without overt maloccusion and given mechanism and history, low suspicion at this time for significant mandibular or maxillary fracture and will defer imaging at this time. Prompt follow up with plastics arranged and discussed. In regards to fractured dentition, likely Ellis II_, patient with access to dentist in 24 hours and after R/B/A discussed, patient deferred antibiotics and cementing of tooth which is reasonable given degree of fracture and prompt follow up. Strict return precautions discussed.
MDMDiplopiaBenign
with isolated episode of binocular_ diplopia now resolved with nonfocal neuro exam with low suspicion for TIA. Patient with minimal neurovascular/CVA risk factors and with prompt follow up with neurology already arranged. Low suspicion given exam and history for CNS or facial infection including meningitis or cavernous sinus thrombosis (no facial tenderness, ptosis and no limitation of CN III, IV, V, VI) , aneursym (no e/o CN III palsy, headache, no personal or family history). No e/o Horner’s syndrome or inflammatory process (i.e. GBS/MF, myasthenia, or temporal arteritis). Exam and history with no overt e/o monocular diplopia with low suspicion for acute media or refractive pathology, optic neuritis, or uveitis.
MDMElbowSprain
with elbow pain after fall. X-ray does not reveal any overt fractures. Discussed discharge instructions with patient and return precautions. Given sling for comfort and adhesive capsulitis precautions discussed. No overt e/o compartment syndrome or supracondylar fracture. Distally NVI per routine. Patient is well-appearing, in no apparent distress, and vital signs stable for discharge home. Return precautions for occult fracture and return for repeat imaging if needed discussed.
MDMFallMild
Patient with ground level fall _ without frank head trauma and non-focal neurologic exam. Patient with multiple abrasions but no lacerations requiring repair_. Affected areas inspected, irrigated and dressings applied. Wound care discussed. TDAP up to date. Patient initially with mild headache_, single episode of emesis_ without frank abdominal injury and shoulder pain, now resolved_. Given nonfocal exam and currently well appearing, query possible mild concussive symptoms_. As above, given mechanism and nonfocal neurologic exam, low suspicion at this time for ICH or significant C-spine injury. Concussion care and precautions discussed. After extensive discussion with patient and companion regarding observation versus CT and risks and benefits of both, mutual decision making to observe and not pursue further workup at this time. Patient tolerating PO, continue to be at baseline and well appearing. As above, does not have signs of altered mental status or basilar skull fracture. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Friend agreeing to bring patient back if any concern including if patient with recurrent vomiting or altered behavior.
MDMPEDSFussy
otherwise healthy, full term, brought in by parents for 1 day_ of increased fussiness. Afebrile, full term, currently well appearing, nontoxic. Given history and exam, low suspicion for serious bacterial infection including meningitis, pneumonia, UTI or bacteremia. Tolerating PO and appearing euvolemic with appropriate linear weight gain since birth. No meningismus, otherwise at baseline activity level with low suspicion for CNS infection. Patient wearing mittens_, no excessive tearing or redness, and without long nails with low suspicion for corneal abrasion. No overt evidence of NAT or hair tourniquets. No malignant rashes noted and improving diaper rash per parents on exam. Discussed strict return precautions for worsening of symptoms, increased respiratory effort, signs of CNS infection including but not limited to changes in mental status or vomiting, or fever. Discussed prompt follow up with primary pediatrician in 24-48 hours for recheck or return to ED sooner if concern or if cannot schedule appointment.
MDMGastroenteritis
presenting with 3 days_ of vomiting and diarrhea. Currently euvolemic without any abdominal tenderness or peritoneal signs. Nontoxic appearing; query possible gastroenteritis. Patient also with URI symptoms and a cough over past several days – suspect viral etiology and will low suspicion for pneumonia at this time_. Nausea control, rehydrate, serial abdominal exam, reassess. At this time, given initial history and exam, low suspicion for torsion, PID, atypical appendicitis or cholecystitis.
MDMHeadLac
not on anticoagulation_ with resultant laceration requiring simple repair. TDAP updated. NVI distally. Relatively clean wound, irrigated copiously and repaired in simple fashion with dermabond. No antibiotics indicated at this time. Given mechanism and nonfocal neurologic exam, low suspicion for ICH or significant c-spine injury. Discussed strict return precautions and wound care.
MDMHIVExposure
otherwise healthy with moderate risk HIV exposure (unprotected vaginal sex with HIV+ patient albeit with unclear last CD4 + VL)_. Extensive discussion with patient regarding risk of transmission in regards to Hep B/C, RPR, G/C and HIV and relative rates given source patient and mechanism. Patient declining vaginal exam to evaluate for tears at this time after risks discussed with full understanding and capacity. Discussed PEP at length with patients and after review of primary risks, benefits and alternative, given risk of transmission, mutual decision making to use PEP at this time. Discussed prompt follow up with clinic for bloodwork and serial serologies. Discussed at length regarding consensual nature of sex and patient does not feel that encounter was not consensual. Discussed that if patient changes mind, given STI treatment center resources. Patient contracts to safety and feels safe at home.
Given history, per CDC (2013) and NYSDOH (2014), patient not pregnant and will treat with Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily + Either Raltegravir 400 mg PO twice daily. Discussed post exposure testing at baseline6 weeks post-exposure, 12 weeks post-exposure. 6 months post-exposure at clinic. Will provide 5 days of PEP_ but discussed prompt need for follow up and full course being at least 4 weeks. Cautious return precautions discussed w/ full understanding.
MDMKneePain
subacute worsening of chronic right knee pain. Atraumatic. Neurovascularly intact distally. Given focal tenderness, query possible MCL strain vs bursitis. No systemic symptoms and nontoxic; given exam and history, low suspicion for septic arthritis, pyomyositis or necrotizing fascitis. No e/o compartment syndrome or DVT.
MDMKneePainTrauma
with R_ knee pain and mild swelling after injury. Neurovascularly intact distally. Given focal tenderness, query possible ligamentous injury however no gross instability. No tibial plateau tenderness. XR without frank fracture. Low suspicion for vascular injury with dislocation-relocation. No ankle or hip pain. No back pain with low supicion for significant axial load. No systemic symptoms and nontoxic; given exam and history, low suspicion for septic arthritis, pyomyositis or necrotizing fascitis. No e/o compartment syndrome or DVT. Pain control. Follow up with PMD and ortho as needed. Cautious return precautions discussed w/ full understanding.
MDMLacChin
with chin injury and superficial arm abrasions s/p fall from scooter_ prior to arrival. Pt with resultant chin laceration requiring simple repair. TDAP UTD. No maloccusion with low suspicion for mandibular fracture. No LOC and low suspicion for ICH. Relatively clean wound, irrigated copiously and repaired in simple fashion with sutures. No antibiotics indicated at this time. Discussed strict return precautions, follow up for suture removal and wound care. Extremity exam with full range of motion, no bony tenderness and distally neurovascularly intact.
MDMLacGen
with resultant laceration requiring simple repair. TDAP updated. XR w/o overt e/o fracture. NVI distally. Relatively clean wound, irrigated copiously and repaired in simple fashion with staples_. No antibiotics indicated at this time. NVI per routine post repair. No overt e/o compartment syndrome. Discussed strict return precautions, follow up for staple removal and wound care.
MDMMigraine
with history of chronic intermittent migraines, recently started on triptan_, now presenting with similar constellation of symptoms without overt evidence and low suspicion for intracranial hemorrhage, subarachnoid hemorrhage, or CNS affection. Patient with non-focal neuro exam. Patient not immunocompromised and no family history of bleeding dyscrasias or aneursymal rupture. Headache slow onset and similar to prior exacerbations. Will attempt pain control, serial neuro exams, and reassess.
MDMMVALowSpeed
otherwise healthy involved in restrained MVA with airbag deployment. Patient with pain predominantly to L paraspinal and L clavicular area_. Hemodynamically appropriate with nonfocal neurologic exam. Given exam and history, low suspicion for traumatic dissection or ICH. CT c-spine without overt fracture or dislocation with low suspicion for ligamentous injury on re-examination. Serial abdominal exam without tenderness and FAST initially unremarkable. Observed for several hours in ED with clinical improvement. Stable gait and tolerating PO. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
MDMNeckPainTrauma
with no pertinent history presents with now resolving R_ paraspinal neck pain. No acute findings on exam; in particular, no midline spinal tenderness to palpation. Non-focal neuro exam with sensation and strength intact and equal bilaterally. Low suspicion for cervical ligamentous or vascular injury. Intact grips and UE exam with low suspicion for central cord. Discussed pain control, observation of symptoms. Cautious return precautions discussed w/ full understanding.
MDMPECARNAbdominalTrauma
Patient denies severe mechanism of injury. Patient does not have overt evidence of abdominal wall trauma or seat belt sign. Patient is currently alert and at baseline mental status and activity level per family. Patient denies any abdominal tenderness and does not have evidence of thoracic wall trauma. Breath sounds remain equal bilaterally. Denies nausea or vomiting.
MDMPEDSURI
with vaccinations up to date_, full term, otherwise healthy boy presenting with fever and constellation of upper respiratory symptoms. Currently well appearing, nontoxic. Given history and exam, low suspicion for serious bacterial infection including meningitis, pneumonia, UTI or bacteremia. Tolerating PO and appearing euvolemic. Mild fever and well appearing after ibuprofen administration. No meningismus, otherwise at baseline activity level with low suspicion for CNS infection. Query likely viral etiology. Discussed low risk but possible UTI and offered catherterized urine sampling, but mutual decision making at this time to defer after discussion with parents_. Discussed alternating tylenol and ibuprofen as directed over the counter for antipyresis. Discussed strict return precautions for worsening of symptoms, increased respiratory effort, signs of CNS infection including but not limited to changes in mental status or vomiting, or fever for more than 5 days. Discussed prompt follow up with primary pediatrician in 24-48 hours for recheck or return to ED sooner if concern or if cannot schedule appointment.
MDMPEDSUTI
immunizations UTD_, otherwise healthy, not immunocompromised, presenting with fever and malaise. Constellation of symptoms and history concerning for possible UTI_. Patient is extremely well appearing, mentating well, at baseline per parents, lucid and without meningismus. Nonfocal neuro exam with low suspicion for CNS infection. No respiratory distress with low suspicion for pneumonia. No abdominal pain and benign abdominal exam with low suspicion for atypical appendicitis. No overt findings for vulvovaginitis_. UA with some WBC and + LE_. Given symptoms, will treat with Keflex_ for possible upper tract infection. Tolerating PO including juice and crackers in ED. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Appendicitis return precautions discussed.
Pain Regimen
- - Pain regimen: warm compress, cold compress, Tylenol 1g PO q6hr, oxycodone 5mg PO q4hr prn
Palliative Note
- Date consult received:
Patient location at time of referral:
Date patient seen:
Consulting MD/Service:
Reason for consultation:
Other Disciplines Already Involved:
History of Present Illness:
Past Medical History:
#Hospitalizations/ED visits in past 6mo? 12mo?
Surgical/Procedure History:
Allergies:
Meds:
Family History:
Social History:
Family Situation:
Employment:
Substance Use/Abuse:
Preferred Language/Interpreter:
Preferred Name/pronouns:
Getting enough support currently:
Spiritual screening:
Active spiritual life/religion:
Functional Status:
Palliative Performance Scale Prior to Admission:
Palliative Performance Scale at Time of First Contact:
Advance Directive: no/yes/unknown
POLST: no/yes/unknown
Goals of Care Discussion: alone/with family/none:
Information Preferences:
Review of Systems:
Pain: none/ mild/mod/severe
Appetite Loss: none/mild/mod/severe
Anxiety: none/mild/mod/severe
Fatigue: none/mild/mod/severe
Nausea: none/mild/mod/severe
Depression: none/mild/mod/severe
Dyspnea: none/mild/mod/severe
Drowsiness: none/mild/mod/severe
BM last 24 hrs: yes/no/unknown
Wellbeing: poor/acceptable/good
PE:
Gen:
HEENT:
CV:
Resp:
Abd:
Extr:
Neuro:
Labs:
Imaging:
Assessment:
Patient's decision-making capacity:
[ ] Has capacity
[ ] Has limited capacity
[ ] Does not have capacity
[ ] Defers decision making to surrogate decision maker or family (name & relationship):
Code Status: full/DNR/DNI:
Surrogate:
Recommendations:
Thank you for involving us in the care of your patient. Palliative Care will continue to follow along with you.
Please contact us M-F 8am-4:30pm for any questions/concerns.
Service #: 424-306-5667
Service Pager: 310-501-4808
Pancreatitis Work up
- Pancreatitis
Seen on CT/US. Lipase: _. Etiology: gallstone, alcohol, hypertriglyceridemia, post-ERCP, drug induced, hypercalcemia. No e/o of gallstone pancreatitis in this patient. No other intraabdominal/biliary pathology noted. No pancreatitic pseudocyst or necrosis no imaging.
- IVF @ .5-10cc/kg/hr
- APAP 1000mg q8 ATC, oxycodone 5mg po q6hr prn, morphine 2mg IV q2hr prn breakthrough pain
- NPO
- Strict intake ouput (goal UOP 0.5cc/hr)
- Acute pancreatitis:
Criteria for diagnosis: clinical, biochemical (>3x ULN), radiographic
BISAP score: 1 2 3 4 5
No evidence of cardiovacular (hypotension/volume overload), renal (AKI/ oliguira), GI (vomiting/ileus), AMS, pulmonary (hypoxemia/ ARDS) complications or local complications (pseudocyst, pancreatic necrosis, peripancreatic fluid)
DDx:
Gallstone, alcohol, TG
Ca, drugs (AZA, 6MCP, didanosine, valproic acid, ACEi, mesalamine or other), post- ERCP
Infection (CMV, mumps, ascaris, clonorchis), trauma, toxin, genetic (SPINK1, CFTR, CSR, claudin-2, chymotrypsin C), autoimmune, idiopathic
- NPO with goal of early refeeding with low fat soft diet
- Fluid resuscitation with LR NS at 150 175 200 250 300 350 400 cc/hr
- Trend Cr, BUN, Hct
- Consult GI for ERCP
- Consult trauma for cholecystectomy
- ETOH cessation
- SW consult for substance abuse
- Insulin gtt or plasmaphoresis for hyperTG
- Monitor TG q 12 6
- POC glc q1 hr
- D5 or D10
Paracentesis
-
Signed consent signed. Copy provided to patient.
Appropriate landmarks were palpated. Chlorhexidine applied x 2.
5ml of 1% lidocaine used to anesthetize locally via 22G needle. Ascitic fluid aspirated and the track was then anesthetized.
The tract was then dilated with a scalpel. Paracentesis kit was then introduced and yellow ascitic fluid removed.
At the end of the procedure, the paracentesis apparatus was removed, pressure applied with gauze.
Once hemostasis was achieved, bandage was applied.
Paracentesis note
- Patient was explained the benefits and risks of paracentesis and consented to the procedure.
Patient was supine in the bed and ____abdomen was examined with an ultrasound. After a pocket of fluid > 3 cm was identified on the right/left side of the abdomen, a marking pen was used to mark the injection site. Injection site was sterilized with ChloraPrep in a circular fashion starting from the site outward x 2. Physician was gowned and gloved in sterile fashion and patient’s paracentesis site was covered with sterile drape. With a 10cc syringe, a wheal of lidocaine was injected subcutaneously and the ndeeper while applying negative pressure during insertion. Peritonitic fluid was aspirated after needle penetrated approximately __ cm and then needle was withdrawn while injecting more lidocaine through the tract. After the site was anesthetized, a 0.5 cm nick was made in the site with a 10 scapel. Then the paracentesis needle with catheter was inserted with negative pressure until peritonitic fluid was aspirated. Fluid was _______ . With needle in static position, the catheter was slid over the needle and inserted into the abdomen until it was hubbed. 50 cc of fluid was aspirated and allocated among three test tubes. Then the rest of the fluid was aspirated into paracentesis bottles. Patient was leaned on the ipsilateral side and pressure was applied to the abdomen to aspirate more fluid without pain or discomfort. ____ L total was aspirated.
After aspiration, the catheter was withdrawn, pressure was applied to the paracentesis site and then a bandage was placed. Patient successfully underwent the procedure without complications.
Pelvic Exam
- The external genitalia were wnl without lesions or skin breakdown. The vaginal canal was normal and non-atrophic. The cervical OS was visualized, slightly positioned to the right, there were no lesions or polyps. There was normal physiologic discharge present. The OS was swabbed with the brush, slight bleeding was noted at the OS afterwards.
Pericardial Drain Note
- Pericardial Drainage Note
Pericardial drain catheter prepped in sterile fashion. 15 cc of sanguinous drainage pulled by manual aspiration into drainage bag. At the end of drainage, 2cc of 100U/ml heparin flush was instilled into the catheter lumen and the drain was clamped. A new sterile cap and dressing placed. The patient tolerated the drainage well without complications.
Drainage: 15cc sanguinous fluid
Time: 2100p
Pituitary
- energy
galactorrhea
perods/post menopausal
salt cravings
hot/cold/weght change/constipation/skin
vison changes
Pre-Discharge Order
- The pre-discharge order set is used to alert ancillary services of pending items still needed for discharge, improving efficiency of communication prior to discharge and decreasing the burden of coordination of care for physicians.
- Once a patient is deemed to likely be medically stable for discharge within the next 18-24 hours, please place the pre-discharge order using the pre-discharge order set (the patient does NOT need to have a final dispo plan prior to using this order set)
- Click Orders tab > Inpatient Wards Order Set > Pre Discharge
- Complete Form
Preeclampsia, Assessment
- history of hypertension presents for hypertension with SBP _ sent in by PMD with concern for possible pre-eclampsia. Of note, patient without severe range BP in ED. Patient without neuro or ocular concerns at this time. No RUQ and no frank proteinuria. No seizure activity and without cardiothoracic symptoms.. Benign abdominal exam and non-focal neuro exam. Labs largely reassuring_. Therefore, given history and exam, low suspicion at this time for fulminant pre-eclampsia requiring admission. No overt evidence of HELLP, acute cholestasis of pregnancy, or eclampsia at this time. Discussed case with OB and after evaluation, will _. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician/OB arranged and discussed_.
Problem
- #
x
Changes Today:
Continue With:
Psych ROS
- Constitutional: no fevers, chills
HEENT: no vision or hearing changes
CV: no chest pain or palpiations
Resp: no cough or SOB
GU: no dysuria or incontience
GI: no n/v/d constipation or incontenince
Msk: no myalgias
Integumentary: no rashes
Neuro: no numbness / weakness
Psych: no mood disturbances
Endocrine: no hot/cold intolerance, tremors, fatigue, weight changes
Hematologic: no bleeds
Pulmonary Embolism
- #Pulmonary Embolism
Modified Wells score, PESI score;
RECOMMENDATIONS
- Begin UFH now; no contraindications to anticoagulation noted
- Order BNP, trend troponin q6h until peak
- Obtain thrombolytic checklist
- Full neurological and volume status exam
- Order TTE (indication: other --> type "PERT Activation")
- Order US bilateral LE duplex venous
Contingency Plan
IF patient develops hypotension (SBP<90mmHg for 15mins despite resuscitation), worsening tachycardia, new or worsening hypoxemia, or tachypnea, please page PERT. Would tentatively plan to hold UFH and then plan for tPA administration: 100mg tPA over 2 hours with close monitoring. Once tPA infusion is completed, an aPTT (not anti-Xa) should be drawn 1 hour later to guide resumption of heparin drip. Once the aPTT falls below 2x upper limit of normal, heparin should be resumed. If the first aPTT is elevated beyond the 2x ULN, another aPTT should be drawn 1 hour later. It is imperative these labs be ordered and drawn exactly on time.
Thrombolytic Contraindications Checklist:
- Hx of CVA, CVD, AVM, CNS neoplasm, CNS surgery
- Recent head trauma with fracture or brain injury within past 3 months, recent surgery
- Active bleeding, known bleeding diathesis
- Thrombocytopenia, coagulopathy
- Oral anticoagulation, anticoagulating drugs
- Severe HTN >185/110
- Age >75 (relative)
Please page PERT (p9956) with questions or concerns.
Pulmonary Embolism AP
- #_▼ pulmonary embolism, _▼, _▼
CTPA showing _. PESI score _. REITE score _.
Therapy: _▼
Contraindications: __▼
Recent surgery (within 6 weeks): _▼
Recent hospitalizations (within 6 weeks): _▼
Pregnant: _▼
Hormonal therapy: _▼
Active cancer: Mammo _▼, Pap _▼, Colonoscopy _▼
Connective tissue disease: _▼
Hx of thrombophilia: _▼
Myeloproliferative disorder: _▼
Family history of VTE: _▼
Pulmonary Valve Stenosis
- - PS causes obstruction to RV outflow, usually isolated
- mild-mod PS generally asx
- severe PS causes exertional dyspnea, RV hypertrophy from pressure overload, prominent a wave on jugular venous waveform and palpable RV lift
- early systolic ejection click then crescendo-decrescendo murmur
- severe PS has systolic ejection murmur at LLSB with incr intensity/duration & delayed pulmonic component of S2 (split S2) and eventually disappears, sometimes can hear RV S4
- EKG: RA enlargement, RAD, RVH
- CXR: PA dilatation, calcification of PV, RA enlargement
- post repair may get severe PV regurgitation after pulmonary valvotomy or valvuloplasty
- echo: severe PS when peak gradient >64mmHg and mean gradient >35mmHg
- diagnostics: depends on valve mobility, calcification, effects of obstruction on RV. Causes RVH rather than enlargement. RV dilatation should prompt a search for an associated lesion, such as PR or ASD. cardiac cath when percutaneous intervention for PS considered.
- tx:
- pulmonary balloon valvuloplasty is preferred for valvular PS, indicated for symptomatic patients with appropriate valve morphology w/ moderate-severe valvular PS (moderate peak gradient 36-64, severe peak gradient >64, mean gradient >35) and otherwise unexplained sx of HF, cyanosis from interatrial R-to-L communication, and/or exercise intolerance
- surgical intervention recommended for PS associated with small annulus, >moderate PR, severe subvalvular or supravalvular PS, or another cardiac lesion requiring operative intervention
- recs: no exercise restriction for mild-mod PS, low intensity sports if severe PS, pregnancy well tolerated
# Q
# R
RCRI
- RCRI score of 0 (class I risk). Patient has >4 mets (walk up a flight of stairs, walk >20 minutes, no h/o angina). No current chest pain, trops negative in ED.
- per the 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation, patient does not warrant further cardiac workup.
ROS Admit Review of Sysems
- Constitutional: no fevers, no chills, no fatigue
Eyes: no visual changes
HENT: no otalgia, no sore throat, no oral sores, no neck pain
Neuro: no headache, no muscle weakness, no sensation changes, no dizziness (vertigo, syncope, ataxia)
CV: no chest pain, no palpitations, no edema
Pulm: no cough (productive or hemoptysis), no wheezing, no SOB (DOE, orthopnea, PND)
GI: no n/v, no diarrhea, no constipation, no abdominal pain, no hematochezia, no melena
GU: no dysuria, no hematuria
MSK: moving all ext.
Skin: no rash, no pruritus
ROS
- 12 point review of systems otherwise negative except for what is listed above.
- Constitutional: Denies fevers, chills, night sweats, unintentional weight loss.▼
Head/Ears/Eyes/Nose/Throat: Denies acute vision changes, hearing loss, eye/ear/nasal discharge.▼
Neurologic: Denies focal neurologic deficit.▼
Cardiovascular: Denies chest pain, palpitations, paroxysmal nocturnal dyspnea, orthopnea, lower extremity edema.▼
Pulmonary: Denies cough, wheezes, or dyspnea on exertion.▼
Gastroenterology: Denies nausea, vomiting, early satiety, dysphagia, odynophagia, melena, hematochezia, diarrhea, or constipation.▼
Genitourinary: Denies hematuria, dysuria, urinary frequency, urgency, incomplete voiding, incontinence.▼
Hematologic: Denies easy bruising or bleeding.▼
Musculoskeletal: Denies joint swelling, cramping, pains.▼
Skin: Denies rashes, lesions, pruritis.▼
Psychiatric: Denies suicidal or homicidal ideation, no hallucinations.▼
_▼
ROS AMS
- Unable to assess 2/2 patient's mental status.
ROS Clinic
- General: No acute distress, answering questions appropriately. Normal body habitus, appears stated age.
HEENT: MMM, no LAD
CV: RRR, normal s1,s2, no m/g/r
Resp: CTABL, no w/r/r
Abdominal: Soft, nontender, nondistended. Normoactive bowel sounds
Extremities: Extremities warm, 2+ radial, DP, PT pulses b/l. No lower extremity edema b/l.
Neuro: AAOx3
Rectal Bleed, Assessment
- This patient has a presentation consistent with rectal bleeding, most likely due to _. Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. No evidence of hemorrhagic shock.
Regeneron Consent
- I talked to Ms./Mr. ________ on ______ at _______.
I explained that we are able to offer Casirivimab + Imdevimab therapy for treatment of mild COVID-19 disease at this time. I explained the risks, benefits, and alternatives to treatment including no treatment to the patient. Specifically, we discussed the following:
· Casirivimab + Imdevimab has not been approved, but has been authorized for emergency use by the FDA for the treatment of mild-moderate cases of COVID-19 in outpatients with certain risk factors for progression to severe disease.
· Casirivimab + Imdevimab may decrease the likelihood of hospitalization or death from COVID-19.
· There is no guarantee that the above benefit will occur with treatment.
· The potential side effects of this medication include fever and rash. Rarely, more severe side effects such as hypersensitivity reactions including anaphylaxis and infusion-related reactions may occur.
· Casirivimab + Imdevimab is still being studied, and as such, side effects other than those listed above may occur.
· Casirivimab + Imdevimab is given via IV infusion over 1 hour and requires 1 hour of monitoring post-infusion.
· The patient is under no obligation to accept treatment with this medication.
Retinal Detachment, Assessment
- Patient presenting with constellation of symptoms concerning for vitreous hemorrhage vs retinal detachment. Not contact lens wearer_. No prior ocular history_. Patient is headache free and visual acuity intact with low suspicion for temporal arteritis or CRAO/CRVO. No vision changes or conjunctival injection with low suspicion for acute angle closure glaucoma. No trauma to the eye and no sensation of foreign body with low suspicion for corneal ulceration or globe injury. No evidence of overt hyphema or hypopyon on exam. No ocular pain or consensual photophobia with low suspicion for scleritis or iritis. Plan to discuss case with ophthalmology for dilated exam and further assessment.
Return Precautions
- If you experience worsening symptoms, including but not limited to fevers, chills, nausea, vomiting, intolerable pain, blood in urine, inability to urinate, pus or drainage from tube, please return to the emergency department for further evaluation.
Si experimenta síntomas que empeoran, incluidos, entre otros, fiebre, escalofríos, náuseas, vómitos, dolor intolerable, sangre en la orina, incapacidad para orinar, pus o drenaje del tubo, regrese al departamento de emergencias para una evaluación adicional.
Constipation
- #Constipation
No BM for the past *** days
- Start miralax 17g PO tid
- Start senna 1 tab PO bid
- Monitor and adjust meds PRN
Return To Clinic | RTC
- RTC: Patient to f/u in our clinic in _ months via _ or sooner if needed
PrePara
- Pre-procedure Paracentesis H&P
HPI: This is a *** with hx of *** who presents with abdominal distention in setting of needing a paracentesis. Pt reports last paracentesis *** and had ***L removed. Typically has *** paracentesis/week with ***L taken out.
Currently taking lasix *** and spironolactone ***
Denies any f/c/s/N/V/diarrhea/constipation/melena/hematochezia/hematesis.
ROS:
Constitutional Cardiovascular Genitourinary Neurological Hematologic/Lymphatic
Eyes Respiratory Musculoskeletal Psychiatric Allergic/Immunologic
Ears, Nose, Mouth, Throat Gastrointestinal Integumentary Endocrine
All systems negative except as mentioned in HPI
Allergies:
Home Medications:
PMH:
Reviewed
PSH:
Reviewed
SH:
Reviewed
FH:
Reviewed
Physical Exam:
Vitals reviewed
General: Awake, Alert, NAD
HEENT: PERRL, EOMI, icteric sclera, OP clear, MMM
CV: Normal S1, S2; no murmurs
Pulm: No increased work of breathing; Clear to auscultation bilaterally, No wheeze/rhonchi/crackles
Abdomen: Bowel sounds present; Distended; NT; shifting dullness present
Neuro: A, Ox4, No gross focal deficits
Extremities: warm, well perfused; no clubbing, cyanosis, edema
Skin: no rashes, jaundice
Laboratory Data:
Labs reviewed
Assessment and Plan:
This is a ***y/o male/female*** with hx of *** who presents for paracentesis:
- No contraindications to paracentesis
- Plan to proceed with paracentesis if safe pocket found
- Will not remove more than 5L
- Strict return precautions given to patient including fever, chills, abdominal pain, leaking from site, cellulitis around site
Shadi Dowlatshahi, MD, MSc
Director of Procedure Services
Hospitalist, Division of Internal Medicine
Adjunct Clinical Associate Professor
USC Keck School of Medicine
Email: SDowlatshahi@dhs.lacounty.gov
Office: 323-409-5931
heart failure ap
- HF exacerbation
-lasix
-beta blocker therapy
-ACEI
-hydral/isordil
-ASA/statin
-TTE
-cardiac diet, fluid restrict, Na restrict
-strict i/o, daily weight
-trend BMP
-goal K/Mg 4/2
exam clinic
- GEN - NAD, answering questions appropriately
Cardio - RRR, nml S1/S2, no m/r/g
Resp - CTAB
Ab - +BS, soft, ND, NT
Extrem - no pitting edema
ed phone brief note syncope
- Accepted patient from ER to CORE service for concern for cardiac syncope. Briefly, per ER sign out, this is a “***enter what the ER tells you over the phone.”
//vitals
Cardiac: RRR, normal S1/S2, no m/r/g
Respiratory: CTAB, no wheeze/crackles
Extremity: no pitting edema
Plan – further workup of syncope and monitoring per CORE team in AM, full H&P to follow
ed phone brief note heart failure
- Accepted patient from ER to CORE service for decompensated heart failure. Briefly, per ER sign out, this is a “***enter what the ER tells you over the phone.”
//vitals
Cardiac: RRR, normal S1/S2, no m/r/g
Respiratory: crackles in the bases bilaterally
Extremity: 1+ pitting edema
Plan – further diuresis and HF optimization per CORE team in AM, full H&P to follow
EDPhoneBrief NoteCardiac Risk
- Accepted patient from ER to CORE service for further cardiac risk stratification. Briefly, per ER sign out, this is a “***enter what the ER tells you over the phone.”
//vitals
Cardiac: RRR, normal S1/S2, no m/r/g
Respiratory: CTAB, no wheeze/crackles
Plan – further cardiac risk stratification per CORE team in AM, full H&P to follow
Angina
- Classic angina - midsternal pressure, worse with exertion, better with rest and nitroglycerin. ECG unremarkable. trop neg. CXR neg. no e/o HF. no e/o valvular dz. Carduac risk factors include ***
-ASA 81mg qDay
-atorvastatin 40mg QHS
-metoprolol 25mg BID
-optimize BP
-nitro SL PRN
-smoking cessation
-check A1c/FLP
-TTE
-would perform further cardiac risk stratification
PreLP
- Pre-procedure Lumbar Puncture H&P
HPI: This is a *** with hx of ***. Pt scheduled in procedure clinic for an LP for further evaluation of possible etiology of R oculomotor nerve palsy.
***Pt not on AC/antiplatelet therapy***
Denies any f/c/s/N/V/HA/vision changes/unsteady gait/rashes/confusion/dizziness/lightheadedness/eye pain.
ROS:
Constitutional Cardiovascular Genitourinary Neurological Hematologic/Lymphatic
Eyes Respiratory Musculoskeletal Psychiatric Allergic/Immunologic
Ears, Nose, Mouth, Throat Gastrointestinal Integumentary Endocrine
All systems negative except as mentioned in HPI
Allergies:
***
Home Medications:
***
PMH:
Reviewed
PSH:
Reviewed
SH:
Reviewed
FH:
Reviewed
Physical Exam:
Vitals reviewed
General: Awake, Alert, NAD
HEENT: PERRL, EOMI, icteric sclera, OP clear, MMM
CV: Normal S1, S2; no murmurs
Pulm: No increased work of breathing; Clear to auscultation bilaterally, No wheeze/rhonchi/crackles
Abdomen: Bowel sounds present; ND, NT
Neuro: A, Ox4, No gross focal deficits
Extremities: warm, well perfused; no clubbing, cyanosis, edema
Skin: no rashes, jaundice
Laboratory Data:
Labs reviewed
Assessment and Plan:
This is a *** presenting for an LP:
- Please see safety LP checklist placed in chart by requesting provider
- No contraindications to LP
- Strict return precautions given to patient including fever, chills, HA, N/V, back pain, weakness/numbness, any other concerns
Shadi Dowlatshahi, MD, MSc
Director of Procedure Services
Hospitalist, Division of Internal Medicine
Adjunct Clinical Associate Professor
USC Keck School of Medicine
Email: SDowlatshahi@dhs.lacounty.gov
Office: 323-409-5931
PreArtho
- Pre-procedure Knee Arthrocentesis H&P
HPI: This is a *** with hx of ***. Pt scheduled in procedure clinic for an knee ***injection/aspiration*** in setting of ***R/L*** ***pain/effusion***
Denies any f/c/s/no erythema at the knee/no drainage from the knee.
ROS:
Constitutional Cardiovascular Genitourinary Neurological Hematologic/Lymphatic
Eyes Respiratory Musculoskeletal Psychiatric Allergic/Immunologic
Ears, Nose, Mouth, Throat Gastrointestinal Integumentary Endocrine
All systems negative except as mentioned in HPI
Allergies:
***
Home Medications:
***
PMH:
Reviewed
PSH:
Reviewed
SH:
Reviewed
FH:
Reviewed
Physical Exam:
Vitals reviewed
General: Awake, Alert, NAD
HEENT: PERRL, EOMI, icteric sclera, OP clear, MMM
CV: Normal S1, S2; no murmurs
Pulm: No increased work of breathing; Clear to auscultation bilaterally, No wheeze/rhonchi/crackles
Abdomen: Bowel sounds present; ND, NT
Neuro: A, Ox4, No gross focal deficits
Extremities: warm, well perfused; no clubbing, cyanosis, edema
Skin: no rashes, jaundice
Assessment and Plan:
This is a *** presenting for an ***R/L*** knee ***injection/aspiration:
- No contraindications to knee injection/aspiration
- Will plan for 40mg of kenalog***
- Strict return precautions given to patient including fever, chills, erythema, drainage, warmth, other concerns
Shadi Dowlatshahi, MD, MSc
Director of Procedure Services
Hospitalist, Division of Internal Medicine
Adjunct Clinical Assistant Professor
USC Keck School of Medicine
Email: SDowlatshahi@dhs.lacounty.gov
Office: 323-409-5931
tobacco use
- #Tobacco Abuse
- Encouraged cessation
- Nicotine patch/gum PRN for withdrawal sx
PreThora
- Pre-procedure Paracentesis H&P
HPI: This is a*** with hx *** who presents with SOB in setting of needing a thoracentesis. Undergoes thoracentesis ***/week.
On lasix *** and spironolactone ***
Denies any f/c/s/N/V/diarrhea/chest pain/palpitations/SOB/melena/hematochezia/hemametesis.
ROS:
Constitutional Cardiovascular Genitourinary Neurological Hematologic/Lymphatic
Eyes Respiratory Musculoskeletal Psychiatric Allergic/Immunologic
Ears, Nose, Mouth, Throat Gastrointestinal Integumentary Endocrine
All systems negative except as mentioned in HPI
Allergies:
***
Medications:
***
PMH:
Reviewed
PSH:
Reviewed
SH:
Reviewed
FH:
Reviewed
Physical Exam:
Vitals reviewed
General: Awake, Alert, NAD
CV: RRR
Pulm: decraesed BS on ***
Abdomen: +BS, soft, NT, nD
Neuro: no focal neurologic deficits
Extremities: no clubbing/cyanosis
Assessment and Plan:
This is a*** with hx *** who presents for a thoracentesis:
- No contraindications to thoraentesis
- Plan to proceed with thoracentesis if safe pocket found
- Will not remove more than 1.5L
- Strict return precautions given to patient including fever, chills, chest pain, SOB, leaking from site, cellulitis around
uncontrolled pain
- #Uncontrolled Pain
- dc IV pain meds
- Start oxycodone to 5-10mg PO q4hrs PRN
- Start voltaren gel qid
- Start tylenol 1g PO tid
- Aggressive BM regimen
malnutrition
- #Moderate Protein Calorie Malnutrition
- Appreciate nutrition consult
- Encourage high protein diet
normocytic anemia
- #Normocytic Anemia
Mild
- f/up ferritin
- Transfuse for Hb < 7 or sx
Return of Spontaneous Circulation - ROSC
- Per EMS report, patient was found down_, had witnessed arrest_. Approximate downtime prior to compressions: _. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital, upon arrival patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. The patient was placed on a levophed drip and resuscitated. Cardiac arrest was likely secondary to _. Critical care time spent > 30 minutes in coordination of efforts for ROSC resuscitation. Patient admitted to ICU.
Diabetes Mellitus Uncontrolled
- #Type II DM, Uncontrolled
HbA1c *** from ***. On *** at home.
- Continue ***
- Moderate SSI
- Monitor BS and adjust insulin PRN
Revised Cardiac Risk Index
- Patient pending OR for urgent intermediate risk procedure with orthopedics team.
Revised Cardiac Risk Index:
Elevated-risk sugery: 0
History of ischemic heart disease: 0
History of congestive heart disease: 0
History of cerebrovascular disease: 0
Pre-operative treatment with insulin: 0
Pre-operative creatinine >2mg/dL: 0
0 points: Class I risk, 3.9% of 30-day risk of death, MI, or cardiac arrest
Pt with HTN, HLD, DM, no significant cardiac history. No active chest pain. EKG reviewed.
Patient is medically optimized and can proceed to OR without further risk stratification.
COPD Controlled
- #COPD
Controlled***
- Continue inhaler ***
- Titrate oxygen saturation to 88-92%
- Encouraged smoking cessation
# S
S - HPI - COVID NO RISK FACTORS
- This patient presents with fever and cough for ***_ days.
- Risk Factors:
- -Denies HCW status
- -Is not immunocompromised
- -Denies close contact with suspect or confirmed COVID-19 patient
- -No cluster status (SNF, group home, etc)
STEMI Work up
- STEMI
- Emergent cardiac catheterization
- ASA 325
- Heparin gtt
- Atorva 80
- Metop 25-50 q6-12 hours (Contraindications include active heart failure, evidence of a low output state, high risk for cardiogenic shock, bradycardia, heart block, or reactive airway disease)
STEMI problem list
- STEMI
Patient presented for chest pain. Underwent cath procedure with findings of _. Loaded with _ in the cath lab.
- Rx ASA 81 daily
- Rx Plavix or Prasugrel qday (Prasugrel contraindicated if history of stroke)
- Rx Atorvastatin 80mg nightly
- Consider Rx Metoprolol
- Consider Rx Lisinopril
- Post-cath EKG
- TTE ordered
STEMI, Assessment
- This patient presents with chest pain and an EKG showing _ STEMI or STEMI equivalent (Wellens, de Winter’s, Sgarbossa criteria)_. Patient given aspirin. Pain controlled with _. Presentation not consistent with acute thoracic aortic dissection. No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. Patient taken to cath lab.
Seizure
- Seizure history:
Onset: ***
Aura: ***
Semiology/seizure types: ***
Triggers: ***
Epilepsy risk factors:
Head trauma/surgeries: ***
Sleep issues: ***
Illness/infections: ***
Education completed: ***
History of ADHD/special education: ***
Drugs: ***
Seizure frequency: ***
Last seizure: ***
Epilepsy workup:
MRI brain: ***
EEG: Normal ***
Does patient know he/she had a seizure?: ***
Seizure, Assessment
- This patient presents with symptoms consistent with acute seizure, most likely due to _. I considered, but think less likely, secondary etiologies of epileptic seizures to include drug / toxin etiologies (ETOH, stimulants, medication side effects), metabolic disturbances (glucose, Na), acute CNS infections (meningitis, encephalitis, abscess), ICH / tumor / CVA. Presentation not consistent with impact seizure related to head trauma. Patient with no signs of trauma from the seizure. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. DMV was notified to remove patient's licence_, patient was given strict seizure precautions. Patient to follow up with PMD.
Stroke MDM
This patient presents with symptoms concerning for acute CVA versus TIA. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todd’s paralysis. However, presentation most concerning for a CVA. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. CT head showed _. CTA head and neck showed _. Per neuro _.
Headache MDM
This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. No headache red flags. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). No history of trauma so doubt ICH. Given history and physical temporal arteritis unlikely, as is acute angle closure glaucoma. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. Patient with no signs of increased intracranial pressure or weight loss and history and physical suggest more benign headache so less likely mass effect in brain from tumor or abscess or idiopathic intracranial hypertension. Pain was controlled with headache cocktail and patient discharged home with PMD follow up.
if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. Considered, but think unlikely, CVT given no cranial nerve deficits, blurry vision, diplopia.
AMS MDM
This patient presents with altered mental status, concerning for _. Labs and exam were inconsistent with toxic metabolic etiologies such as electrolyte disturbances (Na/Ca), hypoglycemia, and uremia; acidosis states, infection (i.e. Sepsis). History and exam make toxidromes of intoxication or withdrawal, hypoxemia or hypercarbia, liver disease or failure causing hepatic encephalopathy, endocrine emergencies (hyper/hypothyroidism, adrenal insufficiency), seizure, trauma, intracranial bleeds or ischemic stroke less likely_.
Weakness MDM
This patient presents with generalized weakness and fatigue likely secondary to dehydration. Suspect acute kidney injury of prerenal origin. Doubt intrinsic renal dysfunction or obstructive nephropathy. Considered alternate etiologies of the patient’s symptoms including infectious processes, severe metabolic derangements or electrolyte abnormalities, ischemia/ACS, heart failure, and intracranial/central processes but think these are unlikely given the history and physical exam.
Respiratory
SOB MDM
This patient presents with dyspnea, most likely secondary to _. Presentation not consistent with acute cardiac etiologies to include ACS (non ischemic ekg, unremarkable trop), CHF, pericardial effusion / tamponade . Presentation not consistent with acute respiratory etiologies to include acute PE (Wells low risk), pneumothorax , asthma, COPD exacerbation, allergic etiologies, or infectious etiologies such as PNA. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. demyelinating diseases).
COPD exacerbation
This patient presents with symptoms most consistent with an acute COPD exacerbation. These constellation of symptoms are similar to prior exacerbations. The likely precipitant is acute respiratory infection_ weather change or air quality _ recent beta-blocker or opiate use_. Low suspicion for alternate etiologies such as pneumothorax, acute PE, pneumonia. Presentation not consistent with other acute cardiopulmonary causes including ACS, CHF. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. And will be sent home with steroid burst and azithromycin.
Cough MDM
This patient presents with acute cough, most consistent with _. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. Presentation not consistent with chronic causes of cough (including GERD, asthma, postnasal discharge, medication side effect, CHF, lung cancer or mass).
URI MDM
This patient presents with symptoms suspicious for likely viral upper respiratory infection. Based on history and physical doubt sinusitis. COVID test was sent off and pending. Do not suspect underlying cardiopulmonary process. I considered, but think unlikely, dangerous causes of this patient’s symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Patient is nontoxic appearing and not in need of emergent medical intervention. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results.
Skin and soft tissue
Skin infection MDM
This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis. Sensitivity/pain to light touch around the erythematous area. No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. Low concern for osteomyelitis or DVT. No immune compromise, bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Patient to be discharged home with keflex with follow up with their PMD.
Abscess MDM
This patient presents with a painful fluid pocket with fluctuance and surrounding induration and erythema, concerning for an abscess of _. The abscess was anesthetized with lidocaine and then I&D was performed with deloculation and purulence was expressed. There is no lymphangitic spread visible. Low concern for osteomyelitis. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Patient to be discharged home with bactrim and keflex with follow up with their PMD.
Diabetic Foot infection - admit MDM
Presentation most consistent with diabetic foot infection. Given History, Exam, and Workup can not rule out underlying osteomyelitis_, however have low suspicion for Necrotizing Fasciitis, Abscess, DVT. Patient with no signs of sepsis. Patient given empiric vanc, cipro, flagyl_.
Rash MDM
This patient who presents with rash for _, consistent with _. History and exam findings not consistent with dangerous etiologies of rash such as SJS/TEN, or secondary dangerous causes such as petechial rashes from thrombocytopenia or rickettsial infections. Rash does not appear urticarial with no signs of anaphylaxis either. Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN.
Allergic rash MDM
This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. Presentation not consistent with acute anaphylaxis (lack of pulmonary, dermatologic, cardiovascular or GI symptoms, lack of hypotension or exposure to known allergen), angioedema, serum sickness (no recent drug exposure, lacks fevers, arthralgias). No evidence of airway compromise or shock at this time. Patient improved with H1/H2 blockers, steroids. No need for epinephrine. Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing.
Laceration MDM
Wound inspected under direct bright light with good visualization. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. No overt foreign body. Area hemostatic. Neurovascular exam congruent with above. Area extensively irrigated with sterile normal saline under pressure. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Patient tolerated procedure well and neurovascular exam intact and unchanged post repair with intact distal pulses and cap refill_. Cautious return precautions discussed w/ full understanding. Wound care discussed. Prompt follow up with primary care physician discussed and return for suture removal in _ days.
Back Pain
Upper back pain MDM
This patient presents with back pain most consistent with musculoskeletal spasm/strain. No back pain red flags on history or physical. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), transverse myelitis, (no sensory loss, no distal weakness), thoracic aortic dissection (equal peripheral pulses, no tachycardia, story does not fit), pneumonia (afebrile, no infectious symptoms), pulmonary embolism (Well’s low risk), osteomyelitis or epidural abscess (no IVDU, vertebral tenderness). Given the clinical picture, no indication for imaging at this time.
Lower back pain MDM
This patient presents with back pain most consistent with _. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. Less likely sciatica as straight leg raise test was negative. No back pain red flags on history or physical. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), cauda equina (no bowel or urinary incontinence/retention, no saddle anesthesia, no distal weakness), AAA, viscus perforation, osteomyelitis or epidural abscess (no IVDU, vertebral tenderness), renal colic, pyelonephritis (afebrile, no CVAT, no urinary symptoms). Given the clinical picture, no indication for imaging at this time.
Ortho
Fracture MDM
The Pt was found to have a closed _ fracture on XR. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_.
The Pt presents with an acute open _ fracture after _. The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. Patient received empiric Ancef and orthopedics was consulted who reduced the fracture under conscious sedation and placed in splint with plan to admit patient for likely orthopedic operation.
Dislocation MDM
The Pt presents with acute _ pain after _ with evidence of _ dislocation on XR. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. _ was reduced at bedside with conscious sedation_ and post reduction Xray shows successful reduction. Patient pain was controlled and patient discharged with ortho follow up.
Joint pain MDM
Patient presents with _ joint pain. Given history, exam and workup patient likely has arthritis. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy.
Trauma
Blunt Trauma-no serious injury MDM
Given work up, exam, and history low suspicion for intracranial hemorrhage or trauma, carotid or vertebral artery dissection, intrathoracic trauma (pulmonary contusion, blunt cardiac trauma, pneumothorax, hemothorax, cardiac tamponade, rib fractures), intra abdominal trauma (no liver, spleen, or renal lacerations, doubt hollow viscus injury given soft abdomen on repeat exams, no free air seen, consistently normotensive), extremity fracture, extremity dislocation, compartment syndrome.
MVA Discharge MDM
This _ patient presents subacutely after a motor vehicle accident with _ pain. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. Low suspicion for ICH or other intracranial traumatic injury. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. Pelvis without evidence of injury and patient is neurologically intact. Explained to patient that they will likely be sore for the coming days and can use tylenol/ibuprofen to control the pain, patient given return precautions.
Extremity Penetrating Trauma MDM
Given history, exam, and workup, low suspicion for emergent neurovascular or orthopedic complications of gunshot wound to extremity such as compartment syndrome, large vascular injury, hemorrhagic shock, penetrating nerve injury, fracture. No evidence of intraabdominal or intrathoracic involvement of GSW.
Genitourinary
Urinary Retention Male MDM
Patient presents with urinary retention for _ days. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. Considered other etiologies but given history, exam and workup have low suspicion for cauda equina, infectious etiology (pyelonephritis or cystitis), constipation induced retention, intraabdominal mass, trauma, nephrolithiasis, urolithiasis, drug reaction. Urology was consulted_ and patient will follow up with them for trial of void. Patient prescribed flomax_.
Flank Pain MDM
Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. Given history, exam, and work up I have low suspicion for atypical appendicitis, genital torsion, acute cholecystitis, AAA, infected obstructed stone, pyelonephritis, or other emergent intraabdominal pathology. Symptoms and UA indicate no infection. BMP witohut evidence of AKI. Pain treated in ED with ____. Patient appropriate for discharge with outpatient follow-up and ___ for pain.
Infected Obstructed kidney stone
Patient presents with flank pain and is found to have a kidney stone that is obstructed with signs of infection concerning for infected obstructed kidney stone so Urology was consulted and patient to be taken to OR with urology for stent placement to relieve obstruction. Patient given fluids and ceftriaxone. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion).
Pyelonephritis
Patient presenting with flank/back pain and fever. Differential included UTI, pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_. Also considered but less likely given history and physical exam included constipation, bowel perforation, gastritis, pancreatitis, mesenteric ischemia, genital torsion_. Patient febrile and given tylenol and normal saline bolus_. Given ceftriaxone and prescribed cefdinir/keflex_. Follow up with PMD this week. Return precautions given.
UTI Female nonpregnant MDM
This patient presents with symptoms consistent with acute uncomplicated cystitis. No systemic symptoms. Not septic. Well appearing. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. Low suspicion for kidney stone or infected stone. Upreg negative so doubt ectopic pregnancy_. Low suspicion for ovarian torsion, PID, or appendicitis.
STD MDM
This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. Differential includes simple cystitis, pyelonephritis, epididymitis_. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline.
Dizziness
Dizziness - low risk peripheral vertigo MDM
This patient presents with dizziness, most consistent with a peripheral cause, likely BPPV. No history of recent infection so doubt vestibular neuritis. History not consistent with meniere's disease. No history of trauma. No red flag features for central vertigo to include gradual onset, vertical/bidirectional or non-fatigable nystagmus, focal neurologic findings on exam (including inability to ambulate, ataxia, dysmetria). Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed.
Dizziness- high risk central vertigo MDM
Patient with persistent vertigo that is not fatigable with no obvious trigger which is concerning for central etiology of either posterior circulation stroke vs intracranial mass vs intracranial hemorrhage vs vertebral basilar artery insufficiency. CT head and CTA head and neck ordered and shows _. Neurology consulted and MRI ordered which shows _.
Vaginal Bleeding
Vaginal Bleeding non pregnant MDM
Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. Based on History, Exam, and ED Workup patient’s presentation not consistent with ectopic pregnancy, molar pregnancy, life-threatening coagulopathy, trauma, serious bacterial infection. Patient given provera taper_, OCPs_ and will follow up with OBGYN.
Vaginal bleeding pregnant MDM
This pregnant patient presents with vaginal bleeding in the first trimester. Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Patient without a history of coagulopathy or infectious symptoms. Doubt alternate acute emergent pathology. Patient is Rho + so Rho gam is not indicated_, Rho - so Rho gam was given_. Patient with TVUS that showed _.
Symptomatic Anemia MDM
Patient presents for symptomatic anemia secondary to _. Patient with known cause of bleeding and follow up scheduled. Given _ units of blood with resolution of symptoms afterwards. Patient had no reaction to blood transfusion. Patient feels well on discharge with plan to follow up with PMD.
Vital sign abnormalities
Tachycardia-discharge MDM
This patient presented with tachycardia with no apparent emergent cause. Patient is afebrile with no infectious symptoms, no signs of hyperthyroidism in the history and TSH pending_, considered PE but less likely (no chest pain, sob, DVT risk factors, leg swelling, and satting well), doubt ACS (no chest pain, non STEMI ekg, and neg trop_), no anemia on CBC, patient denies any drug/alcohol intoxication or withdrawal, patient euvolemic on exam and does not appear dry so doubt orthostatic changes.
Bradycardia - dicharge MDM
The patient is suffering from bradycardia without concerning signs of instability on exam such as altered mental status, hypotension, evidence of cardiac end organ dysfunction, or acute heart failure. Possible causes include sick sinus syndrome, vasovagal. Considered but low risk for any emergent causes including unstable heart block (ekg with no signs of Mobitz II, complete heart block), right coronary artery myocardial infarction (neg trop_, non STEMI, no chest pain), infection (afebrile, no leukocytosis, no recent illness), hypothyroidism, hyperkalemia, hypoglycemia, dehydration, or intoxication (beta blockade, calcium channel blockade, clonidine, digoxin, opiates, alcohol or other).
Asymptomatic HTN
Patient presents to the emergency department complaining of high blood pressure. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. Patient is hypertensive here. Patient has not been taking their HTN medication _. Doubt hypertenstive emergency, patient with no signs of AMS, pulmonary edema, heart failure, ACS, PRESS syndrome, intracranial hemorrhage, renal infarction or failure or other end organ damage. Plan to discharge patient home with PMD follow up.
Eye
Corneal Abrasion MDM
The Pt presents with _ likely due to a corneal abrasion seen on fluorescein staining of eye. The Pt is otherwise well-appearing without evidence of retained foreign body, corneal ulcer_, globe rupture, or superimposed infection. Prescribed antibiotics and instructed the Pt to follow up closely with ophthalmology and avoid wearing contacts_.
Eye redness benign MDM
Patient presents with Scleral injection. No recent eye trauma or suspected microtrauma (dust, sand, etc). Negative Seidel sign, no sign of corneal abrasion/ulcer. No history of discharge so less likely bacterial or viral conjunctivitis. No significant photophobia. IOP is _ so doubt acute angle closure glaucoma. Given history and exam I have low suspicion for globe rupture, uveitis, HSV keratitis, Endopthalmitist, Foreign Body. Patient likely has allergic conjunctivitis and was prescribed _.
Subconjunctival hemorrhage MDM
Presentation consistent with subconjunctival hemorrhage. Given history and exam I have low suspicion for corneal abrasion or ulcer, globe rupture, uveitis, HSV keratitis, Endopthalmitis, Retinal Detachment, Angle Closure Glaucoma, Foreign Body, hyphema.
Swollen Eye MDM
[]-year-old patient presenting with swollen eye. Otherwise well-appearing.No history of trauma. No urticarial rash to suggest allergic reaction. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. Ddx includes allergic reaction vs. preseptal cellulitis. Will treat empirically with antibiotics and antihistamines. Discussed need for outpatient follow-up and return precautions for signs/symptoms of orbital cellulitis or anaphylaxis.
Vision loss painless MDM
Given history of flashers and floaters with acute visual acuity loss and ocular ultrasound findings, presentation is concerning for Retinal Detachment vs Vitreous Hemorrhage vs Posterior Vitreous Detachment. Given vision loss is painless I have low suspicion for normally painful syndromes such as Corneal Abrasion/Ulcer, Complex Migraine, Globe Rupture, Acute Angle Glaucoma, Uveitis, Endopthalmitis, Iritis. Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke.
Given history of painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs CRVO. Vision is unilateral with no other focal neuro deficits so doubt stroke, patient exam and history make retinal detachment, vitreous hemorrhage, posterior vitreous detachment lower on differential. Given painless vision loss low suspicion for normally painful syndromes such as corneal abrasion/ulcer, complex migraine, globe rupture, acute angle closure glaucoma, optic neuritis, temporal arteritis, uveitis, endophthalmitis, iritis.
Painful vision loss nontraumatic MDM
Patient presents with nontraumatic painful, unilateral vision loss for which the initial differential is optic neuritis, temporal arteritis, acute angle closure glaucoma, endophthalmitis, and uveitis. Given patient had increased IOP and concerning ocular exam likely cause is acute angle closure glaucoma. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. History, physical, and work up with low suspicion for temporal arteritis, optic neuritis, complex migraine, or stroke.
Patient presents with nontraumatic painful, unilateral vision loss for which the initial differential is optic neuritis, temporal arteritis, acute angle closure glaucoma, endophthalmitis, and uveitis. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. Normal IOP so doubt acute angle closure glaucoma. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke.
Oral
Sore throat MDM
No history of immunocompromise. Nontoxic appearance. Patient euvolemic with no trismus. No airway compromise. No change in voice, exudates, enlarged lymph nodes. Able to tolerate PO. Given History and Exam I have low suspicion for this presentation being caused by PTA, RPA, Ludwigs angina, Epiglottitis or Bacterial Tracheitis, EBV, acute HIV, or Strep throat.
PTA discharged MDM
Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. Patient is able to tolerate secretions. Peritonsillar abscess was drained with 18 gauge needle after anesthesia by bupivacaine with no complications_, patient feeling better_. Given that the patient is not immunocompromised, able to tolerate PO, nontoxic appearing, and no signs of trismus or airway compromise, plan to discharge the patient home with augmentin_. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV.
Dental Pain MDM
Patient presents for dental pain due to suspected dental cary. Patient not immunosuppressed, afebrile and well appearing with patent airway, have low suspicfion for deep space infection or any concern for airway compromise. Based on history, physical, and work up. No evidence of tooth fracture, avulsion, or bleeding socket. No evidence of RPA, PTA, Ludwig’s angina, periapical abscess. Offered patient dental nerve block for pain which patient accepted/declined_. Instructed patient to continue to treat pain with ibuprofen/acetaminophen until they see a dentist. Defer ABX for dental pain alone with no overt evidence of infection_. Patient discharged home and will follow up with dentist. Discussed return precautions for odontogenic infections and other dental pain emergencies. Will provide dental clinic list_.
Ear
Acute Otitis media MDM
Exam and history most consistent with AOM. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. Will give wait and see prescription for amoxicillin. If symptoms worsen or persist for 48-72 then pt to fill the prescription_. Cautious return precautions discussed w/ full understanding.
Otitis Externa MDM
Exam and history are most consistent with Otitis Externa. No diabetes or immunosuppression. Low suspicion for mastoiditis, malignant otitis externa, AOM, herpes zoster oticus. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days.
Nose
Epistaxis
Simple discharge This _ patient presents with likely anterior epistaxis, which appears to have resolved. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. No evidence of anemia. Patient discharged with nasal gel.
Intervention needed This _ patient on anticoagulant _not on anticoagulant presents with active epistaxis. The patient is hemodynamically stable without evidence of symptomatic anemia. Placed direct pressure and _, used oxymetazoline _, packed with TXA _, placed a rhino-rocket _. Could not control bleeding despite all measures above so ENT consulted _.
Hyper/hypoglycemia
Hyperglycemia MDM
This patient presenting with apparent acute hyperglycemia. Considered DKA versus HHS, sepsis as possible etiologies of the patient’s current presentation. However, given the current history & physical, including current lab values, the current presentation is consistent with acute, asymptomatic hyperglycemia with no signs of DKA or HHS. Patient non toxic appearing with no signs of infection or ischemia. Patient advised to follow up with PMD for better blood sugar control.
DKA MDM
This patient presents with hyperglycemia and symptoms concerning for DKA. Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. Considered possible causes of DKA to include infection (intrabdominal infection, UTI, pneumonia), infarction / ischemia (acute coronary syndrome, cerebral vascular accident, pulmonary embolism), medication non-compliance with insulin therapy, illicit substance abuse, iatrogenic (including prescription medications and drug-drug interactions), idiopathic causes. Most likely etiology at this time is _. Patient given fluids and started on insulin drip, admitted to MICU _.
Hypoglycemia MDM
This patient presents with symptoms and labs consistent with acute hypoglycemia, most likely due to _. Considered other etiologies of acute hypoglycemia to include drugs (anti-hyperglycemics, alcohol, beta blockers, ACE-I, APAP) or drug related error (missed meal, incorrect dosing, intentional overdose), systemic illness (sepsis, acute coronary syndrome, renal / hepatic failure, adrenal insufficiency), malignancy, or post-op complications such as Gastric bypass. Presentation not consistent with other acute emergencies related to hypoglycemia.
Renal failure / electrolyte abnormalities
Renal failure MDM
Patient presents with renal failure with uncertain cause but likely due to longstanding DM/HTN_. Patient not taking any nephrotoxic medications_. UA was remarkable for _. Renal ultrasound ordered_, urine lytes sent off_. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. Patient admitted to medicine for further work up and possible initiation of hemodialysis.
AVF hemorrhage MDM
Patient presented with bleeding over their fistula site which was controlled with _. This patient’s fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem.
Hyperkalemia MDM
Asymptomatic no ekg changes
Patient found to have asymptomatic hyperkalemia with no ecg changes likely secondary to ESRD_. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. Doubt drug induced, unlikely secondary to crush or thermal injury. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _.
Symptomatic, ekg changes
Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to ESRD_. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia, doubt drug induced, unlikely secondary to crush or thermal injury. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Patient given temperazing measures of calcium gluconate, bicarb, insulin, as well as lasix and lokelma_ to reduce potassium level. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _.
Hyponatremia MDM
Patient found to be hyponatremic to _ Patient mentating normally. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. Labs are not consistent with adrenal insufficiency. Patient euvolemic on exam so likely cause is SIADH. Patient not hypervolemic on exam with no history of CHF, cirrhosis, nephrotic syndrome, no acute renal failure.
Psych, Drugs, Alcohol
Psych MDM
This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). Given the H&P, I suspect this patient is suicidal/homicidal/gravely disabled_ and patient was placed on 5150. Psychiatry was consulted and continued patient’s hold. Patient was medically cleared and transferred to psychiatric care.
Panic attack/anxiety MDM
This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Low suspicion for acute cardiopulmonary process including ACS, PE, or thoracic aortic dissection. Denies any ingestions or any other medical complaints. No evidence of alcohol withdrawal symptoms. Given history and physical presentation not consistent with overt toxidrome, ingestion. Presentation not consistent with a medical emergency at this time. No acute indication for psychiatric consultation (without SI/HI, AH/VH). Cautious return precautions discussed with full understanding.
Drug intoxication MDM
Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. Patient maintained their airway. Given clinical picture have low suspicion for thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism. Symptoms treated with ativan. Patient denies suicidal intention or coingestion. Patient offered transferred to rehab facility but declined. Patient observed until clinically sober.
Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. Patient denies suicidal intention or coingestion. Patient offered transferred to rehab facility but declined. Patient observed for __ and was clinically sober at time of discharge. Safe ride home was arranged with __. Patient discharged with prescription for narcan.
Alcohol intoxication MDM
Patient presents with altered mental status likely secondary to EtOH intoxication. Patient maintained his airway, and metabolized to sobriety and no longer altered. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. No infectious symptoms and afebrile so doubt sepsis. Exam prior to discharge shows no evidence of Wernicke's encephalopathy. Patient with no signs of any medical emergencies at this time. Patient observed for until clinically sober. No signs or symptoms of alcohol withdrawal while in the emergency department. Safe ride home was arranged with __. Patient offered transferred to rehab facility but declined.
Alcohol withdrawal MDM
Patient presents in alcohol withdrawal last drink was _ ago. Patient tachycardic with tremors and tongue fasciculations. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_.
Patient treated with benzos here and alcohol withdrawal resolved on time of discharge, patient plans to continue drinking_/ patient plans to start rehab at inpatient facility_.
Patient was persistently in withdrawal despite multiple repeated doses of benzos, plan to admit patient for alcohol withdrawal._
Patient devolved and had withdrawal seizure/delirium tremens/alcoholic hallucinosis plan to admit patient to to ICU._
Sickle Cell
Sickle Cell - pain crisis MDM
This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. Considered alternate etiologies of this patient’s pain to include fracture, MSK pain, infection/abscess, and other ischemic etiologies (stroke, MI) but doubt these are likely. Patient treated with opioids which controlled their pain and they were discharged _. Despite multiple rounds of opioids patients pain was not controlled, so patient was admitted for pain control.
Sickle cell - acute chest syndrome
This patient with known SCD presents with chest/back pain with constellation of symptoms and findings concerning for acute chest syndrome; this presentation is different than the patient’s typical pain crisis. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. Patient given antibiotics, hematology was consulted and patient was admitted _
Signature
-
Christopher O. Brown, MD, MPH
Department of Medicine, Division of General Internal Medicine
Harbor-UCLA Medical Center
Pager: p0004
Preferred Communications: Microsoft Teams or Outlook
Skin Tag / Wart
- Skin Tag or wart removal
PRE-OP DIAGNOSIS: _
POST-OP DIAGNOSIS: Same
PROCEDURE: skin lesion excision
Performing Physician: _
Supervising Physician (if applicable): _
PROCEDURE:
_ Shave Biopsy _ Scissors _ Cryotherapy _ Punch (Size _)
The area surrounding the skin lesion was prepared and draped in the usual sterile manner. The lesion was removed in the usual manner by the biopsy method noted above. Hemostasis was assured.
Closure: _ Monsel’s for hemostasis _ suture _ _ None
Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.
Spontaneous Bacterial Peritonitis SBP
- SBP
Abdominal pain, distention, ascites, and > 250 PMNs on ascitic fluid consistent w/ diagnosis in a known liver cirrhosis patient. Pt also having concurrent renal dysfunction (Cr 1.11 -> 1.43) for which albumin is started (Tbili > 4.0 as well, PTT > 30). SAAG ~ 2.0 c/w portal HTN.
- Ceftriaxone 2g daily (expect 5d course)
- Albumin 1.5g/Kg Day 1, 1.0g/Kg Day 3
- Daily CBC/BMP
- RUQ U/S w/ doppler
- Hold propranalol as non-selective BB assx w. worse outcomes in SBP
- Upon completion of treatment, expect ppx abx outpatient given high risk of repeat SBP (cirrhosis, 1 episode SBP, hx of GI bleeding, renal dysfunction)
Stroke
- Stroke
- EKG/CXR
-UA, UTox, Troponin, TSH, fasting lipid panel, HbA1c, PT/INR/PTT, RPR, HIV (with patient consent), blood EtOH
- pregnancy test
- noncontrast CT head
- CT angio of head and neck (Cr <1.5) OR MRA of head/neck OR Carotid U/S
- TTE, no bubble study (bubble study for <50 y/o with no risk factors or older patient with likely embolic stroke)
- MRI brain w/o contrast
- stroke in age <50: confirm on MRI first, then consult heme (ANA, ESR, CRP, ANCA, Factor 5 Leiden, homocysteine, protein C, protein S, lupus anticoagulant, anti-b2 glycoprotein, anticardiolipin, antithrombin 3, rheumatoid factor, sickle cell, prothrombin gene mutation 20210 A, MTHFR)
- permissive HTN for 24 hours after onset, goal SBP < 220, IV labetalol 10mg q10min PRN
- PT/OT/SLP pending
- q4hr neuro checks
- ASA 81mg daily, consider clopidogrel 75mg daily
- atorvastatin 80mg daily
-
- NIHSS:
- Localization:
- ASA 81mg PO qday
- Lipitor 80mg PO qday
- Permissive BP for first 24H. Goal <220. Labetolol 100mg PO prn BP>220/110
- MRI Head, MRA Head/neck ordered
- TTE ordered
- HbA1c, FLP, RPR, CRP ordered
cirrhosis ascites aki
- This is a ***y/o ***man/woman with cirrhosis c/b ascites and baseline ***Cr of ~2 who presented to paracentesis clinic and found to have AKI with Cr *** on POC. Patient requires inpatient admission for albumin 1g/kg IV q6hrs which cannot be done in the outpatient setting.
- Avoid nephrotoxic agents/NSAIDs
- Renally dose medications
- Continue to monitor***
Substance Use Disorder Hotlines
- L.A. County Substance Abuse Service Helpline
(844) 804-7500
California Substance Use Line:
(844) 326-2626
CA Poison Control Hotline (24/ 7)
(800) 222-1222
UCSF Substance Use Warmline (Addiction-certified MD, RN, clinical pharmacists)
(844) 326-2626
M-F 6am-5pm; Voicemail 24/ 7
National Substance Use Warm Line
(855) 300-3595
Substance Use Disorder ROS
- Denies abdominal pain, nausea, vomiting, diarrhea, tactile/auditory/visual disturbances, seizures, loss of consciousness, anxiety.
Substance Use Disorder Screen
- NIDA Quick Screen: In the past year, how often have you used the following:
- Alcohol: Never▼
--(if positive)--> Perform AUDIT-C
--(if positive, >3)-> Perform ASSIST; If negative, implied negative AUDIT
--Provider notified if >10 (Low Risk 0-10, Moderate Risk 11-26, High Risk 27+)
- Tobacco: Never▼
--(if positive)-> Perform Fagerstrom Test
- Marijuana and/or Cannabis Products: Never▼
--(if positive)-->Perform ASSIST
--Provider notified if >3 (Low Risk 0-3, Moderate Risk 4-26, High Risk 27+)
- Illicit Drugs/Prescription Drugs: Never▼
--(if positive)-->Perform ASSIST
--Provider notified if >3 (Low Risk 0-3, Moderate Risk 4-26, High Risk 27+)
syncope - ddx
- - Vasovagal:
- Electrolytes: Na, BUN
- Metabolic: Hypoglycemia, hyper/hypothyroid.
- Orthostatic:
- Cardiac Arrhythmia: Will place on telemetry x24 hour
- Vascular: Stroke/MI
- Neurogenic: Hydrocephalus, Migraine, Panic Disorder, Seizure
- Trauma:
- Situational: Micturition, Defecation, Posttussive, or Swallow.
Syncope - Admit, Assessment
- This patient presents with symptoms consistent with syncope, most likely due to _. Differential diagnosis includes reflexive syncope (vasovagal). Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage (stable hgb). Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry.
- MDM Syncope low risk
- Given history, exam and workup, low suspicion for HF, ICH (no trauma, headache), seizure (no witnessed seizure like activity, no postictal period, tongue laceration, bladder incontinence), stroke (no focal neuro deficits), HOCM (no murmur, family history of sudden death), ACS (neg troponin, no anginal pain), aortic dissection (no chest pain), malignant arrhythmia on ekg or any family history of sudden death, or GI bleed (stable hgb). Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. Based on canadian syncope rule, patient is low risk and well appearing here, plan to discharge the patient home with PMD follow up.
# T
TAVR
- TAVR protocol
TAVR CT order
CT heart
CTA thorax w/ and w/o
CT abd/pelvis w/ and w/o
18G R AC IV
No nitro, no new BB (unless if already on standing dose)
Indication: AS/TAVR CT
Call 65245 and tell techs in am of TAVR CT
(And ask to page 0240, Chung MD when pt in the room)
TIA Transient ISchemic Attack
- #c/f TIA
- s/p Plavix Load 300mg x 1
- started on ASA 81mg QDay and Plavix 75mg QDay
- started on Atorvastatin 80mg QHS, can adjust pending lipid panel
- follow up UA, UTox, TSH, Fasting Lipid Panel, HbA1c
- pending MRI brain w/o contrast
- TTE r/o cardioembolic sources
- Permissive HTN for 24 hours after onset, goal SBP < 220, labetalol 10mg q10minx3 prn
- ok off monitor for studies
- q4hr neuro checks
TR band
- TR Band Removal
TR band removed from ***left/right*** radial access site by serial deflation in the usual fashion. Upon removal, no hematoma was noted and radial access site was without bleeding. Patient denied arm or wrist pain. Radial pulses 2+ and distal extremity neurovascularly intact. Access site was covered with gauze and a Tegaderm. Instructed patient to notify medical care team if bleeding recurs.
Thrombocytopenia | Low Platelets
- # Thrombocytopenia
Differential: Production vs Destruction vs Sequestrative/Dilutional.
- Destructive
- Ex: TTP/HUS/ITP/DIC/drug-induced/Pregnancy (HELLP)/drug-induced immune mediated/rheum conditions from secondary ITP
- review recent drugs (penicillins/Vanc/PPI/heparin-products)
- orders: Retic count/LDH/Hapto/Fibrinogen/DDimer/peripheral smear
- Production
- Ex: Infiltrative process (MM, MDS, AML, CLL) should have other cell line dyscrasias
- Ex: acute illness (sepsis), HIV, Hep C, H. Pylori
- Ex: Alcohol/Dapto/Linezolid (direct cytotox, bone marrow suppression, nutritional def)
- orders: B12/Folate/MMA/Homocysteine
- Sequestrative/Dilutional
- lots of IVFs? (>3L)
- US Abdomen for splenomegaly
- Plan
- transfuse as necessary (<10, <20 febrile, <50 bleeding)
Testicular Pain, Assessment
- The patient is suffering from testicular pain, but based on the history, exam, and work up, I do not suspect that the patient has testicular torsion, abscess, severe cellulitis, Fournier’s gangrene, orchitis, epididymitis, inguinal hernia or other emergent cause.
Thoracentesis
- Thoracentesis Procedure Note
INDICATION:
PROCEDURE OPERATOR: _
ATTENDING PHYSICIAN: _
CONSENT:
[_] During the informed consent discussion regarding the procedure, or treatment, I explained the following to the patient/designee:
a. Nature of the procedure or treatment and who will perform the procedure or treatment.
b. Necessity for procedure and the possible benefits.
c. Risks and complications (most common and serious).
d. Alternative treatments and the risks, benefits and side effects of each (including no treatment).
e. Likelihood of the patient achieving his/her goals without this procedure and surgery treatment.
f. Problems that might occur during the recuperation.
g. Conflicts of interest, if any
[_] The procedure was emergent, the patient was unable to provide consent, and a designee was not immediately available.
PROCEDURE SUMMARY:
A time out was performed and the chest x-ray was reviewed, the appropriate side was confirmed and marked. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask, sterile gown and sterile gloves throughout the procedure. The patient was prepped and draped in a sterile manner using chlorhexidine scrub after the appropriate level was percussed and confirmed by ultrasound. 1% lidocaine was used to anesthesize the skin, subcutaneous tissue, superior aspect of the rib periosteum and parietal pleura. A finder needle was then introduced over the superior aspect of the rib to locate the pleural fluid; _ colored fluid was aspirated at a depth of approximately _ cm. A 10-blade scalpel was used to nick the skin at the insertion site. The thoracentesis catheter/needle was then introduced through the skin incision into the pleural space using negative aspiration pressure and the red colormetric indicator to confirm appropriate positioning of the needle. The thoracentesis catheter was then threaded without difficulty. _ ml of _ colored fluid was removed without difficulty. The catheter was then removed. No immediate complications were noted during the procedure. A post-procedure chest x-ray is pending at the time of this note. The fluid will be sent for studies. Estimated blood loss is _.
Tylenol Overdose
- 150mg/kg loading, 50mg/kg/hr over 4hrs, 100mg/kg/hr over next 16 hrs (20hours total)
Indications to continue NAC:
- elevated ALT near end of first round OR detectable tylenol level -> start 6.25mg/kg/hr for 16hrs
- check ALT/INR/Tylenol Q12H
- stop therapy once:
- Tylenol <10 (undetectable)
- Downtrending ALT x2
- INR<2 or downtrending
Trigger Finger Injection
- Trigger Finger
Procedure: Trigger Finger Injection
Operator: Jessica Matthiesen
Supervisor: Dr. Abhat
My hands were washed prior to the procedure and clean gloves were worn. The movement of the swollen part of the tendon in the palm was felt by palpation prior to the procedure. The injection location is marked and the skin is cleansed. A thin needle is inserted perpendicular towards the tendon and the patient is asked to flex her finger until the tip of the needle touches the surface of the tendon, making the syringe tilt forward during finger flexion. At this point, the needle is retracted about 1 mm, and the finger is flexed again to ascertain that the tip of the needle is not in the tendon any more. 1 ml of methylprednisolone and bupivacaine is injected into the tendon sheath C. The injection site is covered with a band-aid.
Troponin Elevated
- #elevated troponin
Trop elevated to __. Likely 2/2 demand ischemia. EKG with no evidence of ischemia.
- trend trop to peak
# U
Unstable Angina
- Unstable Angina
Patient presented with constant/worsening chest pain since AM, associated with nausea/diaphoresis/dizziness/SOB. Hx/no hx of ACS. Prior cath in (month/year) with (findings). Troponins were _____ and _____ . Ekg with ______. Plan for heparinization and cath this admission.
- Antiplatelet: aspirin 81mg PO daily
- Afterload reduction: restart home (insert anti-hypertensive)
- B-blocker: coreg 6.25 mg PO BID
- Cholesterol: atorvastatin 80mg PO daily
- Lovenox 80mg BID, maintain for 48 hours.
- Continue trending troponin and ECG Q6H until peaks and downtrends x 2
- Plan for L heart cath (date); clear liquid diet at midnight prior to cath
Unstable Angina, AP
- # Chest pain concerning for unstable angina
# History of vasospastic angina
# Coronary artery disease, last cath 1/30/2020 at UCI
- #Chest pain concerning for unstable angina
#History of vasospastic angina
#Coronary artery disease, last cath @@@ at @@@
Status post aspirin load in the emergency department, on heparin gtt. CXR neg for any acute process. s/p LHC ****, showed normal coronary arteries. Cardiology following, appreicate recs
- Continue aspirin 81
- Continue verapamil immediate release 80 mg every 8 hours.
- Up titrate per cardiology
- Consider Ranexa and nitrates
- Continue albuterol PRN for dyspnea
- TTE pending
# V
Vasospastic Angina
- #Chest pain concerning for unstable angina
#History of vasospastic angina
#Coronary artery disease, last cath @@@ at @@@
Status post aspirin load in the emergency department, on heparin gtt. CXR neg for any acute process. s/p LHC ****, showed normal coronary arteries. Cardiology following, appreicate recs
- Continue aspirin 81
- Continue verapamil immediate release 80 mg every 8 hours.
- Up titrate per cardiology
- Consider Ranexa and nitrates
- Continue albuterol PRN for dyspnea
- TTE pending
Volume Overload
- - spot dose IV lasix for goal of negative 2-3L daily
- strict Is &Os, daily weights
- fluid restrict to 1L
- BMP q12hr, replete lytes as needed
Volume Overload | Assessment
- Patient presents for swelling and shortness of breath and found to be volume overloaded on exam likely secondary to renal failure _, heart failure _, nephrotic syndrome _, cirrhosis based on history, exam, and work up. Patient was given lasix_, nephrology consulted and patient was dialyzed. Patient admitted for volume overload.
# W
Wards Checklist
- FEN/GI/PPX
Diet:
DVT ppx:
GI ppx:
Pain regimen:
Lines/Catheters:
Fluids:
Code Status: full
Dispo:
Contact:
- Wards Checklist
Level of Care:
Diet:
Fluids: none
Analgesics: none
DVT prophylaxis: lovenox
Ulcer PPx: none
Glucose:
Activity: up w assistance
BM: none
Lines: PIV
Sleep aid: melatonin
Nausea PRN: none
Code Status: full
Contact:
Wards Checklist
- #FEN/GI/PPX
Diet: renal
GI PPX: none
DVT PPX: Heparin
Bowel Regimen: None
Lines/catheters: 20g R PIV
Fluids: none
Code status: FULL
Contact: TBD
Discharge Plan: TBD
Patient requires acute care hospitalization for: Acute on chronic renal failure
Anticipated Discharge Date: TBD
Anticipated Discharge Location: Home
Anticipated Discharge Mode of Transportation: Private vehicle
Are patient and family aware of discharge plan? Yes
Clinical goals or barriers to overcome prior to discharge:
Logistical needs for a safe discharge: TBD
Withdrawal, Assessment
- __[MDM](https://natedotphrase.com/tag/mdm/)__
- This _ patient presents with tremulousness, vomiting, and recent ETOH abuse suspicious for withdrawal. DDx includes intoxication, other toxidromes or withdrawal states, infection, metabolic derangements. Nontoxic appearing_. Considered other causes of patient’s vital sign abnormalities including primary cardiopulmonary etiologies such as ACS, PE, PNA but think these are unlikely. Doubt acute intraabdominal process.
- Plan: BZDs, fluid resuscitation, labs, monitoring, _
# X
# Y
# Z
death note
- Briefly, this is a ___ year old patient who was admitted and treated for ____(major medical illness)____.
At (date and time), I was notified by the nurse that the patient was pulseless and not breathing.
Patient was ___(full code, DNR/DNI, DNR/DNI on comfort care)____ at the time of passing.
(Describe here if resuscitation efforts were provided, for example, 6 cycles of CPR, epinephrine, bicarbonate, intubation)
On physical exam, Patient was unresponsive to painful stimulation.
Heart and lung sounds are absent. No spontaneous cardiac or respiratory activity. No pulses palpated in all 4 ext or carotids BL. Patient is not responding/nonreactive to verbal or painful stimuli. Pupils _Nonreactive_blown and fixed. No gag or corneal reflexes noted.
The patient was pronounced dead at __(time)__ on _(date)___. Cause of death:
Patient’s family and patient’s nurse were present in the patient’s room.
Spoke with family in the room. Family ___(does or does not)____ want the patient to have an autopsy. Condolences were provided to the patient’s family.
Attending Dr. _ notified. One Legacy contacted at _; #_
eye abbreviations
- ===================
AAU: acute anterior uveitis
AFT: artificial tears
AGV: Ahmed glaucoma valve
ARMD or AMD: age-related macular degeneration
DR: diabetic retinopathy
BRAO: branch retinal artery occlusion
BRVO: branch retinal vein occlusion
BULB: bilateral upper lid blepharoplasty
BVS: borderline visually significant
C/D: cup-to-disc ratio
CEIOL: cataract extraction with insertion of intraocular lens
CME: cystoid macular edema
CRAO: central retinal artery occlusion
CRVO: central retinal vein occlusion
CSME: clinically significant macular edema
CS: cortical spoking (cataract)
CSR: central serous retinopathy
DES: dry eye syndrome
DME: diabetic macular edema
DWC: dense white cataract
ED: epithelial defect
EL: endolaser
ERM: epiretinal membrane
FML: focal macular laser
GS: glaucoma suspect
HST: horseshoe tear
HVF: Humphrey visual field
K: cornea
LH/WC/AFTs: lid hygiene, warm compresses, artificial tears
LPI: laser peripheral iridotomy
MMCR: Muller's muscle conjunctival resection
MP: membrane peel
NCVH: non-clearing vitreous hemorrhage
NPDR: non-proliferative diabetic retinopathy
NS: nuclear sclerosis (cataract)
NTG: normal tension glaucoma
NVG: neovascular glaucoma
NVS: not visually significant
OD: right eye
OHTN: ocular hypertension
OS: left eye
OU: both eyes
POAG: primary open angle glaucoma
PCO: posterior capsular opacity (aka, secondary cataract)
PDR: proliferative diabetic retinopathy
PKP: penetrating keratoplasty (aka corneal transplant)
PPV: pars plana vitrectomy
PRP: pan retinal photocoagulation
PSC: posterior subcapsular cataract
PTG: pterygium
PVD: posterior vitreous detachment
RRD: rhegmatogenous retinal detachment
RT: retinal tear
SB: scleral buckle
SRD: serous retinal detachment
Trab: trabeculectomy
TRD: tractional retinal detachment
VA: visual acuity
VH: vitreous hemorrhage
VS: visually significant
XT: exotropia
YAG cap: YAG capsulotomy
===================
geriatrics HPI
- Geriatric Consultation Initial Consult Note
Primary Service: _ [press F3 to tab to the next underscore]
Attending Requesting Consult: _
Geriatrics Attending: _
Primary Care Physician: _
Reason for Consultation: _
History of Present Illness:
_
Review of Systems:
Constitutional:
HEENT:
CV:
Resp:
GU:
GI:
Msk:
Integumentary:
Neuro:
Psych:
Endocrine:
Hematologic:
Allergies: _
Past Medical Hx:
_
Past Surgical Hx:
_
Home Medications:
//meds-home_
Inpatient Medications:
//meds-inpatient_
Inpatient Diet:
_
Social History:
Lives with: _
Lives where: _
Family/Children/Social Support: _
Language: _
Level of education/Literacy: _
Occupation: _
EtOH: _
Smoking: _
Drugs: _
Physical Exam:
Vitals: //vitalsdd_
Orthostatic BP: _
Ht: _ Wt: _ BMI: _
General: _
HEENT: _
Neck: _
Pulm: _
Cardiac: _
Abd: _
GU/Rectal: _
MSK: _
Skin: _
Neuro: _
Mental Status: _
Gait: _
Balance: _
Neuromuscular: _
Labs & Studies:
(to auto-populate labs in ORCHID, you just type // and a list will pop-up and you can pick latest labs of interest ie CBC, Chemistry, etc)
(to bring in results of imaging and other studies reported, have to open report and then can copy and past or can highlight area and “tag” it, which will save it and then you can move the “tagged” text into the area in your note where you want the results listed)
GERIATRIC ASSESSMENT:
Primary Care Physician: _ Tel/Fax: _
Preferred Pharmacy: _
Insurance: ( _) Medicare ( _) Medi-Cal (_)Other
Hospital Patient Safety:
Delirium: Confusion Assessment Method: _/5 (Positive Screen >=4/5)
Cognitive: Mini-Cog (Positive Screen 0-2) or AD8 Interview (Positive Screen >=2), MoCA _ RUDAS _
Age & Weight Adjusted GFR (Cockcroft-Gault): _
Age-related Medication Issues: _
Incontinence: ( )Yes ( )No
Skin Evaluation: (_)Yes ( ) No Pressure Ulcer(s)
History of Falls (see below): ( )Yes ( ) No
Mobility/Falls:
Vision Problems:
Hearing Evaluation (whisper test):
Assistive Device:
Fear of Falling: (_)Yes ( ) No
Fallen in past year: (_)Yes, What Circumstance? ( )No
Function & Frailty:
Basic Activities of Daily Living (ADLs) _/6 (dress, feed, toilet, transfer, bathing, continence)
Instrumental Activities of Daily Living (IADLs) X/8 (housekeeping, laundry, food prep, transportation, shopping, finances, medications, telephone use)
FRAIL Score: _/5 (_) Frail
Medication Management: _
Life Expectancy (ePrognosis.ucsf.edu): _
Psychosocial & Advance Care Planning:
Mood: PHQ-2:__ (Positive Screen >=1)
PHQ-9 __ (1-4 min depression; 10-14 moderate depression; 20-27 severe depression)
Medical Decisions: _
Spokesperson/Relationship: _
Caregiver(s): _
Medical Durable Power of Attorney: _
Advance Directive: _
Advance Care Planning Form Updated in ORCHID: (_) Yes
Preferences: _
(_) POLST
(_) DNR/DNI
IMPRESSION: (Your one-liner, include baseline function)
_
Assessment/Plan: (Write and discuss all medical problems for trauma/surgical pts)
_
Geriatric Syndromes/Problems:
_
#. eConsult to the Geriatrics Navigator for Community Services
SUMMARY OF RECOMMENDATIONS: (keep brief and at the most 5 recs)
1.
2.
3.
4.
5.
Please contact geriatrics prior to discharge to assist w/ medication reconciliation
Thank you for allowing us to participate in this patient’s care. Case discussed with geriatrics attending, Dr. _.
Please call us at p0840 with any questions or comments.
For urgent issues after 8 pm to 8 am call 310-501-1325
geriatrics ros
- Constitutional: no fevers, chills, weight loss
HEENT: no acute vision, hearing changes
CV: no CP, palpitations
Resp: no cough, SOB
GU: no dysuria
GI: no n/v/d
Msk: no arthralgias / myalgias
Integumentary: no rashes
Neuro: no numbness or weakness
Psych: no depression or agitation
Endocrine: no tremors, heat/cold intolerance, weight changes
Hematologic: no bleeds
groin check
- Groin Check Note
*Right Femoral Access Eval post-cath
- Subjectively, patient has minimal pain at site
- Site is c/d/i, no hematoma, no ecchymosis. There is small amount of oozing blood
- 2+ femoral pulse on R side
- DP pulse was palpable, PT pulse obtained via Doppler
- Plan: apply pressure dressing and reassess in 2 hours
*Left Femoral Access Eval post-cath
- Subjectively, patient has minimal pain at site
- Site is c/d/i, no hematoma, no bruit, no ecchymosis, no bleeding
- 2+ femoral pulse on L side
- DP pulse palpable; PT pulse was obtained via Doppler
Plan: continue bedrest given small amount of oozing blood on right fem access site
or
Plan: up ad lib, nurse and patient instructed to alert physician to any bleeding, pain, or swelling.
hpi - GI
- Constitutional: no fevers, chills, weight loss
HEENT: no acute vision, hearing changes
CV: no CP, palpitations
Resp: no cough, SOB
GU: no dysuria
GI: no n/v/d
Msk: no arthralgias / myalgias
Integumentary: no rashes
Neuro: no numbness or weakness
Psych: no depression or agitation
Endocrine: no tremors, heat/cold intolerance, weight changes
Hematologic: no bleeds
p - new med discussion
- Discussed side effect profile of statin▼as below. Risks and benefits discussed at detail. Patient amenable to starting today▼. Patient education provided. Strict return precautions advised (abdominal pains, diarrhea, loss of consciousness, dysuria.▼).
p./e - clinic
- General: No acute distress, answering questions appropriately. Normal body habitus, appears stated age.
HEENT: MMM, no LAD
CV: RRR, normal s1,s2, no m/g/r
Resp: CTABL, no w/r/r
Abdominal: Soft, nontender, nondistended. Normoactive bowel sounds
Extremities: Extremities warm, 2+ radial, DP, PT pulses b/l. No lower extremity edema b/l.
Neuro: AAOx3
p.e. gen
- Gen: No acute distress. No pallor or jaundice. Appropriate affect.
Ext: Moving all extremities normally
p.e. phone visit
- Patient not directly examined during this telephone consultation.
- Gen: Speaking in full sentences. Speech coherent, not slurred.
p.e. video
- Gen: Speaking in full sentences. Speech coherent, not slurred.▼
Neuro: Alert and fully oriented.▼
Ext: Moving all extremities normally. No sign of edema.▼
Skin: No sign of rash in _▼
Surroundings: no sign of clutter, filth.▼
p/e abdominal pain
-
Abdomen soft, non-tender, without rebounding, guarding. No hepatosplenomegaly. No palpable masses or shifting dullness.
Negative Murphy's sign.▼
please
- Please see old notes for chronic / resolved problems
quick clot removal
- Quick Clot Removal:
Quick Clot removed from *** radial access site by cutting off remaining alternating bands. Upon removal no hematoma or bleeding was noted. Distal extremity neurovascularly intact.
Arteriotomy site covered with 2x2 gauze and Tegaderm. Instructed patient and bedside nurse to page if there is any bleeding.
sarcastic letter
- Dear Dr. ,
I hope this message finds you well.
Please do not hesitate to reach out to me with any further questions.
Warmest regards,
Christopher M. Armenia, M.D.
Department of Internal Medicine
Harbor-UCLA Medical Center
strict return precautions
- Strict return precautions advised (Fevers or worsening pain▼).
voicemail
- Attempted to call patient at phone number listed in the chart. Patient did not answer.
Left a voicemail saying
Patient did not have voicemail set up / voicemail was full.
Result - Copy and paste this output:
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