Progress Note – VALON

MEDICINE INTERIM PROGRESS NOTE/MULTIUSE NOTE
|PATIENT NAME FIRST,LAST| |PATIENT SSN|
ADMISSION DATE: |ADMISSION DATE|
ADMISSION DIAGNOSIS: |ADMITTING DX|
_________________________________________________



24hr events:
[conditional field="No_adverse_events_overnight" condition="(No_adverse_events_overnight).is('')"]No adverse events were reported overnight.[/conditional][conditional field="Adverse_events_overnight" condition="(Adverse_events_overnight).is('')"]Overnight, the patient [textarea memo="" rows="2"].[/conditional][conditional field="Afebrile" condition="(Afebrile).is('')"]Patient is currently afebrile.  [/conditional][conditional field="Febrile" condition="(Febrile).is('')"]Patient is currently febrile with a temperature of [text name="temp_febrile" default=""]. [/conditional][conditional field="No_flatus" condition="(No_flatus).is('')"]Patient has had no flatus and [/conditional][conditional field="Flatus" condition="(Flatus).is('')"]Patient has had flatus and [/conditional][conditional field="No_BMs" condition="(No_BMs).is('')"]has had no bowel movements. [/conditional][conditional field="BMs" condition="(BMs).is('')"]has had [text name="number_BMs" default=""] [select name="character_BMs" value="|loose|formed"] stools.[/conditional] [conditional field="Not_ambulating" condition="(Not_ambulating).is('')"]As of yesterday afternoon, patient has not ambulated. [/conditional][conditional field="Ambulating" condition="(Ambulating).is('')"]As of yesterday afternoon, patient has ambulated [select name="times_ambulating" value="|1|2|3|4|5|6|7|8|9|10"] times.[/conditional] 


[comment memo_color="blue" memo="LABS"]
[checkbox name="VS_WNL" memo="VS WNL" value=""][checkbox name="VS_Abnormal" memo="VS Abnormal" value=""]
[checkbox name="CMP_WNL" memo="CMP WNL" value=""][checkbox name="CMP_Abnormal" memo="CMP Abnormal" value=""]
[checkbox name="CBC_WNL" memo="CBC WNL" value=""][checkbox name="CBC_Abnormal" memo="CBC Abnormal" value=""]
 

SUBJECTIVE:
[text name="name" default=""] is a [text name="age" default=""] year-old [select name="sex" value="|male|female"] with a past medical history of [text name="hx" default=""] and is currently post-op day [select name="pod" value="|1|2|3|4|5|6|7|8|9|10"] following a [text name="proc" default=""]. This morning, the patient reports feeling "[text name="variable_1" default=""]". Last pain score was [select name="painscore" value="|1|2|3|4|5|6|7|8|9|10"]/10 obtained at [text name="paintime" default=""] currently being managed with [text name="paindrug" default=""]



Problem List
|PROBLEM LIST BRIEF|

 

 

OBJECTIVE:
=============
VITALS
Temp: |TEMPERATURE|
BP: |BLOOD PRESSURE|
HR: |PULSE|
RR: |RESPIRATION|
O2: |POX|
Weight: |PATIENT WEIGHT|
BMI: |BODY MASS INDEX|
Pain: |PAIN|

 

|WEIGHT-LAST 3|

 


PHYSICAL EXAM
Gen: laying in bed in NAD
HEENT: NC/AT, EOMI, PERRL, MMM, OP clear
Neck: supple, no cervical LAD, no JVD
Heart: Normal rate and regular rhythm, normal S1 and S2. No murmurs.
Pulm: Clear to auscultation bilaterally, no wheezes or crackles
Abd: soft, non-tender, non-distended. active bowel sounds
Exts: no edema, clubbing, cyanosis. Warm and well perfused
Neuro: A&Ox4, normal speech, motor and sensory grossly intact


 

I&Os
in:
out:
net:
uop:

 

 

ACTIVE MEDICATIONS:
|ACTIVE MEDICATIONS|

 

LABS

 

CBC
|HS:SCL1-CBC-AFTER10/14-5;10Y|

 

CHEMISTRY
|LAB-SODIUM;1;1Y|
|LAB-POTASSIUM;1;1Y|
|LAB-CHLORIDE;1;1Y|
|LAB-CO2;1;1Y|
|LAB-BUN;1;1Y|
|LAB-CREATININE;3;1Y|
|LAB-GLUCOSE;1;1Y|
|LAB-CALCIUM;1;1Y|
|LAB-MAGNESIUM;1;1Y|
|LAB-PHOSPHORUS;1;1Y|

 

LFTS
|LAB-PROTEIN,TOTAL;3;1Y|
|LAB-ALBUMIN;1;1Y|
|LAB-AST;1;1Y|
|LAB-ALT;1;1Y|
|LAB-ALK PHOS;1;1Y|
|LAB-BILIRUBIN,TOTAL;1;1Y|

 

COAGS
|LAB-PT;3;1Y||LAB-PTT;3;1Y||LAB-INR;3;1Y|
|LAB-A1C;1;1Y|
|LIPID PROFILE|

 

UA
|LAB-UA;1;1Y|

 

IMAGING/PROCEDURES/PATHOLGY

 

|IMAGING T-60|

 

 

_________________________________________________

 

ASSESSMENT/PLAN:
====================

 

|PATIENT NAME FIRST,LAST| is a [text name="variable_3" default=""] y.o. [select name="variable_4" value="male|female"] that is hospital day [text name="variable_5" default=""] for [select name="variable_16" value="***|A|Abdominal Pain|Alcohol Withdrawal|Altered Mental Status / Confusion|B|Bilateral Leg Pain|C|Chronic Obstructive Pulmonary Disease (COPD)|Confusion / Altered Mental Status|D|Diabetes Mellitus|E|Ethanol abuse|F|G|H|Headache|I|Intractable Headache||Intractable Back Pain|J|K|L|Left Leg Pain|M|N|Nausea|Nausea + Vomiting|O|P|Paresthesia|Pulmonary Exacerbation Secondary To Cystic Fibrosis|Q|R|Right Leg Pain|S|Shortness of Breath (SOB)|Shortness of Breath (SOB) Secondary To Congestive Heart Failure Exacerbation|Shortness of Breath (SOB) Secondary To Suspected Congestive Heart Failure Exacerbation|Sickle Cell Crisis|T|Type I Diabetes|Type II Diabetes|U|V|Vaso-Occlusive Crisis|W|X|Y|Z"] 

[checkbox memo="COVID MDM" name="variable_75" value=""][conditional field="variable_75" condition="(variable_75).is('')"][textarea cols=80 rows=5 default="This patient was evaluated in the context of a global pandemic and severe resource limitations which necessitated consideration that the patient may be at risk for infection with COVID-19. Institutional policies and protocols about patient management for COVID-19 are currently in a state of rapid change and guided by CDC, federal and state regulatory bodies. These policies and algorithms were followed during the patient's care.

Patient is aware to return to the ED for any worsening of shortness of breath, lethargy, or dizziness.

**Send out COVID test sent. Anticipatory guidance guven. Patient informed that he should self isolate until 10 days has passed since symptom onset or 3 days without symptoms.

**Patient with possible COVID but symptoms are mild and patient with no high risk features or indication for testing. Patient educated on importance of self-quarantine - handout given. List of testing centers provided."][/conditional][checkbox memo="COVID DCI" name="variable_76" value=""][conditional field="variable_76" condition="(variable_76).is('')"][textarea cols=80 rows=5 default="
*********************************************
Stay well hydrated.
Tylenol for fever, body aches.
Over the counter cough and decongestant medications are safe (as long as you don´t have uncontrolled high blood pressure) and may help the cough and congestion slightly.
Close follow up with a physician is important if you are not improving over the next few days or you experience worsening of your symptoms.
Return to the ER for severe weakness, significant  chest pain or shortness of breath, abdominal pain, or severe headache, neck stiffness , confusion or any other new, worsening, or concerning symptoms.

-If you were tested today - you should expect your results in approximately 4-5 days or sooner.
-If you were not tested today, The test for COVID-19 is free. Call your clinic or the COVID-19 Nurse Advice Line at 844-804-0055 for medical advice. Currently, LA county is testing patients who have symptoms. To schedule an appointment at a county test site, go to covid19.lacounty.gov/testing.

Although it is impossible to know at this point if you have COVID-19 (the Corona virus), here are the current guidelines for self quarantine.
Please quarantine yourself and anyone else that is residing with you for the longer of the following time periods:
-If known COVID + or Symptomatic:  10 days since symptoms onset or positive COVID test OR  3 days after the last of your symptoms has resolved.
-If asymptomatic but close contact with someone with known COVID - self quarantine for 14 days from time of exposure.

See Handout for more detailed information. http://publichealth.lacounty.gov/acd/docs/HomeisolationenCoV.pdf
**************************************************"][/conditional][checkbox memo="Ddx abd pain LLQ" name="variable_BA" value=""][conditional field="variable_BA" condition="(variable_BA).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes diverticulitis, perforation, abscess, colitis, IBD, GU pathology, among others."][/conditional][checkbox memo="Ddx abd pain lower female " name="variable_D" value=""][conditional field="variable_D" condition="(variable_D).is('')"][textarea cols=80 rows=5 default="Differential diagnosis entertained was broad with potential high acuity and includes appendicitis, diverticulitis, ectopic pregnancy, ovarian torsion, hemorrhagic ovarian cyst, kidney stone, UTI, small bowel obstruction, volvulus, AAA, pancreatitis, among others. Considering pt’s lack of risk factors for AAA, normal dorsalis pedis pulses, no radiation of pain to the back, and no pulsatile mass felt on exam, the patient's profile was overall low risk for AAA and definitive workup was not pursued. Pt has no significant risk factors for PID, such as multiple sexual partners, history of STDs, vaginal discharge, or any cervical motion tenderness. Pregnancy test is negative, ruling out ectopic pregnancy. Presentation is not consistent with ovarian torsion or hemorrhagic ovarian cyst, pain was not sudden onset, not associated with vomiting, and has no significant tenderness on exam. The patient denies any bloody stool and has no pain out of proportion to exam, and no significant risk factors for mesenteric ischemia such as atrial fibrillation or severe PAD/PVD (peripheral arterial / vascular disease), thus definitive workup to rule out mesenteric ischemia was not pursued. "][/conditional][checkbox memo="ddx abd pain lower male" name="variable_G" value=""][conditional field="variable_G" condition="(variable_G).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes appendicitis, diverticulitis, testicular torsion, kidney stone, small bowel obstruction, volvulus, AAA, pancreatitis, among others. The patient has no significant risk factors for AAA (abdominal aortic aneurysm) such as age over 50 with history of hypertension, connective tissue disorder, or 1st degree relative with AAA. In addition, the patient has normal dorsalis pedis pulses, no radiation of pain to the back, and no pulsatile mass felt on exam. The patient's profile was overall low risk for AAA and definitive workup was not pursued. The patient's presentation is not consistent with testicular torsion. The patient denies any testicular pain, pain was not sudden onset or associated with vomiting. Testicular exam is normal without any evidence of torsion. The patient denies any bloody stool and has no pain out of proportion to exam, and no significant risk factors for mesenteric ischemia such as atrial fibrillation or severe PAD/PVD (peripheral arterial / vascular disease), thus definitive workup to rule out mesenteric ischemia was not pursued."][/conditional][checkbox memo="ddx abd pain rlq" name="variable_H" value=""][conditional field="variable_H" condition="(variable_H).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes appendicitis, mesenteric adenitis, obstruction/volvulus, crohn's disease, gastroenteritis, UTI/pyelo, kidney stone, GU pathology, among others."][/conditional][checkbox memo="ddx abd pain ruq" name="variable_I" value=""][conditional field="variable_I" condition="(variable_I).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cholecystitis, cholelithiasis, biliary obstruction, hepatitis, pancreatitis, obstruction, GERD/PUD, gastroparesis, dehydration."][/conditional][checkbox memo="ddx abd pain upper" name="variable_J" value=""][conditional field="variable_J" condition="(variable_J).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cholecystitis, choledocholithiasis, hepatitis, small bowel obstruction, volvulus,AAA, atypical appendicitis, pancreatitis, gastritis, peptic ulcer disease, among others."][/conditional] [checkbox memo="ddx ams / weakness" name="variable_K" value=""][conditional field="variable_K" condition="(variable_K).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes infection/sepsis, dehydration, anemia, renal failure, electrolyte abnormality, endocrine abnormalities, rheumatologic disorders, tox, neurologic disease."][/conditional] [checkbox memo="ddx asthma" name="variable_L" value=""][conditional field="variable_L" condition="(variable_L).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes asthma/copd, ptx, pneumomediastinum, pneumonia, pleural effusions, bronchitis, restrictive lung disease."][/conditional][checkbox memo="ddx back pain" name="variable_M" value=""][conditional field="variable_M" condition="(variable_M).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes most likely musculoskeletal pain, muscle spasm / sprain, spinal stenosis, vertebral fracture, spinal epidural abscess, spinal epidural hematoma, pyelonephritis, kidney stone, AAA, aortic dissection among others."][/conditional][checkbox memo="ddx bronchitis" name="variable_N" value=""][conditional field="variable_N" condition="(variable_N).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes influenza like illness, bronchitis, pneumonia, dehydration, pharyngitis."][/conditional][checkbox memo="ddx cough/wheezing" name="variable_P" value=""][conditional field="variable_P" condition="(variable_P).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes pneumonia, pleural effusions, ptx, bronchospasm, restrictive lung disease, PE, CHF, pericardial effusion, atypical ACS"][/conditional] [checkbox memo="Ddx Chest Pain" name="variable_A" value=""][conditional field="variable_A" condition="(variable_A).is('')"][textarea cols=80 rows=5 default="Differential includes acute coronary syndrome, pulmonary embolism, pneumonia, aortic dissection, pericardial tamponade, musculoskeletal chest pain, among others. EKG, chest xray and cardiac workup obtained. Final disposition pending results of tests and pt's ED course."][/conditional] [checkbox memo="ddx dysuria female" name="variable_Q" value=""][conditional field="variable_Q" condition="(variable_Q).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cystitis, pyelonephritis, ureterolithiasis, PID/TOA, vaginitis, among others."][/conditional] [checkbox memo="ddx dysuria male" name="variable_R" value=""][conditional field="variable_R" condition="(variable_R).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cystitis, pyelonephritis, ureterolithiasis, prostatitis, urethritis, among others."][/conditional] [checkbox memo="ddx extremity injury / joint pain" name="variable_S" value=""][conditional field="variable_S" condition="(variable_S).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes fracture, dislocation, ligamentous rupture, sprain/strain, contusion/hematoma."][/conditional] [checkbox memo="ddx flank pain left" name="variable_T" value=""][conditional field="variable_T" condition="(variable_T).is('')"][textarea cols=80 rows=5 default="Differential diagnosis kidney stone, pyelonephritis, cystitis, pancreatitis, diverticulitis, colitis, aortic dissection, AAA among others."][/conditional] [checkbox memo="ddx flank pain right" name="variable_U" value=""][conditional field="variable_U" condition="(variable_U).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cystitis, pyelonephritis, ureterolithiasis, prostatitis, urethritis, aortic dissection, AAA among others."][/conditional] [checkbox memo="ddx general admit" name="variable_V" value=""][conditional field="variable_V" condition="(variable_V).is('')"][textarea cols=80 rows=5 default="The patient's presentation appears most consistent with a diagnosis of ******"][/conditional] [checkbox memo="ddx gi bleed lower" name="variable_X" value=""][conditional field="variable_X" condition="(variable_X).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes lower GI bleeding from diverticulosis, arteriovenous malformation, colon cancer, colonic polyps, mesenteric ischemia, hemorrhoids, varices, anal fissures, among others."][/conditional] [checkbox memo="ddx gi bleed upper" name="variable_Y" value=""][conditional field="variable_Y" condition="(variable_Y).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes upper GI bleed from bleeding peptic ulcer, bleeding duodenal ulcer, gastritis, esophageal varices, gastric varices, among others."][/conditional] [checkbox memo="ddx headache" name="variable_Z" value=""][conditional field="variable_Z" condition="(variable_Z).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes primary headache, ICH, central venous sinus thrombosis, meningitis/encephalitis, sinusitis, tumor, and temporal arteritis, among others."][/conditional] [checkbox memo="ddx hyperglycemia / dka" name="variable_AA" value=""][conditional field="variable_AA" condition="(variable_AA).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes DKA, HHNKC, hyperglycemia w/o other complication, dehydration, medication/dietary noncompliance, infectious process, renal failure, electrolyte abnormalities, AKA, uremia, starvation ketosis."][/conditional] [checkbox memo="ddx lightheaded/syncope" name="variable_AB" value=""][conditional field="variable_AB" condition="(variable_AB).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes vasovagal, dehydration, arrhythmia, structural cardiac disease, heart failure, autonomic dysfxn, anemia, seizure, metabolic disorders."][/conditional] [checkbox memo="ddx missed dialysis" name="variable_AC" value=""][conditional field="variable_AC" condition="(variable_AC).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes hyperkalemia, arrhythmia, acidosis, fluid overload, uremia."][/conditional] [checkbox memo="ddx psychiatric" name="variable_AD" value=""][conditional field="variable_AD" condition="(variable_AD).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes suicidal ideation, primary psychiatric disorder such as depression/schizophrenia/bipolar disorder, supratherapeutic ingestion of RX or OTC meds, intoxication, substance induced mood disorder."][/conditional] [checkbox memo="ddx sepsis" name="variable_AE" value=""][conditional field="variable_AE" condition="(variable_AE).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes sepsis/severe sepsis/septic shock,meningitis, UTI, pneumonia, cellulitis, endocarditis, gastroenteritis, emergent abdominal infection, among others."][/conditional] [checkbox memo="ddx vag bleed" name="variable_AF" value=""][conditional field="variable_AF" condition="(variable_AF).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes pregnancy, dysfunctional uterine bleeding, fibroids, cervical/endometrial polyps, vaginal/cervical trauma, cervicitis, coagulopathy, symptomatic anemia."][/conditional] [checkbox memo="ddx vag bleed pregnant" name="variable_AG" value=""][conditional field="variable_AG" condition="(variable_AG).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes threatened abortion, complete abortion, incomplete abortion, inevitable abortion, fetal demise, septic abortion, ectopic pregnancy, molar pregnancy, placental abruption, placental previa, vasa previa, cervicitis, bleeding disorders."][/conditional] [checkbox memo="ddx vague neuro sx" name="variable_AH" value=""][conditional field="variable_AH" condition="(variable_AH).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes ICH, ischemic stroke, TIA, hypoglycemia, seizure or Todd's paralysis, neoplasm, MS, meningitis/encephalitis, intracranial abscess, complicated migraine."][/conditional] [checkbox memo="ddx vertigo" name="variable_AI" value=""][conditional field="variable_AI" condition="(variable_AI).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes BPPV, vestibular neuritis, acute labyrinthitis, meniere's disease, acoustic neuroma, ototoxic drugs, vertebrobasilar insufficiency, cerebellar infarct/hemorrhage, MS, hypertensive encephalopathy."][/conditional]

[checkbox memo="ED Course" name="variable_AZ" value=""][conditional field="variable_AZ" condition="(variable_AZ).is('')"][textarea cols=80 rows=5 default=""][/conditional]

[checkbox memo="MDM ABD PAIN W/ IMAGING + LABS" name="variable_1" value=""][conditional field="variable_1" condition="(variable_1).is('')"][textarea cols=80 rows=5 default="The patient had * ordered to evaluate for an emergent etiology related to the abdomen. Over the course of their emergency department stay, serial abdominal exams were performed. The patient's abdominal imaging did not show any evidence of any emergent process or condition requiring immediate surgery. The patient's labs and serial abdominal exams were reassuring, without any peritoneal signs, and without any obvious source of the patient's symptoms. The patient's symptoms significantly improved, exam upon discharge revealed a benign abdomen, and tolerating oral fluids. The patient appears stable for discharge to follow up with their primary medical doctor in 1-2 days, and understand to return to the ED immediately if symptoms change or worsen. "][/conditional][checkbox memo="MDM ABD PAIN W/O IMAGING + LABS" name="variable_2" value=""][conditional field="variable_2" condition="(variable_2).is('')"][textarea cols=80 rows=5 default="The patient's current symptoms and exam do not appear to be from an emergent process or condition requiring immediate surgery. Although I considered abdominal imaging, given the patient's benign exam, the patient's presentation does not warrant urgent / immediate imaging. At this time, the risk of CT scan and associated radiation likely outweigh the benefits, and thus CT imaging was deferred. The patient also had labs drawn. Results were reassuring, without any identified dangerous source of the patient's symptoms. The patient's symptoms significantly improved, exam upon discharge revealed a benign abdomen without any surgical or peritoneal signs , and tolerating oral fluids. The patient appears stable for discharge with abdominal recheck in 24 hours, and understand to return to the ED immediately if symptoms change or worsen."][/conditional][checkbox memo="MDM ALLERGIC REACTION" name="variable_3" value=""][conditional field="variable_3" condition="(variable_3).is('')"][textarea cols=80 rows=5 default="Pt appears to have an allergic reaction. Pt reported sx consistent with possible angioedema earlier however, the airway is patent and intact and does not appear involved currently. Epinephrine deferred. The patient denies any difficulty breathing. The patient is tolerating po without any difficulty. The symptoms are not worsening and appear resolved. The patient looks great, the findings are minimal and due to nonprogression of symptoms here and loading of antihistamine and steroid medications in the ED, the patient is safe to discharge home. The patient feels comfortable with plan and will return immediately if symptoms begin to worsen. No visible rash or urticaria. The patient is to continue histamine 1 and 2 blockade as well as steroids. The patient was instructed to avoid potential precipitating factor and to follow up with their regular physician and or follow up."][/conditional][checkbox memo="Ddx MDM ANXIETY" name="variable_4" value=""][conditional field="variable_4" condition="(variable_4).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes anxiety attack, generalized anxiety disorder, stress reaction, acute psychiatric break, drug abuse, drug intoxication, drug overdose, among others. The patient denies any suicide attempt, overdose, or ingestion. They exhibit no signs of any severe toxic syndrome or drug / alcohol withdrawal. The patient was observed for a period of time in the ED with serial exams. After serial exams in the emergency department, the patient remains sober and without any suicidal ideation, homicidal ideation or evidence of grave disability.They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. The patient's presentation seems to be consistent with anxiety, without any  evidence of dangerous arrhythmias, thyrotoxicosis, metabolic / endocrinologic emergency, or indication for emergency psychiatric evaluation. The patient appears to be stable for dc home and follow with psychiatry as an outpatient."][/conditional][checkbox memo="MDM ASTHMA ADMIT" name="variable_5" value=""][conditional field="variable_5" condition="(variable_5).is('')"][textarea cols=80 rows=5 default="The patient's presentation seems most consistent with an asthma exacerbation given their wheezing on exam with a history of asthma. Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments. Although the patient has had some minimal improvement in their symptoms, they still have persistent severe dyspnea and their symptoms are unlikely to resolve with typical outpatient therapy so the patient will be admitted for further intensive serial treatments with bronchodilators and close observation.

"][/conditional][checkbox memo="MDM ASTHMA DC HOME W/ X-RAY" name="variable_6" value=""][conditional field="variable_6" condition="(variable_6).is('')"][textarea cols=80 rows=5 default="The patient's presentation seems most consistent with an asthma exacerbation given their wheezing on exam with a history of asthma. Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.   The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids, as well as a refill of their inhaler if needed.

"][/conditional][checkbox memo="MDM ASTHMA DC HOME W/O X-RAY" name="variable_7" value=""][conditional field="variable_7" condition="(variable_7).is('')"][textarea cols=80 rows=5 default="The patient's presentation seems most consistent with an asthma exacerbation given their wheezing on exam with a history of asthma. The patient had wheezing symmetrically on exam, without any rales, fever, hypoxic, productive cough, or evidence of peripheral edema. Chest Xray was not ordered given that pneumonia, pneumothorax, pulmonary edema appear to be extremely unlikely. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.

The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids, as well as a refill of their inhaler if needed.

"][/conditional][checkbox memo="MDM BACK PAIN" name="variable_8" value=""][conditional field="variable_8" condition="(variable_8).is('')"][textarea cols=80 rows=5 default="The patient has normal dorsalis pedis pulses, and no pulsatile mass felt on exam. The patient's profile was overall low risk for AAA and definitive workup was not pursued. The patient has no significant red flags on history or exam. Patient has no history of malignancy, active or distant history. Patient has no fever or midline tenderness making epidural abscess or fracture unlikely.  Patient has no vertebral deformity or midline tenderness and has a normal gait. No mechanism for significant trauma. Presentation not consistent with a vertebral fracture, so definitive imaging not pursued.

Patient has no significant risk factors for spinal epidural emergency such as fever, IVDU, HIV, or anticoagulant use. Patient is neurologically intact without any lower extremity weakness / numbness, saddle anesthesia, urinary retention or fecal incontinence. No evidence of any emergent process of the spinal cord or cauda equina at this time.

No sx of UTI and no CVAT/fever and history is not suggestive of kidney stone.

The patient's symptoms appear consistent with a musculoskeletal origin. Given morphine and flexeril with relief. Remains neuro intact, appears stable for dc home.

The patient was counseled and understand that they need to see their primary medical doctor in the next 1-2 days for reevaluation and further treatment, and to return immediately if symptoms change or worsen. Pt agrees with plan.

"][/conditional][checkbox memo="MDM BACK PAIN MSK BRIEF" name="variable_9" value=""][conditional field="variable_9" condition="(variable_9).is('')"][textarea cols=80 rows=5 default="Patient likely with MSK back pain, will treat with gentle exercise and stretching, heat, NSAIDs, short course of norco, and have f/u with PMD. Given strict return precautions.

Doubt spinal epidural abscess / hematoma, as no risk factors, afebrile.

Doubt fracture as no steroid use, no recent trauma, and age <70.

Doubt cauda equina as no urinary retention and no neuro deficits.

No hx of cancer to suggest metastatic lesions. "][/conditional][checkbox memo="MDM BRONCHITIS, Neg xray" name="variable_10" value=""][conditional field="variable_10" condition="(variable_10).is('')"][textarea cols=80 rows=5 default="Likely bronchitis given duration less than 3 weeks, absence of chronic lung disease, normal vital signs, and no abnormalities on pulmonary examination or imaging. Antibiotics not indicated at this time. Return precautions given and patient to follow up with pmd."][/conditional][checkbox memo="MDM CHEST PAIN ADMIT" name="variable_11" value=""][conditional field="variable_11" condition="(variable_11).is('')"][textarea cols=80 rows=5 default="EKG shows no evidence of STEMI, and initial troponin is negative, however given patient's presentation and risk factors, patient will be admitted for serial troponins and risk stratification and evaluation for likely stress testing.     Aspirin given. However, given that chest pain is currently resolved, risks likely outweigh benefits of IV heparin at this time, so deferred."][/conditional][checkbox memo="Ddx/MDM CHEST PAIN ATYPICAL home" name="variable_12" value=""][conditional field="variable_12" condition="(variable_12).is('')"][textarea cols=80 rows=5 default="Differential includes acute coronary syndrome, pulmonary embolism, pneumonia, aortic dissection, pericardial tamponade, musculoskeletal chest pain, among others.

Acute coronary syndrome is unlikely and the patient is low risk, pain is atypical, nonexertional, and troponin is negative with over 6 hrs of symptoms. EKG without any obvious signs of ischemia. The pain is not classic for pericarditis or myocarditis, and the patient has no significant risk factors for a pericardial effusion and has stable vitals signs, unlikely to have tamponade. Chest xray shows no evidence of pneumothorax, pneumonia, or significant pleural effusion. Pain is not likely to be pulmonary embolism (PERC negative), and no significant PE risk factors. The patient has no significant risk factors for aortic dissection, no history of connective tissue disorder, and the patient's pain is not severe, radiating to the back, or tearing in nature. They have normal bilateral radial and pedal pulses. Currently well appearing with stable vitals.

Initial plan: patient observed for several hours in the ED, ECG with no emergent findings, patient discharged with no dangerous vital signs, patient instructed to follow up with PMD in the next 1-2 days to be referred for a treadmill stress test within the next 48-72 hours. Upon calculating the patient's HEART score, they were found to have a HEART score less than four, which indicates low risk, so the patient can be safely discharged with the understanding that they need to make an appointment with a primary care doctor to be referred for a stress test within the next 48-72 hours, or if they cannot arrange that they are to return to the ED, or sooner than that if they have any changing, persistent, or worsening symptoms.

 "][/conditional][checkbox memo="Ddx/MDM CHEST PAIN MSK (NO TROP)" name="variable_13" value=""][conditional field="variable_13" condition="(variable_13).is('')"][textarea cols=80 rows=5 default="Differential includes acute coronary syndrome, pulmonary embolism, pneumonia, aortic dissection, pericardial tamponade, musculoskeletal chest pain, among others. However, acute coronary syndrome is unlikely and the patient is low risk, pain is atypical, nonexertional. EKG without any obvious signs of ischemia. The pain is not classic for pericarditis or myocarditis, and the patient has no significant risk factors for a pericardial effusion and has stable vitals signs, unlikely to have tamponade. Chest xray shows no evidence of pneumothorax, pneumonia, or significant pleural effusion. Pain is not likely to be pulmonary embolism (PERC negative), and no significant PE risk factors. The patient has no significant risk factors for aortic dissection, no history of connective tissue disorder, and the patient's pain is not severe, radiating to the back, or tearing in nature. They have normal bilateral radial and pedal pulses. Currently well appearing with stable vitals.

The patient's pain appears consistent with a musculoskeletal origin. Pain is reproducible with palpation.

Initial plan: Given that the patient's pain appears to clearly be musculoskeletal in nature, and has no significant coronary artery disease risk factors, a troponin was not ordered as part of the workup, since the patient's presentation is not consistent with acute coronary syndrome.

 "][/conditional][checkbox memo="MDM CHF ADMIT,bipap" name="variable_14" value=""][conditional field="variable_14" condition="(variable_14).is('')"][textarea cols=80 rows=5 default="Differential includes CHF, pulmonary edema, pulmonary embolism, pneumonia, pleural effusions, pneumothorax, among others.

EKG without any obvious signs of ischemia. Chest xray shows no evidence of pneumonia, but does have findings consistent with vascular congestion from CHF. Symptoms are not likely to be due to pulmonary embolism, the patient has no significant PE risk factors and has a more likely alternate cause of their symptoms, given their chest xray findings, lung exam and presentation so workup was deferred and not pursued. The patient appears to be in decompensated CHF in exacerbation and not a suitable candidate for outpatient treatment so will be admitted for inpatient diuresis and further evaluation and treatment.

I spent ___ minutes of critical care time. This time excludes any separately billable procedures.
Treatments/Evaluations: Emergent and rapid respiratory assessment and management with continuous monitoring. Advanced airway equipment at the ready, while the patient's respiratory symptoms were stabilized.

Given the patient's presentation with CHF requiring BiPAP/ hypoxic respiratory failure, there existed the potential for imminent deterioration in the patient's condition due to respiratory compromise. Organ systems at risk for failure without immediate intervention include pulmonary / respiratory. This time was spent reviewing the patient's records, reviewing vital signs, reassessing the patient's clinical status, discussing the case and care with staff and consultants, and performing high-complexity medical decision making.

I considered the possibility of intubation, but at this time the patient is protecting their airway and maintaining their saturation on supplemental oxygen so will defer intubation at this time, although they will be closely monitored for any further deterioration.
"][/conditional][checkbox memo="MDM CHF DC HOME" name="variable_15" value=""][conditional field="variable_15" condition="(variable_15).is('')"][textarea cols=80 rows=5 default="Differential includes CHF, pulmonary edema, pulmonary embolism, pneumonia, pleural effusions, pneumothorax, among others.

EKG without any obvious signs of ischemia. Chest xray shows no evidence of pneumonia, but does have findings consistent with mild vascular congestion from CHF. Symptoms are not likely to be due to pulmonary embolism, the patient has no significant PE risk factors and has a more likely alternate cause of their symptoms, given their chest xray findings, lung exam and presentation so workup was deferred and not pursued. The patient appears to be in CHF in exacerbation, which improved with treatment in the ED, appears to be a suitable candidate for outpatient treatment and understands to f/u with PMD in 2-3 days.
"][/conditional][checkbox memo="MDM CLOSED HEAD INJURY W/ CT" name="variable_16" value=""][conditional field="variable_16" condition="(variable_16).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes closed head injury, scalp contusion, neck muscle spasm / strain, vs less likely skull fracture, intracranial bleeding, vertebral fracture, spinal cord compression / injury, among others.
Given the patient's mechanism, CT scans of the head were immediately obtained and showed no evidence of any emergent findings.
The patient is Nexus negative, no indication for imaging of the spine
There was no evidence of any wounds that required repair
The patient's tetanus status was.
Plain films were within normal limits
Hips have no tenderness or significant pain with range of motion and the patient is able to ambulate without difficulty, no evidence of hip fracture.
The patient is non-toxic, well appearing and significantly improved with observation and serial exams in the emergency department.
They are neurologically intact and able to ambulate, no evidence of spinal cord injury.
They appear to be stable for discharge home and follow up with their regular doctor in 2-3 days.
"][/conditional][checkbox memo="MDM CLOSED HEAD INJURY W/O CT" name="variable_17" value=""][conditional field="variable_17" condition="(variable_17).is('')"][textarea cols=80 rows=5 default=""][/conditional][checkbox memo="MDM COPD ADMIT" name="variable_18" value=""][conditional field="variable_18" condition="(variable_18).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes: COPD exacerbation, pneumonia, bronchitis, pneumothorax, pulmonary embolism, pulmonary edema, CHF, among others.

The patient's presentation seems most consistent with a COPD exacerbation given their wheezing on exam with a history of COPD . Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments. Although the patient has had some minimal improvement in their symptoms, they still have persistent severe dyspnea and their symptoms are unlikely to resolve with typical outpatient therapy so the patient will be admitted for further intensive serial treatments with bronchodilators and close observation.
"][/conditional][checkbox memo="MDM COPD DC HOME W/ X-RAY" name="variable_19" value=""][conditional field="variable_19" condition="(variable_19).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes: COPD exacerbation, pneumonia, bronchitis, pneumothorax, pulmonary embolism, pulmonary edema, CHF, among others.

The patient's presentation seems most consistent with a COPD exacerbation given their wheezing on exam with a history of COPD . Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.

Given the patient's productive cough, and change in the color/amount of sputum, empiric antibiotics are indicated and were prescribed.

The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids, as well as a refill of their inhaler if needed.

"][/conditional][checkbox memo="MDM COPD DC HOME W/O X-RAY" name="variable_20" value=""][conditional field="variable_20" condition="(variable_20).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes: COPD exacerbation, pneumonia, bronchitis, pneumothorax, pulmonary embolism, pulmonary edema, CHF, among others.

The patient's presentation seems most consistent with a COPD exacerbation given their wheezing on exam with a history of COPD . The patient had wheezing symmetrically on exam, without any rales, fever, hypoxic, productive cough, or evidence of peripheral edema. Chest Xray was not ordered given that pneumonia, pneumothorax, pulmonary edema appear to be extremely unlikely. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.

Given the patient's productive cough, and change in the color/amount of sputum, empiric antibiotics are indicated and were prescribed.

The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids, as well as a refill of their inhaler if needed

"][/conditional][checkbox memo="MDM CORNEAL ABRASION" name="variable_21" value=""][conditional field="variable_21" condition="(variable_21).is('')"][textarea cols=80 rows=5 default="Differential includes conjunctivitis, glaucoma, corneal abrasion, corneal ulceration, foreign body, among others.

Patient's presentation c/w corneal abrasion.
No evidence of foreign body by history or exam.
No evidence of corneal ulceration as well.
There is no evidence of iritis, glaucoma, preseptal cellulitis, periorbital or orbital cellulitis.
Will place patient on polytrim for prophylaxis of infection in corneal abrasion.This was discussed with the patient.
The patient was also instructed to stop wearing all contacts and use their prescription eyeglasses.
The patient was instructed to follow up with their ophthalmologist or return here if worsened, increased pain, decreased vision, swelling around the eye or as needed. The patient agreed with plan

"][/conditional][checkbox memo="MDM DIARRHEA" name="variable_22" value=""][conditional field="variable_22" condition="(variable_22).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes viral gastroenteritis, bacterial gastroenteritis, norovirus, Clostridium difficile infection, hemolytic uremic syndrome, food poisoning, colitis (infectious, ischemic, inflammatory), Celiac disease, dehydration, among others.

On exam, the patient's abdomen is benign, no e/o abdominal surgical emergency. Patient appears well hydrated. The stool is watery, nonbloody, without any evidence of GI bleed. No significant risk factors for mesenteric ischemia, patient without any pain out of proportion or bloody stool.
The patient has no significant risk factors for Clostridium difficile infection, no recent antibiotics use, hospitalization, or bloody stool.

The patient's current symptoms and exam do not appear to be from an emergent process or condition requiring immediate surgery. Although I considered abdominal imaging, given the patient's benign exam, the patient's presentation does not warrant urgent / immediate imaging. At this time, the risk of CT scan and associated radiation likely outweigh the benefits, and thus CT imaging was deferred. The patient's symptoms significantly improved, exam upon discharge revealed a benign abdomen without any surgical or peritoneal signs, and patient tolerating oral fluids. The patient appears stable for discharge with abdominal recheck in 24 hours, and understand to return to the ED immediately if symptoms change or worsen

"][/conditional][checkbox memo="MDM DIZZY ADMIT" name="variable_23" value=""][conditional field="variable_23" condition="(variable_23).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's symptoms include causes of peripheral vertigo (including BPPV, vestibular neuritis, Meniere's disease, viral labyrinthitis), causes of central vertigo (including cerebellar ischemic stroke, hemorrhagic stroke, acoustic neuroma, vertebrobasilar insufficiency), malignant arrhythmias, obstructive heart disease (critical aortic stenosis, hypertrophic cardiomyopathy), acute anemia, severe dehydration, electrolyte abnormalities, among others.

The patient denies any external blood loss and has no significant pallor or evidence of acute anemia as a cause of their symptoms. Hemoglobin is not severely low, and acute blood transfusion is not indicated. EKG shows no signs of malignant arrhythmia such as Brugada syndrome, delta wave, significant heart block, or QTc >500. In addition, the patient has no loud murmur or evidence of significant obstructive heart disease, symptoms are not in the setting of exertion. Labs show no severe electrolyte derangement such as severe hyponatremia, hypokalemia, acidosis, or hypoglycemia. The patient is neurologically intact, with normal cerebellar exam, without any evidence of central vertigo as a cause of their symptoms. They appear well hydrated without any evidence of severe dehydration or acute hypovolemia.

However, given the patient's risk factors, the patient would benefit from admission to observation for continuous cardiac monitoring, given the possibility of cardiac syncope

"][/conditional][checkbox memo="MDM DIZZY DC HOME" name="variable_24" value=""][conditional field="variable_24" condition="(variable_24).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's symptoms include causes of peripheral vertigo (including BPPV, vestibular neuritis, Meniere's disease, viral labyrinthitis), causes of central vertigo (including cerebellar ischemic stroke, hemorrhagic stroke, acoustic neuroma, vertebrobasilar insufficiency), malignant arrhythmias, obstructive heart disease (critical aortic stenosis, hypertrophic cardiomyopathy), acute anemia, severe dehydration, electrolyte abnormalities, among others.

The patient denies any external blood loss and has no significant pallor or evidence of acute anemia as a cause of their symptoms. Hemoglobin is not severely low, and acute blood transfusion is not indicated. EKG shows no signs of malignant arrhythmia such as Brugada syndrome, delta wave, significant heart block, or QTc >500. In addition, the patient has no loud murmur or evidence of significant obstructive heart disease, symptoms are not in the setting of exertion. Labs show no severe electrolyte derangement such as severe hyponatremia, hypokalemia, acidosis, or hypoglycemia. The patient is neurologically intact, with normal cerebellar exam, without any evidence of central vertigo as a cause of their symptoms. They appear well hydrated without any evidence of severe dehydration or acute hypovolemia.

The patient was observed for a period of time, with symptoms improved, and no emergent cause of their symptoms. The patient appears stable for discharge and to follow up with their regular doctor

"][/conditional][checkbox memo="MDM DVT" name="variable_25" value=""][conditional field="variable_25" condition="(variable_25).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes DVT, musculoskeletal pain, without evidence of fracture, dislocation, soft tissue infection such as cellulitis or abscess, necrotizing fasciitis, compartment syndrome, septic arthritis, arterial occlusion, among others.

Distally the patient has capillary refill <2 seconds and strong pulses. There is no pallor or pain out of proportion to exam. No evidence of arterial occlusion The associated joints have full range of motion without any significant pain or restriction in mobility. There is no crepitus or pain out of proportion to exam and the patient is afebrile and nontoxic. There is no overlying redness, induration, tenderness, pus, or evidence of drainable fluid collection. No evidence of septic arthritis, necrotizing fasciitis, or soft tissue infection such as abscess or cellulitis. compartments are soft, the patient is able to bear weight and has no neurologic deficits. No evidence of fracture, dislocation or compartment syndrome at this time. There is no swelling so vascular US to evaluate for DVT was obatined which did reveal an acute DVT of the L leg. The patient was prescribed Lovenox 1mg/kg SQ BID x 1 week, and given the 1st dose here and taught how to self administer. They understand to f/u with their PMD tomorrow to be transitioned to oral anticoagulation, and understands to return immediately to the ER if they are about to run out of Lovenox and have not been able to see the PMD

"][/conditional][checkbox memo="MDM ETOH INTOX W/ CT/LABS" name="variable_26" value=""][conditional field="variable_26" condition="(variable_26).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes alcohol intoxication, alcohol withdrawal, hypoglycemia, drug intoxication or overdose, head injury, epidural hematoma, subdural hematoma, among others. 

Upon arrival the patient's fingerstick glucose was normal with no evidence of hypoglycemia. Because of the patient's symptoms imaging of the brain / spine was obtained to rule out intracranial bleeding and / or vertebral fractures although the patient does not currently exhibit any focal neurologic deficits. The patient has no significant tremors or tachycardia, and their presentation seems most consistent with alcohol intoxication without withdrawal. The patient will be observed in the emergency department with serial neurologic exams for improvement in their mental status. 

After serial neurologic exams in the emergency department, the patient's mental status significantly improved. The patient was able to follow commands and is clinically sober. Imaging did not reveal any acute findings, and the patient is now able to fully participate in the neurologic exam. They are fully alert oriented and conversant have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. The patient's presentation seems to be consistent with alcohol intoxication, which has resolved, without any complications such as alcohol withdrawal, GI bleeding, or intracranial bleeding. Lab results were reassuring with no evidence of significant metabolic derangement. The patient appears to be safe for discharge home. Patient understands not to drive and appears able to care for themselves

"][/conditional][checkbox memo="MDM ETOH INTOX W/O CT/LABS" name="variable_27" value=""][conditional field="variable_27" condition="(variable_27).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes alcohol intoxication, alcohol withdrawal, hypoglycemia, drug intoxication or overdose, head injury, among others. Upon arrival the patient's fingerstick glucose was normal with no evidence of hypoglycemia. 

The patient has no evidence of injury or tenderness of the head or neck, thus immediate imaging of the brain and spine was not felt to be necessary. The patient has no significant tremors or tachycardia, and their presentation seems most consistent with alcohol intoxication without withdrawal. The patient will be observed in the emergency department with serial neurologic exams for improvement in their mental status. 

After serial neurologic exams in the emergency department, the patient's mental status significantly improved. The patient was able to follow commands and is clinically sober. They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. The patient's presentation seems to be consistent with alcohol intoxication, which has resolved, without any complications such as alcohol withdrawal, head injury, GI bleeding, or intracranial bleeding. The patient appears to be safe for discharge home. Patient understands not to drive and appears able to care for themselves

"][/conditional][checkbox memo="MDM ETOH WITHDRAWAL ADMIT" name="variable_28" value=""][conditional field="variable_28" condition="(variable_28).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes alcohol intoxication, alcohol withdrawal, hypoglycemia, drug intoxication or overdose, head injury, among others. Upon arrival the patient's fingerstick glucose was normal with no evidence of hypoglycemia. 

The patient has no evidence of injury or tenderness of the head or neck, thus immediate imaging of the brain and spine was not felt to be necessary. The patient had tremors and tachycardia, and their presentation seems most consistent with alcohol withdrawal. The patient was given Ativan and will be observed in the emergency department with serial neurologic exams for improvement in their mental status. The patient's presentation seems to be consistent with alcohol withdrawal,, without any complications such as alcohol intoxication, head injury, GI bleeding, or intracranial bleeding. 

After serial neurologic exams in the emergency department, the patient improved but still has evidence of persistent alcohol withdrawal requiring admission to prevent delirium tremens

"][/conditional][checkbox memo="MDM ETOH WITHDRAWAL DC HOME" name="variable_29" value=""][conditional field="variable_29" condition="(variable_29).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes alcohol intoxication, alcohol withdrawal, hypoglycemia, drug intoxication or overdose, head injury, among others. Upon arrival the patient's fingerstick glucose was normal with no evidence of hypoglycemia. 

The patient has no evidence of injury or tenderness of the head or neck, thus immediate imaging of the brain and spine was not felt to be necessary. The patient had mild tremors and tachycardia, and their presentation seems most consistent with mild alcohol withdrawal. The patient was given Ativan and will be observed in the emergency department with serial neurologic exams for improvement in their mental status. 

After serial neurologic exams in the emergency department, the patient significantly improved. The patient's tachycardia and tremor have resolved. They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. The patient's presentation seems to be consistent with mild alcohol withdrawal, which has resolved, without any complications such as alcohol intoxication, head injury, GI bleeding or intracranial bleeding. The patient appears to be safe for discharge home. Patient understands not to drive and appears able to care for themselves

"][/conditional][checkbox memo="MDM EXTREMITY INJURY" name="variable_30" value=""][conditional field="variable_30" condition="(variable_30).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes musculoskeletal pain, fracture, dislocation, compartment syndrome, arterial occlusion, nerve damage, among others. 

Distally the patient has capillary refill <2 seconds and strong pulses. There is no pallor or pain out of proportion to exam. There is no significant swelling, deformity, or report of significant dislocation that subsequently reduced.. No evidence of arterial occlusion or injury. The associated joints have full range of motion without any significant pain or restriction in mobility. No evidence at this time of major ligamentous disruption. 

Xrays of the __ are within normal limits, compartments are soft, the patient is able to bear weight and has no neurologic deficits. No evidence of fracture, dislocation, foreign body, significant nerve damage, compartment syndrome at this time. 

However, the patient was informed that occult fractures or foreign bodies are not always apparent on their first visit and understand to follow up with their regular doctor for a reevaluation within the next 2-3 days, to ensure their symptoms completely resolve

"][/conditional][checkbox memo="MDM EXTREMITY PAIN" name="variable_31" value=""][conditional field="variable_31" condition="(variable_31).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes musculoskeletal pain, fracture, dislocation, soft tissue infection such as cellulitis or abscess, necrotizing fasciitis, compartment syndrome, septic arthritis, arterial occlusion, deep venous thrombosis, among others. 

Distally the patient has capillary refill <2 seconds and strong pulses. There is no pallor or pain out of proportion to exam. There is no significant swelling or venous engorgement. The patient has no significant DVT risk factors or known hypercoagulable disorder. No evidence of arterial occlusion or deep venous thrombosis. 

The associated joints have full range of motion without any significant pain or restriction in mobility. There is no crepitus or pain out of proportion to exam and the patient is afebrile and nontoxic. There is no overlying redness, induration, tenderness, pus, or evidence of drainable fluid collection. No evidence of septic arthritis, necrotizing fasciitis, or soft tissue infection such as abscess or cellulitis. 

Xrays of the __ are within normal limits, compartments are soft, the patient is able to bear weight and has no neurologic deficits. No evidence of fracture, dislocation or compartment syndrome at this time. 

However, the patient was informed that occult fractures or foreign bodies are not always apparent on their first visit and understand to follow up with their regular doctor for a reevaluation within the next 2-3 days for a reevaluation, to ensure their symptoms completely resolve

"][/conditional][checkbox memo="MDM FOLEY REPLACEMENT" name="variable_32" value=""][conditional field="variable_32" condition="(variable_32).is('')"][textarea cols=80 rows=5 default="Patient with history of chronic urinary retention and chronic indwelling foley presents with catheter dysfunction, leading to urinary retention and abdominal swelling with discomfort. Differential includes foley dysfunction, UTI, BPH, AKI, among others. Pt was afebrile, nontoxic. No e/o sepsis. Catheter was replaced and drained 2L of clear urine, obstruction relieved.. UA shows no evidence of UTI. Labs shows no evidence of development of renal failure. Patient appears stable for discharge home and understand to f/u with PMD in 1-2 days. Patient will be discharged home with antibiotics

"][/conditional][checkbox memo="MDM GENERAL WEAKNESS ADMIT" name="variable_33" value=""][conditional field="variable_33" condition="(variable_33).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes dehydration, hypovolemia, electrolyte derangement such as hyponatremia / hypoglycemia, neuromuscular junction disorder such as myasthenia gravis, GI bleed, anemia, UTI, sepsis, among others. 

The patient feels generally weak but has no focal neurologic deficits, abnormal muscle tone, hypo/hyperreflexia, or fatigability. No evidence of stroke, spinal cord emergency, neuromuscular junction disorder, or multiple sclerosis at this time. 

Lab results were reassuring without any evidence of severe sepsis, UTI, acute anemia requiring transfusion, or severe metabolic derangement such as significant hyponatremia or severe hypoglycemia. 

The patient appears well hydrated and has normal vitals, no evidence of significant dehydration / hypovolemia at this time. Although the patient does not have any evidence of an emergent cause of their symptoms, they do appear to be significantly generally weak and deconditioned with failure to thrive. The patient will therefore be admitted for rehabilitation, physical therapy, and potential placement into a facility with increased resources for care given the patient's inability to adequately perform their activities of daily living which would be required to be safely discharged home

"][/conditional][checkbox memo="MDM GENERAL WEAKNESS DC HOME" name="variable_34" value=""][conditional field="variable_34" condition="(variable_34).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes dehydration, hypovolemia, electrolyte derangement such as hyponatremia / hypoglycemia, neuromuscular junction disorder such as myasthenia gravis, GI bleed, anemia, UTI, sepsis, among others. 

The patient feels generally weak but has no focal neurologic deficits, abnormal muscle tone, hypo/hyperreflexia, or fatigability. No evidence of stroke, spinal cord emergency, neuromuscular junction disorder, or multiple sclerosis at this time. 

Lab results were reassuring without any evidence of severe sepsis, UTI, acute anemia requiring transfusion, or severe metabolic derangement such as significant hyponatremia or severe hypoglycemia. 

The patient appears well hydrated and has normal vitals, no evidence of significant dehydration / hypovolemia at this time. The patient has no evidence of any emergent cause of their symptoms at this time, and appear stable for discharge home and follow up with their regular doctor for reevaluation, further workup, and continued care in 2-3 days

"][/conditional][checkbox memo="MDM GI BLEED" name="variable_35" value=""][conditional field="variable_35" condition="(variable_35).is('')"][textarea cols=80 rows=5 default="Given the possibility of a bleeding peptic ulcer, Protonix IV was immediately started. Because of __, the patient is at risk for portal hypertension and varices from cirrhosis, so octreotide IV was also started and Ceftriaxone IV also given. 

Because of __, the patient will immediately be transfused __ units of PRBC, and admitted for further care and management. The patient does not require any emergent anticoagulation reversal at this time point, although it was considered. Gastroenterology on-call, Dr. __ was consulted and will evaluate the patient for endoscopy. 

The patient is currently hemodynamically stable, and stable for transfer to the floor at this time. 

Because the patient's hemoglobin is stable, emergent transfusion was not started; however, the patient will need to be admitted for serial hemoglobin checks, and if downtrending, transfusion may be indicated at a later time. 

Patient is protecting their airway, no active vomiting, no need for NG tube or intubation at this time

"][/conditional][checkbox memo="MDM HEADACHE W/ CT" name="variable_36" value=""][conditional field="variable_36" condition="(variable_36).is('')"][textarea cols=80 rows=5 default="Differential for the patient's headache includes primary headache (migraine, tension, cluster), subarachnoid hemorrhage, intracranial mass / tumor, meningitis, encephalitis, increased intracranial pressure, mastoiditis, acute sinusitis, dural venous thrombosis, temporal arteritis, acute angle closure glaucoma, among others. 

Headache not sudden and severe, not worst headache of life, no family hx of SAH, neurologically intact without any persistent vomiting. Not consistent with subarachnoid hemorrhage, dural venous thrombosis, increased intracranial pressure, or significant tumor at this time. 

Patient without meningismus, mastoid / sinus tenderness, altered mental status or seizure. Doubt subdural abscess, meningitis, encephalitis, mastoiditis. 

No significant trauma mechanism, not anticoagulated. No evidence of subdural / epidural hematoma. Canadian CT head criteria negative. 

No temporal tenderness, jaw claudication or vision loss. Eyes are reactive, with normal appearing anterior chambers. No evidence of temporal arteritis or acute angle closure glaucoma. 

Given the patient's presentation, with new type of headache and vomiting, despite normal neurologic exam, advanced imaging of the head with CT was felt to indicated and was obtained after weighing the risks and benefits of radiation to rule out cause of increased intracranial pressure such as tumor or mass which was negative. CT negative for tumor / mass. remains neuro intact, all sx resolved after compazine / toradol / benadryl. Patient appears stable for discharge home and f/u with PMD

"][/conditional][checkbox memo="MDM HEADACHE W/O CT" name="variable_37" value=""][conditional field="variable_37" condition="(variable_37).is('')"][textarea cols=80 rows=5 default="Differential for the patient's headache includes primary headache (migraine, tension, cluster), subarachnoid hemorrhage, intracranial mass / tumor, meningitis, encephalitis, increased intracranial pressure, mastoiditis, acute sinusitis, dural venous thrombosis, temporal arteritis, acute angle closure glaucoma, among others. 

Headache not sudden and severe, not worst headache of life, no family hx of SAH, neurologically intact without any persistent vomiting. Not consistent with subarachnoid hemorrhage, dural venous thrombosis, increased intracranial pressure, or significant tumor at this time. 

Patient without meningismus, mastoid / sinus tenderness, altered mental status or seizure. Doubt subdural abscess, meningitis, encephalitis, mastoiditis. 

No significant trauma mechanism, not anticoagulated. No evidence of subdural / epidural hematoma. Canadian CT head criteria negative. 

No temporal tenderness, jaw claudication or vision loss. Eyes are reactive, with normal appearing anterior chambers. No evidence of temporal arteritis or acute angle closure glaucoma. 

Given the patient's presentation, and normal neurologic exam, advanced imaging of the head with CT was not felt to be necessary or indicated and not pursued after weighing the risks and benefits of radiation

"][/conditional][checkbox memo="MDM HYPERKALEMIA" name="variable_38" value=""][conditional field="variable_38" condition="(variable_38).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes Hyperkalemia, arrhythmia, acidosis, fluid overload, uremia, among others.

Initial Plan:
The patient's presentation appears most consistent with a diagnosis of hyperkalemia related to their end stage renal disease.

They were given Insulin, D50W, Albuterol, Kayexalate, Calcium_Gluconate and will also need emergent dialysis.
Currently stable with no malignant arrhythmias or hypotension, but has a critically high potassium

"][/conditional][checkbox memo="MDM HYPERTENSION W/ LABS" name="variable_39" value=""][conditional field="variable_39" condition="(variable_39).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes essential hypertension, malignant hypertension, hypertensive emergency, end-organ damage (such as renal failure, cardiac ischemia, pulmonary edema, hypertensive encephalopathy, intracranial hemorrhage, among others), medication noncompliance, among others. Alert and oriented, no neuro deficits, no severe headache, no evidence of hypertensive encephalopathy or intracranial bleeding. No volume overload, chest pain, or shortness of breath, no evidence of cardiac ischemia or CHF. On history and exam and labs, the patient exhibits no features of end-organ damage. They have no no chest pain, shortness of breath, or evidence of volume overload. The patient was given a new prescription for amlodipine and appears to be stable for discharge home, and blood pressure recheck with their PMD in 1-2 days as instructed.

"][/conditional][checkbox memo="MDM HYPERTENSION W/O LABS" name="variable_40" value=""][conditional field="variable_40" condition="(variable_40).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes essential hypertension, malignant hypertension, hypertensive emergency, end-organ damage (such as renal failure, cardiac ischemia, pulmonary edema, hypertensive encephalopathy, intracranial hemorrhage, among others), medication noncompliance, among others. Alert and oriented, no neuro deficits, no severe headache, no evidence of hypertensive encephalopathy or intracranial bleeding. No volume overload, chest pain, or shortness of breath, no evidence of cardiac ischemia or CHF. On history and exam , the patient exhibits no features of end-organ damage. They have no no chest pain, shortness of breath, or evidence of volume overload. The patient was given a new prescription for *amlodipine and appears to be stable for discharge home, and blood pressure recheck with their PMD in 1-2 days as instructed. .

"][/conditional][checkbox memo="MDM HYPOGLYCEMIA ADMIT" name="variable_41" value=""][conditional field="variable_41" condition="(variable_41).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's hypoglycemia includes relative overdose of the pt's insulin, acute renal failure, poor PO intake, insulin secreting tumor, among others.

Given that *, the patient will be admitted for further serial blood glucose monitoring, as well as further evaluation and management.

Patient was fed  *and placed on D5 1/2 NS to prevent further hypoglycemic episodes.

Because of the patient's altered level of consciousness related to poor glucose control, this may be an area of risk should it recur while the patient is driving. The patient was instructed not to drive until cleared by their doctor and a DMV form was submitted.

"][/conditional][checkbox memo="MDM HYPOGLYCEMIA DC HOME" name="variable_42" value=""][conditional field="variable_42" condition="(variable_42).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's hypoglycemia include relative overdose of the pt's insulin, acute renal failure, poor PO intake, insulin secreting tumor, among others. Patient had serial blood glucose checks while in the ED, and was fed.

Serial blood glucose checks remain normal and stable in the ED. Symptoms appear to be from insulin use with poor Po intake, which is now resolved and unlikely to recur now that the patient has received further education regarding his insulin use. Appears stable for discharge home and follow up with their PMD in 2-3 days.

Because of the patient's altered level of consciousness related to poor glucose control, this may be an area of risk should it recur while the patient is driving. The patient was instructed not to drive until cleared by their doctor and a DMV form was submitted.

"][/conditional][checkbox memo="MDM METHADONE" name="variable_43" value=""][conditional field="variable_43" condition="(variable_43).is('')"][textarea cols=80 rows=5 default=""][/conditional][checkbox memo="MDM OTITIS MEDIA (NO ABX)" name="variable_44" value=""][conditional field="variable_44" condition="(variable_44).is('')"][textarea cols=80 rows=5 default="Diagnosis includes viral otitis media, bacterial otitis media, otitis externa, mastoiditis, among others.
Patient is nontoxic and well appearing. The patient is tolerating fluids and is well hydrated.
No evidence of mastoiditis, perforated tympanic membrane or otitis externa on exam.
Presentation appears consistent with viral otitis media, no indications for antibiotics.
No clinical evidence by history or evaluation to suspect meningitis and/or sepsis. The lung exam is normal with normal respirations and clear lung sounds. I discussed with the diagnosis, plan of care and to follow up with the patient's primary medical doctor within the next 1-2 days. Instructed to return if the patient worsens in anyway, especially if not tolerating fluids, decreased activity, increased irritability or as needed. They agreed with plan. .

"][/conditional][checkbox memo="MDM OTITIS MEDIA W/ ABX" name="variable_45" value=""][conditional field="variable_45" condition="(variable_45).is('')"][textarea cols=80 rows=5 default="Diagnosis includes viral otitis media, bacterial otitis media, otitis externa, mastoiditis, among others.

Patient is nontoxic and well appearing. The patient is tolerating fluids and is well hydrated.

No evidence of mastoiditis, perforated tympanic membrane or otitis externa on exam.

Presentation appears consistent with bacterial otitis media, and will be prescribed antibiotics

No clinical evidence by history or evaluation to suspect meningitis and/or sepsis. The lung exam is normal with normal respirations and clear lung sounds. I discussed with the diagnosis, plan of care and to follow up with the patient's primary medical doctor within the next 1-2 days. Instructed to return if the patient worsens in anyway, especially if not tolerating fluids, decreased activity, increased irritability or as needed. They agreed with plan.

"][/conditional][checkbox memo="MDM PEDS CRYING" name="variable_46" value=""][conditional field="variable_46" condition="(variable_46).is('')"][textarea cols=80 rows=5 default="The patient presented with parent complaining of crying and fussiness. There is no history to suggest an obvious source of
discomfort. There has not been any fever, rash, vomiting, diarrhea or bloody stools.
There has not been any recent change in formula or diet.
The patient has been tolerating feeds and stooling well. There has not been any URI symptoms, recent illness or known ill contacts. Exam is similar and without findings. Vitals are within normal limits and no fever. There is no rash and the patient is nontoxic and well appearing. Ears and throat are normal. Chest, abdomen and genitalia exams are unremarkable without tenderness, mass or herniations. Extremity exam reveals no infection, injury, edema, erythema, effusions or hair tourniquets or tenderness. There is no evidence to suggest nonaccidental trauma. During the course of the evaluation the patient improved and was not crying and was tolerating fluids without difficulty. Plan of care was discussed with the parent and the patient was referred to their primary pediatrician. Warnings were discussed with the parent such as fever, vomiting, blood in stool, develops rash, not tolerating fluids or if worsens. Parent agreed with plan.

"][/conditional][checkbox memo="MDM PEDS UTI" name="variable_47" value=""][conditional field="variable_47" condition="(variable_47).is('')"][textarea cols=80 rows=5 default="Differential includes UTI, PNA, URI, among others. No clinical evidence by history or evaluation to suspect meningitis and/or severe sepsis.The lung exam is normal with normal respirations and clear lung sounds. Chest xray negative for any PNA, but UA c/w UTI. Pt given CTX IM, and Rx for Cefpodoxime. I discussed with the parent, diagnosis, plan of care and to follow up with the patient's primary pediatrician within the next 3 days and to take Cefpodoxime (preferred atbx), but that if they are not able to buy it (from either availability or insurance refusal), prescription for keflex was provided as second option.. The parent was instructed to return if the patient worsens in anyway, especially if not tolerating fluids, decreased activity, increased irritability or as needed. The parent agreed with plan.

"][/conditional][checkbox memo="MDM PID" name="variable_48" value=""][conditional field="variable_48" condition="(variable_48).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes UTI, pelvic inflammatory disease, yeast infection, bacterial vaginosis, trichomonas infection, chlamydia infection, gonorrhea infection, among others.
UA negative for_UTI.
Chlamydia / Gonorrhea testing obtained and patient will receive telephone follow up to confirm if positive.
No evidence of yeast infection, BV or trichomonas on wet mount.
Patient appears stable for discharge home and follow up with PMD. Pelvic exam notable for cervical motion tenderness, so consistent with PID, but no rebound or guarding, patient nontoxic and well appearing, no evidence of TOA.
Patient given empiric Ceftriaxone 250mg IM and will be given Doxycycline x 2 weeks.
Pt instructed to f/u with PMD as outpatient for remainder of STD testing, including syphilis and HIV.

"][/conditional][checkbox memo="MDM PNEUMONIA ADMIT" name="variable_49" value=""][conditional field="variable_49" condition="(variable_49).is('')"][textarea cols=80 rows=5 default="Differential includes pneumonia, bronchitis, CHF, pulmonary edema, pulmonary embolism, pleural effusion among others. Symptoms are not likely to be pulmonary embolism, patient no significant PE risk factors, and has more likely alternate cause of symptoms.
Chest xray seems to be consistent with pneumonia, rather than CHF.
Presentation not consistent with ischemia / ACS.
Based on  *the patient's PSI/PORT score, has high enough mortality risk that inpatient admission for IV antibiotics and clinical observation is most appropriate.
Patient given *Ceftriaxone / Azithromycin.
No evidence of severe sepsis at this time

"][/conditional][checkbox memo="MDM PNEUMONIA DC HOME" name="variable_50" value=""][conditional field="variable_50" condition="(variable_50).is('')"][textarea cols=80 rows=5 default="Differential includes pneumonia, bronchitis, CHF, pulmonary edema, pulmonary embolism, pleural effusion among others. Symptoms are not likely to be pulmonary embolism, patient no significant PE risk factors, and has more likely alternate cause of symptoms. *Additionally, PERC score is negative, very low risk for PE
Chest xray seems to be consistent with pneumonia, rather than CHF.
Presentation not consistent with ischemia / ACS.
Based on the patient's PSI/PORT score, seems reasonable for outpatient therapy.
Stable for discharge home and follow up with PMD in 1-2 days.
Patient given prescription for Azithromycin.

"][/conditional][checkbox memo="MDM POSSIBLE ECTOPIC" name="variable_51" value=""][conditional field="variable_51" condition="(variable_51).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes, ectopic pregnancy, miscarriage, hemorrhagic ovarian cyst, threatened abortion, inevitable abortion, fibroids, severe anemia, dysfunctional uterine bleeding, vaginal / uterine mass, among others.

Pregnancy test is POSITIVE.
Ultrasound was obtained but was indeterminate, not able to identify a definitive IUP, no yolk sac or fetal heart activity found
Possibilities still include ectopic pregnancy vs miscarriage
Rh status is *, Rhogam was not indicated.
Unlikely ruptured ectopic at this time point, patient's abdomen is not peritoneal, no significant tenderness.
The patient's presentation is not consistent with hemorrhagic ovarian cyst or torsion, and has no significant tenderness on exam.
Patient's hemoglobin is not severely low, vitals are hemodynamically stable, and no symptoms of severe anemia (near syncope, lightheadedness, severe fatigue), no indication for blood transfusion at this time.

The patient appears stable for discharge home and follow up here in the ED in 48 hrs for repeat HCG quant testing, reevaluation and further treatment.

"][/conditional][checkbox memo="MDM PSYCH 5150 AGITATION" name="variable_52" value=""][conditional field="variable_52" condition="(variable_52).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes severe depression, suicidal ideation, bipolar disorder, psychosis, delusions, paranoid schizophrenia, drug abuse, drug intoxication, drug overdose, among others.
The patient denies any suicide attempt, overdose, or ingestion.
They exhibit no signs of any toxic syndrome or drug / alcohol withdrawal.
Labs were ordered for evaluation, and results are reassuring with no evidence of occult overdose, or severe metabolic derangement.
EKG shows no obvious signs of TCA overdose.
The patient was observed for a period of time in the ED with serial neurologic exams.

After serial neurologic exams in the emergency department, the patient remains clinically sober.
They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance.
The patient's presentation seems to be consistent with agitation / psychosis, without any complications such as suicide attempt or overdose.
They meet psychiatric hold criteria because of *danger to others / grave disability.
The patient appears to be stable for transfer to a psychiatric facility for further psychiatric evaluation and care, without any obvious medical etiology for their symptoms.
Social worker was consulted to assist with placement into an inpatient psychiatric team, and the patient is awaiting evaluation and placement on a psychiatric hold by the PET team.

"][/conditional][checkbox memo="MDM PSYCH 5150 SI/DEPRESSION" name="variable_53" value=""][conditional field="variable_53" condition="(variable_53).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes severe depression, suicidal ideation, bipolar disorder, schizophrenia, drug abuse, drug overdose,among others.
The patient denies any suicide attempt, overdose, or ingestion.
They exhibit no signs of any toxic syndrome or drug / alcohol withdrawal.
Labs were ordered for evaluation, and results are reassuring with no evidence of occult overdose, or severe metabolic derangement.
EKG shows no obvious signs of TCA overdose.
The patient was observed for a period of time in the ED with serial neurologic exams.

After serial neurologic exams in the emergency department, the patient remains clinically sober.
They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance.
The patient's presentation seems to be consistent with suicidal ideation, without any complications such as suicide attempt or overdose.
The patient appears to be stable for transfer to a psychiatric facility for further psychiatric evaluation and care, without any obvious medical etiology for their symptoms.
Social worker was consulted to assist with placement into an inpatient psychiatric team, and the patient is awaiting evaluation and placement on a psychiatric hold by the PET team.

"][/conditional][checkbox memo="MDM REACTIVE AIRWAY DISEASE" name="variable_54" value=""][conditional field="variable_54" condition="(variable_54).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes: reactive airway disease, asthma exacerbation, pneumonia, bronchitis, pneumothorax, pulmonary embolism, pulmonary edema, CHF, among others.

The patient's presentation seems most consistent with reactive airway disease given their wheezing on exam without a history of asthma. Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.

The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids and albuterol inhaler.

Differential includes new onset seizure, epilepsy, brain tumor, intracranial bleeding, metabolic encephalopathy, hyponatremia, hypoglycemia, among others.
Labs were checked, which were reassuring, no evidence of severe acidosis, or significant metabolic derangement.
CT was ordered, given that patient that this is the patient's first reported seizure.
Patient is back to their baseline neurologic status, no focal deficits, no e/o brain tumor, bleed.
No headache, not consistent with subarachnoid hemorrhage , no indication for LP.
Pt is very low risk for subarachnoid hemorrhage - CT negative for any blood within 6 hours of symptoms.
Patient had serial neurologic exams in the ER, and is back to baseline, no neuro deficits, ambulating steadily without any assistance, and stable for dc home and f/u with PMD.
Patient instructed not to drive until cleared by PMD, and DMV form faxed.

"][/conditional][checkbox memo="MDM SEIZURE (NEW ONSET - NEG CT)" name="variable_55" value=""][conditional field="variable_55" condition="(variable_55).is('')"][textarea cols=80 rows=5 default=""][/conditional][checkbox memo="MDM SEIZURE (NO CT)" name="variable_56" value=""][conditional field="variable_56" condition="(variable_56).is('')"][textarea cols=80 rows=5 default="Differential includes noncompliance with medication, brain tumor, intracranial bleeding, metabolic encephalopathy, hyponatremia, hypoglycemia, among others.
Labs were checked, which were reassuring, no evidence of hypoglycemia, severe acidosis, or significant metabolic derangement.
CT was not ordered, given that patient has history of seizures, is back to baseline neuro status, no focal deficits, no e/o brain tumor, bleed.
Dilantin level was noted to be subtherapeutic, patient was loaded with Dilantin in the ED.
The patient will be discharged with a refill of their maintenance medication.
Patient had serial neurologic exams in the ER, and is back to baseline, no neuro deficits, ambulating steadily without any assistance, understands to take their antiepileptics, and stable for dc home and f/u with PMD.
Patient instructed not to drive until cleared by PMD, and DMV form faxed.

"][/conditional][checkbox memo="MDM SEPSIS" name="variable_57" value=""][conditional field="variable_57" condition="(variable_57).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes sepsis / severe sepsis, septic shock, meningitis, cellulitis, UTI, pneumonia , viral syndrome, gastroenteritis, emergent abdominal infection, among others.
Patient abdomen is benign, no evidence of emergent abdominal condition.
UA is clear, and without evidence of UTI.
No meningismus, not altered, no neuro deficits, not consistent with meningitis or encephalitis.
Chest xray with no evidence of infiltrate / pneumonia.
Presentation not consistent with severe sepsis / septic shock.
Sepsis bundle initiated on arrival.
Blood cultures, lactate drawn.
Lactate was elevated, patient given 30 cc/kg IV fluids by bolus and empiric antibiotics were started.
Patient will be admitted to the hospital for further care and evaluation.

Critical Care Statement
Critical care performed 35 minutes) Time is exclusive of separately billable procedures.
Time includes: direct patient care, patient reassessment, coordination of patient care, review of patient's medical records, medical consultation, family consultation regarding treatment decisions and documentation of patient care.
Organ systems at risk: Cardiac / circulatory.

"][/conditional][checkbox memo="MDM STROKE (NO TPA)" name="variable_58" value=""][conditional field="variable_58" condition="(variable_58).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others.
The patient's presentation appears most consistent with a diagnosis of ischemic stroke..
CT shows no evidence of bleed or mass.
However the patient is not a tPa candidate because * The patient is not an interventional candidate because *
The patient will be admitted to the hospital to a telemetry bed for further workup and treatment.
Aspirin was given and
Patient is protecting their own airway, no indication for intubation.

"][/conditional][checkbox memo="MDM STROKE (TPA GIVEN)" name="variable_59" value=""][conditional field="variable_59" condition="(variable_59).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others.
The patient's presentation appears most consistent with a diagnosis of ischemic stroke.
The patient is a tPa candidate because they have deficits and presented within 4.5 hours.
They do not meet any exclusion criteria.
The stroke neurologist on-call, Dr Zangiabadi was immediately consulted upon arrival and CT scans were performed.
No evidence on CT of hemorrhagic stroke, so stroke neurologist ordered to start tPA over the phone.
BP elevated but no high enough to contraindicate tPA.
The patient will be admitted to the hospital to ICU for further workup and treatment.
Patient is protecting their own airway, no indication for intubation at this time.

"][/conditional][checkbox memo="MDM SYNCOPE ADMIT" name="variable_60" value=""][conditional field="variable_60" condition="(variable_60).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's symptoms include , malignant arrhythmias, obstructive heart disease (critical aortic stenosis, hypertrophic cardiomyopathy), acute anemia, severe dehydration, electrolyte abnormalities, among others.

The patient denies any external blood loss and has no significant pallor or evidence of acute anemia as a cause of their symptoms.
Hemoglobin is not severely low, and acute blood transfusion is not indicated.

EKG shows no signs of malignant arrhythmia such as Brugada syndrome, delta wave, significant heart block, or QTc >500. In addition, the patient has no loud murmur or evidence of significant obstructive heart disease, symptoms are not in the setting of exertion.

Labs show no severe electrolyte derangement such as severe hyponatremia, hypokalemia, acidosis, or hypoglycemia.
The patient is neurologically intact, with normal cerebellar exam, without any evidence of central vertigo as a cause of their symptoms.

No report of seizure activity.

They appear well hydrated without any evidence of severe dehydration or acute hypovolemia. Denies any headache or neck pain. NEXUS negative, so CT scans not indicated and deferred.

Patient instructed not to drive until cleared by PMD, and DMV form faxed.

Considering the patient's presentation, risk factors, and lack of an obvious cause of their syncope, there is concern for possible cardiac cause of syncope, so the patient will be admitted to telemetry for further workup and risk stratification.

"][/conditional][checkbox memo="MDM SYNCOPE DC HOME" name="variable_61" value=""][conditional field="variable_61" condition="(variable_61).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's symptoms include , malignant arrhythmias, obstructive heart disease (critical aortic stenosis, hypertrophic cardiomyopathy), acute anemia, severe dehydration, electrolyte abnormalities, seizure, among others.

Patient presents with syncope. Preceded by nausea, vomiting, tunnel vision, pallor.
No associated headache, chest pain, shortness of breath, abdominal pain, back pain, blood in stool.
No family history of sudden cardiac death. with stable vital signs.
Pt without any risk factors for PE, coronary artery disease, or CVA and has reassuring exam.

-EKG shows: NSR rate. Normal axis and intervals. No ectopic beats, No ST elevation or depression. No overt tachy or bradydysrhythmias. No evidence of WPW, Brugada, or dagger like q waves to suggest HOCM. No murmur. Not provoked by exertion.
-The patient denies any external blood loss and has no significant pallor or evidence of acute anemia as a cause of their symptoms. Hemoglobin is not severely low, and acute blood transfusion is not indicated.
-Labs show no severe electrolyte derangement such as severe hyponatremia, hypokalemia, acidosis, or hypoglycemia.
-No report of seizure activity. Pt now back at baseline.

They appear well hydrated without any evidence of severe dehydration or acute hypovolemia.
The patient was observed for a period of time, with symptoms improved, and no emergent cause of their symptoms at time time
The patient appears stable for discharge and to follow up with their regular doctor.
- Will get CBC to rule out anemia, urine pregnancy to rule out pregnancy as contributory.

"][/conditional][checkbox memo="MDM THREATENED AB" name="variable_62" value=""][conditional field="variable_62" condition="(variable_62).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes, ectopic pregnancy, hemorrhagic ovarian cyst, threatened abortion, inevitable abortion, fibroids, severe anemia, dysfunctional uterine bleeding, vaginal / uterine mass, among others.

Pregnancy test is POSITIVE.
Ultrasound was obtained which revealed an intrauterine pregnancy, with a viable fetus.
Patient was diagnosed with threatened abortion.
No evidence of trauma or severe bleeding or fetal distress that would be concerning for placenta previa or placental abruption.
Rh status is *, Rhogam was not indicated.

The patient's presentation is not consistent with hemorrhagic ovarian cyst, and has no significant tenderness on exam.
Patient's hemoglobin is not severely low, vitals are hemodynamically stable, and no symptoms of severe anemia (near syncope, lightheadedness, severe fatigue), no indication for blood transfusion at this time.

The patient appears stable for discharge home and follow with PMD in 2-3 days for reevaluation and further treatment.

"][/conditional][checkbox memo="MDM TIA" name="variable_63" value=""][conditional field="variable_63" condition="(variable_63).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes TIA, ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others.
The patient's presentation appears most consistent with a diagnosis of TIA given transient neurologic symptoms that have completely resolved in_a_potential_vascular_distribution.
CT shows no evidence of bleed or mass.
The patient is not a tPa candidate because their NIH stroke scale is zero. They have a normal neurologic exam, all symptoms resolved and back to baseline
The patient will be admitted to the hospital to a telemetry bed for further workup and treatment.
Aspirin was given and care transitioned to the admitting physician

"][/conditional][checkbox memo="MDM with Primary Survey" name="variable_64" value=""][conditional field="variable_64" condition="(variable_64).is('')"][textarea cols=80 rows=5 default="Patient BIBA as a tier *** activation for ***.
AIRWAY: Intact
BREATHING: Spontaneous and equal bilaterally.
CIRCULATION: PUlses intact.
DISABILITY: GCS:
EXPOSURE - patient undressed for exam."][/conditional][checkbox memo="MVC DCI" name="variable_65" value=""][conditional field="variable_65" condition="(variable_65).is('')"][textarea cols=80 rows=5 default="
********************************************************************************
No apparent injury was found during today's exam. You xrays were negative today.
You may develop some soreness and stiffness over the next two days. Mild neck and back strain is common in auto accidents, and may not be painful until the muscle becomes inflamed.
Take the medication prescribed for pain and spasm.
If you develop pain over the next couple of days, treat each tender area. Apply cold packs directly to the painful spot.
Rest.
Antiinflammatory pain medication, such as ibuprofen, can decrease soreness and inflammation.
Most of the time, these late-developing pains go away within a few days. Most patients are back at work or school within a couple days.
Follow up with your doctor in 1-2 days.
Return to the ER if you develop severe neck, chest, or abdominal pain, repeated vomiting, severe lightheadedness or weakness, trouble breathing, numbness or weakness in any extremity, problems with your bladder or bowel, or pain radiating down an arm or leg.
********************************************************************************"][/conditional][checkbox memo="MDM VAG BLEED NON-PREGNANT" name="variable_66" value=""][conditional field="variable_66" condition="(variable_66).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes, ectopic pregnancy, hemorrhagic ovarian cyst, threatened abortion, fibroids, severe anemia, dysfunctional uterine bleeding, vaginal / uterine mass, among others.

Pregnancy test is negative, ruling out ectopic pregnancy, or threatened / inevitable abortion.
The patient's presentation is not consistent with hemorrhagic ovarian cyst, and has no significant tenderness on exam.
Patient's hemoglobin is not severely low, vitals are hemodynamically stable, and no symptoms of severe anemia (near syncope, lightheadedness, severe fatigue), no indication for blood transfusion at this time.
The patient appears stable for discharge home and follow with PMD in 2-3 days for reevaluation and further treatment.

"][/conditional][checkbox memo="MDM VAG DISCHARGE W/ TREATMENT" name="variable_67" value=""][conditional field="variable_67" condition="(variable_67).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes yeast infection, bacterial vaginosis, trichomonas infection, chlamydia infection, gonorrhea infection, among others.
UA *negative for_UTI.
Chlamydia / Gonorrhea testing obtained and patient will receive telephone follow up if testing is positive
No evidence of yeast infection, BV or trichomonas on wet mount.
Pelvic exam without any evidence of PID.
Patient appears stable for discharge home and follow up with PMD.
Because patient does have risk factors for chlamydia / gonorrhea, was empirically treated with Ceftriaxone and Azithromycin.
Pt instructed to f/u with PMD as outpatient for remainder of STD testing, including syphilis and HIV.

"][/conditional][checkbox memo="MDM VAG DISCHARGE W/O TREATMENT" name="variable_68" value=""][conditional field="variable_68" condition="(variable_68).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes yeast infection, bacterial vaginosis, trichomonas infection, chlamydia infection, gonorrhea infection, among others.
UA  *negative for_UTI.
Patient has NO risk factors for STD.
Chlamydia / Gonorrhea testing obtained and patient will receive telephone follow up if testing is positive and to have treatment started.
No evidence of yeast infection, BV or trichomonas on wet mount.
Pelvic exam without any evidence of PID.
Patient appears stable for discharge home and follow up with PMD.
Pt instructed to f/u with PMD as outpatient for remainder of STD testing, including syphilis and HIV.

"][/conditional][checkbox memo="STROKE TEMPLATE" name="variable_69" value=""][conditional field="variable_69" condition="(variable_69).is('')"][textarea cols=80 rows=5 default="Pt presented with "][/conditional][checkbox memo="LKWT" name="variable_70" value=""][conditional field="variable_70" condition="(variable_70).is('')"][textarea cols=80 rows=5 default="Last known well time was "][/conditional][checkbox memo="NIHSS" name="variable_71" value=""][conditional field="variable_71" condition="(variable_71).is('')"][textarea cols=80 rows=5 default="NIHSS is "][/conditional][checkbox memo="tPA MDM" name="variable_72" value=""][conditional field="variable_72" condition="(variable_72).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others.
The patient's presentation appears most consistent with a diagnosis of ischemic stroke.
The patient is a tPa candidate because they have deficits and presented within 4.5 hours.
They do not meet any exclusion criteria.
The stroke neurologist on-call, Dr Zangiabadi was immediately consulted upon arrival and CT scans were performed.
No evidence on CT of hemorrhagic stroke, so stroke neurologist ordered to start tPA over the phone.
BP elevated but no high enough to contraindicate tPA.
The patient will be admitted to the hospital to ICU for further workup and treatment.
Patient is protecting their own airway, no indication for intubation at this time.

"][/conditional][checkbox memo="PEDS Fever no symptoms w/ UTI" name="variable_73" value=""][conditional field="variable_73" condition="(variable_73).is('')"][textarea cols=80 rows=5 default="Assessment and Plan
1: Acute febrile illness with UTI. No evidence at this time for meningitis, pneumonia, otitis media, parapharyngeal infection, epiglottitis, skin infection, or causes of peritonitis. Patient is nontoxic appearing in the emergency department.
Patient was given antibiotics in the emergency department. Prescription for antibiotics was given.
Patient is stable for discharge. Family will use OTC antipyretics as directed for fever control. Encourage plenty of fluids. Family instructed to follow up with PCP within 24 hours. Return to the emergency department if symptoms worsen, or as needed.

"][/conditional][checkbox memo="PEDS Fever no symptoms" name="variable_74" value=""][conditional field="variable_74" condition="(variable_74).is('')"][textarea cols=80 rows=5 default="Assessment and Plan
UA is negative, child otherwise very well appearing, tolerating po, no lethargy, no shortness of breath, no signs of dehydration, no rash, up to date. Careful return indications, discussed with family, supportive care and close follow up with PMD advised. See DCI.

Urinalysis was negative.
Take Motrin and/or Tylenol alternating every three hours for fever.
Give plenty of fluids.
Follow-up with PMD in 1-3 days.
Return to the ER for shortness of breath, vomiting, signs of dehydration, fever lasting longer than 5 days or other concerns.

"][/conditional]
[link memo="Ddx" url="Ddx"]

#


1. [comment memo="Problem 1"][select name="variable_1" value="|# ABDOMINAL PAIN (UNSPECIFIED) # 
Patient reports new abdominal pain characterized by ***. Although with benign abdominal exam, ddx for acute abdominal pain include inflammatory (gastritis, PUD, cholecystitis, appendicitis, peritonitis, diverticulitis), vascular (AAA, mesenteric ischemia), obstruction (bowel, ureter, bladder), luminal perforation, and obstetric. Image negative abdominal pain include DKA, IBS/functional pain, withdrawal, angioedema, lead toxicity, vaso-occlusive events and porphyria.
- CBC, CMP, lipase, INR
- UA, UTox
- Consider imaging PRN

|# ACUTE ADRENAL INSUFFICIENCY (ADRENAL CRISIS) # 

Patient with*** history of adrenal insufficiency who presents with lethargy, fever, nausea, nonspecific abdominal pain, and hypotension concerning for adrenal crisis. Common etiologies include autoimmune, infectious, infarction, and medication inadherence.

Dx

- CBC, CMP, cortisol, ACTH, aldosterone, renin, TSH, lactate
- CXR, BCx x2, UA, Utox
- Evaluate fever, abdominal pain, hypotension per clinical scenario

Tx

- Hydrocortisone 100mg IV x1, then 50mg IV q6h (following lab draws)
- Consider empiric antibiotics and fluids if concerned for sepsis

|# ACUTE CHEST SYNDROME / VASO-OCCLUSIVE PAIN EPISODE # 

Patient with known history of sickle cell disease who present with concern for acute chest syndrome given segmental pulmonary infiltrate and symptoms of ***. Most likely due to ***. Common triggers include dehydrations, drugs/ETOH, stress, infection, and hypoxia. Patient with*** hx of acute chest syndrome, with *** hospitalizations over the past year for vaso-occlusive pain episodes.
Dx
- CBC, retic count
- CXR, BCx x2, Sputum Cx, Procalcitonin. Consider influenza, viral panel per clinical scenario
- EKG, Troponin. Consider PE eval per clinical scenario
Tx
- Aggressive pain control
- Aggressive fluid resuscitation with maintenance (assuming no heart failure)
- Antibiotics per clinical scenario
- Supplemental O2, Bronchodilator, incentive spirometry
- DVT ppx
- If concern for moderate/severe/very severe acute chest syndrome, consult hematology for exchange transfusion

|# ACUTE KIDNEY INJURY (AKI) # 

Patient noted to have AKI with Cr *** over baseline ***. Suspect due to relative hypovolemia and systemic illness. Currently producing urine and with normal bladder scan; will defer additional lab/imaging diagnostics pending fluid resuscitation.
- BMP
- s/p *** L IVF
- Consider UA with microscopy, Renal/bladder US, UNa, UCr if refractory or significant AKI

|# ACUTE LIVER FAILURE # 

Patient without history of liver dysfunction who presents with INR >1.5 and encephalopathy concerning for ALF. Should this be ALF, etiologies include viral, tox, autoimmune, vascular, shock, and iatrogenic med effect. Will proceed with broad diagnostics and evaluation for altered mental status. If this is not acute liver failure, may be acute liver injury from similar reasons listed above, with INR elevation from poor nutrition, DIC, MAHAs, or anticoagulation.
Dx
- RUQ with Doppler
- APAP level, arterial ammonia
- Hepatitis A IgM, anti-HBC IgM, anti-HCV IgG, HCV RNA,
- HBsAg, HBsAb, HBcAb, HBV DNA,
- ANA, ASMA, IgG, ceruloplasmin, and Utox
- INR, LFTs BID
- Q2hr POC Glucose
Tx
- Appreciate Liver Transplant Unit assistance
- NAC
- Elevate Head of bed
- 2g APAP limit

|# ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) # 

Patient presents with acute onset of bilateral alveolar infiltrates (noncardiogenic) and hypoxemia concerning for ARDS. Likely due to ***, with common etiologies including sepsis, pneumonia/pneumonitis, meds, toxins/inhalation injury, trauma/surgery, burns, and pancreatitis. P/F ratio: ***
Dx
- CBC, CMP, INR, Lactate
- CXR, BNP, SputumCx, BCx x2
- CPO, Telemetry
Tx
- ARDSnet protocol, VC 6cc/kg of ideal body weight
- Goal CVP <4
- Proning, paralysis per ICU

|# ALCOHOLIC HEPATITIS # 

Patient presents with right upper quadrant abdominal pain, fever, and leukocytosis in the setting of significant alochol use, concerning for alcoholic hepatitis. Ddx also includes ***. On presentation, MELD is *** and Maddrey's Discriminant Function is ***. Empiric treatment for alcoholic hepatitis with steroids is generally indicated in patients with MDF >32.
- CBC, CMP, INR, Lactate, BCx x2
- Thiamine, Folate, multivitamin
- Dx Para if ascites present
- Consider Prednisolone 40 mg QD if no contraindications
- If receiving steroids, measure Lille score at one week, If >0.45, consider stopping steroid treatment.
- Alcohol abstinence counselling and SW assistance.

|# ALTERED MENTAL STATUS (AMS) # 

Most likely due to ***. Ddx also includes infectious encephalopathy, substance/tox, metabolic derangement, and endocrinopathy.
- NCHCT
- CXR, UA/UCx, BCx x2
- BMP, VBG, CBC
- UTox

|# ANAPHYLAXIS # 

Patient with*** history of anaphylaxis, who presents with acute onset respiratory compromise or hypotension, with skin or mucosal involvement concerning for anaphylaxis. Suspect triggered by ***. Ddx includes but is not limited to acute generalized urticaria, angioedema, asthma exacerbation, panic attack, and shock.
Dx
- CBC w/ diff, CMP, INR, Lactate, Tryptase
Tx
- Airway – Albuterol, racemic epinephrine nebulizer
- Epinephrine initial management: 0.3 – 0.5 mg IM, repeat q5-15min for hypotension
- Epinephrine gtt: 0.1 mcg/kg/minute, with increase every 2 min by 0.05 mcg/kg/min to MAP >65
- IVF: ***L bolus
- H1: Benadryl 50 IV
- H2: Ranitidine 50 IV (for urticarial relief)
- Methylprednisolone 125 IV
- Telemetry, CPO, Airway management per ICU

|# ANION GAP METABOLIC ACIDOSIS # 

Pt presents with elevated anion gap of *** and acidosis. Renal insufficiency is ***present. Suspicion of toxic ingestion is ***. Most likely etiology is ***, with a differential including lactic acidosis, uremia/ESRD, ketosis (starvation, alcoholic, diabetic), toxic alcohols (ethylene glycol, methanol, ASA).

Dx:

- osm, EtOH, ASA, APAP, osm gap calculation per clinical scenario
- BHB
- VBG/lactate

Tx:

- per etiology

|# ANXIETY DISORDER, NEW # 

GAD-7: ***. The patient meets criteria for generalized anxiety disorder, given functional impairment from excessive unconrollable worry about a number of concerns. No psychotic features, personal history of PTSD or manic episodes, or significant fam hx of bipolar disorders. No SI HI AVH. Given new onset, consider secondary causes including hypoglycemia, hyperthyroid, anemia, withdrawal (EtOH, opioids, BZD, antidepressants), and excess caffeine.

- TSH, CBC, BMP, consider Utox
- psychotherapy referral for CBT and/or exposure therapy
- Biofeedback, yoga, meditation
- Pharm Tx:
- f/u 4 weeks

|# ANXIETY DISORDER, NEW # 

The patient meets criteria for anxiety disorder, specifically...
***generalized anxiety disorder given functional impairment from excessive unconrollable worry about a number of concerns, with*** agoraphobia. Screen with GAD-7: ***.

***panic disorder given recurrent out of the blue panic attacks with concern about recurrences. Screen with panic disorder severity scale: ***.

***social anxiety disorder given excessive anxiety related to social situations and potential scrutiny of others. Screen with Mini-SPIN: ***.

***specific phobia given excessive fear about *** with avoidance and/or enduring distress.

No personal history of PTSD or manic episodes, significant famhx of bipolar, and no psychotic features. Given new onset, consider secondary causes including hypoglycemia, hyperthyroid, anemia, withdrawal (EtOH, opioids, BZD, antidepressants), SUD, excess caffeine.

Dx:

- TSH, CBC, BMP, consider Utox
- psychiatry referral for suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple therapiest

Tx:

Non-Pharm Tx:

- psychotherapy referral for CBT and/or exposure therapy
- biofeedback, yoga, meditation

Pharm Tx: 

(uptitrate qweekly to qmonthly as tolerated; anxiolytic effect may require higher doses than for depression; trial slow taper off 6-9 months post-remission)

- start SSRI (escitalopram 5mg qd, then increase to 20-30 mg qd as tolerated) (sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max)
-- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly
- consider starting other classes of meds instead in special circumstances:
-- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain
-- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD)
-- avoid buproprion
- can augment with buspirone 10-60mg in 2-3 divided doses
- can augment with gabapentin/pregabalin (slow uptitration to max 3600mg total daily / 300mg total daily)
- consider propranolol 20-40mg BID PRN especially for social or performance anxiety; occasional PRN BZD reasonable for specific phobias
- reasonable for SHORT bridge of eg clonazepam 0.25-0.5mg BID PRN during SSRI uptitration but long term BZD should be reserved for patients who have failed first line treatments;
- f/u 4 weeks

|# ASTHMA EXACERBATION # 

Increased frequency of SABA, using MDI (>2x per week), increased dyspnea, night awakenings, limited normal activity. Most recent spirometry was . Number of ED visits in the past year that required oral steroids (#).

DDx: laryngeal / tracheal dysfunction, narrow supraglottic airway, foreign body aspiration, airway edema, chronic bronchitis or emphysema, bronchiectasis, allergic bronchopulmonary mycosis, cystic fibrosis, eosinophilic pneumonia, hypersensitivity pneumonitis, sarcoidosis, and bronchiolitis obliterans, eosinophilic granulomatosis with polyangitis, heart failure and pulmonary hypertension, conversion disorder.

- SpO2 >95% on 5L nasal cannula
- peak expiratory flow (PEF), normally 450-650 L/min in men and 350-500 L/min in women.

MILD: 

-PEF >300L/min
-HR<100, SaO2>95
-speaks in sentences
-can lie down
-not using accessory muscles

MODERATE:
100-300L/min, RR>20, HR>100, SaO2>90, FEV1 40-69%, speaks in phrases, Pulsus paradoxus >10mmgHg drop in BP blood pressure during inspiration

SEVERE: 
PEF <100L/min, RR>30, HR>120, SaO2<90, speaks in words, sits upright, Pulsus paradoxus >20mmgHg drop in BP blood pressure during inspiration

- CXR

Tx:

MILD

-SABA by MDI, q20min in first hour or Neb 0.15 mg/kg with a max dose of 5 mg.
- predisone PO 0.5-1.0 mg/kg/day), prednisolone 40-50mg, children 1-2mg/kg
-consider ipratropium (IB), 17 mcg/puff, 2-3 puffs q6h
-if good response SABA q4h 7 days, oral steroid 7 days, continue controller meds, consider ICS

MODERATE

- continuous SABA and ipratropium bromide (IB) by neb, oral corticosteroids, then SABA q40min

SEVERE:

- continuous SABA, IB, consider heliox, epinephrine IM, 2g Mg sulfate IV over 20min

Admit if...

ARDS, Decreased level of consciousness, Hypoxia: <93%, Hypercapnea: CO2 >42, Dehydration, Peak flow <50% predicted, pulsus paradoxus >15mmHg, need for IV SABA, mechanical vent

Underlying high risk factors: heart disease, neuromuscular disease, cystic fibrosis, bronchopulmonary dysplasia, history of ICU admission, unreliable parents or care givers, long distance from the ER.

ER visit within the preceding 24 hours.

D/c

Provide written action plan

Train for self-monitoring (peak flows), Educate and reinforce correct inhaler techniques, Refer to an asthma education program

Schedule follow-up

Consider home environment (tobacco exposure, allergen avoidance, social support)

Step down therapy is considered after at least 3 months of being well-controlled

|# AFIB (NEW) # 

Patient with new atrial fibrillation, with symptoms/onset notable for ***. Suspect due to ***, with common etiologies including infection, cardiac disease (ischemic, heart failure, structural), HTN, PE, ETOH/tox, sleep disorder and endocrinopathy. CHA2DS2-VASc: ***

- Rate Control:
- Anticoagulation:
- CBC, BMP, TSH

|# AFIB WITH RVR (STABLE) # 

Acute management of stable Afib with RVR with IV Metoprolol tartrate 5mg IV q15min x3 or Diltiazem 10-20mg IV q15min x3 may be warranted. Amiodarone can be used if the patient's blood pressure may not support IV metop/dilt, althought it carries the thromboembolic risk of chemical cardioversion. If the patient is hemodynamically unstable, synchronized cardioversion is warranted, with subsequent anticoagulation depending on Afib chronicity and onset.

|# ATYPICAL CHEST PAIN # 

Pt presents with atypical chest pain without troponinemia, ischemic EKG changes, or hemodynamics compromise, with low suspicion for acute coronary syndrome. Highest suspicion for ***. DDx also includes dissection, pericarditis, tamponade, PE, PTX, PNA, esophageal rupture, food impaction, and MSK strain/injury.

- HEART score ***
- Trop, EKG
- CBC, BMP, VBG
- CXR
- Consider 6hr repeat Trop, EKG per clinical scenario
- Consider DDimer, BP in 4 extremities per clinical scenario
|B
|C
|# CAD S/P PCI/CARDIAC CATHETERIZATION # 

Admitted for observation post-LHC that was significant for ***. S/p PCI with stents placed to ***. Pt recovering adequately from procedure with no evidence of swelling, hemorrhage, loss of perfusion, strength or sensation at arterial entry site.

-Admit for observation on telemetry
-Patient will need at least 6 months of uninterrupted DAPT.
-Aspirin 81 mg 1 tablet by mouth daily for heart attack prevention
-Clopidogrel (Plavix) 75 mg 1 tablet by mouth daily for heart attack prevention
-Optimization of guideline directed medical therapy for coronary atherosclerosis: beta blocker, ARB, and statin (high intensity preferred) as indicated.
-Optimize antianginal therapy.
-Aggressive risk factor modification.
-Consider referral to cardiac rehab outpatient
-Outpatient follow up with cardiology
|# CARDIOGENIC SHOCK # 

Patient presents in shock with history, physical exam, lab, and imaging findings of hypervolemia concerning for cardiogenic shock. Past clinical hx and TTE notable for ***. Alternative causes of shock less likely (see # Shock).

Dx
- Bedside TTE showing ***
- Bedside IVC showing ***
- EKG, Troponin, CBC, CMP, BNP
- Q6h CBC, ABG with COOX, Central Venous O2 saturation with COOX, CVP, Lactate
- BMP, Mg BID to TID
- CXR, UA with microscopy, consider BCx
- Strict I/O, daily standing weights
- Formal TTE, telemetry

Tx
- Goal net negative: ***
- Bumex 4 IV, Diuril 250 IV x1 with 1 hour UOP re-assessment
- Replete K>4, Mg>2
- Na-restricted diet (<3 grams per day), 2L fluid restriction
- ICU admission, central line placement
- Goal MAP 65, pressors (norepinephrine first line) and afterload reduction PRN
- Avoid initial BB, CCB

|# CAVITARY NODULE # 

Imaging notable for cavitary nodule, generally defined by thick walls greater than 4mm (cystic lesions < 4mm). Ddx includes infectious (bacterial, fungal, septic emboli, TB), malignancy, GPA, and foreign body.
|# CELLULITIS # 

Patient presents with skin and soft tissue infection of *** with *** evidence of purulence. No evidence of abscess at this time.

- Abx:
- CBC, CMP, Lactate
- Consider HIV, A1c, BCx per clinical scenario

|# CHEST PAIN. ATYPICAL # 

Pt presents with atypical chest pain without troponinemia, ischemic EKG changes, or hemodynamics compromise, with low suspicion for acute coronary syndrome. Highest suspicion for ***. DDx also includes dissection, pericarditis, tamponade, PE, PTX, PNA, esophageal rupture, food impaction, and MSK strain/injury.

- HEART score ***
- Trop, EKG
- CBC, BMP, VBG
- CXR
- Consider 6hr repeat Trop, EKG per clinical scenario
- Consider DDimer, BP in 4 extremities per clinical scenario
|# CHRONIC KIDNEY DISEASE # 

Defined by CKD <60 (Stage II) for 3 months or proteinuria (or evidence) for 3 months

A.  Progression/proteinuria: Slowly progressive. Cr **. Proteinuria increased to ** compared to ***, remains < 1g/g. Continue RAAS blockade.
P/Cr: <150 mg/g (<15mg/mmol), severe >500
Alb/Cr: <30 mg/g (<3mg/mmol), severe >300
Cr >2.5: hold RAAS
B.  Hypertension:  SBP goal <140 w/o proteinuria, SBP<130/80 + proteinuria use ACEi, ARB, Dilt/Verapamil, thiazide if GFR>30, if <30 need Lasix, (Spironolactone, Aliskiren). S/E: hyperkalemia, angioedema, and teratogenicity
C.  Bone/mineral metabolism: Ca, Phos, PTH, 25-OH-VitD (longer half-life). Calcium repletion if……Phosphate binders if >4.5 in CKD3b-5.  When 25OH vitamin D levels are <10ng/ml, start with ergocalciferol 50,000IU weekly for 6-8 weeks, then switch to cholecalciferol 800-1000IU daily. Calcitriol if ……….
D.  Acid/base and electrolytes:  derangements.
E.  Erythropoiesis:  screening begins with Stage 3a. Erythropoiesis-stimulating agents (ESA) for Hb <10. Anemia 2/2 is dx of exclusion
F.  Volume:  Euvolemic.
G.  Cardioprotection:  Continue aspirin and statin.

|# CODE BLUE NOTE (ROSC) # 

Code blue called at approximately ***. On my arrival, patient was without a pulse with rhythm showing ***. ACLS performed with *** rounds prior to ROSC. Patient's neurologic status was notable for ***, with GCS***. Family/contact was notified.

- EKG, Trop, CBC, CMP, Lactate, CXR
- CPO, Tele, ICU admission
- Cooling Protocol per Neuro PRN

// CODE BLUE OVERVIEW (NOT FOR NOTE DOCUMENTATION) //

** Your main job is to coordinate/run the room! You are not alone!**

☐ Walk into the roomHi my name is _____ and I am the code leader. Does the patient have a pulse? Is he/she full code?
☐ Quiet the room – ask directly for people to quiet down if needed and ask extra people to step out if too crowded
☐ Stand at the foot of the bed, stay calm but make sure your voice is loud enough
☐ Used close loop communication
☐ Identify your team: announce rolesCode whisperer: ____________
☐ Place back board/pads: Ask that someone places backboard and leads/pads if not already done
☐ CPR: 100-120/min- beat of “Staying alive”. Make a line and get LUCAS if available.
☐ Time-keeper: _____________  consider using Code Blue App
☐ Airway: Identify anesthesia and intubate asap if needed. If trach patient, make sure pt hooked up to oxygen. Ask for end tidal CO2- ideally >20 if good compressions, if <10 then improve chest compressions or think about reasons for poor ventilation and V/Q mismatch (e.g. PE!).
☐ Pharmacist: __________ Ask for 1mg epi right away, then see algorithm below. Ask for closed loop communication to confirm when meds are given.
☐ Labs: Ask for rainbow to be sent (iSTAT; ABG with lytes/lactate, CBC, CMP, coags, type and cross, POC glucose, troponin). Ask to confirm when sent or let you know in two minutes if can’t get them. If at SFGH can run ABG with lytes faster in ED so another resident to run it down
☐ Access: Get IV access. If no PIVs, get IO access. Occasionally get central line / Aline during code if long code, needed for access, etc but not an immediate priority.
☐ Other tasks:Ask another resident to look up recent labs, review tele, etc
☐ Ask primary team for basic info and that they call family asap
☐ Ask another resident to grab an ultrasound- look for e/o tamponade, right heart strain

ACLS ALGORITHM AND MEDICATIONS

☐ Immediately: 1mg epinephrine if PEA/asystole, 1L NS wide open (unless cardiogenic shock)
☐ Then per ACLS algorithm epi every 3-5min (I do every 4min) and amio if shock! See next page
☐ Next: Consider 1 gram calcium chloride, 1 gram mag sulfate, 2-3 amps bicarb, 1amp D50 I often give all of these within the first few rounds, but not part of ACLS. Caution with multiple rounds of bicarb if not intubated yet.
☐ If you want TPA (PEA/asystole only), ask early! Takes 10-15min to make it, then after given it takes 20min to take effect so need to continue the code for at least 25 more minutes
☐ Ask for levophed to be hung so ready when ROSC achieved

SUMMARIZE and TALK OUT LOUD

☐ Review pt one liner and where we are in the algorithm every few minutesExample “This is a 75M admitted with PNA who was hypoxic and then lost a pulse, we are in the PEA algorithm. This is our second round of check compressions, we have given 1mg epi and 1amp bicarb, he was just intubated and end tidal being set up, labs are being drawn, etc etc)”

THEN GO THROUGH THE H’S AND TS OUT LOUD

☐ Hs: 1. Hypovolemia 2. Hypoxia 3. Hydrogen (acidosis) 4. Hypo/hyperK 5. Hypothermia
☐ Ts: 1. Tension pneumo 2. Tamponade 3. Toxins 4. Thrombosis (PE) 5. Thrombosis (ACS)
☐ Invite thoughts from the room
☐ End of code

IF YOU GET ROSC, SEE POST-ROSC INSTRUCTIONS ON PAGE 2

CALL CODE IF...

☐ 20 minus with end tidal <10 = call code; 
☐ 30 mins without clear etiology = call code

If the code has gone on >10 rounds, check with the ICU triage fellow/attending quietly first whether you should consider calling it then also ask the room. It is a group decision, you definitely don’t decide alone!

Once decided, continue the round of chest compressions and tell the room that we will continue chest compressions until the next rhythm check and if no pulse at that time we will call it – gives chance for everyone to anticipate ending mentally/emotionally and to make sure no final ideas

Can invite family into room during code or after- if during, ask primary team to stay with them

It’s just an algorithm! The harder part is the leadership/organization piece above… the meds are pretty easy once you’ve done it a few times. This is a brief summary, see Code Cards for complete version. I typically didn’t look at Code Cards during the code since distracting, but can hand them to the Code Whisperer or have them in your pocket in case.

// ACLS Algorithms //

# PEA ARREST

0 Min:

☐ Begin chest compressions. 

As soon as leads/pads set up
☐ stop compressions to do a rhythm check 
- (don’t wait for 2min the first time around!). 
- No need to shock for PEA algorithm
☐ Give 1mg epinephrine right off the bat

2 Min:

☐ Pulse/rhythm check.

4 Min:

☐ Pulse/rhythm check.
☐ Give 1mg epinephrine (Give every 3-5minues)

// VFIB/VTACH ARREST //

0 Min:

☐ Begin chest compressions. 
☐ leads/pads set up
☐ stop compressions
☐ do a rhythm check
? If shockable rhythm (Vfib/Vtach)
☐ charge to 200J
☐ shock. 
☐ continue chest compressions

2 Min:

☐ Pulse/rhythm check. 
? If shockable rhythm, charge to 200J and shock.
☐ Give 1mg epinephrine at 2-4 mins (consider 1mg epi + vaso 20 + methylpred 40mg)

4 Min:

☐ Pulse/rhythm check. 
? If shockable rhythm = charge to 200J and shock.
☐ Give 300mg amiodarone (for refractory Vfib/Vtach)

6 Min:

☐ Pulse/rhythm check. 
?If shockable rhythm
☐ charge to 200J
☐ shock.

☐ Give 1mg epinephrine (consider + vaso 20mg)

8 Min:

☐ Pulse/rhythm check.

? If shockable rhythm
☐ charge to 200J
☐ shock.

☐ Give 150mg amiodarone

ROSC: POST-ARREST CARE

☐ Make sure pressors ready
☐ ask for levophed to be hung during code if possible. 
☐ Can consider asking for 1mg epi with you for transport.
☐ Consider sedation if intubated, esp if paralytics used to intubate (often forgotten)

// WHERE IS PATIENT IS GOING? //

? ICU, CATH LAB, SCANNER ETC. 

☐ Ask charge when bed ready and you help transport
☐ Make pt stable for a couple min
☐ transport monitors ready, etc before transport

// PT ARRIVES IN ICU //

☐ Get EKG
☐ repeat labs
☐ CXR 
☐ additional imaging
☐ lines 
☐ Ask primary team to call neuro to get their recommendation about cooling 
☐ primary team calls family
☐ notifies attending (remind/offer to help the early Foxes if medicine pts)
☐ Always write code note (even if code is a false alarm!). “Significant Event Note” or “Code Documentation”

// POST-CODE DEBRIEF //

☐ ask all parties to meet 20min after to debrief. 
- If floor code, try to do this on the floor so floor RNs there
☐ Ask for feedback – from ICU triage fellow, attending, co-residents, charge nurse, etc… ask specific questions!

// PERI-CODE SITUATIONS //

These situations can sometimes be more challenging than codes, since less algorithmic. Ask for help! 

☐ Ask somebody in the room to stat call cardiology or other relevant consultants if needed.

// BRADYCARDIA WITH A PULSE //

☐ Atropine 0.5mg IV bolus
☐ set up transcutaneous pacing at the same time.
3-5min (3-5m)
☐ Atropine 0.5mg IV bolus
3-5min (6-10m)
☐ Atropine 0.5mg IV bolus
3-5min (9-15m)
☐ Atropine 0.5mg IV bolus
3-5min (12-20m)
☐ Atropine 0.5mg IV bolus
3-5min (15-25)
☐ Atropine 0.5mg IV bolus
max 3mg Reached

– but note won’t work if third degree block so ALSO 
☐ set up transcutaneous pacing at the same time.

Transcutaneous pacing
☐ look for capture. 
☐ Start 60 beats/min and go up

Dopamine infusion (2-20mcg/kg/min) or Epinephrine infusion (2-10 mcg/min)
☐ Call cardiology!

DATE: Dopamine, Atropine, Transcutaneous pace, Epi

// TACHYCARDIA WITH A PULSE //

(Narrow regular)
☐ Attempt vagal maneuvers
☐ Give adenosine (only if regular!)
- 6mg, then 12mg (but 3mg if via central line)
☐ Call cardiology. 
☐ Consider beta blocker, calcium channel blocker

// UNSTABLE //

☐ synchronized cardioversion. 
☐ 50 J
☐ 100 J. 
cardiovert! 
? Awake
☐ Provide sedation (50mcg fentanyl)

// IRREGULAR + NARROW //

Afib with RVR: 
☐ Give metop 2.5 or 5mg IV if BPs can tolerate. 
☐ Consider amio loading

// UNSTABLE //

☐ synchronized cardioversion. 
☐ 120-200J biphasic / 200J monophasic.

// REGULAR + WIDE //

☐ Call cardiology. 

// REGULAR + MONOMORPHIC//

☐ Consider adenosine 
☐ check with cardiology - Consider anti-arrythmic infusion (Amio) 

// UNSTABLE //

☐ synchronized cardioversion: 100J

// WIDE IRREGULAR //

☐ Call cardiology – specifically EP if possible. 
☐ Defibrillation dose (200J).

// OTHER NON-PULSELESS SITUATIONS //

AMS: 
☐ empirically given 1amp D50. 
☐ Check glucose
☐ VBG to r/o hypercarbia. 
☐ Review MAR- consider narcan. 
☐ Consider stroke, seizure. 
☐ Intubate if not protecting airway

HYPOTENSION: 
☐ Ask pharmacy to get levo or epi gtt ready; 
☐ give smaller pushes of epi in meantime (eg 0.2mg epi). 
☐ Ask for IVF wide open unless cardiogenic shock

SEIZURE: 
☐ Give Ativan, 
☐ call neuro

CVA: 
☐ Check pupils, 
☐ call code stroke

DISSECTION: 
☐ Check bilateral cuff pressures and pulses. 
☐ Get imaging if stable enough. 
☐ Call vascular stat if concern

ANAPHYLAXIS: 
☐ Steroids
☐ benadryl
☐ famotidine
☐ fluids
☐ airway

TAMPONADE: 
☐ Call cards stat. 
☐ Avoid intubation if possible (drops preloadà HD collapse)

CHEST TUBES: 
☐ If had air leak and now doesn’t, think about tension pneumo. 
☐ Ask nurses to strip chest tubes. 
☐ Call CT surgery stat for trouble shooting

MASSIVE TRANSFUSION PROTOCOL: 
☐ Ask co-resident to help count blood products – write on board or wall. ☐ Call GI/IR. 
☐ Ask to get Belmont from the OR.

TRACH ISSUES: 
☐ Cuff up/down? 
☐ Call ENT stat for help. 
☐ Get oral airway if issues and no contraindication

TORSADES: 
☐ Give magnesium

// MASSIVE TRANSFUSION PROTOCOL //

DEFINITION: 
4U in 4 hours, 3U in 1 hour, anticipated ongoing bleeding

SETUP:
☐ Identify point person to blood bank to activate MTP
☐ Ask co-resident to help count blood products – write on board or wall.

IDENTIFY CAUSE:
☐ FAST exam
☐ start compression/tourniquet
☐ Call surgery/GI/IR.
☐ Ask to get Belmont from the OR. 
☐ Start active warming of patient

ACCESS? 
☐ 2 16-18g PIVs at least, 
☐ consider upsizing with RIC.

ANTICOAGULATION? 
☐ Consider K-centra/vitK; 
☐ TXA in trauma patients

PLYTE/LR 
☐ Initial 1:1:1 pRBC/FFP/platelets 
☐ labs q30m
- damage control approach then guided by labs q30m

LABS: 
☐ iSTAT
☐ CBC
☐ coags
☐ fibrinogen
☐ iCal
☐ Type and cross
☐ thromboelastography

GOALS
-MAP>65 (>85 if CNS)
-Temperature >35 °C
- Acid-base status
-- pH >7.2
-- base excess <–6
-- lactate <4 mmol/L
- Ionised calcium (Ca) >1.1 mmol/L
- Haemoglobin (Hb)  >10.
- Platelet (Plt) ≥ 50 (>100 if CNS)
- PT/APTT ≤ 1.5x of normal (FFP)
- Fibrinogen ≥ 100 (cryo)

//COMPLICATIONS//

- volume overload (careful monitoring of filling pressures, response to volume, diuresis etc)
- over-transfusion (monitor Hb regularly, titrate according to needs)
- hypothermia (monitor temp, use fluid warmers and other measures to reduce heat loss)
- dilutional coagulopathy of clotting factors and platelets (regular and early monitoring of coagulation, involvement of haematology for replacement therapy )
- Transfusion related acute lung injury (consider use of filters, leukodepletion)
- excessive citrate causing metabolic alkalosis and hypocalcaemia (monitor pH and ionised calcium, replace calcium as necessary)
- hyperkalaemia (use of younger blood, monitor regularly, may require specific therapy)
- disease transmission (use of products only on a needed basis only, standard blood banking precautions etc)

|# COPD EXACERBATION (ACUTE ON CHRONIC) # 

Patient with history of COPD who presents with wheezing, worsening cough and dyspnea, concerning for COPD exacerbation without concomitant pneumonia.

- Influenza, viral panel per clinical scenario
- CBC, BMP, ABG/VBG
- CPO, SpO2 goal>88%
- Albuterol/Ipratroprium nebulizer q4hr, reassessment
- Prednisone 40mg QD x 5 days
- Consider CRP, Azithro or Doxy x 5 days

|# COVID-19 CONFIRMED WITH ACUTE HYPOXIC RESPIRATORY FAILURE (ARDS) # 

Onset of symptoms on 8/18, including fever, cough, SOB, GI sx. Admitted to *med floor *ICU* on 8/25 with hypoexmic/hypercarbic respiratory failure. CXR notable for ***. COVID test positive on ****. Received therapies include *** proning, convalescent plasma, remdesivir, flolan, and/or ECMO.

Goal SpO2 92-96, PaO2>75

Labs/dx

- Admission: CBC w diff, CMP, CRP, procal, CPK, PTT, INR, BNP, ferritin, EKG, CXR
- Daily: CBC w diff, BMP, Mag, CPK, BNP
- Strict isolation = Contact (gown+ gloves) + Droplet (N95)
- AVOID aerosolizing procedures when possible (Non-invasive, high flow, nebs, bronchoscopy)

Tx:

- Duoneb q6h
- Budesonide 0.5mg bid
- Remdesivir
- Baricitinib
- Methyprednisolone (Solumedrol)
- Zinc 220mg qd, Vitamin D 4,000u qd, Vitamin C 500mg q6h, Thiamine 100mg, Famotidine 20mg bid, Melatonin 9mg qhs
- Lovenox 55mg q12


|# CYSTIC LUNG DISEASE # 

Imaging notable for cystic lung disease, generally defined by thin walls less than 4mm (cavitary lesions > 4mm). Parencyhmal mimickers of cystic lung disease include emphysema, bronchiectasis, blebs, bullae and pneumatocele. Cystic lung disease ddx includes lymphoid interstitial pneumonia (LIP), lymphangioleiomyomatosis (LAM), Birt-Hogg-Dubé syndrome (BHD), and pulmonary Langerhans cell histiocytosis.

|D
|# DECOMPENSATED CIRRHOSIS #

Pt with known history of cirrhosis secondary to ***, with decompensation as evidenced by varices, ascites, and/or hepatic encephalopathy. MELD-Na: ***.

## Hepatic Encephalopathy

- Lactulose titrate to 4 BM/day, Rifaximin 550 mg BID

## Variceal Bleeding

- Last EGD ***
- Octreotide gtt, PPI, CTX x 5 days

## Ascites

- Lasix 20mg, spironolactone 50 mg
- Dx/Tx paracentesis
- SBP ppx PRN

## HCC Screening

- AFP + US/CT/MRI every 6 months; last ***

| # DECOMPENSATED CIRRHOSIS # 

Pt with known history of cirrhosis secondary to ***, with decompensation as evidenced by varices, ascites, and/or hepatic encephalopathy. Child Pugh Class: ***. MELD-Na: ***. Potential precipitants of decompensation: ***.

## Hepatic Encephalopathy

- Lactulose 25mL q2-3h until BM, then titrate to 3-4 BM/d. (Lactulose + Rifaximin 550 mg BID better than lactulose alone for HE reversal and all-cause mortality)

## Variceal bleeding

- Baseline EGD performed?
- Management: IV access, transfusions PRN, octreotide gtt, PPI, CTX x 5 days, and EGD; in refractory cases consider TIPS
- Secondary prophylaxis: Propranolol with goal HR 50-60s AND Serial EVL until obliteration & then re-assessment every 6-12 months

## Ascites/volume overload

- Management: 2g Na restriction, Start with 100mg/day spironolactone + 40mg/day furosemide (titrate every 3-5 days as tolerated, max doses: 400mg spironolactone, 160mg furosemide)
- Therapeutic Paracentesis PRN, If >4L ascites removed, then transfuse 6-8g albumin for every 1L ascites removed
- D/C Beta-Blocker as no longer beneficial once in decompensated state

## Spontaneous bacterial peritonitis (SBP)

Must rule out SBP in ALL inpatients with cirrhotic ascites
- Workup: Diagnostic Paracentesis with fluid sent for Cell count with Diff, Gram Stain, Culture, Glucose, Protein,
- Diagnosis: >250 PMNs, regardless of GS/Cx
- Treatment: Ceftriaxone x 5 days; 25% Albumin (1.5 g/kg day 1 & 1.0 g/kg day 3, max 100 g); d/c Beta-Blocker
- Prophylaxis: Cipro 500mg qday

## HCC Screening: AFP + US/CT/MRI every 6 months; last ***

## Transplant candidacy: ***

## Healthcare maintenance:

- Vaccinations: Pneumovax, Influenza, HAV, HBV
- Alcohol abstinence
- Avoid NSAIDs, limit APAP <2g/daily, avoid raw oysters/shellfish

|# DEMAND ISCHEMIA / TYPE 2 MI # 

Positive troponin without clinical history or EKG suggestive of acute coronary syndrome. Demand ischemia most likely secondary to ***. Common alternative etiologies include LVH, pericarditis, myocarditis, drug toxicity, trauma, and PE.

- Trend to peak PRN
- EKG

|# DEPRESSION, NEW # 

The patient meets criteria for a depressive episode based on PHQ9 of ***. Denies SI, HI, AVH. No personal history of panic attacks, PTSD or manic episodes, significant famhx of bipolar, and no psychotic features.

Dx:

- TSH, CBC, BMP, HIV, HCV. Consider Utox, LFTs, HgbA1C, RPR
- Psychotherapy referral for CBT and/or supportive therapy
- Aerobic exercise 30m qd x 5 days/week
- Biofeedback, yoga, meditation

Tx:

- Meds:
- f/u 4 weeks

|# DEPRESSION, NEW # 

The patient meets criteria for a depressive episode based on PHQ9 of ***. Denies SI, HI, AVH. No personal history of panic attacks, PTSD or manic episodes, significant famhx of bipolar, and no psychotic features.

Dx:

- TSH, CBC, BMP, HIV, HCV. Consider Utox, LFTs, HgbA1C, RPR
- Psychotherapy referral for CBT and/or supportive therapy
- Aerobic exercise 30m qd x 5 days/week
- Biofeedback, yoga, meditation

Tx:

- Meds:
- f/u 4 weeks

| # DEPRESSION; MAJOR DEPRESSIVE EPISODE, NEW # 

The patient meets criteria for a depressive episode based on PHQ9 of ***. ***Denies suicidal or homicidal ideation. Functional impairment manifested by ***. No personal history of panic attacks, PTSD or manic episodes, significant famhx of bipolar, and no psychotic features. Given new onset, consider secondary causes including cardiac disease, neoplasm (especially oropharyngeal and pancreatic), neurologic disease (including stroke and movement disorders), anemia, diabetes, hypothyroidism, chronic infection (including HIV and HCV), medications (eg, AEDs, steroids, BZDs, BBs, others), and substance use (eg, alcohol, any illicits).

Dx:
- TSH, CBC, BMP, HIV, HCV
- consider Utox, LFTs, HgbA1C, RPR
- defer addn’l cardiac and neoplastic testing for now
- psychiatry referral for suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple antidepressants

Non-Pharm Tx:
- psychotherapy referral for CBT and/or supportive therapy
- light therapy (light box vs glasses on Amazon), gradually incresase to 30-45m qd
- aerobic exercise 30m qd x 5 days/week
- biofeedback, yoga, meditation

Pharm Tx: 
(uptitrate qweekly to qmonthly as tolerated; slow taper off 6-9 months post-remission)
- Medication shared decision making aid: https://depressiondecisionaid.mayoclinic.org/
- start SSRI (escitalopram 5mg qd, then increase to 10-20 mg qd as tolerated) (sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max)
-- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly
- consider starting other classes of meds instead in special circumstances:
-- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain
-- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD)
-- consider buproprion (start 150mg qd -> max 450mg) if desire to avoid weight gain or sexual side effects, or for smoking cessation; (CI: h/o seizures or anxiety)
-- especially if pt naturally inclined, consider adding trial EPA 2g/day and/or SAMe up to 800mg BID (for SAMe, theoretical risk of serotonin syndrome if also taking serotonergic meds)

Resistant/refractory Tx: 
(unresponsive to 2 therapeutic doses of antidepressant meds)
- trial AD from another class and augment with CBT
- refer to psychiatry
- reassess organic causes, treat SUD/personality disorder/hx trauma
- augment with buproprion/mirtaz or atypical antipsychotic (eg aripiprazole)
- augment with T3, transcranial magnetic stimulation
- consider referral for psychadelic assisted psychotherapy (ketamine is legal, MDMA/psilocybin as part of clinical trials)
- consider electroconvulsive therapy
- f/u 4 weeks

|# DEPRESSION; MAJOR DEPRESSIVE DISORDER, RECURRENT

Diagnosed ***year. Has comorbid ***anxiety but no prior manic episodes, suicide attempts or psychosis. Workup for secondary causes unrevealing and denies ongoing substance use. Previous medication trials have included: (med, max dose, duration, response, limiting side effects). Max PHQ9 of *** on ***. Most recent PHQ9 of *** on ***. Plan for today: ***.

- follows with ***therapist, ***psychiatrist (refer if suicidality, thought d/o, unclear dx, psychotic features, bipolar, refractory to multiple antidepressants)

Non-Pharm Tx:
- psychotherapy referral for CBT and/or supportive therapy
- light therapy (light box vs glasses on Amazon), gradually incresase to 30-45m qd
- aerobic exercise 30m qd x 5 days/week
- biofeedback, yoga, meditation

Pharm Tx: 
(uptitrate qweekly to qmonthly as tolerated; slow taper off 6-9 months post-remission or continue lifelong if >2 episodes of depression)
- start previously effective medication or if none, review medication shared decision making aid: https://depressiondecisionaid.mayoclinic.org/
- start SSRI (escitalopram 5mg qd, then increase to 10-20 mg qd as tolerated) (sertraline (more stimulating, more diarrhea) start 50mg qd, uptitrate by 25-50mg qweekly as tolerated to 200mg qd max)
-- if comorbid panic attacks or inability to tolerate low dose SSRIs, can start with liquid formulation of eg escitalopram 1mg qd and increase by 1mg weekly
- consider starting other classes of meds instead in special circumstances:
-- consider SNRI (esp duloxetine start 30mg qd -> 60-120mg qd max) if chronic pain
-- consider TCA eg nortryptyline (25mg->50-150mg qd) if chronic pain/migraine or amitriptyline (25mg->100-300mg qd) if significant insomnia (caution: TCA lethal in OD)
-- consider buproprion (start 150mg qd -> max 450mg) if desire to avoid weight gain or sexual side effects, or for smoking cessation; (CI: h/o seizures or anxiety)
-- especially if pt naturally inclined, consider adding trial EPA 2g/day and/or SAMe up to 800mg BID (for SAMe, theoretical risk of serotonin syndrome if also taking serotonergic meds)

Resistant/refractory Tx: 
(unresponsive to 2 therapeutic doses of antidepressant meds)
- trial AD from another class and augment with CBT
- refer to psychiatry
- reassess organic causes, treat SUD/personality disorder/hx trauma
- augment with buproprion/mirtaz or atypical antipsychotic (eg aripiprazole)
- augment with T3, transcranial magnetic stimulation
- consider referral for psychadelic assisted psychotherapy (ketamine is legal, MDMA/psilocybin as part of clinical trials)
- consider electroconvulsive therapy
- f/u 4 weeks

|# DIABETIC KETOACIDOSIS (DKA) # 

Patient presents with malaise, polydipsea and polyuria, found to have significant hyperglycemia. pH ***, AG ***, BHB ***, UA with Ketones. Last A1c ***. Suspect trigger is ***. No history of heart failure or evidence of volume overload.

Dx
- tele/CPO
- CBC, CMP, VBG, BHB, UA, Utox
- CXR, BCx x2
- q1-2hr Na, K, glucose checks per DKA protocol
- Troponin if chest discomfort
- A1c

Tx
- DKA protocol, s/p 10u IV regular (0.1U/kg), then insulin gtt
- IVF: *** (LR preferred; 1L/hr x 4h; 250-500cc/hr x 4h; 100-250cc/hr)
- Hold insulin for K<3.3

|# DIABETIC KETOACIDOSIS (DKA) # 

Patient presents with malaise, polydipsea and polyuria, found to have significant hyperglycemia. pH ***, AG ***, BHB ***, UA with Ketones. Last A1c ***. Suspect trigger ***med inadherence, as pt without infectious symptoms and low concern for stroke or MI. No history of heart failure or evidence of volume overload.

Dx
- tele/CPO
- ICU for pH<7.1, access issues, hypotension, oliguria, AMS
- CBC, CMP, VBG, BHB, UA, Utox
- CXR, BCx x2
- q1-2hr Na, K, glucose checks per DKA protocol
- Troponin if chest discomfort
- A1c

Tx
- Access: ***
- hold insulin for K<3.3; supplement 20-30mEq/1L IVF for K 3.3-5.3)
- DKA protocol, s/p 10u IV regular (0.1U/kg), then insulin 5u/hr gtt
- NaHCO3 for pH<7
- IVF: *** (LR preferred; 1L/hr x 4h; 250-500cc/hr x 4h; 100-250cc/hr)
- Holding Home insulin regimen: ***

|# DISSEMINATED INTRAVASCULAR COAGULATION (DIC) # 

Concern for DIC given ***, most likely due to ***. Common etiologies include sepsis, malignancy (APML, mucinous adenocarcinoma (GI), prostate), tumor lysis, liver dysfunction, drugs, trauma, pancreatitis, and obstetric.

- Trend CBC, INR, LDH, Fibrinogen, Ddimer
- Tbili/Dbili, Smear, iron panel

|# DYSPHAGIA # 

Patient reports progressive dysphagia characterized by ***. Oropharyngeal ddx includes neuromuscular (CVA, dementia, ALS, myelopathy), mass (malignancy, Zenker, web), and other (infection, xerostomia, medications, radiation). Esophageal ddx includes dysmotility (achalasia, DES, scleroderma, Chagas, neuromuscular disease), internal obstruction (malignancy, stricture, web, rings) and external compression.

- NPO
- Endoscopic evaluation/imaging per clinical scenario

|E

|# END STAGE RENAL DISEASE (ESRD) # 

Hemodialysis vs. Peritoneal dialysis, Treatment location and schedule, Date of last dialysis: ***
Access HD: (fistula, graft, catheter) or ...PD: catheter
fistula - native vein or artery
graft - artificial conduit connecting native vein and artery
catheter - temporary (vascath) or tunneled/permanent (permacath)

- consult IR if weak thrill or pulsatility (stenosis)
- patient making urine?
- assess volume status, oxygen, BP
- potassium
- pH

Routine Management:

- No BP or labs in access arm (No PICC or IVs or subclavian lines in the nondominant arm of CKD 4-5 pt's)
- renal diet (low K and phos)
- dose meds appropriately
- No maintenance IVF
-be very cautious repleting electrolytes
- HTN
- goal Hb 9.5-11, check iron stores, consider ESA as out pt
- Bone mineral disease (phos binder with meals, hold if NPO. calcium binders (Ca carbonate vs sevelamer or lanthanum)

// Contrast Considerations: // 

- if pt still makes urine avoid iodinated contrast. If used, maintain dialysis schedule.
- Avoid gadolinium if GFR<30 (risk of nephrogenic systemic fibrosis), if needed in life-threatening situtaion, dialyze immediately after GAD.

// Contrast Nephropathy: //
- High risk: diabetics, proteinuria, AKI, CKD4-5, heart / liver failure, dehydration.

Pretreatement:
- hold diuretics,
- hold RAAS inhibitor if new med (ok if chronic med and renal fxn at baseline)
- hydrate, NS or NaB (sodium bicarb 150mEq in 1L). infuse 3cc/kg for 1 hour prior to contrast, 1cc/kg for 6 hours after contrast
- consider Mucomyst 1300mg bid, two doses before and after contrast
- supportive care and avoidance of additional injury if contrast injury manifests 12-48 hrs after administration of contrast

|# EPIDURAL HEMATOMA # 

Pt presents with ***, found to have epidural hematoma (likely traumatic arterial injury).  GCS on admission ***. Clinically stable, small volume EDH (<15 mm clot thickness and <5 mm midline shift) may be monitored with serial imaging, while patients with focal neurologic deficits or EDH >30 mL should be managed surgically.

- NCHCT with q6hr repeat
- Neuro monitoring
- AC Reversal if safe to do so
- LP, steroids contraindicated

|# EXTUBATION CRITERIA #

☐ FIO2 <= 0.5, PEEP <=10
☐ RSBI <=105
☐ Treatment of underlying disease
☐ Spontaneous breathing, cough, gag, minimal sputum
☐ Following commands

# Extubation Criteria

☐ FIO2 <= 0.5, PEEP <=10
☐ RSBI <=105
☐ Treatment of underlying disease
☐ Spontaneous breathing, cough, gag, minimal sputum
☐ Following commands

# Extubation checklist

☐ Is the patient ready for an SBT?

Required criteria

☐ Cause of respiratory failure/intubation is treated and improving
☐ Adequate oxygenationPO2>=60 on FiO2 <=0.5
☐ PEEP <=10
☐ P/F >=150 (>=120 for patients with chronic hypoxemia)
☐ Adequate ventilationNo significant respiratory acidosis
☐ Patient-initiated inspiratory effort
☐ Hemodynamic stability without active cardiac ischemia
☐ HR <=140
☐ Stable BP and at most moderate dose of 1 pressor
☐ pH>=7.25

Optional Additional criteria

☐ Adequate mentation: arousable, GCS>=8-13
☐ Afebrile T<=38-38.5
☐ Hb>8-10 g/dL
☐ No general anesthesia planned in next 24 hours
☐ Should not be on paralytics, have an open abdomen or undergoing therapeutic hypothermia

// Did the patient PASS their SBT? //

- Best validated measurement of predicting successful extubation: 
- Rapid shallow breathing index (RSBI) = RR/TV in mlPS 10-12cm, PEEP<=8, FiO2<=0.6 for 30-120 mins
- 80% of patients with RSBI<=105 are successfully extubated

// Other predictors of successful extubation //

Ventilator numbers
☐ RR<=30
☐ TV>=5 ml/kg
☐ MV<=15 L/min
☐ Negative maximal inspiratory force (MIF or NIF) <=-20 to -30cm H20

Patient characteristics
☐ Strong cough
☐ Scant secretions
☐ Adequate mentation: Opens eyes, tracks (aware and alert)
☐ Sticks out tongue (higher cortical function)
☐ Lifts head off of bed (sufficient strength)

// Did the patient FAIL their SBT? //

Objective criteria
☐ RR>=30 or RR changes >=50%
☐ Inadequate gas exchange: PaO2 <=60 or O2 sat <=85-90%
☐ Increase in PaCO2 >=10 mmhg
☐ Hemodynamic instability: HR change >20%
☐ SBP >=180, DBP>90 or BP change >=20%

Subjective criteria
☐ Change in mentation (ex: anxiety, agitation, somnolence)
☐ Increased work of breathing (ex: diaphoresis, accessory muscles, paradoxical abdominal movement)

// Post extubation care //

Before extubation, consider the most likely causes of post-extubation failure and develop a post-extubation care plan:
☐ Volume (diuresis)
☐ Mucous (suctioning, pneumonia treatment, acapella, meta-nebs, cough assist)
☐ Atelectasis/collapse (positive pressure (NIVV, EZPAP), IS, meta-nebs, early ambulation)
☐ Bronchospasm (bronchodilators)
☐ Monitor for upper airway obstruction aka post-extubation stridor
☐ Avoid sedation and medication that can cause respiratory depression
☐ Good patient positioning
☐ Non-invasive ventilation (NIVV) -- in patients with high risk of failure, extubate directly to NIVV, don't want for post-extubation respiratory failure
☐ SOAR to RSBI

|F

|# FEVER AND RASH # 

Patient presents with new fever and rash, concerning for ***. Common etiologies include infectious (bacterial SSTI, necrotizing fasciitis, endocarditis, viral, disseminated gonorrhea, rickettsia), autoimmune, drug reaction, malignancy, and dermatologic emergencies (toxic shock, SJS/TEN, DRESS, staph scalded).

- CBC, CMP, BCx2
- See alternative problem for more specific dx/tx

|# FEVER IN A RETURNING TRAVELER # 

Patient presents with fever and *** symptoms following travel to *** that began *** days after returning. History notable for ***. First, must determine if this travel is related to travel. If so, consider exposures, timecourse, route of entry, and endemic pathogens. Common atypical organisms include typhoid/paratyphoid fever, EBV, CMV, Rickettsia, Dengue, and malaria.

- CBC w/ diff, CMP, Lactate, INR
- CXR, UA/UCx, BCx x2, consider HIV
- Additional labs and imaging per clinical scenario

|# FEVER OF UNKNOWN ORIGIN (FUO) # 

Patient presents with FUO, as defined by 3 weeks of intermittent fevers without diagnosis after inpatient stay or 3 outpatient visits. History notable for ***. FUO ddx includes infectious, autoimmune, malignancy, and other.

Dx
- Past workup:
- CBC w/ diff, CMP, Lactate, INR
- HIV, ESR, CRP, ANA, RF, SPEP, EBV, LDH, CK, appropriate TB evaluation
- Hep A, B, C, serologies if LFT abnormalities
- CXR, UA/UCx, BCx x2
- CT Chest, A/P

|G

|# GERD # 

Reflux or retrosternal burning sensation worse with eating or when lying flat.

DDx: 
dyspepsia (epigastric discomfort, gas, nausea), esophagitis, stricture, adenocarcinoma

Complicatons: 
barret esophagus, stricutres, esophagitis, adenocarcinoma.

Worrisome: 
bleeding, odynophagia, dysphagia, anorexia, weight loss, and signs of systemic illness, unexplained IDA, should prompt referral.

|# GI BLEED, LOWER # 

Patient presents with bright red blood per rectum concerning for lower GI bleed. History and rectal exam notable for ***. DDx includes anatomic (diverticulosis), vascular (angiodysplasia, hemorrhoids, ischemic, post-polypectomy), inflammatory (infectious, IBD, radiation) or neoplastic (polyp, carcinoma), as well as brisk upper GI bleed.

|# GROSS HEMATURIA #

Patient presents with gross hematuria without clots. No UTI symptoms and UA not suggestive of infection. Ddx includes inflammation/infection of prostate or bladder, menstruation, kidney stones, malignancy, and glomerular bleeding.

- UA with microscopy/Cx, CBC, BMP, Albumin
- Consider Upreg to guide imaging
- Consider CT Urogram per clinical situation

|H

|# HAP (HOSPITAL ACQUIRED PNEUMONIA) # 

Patient with symptoms of *** and CXR showing ***, ≥48 hours after hospitalization, in the absence of intubation. Past cultures notable for ***.

Dx

- CBC, BMP, Lactate, sputum Cx, BCx x2, CXR
- CPO
- Abx:

|# HEADACHE # 

Most likely ***. Primary headaches include tension, migraine, and cluster. Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging.

|# HEART FAILURE WITH REDUCED EJECTION FRACTION (HFREF), ACUTE ON CHRONIC DIASTOLIC HEART FAILURE EXACERBATION # 

Patient presents with symptoms and evidence of volume overload. Trigger likely ***. Last TTE ***.

- Admission weight ***, dry weight ***.
- Goal net negative: ***
- CBC, CMP, BNP, Lactate
- BMP, Mg BID
- Strict I/O, daily standing weights, 2L fluid restriction, Na-resticted diet
- Inpt med regimen: ***
- Home med regimen: ***

|# HEART FAILURE WITH REDUCED EJECTION FRACTION (HFREF), ACUTE ON CHRONIC SYSTOLIC HEART FAILURE EXACERBATION # 

Patient presents with symptoms and evidence of volume overload. Trigger likely ***. Last TTE ***.

- Admission weight ***, dry weight ***.
- Goal net negative: ***
- CBC, CMP, BNP, Lactate
- BMP, Mg BID
- Strict I/O, daily standing weights, 2L fluid restriction, Na-resticted diet
- Inpt med regimen: ***
- Home med  regimen: ***

|# HEART FAILURE WITH REDUCED EJECTION FRACTION (HFREF), ACUTE ON CHRONIC SYSTOLIC HEART FAILURE EXACERBATION # 

Patient presents with symptoms and evidence of volume overload. Trigger likely ***. Last TTE ***.

- Admission weight ***, dry weight ***.
- Goal net negative: ***
- CBC, CMP, BNP, Lactate
- BMP, Mg BID
- Strict I/O, daily standing weights, 2L fluid restriction, Na-resticted diet
- Inpt med regimen: ***
- Home med  regimen: ***

|# HEART FAILURE, NEW (UNSPECIFIED) # 

Patient presents with new symptoms of heart failure and evidence of volume overload. Suspect secondary to ***. Common etiologies include ischemic, infiltrative, structural, endocrine, viral, toxin-mediated, tachycardia, and idiopathic.

Admission weight ***, dry weight ***.

Dx
- Bedside TTE showing ***
- Bedside IVC showing ***
- BMP, Mg, CBC, troponin, BNP
- CXR, EKG
- HgbA1C, Lipid panel
- TSH, HIV, Ferritin, Utox, UA
- Formal TTE, telemetry
- Consider left heart cath
- Strict I/O, daily standing weights

Tx
- Goal net negative: ***
- Preload: ***
- Afterload: ***
- Neurohormonal blockade: ***
- Na-restricted diet (<3 grams per day), 2L fluid restriction
- Replete K>4, Mg>2

|# HEART FAILURE, SYSTOLIC # 

Etiology:
- Coronary evaluation.
- Non-ischemic evaluation. First pass: EtOH/drug hx, TSH, HIV, +/- SPEP/UPEP. 2nd Pass V/Q scan, Cardiac MRI, PET.

Volume:
-Estimated Dry Weight =
-Goal net neg ***L/day
-Spot dose Lasix *** IV q6 hours to meet above goal.
-Keep K>4, Mg>2
-Daily Standing weights
-Strict I/O

Inotropic Support:
-Indicated for cardiogenic shock or failure to make urine with very high dose diuretic.

Hormonal Blockade:
-ACE/ARB:
-BB:
-Aldo: (EF < 30%, NYHF III).
-Further Afterload:
-Advanced meds:
-Valsartan/sacubitril (Entrusto) instead of ACE/ARB, no ACE/ARB x 48 hours, eGFR >30, ?dementia?
-Ivabradine (Corlanor): If on goal dose bblocker, NSR only, & HR > 70.

DM:
-Consider empagliflozin (Jardiance) if eGFR > 45 and A1C > 7 despite metformin

Devices:
-AICD: Secondary prevention, Primary prevention (Ischemic EF<40%, non-ischemic EF<35%, both s/p optimal medical Rx x 3 months)
-CRT: EF < 30% and QRS > 120.

Follow up:
-Ensure f/u with PCP or cardiology within 10 days of DC
-Ensure pt has scale at home and can weigh self daily. If pt gains > 3lbs in 24 hours or >5lbs in 7 days, pt is to double diuretic dose x1 and call MD.
-Torsemide (and bumex) PO preferred over lasix for reduction in HF hospitalizations and CV mortality (https://pubmed.ncbi.nlm.nih.gov/30846351/)

|# HEMATURIA, GROSS #

Patient presents with gross hematuria without clots. No UTI symptoms and UA not suggestive of infection. Ddx includes inflammation/infection of prostate or bladder, menstruation, kidney stones, malignancy, and glomerular bleeding.

- UA with microscopy/Cx, CBC, BMP, Albumin
- Consider Upreg to guide imaging
- Consider CT Urogram per clinical situation

|# HEMOPTYSIS # 

Patient with history of *** presents with hemoptysis, most likely due to ***. Common etiologies include infection (bronchiectasis, PNA, TB, abscess, fungal), malignancy, vascular (PE, AVM), autoimmune (GPA, SLE, Goodpastures), medications and contusion.

- Massive hemoptysis is generally defined as ~100-150ml (~half a cup) in 24 hours.
- If massive, consider urgent bronchoscopy vs CTA Chest/IR
- CBC w/ diff, CMP, ABG, type and cross, INR
- CXR, UA with micro
- Consider sputum cultures (AFB, isolation per clinical scenario), BNP
- CPO

|# HYPERCALCEMIA # 

Patient with new significant hypercalcemia, likely due to ***. If PTH elevated, ddx includes primary/tertiary hyperparathyroid, FHH, and lithium. If PTH low (consider ordering PTHrP, 25D and 1,25D), ddx includes malignancy, Vitamin D toxicity, granulomatous disease, Drugs, Milk alkali, Thyrotoxicosis, and Immobilization.

- Corrected Calcium = Measured + (4-albumin)
- CBC, CMP, Albumin
- s/p *** L IVF. If refractory, consider furosemide, calcitonin, and bisphosphonates

|# HYPERCARBIC RESPIRATORY FAILURE # 

Elevated PaCO2 with acidosis concerning for hypercarbic respiratory failure. Most likely secondary to ***. Common etiologies include obstructive lung physiology, pulmonary edema, effusions, and central or mechanical hypoventilation. Bilevel ventilation indications include COPD with pH <7.3, cardiogenic pulmonary edema, neuromuscular disease, and pneumonia in an immunocompromised host.

- CPO, Telemetry, RT assessment
- CBC, CMP, Lactate, ABG/VBG
- CXR

|# HYPERFERRITINEMIA #

Nonspecific measure of inflammation, with common etiologies including infection, autoimmune, malignancy, renal failure, and liver failure. Extreme hyperferritinemia (greater than 5x upper limit of normal) still nonspecific, but warrants considering Stills, HLH, infection in immunocompromised host (e.g., crypto, histo), and hemochromatosis.

|# HYPERKALEMIA #

Hyperkalemia likely due to ***. Etiology related to decreased K excretion include CKD, adrenal insufficiency, RTA T4 and meds (e.g., K sparing diuretics, ACEi/ARB, NSAIDS, Bactrim, Heparin). Etiology related to increased K production include tumor lysis syndrome, hemolysis and rhabdomyolysis.

- Albuterol, furosemide, insulin with glucose, kayexalate PRN
- EKG, Calcium/Bicarb PRN per severity

|# HLD #

Likely primarily secondary to diet, lifestyle, weight, and/or genetics. No known secondary etiologies including hypothyroid, DM, nephrotic syndrome, CKD, EtOH, liver disease, meds (OCPs, steroids, antipsychotics, thiazides, BB). ASCVD 10 year risk ***

|# HLD #

Mainly hyperLDL, hyperTG. Likely primary 2/2 diet, lifestyle, weight, genetics. No known secondary etiologies including hypothyroid, DM, nephrotic syndrome, CKD, EtOH, liver disease, meds (OCPs, steroids, antipsychotics, thiazides, BB). No known prior ASCVD. ASCVD 10 year risk *** (https://statindecisionaid.mayoclinic.org/). Likely underestimate given risk enhancers including family history early CAD, CKD, metabolic syndrome, inflammatory disease, south Asian ancestry, TG>175.

- consider TSH, BUN/Cr, UA, A1c, Crp; consider baseline LFTs/CK if starting statin (no need for routine monitoring subsequently)
- if famhx early CAD, borderline/intermediate risk (5-20%), or equivocation about statin consider coronary calcium CT ($150 out of pocket, may be covered by insurance; CAC of 0 = no benefit from statin)
- consider statin if risk>7.5%; strongly encourage if >20%
-- moderate vs high dose per: https://tools.acc.org/ASCVD-Risk-Estimator-Plus/assets/graphics/new-primary-prevention.svg
-- rosuvastatin 10-20mg; atorva 20-80mg (both now generic; QHS may be best)
-- note myalgias are equally common in placebo vs statin groups; statin intolerance extremely rare
-- associated with 10% increased risk of new DM (NNH 100); memory loss may be rare side effect of lipophilic (eg atorva) but not hydrophilic (eg rosuva)
- consider EPA fish oil (OTC vs vascepa) 2g BID for 20-50% TG reduction and 25% MACE reduction
- consider aspirin 80-100mg if ASCVD risk >10% and no increased bleeding risk
-- https://aspirinbenefitharmcalculator.shinyapps.io/calculator/
- note: niacin, fibrates no ASCVD reduction; ezetimibe has clinically insignificant effect
- start fenofibrate for TG persistently >885; for <885 maximize statin and EPA; if fasting TG>500, reduce dietary fat to <20g/day
- avoid NSAIDs (a/w 42% increase in CV death)
- encourage concomitant lifestyle interventions
-- aerobic exercise 30mins 3-4x/wk; wt loss 2%->6% decrease LDL
-- more whole foods including veg/fruits, complex carbs
-- less saturated and trans fats but no restriction on dietary cholesterol
-- quit smoking (up to 40% risk reduction)
-- avoid EtOH (esp if high TG)
- recheck lipids 3 months after regimen changes then q1-3 years when on stable regimen (or more often for adherence)
Risk scores using CAC:
- https://www.mesa-nhlbi.org/MESACHDRisk/MesaRiskScore/RiskScore.aspx
- http://astrocharm.org/calculator-working/
Statin decision aid:
- https://statindecisionaid.mayoclinic.org/

|# HYPERNATREMIA # 

Likely due to decreased PO intake. Ddx also includes excessive sweating, diarrhea, diuretics, diabetes insipidus, hyperaldosteronism, and Lithium.

|# HYPERTENSION, NEW, UNCONTROLLED #

Confirmed based on two appropriately measured readings >2 weeks apart. Goal BP ***.  ASCVD risk ***.

- Initial workup: CBC, BMP, LFTs, lipids, TSH, UA, A1c, EKG
- Diet and lifestyle modifications:
- Meds:

|# HYPERTENSION, NEW, UNCONTROLLED # 

Confirmed based on two appropriately measured readings >2 weeks apart. Stage 1 (130-139/80-89) vs Stage 2 (140+/90+). Goal (ACC, 2017) <130/80 especially if ASCVD (or risk>10%), CKD, DM (goal <140/80 if labile HTN, side effects, age >75 with many cormorbidities or DBP<55) (goal individualized if frail or limited life expectancy). ASCVD risk ***.

- initial workup: CBC, BMP, LFTs, lipids, TSH, UA, A1c, EKG; if DM/CKD, add urine albumin/creatinine.
- low threshold for ambulatory 24h monitor for episodic, resistant or white coat HTN
- reviewed consequences of untreated HTN (eg, 10mm decrease--> decrease of 20% MACE, 28% HF, 13% mortality)
- encouraged lifestyle modifications:
-- weight loss: 1mmHg/kg
-- decrease EtOH 1(F) or 2(M)/day: 4mm
-- reduce sodium to <2.4g: 2-8mm
-- DASH diet: 6mm alone; 14mm if combined with low sodium
-- aerobic exercise 30mins/day: 4-9mm
- given Stage 2 HTN and/or patient preference, will also start first line pharmacologic therapy:
-- amlodipine 2.5mg qd
-- chlorthalidone 12.5mg qd (mortality benefit vs HCTZ; thiazides effective even in CKD4)
-- ACE/ARB
-- note: metaanalyses show decreased side effect profile with multiple low dose (eg 1/4 of max dose) antihypertensives compared to single agents at full doses; thiazide and ACE/ARB can balance K
-- consider spironolactone/eplereonone as 4th line or if hypoK
-- no BBs indicated unless symptomatic CAD or HRrEF (then choose metoprolol succinate or carvedilol)
- pt advised to buy home upper arm-cuff BP monitor to bring to next visit for calibration and teaching
- defer workup for secondary hypertension
- decision aids:
-- https://www.healthwise.net/ohridecisionaid/Content/StdDocument.aspx?DOCHWID=zx1768
-- https://www.healthdecision.org/tool#/tool/hypertension
-- https://statindecisionaid.mayoclinic.org/index.php/statin/index

|# HYPERTENSION; SUSPECTED SECONDARY # 

Will pursue workup for secondary HTN, with most common etiologies being OSA, renal artery stenosis, hyperaldo, CKD, illicits, and endocrinopathies

- 24 hr ambulatory BP monitor for baseline
- TSH, UTox, BMP, Renin/Aldo
- Second pass workup: consider sleep study, 24hr urine free cortisol, 24hr catecholeamines and metanephrins, Renal artery doppler
- Med review for OCPs, NSAIDs, SNRIs, stimulants, VEGFi/TKIs

|# HYPERTENSION (RESISTANT); CONCERN FOR SECONDARY HYPERTENSION # 

This patient has indication for a secondary hypertension work-up (age < 30 in a non-obese, non-black patient with no family Hx; resistant hypertension defined as persistent HTN on >= 3 hypertensives at adequate doses or 4 at 50% doses, at least one of which is a diuretic; malignant hypertension w/ end-organ damage; or proven age of onset before puberty). Most common etiologies are OSA (60-70%), hyperaldo (7-20%), RAS (2-24%), meds/illicits (2-24%), CKD (1-2%), endocrine (1%).

- TSH, UTox, Scr for CKD
- medication review for OCPs, NSAIDs, SNRIs, stimulants, VEGFi/TKIs
- 24 hr ambulatory BP monitor for baseline
- sleep study (if obese, snoring, daytime somnolence, headaches, fatigue)
- renin/aldosterone (consider oral sodium suppression test if negative)
- 24 hr urine free cortisol (only if facies, obesity, bruising, muscle weakness, or adrenal incidentaloma)
- renal artery dopplers (only if patient might be a surgical candidate: flash pulmonary edema, refractory heart failure with unexplained impaired kidney function, short duration of BP elevation, intolerance to optimal medical therapy) and something to suggest RAS (> 50% Cr bump after RAAS inhibition, unexplained kidney asymmetry, abdominal bruit)
- consider 24 hr urine catecholeamines and metanephrins (prefer over plasma fractionated metanephrines given high false positive rate if not measured supine via indwelling cannula after 30 minutes of supine rest)
- consider referral to cardiology/renal

|# HYPOCALCEMIA # 

Likely due to ***. Ddx also includes hypoparathyroidism, hyperphosphatemia, massive transfusions (citrate toxicity), secondary hyperparathyroidism, Vitamin D deficiency, pseudohypoparathyroidism.

|# HYPOXEMIC RESPIRATORY FAILURE # 

Patient with persistently low O2 saturation or PaO2<60 on room air. Most likely secondary to ***. Common etiologies include aspiration, PE, PTX, PNA. Lower suspicion for ARDS, shunting, hypoventilation, TACO/TRALI, pulmonary edema, ILD, alveolar hemorrhage or pulmonary contusion.

- CPO, Telemetry, RT assessment PRN
- CXR, Cross-sectional chest imaging PRN
- CBC, CMP, ABG

| I
|# ICU BUNDLE # 

- Code Status:
- ICU indication:
- GI ppx:
- DVT ppx:
- Lines:
- Tubes, Drains, Foley:
- Last contact update:

# ICU BUNDLE # 

VENTILATOR
? Spontaneous Awakening Trial (SAT)
= turn off sedation
? Spontaneous Breathing Trial (SBT)
= Place patient on Pressure Support 5/5
- Perform SAT & SBT concurrently if able
- Contraindications to SAT/SBT include FiO2 > 50%, PEEP > 8, O2 sat < 90%, pH < 7.30, SBP < 90 or MAP < 60, paralysis, intracranial pressure >15, concern for significant bleeding
? If ARDS: goal Vt 4-6 cc/kg of ideal body weight (calculated by height), plateau pressure < 30
? Head of bed at >30 degrees
? Oral care is ordered

SEDATION / DELIRIUM
? Ask: Is patient delirious (CAM+)?
? Review med list for any deliriogenic medications and discontinue/change where possible
? Define RASS goal
? Record QTc daily, consider changing medications if QTc > 500

RESTRAINTS
? Ask: Are restraints needed?
? Sign necessary restraint orders
? Discuss barriers to removing restraint orders

MOBILITY
? Consult PT for early mobility
- Contraindications include: deep sedation, paralysis

PRESSURE ULCERS
? Ask: Are pressure ulcers present? Is a wound care consult needed?
? Discuss whether any changes are needed to ulcer management plan

DVT PROPHYLAXIS
? Review patient’s current DVT prophylaxis orders and adjust if needed
- Contraindications to LMWH DVT ppx include AKI (switch to UFH TID), clinically significant bleeding (hold pharmacologic), platelet count < 30K (hold pharmacologic)
- Add sequential compression boots if holding pharmacologic prophylaxis

GI / NUTRITION
? Famotidine 20mg IV BID in intubated patients; Pantoprazole 20-40mg IV daily if history of GERD or GI bleed
? Review nutrition, consult nutrition if not already done. While awaiting nutrition input, start enteral nutrition:
- In most patients, Osmolite 1.5 @10mL/hr, advance by 20mL Q6h to goal 50mL/hr
- If renal failure and high K or phos: Nepro @ 10mL/hr, advance by 10mL Q6h to goal 40mL/hr
- MVI with minerals daily
- thiamine 100mg daily x3 days
- folate 1mg daily x 3 days
? Ask: Is bowel regimen adequate? Make changes if necessary.
? Review glucose range over past 48h and insulin regimen, adjust regimen if needed.
- Goal glucose range is 70-180

TUBES / LINES / DRAINS
? List all tubes / lines / drains and discuss if any can be removed or should be changed

PATIENT / FAMILY COMMUNICATION
? Discuss if patient has healthcare making capacity - if not, activate healthcare proxy
? Update families by phone
- Suggest RN update at least daily
- MD update Q3 days, with any significant clinical change, or per family request

DISPOSITION
? Discuss anticipated dispo, barriers to dispo

CODE STATUS
? Review current code status, discuss if goals of care are realistic with prognosis - if not, discuss with patient / family

ABBREVIATIONS:
SAT = Spontaneous Awakening Trial
SBT = Spontaneous Breathing Trial
CAM = Confusion Assessment Method
RASS = Richmond Agitation and Sedation Scale

|# INFLAMMATORY ARTHRITIS # 

Patient presents with inflammatory arthritis (warm, swollen joints that are worse in morning, improve with use), with additive***migratory pattern. Common etiologies based on distribution include:

- Monoarticular arthritis - Bacterial, Crystalline
- Oligoarticular arthritis - Spondyloarthropathies, gonococcal, Lyme
- Polyarticular arthritis - Viral, RA, SLE, Psoriatic

|# INFLAMMATORY ARTHRITIS (MONOARTICULAR, CONCERN FOR SEPTIC)

New monoarticular arthritis of *** joint. With*** limited range of motion and severe pain concerning for septic vs crystalline joint. No history of recent infection, RA, prosthetic joint, or IVDU. Sexual history notable for ***. Appreciate orthopedics consult and joint tap.

- Serum: CBC, CMP, INR, BCx x2. Consider Uric acid, A1c, HIV, ESR, CRP per clinical scenario
- Synovial fluid: CBC diff, Bacterial GS/Cx, crystalline analysis
- XR of joint, additional imaging per orthopedics
- Empiric abx: Consider Vancomycin Ceftriaxone
- Pain control:
- NPO

|# INFLAMMATORY BOWEL DISEASE, ACUTE ON CHRONIC FLARE # 

Patient with known history of inflammatory bowel disease, who presents with likely acute flare characterized by worsening pain and increasing bloody stool frequency. Will rule out infectious etiology prior to proceeding with IV steroids.

Dx

- Serum: CBC, CMP, Lactate, ESR, CRP, INR, Full Iron panel, Prealbumin, Vitamin D level
- Stool: Cdiff, Bacterial assay/culture, fecal calprotectin. Consider O&P per clinical scenario
- Consider CT A/P if concern for extraluminal complications or acute abdominal findings
- Appreciate RN staff recording timing and quality (?bloody) of stools to assess response to therapy

Tx

- s/p *** L IVF
- IV steroids per GI pending stool studies
- DVT ppx
- NPO midnight on day of admission
- Minimize opioid use as possible, tramadol preferred
|I

|# INTERSTITIAL LUNG DISEASE (ILD) # 

Patient presents with progressive dyspnea concerning for new diagnosis of interstitial lung disease. ILD can have known etiologies (exposures, drugs, connective tissue disease, eosinophilic PNA, amyloid, sarcoid) or unknown etiologies known as idiopathic interstitial pneumonia (IPF and non-IPF (NSIP, COP, AIP, LIP)).

|# INVOLUNTARY WEIGHT LOSS # 

Involuntary weight loss (IWL) is typically defined as a loss of weight >10 lbs or >5% of one’s body weight over a period of 6-12 months. The differential diagnosis for IWL is wide, and includes neoplastic and psychiatric causes, as well as diseases in nearly every organ system. Notably, exhaustive investigation will not yield a definitive diagnosis in up to a quarter of patients.

-- History, physical, MMSE, nutritional assessment, ADL/IADL assessment, medication review
-- Age appropriate cancer screening
-- CBC with diff, CMP, TFT, ESR, CRP, Ferritin, HIV testing
-- Nutrition referral
|J
|K
|L
|# LEUKOCYTOSIS # 

Likely due to ***. Common etiologies include infection/sepsis, stress demargination, and steroids, with less common etiologies including systemic inflammation, medications, smoking, malignancy, asplenia, and congenital/genetic disorders.

- Trend CBC with diff

|# LOW BACK PAIN, NON-RADICULAR, ACUTE # 

Likely lumbar muscle strain (70% of cases) vs DJD (10%), no hx/exam features of radiculopathy. Conservative management given no red flags (specifically no trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and normal neuro exam

- Consider NSAIDs, APAP for 7-14 days per clinical scenario
- Activity as tolerated, Avoid bedrest
- Complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage
- PT if not improving in 4-6 weeks or now if severe pain/disability
- RTC for any increased pain or new symptoms.

|# LOW BACK PAIN, NON-RADICULAR, ACUTE # 

Likely lumbar muscle strain (70% of cases) vs DJD (10%), no hx/exam features of radiculopathy. Conservative management given no red flags (specifically no h/o trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and normal neuro exam (no saddle anesthesia, midline spinal TTP or weakness).

Non-pharmacologic:

- activity as tolerated, avoid bedrest
- complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage, The Back Book
- good lifting technique, sleep flat w/ pillow under knees, tempurpedic mattress
- PT if not improving in 4-6 weeks or now if severe pain/disability

Pharmacologic:

- NSAIDs x 7-14 days: Naproxen 500 mg BID (add PPI if prior GI sx; consider replacing with nabumetone if CKD1-2; no NSAIDs if CKD3-4)
-- discussed GI symptoms to be watchful for
- APAP up to 3g/day if helpful (Cochrane: same as placebo https://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain)
- cyclobenzaprine/baclofen PO PRN, voltaren gel PRN (lidocaine not usually helpful)
- RTC for any increased pain or new symptoms.

|# LOW BACK PAIN WITH RED FLAGS # 

Concern for spinal process +/- cord compression 2/2 ***
* recent trauma (major vs minor in elderly/known CA);
*malignancy given night pain, supine pain, new urinary symptoms, saddle anesthesia, new weakness, constitutional sx;
* infection given fever, neurological deficits, recent instrumentation, h/o HIV or TB, IVDU, recent infection (UTI, SSTI, bacteremia, osteomyelitis, line-associated);
* compression fracture given h/o osteporosisis/steroid use/malignancy/elderly and sudden onset after 
coughing/bending/lifting/minor trauma with point TTP

- lumbar XR if concern for compression fracture
- MRI L-spine w/o contrast (plus contrast if immunosuppressed or suspicion for cancer or infection)
- CBC/diff, ESR/CRP, BCx, AlkPhos, PSA
- urgent ortho/neurosurg eval if cauda equina/motor weakness

|# LOWER GI BLEED # 

Patient presents with bright red blood per rectum concerning for lower GI bleed. History and rectal exam notable for ***. DDx includes anatomic (diverticulosis), vascular (angiodysplasia, hemorrhoids, ischemic, post-polypectomy), inflammatory (infectious, IBD, radiation) or neoplastic (polyp, carcinoma), as well as brisk upper GI bleed.

Dx

- CBC, CMP, INR, Type and screen
- Telemetry
- GI consult/Endoscopic evaluation per clinical scenario

Tx

- NPO
- 2 large bore IVs
- Transfuse to keep hgb >7
- If concern for brisk upper, Protonix 80mg bolus x1, followed by Protonix 40 mg IV BID
- Hold antiplatelet agent, anticoagulation, anti-hypertensives
- Correct coagulopathy (Goal plt > 50k, INR < 2.0)

|# LUMBAR RADICULOPATHY, ACUTE # 

Most likely given radiation below knee in dermatomal distribution, positive SLR, worse with coughing/straining. Likely (L4 given weak ankle dorsiflexion/inversion, decreased patellar reflex, pain/numbness of medial ankle/foot) (L5 given weakness of EHL/1st toe extension, decreased medial hamstring reflex, pain/numbness dorsal surface of foot) (S1 given weakness ankle plantarflexion/eversion, decreased achilles reflex, pain/numbness lateral foot/leg). Note: L4/L5 compresses L5 root. Conservative management given no red flags (specifically no h/o trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and otherwise normal neuro exam (no saddle anesthesia, midline spinal TTP or weakness).

Dx:

- consider MRI if muscle weakness (not 2/2 pain, with maximal effort) or no improvement in 4-6 weeks
- for subacute, consider EMG/NCS if MRI unrevealing

Non-pharmacologic:

- activity as tolerated, avoid bedrest
- complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage, The Back Book
- good lifting technique, sleep flat w/ pillow under knees, tempurpedic mattress
- PT if not improving in 4-6 weeks or now if severe pain/disability

Pharmacologic:

- NSAIDs x 7-14 days: Naproxen 500 mg BID (add PPI if prior GI sx; consider replacing with nabumetone if CKD1-2; no NSAIDs if CKD3-4)
-- discussed GI symptoms to be watchful for
- APAP up to 3g/day if helpful (Cochrane: same as placebo https://www.cochrane.org/CD012230/BACK_paracetamol-low-back-pain)
- cyclobenzaprine/baclofen PO PRN, voltaren gel PRN (lidocaine not usually helpful)
- RTC for any increased pain or new symptoms.

|# LUMBAR RADICULOPATHY, ACUTE # 

Most likely lumbar radiculopathy in the setting of ***. Will pursue conservative management given no red flags (specifically no trauma, steroid use, malignancy, IVDU, constitutional sx, GI/GU sx) and otherwise normal neuro exam.

- Consider NSAIDs, APAP for 7-14 days per clinical scenario
- Activity as tolerated, Avoid bedrest
- Complementary therapies: heat/cold x 10-20 mins QID, yoga, acupuncture, chiropractic, aquatherapy, massage
- PT if not improving in 4-6 weeks or now if severe pain/disability
- RTC for any increased pain or new symptoms.

|M

|# MENINGITIS (SUSPECTED) # 

Patients presents with altered mental status, nuchal rigidity, and fever, concerning for meningitis. Ddx also includes alternative infectious encephalopathy, substance/tox, respiratory/metabolic derangement, endocrinopathy or intracranial mass effect. NCHCT and antibiotics prior to Lumbar Puncture if abnormal consciousness, focal neuro deficits, over 60 y.o., immunocompromised host, history of CNS disease, new onset seizures within 1 week, or papilledema.

Dx

- CXR, UA/UCx
- Serum: CBC, CMP, VBG, Lactate, BCx x2, INR, Utox, TSH, HIV, RPR,
- CSF: Protein, Glucose, Bacterial Gram Stain+Cx, Cell count + diff, HSV DNA. Consider VZV IgM+IgG, CrAg, Cocci, Histo, VDRL
- Opening pressure: ***
- CPO/Tele
- NCHCT as above PRN

Tx

- Droplet precautions if concerned for Neisseria meningitidis
- Vanc Ceftriaxone (meningeal dosing)
- Add Acyclovir if concern for HSV or encephalitis
- Add Ampicillin if >50 y.o.
- Dexamethasone 10q4 if suspected Streptococcus pneumoniae

|# METABOLIC ACIDOSIS (GAP) # 

Most likely due to ***. Ddx includes lactate, ketones, ingestions (glycols, oxoproline, methanol, ASA), and renal failure.

- Lactate, UA
- Consider Tox screen PRN

|# MONOARTICULAR INFLAMMATORY ARTHRITIS (CONCERN FOR SEPTIC) # 

New monoarticular arthritis of *** joint. With*** limited range of motion and severe pain concerning for septic vs crystalline joint. No history of recent infection, RA, prosthetic joint, or IVDU. Sexual history notable for ***. Appreciate orthopedics consult and joint tap.

- Serum: CBC, CMP, INR, BCx x2. Consider Uric acid, A1c, HIV, ESR, CRP per clinical scenario
- Synovial fluid: CBC diff, Bacterial GS/Cx, crystalline analysis
- XR of joint, additional imaging per orthopedics
- Empiric abx: Consider Vancomycin Ceftriaxone
- Pain control:
- NPO

|# MYOCARDIAL INFARCTION - NSTEMI # 

Patient presents with chest discomfort with concern for NSTE-ACS given troponin elevation and EKG with ***.

Dx

- GRACE score ***
- Trop, EKG, with 4-6hr repeat
- CBC, BMP, VBG
- CXR
- CPO, Telemetry
- Consider DDimer, BP in 4 extremities
- Consider urgent to emergent cath if with refractory chest pain, new heart failure, new MR murmur, shock, or sustained VT.

Tx

- s/p ASA 325 mg, Atorvastatin 80 mg
- P2Y12 inhibitor per institutional preference
- Metoprolol tartrate 12.5 q8h if not in heart failure/shock
- ACEi within 24hrs.
- Heparin gtt (ACS orderset)
- Nitroglycerin 0.4 mg SL q5m x 3 PRN -> Nitroglycerin gtt if refractory
- Avoid morphine

|# MYOCARDIAL INFARCTION - STEMI # 

Patient presented with chest discomfort with concern for STEMI given troponinemia and EKG with ***; now s/p cath lab with ***.

- s/p ASA 325, P2Y12, heparin gtt, SL Nitro PRN
- CBC, BMP, Lactate, Trop, EKG
- CPO, Telemetry
- Continue ASA 81 QD, P2Y12
- Atorvastatin 80mg QD
- BB and ACEi/ARB within 24 hours

|# STEMI, TYPE I NSTEMI, OR UNSTABLE ANGINA # 

Coronary evaluation:
-EKG, trop, TTE WMA, Stress, LHC.

Antithrombotic:
- ASA: Cont. ASA 81mg PO QD x life.
- P2Y12:-Clopidogrel (Plavix) load 600mg PO x 1 then 75mg qD (some resistance particular in East Asian and Pacific Islander).
- Ticagrelor (Brilinta) load 180mg PO x 1 then 90mg BID (may cause bradycardia and/or SOB).
- Prasugrel (Efient, Effient) load 60mg PO x 1 then 10mg PO qD (contraindicated if h/o CVA).

- IIb/IIIa:
-- Eptifibatide (Integrilin): Can be given “up front” prior to cath.
-- Abciximab (ReoPro): Okay in ESRD, can be given only after cath

Anticoagulation:
- Heparin bolus and gtt.

Demand reduction:
- Nitrates: (SLNTG, nitro paste, nitro gtt).
- BB: (within 24 hours of MI).
- ACE/ARB: (within 24 hours of MI).
- CCB: (if intolerant to BB).
- Pain medication: (Morphine a/w increased mortality in retrospective studies, if possible maximize above and use fentanyl).
- Advanced meds: Ranolazine (Renexa) for intractable UA, avoid in renal/liver failure and with long QTC.

Antiinflammatory/Antilipid:
- Start Atorva 80mg QHS.
- If admitted for ACS on high intensity statin and LDL > 50, consider adding Zetia 10mg PO QHS.
- If familial hyperlipidemia or cannot tolerate statin, consider PCSK9.
- In acute MI, avoid NSAIDs & steroids if at all possible.
- Defer screening and management of DM2 and inflammatory dz to PCP.

|# MYOSITIS # 

Concern for myositis (inflammation) over isolated myopathy (weakness) given ***. Common etiologies include dermatomyositis, polymyositis, rheumatologic overlap syndromes, drug associated, immune mediated, and inclusion body myositis.

- CBC, CMP, ESR, CRP, CK
- Location specific imaging per clinical scenario
- Med list review

|# MYXEDEMA CRISIS # 

Patient with*** history of hypothyroidism who presents with altered mental status, hypothermia, and bradycardia, concerning for myxedema crisis. DDx includes ***.

Dx

- CBC, CMP, Free T4, TSH, cortisol, lactate
- CXR, BCx x2, UA, Utox
- Na, Glucose q2-4h PRN
- EKG

Tx

- Following endo consultation, consider T4 200-400mcg IV, T3 5-20mcg IV, and hydrocortisone 100mg q8h IV
- Consider empiric antibiotics and fluids if concerned for sepsis
- Passive warming, mechanical ventilation, pressors PRN

|N

|# NECROTIZING FASCIITIS # 

Patient with fever, severe pain, edema, and erythema of ***, concerning for necrotizing fasciitis. LRINEC ***

- Urgent Gen Surg consultation, site-specific imaging
- Abx: Vanc Erta Clinda
- s/p *** L IVF
- CBC, CMP, Lactate, CRP, ESR, BCx x2
- INR, Type and screen
- Consider HIV, A1c

|# NEUTROPENIC FEVER # 

Patient who has received cytotoxic antineoplastic therapy presents with neutropenic fever likely due to ***.

Dx

- CBC with diff, BCx x2
- UA/UCx, CXR
- Influenza, viral panel, additional imaging per clinical scenario

Tx

- Cefepime 2g IV q8h (per renal function)
- Consider Vancomycin if suspected catheter-associated infection, SSTI, PNA, or HD unstable.

|# NEW INTRACRANIAL LESIONS (SUSPECTED METASTASIS) 

Patients presents with symptoms of ***, with imaging concern for new metastatic intracranial lesions. Following consultation with NSGY, no current surgical intervention, and future intervention dependent on patient prognosis. Will coordinate care with NSGY, Rad Onc, and Med Onc.

Dx

- Appreciate NSGY, Rad Onc, and Med Onc consults
- MRI w w/o contrast
- CT C/A/P for staging
- EKG for baseline QTC

Tx

- Dexamethasone 4mg q6h IV
- Q2 hr neuro checks
- Zofran PRN
- Elevate HOB

|O

|# ORGANIZING PNEUMONIA # 

Imaging notable for patchy consolidation concerning for organizing pneumonia. Organizing pneumonias can be unilateral or bilateral, are often peripherally located, and may have small nodules or associated atoll sign (low sensitivity, high specificity). Cryptogenic (primary) organizing pneumonia is characterized by excessive granulation tissue proliferation, and is often treated with steroids. Secondary organizing pneumonia may be associated with meds/drugs, infections, autoimmune conditions, malignancy,mixed cryoglobulinemia, hypersensitivity pneumonitis, CVID, IBD, radiation and transplantation.

|# ORTHOSTATIC HYPOTENSION # 

Most likely secondary to ***. DDx also includes decreased PO intake, age-related baroreceptor dysfunction, primary or secondary autonomic insufficiency, neurodegenerative disease, med effect, and cardiac etiology.

- Fluid resuscitation challenge, IVC US
- Eval for dysautonomia
- A1c, HIV, TSH, RPR, B12
- EKG
|P

|# PANCYTOPENIA # 

Patient with new pancytopenia likely due to ***. Ddx includes aplastic anemia (meds, tox, viral), infiltrative (malignancy, TB, MAC, Histo), myelodysplastic, nutritional, chronic inflammation, and HLH.

- CBC with diff, retic count, smear

|# PERICARDIAL EFFUSION W/O TAMPONADE # 

*** sized pericardial effusion noted on ***, without hypotension, muffled heart sounds, or jugular venous distention. EKG without electrical alternans. Etiologies include idiopathic, acute infectious pericarditis, drug associated, malignancy-related, autoimmune, post-MI, trauma, aortic dissection with extension, and uremia.

- Telemetry
- Troponin, CBC with differential, CMP, INR
- CXR
- Cardiology consult PRN

|# COMMUNITY ACQUIRED PNEUMONIA (CAP) # 

Patient reports fever and cough, with CXR showing ***, concerning for CAP. No recent hospitalization or abx exposure.

Dx

- CBC, BMP, Lactate
- Influenza, viral panel, procalcitonin, sputum Cx per clinical scenario
- Defer BCx if clinically stable
- CPO

Tx

- CTX Doxy
- s/p *** L IVF

|# PNEUMONIA, HOSPITAL ACQUIRED (HAP) # 

Patient with symptoms of *** and CXR showing ***, ≥48 hours after hospitalization, in the absence of intubation. Past cultures notable for ***.

Dx

- CBC, BMP, Lactate, sputum Cx, BCx x2, CXR
- CPO
- Abx:

|# VENTILATOR ASSOCIATED PNEUMONIA (VAP) # 

Patient with fever, leukocytosis, and increased secretions ≥48 hours after intubations, concerning for VAP. Past cultures notable for ***.

Dx

- CBC, BMP, Lactate, BAL Cx, BCx x2, CXR
- CPO
- Abx: MRSA and Pseudomonal coverage


|# POST-CARDIAC ARREST # 

Out of hospital cardiac arrest with PEA***VT/VF noted in field. ROSC achieved after *** rounds of compression. EKG notable for ***. Post-ROSC neuro exam notable for ***.

- CBC, CMP, Troponin, Lactate, INR
- EKG, CXR, TTE if concern for ACS
- CPO, Telemetry, ICU admission
- Cath Lab PRN per EKG, Troponin, and/or clinical scenario
- Cooling per Neuro PRN

|# PREPARTUM ROS # 

Contractions: ***
Nausea vomiting: ***
Vaginal bleeding: ***
Vaginal discharge: ***
RUQ or epigastric pain: ***
Headaches: ***
Swollen legs: ***
Breast tenderness: ***

|# PULMONARY EMBOLISM, ACUTE (SUB-SEGMENTAL) # 

sPESI ***. Pt presents with symptomatic but hemodynamically stable PE without biomarker or imaging findings of right ventricular strain. In these patients, thrombolytics (local or systemic) are not indicated. Unclear trigger, as pt is without past hx suggestive of hypercoagulable state or recent travel.

- Anticoagulation: ***
- CPO, Tele
- Trop, BNP, CBC, BMP, INR
- EKG, CT PE
- Ensure outpatient age appropriate cancer screening
- Consider outpatient hypercoagulability studies, TTE

|# PULMONARY EMBOLISM, ACUTE (SUB-MASSIVE) # 

sPESI *** BOVA ***. Pt presents with symptomatic but hemodynamically stable PE with biomarker or imaging findings of right ventricular strain. In these patients, anticoagulation is the mainstay of treatment, although local thrombolytics are rarely indicated. Unclear trigger, as pt is without past hx suggestive of hypercoagulable state or recent travel.

- Anticoagulation: ***
- CPO, Tele
- Trop, BNP, CBC, BMP, INR
- EKG, CT PE. Consider TTE
- Ensure outpatient age appropriate cancer screening
- Consider outpatient hypercoagulability studies
- If  clinical deterioration, contact IR/PE team regarding thrombolytics vs thrombectomy

|# PULMONARY EMBOLISM, ACUTE (MASSIVE) # 

Patient presents with symptomatic and hemodynamically unstable PE (SBP <90 for greater than 15 minutes) with biomarker or imaging findings of right ventricular strain. Contact IR/PE team regarding local vs systemic thrombolytics. Unclear trigger, as pt is without past hx suggestive of hypercoagulable state or recent travel.

- Start Heparin gtt vs Enoxaparin while awaiting IR decision
- CPO, Tele, ICU
- Trop, BNP, CBC, BMP, INR, ABG
- EKG, CT PE, TTE
- Ensure outpatient age appropriate cancer screening
- Consider outpatient hypercoagulability studies

|# PULMONARY HYPERTENSION (PHTN) # 

Patient with history of pulmonary hypertension. Pre-capillary pHTN is defined as PVR Wood unit>3 or Transpulmonary Pressure gradient (meanPA - PCWP) > 12. Post-capillary pHTN is defined as PCWP >15.

T1 - Vascular (idiopathic, HIV, CTD, drugs/toxins, portopulmHTN). Consider Utox, ANA, RF, HIV, Hep serologies
T2 - LH Disease. Consider RHC
T3 - Chronic Lung Disease/Hypoxemia. Consider High Res CT, sleep study, PFTs, nocturnal and exercise pulse ox
T4 - CTEPH. Consider V/Q scan
T5 - Misc - Sarcoid, Hematologic disease, congenital/metabolid, thyroid disease.

|# PULMONARY NODULES

Patient noted to have ***new pulmonary nodules. Pulmonary nodules can be random, centrilobular (TB, NTM, aspergillus, hypersensitivity pneumonitis, GPA, sarcoid), perilymphatic (malignancy, sarcoid, amyloidosis), or miliary (TB, Cocci, Histo), with overlap in etiologies between categories.

|# RHEUMATOID FACTOR POSITIVE # 

RF is a nonspecific biomarker, with ~10% of population >65 y.o being RF+. Other than true rheumatoid arthritis as a cause of RF+, common etiologies include infection (Hep C, osteomyelitis, SBE, HIV, Syphilis), Cryoglobulinemia (~100%), autoimmune/inflammatory (Sjogrens (20-30%), SLE (15-25%), Scleroderma (10-20%), Polymyositis/Dermatomyositis (5-10%), sarcoidosis), IPF and cirrhosis.

- CCP if concerned for RA, additiona dx per clinical scenario

|# SEPSIS #  

Concern for sepsis with suspected *** source.

- qSOFA *** (high-risk mortality prediction; positive if ≥2 points for GCS <15, RR ≥22, or SBP ≤100)
- Abx:
- s/p *** L IVF
- CBC, CMP, Lactate, INR
- CXR, UA/UCx, BCx x2
- Consider site specific labs and imaging PRN

|# SEPTIC SHOCK # 

Concern for septic shock with suspected *** source. History, exam, and data notable for ***. Alternative shock etiologies includes cardiogenic, distributive (non-septic), obstructive, hypovolemic, and neurogenic.

Dx

- Bedside TTE showing ***
- Bedside IVC showing ***
- CBC, CMP, Lactate
- CXR, UA/UCx, BCx 2
- Telemetry, Strict I/O, Goal MAP >65
- Consider EKG, Troponin, BNP, DDimer/CTPE per clinical scenario

Tx

- s/p *** L IVF
- Empiric abx: ***

|# INTRACEREBRAL HEMORRHAGE (ICH) # 

Patient with new neuro deficits characterized by ***. Last seen normal at ***. NCHCT noted to have ***. Surgical indications based on site of bleed (e.g., cerebellar w/ diameter >3cm).

Dx

- NIHSS score ***, GCS ***
- INR, CBC, Glucose FS
- EKG, Tele, consider TTE

Tx

- SBP Goal <140 (Nicardipine preferred), outpt SBP goal <130
- Head of the bed to 30 degrees
- ICU for q1h neuro checks
- SCD

|# SERONEGATIVE SPONDYLOARTHROPATHY # 

Seronegative (RF neg) spondyloarthropathies include reactive arthritis (GI, GU infections), psoriatic arthritis, IBD associated arthritis, and ankylosing spondylitits.

|# SHOCK # 

Patient presents in undifferentiated shock with history, physical exam, lab, and imaging findings concerning for ***. Common shock etiologies includes cardiogenic, distributive, obstructive, hypovolemic, and neurogenic.

Dx

- Bedside TTE showing ***
- Bedside IVC showing ***
- CXR, UA/UCx, BCx 2
- EKG, Troponin, BNP
- CBC, CMP, Lactate, Random cortisol
- CPO, Telemetry
- Strict I/O
- Consider DDimer vs CTPE
- Goal MAP >65

Tx

- s/p *** L IVF
- Empiric abx: ***

|# STAPH AUREUS BACTEREMIA # 

Patient noted to have ***/2 cultures positive for staph aureus, with suspected source being ***. Best practices for staph aureus bacteremia include identification and control of source, appropriate abx choice and duration, evaluation for endocarditis and other foci of infection, and repeat cultures to demonstrate clearance.

- Vancomycin, goal trough 15-20, pending susceptibilities
- Last BCx positive date: ***
- q48h Bcx until cleared
- TTE, additional imaging per clinical scenario

|# STROKE ; INTRACEREBRAL HEMORRHAGE (ICH) # 

Patient with new neuro deficits characterized by ***. Last seen normal at ***. NCHCT noted to have ***. Surgical indications based on site of bleed (e.g., cerebellar w/ diameter >3cm).

Dx

- NIHSS score ***, GCS ***
- INR, CBC, Glucose FS
- EKG, Tele, consider TTE

Tx

- SBP Goal <140 (Nicardipine preferred), outpt SBP goal <130
- Head of the bed to 30 degrees
- ICU for q1h neuro checks
- SCD

|# STROKE (ISCHEMIC) # 

Patient with focal neuro deficits characterized by ***. Last seen normal at ***. On imaging noted to have ***. Contraindications to TPA reviewed, with decision to ***.

Dx

- NIHSS score ***
- Stat NCHCT/CTA, Neuro consult
- Glucose FS, INR, CBC, Cholesterol, A1c
- EKG, Tele, consider TTE with bubble if <60 y.o

Tx

- If TPA given, ICU admission, Q1hr neuro checks x 24 until repeat NCHCT.  BP goal <185/110 (Nicardipine preferred).
- If TPA not given, BP goal <220/120
- Antiplatelet agent

|# STROKE; (ISCHEMIC) # 

Patient with focal neuro deficits characterized by ***. Last seen normal at ***. On imaging noted to have ***. Contraindications to TPA reviewed, with decision to ***. If given TPA, symptomatic ICH occurs in ~6% with 50% mortality. If large vessel occlusion in anterior circulation and <16h or even <24h LSN, consider mechanical thrombectomy. If cardioembolic etiology, give antiplatelet, with transition to AC in 4d to 2 weeks.

Dx

- NIHSS score ***
- Stat NCHCT/CTA, Neuro consult
- Glucose FS, INR, CBC, Cholesterol, A1c
- EKG, Tele, consider TTE with bubble if <60 y.o

Tx

- If TPA given, ICU admission, Q1hr neuro checks x 24 until repeat NCHCT.  BP goal <185/110 (Nicardipine preferred).
- If TPA not given, BP goal <220/120
- Antiplatelet agent

|# SYNCOPE # 

Acute loss of consciousness (***witnessed) concerning for syncope. Clinical history most suggestive of ***. Cardiogenic ddx includes structural, arrhythmic, and ischemic etiology. Noncardiogenic ddx includes orthostatic, vasovagal, PE, dissection, seizure, and basilar stroke.

- Orthostatic VS
- EKG, Telemetry
- CBC, BMP, Troponin, Lactate
- TTE if with concerning murmur or history
- Consider outpatient rhythm monitor per clinical scenario

|# SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) FLARE # 

Patient with known history of SLE who presents with *** concerning for lupus flare, given change in symptomatology and lab findings.

- CBC with diff, smear, BCx x2, CMP, ESR, CRP, Anti-dsDNA, C3, C4
- No indication to repeat ANA if positive
- CXR, UA with microscopy, Urine P/Cr,
- Additional organ specific labs/imaging per clinical scenario
- Appreciate rheumatology consult

|T

|# T2DM, ESTABLISHED, ***CONTROLLED

Diagnosed (year). Last A1c: *** (q3-6 months), goal: <7 (FBG 70-130, postprandial <180) (<8 in elderly/low life expectancy, high risk of hypoglycemia). Complicated by ***. Aim for aggressive early control to prevent micro/macrovascular complications--leading cause of death is ASCVD.

Changes today: ***
- Medications
-- non insulin therapies:
--- uptitrate metformin to 1g BIDAC by 500mg qweek to minimize GI side effects (caution GFR 30-45); consider B12 supplementation
--- GLP/SGLT if ASCVD
--- SGLT2 if HF/CKD
--- DPP4/GLP/SGLT if c/f hypoglycemia
--- GLP/SGLT if weight loss
--- SU/TZD if cost concern
-- insulin: (consider if initial A1c>10 or not at goal on 3 agents)
-- statin/ASA/ACEi: (consider ASA if ASCVD risk >10%)
-- FSBS frequency: (regular checks not necessary unless on insulin)
- Non-medication therapies
-- Diet/Nutritionist: low-carb or mediteranean
-- Exercise:
-- Weight loss: (goal 5-10% for obese; consider bariatic surgery if BMI>35)
-- DM Education date:
- Monitoring/prevention
-- Microalbuminuria (annual):
-- Blood Pressure < 130/80:
-- Statin: moderate/high intensity, ? LDL goal <100
-- Foot Exam (annual):
-- Podiatry (y/n):
-- Ophthalmology (annual):
-- Flu shot (annual):
-- Pneumovax (before age 65, boost after):
-- Hypoglycemia risk:
- Workup if young, thin, fam/personal hx autoimmune dz, hyperglycemia despite PO agents, h/o DKA
-- send GAD, ICA, IA2, insulin autoab
-- consider hemochromatosis, CF-related, pancreatic CA, cushings, chronic pancreatitis
https://care.diabetesjournals.org/content/diacare/42/Supplement_1/S90/F1.large.jpg

|# TESTOSTERONE DEFICIENCY # 

Patient complains of fatigue, depressed mood, loss of muscle mass, weight gain, low libido and poor sexual function. Physical exam is *absent of* gynecomastia and testicular atrophy (less than 20-30 cc and soft consistency)

-Order AM total testosterone x1. If less than 300 then repeat total T with prolactin, FSH, LH, SHBG and bioavailable testosterone. Consider a brain MRI in young men. (free T, bioT and SHBG are more accurate in the morning)
-Treat modifiable risk factors: opiate abuse, heavy alcohol use, sleep apnea, obesity
-Recommend a trial of topical therapy at 40 mg daily. Goal total T is 400-700.
-Monitor PSA and CBC yearly.

|# TESTOSTERONE DEFICIENCY - CANDIDATE FOR TREATMENT # 

Mixed primary and secondary hypogonadism. Low testosterone x2, Low free/total and low LH in am. Discussed risks and benefits of hormone replacement therapy at length and patient opts for testosterone therapy with the monitoring requirements listed below.

-continue to treat modifiable risk factors: alcohol use, sleep apnea, obesity
-retest total testosterone, PSA and CBC after 6 weeks of therapy
-Monitor PSA and CBC every 6 months, consider DRE and Lipid panel as well
--refer to a urologist if PSA level greater than 4.0 ng/mL or more than 0.75 ng/ml increase in a year
--hematocrit (testosterone stimulates bone marrow production of erythrocytes)
-100mg testosterone cypionate weekly, Goal total T is 400-700.
-150-200mg twice daily estrogen blocker - DIM Supplement (Diindolylmethane) or Indole-3-Carbinol (I3C)
-Call us when your prescription arrives and we can set up a nursing visit to demonstrate proper injection techniques

// Education //

- Step 1) Check total testosterone (total T) between 7am and 10am. Testosterone is 60% bound to sex hormone binding globulin (SHBG), 39% albumin bound and 1% free testosterone.
- Step 2) If total T is less than 300, then repeat total T but add FSH, LH, prolactin, SHBG and bioavailable testosterone. and PSA to establish baseline.
- Step 3) Consider MRI if prolactin high or if low testosterone in a young male
- Note: Obese males have low sex hormone binding globulin. This creates an artifact of low Total T (since 60% is bound to SHBG). Therefore, do not treat these patients unless they have low bioavailable testosterone.

THERAPY:
- Trial of topical therapy recommended. Apply in AM to mimic physiologic levels. Start at 40 mg. Consider repeat level in 2-4 weeks. Goal is Total T 400 to 700 and monitor for improved mood, energy and libido. If no improvement then stop therapy.
- Note: Some patients may ask but use is not recommended in women.

|# 1 Dealing with Male Hypogonadism and Low Testosterone
- Primary if testes unable to produce testosterone.
- Secondary if pituitary is under producing gonadotropins.
- Age related hypogonadism is controversial since men have a 1% per year loss of testosterone after age 30 years old.
- Mixed 1y and 2y: sickle-cell disease, thalassemia, alcoholism, glucocorticoid treatment, and in older men

|# THROMBOCYTOPENIA # 

Physical exam and history e/o thrombocytopenia may include: petechiae, purpura, oral petechiae, ecchymoses, lymphadenopathy, hypersplenism, bloody diarrhea, fever, s/sx of blood clots if hypercoaguable as in HIT. New thrombocytopenia likely due to ***. Common mechanisms include destruction (TTP, HUS, DIC, HIT, ITP), decreased production (leukemia, myelodysplastic, viral, drugs, ETOH, Vit B12, folate, copper deficiencies), and sequestration/hypersplenism (cirrhosis, heart failure, malignancy, infections). Also considered is pseudothrombocytopenia from clumping, smear can exclude.

- CBC w/diff
- HIV, HCV
- HIT Ab with reflex SRA if c/f HIT, stop all heparin products
- Smear, coags, fibrinogen, LDH, retics (if c/f BM suppression)
- Retics, immature platelet fraction (if c/f production problem)
- Platelet goal > *** (often 10 unless active bleeding then 50, 100 if c/f CNS bleed)
- Patient consented for blood products
- Hold DVT prophylaxis for plts < *** (typically 50), otherwise continue as appropriate

|# THROMBOCYTOSIS # 


|U

The differential diagnosis for thrombocytosis can be broadly separated into primary/autonomous thrombocytosis (15%; myeloproliferative neoplasms eg ET, PV, MDS; familial thrombocytosis) and secondary/reactive thrombocytosis (85%). Causes of secondary thrombocytosis can be divided into transient and sustained processes. Amongst transient processes are acute blood loss, recovery from prior thrombocytopenia, acute infection/inflammation, and response to vigorous exercise. Sustained processes include Fe-deficiency, hemolytic anemia, asplenia, cancer, chronic inflammatory or infectious diseases (e.g., connective tissue disease, temporal arteritis, IBD, TB, chronic pneumonitis), and drug reactions (e.g., vincristine, ATRA, cytokines, growth factors). In this patient with ***, the most likely etiology is ***.

- assess for HA, CP, bleeding/clotting, visual disturbances
- assess for vasomotor symptoms (eg, erythromelalgia, flushing, pruritus), and constitutional symptoms
- CBC/diff, smear, ferritin, ESR/CRP
- heme referral for primary (urgent if symptomatic or >1M/uL) or reactive if worsening despite tx, thrombosis/hemorrhage, or symptomatic

|# UPPER GI BLEED # 

Patient presents with new melena/coffee ground emesis concerning for upper GI Bleed. History notable for ***. DDx includes gastric and/or duodenal ulcers, esophagitis, gastritis/duodenitis, Mallory-Weiss syndrome, angiodysplasia, malignancy, and Dieulafoy's lesion. Disposition per Glasgow Blatchford score ***.

Dx
- CBC, CMP, INR, Type and screen, H pylori Ag
- Telemetry
- GI consult/Endoscopic evaluation per clinical scenario

Tx
- Protonix 80mg bolus x1, followed by Protonix 40 mg IV BID
- If concerned for variceal bleed in cirrhotic, consider Octreotide and Ceftriaxone
- NPO
- 2 large bore IVs
- Transfuse to keep hgb >7
- Hold antiplatelet agent, anticoagulation, anti-hypertensives
- Correct coagulopathy (Goal plt > 50k, INR < 2.0)
|V
|# VT (ELECTRICAL) STORM # 

Admitted with electrical storm as defined by >= 3x *** ( symptoms or shocks ) within 24 hours with confirmed VT on *** (tele, device interrogation ). Considered triggers include QT-prolonging drugs or substances, electrolyte disturbance, heart failure, ACS, thyrotoxicosis.

Dx:
- ☐ BMP/Mg, UDS, BNP, TFTs
- ☐ EKG/trop
- ☐ CXR
- ☐ TTE (if c/f CHF)
- ☐ Med review (for QT prolonging medications)
- ☐ Device interrogation (if s/p PPM, CRT)

Initial tx
- HDUS —> ACLS (electrical cardioversion!); if successful, initiate antiarrhythmic therapy with amio as below
- HDS —> IV amio (150 mg  x 10 min f/b 1 mg/min x 6h f/b 0.5 mg/min x 18 h)  + propranolol (PO 40 mg Q6H x 48 h); Amio preferred over lido, procainamide given superior efficacy for VT termination; Beta blockade reduces adrenergic surge associated with VT and defibrillator shocks (which contributes to VT via increased sympathetic output); Propranolol, a non-selective beta-blocker, is more efficacious than B1-selective agents (eg metop)
- If component of ischemia, urgent revascularization indicated

Long-term arrhythmia control:

- Catheter ablation: recommended for patients with persistence of electrical storm or incessant VT despite medical rx with amio and beta blocker
- Maintenance oral antiarrhythmic therapy indicated for recurrence of VT after catheter ablation
- If component of heart failure, initiate or uptitrate GDMT
- Initiate appropriate GDMT

|# VASCULITIS (SMALL VESSEL) # 

Patients presents with concern for new small vessel vasculitis given ***. Pauci Immune/ANCA mediated etiologies include GPA, EGPA, MPA, Paraneoplastic, and medications (e.g., sulfa, penicillin, thiazide). Immune complex mediated etiologies (generally decreased C3/C4) include infection (Post-Strep, SBE, Hep C, HIV, Osteomyleitis), connective tissue disease (SLE, RA, Sjogrens, IgG4), Cryoglobulinemia, and IgA/HSP (immune complex with normal complement levels).
- CBC w/ diff, ESR, CRP
- Consider ANA, ANCA (PR3/MPO), C3, C4, UA w/ micro, BCx, HIV, HBV, HCV, ASO
- Imaging per symptomatology and organ involvement
- Rheumatology and Dermatology consult per clinical scenario


|# VASCULITIS (LARGE AND MEDIUM VESSEL) # 

Patient presents with concern for new large/medium vessel vasculitis given ***. Large vessel vasculitis includes GCA/temporal arteritis and Takayasu. Medium vessel vasculitis includes PAN, Kawasaki, and Buergers (mimic). If concern for GCA/temporal arteritis, following evaluation for infection, consider prompt rheumatology consult and high dose steroids

- CBC w/ diff, ESR, CRP, BCx x2, ANA, UA w/ micro
- Imaging per symptomatology and organ involvement
|W
|# WEAKNESS (DIFFUSE) # 

***Acute/Subacute/Chronic diffuse weakness, most likely due to ***. No evidence of localizing weakness and neuro exam is unremarkable. Dx includes weakness secondary to infection, electrolyte/metabolic disturbance, neuromuscular insult, inflammatory disorders, endocrinopathy, drugs and toxins.

- If true muscle weakness, pain, or localized, consider imaging, ESR, CRP, CK
- TSH, B12, A1c, RPR
- CXR, UA/UCx, BCx x 2
- BMP, CBC
|X
|Y
|Z
"]

[checkbox name="63" value="Chronic Obstructive Pulmonary Disease with Exacerbation - Consult respiratory therapy. Oxygen therapy as needed to keep oxygen saturation greater than 92%.  Solu-Medrol 80mg IV every 8 hours.  DuoNeb treatments every 4 hours. ABG in the morning."]

[checkbox name="116" value="Diabetic Ketoacidosis - Initiate Adult DKA protocol. Trend pH, potassium, blood glucose, anion gap, HCO3, magnesium, phosphorous.  Blood sugar reduction goal no more than 75 mg/dl per hour. Strict intake and outflow monitoring. NPO."]

[checkbox name="30" value="Sepsis (not severe) - Will maintain MAP > 65 with vital signs every 4 hours. Will obtain serial lactic acid measurements and trend CRP. Will obtain procalcitonin and troponin."]

[checkbox name="31" value="Sepsis with Septic Shock - Will maintain MAP > 65 with titration of pressor and with vital signs every 4 hours. Will obtain serial lactic acid measurements and trend CRP. Will obtain procalcitonin and serial troponin."]

[checkbox name="62" value="Pneumonia - Aggressive pulmonary hygeine. Consult respiratory therapy.  Obtain sputum culture.  Blood cultures pending.  Oxygen therapy as needed to keep oxygen saturation greater than 92%.  Solu-Medrol 80mg IV every 8 hours.  DuoNeb treatments every 4 hours. Streptococcus pneumoniae antigen. Respiratory virus / pathogen panel. PSEUDOMONAS risk factors NEGATIVE - (Cystic fibrosis, Mechanical ventilation, Tracheostomy, Neutropenia, Immune compromise: Exam for AIDS, transplantation, cancer chemotherapy)"]



[checkbox name="70" value="Small Bowel Obstruction - Bowel rest.  Nasogastric tube with intermittent suction. Surgery service consultation.  NPO."]

[checkbox name="73" value="GI Bleed - Obtain blood type and screen, serial CBC and BMP. Consult GI. Start PPI. NPO status. SCD as DVT prophylaxis. No NSAIDS. Morphine as needed for pain, ondansetron as needed for nausea."]

[checkbox name="74" value="Pancreatitis - Full liquid diet.  Trend lipase. Obtain lipid panel. Antiemetics and analgesia as needed."]

[checkbox name="" value="Chest Pain - Will obtain serial troponins and EKGs. 81mg Aspirin daily. Will obtain lipid panel."]

[checkbox name="96" value="Congestive Heart Failure WITH Exacerbation - IV lasix as tolerated.  1500mL daily fluid restriction. Will closely monitor electrolytes. Daily weights. Strict IN/OUT monitoring. Low sodium diet. NYHA CHF classification of X.  "]

[checkbox name="99" value="New Onset Atrial Fibrillation - ChadsVasc score of X; Anticoagulate with Eliquis. Cardizem drip titrated to heart rate less than 100. Consult cardiology."]

[checkbox name="101" value="Hypokalemia - Present on admission and mild (3.0-3.5) OR moderate (2.5-2.9) OR severe (<2.9). Repletion per protocol."]

[checkbox name="102" value="Hyperkalemia - IV fluids, monitor renal function and serum magnesium and potassium"]

[checkbox name="103" value="Hypothyroidism - Check TSH. Check lipid panel. Continue levothyroxine."]

[checkbox name="104" value="Hypomagnesemia - Will replete with 2GM magnesium IV and planned re-evaluation in the morning. Present on admission and mild OR severe (<1.4)."]

[checkbox name="105" value="Hyperglycemia (no DM history) - Will obtain A1c in the morning."]

[checkbox name="106" value="DM2 - Diabetic diet.  Continue long-acting insulin and Accu-Checks AC and HS with sliding scale insulin."]

[checkbox name="112" value="Hyponatremia - Will trend serum sodium with a goal of no more than 12 MEQ increase in the first 24 hours, then no more than 8 MEQ increase over subsequent 24 hour periods. Present on admission and mild (130-145) OR moderate (120-129) OR severe (<120)."]
[checkbox name="20" value="Lupus - not exacerbated at this time."]
[checkbox name="21" value="Paraplegic - Total care to be provided including turning every 2 hours."]
[checkbox name="22" value="Parkinson's Disease - Continue home medication regimen."]
[checkbox name="23" value="Dementia - Bed alarm, fall risk, close monitoring."]
[checkbox name="24" value="Dizziness - Will provide gentle IV fluids. Heart healthy diet. Will consult neurology as indicated. Meclizine as needed for dizziness."]
[checkbox name="25" value="Transient Ischemic Attack - Consult neruology. Will obtain CTA head/neck, MRA/MRI, echocardiogram with bubble study, carotid ultrasound. Neuro checks every 4 hours."]
[checkbox name="40" value="Cellulitis - Will treat with cefazolin and vancomycin."]
[checkbox name="41" value="Stage III sacral pressure ulcer with - Turn and reposition q2 hours, continue foley catheter, consult wound care, continue wound VAC, wound culture."]
[checkbox name="50" value="Suicide Attempt - 6404 in place.  One-to-one observation. Suicide precautions."]
[checkbox name="51" value="Anxiety - Ativan 1mg PO as needed every 6 hours."]
[checkbox name="52" value="Chronic depression / anxiety - Will continue home medication regimen."]
[checkbox name="53" value="Insomnia - Will continue home medication regimen."]
[checkbox name="54" value="Altered Mental Status - Will obtain non-contrasted CT of the head and TSH as these were not part of initial work-up. Urinary tract infection presumed cause with urine and blood cultures pending."]
[checkbox name="60" value="Hypoxia - Will obtain chest x-ray and ABG and will support with supplemental oxygen via nasal cannula with respiratory consultation. Duoneb treatments every four hours as needed."]
[checkbox name="61" value="Admit to inpatient due to acute on chronic hypoxic respiratory failure"]
[checkbox name="64" value="Chronic Obstructive Pulmonary Disease WITHOUT Exacerbation - Consult respiratory therapy. Oxygen therapy as needed to keep oxygen saturation greater than 92%.  DuoNeb treatments every 4 hours as needed."]
[checkbox name="65" value="Chronic Respiratory Failure - Continue baseline supplemental oxygen.  Consult respiratory therapy."]
[checkbox name="71" value="Stress Ulcer Prophylaxis - Criteria met (Risk factors include past history of gastric ulcer; GI bleeding in the past 12 months; trauma including TBI, spinal cord injury, major burns; 2 or more of: > 1 week in ICU, occult GI bleeding, steroid dose > 250mg hydrocortisone weekly; mechanical ventilation for more than 48 hours; coagulopathy. Will give pantoprazole daily."]
[checkbox name="72" value="Colitis - IV ciprofloxacin and metronidazole. Liquid diet."]
[checkbox name="75" value="Elevated Liver Enzymes - Will obtain GGT and hepatitis panel, PT, PTT, and amonia level.  Child Pugh score of XX. Will obtain contrasted CT scan of the abdomen if not completed in emergency department."]
[checkbox name="76" value="GERD - Continue home medication regimen."]
[checkbox name="80" value="Dysphagia - A mechanically separated and softened diet will be maintained."]
[checkbox name="81" value="Chronic kidney disease - Gentle IV fluid hydration."]
[checkbox name="82" value="Urinary tract infection - Urine culture pending.  Rocephin 1GM twice daily."]
[checkbox name="58" value="Benign prostatic hyperplasia - Will maintain home medication regimen."]
[checkbox name="83" value="Acute Kidney Injury - Will trend creatinine and BUN with gentle IV fluid repletion."]
[checkbox name="90" value="Chronic venous insufficiency - Will continue diuresis and involve Wound Therapy as indicated for venous stasis ulcers."]
[checkbox name="91" value="Chronic Atrial Fibrillation - Continue anti-arrhythmic medications and aspirin"]
[checkbox name="92" value="Essential Hypertension - Continue current antihypertensive medications"]
[checkbox name="93" value="Hyperlipidemia - Continue statin therapy"]
[checkbox name="94" value="Peripheral Vascular Disease - No evidence of venous stasis ulcers at this time."]
[checkbox name="95" value="Congestive Heart Failure without Exacerbation - Continue oral Lasix and Oral potassium if needed."]
[checkbox name="97" value="Anemia - New onset. Will work up as indicated."]
[checkbox name="98" value="Anemia - Established. Will monitor CBC."]
[checkbox name="100" value="Hypoalbuminemia - Will trend. High protein diet."]
[checkbox name="107" value="Lactic acidosis - Will trend lactate level."]
[checkbox name="108" value="Elevated CPK - Will trend CPK."]
[checkbox name="109" value="Methamphetamine abuse - Will obtain serial troponins and morning EKG."]
[checkbox name="110" value="Dehydration (mild lactic acidosis, proteinuria, ketonuria) - Will gently hydrate with normal saline."]
[checkbox name="111" value="Leukocytosis - trend WBCs."]
[checkbox name="113" value="Gout history - Will maintain home medication regimen."]
[checkbox name="114" value="Alcoholism - CAGE score of X. CIWA score of 1. Last drink was X. Blood alcohol level is X.  Will monitor closely for alcohol withdrawal syndrome.  Will obtian serum phosphorous and TSH.  Benzodiazapenese as needed for withdrawal symptoms. Banana bag per protocol every 24 hours."]
[checkbox name="115" value="Failure to Thrive WITH DNR - Consult Case Management for transition to hospice care."]
[checkbox name="130" value="Femur fracture - Orthopedic service to round in the morning.  NPO after midnight.  Pain and nausea medication as needed.  Foley catheter in place.  Bed in reclined position."]
[checkbox name="200" value="Morphine 2mg IV push as needed every 6 hours with as needed ondansetron 4mg"]
[checkbox name="201" value="Chronic pain - Continue home pain regimen."]
[checkbox name="202" value="Constipation - Bisacodyl 5 mg orally daily when necessary."]
[checkbox name="203" value="Neuropathy - Will continue home medication regimen."]
[checkbox name="204" value="Restless leg syndrome - Will continue home medication regimen."]

Admission Checklist:
#Diet:
#Analgesia:
#DVT PPx:
#GI Ulcer PPx:
#Bowel Regimen:  
#Glycemic Control: 
#Antibiotic Regimen:
#Sleep:
#Lines:

#Disposition:

#Code Status:

# Contacts
|NEXT OF KIN|
|KADD|


I am providing care under supervision of attending |INPATIENT ATTENDING| who
agrees with assessment and plan.
MEDICINE INTERIM PROGRESS NOTE/MULTIUSE NOTE
|PATIENT NAME FIRST,LAST| |PATIENT SSN|
ADMISSION DATE: |ADMISSION DATE|
ADMISSION DIAGNOSIS: |ADMITTING DX|
_________________________________________________



24hr events:



LABS
VS WNL VS Abnormal
CMP WNL CMP Abnormal
CBC WNL CBC Abnormal


SUBJECTIVE:
is a year-old with a past medical history of and is currently post-op day following a . This morning, the patient reports feeling "". Last pain score was /10 obtained at currently being managed with



Problem List
|PROBLEM LIST BRIEF|





OBJECTIVE:
=============
VITALS
Temp: |TEMPERATURE|
BP: |BLOOD PRESSURE|
HR: |PULSE|
RR: |RESPIRATION|
O2: |POX|
Weight: |PATIENT WEIGHT|
BMI: |BODY MASS INDEX|
Pain: |PAIN|



|WEIGHT-LAST 3|




PHYSICAL EXAM
Gen: laying in bed in NAD
HEENT: NC/AT, EOMI, PERRL, MMM, OP clear
Neck: supple, no cervical LAD, no JVD
Heart: Normal rate and regular rhythm, normal S1 and S2. No murmurs.
Pulm: Clear to auscultation bilaterally, no wheezes or crackles
Abd: soft, non-tender, non-distended. active bowel sounds
Exts: no edema, clubbing, cyanosis. Warm and well perfused
Neuro: A&Ox4, normal speech, motor and sensory grossly intact




I&Os
in:
out:
net:
uop:





ACTIVE MEDICATIONS:
|ACTIVE MEDICATIONS|



LABS



CBC
|HS:SCL1-CBC-AFTER10/14-5;10Y|



CHEMISTRY
|LAB-SODIUM;1;1Y|
|LAB-POTASSIUM;1;1Y|
|LAB-CHLORIDE;1;1Y|
|LAB-CO2;1;1Y|
|LAB-BUN;1;1Y|
|LAB-CREATININE;3;1Y|
|LAB-GLUCOSE;1;1Y|
|LAB-CALCIUM;1;1Y|
|LAB-MAGNESIUM;1;1Y|
|LAB-PHOSPHORUS;1;1Y|



LFTS
|LAB-PROTEIN,TOTAL;3;1Y|
|LAB-ALBUMIN;1;1Y|
|LAB-AST;1;1Y|
|LAB-ALT;1;1Y|
|LAB-ALK PHOS;1;1Y|
|LAB-BILIRUBIN,TOTAL;1;1Y|



COAGS
|LAB-PT;3;1Y||LAB-PTT;3;1Y||LAB-INR;3;1Y|
|LAB-A1C;1;1Y|
|LIPID PROFILE|



UA
|LAB-UA;1;1Y|



IMAGING/PROCEDURES/PATHOLGY



|IMAGING T-60|





_________________________________________________



ASSESSMENT/PLAN:
====================



|PATIENT NAME FIRST,LAST| is a y.o. that is hospital day for

COVID MDM COVID DCI Ddx abd pain LLQ Ddx abd pain lower female ddx abd pain lower male ddx abd pain rlq ddx abd pain ruq ddx abd pain upper ddx ams / weakness ddx asthma ddx back pain ddx bronchitis ddx cough/wheezing Ddx Chest Pain ddx dysuria female ddx dysuria male ddx extremity injury / joint pain ddx flank pain left ddx flank pain right ddx general admit ddx gi bleed lower ddx gi bleed upper ddx headache ddx hyperglycemia / dka ddx lightheaded/syncope ddx missed dialysis ddx psychiatric ddx sepsis ddx vag bleed ddx vag bleed pregnant ddx vague neuro sx ddx vertigo

ED Course

MDM ABD PAIN W/ IMAGING + LABS MDM ABD PAIN W/O IMAGING + LABS MDM ALLERGIC REACTION Ddx MDM ANXIETY MDM ASTHMA ADMIT MDM ASTHMA DC HOME W/ X-RAY MDM ASTHMA DC HOME W/O X-RAY MDM BACK PAIN MDM BACK PAIN MSK BRIEF MDM BRONCHITIS, Neg xray MDM CHEST PAIN ADMIT Ddx/MDM CHEST PAIN ATYPICAL home Ddx/MDM CHEST PAIN MSK (NO TROP) MDM CHF ADMIT,bipap MDM CHF DC HOME MDM CLOSED HEAD INJURY W/ CT MDM CLOSED HEAD INJURY W/O CT MDM COPD ADMIT MDM COPD DC HOME W/ X-RAY MDM COPD DC HOME W/O X-RAY MDM CORNEAL ABRASION MDM DIARRHEA MDM DIZZY ADMIT MDM DIZZY DC HOME MDM DVT MDM ETOH INTOX W/ CT/LABS MDM ETOH INTOX W/O CT/LABS MDM ETOH WITHDRAWAL ADMIT MDM ETOH WITHDRAWAL DC HOME MDM EXTREMITY INJURY MDM EXTREMITY PAIN MDM FOLEY REPLACEMENT MDM GENERAL WEAKNESS ADMIT MDM GENERAL WEAKNESS DC HOME MDM GI BLEED MDM HEADACHE W/ CT MDM HEADACHE W/O CT MDM HYPERKALEMIA MDM HYPERTENSION W/ LABS MDM HYPERTENSION W/O LABS MDM HYPOGLYCEMIA ADMIT MDM HYPOGLYCEMIA DC HOME MDM METHADONE MDM OTITIS MEDIA (NO ABX) MDM OTITIS MEDIA W/ ABX MDM PEDS CRYING MDM PEDS UTI MDM PID MDM PNEUMONIA ADMIT MDM PNEUMONIA DC HOME MDM POSSIBLE ECTOPIC MDM PSYCH 5150 AGITATION MDM PSYCH 5150 SI/DEPRESSION MDM REACTIVE AIRWAY DISEASE MDM SEIZURE (NEW ONSET - NEG CT) MDM SEIZURE (NO CT) MDM SEPSIS MDM STROKE (NO TPA) MDM STROKE (TPA GIVEN) MDM SYNCOPE ADMIT MDM SYNCOPE DC HOME MDM THREATENED AB MDM TIA MDM with Primary Survey MVC DCI MDM VAG BLEED NON-PREGNANT MDM VAG DISCHARGE W/ TREATMENT MDM VAG DISCHARGE W/O TREATMENT STROKE TEMPLATE LKWT NIHSS tPA MDM PEDS Fever no symptoms w/ UTI PEDS Fever no symptoms
Ddx

#


1. Problem 1
























































































Admission Checklist:
#Diet:
#Analgesia:
#DVT PPx:
#GI Ulcer PPx:
#Bowel Regimen:
#Glycemic Control:
#Antibiotic Regimen:
#Sleep:
#Lines:

#Disposition:

#Code Status:

# Contacts
|NEXT OF KIN|
|KADD|


I am providing care under supervision of attending |INPATIENT ATTENDING| who
agrees with assessment and plan.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.61, 427 form elements, 283 boilerplate words, 11 text boxes, 108 text areas, 180 checkboxes, 8 drop downs, 1 links, 2 comments, 117 conditionals, 307 total clicks
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