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|A
|#ACS Rule Out/Chest Pain
- Hx: Typical vs. Atypical features, risk factors
- EKG (prelim): 
- Biomarkers:
- Imaging: 
  > CXR ( /): 
  > TTE ( /):  
- Trop_ , BNP _ 
- DDx: UA/NSTEMI/STEMI, pericarditis, ventricular aneurysm, prinzmetal; PUD, esophageal rupture; PNA, PE, PTX/tension PTX, HTN emergency, costochondritis
- Heart Score _  TIMI Score _
 PLAN:
- Trend Trop x3 (Q6h, until downtrending/stable), trend EKG x3 (Q6h)
- Cardiac monitoring, continuous on tele for at least 24hrs_
- Antiplatelet Rx: aspirin 81 daily, clopidogrel 75 daily 
- Anticoagulation Rx: _?
- Antianginal Rx: nitroglycerin subL PRN_
- Antihypertensive: _
- Statin: atorvastatin 80mg qhs_
- HF Rx: carvedilol _?, lisinopril _?, _hydralazine_?, _imdur/isordil_? (spironolactone can be started as outpatient or after stabilization on BB and ACEi)
- Post-cath monitoring: pain, infection, cath site bleeding/hematoma, retroperitoneal bleed, AKI
- Risk stratification: Low/Med/High; HgbA1c, lipids, TSH, urine tox, smoking hx
- F/u outpatient with cardiology _

|#Acute Kidney Injury

- On admission, Serum Cr _ (date) with baseline Cr: unknown
- Etiology: pre-renal vs. intrinsic vs. post-renal
  > Pre-renal: low PO intake, increased output (diarrhea, over-diuresis, bleeding, insensible losses), decreased flow (CHF, cardiorenal, renal artery stenosis), decreased intravascular vol (sepsis, liver failure)
  > Intrinsic: ATN (prolonged pre-renal, contrast), AIN (NSAIDs, beta-lactams, aminoglycosides, TMP-SMX, PPIs, infection), glomerulonephritis/ nephrotic syndrome, emboli (cholesterol)
  > Post-renal: physical obstruction (stones, cancer, BPH, ascites, infection), functional obstruction (neurologic, drugs e.g. anticholinergics)
- Relevant history: recent procedures, medications, PO intake, UOP, diarrhea, thirst
- Physical exam notable for: mucous membranes, JVD, edema (pulmonary, lower extremities)
- Serum BUN/Cr ratio: _
- Urine Na: _
- FeUrea: _
 PLAN
- Check UA w/ micro, urine chemistries (Na, Cr, BUN, Osm), Pr/Cr ratio, PVR, renal ultrasound
- (Treat based on etiology)
- Avoid nephrotoxic agents (NSAIDs, ACE/ARBs, contrast, aminoglycosides, TMP-SMX, vancomycin)

|#Iron Deficiency Anemia

  - Hgb _
  - Iron studies _
PLAN:
- start FeSO4 325mg PO pills qod
   > future labs: maintain a transferrin saturation of >20 percent and a serum ferritin level of >100 ng/mL
  > avoid use of antacids, histamine-receptor blockers, PPIs
  > do not take with Calcium-containing foods
  > counseled regarding potential side effects: metallic taste, nausea, flatulence, constipation, diarrhea, epigastric distress, vomiting, itching, black/green/tarry stools

|#Anemia of Chronic Disease

- Hgb _ MCV _
- Fe Panel _ c/w
- iron replacement IV or PO (eg. IV ferrous gluconate or PO ferrous sulfate)
- aranesp 100mcg qWeek or 0.45mcg/kg weekly vs 0.75mcg/kg q2weeks weight-based while inpatient
- goal Hgb >10, stop aranesp once Hgb at goal

|#Anxiety disorder

- GAD-7 score _: (Anxiety: moderate/possibly clinically significant if 10-14, severe/needing treatment >15)
 *(panic d/o, social phobia, PTSD: cutoff score 8 sensitivity=77%, specificity 82%)
(scoring: 0=never, 1=several days, 2=more than 1/2 days, 3=nearly every day)
   > 1) feeling nervous, anxious, or on edge: _
  > 2) not being able to stop/control worrying: _
  > - 3) worry too much about different things: _
  > 4) trouble relaxing: _
  >  5) restlessness/hard to sit still: _
  > 6) easily annoyed/irritable: _
  > 7) feeling afraid that something awful might happen: _
 
Dx: 
  - need 3/6 for >6mo
restlessness/on edge: _
fatigue: _
concentration: _
irritability: _
muscle tension: _
sleep: _

|# Atrial Fibrillation

- Hx: _
- Triggers: _ (ie. infection, ingestion, ischemia etc)
- CHADS2VASc: _
- HASBLED (risk of bleed): _ 
- Prior cardioversion? chemical vs. electrical/TEE
- Patient's fall risk assessment is _ (low/mod/high)
 - Home medications: 
PLAN:
- Rate control goal <110 (per RACE II trial) 
- RVR: Metoprolol 5mg IV q5min x3. If still not rate controlled, consider amio/dilt. 
- Anticoagulation with _ (lovenox if renal function ok vs heparin while inpatient, warfarin vs doac as outpatient)
- INR goal 2-3 unless other indications
- Discussed with patient the benefits of anticoagulation for stroke prevention and the risks of bleeding in the setting of _ fall risk and _ hx of prior bleed
|B
|C
|# CAPACITY

Capacity: The patient is competent and understands the risks of leaving, including disability and/or death, and had the opportunity to ask questions about his or her condition. Patient had clear speech, linear logic, appropriate comprehension of risks and benefits. No clinical evidence of intoxication with alcohol or other illicit drugs. 

| # CIRRHOSIS:

Assessment:
- Child-Pugh Class  __, MELD-Na __ (date)
- Etiology: _ (NAFLD, ETOH, HCV, Congestive hepatopathy, Hemochromatosis, Wilson’s)
- Stigmata of Liver Disease on Exam: _ spider angiomas, palmar erythema, gynecomastia
- Hepatic Encephalopathy: _ none or grade 1-4
- Esophageal Varices: last screening EGD _
-- secondary prophylaxis with non-selective beta blocker: indicated on Child-Pugh B and C with stigmata of bleed, avoid if pt has SBP or refractory ascites
- Ascites: _ none on exam
- Spontaneous Bacterial Peritonitis: _ no history
- Hepatocellular Carcinoma: _ last abdominal ultrasound, AFP level
- Portal Vein Thrombosis: _ last abdominal ultrasound
- Hepatitis A and B immunity status: _
- Transplant status: _ insurance, citizenship, and last alcohol consumption
Recommendations
- Advised patient to consume Na <2g/day, tylenol <2g/day, avoid NSAIDs, avoid shellfish
- Lactulose
- Diuretics: furosemide and/or spironolactone
- Plan for ultrasound abdomen for HCC and PVT screening with AFP every 6 months

|D

|##Death Note/Exam 1

 Death Summary:
Patient _ . Patient ID was confirmed.
Time of Death at _ on _ at _ .
Cause of Death: _
Exam was done to confirm patient death: pupils dilated and nonreactive, no spontaneous respiration or cardiac sounds auscultated, no pulse palpated, cardiac monitor and O2 sat were flat-lined confirming death.
Patient's family was at bedside at pronouncement.
Death was pronounced by Dr. _
Dr. _ notified of patient's time of death.
Time of death certificate signed.
Summary of Hospital Course: (if appropriate)_

|##Death Note/Exam 2

_One liner_
  
This physician was called by nursing staff at _am/pm as pt appeared to be deceased. On my exam, pt did not respond to sternal rub or loud voice. Pupils bilaterally nonreactive. No visible chest rise. No auditory heart sounds or breath sounds. Pt pronounced dead at _am/pm on _ (Day/Month/year). Death forms filled by me.
  
_ (family member) was contacted at listed phone number_ and was informed of pt's death. Deepest condolences were given. _ (family member) was given phone numbers for the Decedent Office and County Coroner's Office. All questions were answered to satisfaction.
|- Delirium precautions:
   > Keep 1:1 sitter
  > Avoid benzodiazepines, opioids, and anticholinergics, which may precipitate/exacerbate delirium
  > Judicious use of soft restraints
  > Keep lights on and blinds up during day, lights off and blinds closed at night. Minimize daytime napping　
  > Minimize nighttime interruptions; reorder AM labs to 6AM　
  > Frequent reorientation to date, time and situation
  > Provide hearing aid, dentures, glasses if applicable
  > Encourage family and friends to visit
 - Consider other possible causes of Delirium: bowel obstruction, PE, seizures, MI, cardiac arrhythmias.

|DNR/DNI Documentation:
  
Patient: _
DNR/DNI discussion took place on _ at _.
Patient expressed understanding that the benefit of resuscitation (CPR) and intubation (ETT) would be extremely low and is not recommended in the present state of health, and has its inherent risks resulting in extremely low probability of survival as well as increased risks of rib fracture, pneumonia/aspiration, chronic pain, persistent comatose state, and prolonged irreversible intubation.
Patient expressed agreement to DNR and DNI.
POLST _.
Other parties present include: _ .
Please refer to patient's paper chart for DNR/DNI documentation in addition to this electronic documentation.
  
Consenting Physician: _ .
Other Present Physician(s): _ .
|#Acute encephalopathy 
- baseline mental status: _
- On admission, found to be _ 
- CTH w/o contrast: negative for acute findings 
- TSH wnl 
- Vitamin B12 wnl, folate wnl 
- U/A negative for UTI 
- HIV and Syphilis screen negative
- UTox negative 
- Acetaminophen, Salicylates, Ethanol negative
- BMP with serum Na wnl and no elevated BUN or hypo/hyperglycemia 
- Etiology: 
PLAN: 
- 

|#ESRD on HD
- Etiology/date of first dialysis: _
- Access: TDC PD LUE RUE AVF
- schedule: MWF TThS
- HD Center, last dialysis prior to admission:
- Anemia: g/dL
- Urine production: yes no oliguric
- Volume status: Hypo Eu Hypervolemic
- Electrolytes: Hypo Hyperkalemia, Hypo Hypernatremia
- Acid Base status: bicarb _
- BUN　 , Cr　 on admission - improved worsened stable
 - dry weight: _, current weight: _
Plan:
- Daily weights and strict I&O’s please
- Please avoid all PICC lines, not recommended on ESRD pt for vessel integrity for future AVF creation
- Please draw labs (BMP and CBC) prior to HD
- Renally dose all meds
- Recommend 2g Na, 2g K, protein 1.2g/kg per day plus daily urine losses
- Recommend Vitamin B complex with C oral tablet and folic acid QHS
- Recommend anti-hypertensives dosed QHS
|EtOH Use Screening
- Single-Item Screening: #times >/=5 drinks/day (M)? / >/=4 drinks/day (F)? (positive if>/=1): _
- AUDIT-C:
  > How often do you drink EtOH? _
  > How many drinks do you have on a typical day when you are drinking? _
  > How often do you have 6 (M) / 4 (F) or more drinks on 1 occasion? _
- CAGE: _
#ETOH Withdrawal 
- h/o drinking: _
- h/o complications include _ (seizures, DT, intubation, etc)
- last drink _
- exam: _ tongue fasciculations, _ tremors
 - Medications received in ED:
 PLAN:
- start MVI qDay, thiamine 100mg qDay, Folic acid 1mg qDay
- social work consult for substance abuse
- educated patient on cessation/abstinence from alcohol to prevent liver disease and increased morbidity
- Benzodiazepine regimen: Start ativan 2mg Q4H PRN ETOH withdrawal 
- patient amenable to EtOH cessation, start gabapentin 600mg Q8H and naltrexone 50mg qDay
|#Facial nerve palsy, Bell's Palsy:
- central vs peripheral nerve palsy; HSV, VZV, EBV, GBS, HIV(rare), Lyme, sarcoidosis, Sjogren, CVA, tumor
- House-Brackmann Grade: _
- Head imaging: _
 PLAN:
- eye care: lubricant gtt qhr while awake, ointment (w/ mineral oil, white petrolatum) qhs, eye patch/protective goggles qhs
- steroid therapy: prednisolone 60mg x5 days, then taper by 10mg over 5 days for total 10d therapy
- consider surgical/tarsorrhaphy intervention if nonresolving after 3 weeks
- NOTE: if incomplete involvement 95% will have recovery, if complete involvement 60% will have recovery; of pts w/ recovery 70% will have complete recovery, 15% w/ partial, 15% w/ residual

|#Routine Health Maintenance - Adult
 -BMI: _
>Screens
- Depression screen q1y (>11y/o): PHQ2=_, PHQ9=_
- Dental q6-12mo: _
- Cancer Screening:
  - Breast CA (50-74y/o mammo q2y, >/=75y/o stop if life expectancy <10y, positive FHx?): _
  - Cervical CA (21-29y/o pap only q3y, 30-65y/o pap only q3y OR pap+HPV co-testing q5y, >65y/o d/c, HIV? immunosupp? DES? CIN/Cervical CA?: _
  - Colorectal CA (45-75y/o FIT q1y, f/u w colonoscopy if positive; other options CTcolo/FSIG q5y): _
  - Lung CA (low-dose CT q1y for 50-80y/o w >/=20ppy smoking hx + current smoker/quit <15y ago): _
- Other Screening:
  - Osteoporosis via DEXA (male >/=70y/o, female >/=65y/o, post-meno <65y/o w RF - low wt, smoking hx, EtOH, RA, FHx hip fx, steroid use; f/u w FRAX calc): _
  - AAA via abdominal u/s (65-75y/o M w any smoking hx, screen once): _
>Vaccines:
  -Flu q1y: _
  -MenACWY-D (Menactra - 1st dose: 11-12y/o, 2nd dose: 16y/o): _
  -MCV B (Menveo - 16-18y/o, 19-21y/o if dorm): _
  -HPV (</=45y/o): _
  -Tetanus (TDap @11-12y/o f/b Td q10y): _
  -Pneumococcal: (>65y/o unless +RFs): _
  -VZV (>/=50y/o): _
  -covid-19: _
>Labs:
- HbA1c (>45y/o OR BP>135/80 OR obese/overweight / RFs for DM, repeat q3-5y if wnl): _
- STI testing:
  - HIV screen (13-75y/o OR RFs): _
  - HBV screen (DM pts taking fingersticks, HD, prison, IVDU, sex w HBV partner, MSM): _
  - HCV (if born 1956-1965, HD, IVDU, sex w HCV partner, MSM): _
 - GC/CT screen q1y (F 15-25y/o if sexually active, M if symptomatic or partner w infx): _
 - TB screen (consider IGRA >=5y/o): _
- Lipid testing (9-11y/o, 17-21y/o): _
>Education
- Contraception education discussed? directed to bedsider.org/methods website to research methods _
- Smoker? _
- EtOH? _
 
RTC in _

|#Left/Right/Biventricular Acute/Chronic/Diastolic/Systolic Heart Failure Exacerbation

- Hx: NYHA Class (I, II, III, IV)
- Etiology, suspected:
- EF ()%., TTE date:
- EKG: 
- Biomarkers:
- CXR:
- Appears (hypovolemic/euvolemic/hypervolemic) on exam
- ICD: if EF is below 35% on GDMT, an implantable cardioverter-defibrillator (ICD) is indicated to prevent sudden cardiac death
- CRT-D: NYHA II-III or ambulatory IV if EF is below 35% on GDMT, with QRS >120 w/LBBB morphology or QRS >150
- Base dry weight:
- Weight on admission:
PLAN
- F/u q12h BMP, Mg, Phos during aggressive diuresis
- Continuous cardiac monitoring
- Strict I/O, particularly UOP
- Supplemental O2 therapy (CPAP, BIPAP as tolerated)
- Fluid restriction 1-1.5L
- Initiate aggressive diuresis: (3-5x home dose as IV)
- PRN chest pain give SL nitro tab x1 q5-10min up to 3 doses w/ BP monitoring
- PRN hypertension nitrate vs hydralazine for SBP > 150 or DBP > 90
- Start/restart medications GDMT:
--- ACE-i: hold in setting AKI
--- Beta-blocker: hold if Patient has not been reliably taking in setting acute decompensation or for new dx
--- Aldosterone inhibitor: indicated in NYHA Class II-IV
--- Diuretic: indicated for symptomatic relief
--- Nitrate/hydralazine: if African-American, consider adding isosorbide dinitrate and hydralazine

|#Hypernatremia 

- Current Na: _
- Free water deficit: _ (0.5 x kg weight x ((current Na/140) - 1)))
 PLAN:
- Replace 50% of the free water deficit = _ over the next 24hrs, add _cc insensible losses = total _ over next 24hrs
- Replace UOP losses with _ ; match replacement to loss 1 to 1
- In chronic hypernatremia, avoid correcting more than 6-10mEq over the first 24hrs; in symptomatic hypernatremia, can correct to resolve sx and then slow down to 6-10mEq correction over 24hrs
- Follow BMP (Na), Sx

|#Hypernatremia 
- Current Na: _
- Free water deficit: _ (0.5 x kg weight x ((current Na/140) - 1)))
 PLAN:
- Replace 50% of the free water deficit = _ over the next 24hrs, add _cc insensible losses = total _ over next 24hrs
- Replace UOP losses with _ ; match replacement to loss 1 to 1
- In chronic hypernatremia, avoid correcting more than 6-10mEq over the first 24hrs; in symptomatic hypernatremia, can correct to resolve sx and then slow down to 6-10mEq correction over 24hrs
- Follow BMP (Na), Sx
|#Hyperphosphatemia
- Current Phos: _ Ca: _ (Ca-Phos product = _ )
 PLAN:
- Recommend _ (sevelamer 800-4000mg TIDWM, amphojel (Aluminum Hydroxide) 90mL TIDWM, avoid PhosLo (Ca Acetate) given Ca)
- Follow Ca, Mg, Phos per BMP and symptoms

|#Hyponatremia 
Tonicity:
Volume Status:
- Sx: _
- UA: _
- Chronicity: _
- Baseline: _
- DDx: hypovolemic (volume contraction, excessive diuresis, burns, pancreatitis, HONK/DKA) , euvolemic (SIADH, pain, infection, surgery/trauma, hypothyroidism, psychogenic polydipsia) , hypervolemic (cardiac, renal, hepatic)
- Most likely etio: _ 
- Rx: _

|#Lower Back Pain
  - _
  - no red flag symptoms or findings (cord compression, cord injury, cauda equina, focal weakness/paralysis/anesthesia, urinary/fecal incontinence, severe acute on chronic pain)
>PLAN:
- ordered XR lumbosacral spine 4views
  - will consider MRI pending XR results
- counseled regarding gentle home exercises and stretching, avoiding heavy lifting
- pain regimen: _

|#Meningitis 
- Sx: _
- Exam: _
- DDx: meningitis, cluster headache, tension, migraine, SAH
- Most likely etio: _
- Likely infectious organisms: Staph aureus_, strep pneumo_, N. meningitidis_; H. flu_, listeria_ (in elderly and children); HSV_ (in susceptible pts, immunosuppressed, or otherwise high risk or CSF positive)
- _ (LP: rapid meningitis panel negative for E. coli, H flu, listeria, neisseria, strep agalactiae/pneumonia, CMV, enterovirus, HSV1/2, HHV6, VZV, HPV, crypto)
- Imaging: _
- Rx: _
|
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