Smart Phrases And Workups – Dispo/Other

The patient understands the risks of morbidity and mortality if they leaves the hospital and would like to sign out against medical advice at this time. They were oriented and had the capacity to make their own decisions. The patient understands that they must immediately return to the emergency department if any alarming symptoms develop or worsen such as chest pain or shortness of breath.
AMBULATE	
Please document ambulatory saturation on room air. If desaturation to 88% or less, please REPEAT ambulatory saturation and document how much O2 is required for patient to sat >92% while walking. This is needed for home O2 evaluation. Please document your findings in a note. Thank you.
CODE BLUE	
Code Blue was called at *** PM.

I arrived at the bedside while chest compressions were being administered by primary nursing staff and code was being run by Dr. ***

HPI SUMMARY HERE***
HOSPITAL COURSE SUMMARY HERE***

Multiple rounds of epinephrine, bicarbonate, calcium chloride were given to stabilize the patient with CPR. The patient quickly achieved ROSC with epinephrine and CPR. The family was at bedside witnessing the events. At that time I discussed with patient's wishes with the family and they wishes to proceed with full code.

Then again, he had a cardiac arrest and this time after 45 minutes of CPR cycles discussion was had with the family who wishes to continue a bit longer. Multiple access sites were obtained ***. Patient was unable to achieve ROSC after 1 hour of CPR cycles and time of death was called at ***2303.

Discussed with the family extensively at bedside regarding all the events that occurred above and they chose to have*** an autopsy completed.
CODE STATUS DISCUSS
This writer spoke to patient's **** -- at phone number *** / *** respectively. I discussed what it means to full code vs DNR/DNI and that changing the code would not have an impact on current treatment. Shared that if he were to die, he currently would receive chest compressions to attempt to revive him. Given patient's age and comorbidities, made the medical recommendation that he be changed to DNR DNI. *** was agreeable after discussing with family -- and states that if he were to die, medical team is not to attempt chest compression to revive him.
FASTHUGS	
Fluid therapy and Feeding:
Analgesia, antiemetics and ADT (AAA): acetaminophen
Sedation: N/A
Thromboprophylaxis: lovenox
Head up position (30 degrees) if intubated
Ulcer prophylaxis: not indicated
Glucose control: not indicated
SBT: N/A
Bowel cares: miralax, senna PRN
Indwelling catheter/tube
De-escalation (antibiotics, AM labs)
Disposition (PT/OT, etc)
PAIN	
PHYSICAL EXAM	
Gen: A&Ox4, laying in bed in NAD
HEENT: NC/AT, EOMI, white sclera, MMM
Neck: supple, no cervical LAD
Heart: RRR, normal S1 and S2, no murmurs
Pulm: CTAB, no wheezes/crackles/increased work of breathing
Abd: normoactive bowel sounds, soft, non-tender, non-distended, no HSM
Exts: no edema, peripheral pulses intact, warm and well perfused
Neuro: normal speech, motor and sensory grossly intact, moves all extremities
spontaneously
Skin: no suspicious rashes/lesions
PRE-OP	
In summary, patient with PMH of DM2 c/b neuropathy, CKD stage III/IV, HTN, HLD, lumbar spine sx, who originally presented with 2-days h/o intermittent RUQ, found to have choledocholithiasis and treated empirically for cholangitis presenting for higher level of care ERCP given 3v disease seen in coronary cath done on 9/1/2020. Also had TTE in OSH showing EF 30%. Otherwise patient not aware of any previous MI (denies ever having chest pains) and exam not consistent with acute heart failure findings. Patient currently denies any active chest pain, dyspnea, syncope or presyncope, orthopnea or PND. No fever or RUQ pain on presentation, hemodynamically stable.
 
Cardiovascular Risk Assessment:
 
Recent Cardiac Testing (<5 years) Yes
Echocardiogram - yes EF 30%
Stress Test , [n/a]  
Cardiac Catheterization 9/1/2020 report indicated 3v disease
Other  
 
Cardiac Symptoms: no chest pain, shortness of breath, DOE, orthopnea, PND, syncope, or palpitations
Cardiac History: CAD and HF EF 30%
Major Cardiac Contraindications: none
Procedural Risk: low
Hypertension: The patient has HTN and reports inpatient BP is elevated: 146/87
 
Pulmonary Risk Assessment:
 
Pulmonary History or Symptoms: no chronic lung disease
Surgery a/w Pulmonary Complications: no
Potential Pulmonary Contraindications: none
Major Pulmonary Risk Factors: suspected OSA (STOP-BANG >4)
 
Diagnostic Data:
 
EKG [9/1/2020]:  NSR, Q-waves on inferior leads, no significant ST abnormalities noted
TTE: Per report LVEF 30%
Assessment:
? Cardiac Risk:
Procedure Urgency: urgent
Major Cardiac Contraindications: none
Procedural Risk: low risk
Post-Test Cardiac Risk (if known): The patient had a recent coronary intervention without new cardiac symptoms. 
Overall Cardiac Risk for MACE or MICA: moderate (2-9%) 
? Hypertension:
? Abnormal EKG: Controlled
Q waves in inferior leads
? Postoperative Pulmonary Complication (PPC) Risk:
Pulmonary Dx: suspected OSA STOP BANG: 6 out of 8
Surgery-Specific Risk Factors: low risk
Major Patient-Specific Risk Factors: no
Overall Risk for PPC: elevated risk
? Empirically treated for cholangitis from OSH on Zosyn (continued)
? DM, type II: uncontrolled
? CKD: Stage III-IV
 
Recommendations:
? Medical Optimization:
Preoperative Testing: Given patient is asymptomatic not showing any signs/symptoms of acute coronary syndrome or heart failure, no recommendations for further cardiac work up at this time. Would defer to anesthesiology  if further testing (for example repeat TTE) is needed pre-procedure
Medical Optimization: is optimized for the proposed surgery with the following interventions below.
   
Return to Clinic: PRN
 
? The patient needs no further cardiac evaluation or cardiac optimization prior to procedure. Will need cardiology eval and management for triple vessel disease eventually however.
? Suspected OSA given STOPBANG score of 6, no previous sleep study or CPAP mask eval. Will need sleep study outpatient.
? Recommend careful perioperative hemodynamic monitoring per Anesthesiology
? Consider PRBC transfusion PRN Hgb <8 or symptomatic anemia to minimize coronary ischemia
? Recommend incentive spirometry perioperatively to minimize the risk of pulmonary complications.
? Dose all medications for the impaired renal clearance.
? Avoid nephrotoxic medications like NSAIDs, aminoglycosides, IV contrast, etc.
? Optimize diabetes by adjusting diabetic medications:  Started insulin sliding scale, a1c
PRONE	Encourage patient to awake prone positioning to recruit atelectatic lung tissue in dependent lung basis -- ideally 12-18 hours a day. Would only continue if there is an improvement in oxygenation.
RAPID RESPONSE	
RAPID RESPONSE NOTE

Patient: @NAME@
MRN: @MRN@
Attending: @ATTPROVIP@
Primary Team: @SERVICEH@
Date of Service: @TODAYDATE@
Location: @RRROOMBED@

EVENT STATUS

Time Activated: ***
Time of Arrival: ***
Primary Team or Representative Present? {yes no:18735}
  If Not, Was Primary Team Paged? {yes no:18735}
  Time Primary Team Paged: ***
  Time of Primary Team Arrival: ***
Please refer to nursing documentation to corroborate times.

EVENT SUMMARY

Reason for Rapid: {Rapid Response Reasons:19817}

Reason for Admission: @PRIMARYDIAGNOSIS@

Brief Summary of Event:
***


Point of Care Ultrasound Used?
{yes no:18735}
{List pertinent US findings if used}

Diagnostics Ordered:
{Rapid Response Studies:19824}

General Treatment Interventions:
{Rapid Response General Treatment Interventions:19826}

Respiratory Interventions:
{Rapid Response Respiratory Interventions:19825}

Procedures:
{Rapid Response Procedures:19827}

Recommendations:
***

EVENT OUTCOMES

Outcome: {Rapid Response Outcomes:19816}
Total Time Spent by Rapid Response Team: *** minutes
Care Handed off to Primary Team or Representative? {yes no:18735}
Patient Condition: {End of Rapid Patient Status:19818}
Escalated Level of Care? {yes no:18735}

@ME@
@TD@ @NOW@
The patient understands the risks of morbidity and mortality if they leaves the hospital and would like to sign out against medical advice at this time. They were oriented and had the capacity to make their own decisions. The patient understands that they must immediately return to the emergency department if any alarming symptoms develop or worsen such as chest pain or shortness of breath.
AMBULATE
Please document ambulatory saturation on room air. If desaturation to 88% or less, please REPEAT ambulatory saturation and document how much O2 is required for patient to sat >92% while walking. This is needed for home O2 evaluation. Please document your findings in a note. Thank you.
CODE BLUE
Code Blue was called at *** PM.

I arrived at the bedside while chest compressions were being administered by primary nursing staff and code was being run by Dr. ***

HPI SUMMARY HERE***
HOSPITAL COURSE SUMMARY HERE***

Multiple rounds of epinephrine, bicarbonate, calcium chloride were given to stabilize the patient with CPR. The patient quickly achieved ROSC with epinephrine and CPR. The family was at bedside witnessing the events. At that time I discussed with patient's wishes with the family and they wishes to proceed with full code.

Then again, he had a cardiac arrest and this time after 45 minutes of CPR cycles discussion was had with the family who wishes to continue a bit longer. Multiple access sites were obtained ***. Patient was unable to achieve ROSC after 1 hour of CPR cycles and time of death was called at ***2303.

Discussed with the family extensively at bedside regarding all the events that occurred above and they chose to have*** an autopsy completed.
CODE STATUS DISCUSS
This writer spoke to patient's **** -- at phone number *** / *** respectively. I discussed what it means to full code vs DNR/DNI and that changing the code would not have an impact on current treatment. Shared that if he were to die, he currently would receive chest compressions to attempt to revive him. Given patient's age and comorbidities, made the medical recommendation that he be changed to DNR DNI. *** was agreeable after discussing with family -- and states that if he were to die, medical team is not to attempt chest compression to revive him.
FASTHUGS
Fluid therapy and Feeding:
Analgesia, antiemetics and ADT (AAA): acetaminophen
Sedation: N/A
Thromboprophylaxis: lovenox
Head up position (30 degrees) if intubated
Ulcer prophylaxis: not indicated
Glucose control: not indicated
SBT: N/A
Bowel cares: miralax, senna PRN
Indwelling catheter/tube
De-escalation (antibiotics, AM labs)
Disposition (PT/OT, etc)
PAIN
PHYSICAL EXAM
Gen: A&Ox4, laying in bed in NAD
HEENT: NC/AT, EOMI, white sclera, MMM
Neck: supple, no cervical LAD
Heart: RRR, normal S1 and S2, no murmurs
Pulm: CTAB, no wheezes/crackles/increased work of breathing
Abd: normoactive bowel sounds, soft, non-tender, non-distended, no HSM
Exts: no edema, peripheral pulses intact, warm and well perfused
Neuro: normal speech, motor and sensory grossly intact, moves all extremities
spontaneously
Skin: no suspicious rashes/lesions
PRE-OP
In summary, patient with PMH of DM2 c/b neuropathy, CKD stage III/IV, HTN, HLD, lumbar spine sx, who originally presented with 2-days h/o intermittent RUQ, found to have choledocholithiasis and treated empirically for cholangitis presenting for higher level of care ERCP given 3v disease seen in coronary cath done on 9/1/2020. Also had TTE in OSH showing EF 30%. Otherwise patient not aware of any previous MI (denies ever having chest pains) and exam not consistent with acute heart failure findings. Patient currently denies any active chest pain, dyspnea, syncope or presyncope, orthopnea or PND. No fever or RUQ pain on presentation, hemodynamically stable.

Cardiovascular Risk Assessment:

Recent Cardiac Testing (<5 years) Yes
Echocardiogram - yes EF 30%
Stress Test , [n/a]
Cardiac Catheterization 9/1/2020 report indicated 3v disease
Other

Cardiac Symptoms: no chest pain, shortness of breath, DOE, orthopnea, PND, syncope, or palpitations
Cardiac History: CAD and HF EF 30%
Major Cardiac Contraindications: none
Procedural Risk: low
Hypertension: The patient has HTN and reports inpatient BP is elevated: 146/87

Pulmonary Risk Assessment:

Pulmonary History or Symptoms: no chronic lung disease
Surgery a/w Pulmonary Complications: no
Potential Pulmonary Contraindications: none
Major Pulmonary Risk Factors: suspected OSA (STOP-BANG >4)

Diagnostic Data:

EKG [9/1/2020]: NSR, Q-waves on inferior leads, no significant ST abnormalities noted
TTE: Per report LVEF 30%
Assessment:
? Cardiac Risk:
Procedure Urgency: urgent
Major Cardiac Contraindications: none
Procedural Risk: low risk
Post-Test Cardiac Risk (if known): The patient had a recent coronary intervention without new cardiac symptoms.
Overall Cardiac Risk for MACE or MICA: moderate (2-9%)
? Hypertension:
? Abnormal EKG: Controlled
Q waves in inferior leads
? Postoperative Pulmonary Complication (PPC) Risk:
Pulmonary Dx: suspected OSA STOP BANG: 6 out of 8
Surgery-Specific Risk Factors: low risk
Major Patient-Specific Risk Factors: no
Overall Risk for PPC: elevated risk
? Empirically treated for cholangitis from OSH on Zosyn (continued)
? DM, type II: uncontrolled
? CKD: Stage III-IV

Recommendations:
? Medical Optimization:
Preoperative Testing: Given patient is asymptomatic not showing any signs/symptoms of acute coronary syndrome or heart failure, no recommendations for further cardiac work up at this time. Would defer to anesthesiology if further testing (for example repeat TTE) is needed pre-procedure
Medical Optimization: is optimized for the proposed surgery with the following interventions below.

Return to Clinic: PRN

? The patient needs no further cardiac evaluation or cardiac optimization prior to procedure. Will need cardiology eval and management for triple vessel disease eventually however.
? Suspected OSA given STOPBANG score of 6, no previous sleep study or CPAP mask eval. Will need sleep study outpatient.
? Recommend careful perioperative hemodynamic monitoring per Anesthesiology
? Consider PRBC transfusion PRN Hgb <8 or symptomatic anemia to minimize coronary ischemia
? Recommend incentive spirometry perioperatively to minimize the risk of pulmonary complications.
? Dose all medications for the impaired renal clearance.
? Avoid nephrotoxic medications like NSAIDs, aminoglycosides, IV contrast, etc.
? Optimize diabetes by adjusting diabetic medications: Started insulin sliding scale, a1c
PRONE Encourage patient to awake prone positioning to recruit atelectatic lung tissue in dependent lung basis -- ideally 12-18 hours a day. Would only continue if there is an improvement in oxygenation.
RAPID RESPONSE
RAPID RESPONSE NOTE

Patient: @NAME@
MRN: @MRN@
Attending: @ATTPROVIP@
Primary Team: @SERVICEH@
Date of Service: @TODAYDATE@
Location: @RRROOMBED@

EVENT STATUS

Time Activated: ***
Time of Arrival: ***
Primary Team or Representative Present? {yes no:18735}
If Not, Was Primary Team Paged? {yes no:18735}
Time Primary Team Paged: ***
Time of Primary Team Arrival: ***
Please refer to nursing documentation to corroborate times.

EVENT SUMMARY

Reason for Rapid: {Rapid Response Reasons:19817}

Reason for Admission: @PRIMARYDIAGNOSIS@

Brief Summary of Event:
***


Point of Care Ultrasound Used?
{yes no:18735}
{List pertinent US findings if used}

Diagnostics Ordered:
{Rapid Response Studies:19824}

General Treatment Interventions:
{Rapid Response General Treatment Interventions:19826}

Respiratory Interventions:
{Rapid Response Respiratory Interventions:19825}

Procedures:
{Rapid Response Procedures:19827}

Recommendations:
***

EVENT OUTCOMES

Outcome: {Rapid Response Outcomes:19816}
Total Time Spent by Rapid Response Team: *** minutes
Care Handed off to Primary Team or Representative? {yes no:18735}
Patient Condition: {End of Rapid Patient Status:19818}
Escalated Level of Care? {yes no:18735}

@ME@
@TD@ @NOW@

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Sandbox Metrics: Structured Data Index 0, 1152 boilerplate words
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