Assessment & Plan Elements
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[checkbox memo="SOB" name="1" value=""][conditional field="1" condition="(1).is('')"][textarea cols=80 rows=2 default="Pt presents with shortness of breath.<br>"][/conditional][checkbox memo="ddx asthma" name="L" value=""][conditional field="L" condition="(L).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes asthma/copd, ptx, pneumomediastinum, pneumonia, pleural effusions, bronchitis, restrictive lung disease.<br>"][/conditional][checkbox memo="ddx bronchitis" name="N" value=""][conditional field="N" condition="(N).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes influenza like illness, bronchitis, pneumonia, dehydration, pharyngitis.<br>"][/conditional][checkbox memo="MDM CHF Admit w/ BIPAP" name="2" value=""][conditional field="2" condition="(2).is('')"][textarea cols=80 rows=5 default="Differential includes CHF, pulmonary edema, pulmonary embolism, pneumonia, pleural effusions, pneumothorax, among others.<br><br>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.<br><br>I spent ___ minutes of critical care time. This time excludes any separately billable procedures. <br>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.<br><br>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. <br><br>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.<br>"][/conditional][checkbox memo="DCI" name="3" value=""][conditional field="3" condition="(3).is('')"][textarea cols=80 rows=4 default="************************<br>Follow up with your doctor in 2-3 days.<br>Return to the ER for worsened shortness of breath, chest pain, fainting, palpitations, leg swelling or any other concerns.<br>*****************************<br>"][/conditional]
SOB ddx asthma ddx bronchitis MDM CHF Admit w/ BIPAP DCI
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