Cardio-Pulmonary Complaints – © MedTx, LLC 2017

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  •  CC:  year old with pertinent PMH/PSH presents with 
  • HPI:
    • Characteristics:
      •   Onset:
        • time prior to arrival in ED:
          • < 3 hrs
          • 3-6 hrs
          • >6 hrs
          • days
          • weeks
        • gradual,
        • rapid,
        • acute,
        • subacute,
        • chronic,
      •   Circumstances at time of onset:
        • exertional onset,
        • straining muscle,
        • at rest,
        • while eating,
        • with drug use,
      •   Since onset:
        • recurrent for seconds at a time,
        • recurrent for minutes ~15-20 at a time
        • constant,
        • intermittent,
        • resolved, asymptomatic at this time,
      • Description of symptom:
        • pressure,
        • burning,
        • stabbing,
        • dull,
        • aching,
      • Location:
        • substernal
        • epigastric
        • left chest
        • right chest
        • shoulder
          • left
          • right
          • bilateral
      • Radiation
        • shoulder,
          • bilateral
          • right
          • left
        • to back
      • Provocation:
        • exertion,
        • not provoked by exertion,
        • preserved exercise tolerance since onset of symptoms,
        • specific movement of arm/shoulder,
        • eating,
      • Alleviation:
        • nitroglycerin,
        • rest,
        • palpitation of chest,
      • Associated symptoms:
        • nausea,
        • nb/nb emesis,
        • diaphoresis,
        • fatigue,
      • History of similar symptom in past:
        • never,
        • yes,
        • hx of MI in past,
      • Outcome of symptom in past
        • MI,
        • cardiac work up non-revealing of pathologic process
          • included
            • EKG/troponin
            • EKG/serial troponins
            • ED eval and stress test
            • cath
          • time of last work up:
      • Cardiac history:
        • cardiac risk factors:
          • see PMH above
          • individual risk factors:
            • DM
            • HTN
            • HLD
            • tobacco use
            • obesity
              • BMI >30
              • weight (kg):
              • height (cm):
              • calculated BMI:
            • positive family history
              • ((parent or sibling with CVD < 65 y/o)
          • known atherosclerotic disease,
            • prior MI,
            • PCI/CABG,
            • CVA/TIA,
            • peripheral artery disease,
        • last stress test:
          • never
        • last catheterization
          • never
          • findings
      • Pulmonary hx:
        • hx of reactive airway disease,
        • pluertic – worse with deep breath,
        • tob use,
        • immobility,
        • ((part of PERC criteria))
          • hx of VTE,
            • DVT,
            • ((or))
            • PE,
        • recent surgery within 4 weeks that required general anesthesia,
        • hormone use,
        • ((part of Wells Criteria))
          • immobilization for past 3 days,
          • surgery within 4 weeks,
          • hemoptysis,
          • malignancy,
            • w/ treatment within 6 months,
            • ((or))
            • palliative,
      • GI hx:
        • known hx of gallstones,
        • known hx of ulcers,
        • risk factors for H. Pylori though not tested,
        • hx of risk factors for gastritis,
          • etoh use,
          • heavy NSAID use,
      • History unfortunately limited
        • secondary
          • to patient’s condition,
          • to requirement of emergent diagnostics/interventions that take precedence over extensive history,
          • to patient’s lack of understanding of their medical conditions,
          • to patient’s lack of cooperative with interview,
          • to lack of medical records for this patient available in our system,
          • to lack of patient bringing medical information
    • Pertinent positives:
    • Pertinent negatives:
  • REVIEW OF SYSTEMS:
    • Constitutional:
      • fevers,
      • rigors,
    • ENT:
      • rhinorrhea,  otalgia, sore throat
      • as noted in HPI
    • Eye:
      • vision grossly intact
      • as noted in HPI
    • Cardiac:
      • chest pain,
      • LE swelling,
      • no unilateral LE swelling
      • as noted in HPI
    • Pulmonary:
      • shortness of breath,
      • cough,
      • as noted in HPI
    • GI:
      • abdominal pain,
      • nausea,
      • vomiting,
      •   BRBPR, dark tarry stool,
      • diarrhea
      • as noted in HPI
    • GU:
      • no dysuria,
      • no discharge,
        •  male specific:
          • no testicular pain,
        • female specific:
          • no abnormal vaginal bleeding,
      • as noted in HPI
    • Nuero:
      • no recent severe headache outside of normal headaches per patient,
      • no recent ALOC.
      • as noted in HPI
    • MSK:
      • no recent trauma
      • no focal weakness
      • as noted in HPI
    • Pysch:
      • normal speech
      • no SI,
      • no HI,
      • able to care for self
      • no AH
      • no VH
      • as noted in HPI
    • ID:
      • no recent antibiotics
    • Endo:
      • no polyuria/polydipsia
      • as noted in HPI
  • PMH/PSH/PSFH:
    • PMH/PSH:
      • medical/surgical history pertinent to chief complaint as noted in HPI
    • SH:
      • domiciled,
      • tob,
      • etoh use,
        • .
        • Pt advised not to drink/drive/use concurrent sedating meds/drugs and on cessation.
      • illicit drug use,
        • specifically
        • // Pt advised not to drink/drive/use concurrent meds/drugs and and on cessation
    • FH:
      • review and non-contributory to patient’s presenting complaint.
  • EXAM
    • VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-access patient):
      • HR:
          • good chronotropic response
          • asymptomatic
      • BP:
        • normotensive.
        • hypertensive
          • (attempted to inform pt to advise to f/u with PMD).
        • hypotensive.
      • O2 sat:
        • hypoxia on my interpretation of oximtery
        • peri baseline O2 sat
      • RR:
    • PHYSICAL EXAM:
      • Constitutional:
        • well-nourished,
        • distress,
      • HEENT:
        • vision grossly intact,
        • hearing grossly intact.,
        • vision
          • 20/20 bilaterally,
        • EOM intact,
        • PERRLA ::- pupils equal, round, reactive to light and accommodation -::
        • intraocular pressures wnl,  :- normal pressures under 20 -::
        • confrontation visual fields intact,  ::- check for no visual field defect -::
        • external examination non-remakable,
        • slit lamp exam:
          • lids/lashes lacrimal system without lesions
          • conjunctiva/sclera: white and quiet, no injections,
          • cornea: clear,
          • anterior chamber: no cell or flare,
          • iris: round pupil,
          • lens: clear, no cataracts,
          • anterior vitreous: no inflammation/hemorrhage,
        • fundoscopic exam:
          • no papillary edema,
          • no splinter hemorrhage,
        • fluorescein exam:
          • no areas of uptake
      • Cardiovascular:
        • no r/m/g,
        • no LE swelling,
        • no LE asymmetry
        • no JVP
      • Pulmonary:
        • Lungs CBTA,
        • No respiratory distress, non-labored breathing
        • Speaking comfortably in full sentences,
        • symmetric breath sounds
        • wheezing,
          • (inspiratory and expiratory),
          • (expiratory only),
        •  significant decreased aeration
        • rales,
          • throughout,
          • at bases bilaterally,
        • rhonchi,
        • respiratory distress,
          • mild,
          • moderate,
          • severe,
      • GI:
        • abdomen soft,
        • abdomen non-tender in all 4 quadrants,
        • TTP diffusely
        • TTP in RUQ,
        • TTP in RLQ,
        • TTP in LLQ,
        • TTP in LUQ,
        • TTP in epigastric region,
      • Neuro:
        • Normal LOC.
        • No grossly focal neurological deficits.
        • Somnolent though protecting airway.
        • CN II-XII intact,
        • no facial asymmetry
        • PERRL,
        • strength intact throughout,
        • sensation grossly intact throughout,
        • normal reflexes,
        • ambulatory,
        • with steady gate,
        • no dysmetria,
        • no dysarthria,
      • MSK:
        • no deformities,
        • moving all extremities
        • Non-ambulatory,
        • at affected area
          • nuero intact
          • muscular intact
          • vascular intact
      • Pysch:
        • Normal speech.
        • Demonstrates linear thinking.
        • SI,
        • HI.
        • Exam consistent with gravely disabled.
        • No AH/VH.
        • Agitated.
        • Confused.
      • GU exam:
        • Male specific exam:
          • Exam chaperoned
            • by
          • Testicular exam:
            • no testicular tenderness,
            • normal testicular lie,
            • able to elicit cremaster reflex,
          • Penile exam:
            • no discharge at meatus
            • non-erect
          • Prostate exam:
            • enlarged prostate
            • bogginess and tenderness
        • Female specific exam:
          • Exam chaperoned,
            • by ,
          • no CMT,
          • no adnexal TTP,
          • no abnomral discharge
          • no active vaginal bleeding,
          • vaginal bleeding from os,
          • atraumatic, no cervical lacerations
        • Rectal exam:
          • Exame chaperoned
            • by
          • guiac
          • brown stool in vault,
          • no visible external hermorroids,
          • no palpable internal hemorroids,
          • thought appreciate limited sensitivity of DRE
  • ———————————————————————–
  • ED COURSE and MDM:
  • Working Impression/Empiric Management:
  • Diagnostically:
    • Point of Care Testing:
      • Pregnancy Test
        • negative
      • POC gluc
        • wnl
      • POC Hg
        • wnl
      • iStat
        • potassium wnl
        • hyperkalemia
        • no base deficit
      • lactate
        • wnl
    •   EKG (as interpreted by prelim ED):
      • Non-remarkable EKG. No evidence of ischemia. NSR, regular rate, normal intervals, no abnormal TWI, no ST elevation/depression.
      • Rate
        • normal,
        • bradycardic,
        • tachycardic,
      • ST-segment morphology:
        • T waves:
          • abnormal TWI,
        • ST segment:
          • Non-specific repolarization abnormalities,
          • ST depression,
            • ST elevation but does not meet STEMI criteria
            • meets STEMI criteria and cath lab activated (see below)
            • STEMI
              • Given meets criteria of:
                • History consistent with MI and EKG findings c/w STEMI:
                • Male,
                  • >40 y/o
                    • >= 2mm in V2-V3
                    • ((OR))
                    • 1 mm in non-anterior leads
                  • <40 y/o
                    • >= 2.5 mm in V2-V3
                    • ((OR))
                    • 1mm in non-anterior leads
                • Female,
                  • >= 1.5 mm in V2-3
                  • ((OR))
                  • >= 1mm in non-anterior leads
                • LBBB,
                  • Given hx not c/w STEMI, pere AHA 2013 LBB alone does not suffice for criteria for cath lab.
                  • new and concerning history for MI,
                  • Utilized Smiths’ Modified Criteria (on Sgarbossa’s Criteria given per AHA 2013 LBBB alone not sufficient criteria for cath lab
                  • ((Smith’s increases Sn from 52->91% though reduces Sp from 98->90%))
                    • concordant ST elevation > 1 mm (5 pts)
                    • ST depression > 1 mm in V1,V2,or,V3 (3pts)
                    • discordant ST elevation or depression with magnitude > 25% QRS > 5mm (2pts)
                    • Number of points:
                      • ((>=3 = 98% probability of STEMI))
                  • Utilized Sgarbossa’s Criteria
                    • ((Less sensitive than Smith’s))
                    • concordant ST elevation > 1 mm (5 pts)
                    • ST depression > 1 mm in V1,V2,or,V3 (3pts)
                    • discordant ST elevation > 5mm (2pts)
                    • Number of points:
                      • ((>=3 = 98% probability of STEMI))
                • Paced,
                  • Utilized Sgarbossa’s Criteria
                    • ((Less sensitive than Smith’s))
                    • concordant ST elevation > 1 mm (5 pts)
                    • ST depression > 1 mm in V1,V2,or,V3 (3pts)
                    • discordant ST elevation > 5mm (2pts)
                    • Number of points:
                      • ((>=3 = 98% probability of STEMI))
                • Posterior MI
                  • >= 0.5MM ST elevation in V1-V3,
                  • large R waves (which would represent posterior Q waves
                  • ST depression
                • DeWinter T-waves,
                  • hyper-acute T-waves.
                  • While not definitive STEMI criteria, serial EKGs and troponin and early cardiology consultation.
                • ST elevation in AVR > 1-1.5mm
                  • While not definitive STEMI criteria, serial EKGs and troponin and early cardiology consultation.
      • Comparison to prior:
        • Unchanged when compared to prior,
        • Attempted but no old EKG available for comparison,
        • ,
      • Summary to pt’s clinical condition:
        • Normal EKG – not suggestive any pathology elucidated on EKG, Non-specific repolarization abnormalities – no definitive evidence of active ischemia on EKG, Evidence on EKG concerning for active ischemia.
      • Rhythm:
        • Regularly regular:
          • NSR,
          • Sinus tachycardia,
          • Sinus bradycardia,
        • Irregularly irregular:
          • Atrial fibrillation with normal ventricular rate,
          • Atrial fibrillation with RVR,
        • Regularly irregular:
          • tachycardic,
            • Atrial flutter with RVR,
          • bradycardic,
            • Heart block,
              • Type: ,
      • Intervals:
        • Narrow QRS,
          • supraventricular:
            • irregular:
              • AVRT (considering pre-excitation, considering WPW, etc),
                • Tx: Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min.
                • Tx: Synchronized cardioversion.
                  • Per ACLS 120-200J.
            •  regular:
              • AVNRT (considering supraventricular tachycardia),
                • Tx: Adenosine 6mg IV push,
                  • Refractory, therefore second dose 12mg IV push
                • Synchronized cardioverson.
                  • 100 J
                  • per ACLS for narrow regular 50-100J
        • Wide QRS,
          •  bradycardic:
            •  low junctional escape/ventricular origin,
          • tachycardic:
            •  regular:
              •  stable,
                •  Amiodarone 150mg IV / 10 min
                  •  Refractory, repeated PRN recurrence of VT.
                  •  Maintenance 1mg/min x 6 hrs.
                •  Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min.
                • synchronized cardioversion
                  •  100 J (per ACLS)
              •  unstable:
                •  with pulse. Therefore Unstable Ventricular Tachycardia with Pulse.
                  •  Synchronized cardioversion (per ACLS 100J).
              •  pulseless. Therefore pulseless ventricular tachycardia. ACLS initiated: (CPR. Defibrillation 200 J Biphasic. Epi 1mg. Continuation of ACLS.)
    • Labs:
      • Ordered, pending at this time.
        • Labs ordered:
        • CBC,
        • BMP,
        • LFTs/lipase,
        • UA,
        • Urine Cx
        • lactate
        • Blood Cx
          • x2
        • CK,
        • EtOH level,
        • Ingestion labs (acetaminophen, ASA),
        • Troponin,
        • Delta troponin,
        • BNP,
        • HIV,
        • Influenza,
        • Urine toxicological screen,
        • CRP,
        • ESR,
      • Reviewed and interpreted/correlated to clinical scenario to inform diagnosis and plan by me.
        • CBC:
          • No significant unexpected anemia.
          • No significant leukocytosis.
        • BMP:
          • No significant pathologic electrolyte derangements.
        • Troponin
          • undetectable
          • <99th percentile
          • >99th percentile but under cut off for positive
          • positive
          •  
        • Delta troponin
          • undetectable
          • <99th percentile
          • >99th percentile but under cut off for positive
          • positive
          • increasing
          • decreasing
        • LFTs/lipase:
          • No laboratory evidence of hepato-biliary pathology.
        • UA:
          • Not consistent with urinary tract infection.
          • Urine Cx sent with follow mechanism in place
          • Equivocal for infection
            • Empirically treated.
            • UCx sent with f/u mechanism in place
        • Cardiac Labs:
          • Troponin:
            • undetectable
            • <99th percentile
            • >99th percentile but under cut off for positive
            • positive
            •  
          • Delta troponin
            • undetectable
            • <99th percentile
            • >99th percentile but under cut off for positive
            • positive
            •  
          • BNP:
            • ::- please note that greater than 500 suggests CHF, under suggests not CHF -::
            • not suggestive of CHF exacerbation
            • suggestive of CHF exacerbation
            • equivocal
        • HIV:
          • negative,
          • positive,
            • I discussed this finding with patient in sensitive private manner, educated on treatment options, offered resources, answered all questions, advised to have partner evaluated and advised to refrain from any of the common modes of transmission.
          • Prior to test sent, pt was informed that we advise for testing for HIV. Pt did not opt out.
        • Influenza
          • negative
        • CK:
          • significantly elevated, requires trending ::- usually for >500-1000k -::
          • mildly elevated, not anticipated to rise given negated precipitant
          • negative
        • Ingestion labs:
          • acetaminophen
            • non-detectable,
          • ASA:
            • non-detectable,
          • etoh
            • non-detectable
            • positive
        • Urine toxicological screen:
          • negative
          • postive for
        • Markers of inflammation
          • CRP ::- suggestive of more acute inflammation -::
            • wnl
            • elevated
          • ESR ::- suggestive of more chronic inflammation -::
            • wnl
            • elevated
    • Radiographically:
      • Radiographs ordered, pending at this time.
      • Radiographs reviewed, interpreted by me.
      • Radiographs reviewed by me, agree with radiology interpretation.
      • Radiology interpretation reviewed.
      • CXR:
        • Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.
        •  Pulmonary edema,
        •  Cardiomegaly,
        •  lobar opacity,
        • diffuse radio-opacities
        • pneumothorax
          • on right
          • on left
          • mediastenium midline
          • (This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads/changes/critical reads).
      • PXR (Pelvic XR):
        • no evidence of pelvic fracture
        • no evidence of hip fracture
        • appreciate limited sensitivity of PXR and therefore correlated clinically
      • XR of extremity
      • Advanced Imaging:
        • CT head:
          • negative for acute intra-cranial pathology
        • CT c-spine
          • negative for acute cervical neck pathology
        • CT chest
          • PE protocol
            • negative for PE
          • angio
            • negative for aortic dissection
        • CT a/p
          • w/ contrast,
          • non-con,
          • negative for acute intra-cranial pathology
        • CT of extremity:
          • with venous contrast:
          • with arterial contrast:
          • non-con:
    • Consultations:
      • Discussed case with of the service who kindly recommended
      • Discussed case with who kindly agrees to come evaluation patient and provide recommendations.
      • Obtained the collateral information to assist in ED care for patient
        • advises
      • Time of consultation:
  • Therapeutically:
    • Empirically:
      • Anti-platelet agent: ASA
        • Considered dissection however clinically not consistent with dissection and marked mortality benefits for ACS outweigh risk given not consistent with dissection.
        • Empirically administered given ddx includes ACS and potential benefit outweighs potential harm
        • 162mg PO chewed
        • 325mg PO chewed
        • (())
      • O2 (Supplemental)
        • deferred given evidence suggests no benefit and potential harm.
          • ((PMID: )),
        • administered given in accordance with standard of care
      • IVF
        • 30 cc/kg,
        • 250cc,
        • 500cc,
        • 1 L,
        • 2 L,
      • Analgesia:
        • acetaminophen,
        • ibuprofen,
        • hydrocodone/acetaminophen (pt informed not to drive/drink/take fall precautions/not make significant decisions for remainder of day)
        • morphine,
        • ketorolac
        • hydromorphone
        • haloperidol (haldol)
          • indication:
            • sx refractory to other analgesia,
            • side effect profile of opioids likely to exacerbate symptoms,
          • 3mg
            • IV
            • IM
          • 5 mg
            • IM
            • IV
          • 10mg
            • IM
      • Anti-emetics
        • ondansetron (zofran)
          • IV
          • ODT ((oral dissolving tablet))
        • metoclopramide (reglan)
          • 5 mg,
          • 10mg,
          • PO,
          • IV,
          • IM,
        • lorazepam
          • indication:
            • prolonged QTC,
            • sx refractory to other anti-emetics,
        • haloperidol (haldol)
          • indication:
            • sx refractory to other anti-emetics
          • 3mg
            • IV
            • IM
          • 5 mg
            • IM
            • IV
          • 10mg
            • IM
      • Anxiolytic
        • lorazepam
          • 0.5 mg
          • 1 mg
          • 2mg
          • PO
          • IV
          • IM
    • Anti-biotics:
      • Timing:
        • administered as promptly as source identified with sufficient likelihood to inform appropriate antibiotics (goal directed)
        • administered when source identified
        • administered within 1 hrs from triage
        • administered within 3 hrs from triage
      • Regimen:
        • ceftriaxone 1 g IV
        • ceftriaxone 1g IV / azithromycin 500mg IV
        • vancomycin IV / cefepime 1 g IV /  azithromycin 500mg IV
        • ceftriaxone 1g IV / metronidazole 500mg IV
        • unasyn
        • vancomycin / zosyn
        • cefazoline (ancef) 1 g IV
  •   Assessment/Plan:
    • CC: year old with pertinent PMH/PSH presents with 
    • evaluation is most consistent with
      • cardiac etiology (specifically):
        • STEMI
          • Given meets criteria of:
            • History consistent with MI and EKG findings c/w STEMI:
            • Male,
              • >40 y/o
                • >= 2mm in V2-V3
                • ((OR))
                • 1 mm in non-anterior leads
              • <40 y/o
                • >= 2.5 mm in V2-V3
                • ((OR))
                • 1mm in non-anterior leads
            • Female,
              • >= 1.5 mm in V2-3
              • ((OR))
              • >= 1mm in non-anterior leads
            • LBBB,
              • Given hx not c/w STEMI, pere AHA 2013 LBB alone does not suffice for criteria for cath lab.
              • new and concerning history for MI,
              • Utilized Smiths’ Modified Criteria (on Sgarbossa’s Criteria given per AHA 2013 LBBB alone not sufficient criteria for cath lab
              • ((Smith’s increases Sn from 52->91% though reduces Sp from 98->90%))
                • concordant ST elevation > 1 mm (5 pts)
                • ST depression > 1 mm in V1,V2,or,V3 (3pts)
                • discordant ST elevation or depression with magnitude > 25% QRS > 5mm (2pts)
                • Number of points:
                  • ((>=3 = 98% probability of STEMI))
              • Utilized Sgarbossa’s Criteria
                • ((Less sensitive than Smith’s))
                • concordant ST elevation > 1 mm (5 pts)
                • ST depression > 1 mm in V1,V2,or,V3 (3pts)
                • discordant ST elevation > 5mm (2pts)
                • Number of points:
                  • ((>=3 = 98% probability of STEMI))
            • Paced,
              • Utilized Sgarbossa’s Criteria
                • ((Less sensitive than Smith’s))
                • concordant ST elevation > 1 mm (5 pts)
                • ST depression > 1 mm in V1,V2,or,V3 (3pts)
                • discordant ST elevation > 5mm (2pts)
                • Number of points:
                  • ((>=3 = 98% probability of STEMI))
            • Posterior MI
              • >= 0.5MM ST elevation in V1-V3,
              • large R waves (which would represent posterior Q waves
              • ST depression
            • DeWinter T-waves,
              • hyper-acute T-waves.
              • While not definitive STEMI criteria, serial EKGs and troponin and early cardiology consultation.
            • ST elevation in AVR > 1-1.5mm
              • While not definitive STEMI criteria, serial EKGs and troponin and early cardiology consultation.
          • Therapeutically:
            • Cath lab
              • Activated at our facility,
              • Consulted cardiology emergently, cath lab not activated formally indicated given over 12 hours since onset on symptoms, not indicated per standard of care
              • None available at this facility,
                • Arranged for emergent transfer
                • Fibrinolytics
                  • Deferred given anticipated triage to cath lab time under 90 min, risks outweigh benefits.
                    • Administered given anticipated triage to cath time greater than 90 min, benefits outweigh risks. Discussed with patient risk of bleed and pt/family request fibrinolytic option.
                    • Explained risk of 0.5-1% risk of ICH.
                    • No absolute contraindications:
                      • Any prior 
                      • Known structural cerebral vascular lesion (AVM)
                      • Known 
                      •  within 3 mo
                      • Active internal bleeding (excluding menses)
                      • Suspected  or 
                    • No relative contraindications:
                      • Severe uncontrolled BP (>180/110)
                      • History of chronic severe poorly controlled hypertension
                      • History of prior ischemic stroke >3 mo
                      • Known intracranial pathology not covered in absolute contraindications
                      • Current use of anticoagulants with known INR >2–3
                      • Known bleeding diathesis
                      • Recent trauma (past 2 wk)
                      • Prolonged CPR (>10 min)
                      • Major surgery (<3 wk)
                      • Noncompressible vascular punctures (e.g. IJ, subclavian)
                      • Recent internal bleeding (within 2–4 wk)
                      • Patients treated previously with streptokinase should not receive streptokinase a 2nd time
                      • Pregnancy
                      • Active 
                      • Other medical conditions likely to increase risk of bleeding (diabetic retinopathy, etc)
                    • Administered 15mg IV over 1-2min, then 50mg over 30min, then 35mg over next 60min (given pt > 70kg)
            • IV established,
            • O2,
            • ASA given,
              • prehospital
              • in ED
            • nitroglycerin 0.4mg SL
              • administered given meets indications:
                • active chest,
                • no signs on EKG on right/inferior/posterior MI,
                • not hypotensive (SBP>90),
              • not indicated given:
                • no active chest,
                • given prehospital w/ resolution of sx
                • signs on EKG on right/inferior/posterior MI,
                • hypotensive (SBP<90),
              • re-dosed,
                • x2 total,
                • x3 total,
                • maximal benefit likely at 200ug therefore additional deferred,
            • morphine 4mg IV
              • administered given active chest pain
              • deferred given no active chest pain
            • beta blockers deferred in ED given increased mortality, anticipate would benefit within 24 hours by inpatient team per their discretion,
        • NSTEMI/Unstable Angina
          • in addition to obtaining history, inquiry into risk factors, examination, EKG, troponin, employed risk stratification pathway of
          • HEART Score:
            • 0-3
              • Therefore estimated risk 0-3: 2.5% risk of adverse cardiac event. Patient discharged with prompt follow-up with PMD for further outpatient evaluation.
              • Employed HEART Pathway.
                • Pt at very low risk (HEART score <=3 and two neg trop at time 0 and > 3 hr) in Heart Pathway therefore estimated >99% sensitivity for 30 day cardiac event.
              • Given above risk stratification, pt at very low risk for ACS, and while standard practice is for outpatient follow up, given varied risk tolerance of each individual patient, I discussed risks/benefits and offered prolonged observation for possible increased sensitivity, including provocative testing, and via shared decision with pt, we elected for discharge. Pt informed that they may elect to arrange prompt outpt stress test if they wish for further risk stratification. With utilization of HEART pathway, expedited arrangements by ED is not routinely indicated given above risk stratification and patient’s risk tolerance and patient encouraged to make such arrangements per their discretion of arranging outpatient follow up.
            • 4-6
              • Therefore estimated risk 20.3% risk of adverse cardiac event. Plan for admission/cardiac observation status to the hospital for trending of troponin and provocative testing per inpatient .
            • >7
              • Therefore estimated risk 72.7% risk of adverse cardiac event, suggesting early invasive measures with these patients and close coordination with inpatient cardiology. Plan for admission. Discussion with cardiology regarding initiation of antithrombotics.
          • Given high risk for Type I NSTEMI and active symptoms refractory initial empiric managment, started antithrombotics:
            • enoxaparin (Lovenox) 1mg/kg subq BID
              • monitoring of labs not indicated
              • Administered given AHA advises unless likley CABG w/in 24 hrs.
              • Adjusted for creatine clearance CrCl<30ml
            • unfractionated heparin
              • bolused 60-70 units/kg (max at 5k) w/ infusion of 12-15u/kg/hr (max 1k/hr)
              • pre-herparin coags obtained
              • goal PTT 45-74s
              • Administered given sufficiently likely pt may undergo PCI/CAABG within 24 hours.
              • Administered given renal failure, enoxaparin relatively contraindiated.
          • Aortic dissection given
            • evaluation with concerning features
              • hypotension,
              • acute onset,
              • wide mediastinum (>8cm),
              • BP difference b/n UE arms,
              • “classic” pain radiating to back,
              • high risk PMH,
            • Therefore diagnostically CT angio obtained
            • Given inability to obtain stat CT angio emergently, transferring to higher level of care.
            • Empirically treating to decrease hemodynamic stress
              • goal of SBP 100-120
              • goal HR 60
              • regardless of pt’s baseline SBP.
              • Esmolol bolus 0.1-0.5mg/kg over 1min; infuse 0.025-0.2mg/kg/min
              • analgesia with morphine
            • CTA results reveal:
              • Stanford A dissection,
                • surgical servical consulted emergently
                • transfer to higher level of care
              • Stanford B dissection
                • anticipate medical management though will admit to CCU with CT surgery following.
              • 2 large bore IV access obtained,
              • type and crosssed
          • Prinzmetal’s angina
            • given
              • pt does have typical risk factors for ACS,
              • pt endorses sympathometic illict drug use,
              • utox positive for sympathometic,
                • cocaine,
                • meth,
              • toxidrome consistent with  drug use,
            • tx:
              • nitroglycerin 0.4mg SL,
                • repeat dosing administered until resolution of symptoms or hypotension,
              • benzodiazepines
                • ativen 2g IV,
                • repeat dosing administered until resolution of symptoms,
              • calcium channel blocker
                • nifedipine 10mg IV
                • diltiazem
                  • high dose
            • dispo:
              • admitted. given lack of conclusive etiology as being precipitated by sympathometic and possibility of concurrent ACS, will admit for
                • trending of cardiac enzymes
                • provacative testing per discretion of inpt team
                • observation for need for additional treatment if chest pain recurrs
          • CHF exacerbation,
            • given
              • on hx:
                • hx of CHF
                • previous EF
                • med non complaince
                • chest pain
                • productive cough
                • increase in LE swelling
                • weight gain
                • tob use
                • PND (paroxysmal nocturnal dyspnea)
            • on exam:
              • +LE swelling
              • hypervolemic
              • elevated JVP
              • plethoric IVC w/ <50% variation with respirations
              • reduction in EF
            • on diagnostics:
              • given diagnostically BNP >500
              • ((<100 makes CHF less likely)
              • troponin elevation consistent and thought to be 2/2 Type II NSTEMI (demand ischemia) and not Type I NSTEMI
            • severity:
              • mild,
                • lasix 40mg IV given lasix naive
                • lasix IV of PO home dose
                • plan for follow up with PMD and cardiologist
              • moderate,
                • lasix 40mg iV given lasix naive
                • lasix IV of PO home dose
                • based upon response to treatment, pt appropriate for dispo to
                  • observation for diuresis
                  • home w/ diuresis at home and PMD/cardiology f/u
              • severe,
                • Empiric Therapeutics
                  • Aspirin 162 mg PO
                  • Nitroglycerin 0.4mg SL given faster ability to administer.
                  • Nitroglycerin drip. Start 200mcg/min, titrate by 50 mcg/min to symptomatic improvement and patient’s baseline which is presumed to be SBP 120.
                  • Enalapril 1.25 mg IV
                  • Lasix
                    • home dose in IV form
                    • 40mg IV given lasix naive
                  • BIPAP to work of breathing, decrease pulm edema.
                  • Given resp status during ED course stable w/o dsitress, no indication for emergent intubation at this time.
                  • I/Os
                  • Preparations for admission.
                • Diagnosis: Class IV CHF given symptoms at rest.
            • Pericarditis given
              • Meets 2 of the pericarditis criteria, specifically pt has
                • Chest pain (typically sharp and pleuritic, improved by sitting up and leaning forward)
                • Pericardial friction rub
                • New or worsening pericardial effusion
                • Suggestive ECG changes: diffuse PR depression and ST elevation on EKG
                • though no ST depression anywhere except V1 and aVR thereby making ischemia as etiology to ST elevation less likely
                • ((III > II favors STEMI)
                • US performed to evaluate size or existence of peri-cardial effusion.
                  • No significant effusion
                  • and
                  • no tamponade phsyiology
                • no wall motion abnormalities.
              • Therefore will tx empirically with will tx with
                • Aspirin 800mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
                • ((OR))
                • Ibuprofen 600mg every 8 hours for 7 to 10 days, followed by tapering during a period of 3 to 4 weeks
                • considered
                • prednisone  0.2 to 0.5mg/kg of body weight per day for 2 weeks with gradual tapering
            • myocarditis
              • given
                • infectious symptoms, no hx of CHF, but s/s of decreased CO despite being volume replete
                • as expected troponin elevated,
                • echo shows hypokinesis,
                  • unable to obtain endocardial bpx in emergent fashion from ED
              • will initiate supportive therapy, admit for further diagnostics to infectious etiology,
      • Pulmonary etiology (specifically)
        • Pulmonary Embolism
          • given
            • s/s of DVT
            • PE #1 dx
            •  tachycardia,
            • rcent immobilization
            • hx of VTE,
            • hemoptysis, malignancy w/ tx w/in 6 mo (or in palliative)
            • d-dimer positive
          • diagnostically
            • CT PE protocol obtained.
              • Given varied risk tolerance of patients, risks of radiation/time/contrast verses additive diagnostic benefits of further diagnostics including CTPA discussed with patient and shared decision to pursue further diagnostics given level of risk for PE satisfactorily high to warrant further diagnostics per patient’s wishes from my conversation with patient.
              • negative for PE.
              • positive PE
                • massive significant vital sign deranement
                • risks/benefits d/w pt of thrombolyis veres anticoagulation
                • considered thrombolysis,
                  • risks outweighed benefits. started anicoagulation
                  • given massive PE, w/ evience suggestive of adverse prognosis, hemodynamic instability, worsening respiratory status, severe RV dysfunction, major myocardial necrosis, will tx with thombolysis
                    • altepase Alteplase 0.6 – 1 mg/kg or 100 mg with
                    • any of the three possibilities
                    • Two 50 mg boluses, 30 min apart
                    • ((OR))
                    • 15 mg bolus, followed by 85 mg over 90 min
                    • ((OR)
                    • 100 mg over 15 min
              • given non-massive, will treat w/
              • LMWH
                • 1u/kg SC BID (has better outcomes than UFH) continguent on normal renal function
                • and pt not pregnant
                • transition to warfarin
                • 10mg PO days 1 and 2, then 5mg daily,
              • unfractionated heparin (UFH) 80 units/kg bolus; then 18 units/kg/hr
                • sent coags for baseline prior. plan to monitor per inpt team.
        • Pnuemonia
          • given
            • dsypnea,
            • cough,
            • fever,
            • abnormal pulmonary exam w/ rhonchi,
            • CXR c/w PNA,
          • Suspect
            • atypical PNA,
              • given diffuse opacities on CXR,
            • lobar PNA,
              • given lobar opacity on CXR,
            • non-health care associated – community associate pnuemonia (CAP)
              • given
                • not hospitalized for 2 or more days within past 90 days,
                • not nursing home/long-term care residents,
                • not receiving home IV antibiotics
                • dialysis,
                • not receiving chronic wound care,
                • not receiving chemotherapy,
                • not known immunocompromised.
              • risk stratification:
                • utilized CURB-65 clinical decision rule to aid clinical gestalt.
                  • (Port Score not feasible at this time given ABG not indicated and required that decision rule).
                  • Pt is/has:
                  • confused
                  • uremic ((>20mg/dl))
                  • respiratory rate > 30
                  • SBP <90 or DBP <60.
                  • >65
                  • Therefore CURB-65 score is .
                  • And mortality in 30 day:
                    • 1pt -> 3%, per clinical decision rule and clinical gestalt, will opt for outpt tx.
                    • 2pts –>7%, per clinical decision rule and clinical gestalt, will
                      • admit to inpt
                      • treat as outpt
                    • 3pt -> 14% per clinical decision rule and clinical gestalt, will admit to
                      • inpt
                      • ((OR))
                      • ICU
                    • 4-5pt -> 30%, per clinical decision rule and clinical gestalt, will admit to ICU
              • Therapeutically
                • Given outpatient tx, will prescribe azithromycin 500mg PO day 1, 250mg on days 2-5
                • Given inpatient CAP, will tx w/
                  • levofloxacin 750mg IV daily
                • Given inpt HCAP, will tx w/
                  • levofloxacin 750mg IV daily and cefepime 1g q 8-12hrs and vanc 15mg/kg BID
                  • piperacillin-tazobactam (Zosyn) 4.5gm q6h and ciprofloxacin 400mg q8h and vancomycin 15mg/kg q12
        • Pneumothorax
          • Given
            • respiratory distress,
            • decreased breath sounds unilaterally,
            • lack of air marking seen in region on CXR.
          • Consistent with spontaneous pnuemothorax.
          • Stability:
            • stable given:
              • speaking in full sentences,
              • >90% O2 on RA
              • RR <24
              • HR b/n 60-120
              • normal BP
              • no tension physiology.
            • unstable
              • given:
                • tension physiology.
                • cardio-pulmonary instability.
              • Empiric management initiated:
                • need thorocostomy with subsquent
                  • tube thoracostomy
                  • pigtail thoracostomy
          • Classification:
            • primary pneumothorax given no underlying pulmonary disease.
            • secondary pnuemonthorax given underlying pulmonary disease.
              • tob use
              • COPD
              • asthma
              • cystic fibrosis
              • pneumonia
              • TB
              • interstitial lung diasease
          • Estimation of size:
            • very small given
              • < 1/3 of chest on CXR
              • ((OR))
              • only seen on CT
            • small given <3cm lung to cupola
            • large given >3cm lung to cupola
          • Treatment and Disposition informed by above classification:
            • Disposition of outpatient.
              • Given primary pneumothorax,
              • asymptomatic,
              • small in size estimation,
              • observed in ED for 6 hours on non-rebreathing O2,
              • repeat CXR shows no progression,
              • pt reliable and has ability to follow the strict return precautions (which I d/w pt).
              • pt advised no flying until cleared by PMD.
            • Inpatient
              • given
                • large,
                • ((OR))
                • symptomatic,
                • secondary,
                • recurrent,
              • therapeutically:
                • observation by inpt team without thoracostomy/centesis
                  • given
                    • asymptomatic,
                    • very small (<1cm),
                  • will observe on O2,
                  • plan for repeat CXR in 12-24 hrs. If worsens, plan for thoracostomy.
                • observation with thoracostomy/centesis.
                  • thoracentesis (pig tail)
                  • ((OR))
                  • small (8-14 Fr) chest tube
                  • post procedure CXR confirms placement.
      • GI etiology (specifically)
        • boerhaave’s syndrome
          • given
            • subcutaneous emphysema
              • on exam,
              • on CXR,
            • pneumomediastinum, abnormal cardiomediastinal contour,
            • pneumothorax on CXR,
            • pleural effusion
            • Hamman’s sign
          • accessed for stability:
            • unstable,
              • intubated,
              • surgery service required,
                • consulted emergently,
                • intiated emergent transfer to higher level of care
              • 2 large bore IV access, aggressive IVF
              • broad spectrum antibiotics
                • ceftriaxone 1g IV,
                • clindmycin 900mg IV,
                • vancomycin 15-20mg IV,
            • stable,
              • intubatation not required at this time, will closely observe for subsequent need,
              • surgery service required,
                • consulted emergently,
                • intiated emergent transfer to higher level of care
              • 2 large bore IV access, aggressive IVF
              • broad spectrum antibiotics
                • ceftriaxone 1g IV,
                • clindmycin 900mg IV,
                • vancomycin 15-20mg IV,
              • NPO
              • contra-indicated: NG tube
        • biliary pathology,
          • cholelithiasis
            • given
              • evaluated for other more pathologic diagnoses and evaluation was non-revealing to reduce more pathologic cardio-pulomonary-gastro-intestinal etiologies to sufficiently low likelihood,
              • does not meet criteria for cholecystitis,
              • known hx of cholelithiasis
            • Therapeutically
              • prescribed
                • analgesia
                  • ibuprofen
                  • hydrocodone only for break through pain (cautioned pt not to drink/drive/exercise caution for fall risk/not to take other meds w/ acetaminophen)
                • ani-emetics
              • advised for f/u with surgery oupt for eval for cholecystectomy if sx persist
          • cholecystitis
            • given
              • evaluated for other cardio-pulomonary diagnoses was non-revealing,
              • sonographic evaluation shows signs consistent with cholecystitis
            • Therapeutically:
              • Antibiotics:
                • ceftriaxone 1g IV and metronidazole 500g IV,
                • ((OR))
                • ciprofloxacin 400mg IV and metronidazole 500g IV,
                • pipercilling/tazobactam (zosyn) 4.5g IV
                • ertapenem 1g IV
              • surgery service required,
                • consulted emergently,
                • initiated for emergent transfer to higher level of care,
              • NPO,
              • IVF,
              • sympomatic relief PRN with analgesia and anti-emetics
        • GERD
          • given
            • evaluated for other more pathologic diagnoses and evaluation was non-revealing to reduce more pathologic cardio-pulomonary-gastro-intestinal etiologies to sufficiently low likelihood,
            • burning reflux sensation,
            • worse with eating,
            • worse with supine position,
            • hx of GERD,
          • Therapeutically
            • advised for close follow up with PMD for re-evaluation given sufficiently low – albeit still existent risk for more pathologic processes,
            • lifestyle/eating changes d/w pt,
            • initiated empiric pharmacologic therapy
              • famotidine 20mg BID
                • given symptom alleviation faster with H2 blocker than PPI
                • advised for f/u with PMD/GI for possible transition and optimal long term determination of therapy to reduce long term sequelae of GERD
              • pantoprazole 40mg daily
    • DDx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing)
      • Cardiac:
        • ACS – Considered ACS, in addition to obtaining history, inquiry into risk factors, examination, EKG, troponin, employed risk stratification pathways for ACS
        • and post evaluation and post test probability places patient at sufficiently low risk to not be primary etiology thought to be causative of patient’s symptoms.
          • HEART Score:
            • 0-3
              • Therefore estimated risk 0-3: 2.5% risk of adverse cardiac event. Patient discharged with prompt follow-up with PMD for further outpatient evaluation.
              • Employed HEART Pathway.
                • Pt at very low risk (HEART score <=3 and two neg trop at time 0 and > 3 hr) in Heart Pathway therefore estimated >99% sensitivity for 30 day cardiac event.
              • Given above risk stratification, pt at very low risk for ACS, and while standard practice is for outpatient follow up, given varied risk tolerance of each individual patient, I discussed risks/benefits and offered prolonged observation for possible increased sensitivity, including provocative testing, and via shared decision with pt, we elected for discharge. Pt informed that they may elect to arrange prompt outpt stress test if they wish for further risk stratification. With utilization of HEART pathway, expedited arrangements by ED is not routinely indicated given above risk stratification and patient’s risk tolerance and patient encouraged to make such arrangements per their discretion of arranging outpatient follow up.
            • 4-6
              • Therefore estimated risk 20.3% risk of adverse cardiac event. Plan for admission/cardiac observation status to the hospital for trending of troponin and provocative testing per inpatient .
            • >7
              • Therefore estimated risk 72.7% risk of adverse cardiac event, suggesting early invasive measures with these patients and close coordination with inpatient cardiology. Plan for admission. Discussion with cardiology regarding initiation of antithrombotics.
          • Admitting. Further evaluation per inpatient team’s discretion.
          • Discharging home. Given above risk stratification, pt at very low risk for ACS, and while standard practice is for outpatient follow up, given varied risk tolerance of each individual patient, I discussed risks/benefits and offered prolonged observation for possible increased sensitivity, including provocative testing, and via shared decision with pt, we elected for discharge. Pt informed that they may elect to arrange prompt outpt stress test if they wish for further risk stratification. With utilization of HEART pathway, expedited arrangements by ED is not routinely indicated given above risk stratification and patient’s risk tolerance and patient encouraged to make such arrangements per their discretion of arranging outpatient follow up.
        • Not consistent with aortic dissection given
          • history not consistent with dissection,
          • sufficiently low risk factors that patient is not at high risk for aortic dissection,
          • no widened mediastinum on chest x-ray,
          • negative d-dimer in conjuction with hx and risk factors not consistent with aortic dissection,
        • Not consistent with CHF exacerbation given
          • euvolemic on exam,
          • CXR not c/w pulm edema,
          • BNP <100
        • Not consistent with pericarditis given
          • no PR depression,
          • no diffuse ST elevation,
          • no friction rub,
        • Not consistent with myocarditis given
          • no infectious systems,
          • no indication of decreased myocardial contractility.
          • s/s of decreased EF more likely 2/2 to CHF than myocarditis.
      • Pulmonary:
        • PE –  Considered pulmonary embolism given my clinical gestalt is that this is not consistent with a pulmonary embolism based upon the patient’s HPI, PMH, exam, and diagnostics
          • and
            • neg PERC criteria:
              • age<50,
              • HR<100,
              • O2 on RA >95%,
              • no hx of VTE,
              • no trauma/surgery x 4wks,
              • no hemoptysis,
              • no exogenous estrogen,
              • no unilateral LE swelling
            • therefore for being sufficiently low risk for no further indicated diagnostics indicated at this time.
            • unlikely by Wells given
              • low-moderate risk by Wells and d-dimer negative
                • no s/s of DVT,
                • PE not #1 dx,
                • HR<100,
                • no immobilization x 3 days,
                • no surgery x4 wks,
                • no hx of VTE, hemoptysis,
                • no malignancy w/ tx w/in 6 mo or palliative
                • and d-dimer neg
            • Shared decision making utilized to assist in deciding next steps.
            • Given varied risk tolerance of patients, risks of radiation/time/contrast verses additive diagnostic benefits of further diagnostics including CTPA discussed with patient and shared decision not to pursue further diagnostics given level of risk for PE satisfactorily for patient’s wishes per my conversation with patient.
        • Not consistent with pneumothorax given breath sounds symmetric bilaterally, no respiratory distress, no pneumothorax seen on chest x-ray.
        • Not consistent with pneumonia given
          • no productive cough,
          • afebrile,
          • no significant luekocytosis
          • no respiratory distress,
          • no hypoxia
          • no tachypnea
          • no consolidation or radiographic evidence of PNA seen on chest x-ray
      • GI
        • Not consistent with boerhaave’s syndrome given
          • no hx of recent instrumentation in the esophageal region,
          • no hx of esophageal pathology,
          • no  subcutaneous emphysema on exam or CXR,
          • no pneumomediastinum, no abnormal cardiomediastinal contour, no pneumothorax on CXR,
          • no pleural effusion
          • no Hamman’s sign
            • ((crunching sound on auscultation of heart))
        • Not consistent with bleeding peptic ulcer given
          • hx/exam not suggestive of GI pathology,
          • no hx of ucler,
          • no black tarry stool/BRBPR per history,
          • guiac negative with brown stool
          • no risk factors for peptic/duodenal ulcers
        • Not consistent with hepato-biliary pathology given
          • no RUQ TTP,
          • hx not suggestive of GI etiology,
          • LFTs wnl
        • Not consistent with pancreatitis given
          • hx of pain not in location typical for pancreatitis
          • no risk factors for pancreatitis
          • no hx of pancreatitis
          • lipase wnl
      • Other:
        • No evidence of MSK injury on exam. No lesions nor dermatomal distribution suggestive of Zoster
    • Plan:
  • Re-evaluation:
    • Improved on re-evaluation.
      • On thorough re-evaluation, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with clear sensorium, repeat cardio-pulmonary-abdominal exam benign, is ambulatory, has no new development of pain, pain is well-controlled and is amenable to discharge after observation period in the ED.
      • Neurologically Intact.
        • Patient has normal speech, clear sensorium, exhibits linear thinking, able to articulate plan for aftercare, and exhibits normal fine motor skills.
        • Abdominal Benign. Repeat abdominal exam  did not reveal any tenderness in any of the four quadrants. No rebound their guarding. patient  tolerated PO fluids and food to the emergency department without any recurrence of abdominal pain or vomiting.
      • Respiratory status
        • No signs of respiratory distress on exam, able to speak in full sentences without dyspnea. Respiratory related vital signs reassuring and suggestive of improvement. Improved respiratory exam compared to prior.
        • Unchanged respiratory status compared to prior.
        • Worsening respiratory status compared to prior.
      • Clinically Sober.
        • Patient demonstrates clinical sobriety.
          • speak non-slurred speech
          • is alert and oriented
          • ambulatory with steady gate
          • has fine motor intact
          • able to articulate plan for safe aftercare upon discharge from ED.
        • Re-evaluation after sobriety did not reveal any new symptoms/signs. Unlikely initially unappreciated pathology on initial eval given patient has no new complaints and re-examination does not reveal any new abnormalities suggestive of previously undetected pathology.
        • Instructed patient to exercise cautions after discharge
        • Patient requests discharge, will oblige demonstration of capacity, sobriety, and no unevaluated pathology.
    • On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation.
  •   Disposition:
    • home.
      • Counseled patient on assessment, impression, plan.
        • Discussed disposition options with patient after counseling as above and included option for continued observation in medical setting however shared decision making yielded joint decision for disposition to home with self and family observation, prompt follow up with PCP, and return to ED precautions.  Counseled patient on complaint specific return precautions given that there are pathologies that, while sufficiently unlikely to warrant further investigation at this time, may develop/worsen after discharge.  Counseled that early in a disease progress, a work up can be falsely non-revealing of more significant pathology however this does not exclude the possibility of developing serious pathology thereby underscoring the importance of prompt follow-up with PMD and low threshold for return to ED as needed.
    • Observation
      • Indication:
      • transfer of care kindly assumed by
    • Admitted,
      • transfer of care kindly assumed by admitting team
      • at
      • level of care,
      • with service.
    • Sign out at change of shift, transition of care kindly assumed by oncoming ED team
      • to
      • pending
      • at
    • DIAGNOSIS: 
  • Supplemental Documentation:
    • OBSERVATION NOTE:
      • Total observation time
      • Start of observation time
      • End of observation time
      • Decision for disposition made after observation. Disposition to
      • Observation performed in order to attempt to safely preclude an inpatient admission.
      •   Observation was performed given
        • diagnostic uncertainty (i.e. serial examinations and assessments by me to elucidate likelihood of a pathologic process).  
        • to determine intensity therapy required (i.e. there was a reasonable possibility that by observing the patient’s response to therapy, an admission may be abated and safely discharged). 
      • Observation by me in ED.
      • The observation was utilized as the primary diagnostic tool during that time.
      •   Of note, additional history was obtained at this time and there was no family history contributory to the patient’s current condition. 
      • Given patient had initial complaint concerning for significant deterioration resulting in severe morbidity and potential mortality, patient required direct observation and monitoring in the emergency department with trending of vital signs, telemetric monitoring reviewed by me, frequent reassessments by nursing with communication with me of status, re-accessments in addition by me, which were all required for patient’s safety during that time (monitoring while administering medications with risk for CNS/cardiac/pulmonary adverse reactions) and to determine patient’s disposition by assessing for response to interventions/treatment. Patient was observed under my supervision.
      • Revenue code: 0762.  HCPCS Code G0378
    •  CRITICAL CARE PROCEDURE NOTE:
      • Authorized and performed by: Attending physician
      •  Total critical time:
        • minutes.
      • Indication for critical care including pt has exhibited risk factors for and symptoms and signs concerning for impending deterioration included compromise of
        • airway,
        • respiratory stability,
        • cardiovascular collapse,
        • CNS irreversible damage,
        • metabolic derangements
        • renal failure
        • fulminant hepatic failure
      • PRIMARY DIAGNOSIS:
        • ((primary diagnosis must be one of these for critical care time to be documented))
      • Due to patient having a presentation that is concerning for a potentially pathologic process causing an resulting in significant morbidity and potential mortality, the patient required emergent evaluation in the emergency department including emergent diagnostics, emergent assessment and evaluation, and emergent and directed treatment in order to mitigate risk for life-threatening deterioration. The critical care time as indicated above included discussing history with patient, examining patient, interpreting vital signs including pulse oximetry, initiating and interpreting diagnostics, and clinical acumen in order to synthesize patient’s presentation to develop treatment plan and emergently implement the requisite steps. This part of my care the patient is exclusive of other billable procedures, specifically procedures, treating other patients, and any educational time. Please refer to the above rationale for further documentation regarding the critical nature of the patient during my care.
      • This critical care time is separate from teaching or other separately billable procedures or treating other patients.
    •  COUNSELING:
      • Patient/family educated to the extent possible in terminology matched to their understanding on diagnostics, assessment, and treatment plan along with the risks inherent to the diagnostics and therapeutics and plan. Patient/family amendable and in agreement with above plan. All questions and concerns addressed and answered.
      • Attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible.
      • Attempted to explain and obtain patient’s approval for plan however unable to do so secondary to patient’s condition and the requirement of emergent evaluation and interventions.
    • SUPERVISION:
      • Discussed with attending.  Obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician
      •  Evaluated patient with resident physician. I have evaluated the patient and discussed the patient’s history, exam, diagnostics, and plan with the resident physician and agree with plan as stated by resident physician.
    • Of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics.