Chart For Any Complaint (Full Chart with ROS/Exam/Diagnostics) © MedTx, LLC 2017

Disclaimer: Please note, this page is intended for strictly educational purposes. Potential future clinical use may be possible, however the content has NOT been sufficiently reviewed and therefore may not be relied upon.  This page may be used for educational purposed only and only in conjunction with a board certified physician who can appraise by visiting this page, you assume any and all risk. Please read full disclaimer page prior to continuing.
 
  • CC: year old with PMH/PSH of presents with ,
  • Pertinent aspects of HPI:
  • REVIEW OF SYSTEMS:
    • Constitutional:
      • no rigors
      • as noted in HPI
    • ENT:
      • no rhinorrhea, no otalgia, no sore throat
      • as noted in HPI
    • Ocular:
      • no recent vision changes
      • as noted in HPI
    • Cardiac:
      • no chest pain,
      • no palpitations
      • no LE swelling
      • as noted in HPI
    • Pulmonary:
      • no shortness of breath,
      • no new cough
      • as noted in HPI
    • GI:
      • no abdominal pain,
      • no nausea,
      • no vomiting,
      • no dark tarry stool, no BRBPR
      • no diarrhea
      • as noted in HPI
    • GU:
      • no dysuria,
      • no discharge
      • 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
      • as noted in HPI
    • Endo:
      • no polyuria/polydipsia
      • as noted in HPI
  • PMH/PSH/PSFH:
    • PMH:
      • medical history pertinent to chief complaint as noted in HPI
    • PSH:
      •   surgical history pertinent to chief complaint as noted in HPI
    • SH:
      • no tob,
      • no daily etoh use,
      • no illicit drug use,
    • 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:
        • normal HR.
        • tachycardic
      • BP:
        • normotensive.
        • hypertensive
          • (attempted to inform pt to advise to f/u with PMD). 
        • hypotensive.
      • O2 sat:
        • no hypoxia
        • hypoxic
      • RR:
        • normal RR
        • tachypnic
    • PHYSICAL EXAM:
      • General:
        • well nourished
        • no distress
        • mild distress
        • moderate distress
        • severe distress
      • HEENT:
        • vision grossly intact.
        • hearing grossly intact.
      • Cardiovascular:
        • no r/m/g
        • no LE swelling
      • Pulmonary:
        • Lungs CBTA,
        • No respiratory distress,
        • Speaking comfortably in full sentences.
        • I/E wheezing,
        • rales,
        • rhonchi,
        • respiratory distress.
      • GI:
        • abd soft,
        • abd non-tender in all 4 quadrants,
        • TTP diffusely
        • TTP in RUQ
        • TTP in RLQ
      • Neuro:
        • Normal LOC.
        • No grossly focal neurological deficits.
        • Somnolent though protecting airway
      • MSK:
        • no deformities,
        • moving all extremities
        • Non-ambulatory.
      • Pysch:
        • Normal speech.
        • Demonstrates linear thinking.
        • No SI/HI.
        • Endorses SI
        • Endorses HI
        • Exam consistent with gravely disabled.
        • No AH/VH.
        • Agitated.
        • Confused.
  • ———————————————————————–
  • \ ED COURSE:
  • Working Impression/Empiric Management:
  • Diagnostically:
    • Point of Care Testing:
      • Pregnancy Test
        • negative
      • POC gluc
        • wnl
      • POC Hg
        • wnl
      • iStat
        • 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:
        • TWaves:
          • No abnormal TWI,
          • Abnormal TWI,
          • Non-specific repolarization abnormalities,
          • No ST depression, ST depression,
          • No ST elevation, ST elevation but does not meet STEMI criteria, meets STEMI criteria and cath lab activated,
      • 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.)
    • Laboratory Results Reviewed
      • Analysis/Interpretation:
        • CBC:
          • No significant unexpected anemia.
          • No significant leukocytosis. 
        • BMP:
          • No significant pathologic electrolyte derangements.
        • 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
          • CK
          • EtOH level
          • Ingestion labs (acetaminophen, ASA)
        • 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
          •  
    • Radiographically:
      • 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:
        • no evidence of pelvic fracture
      • XR extremity
      • Advanced Imaging:
        • CT head:
        • CT c-spine
        • CT chest
          • PE protocol
          • angio
        • CT a/p
          • w/ contrast
          • non-con
        • CT of extremity
  • Therapeutically:
  • Assessment/Plan
    • Evaluation is most consistent with
    • 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)
  • 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.
      • 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.
      • Employed importance that patient not drive for remainder of day and to exercise extreme caution while around stairs, areas for potential falls, and to avoid areas with potential for being hit by car (street crossing, etc). Patient advised not to drink/use substances which alter mental status/cause sedation/impair judgement or reflexes (alcohol, illicit substances, prescription medications) if driving in general and advised to refrain from those substances in general. Patient advised to seek treatment for substance abuse.
      • Patient requests discharge, will oblige demonstration of capacity, sobriety, and no unevaluated pathology.
    • On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation.
  •  Diposition:
    • 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.
    • observation.
      • Indication:
    • Admitted.
      • level of care.
      • service.
    • Sign out at change of shift to oncoming ED team
      • pending
    •   Additional Notation:
      • Attempted shared decision making in discussion with patient/family to the extent that was possible.
      •  Counseling: patient/family educated on diagnostics, assessment, treatment plan. Patient/family amenable in an agreement with proposed plan. All questions answered and concerns addressed.
      •  Supervision:  discussed and obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician  
  • Supplemental Aspects of Care:
    •  COUNSELING: To the extent that was possible, patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with plan. All questions and concerns answered and addressed.
    • COUNSELING: 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: Evaluation, assessment, plan, and disposition discussed with attending physician who approves and is in agreement with evaluation, assessment, plan, and disposition. 
      • Attending MD  
    • Of note, radiology over-read mechanism in place for formal reads on imaging will hospital call back mechanism in place. 
 

Leave a Comment