Dx

  • [2] [b]Diagnostically:[/b]
    • [2] Point of Care Testing:
      • [2] Pregnancy Test
        • negative
        • __
      • [2] POC gluc
        • wnl
        • __
      • [2] POC Hg
        • wnl
        • __
      • [2] iStat
        • potassium wnl
        • hyperkalemia
        • no base deficit
        • __
      • [2] lactate
        • wnl
        • __
    • [3] EKG (as interpreted by prelim ED):
      • [01] Non-remarkable EKG. No evidence of ischemia. NSR, regular rate, normal intervals, no abnormal TWI, no ST elevation/depression.
      • Rate
        • [01] normal,
        • bradycardic,
        • tachycardic,
      • [2] ST-segment morphology:
        • [01] TWaves:
          • [01] 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,
      • [01] [2] Comparison to prior:
        • [01] Unchanged when compared to prior,
        • Attempted but no old EKG available for comparison,
        • __ ,
      • [01] [2] 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.
        • __
      • [2] 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: __ ,
      • [2] 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.) 
    • [3] Labs: __ __
      • Ordered, pending at this time, including: [1]
        • CBC, 
        • BMP, 
        • LFTs/lipase, 
        • UA, 
        • Urine Cx
        • lactate
        • Blood Cx
          • [01] x2
          • __
        • CK, 
        • EtOH level, 
        • Ingestion labs (acetaminophen, ASA), 
        • Troponin, 
        • Delta troponin, 
        • BNP, 
        • HIV, 
        • Influenza, 
        • Urine toxicological screen, 
        • CRP,
        • ESR,
        • __
      • [2] Reviewed and interpreted/correlated to clinical scenario to inform diagnosis and plan by me.  
        • No significant labratory abnormalities contributory to patient’s presentation.
        • Non-emergent abnormalities __ which I informed the patient about and advised for prompt outpatient follow up for outpatient care.  
        • [1] Specifically: 
        • [01] [1] CBC:
          • __
          • [01] No significant unexpected anemia, No significant leukocytosis, No thrombocytopenia.
          • Hg
            • anemia,
              • transfusion indicated given
                • symptomatic
                • < 7 Hg (6-8 range from restrictive transfusion strategy)
                • active significant bleeding
              • transfusion not indicated (considered)
              • peri-baseline,
              • significantly lower than baseline
              • unknown baseline,
              • suspected iron deficiency contributory, will advise/rx Ferrous sulfate 325mg daily w/ vit C.
          • wbc’s
            • luekocytosis
              • suspect demarginalization given lack of infectious findings on hx/exam,
              • suggestive of infectious process, 
              • concerning for malignancy, advised to for follow up
            • leukopenic
              • neutropenic 
                • ((ANC < 500))
          • platelets:
            • thrombocytopenic 
              • ((platelets < 150k))
              • transfusion not indicated
                • given suspected consumptive process 
                • ((ITP, TTP, HIT))
            • transfusion indicated given
              • <10 k (regardless that pt is asymptomatic)
              • <20k and and planned CVP or pt febrile
              • <50k and planned LP or neurosurgical procedure
          • pancytopeniac
            • likely 2/2 chemo
            • likely 2/2 HIV
            • likely 2/2 hep C
            • unclear etiology, will initiate eval w/ completion of eval and monitoring/treatment to be continef as outpatientafter ED
        • [01] [2] BMP:
          • No significant pathologic electrolyte derangements.
          • AKI, 
            • [::- 50% increase from baseline -::]
            • BUN/Cr >20 suggestive of prerenal process, 
              • will administer IVF
              • and recheck
          • CKD, 
            • grossly unchanged from prior, 
          • Hyperkalemia, 
          • Anion gap 
            • ((> 12))
          • acidotic suggested by low bicarb, 
          • __
        • [2] LFTs/lipase:
          • [01] No laboratory evidence of hepato-biliary pathology.
          • Transaminitis without elevated bilirubin, suggestive of hepatic pathology
          • Elevated direct bilirubin suggestive of biliary pathology
          • Elevated indirect bilirubin suggestive of increased rbc breakdown
          • __
        • [2] UA:
          • [01] 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
            • __
          • __
        • [2] Cardiac Labs:
          • [01] [2] Troponin: 
            • undetectable
            • [01] <99th percentile
            • >99th percentile but under cut off for positive
            • positive
            •  __
          • [2] Delta troponin
            • pending, pt under care of other service at time of delta troponin, 
            • undetectable, 
            • <99th percentile, 
            • >99th percentile but under cut off for positive, 
            • positive, 
            •  __
          • [2] BNP:
            • [::- please note that greater than 500 suggests CHF, under suggests not CHF -::]
            • not suggestive of CHF exacerbation
            • suggestive of CHF exacerbation
            • non-diagnostic
            • __
        • [2] HIV:
          • negative,
          • positive, 
            • [01] 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. 
        • [2] Influenza
          • negative
          • __
        • [2] CK: 
          • significantly elevated, requires trending,  [::- usually for >500-1000k -::]
          • mildly elevated, not anticipated to rise given negated precipitant, 
          • not high enough to suggest concern for pathology, 
          • __
        • [2] Ingestion labs: 
          • [01] acetaminophen
            • [01] non-detectable, 
          • [01] ASA:
            • [01] non-detectable,
          • [01] etoh
            • [01] non-detectable, 
            • positive __
            • __
        • [2] Urine toxicological screen:
          • [01] negative
          • postive for __
          • __
        • [2] Markers of inflammation
          • CRP [::- suggestive of more acute inflammation -::]
            • wnl
            • elevated
            • __
          • ESR [::- suggestive of more chronic inflammation -::]
            • wnl
            • elevated
            • __
        • __
    • [3] Radiographically:
      • [01] [1] [Radiographs ordered pending at this time, Radiographs reviewed interpreted by me, Radiographs reviewed by me agree with radiology interpretation, Radiology interpretation reviewed,__;dxrads]
      • [2] CXR:
        • [01] 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).
      • [2] PXR (Pelvic XR):
        • no evidence of pelvic fracture
        • no evidence of hip fracture
        • appreciate limited sensitivity of PXR and therefore correlated clinically
        • __
      • [2] XR of extremity
        • __
      • [2] Advanced Imaging:
        • CT head:
          • [01] negative for acute intra-cranial pathology
          • __
        • CT c-spine
          • [01] 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:
        • __
    • [2] 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: __
    • __

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