Updated with your comments/suggestions – thanks!
CC:
HPI
1-liner: Mr. _ is a _-year-old _ with a PMH of _ presenting with _ days of _.
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Mr. _ was in his usual state of health until last _ _/_/_, _ days ago, when s/he _ . S/he localizes the pain to _ and describes the pain as “_, a _/10”. The _ is provoked by _ and alleviated by _. It radiates _.
Pertinent positives include _. Pertinent negatives include _, complete ROS below.
Pt also complains of _.
Last admission was _ for _.
On arrival, ER/ICU ordered _ and administered _.
_ was consulted.
Review of Systems
Constitutional: +fatigue, denies fever, N/V/Ha/dizziness (dialysis)
Eyes: denies change in vision
Ears: denies change in hearing
Resp: denies change in breathing, SOB
Cardio: denies chest pain, palpitations
GI: +constipation, denies diarrhea, hematochezia, change in BM
GU: denies polyuria, dysuria, hematuria
MSK: denies muscle aches, joint pain
PMH
PSH
Social
Born/raised:
Occupation: *occupational hazards
Residence:
Tobacco:
–(packs/day) * (years/smoker) = e.g. 2 packs/day for 20 years = 40 pack-year
–(# cigarettes day/20) * (years/smoker) = e.g. 10 cigarettes/day for 6 years = 3 pack-year
ETOH using as standard drink: 12 oz beer = 5 oz wine = 1.5 oz shot
–during wk: _ standard drinks
–weekend: _ standard drinks
Drugs:
Family *focus on: (1) MI/HTN (2) diabetes (3) cancer (genetic screening referral)
Father: Passed of _ at age _
Mother: Passed of _ at age _
Brother:
Sister:
Meds
for admission H&P, home meds go here; for Progress note, replace with copy-paste inpatient meds
*for every problem, START HERE 1st i.e. look at meds for etiology
Allergies
NKDA; _ since _ triggers _ carries _
Physical Exam
V/S: BP HR RR Sat Temp
General: no acute distress, well/ill appearing, obese/cachectic, calm, conversational, IVs/lines
HEENT: Normocephalic and atraumatic. Eyes PERRLA, no conjunctivitis, no icterus. Oropharynx is clear of exudate/thrush. No LAD.
Neuro: CN II-XII intact; nl motor and sensation x4
Cardio: Normal S1, S2, PMI. No audible murmurs or palpable thrills.
Resp: lungs clear x4.
GI: no ascites, guarding; BS x4; soft and nontender x4; liver non-palpable
GU: deferred; foley/condom cath
MSK: warm x_ w. pulse / cold x_ w. decreased pulse, decreased hair _ concerning for PAD; no palpable clots, edema, tenderness
Skin: no rashes *infection, lesions *biopsy, bruising *bleeding risk, anticoagulation
Labs
Baseline _
Culture
Blood cx: x1 each arm:
Plate on basic agar -> gram +/– -> new agar to differentiate species -> speciation
–if 1 out of 2: gram + (possible containment, can tx empirically, wait for speciation or repeat) vs gram – rod (sufficient)
Imaging
Baseline _
Contrast in CKD, age >75
MRI: implant _
A & P
1-liner + ER course _ + admitted for _
#A-fib: Old: CHADS2 vs New: CHA2DS2-VASc; Why not always anti-coagulate? HAS-BLED score
Old: Warfarin (exception +valvular dz) = narrow therapeutic range: need to monitor INR, diet
New: NOACs = Non-vitamin K Oral Anticoags: cannot use coag studies
AFFIRM trial: no mortality difference b.w rate vs rhythm control
–Tele: <7 day: paroxysmal
–Holter (24-48 hrs): >7 day: persistent
–Zio patch: >1 yr: permanent
–TSH for hyperthyroid-induced a-fib
#Anemia, microcytic: clinical history of fatigue, melena, hematemesis, Hb of _ (_/_/_) -> _ (_/_/_) and risk factors of NSAID, ETOH, H pylori concerning for Fe-deficient anemia 2/2 GI bleed. Also considered was some component of anemia of chronic dz given chronic medical conditions; some component of CKD from a drop in EPO given Cr _; and thalassemia, however MCV of mid-70s more consistent w. Fe-deficiency. Ferritin acute-phase rx, FP in acute admission, f/u outpatient
–work-up b.f GI consult: w. iron studies: Fe (drops b.f Hb if Fe-deficient i.e. have to be Fe-deficient to be anemic from GI blood loss), Ferritin, TIBC, past scopes
–Ordered CMP for LFTs, bilirubin *clotting fx
–Started PPI for clot stabilization *neutral gastric pH helps to stabilize clot formation over bleeding vessels
–Inpatient GI consult for active bleeding melena, hematemesis
–Outpatient GI referral for source of Fe-deficiency *if not Fe-deficient, not GI blood loss
#Anemia, macrocytic:
–Folate, B12 (serum methylmalonic acid and homocysteine levels)
#Anemia, normocytic:
–chronic dz, CKD, hemolysis, acute blood loss, hypoT, bone marrow d/o
#AMS: AAOx_ ; baseline _
–Pocket Med; don’t bother Neuro consult, tx of delirium is underlying condition
#AKI: clinical history of dehydration, contrast, Cr, BUN; if on diuretic, calculate FeUrea; if not on diuretic, calculate FeNa; score RIFLE criteria _, AKIN, KDIGO *creatinine curve, GFR moves 1st
–Hold ACE-i/ARB/PPI for AKI
–BUN/Cr _ concerning for pre-renal: fluid bolus
–BUN/Cr _ concerning for intrinsic renal: med rec (CK for statin, lactic a. for metformin)
–BUN/Cr _ concerning for post: bladder/renal U/S for post-void residual/obstruction, BPH
#Chest pain: clinical history of chest pain, troponins, EKG, echo, HEART, TIMI (M: <55, F: <65), GRACE. STEMI/NSTEMI: + troponins; unstable/stable angina: – troponins.
–Ordered serial troponin to rule out MI q 6 hrs
–Ordered Mg to maintain K >4, Mg >2 for membrane stabilization and decreased automaticity
–Started ACS protocol: telemetry monitoring for at least 24 hrs, Heparin drip, loaded Plavix 300 mg -> 75 mg, b-blockers, high-intensity statin, nitro 0.4 mg prn for chest pain
–Ordered BNP to r/o HF exacerbation
–Ordered respiratory viral panel to r/o viral pericarditis
–NPO for stress test for -troponin
–Consult cardiology for cath for +troponin
#Cirrhosis 2/2 _: clinical history of ascites, caput medusae, gynecomastia, spider angioma, palmar erythema, hepatojugular reflex, Is/Os, weight gain, encephalopathy. CMP for liver enzymes, last paracentesis SAAG (serum-ascites albumin gradient) for SBP/etiology: <1.1: capillary permeability -> leakage of albumin -> exudative: malignancy, TB, pancreatitis, nephrotic syndrome vs >1.1: fibrosis limits leakage of protein -> transudative: CHF, cirrhosis, ETOH hepatitis; even if serum [albumin] is low e.g. 2.5 (nl 3-4) b.c the liver is cirrhotic, the ascites albumin will be even lower b.c the fibrosis limits albumin leakage (fluid is forced by hydrostatic P from portal HTN). Last abdominal U/S q 6 mos for HCC, last endoscopy q 3 yrs for varices. MELD score _.
–Ordered serum ammonia/lactulose for encephalopathy
–Ordered paracentesis cell count & culture for neutrophil >250 or cytology for SBP <1.1
–Nadolol for varices
–Consider prophylaxis fluoroquinolone for variceal bleeding
–PT/INR for MELD
–Albumin 6-8 g/L if paracentesis >5 L
—Hepato-renal: splanchnic dilation -> pre-renal AKI picture -> to make diagnosis of HRS, 1st r/o pre-renal AKI: IV fluid challenge w. 1 g/kg albumin qd x2 days -> repeat BMP 6-12 hrs -> if refractory makes HRS as diagnosis of exclusion: HRS: midodrine / octreotide (vasoconstrictors)
-preventative: splanchnic dilation upregulates RAAS -> loop diuretic/spironolactone + low-salt diet induces natriuresis which limits 3rd spacing to begin with i.e. less Na, less spacing, more kidney perfusion; ideal weight loss 1 kg/day
–Outpt f/u w Hepatology *consider IR referral for TIPS not indicated for past encephalopathy, CHF
–Diet: Na-restriction
#COPD exacerbation: clinical history of _ pack-year, cough w. productive sputum, saturation _%, barrel-shaped CXR. Most recent _/_/_ PFTs _, GOLD score _ *MD Calc #Edema likely 2/2 cor pulmonale, most recent echo _/_/_ _.
*if serious enough for ER to call, admit, ER will have most done
–ER CBC: mild leukocytosis
–ER CXR: barrel-chest w. flat diaphragm
–ABG for poor saturation: pH _, pCO2 _ resp acidosis from CO2 retention
–Nebulized albuterol, ipratropium prn
–mild exacerbation: methylprednisolone [Medrol dosepak] or prednisone 40 mg x5 days
–mod-severe (fever, cough, sputum, wheeze): Azithromycin [Z-pak]
#Diarrhea: clinical history of fever, malodorous, green-mucus diarrhea in setting of Abx
–Hold docusate-Senna for 24 hr for stool studies
–Ordered stool culture for growth of Salmonella, Shigella, Campylobacter, E. Coli, stool leukocytes (very sensitive), C. diff toxin, stool Ova & Parasite for Entamoeba histolytica and Giardia, microscopy for acid-fast smear will test for Mycobacterium Avium Complex, Cryptosporidium
#Dizziness/Orthostasis: clinical picture of hypotension, dry mucus membranes, delayed cap refill, dizziness, nl CN II-XII, no ep of syncope concerning for hypovolemia. ER administered fluid bolus and f/u neg orthostatics consistent with 2/2 hypovolemia.
—Med rec (Tamsulosin [Flomax], opiates, MiraLax), DM nephropathy
–Positive/Negative Orthostatics from drop in systolic >20 or diastolic >10 *wait 2 mins *orthostatics diagnose hypovolemia
–EKG/TSH for arrhythmia *2 birds w. 1 stone b.c TSH and a-fib i.e. a-fib alone can cause syncope if reduced diastolic filing -> decreases CO -> cerebral blood flow
–Infectious workup
–Consider Midodrine
–Consult neuro
#DM: clinical history of neuropathy. A1c,
–Started insulin at 0.2 U/kg
–Hypoglycemia protocol: over past 24 hrs, reqd additional _ U on ISS, increase basal-bolus to _
#Edema
–pitting: HF, liver, kidney, malnutrition
–non-pitting: vasculitis (“tubes leak”), every conceivable space is taken up w. fluid
#Headache: anything can cause HA inpatient… time to go!
–Ondansetron [Zofran], Granisetron [Kytril] 5-HT3-antagonist so opposite effect to -triptan 5-HT3-agonist vasoconstrictors
–CT brain w/o contrast or MRI w/ w/o contrast
–Migraine cocktail: 2L bolus or at 100 cc/hr, IV Benadryl 25 mg, Magnesium 1 g IV, Reglan 10 mg IV, Toradol 30 mg IV (check renal function, bleeding risk, h/o movement disorder)
–escalate after 2 hrs to IV VPA 500 mg, IV Keppra 500 mg or IV methylprednisolone 200 mg or 10 mg Decadron depending on comorbidities
–if persistent headache, admit for IV DHE 0.5-1 mg IV – check UA, EKG, CXR, CBC, CMP and no triptans in the last 24 hrs
#HF exacerbation: clinical history of crackles, BNP, weight change. Diagnosed _ HFpEF / HFrEF 2/2 _. Most recent echo _/_/_ EF _%.
–ACS r/o: troponin _
–Started tele
–Ordered BNP (baseline _ (_/_/_))
–Weight _ (_/_/_) -> _ (_/_/_)
–Ins _ / Outs _
–Cont ABCs
—Cardio-renal: fluid challenge c/i
-diastolic: decrease CO -> increase pre-load -> venous congestion on kidney -> diuretic decrease pre-load -> decrease stiffness, increase compliance -> switch PO loop to IV b.c bowel congestion limits absorption of PO and furosemide [Lasix, last six hrs] not predictable absorption
-systolic, acute decompensated: cold extremities, no edema, BP <100, lactic a., clear CXR: inotrope dobutamine / midodrine
–Consult palliative care for end of life
#Hyponatremia (red line 130): clinical picture of dehydration, hypotension, orthostasis, diarrhea likely hypovolemia hyponatremia. clinical picture of pitting edema, crackles, orthopnea, elevated JVP likely hypervolemia hyponatremia
–Ordered serum osmolarity: +hypotonic <275, +hypertonic >295 (DM2, for every BG 100 over 100, give 2 units Na)
–Ordered urine osmoles: <100 r/o SIADH; >150 SIADH *if hypotonic, urine should be as well; a concentrated urine w. osmoles >150, concern for SIADH
–Ordered urine lytes: Na >20 diuretics; lab way to know volume status: ADH secretes when hypovolemic, concentrating urine to a specific gravity >10.10
–Calculated _ ml/hr from MDCalc Sodium Correction Rate
#Nephrolithiasis: clinical history of severe lower abdominal and flank pain w. radiation to groin
–Ordered non-contrast spiral CT of abdomen and pelvis
–stone >one cm is no fun i.e. <1 cm (10 mm) can pass spontaneously
–Ordered increased fluid intake, Tamsulosin & counseled to strain urine
–Consulted urology for stone >1 cm, refractory pain, AKI
#Neutropenic/HIV fever
–Ordered CXR (reactivation TB 10% HIV), UA, BCx, skin exam, bone MRI (MC osteo is afebrile), C-diff for source of infection
–Started empiric Abx w. IV Zosyn
–Consider isolation precautions
–pending neg culture for 48 hrs, afebrile for 24 hrs
#Osteomyelitis: peripheral hyperemia from increased contrast uptake w. central necrosis
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#Pain: 100% morphine equivalents for long-acting (XR [-contin]) + 15% prn for breakthrough
–Mild: NSAIDS: take w. food, c/I abdominal/CKD pain
–Mod-severe: Fentanyl > Buprenorphine > Methadone > Hydromorphone [Dilaudid]/Oxymorphone [Opana] > Oxycodone/APAP [Percocet] > Hydrocodone/APAP [Vicodin] > Morphine (c/I CKD) > Tramadol > Codeine/APAP [Tylenol 3]/Meperidine [Demerol] (c/I CKD)
-Oxycontin 2 mg PO bid
-Oxycodone IR 1 mg PO q4h prn breakthrough pain
#Pancreatitis: 2/3: characteristic epigastric pain, lipase of _, >3x nl, and +imaging _. Etiology likely 2/2 gallstones, ETOH, lipids – pending workup as below.
–Ordered RUQ U/S for intrahepatic gallstone choledocholithiasis
–Counseled to limit drinking *ETOH, not smoking for pancreatitis
–Ordered lipid panel for triglycerides
–Started NPO for bowel rest w. IVF 200 cc/hr, IV morphine for pain control, Zofran for N/V
–Ordered CT (not sensitive for biliary pathology) for clinical deterioration shows uncomplicated peripancreatic fluid, fat stranding vs. complicated necrotization, abscess, cyst
–Consulted GI for Abx for complicated CT showing necrotization, abscess, cyst
–Consulted GI for further workup: EUS for extrahepatic gallstone pancreatic duct, malignancy; ERCP for gallstone choledocholithiasis; genetic (CF), auto-I (IgG4)
–Consulted surgery for cholecystectomy for acute gallstone pancreatitis
#PE/DVT: clinical picture of tachypnea, pleuritic pain c/w symptomatic PE, RV strain c/w sub-massive, shock c/w massive; provoked vs unprovoked: stasis (sedentary lifestyle), injury (DVT), thrombophilia (OCPs), idiopathic (hypercoagulable ca. state); Well’s score _ for PE likelihood, Hestia criteria _ for inpt admission, PESI/sPESI score _ for prognosis
–D-dimer _ product of fibrin degradation; >age x10 i.e. 50 y/o -> +D-dimer >500
–U/S _, CTA _, CT _ wedge-shaped opacification from vascular distribution
–ABG pH _, CO2 _, HCO3 _ c/w resp alkalosis from tacypnea
–Echo to r/o RV strain, Troponins x2 q 6 hrs, BNP, lactic a. to r/o RV strain as RV output falls, LV output falls -> hypotension -> RV ischemia -> +troponins
–Telemetry to r/o arrhythmia; MC EKG in PE: NSR
–LMWH for symptomatic PE, heparin for sub-massive, tPA for massive; IVC filter for c/I to anticoagulation
–Provoked: 3 mos vs Unprovoked: 6 mos
-Discharge on Enoxaparin [Lovenox] -> Dabigatran [Pradaxa] and counseled to limit contact sports, construction work on anticoagulation
-Apixaban [Eliquis] can use in CKD and no bridge
–Rivaroxaban [Xarelto; river x-ing] 20 mg bid wk 1 -> 20 mg qd wk 2 -> 15 mg maintenance
-High-risk bleed: warfarin for reversal w. FFP
#Pneumonia: clinical history of fever, tachypnea, leukocytosis w. left shift, lactic a., CXR. CURB-65 _, PSI _.
–Ordered CXR _, CT _
–Ordered sputum induction & culture
–Ordered rapid flu, respiratory viral panel
–Ordered mycoplasma, legionella
–Repeat CBC
–Community acquired: PO levofloxacin (same absorption IV or PO), ceftriaxone & azithromycin, Ampicillin-Sulbactam [Unasyn] for anaerobe
–Hospital acquired (>48 hrs w.in 30 d): IV Piperacillin-Tazobactam [Zosyn] for pseudomonas coverage, Vanc for MRSA
–pending neg culture for 48 hrs, afebrile for 24 hrs
#Sickle cell crisis: microcytotic Hb _ from retic count _%, leukocytosis likely 2/2 to chronic inflammation, hydroxyurea _, pulmonic stenosis likely 2/2 pulmonary HTN from free Hb scavenger of NO,
–Encourage Incentive-spirometry, ambulation, sat _% off O2 _% on O2
–Morphine PCA _ injections/attempts/24 hrs (Cerner: view -> layout -> navigator bands -> add pca-pcea) ideal bolus: ½-basal x1 q1-2 hr
-basal: _ mg/kg = _ mg/hr
-bolus: _ mg/kg = _ mg/hr
-total max =
-wean: don’t tell patient to avoid perception bias; convert based off basa
-switch: when morphine requirements <0.02 mg/kg -> codeine: max dose 1 mg/kg q4hr
–IVF: _ ml/kg D5W
–Fever 2/2 SCC/chronic inflammation, atelectasis from inflamed consolidation & cytokines, bacteremia from auto-splenectomy, started empiric ceftriaxone
–ACS: CXR _, azithromycin for atypicals, albuterol, d/c fluids
–Transfusion for low [Hb] or pain to dilute sickle cell concentration, if splenic sequestration by palpation limit to 5 pRBCs/kg to avoid HF b.c transfusion will force RBCs out of spleen
amount to transfuse: max Hb 11.5 (to prevent hyperviscosity) – baseline [Hb] * constant 3.5 * weight kg = _ cc RBCs
-normal hemolysis ~1%, HbS hemolyze 10% of sickle cells/day, cannot discharge if aplastic by retic count
-normal RBC lifespan 120 days, ½-life 60 day; transfused blood half of that; post-transfusion to pre-transfusion ~1 mon
–Outpatient: schedule echo for pulmonary HTN to r/o tricuspid regurg, prophylactic penicillin
–Vaccination: Prevner x1 & followed by Pneumovax -> Pneumovax 8 wks -> Pneumovax 5 yrs after 1st dose -> >65 Pneumovax 5 yrs after last dose
#Stroke/TIA treated as same
–non-contrast CT r/o hemorrhage
CHANCE: Chinese 21-day
POINT: US 30-day
SAMMPRIS:
–Loading dose Plavix 600 mg -> 75 mg x21 d
–Aspirin 325 mg -> 81 mg x21 d
–Etiology: Echo (thrombus), A1c, LDL, tele (a-fib)
–PT/OT evaluation and treatment.
–MRI brain w.out contrast,
–U/S carotid vessels
#Tobacco
–nicotine lozenges, patches
#ETOH: CIWA score _
–Consider lorazepam taper
#Isolation: Droplet for influenza, N. meningitides, group A strep; Contact for C. diff, herpes, MRSA, MDR GNR; Airborne for TB, MMR
#Diet: Regular, NPO
#DVT: PADUA score
–nonpharmacologic: compression stockings (venous insufficiency) vs SCD (sequential compression device: prophylaxis)
–pharmacologic: Heparin 5000 U SQ BID can stop w.in 6 hrs vs LMWH enoxaparin [Lovenox] 40 mg SQ qd for h/o of ca., pregnancy, c/I CKD, procedure w.in 24 hrs, Warfarin for mechanical valve, valvular A-fib: bridge 5 days w. Lovenox at 1 mg/kg BID or 1.5 mg/kg qD preferred over heparin b.c heparin req’d infusion & PTT monitoring
#Code: Full, DNR/DNI
#Dispo: Admit to Team _, pending _ *barrier to discharge