Palomar Dragon Phrases Flashcards
(30 cards)
OK to by pass labs for CT
Radiology reports in DC summary
Rectal/Stoma prolapse reduction
RECTAL/STOMA PROLAPSE REDUCTION:
Patient was medicated with [] prior to the procedure.
The affected mucosa was covered in sugar and left on for 30 minutes. Broad-based and slow pressure was applied to the prolapse segment with reduction of the prolapse segment. Digital examination of the [] status post reduction showed complete resolution of the prolapse past the [***].
Complications:[***]
C spine clearance
Cervical spine clearance: The patient is alert and oriented, GCS 15, does not appear clinically intoxicated, has no distracting/painful injury, no complaints of neck pain, a non-tender midline c-spine on palpation, no paresthesias in extremities, and no peripheral strength or sensory deficits. With c-collar removed, patient able to actively range neck through full flexion/extension without pain. C-spine cleared based on consideration of Canadian C-spine criteria, NEXUS criteria and clinical gestalt.
Code Sepsis
SEVERE SEPSIS CRITERIA:
Infectious source: [***]
End organ damage indicated by:
[Lactate > 2.0 mmol/L
Hypotension (SBP < 90 or >40 mmHG drop or MAP < 65)
Acute Resp Failure (new need for invasive or non-invasive mechanism ventilation)
Crt > 2.0
INR > 1.5
Plt < 100
Bili > 2]
**Any of the above correlates with a qSOFA of 2 or more
SEPSIS MANAGEMENT:
Time of recognition of severe sepsis: []
Within 3 hours of recognition:
[Yes] Blood cultures x 2 before broad-spectrum antibiotics
Initial lactate: []
Repeat lactate: [Not indicated as initial lactate < 2.0]
[30ml/kg fluid bolus was completed, and ideal body weight was utilized for BMI > 30]
[30mL/kg fluid bolus was contraindicated in this patient with severe sepsis/septic shock as it would be detrimental or harmful as at least 1 of the following are present]:
[Concern for volume overload and/or End-Stage Heart Failure OR
BP stabilized with lesser fluid volume OR
End Stage Renal disease]
Alternative Target Volume ordered/given: [ml over hours]
SEPTIC SHOCK ASSESSMENT:
[No] Any lactic acid > 3.99
[No] Persistent hypotension (SBP < 90 or 40 mmHg drop, MAP < 65) despite 30 mL/kg IV fluid bolus
POST FLUID ASSESSMENT/REPERFUSION EXAM WAS DONE WITHIN 1 HOUR OF FLUID END @ TIME [***]
[Temp, BP, HR, RR, Pox]
PERSISTENT HYPOTENSION TREATMENT:
[No] Comfort care
[No] Hypotension caused by: pt. baseline, med-induced, erroneous value, condition other than infection
[No] Refusal by patient/decision maker for treatment
Central line [ ]
Vasopressor started [Norepinephrine]
CRITICAL CARE TIME: [*** ] minutes
Treatments/Evaluations: Close monitoring and treatment of unstable vital signs, cardiorespiratory, and neurologic status, while maintaining tight balance of fluid, respiratory, and cardiac interventions. This includes the administration of emergency fluid management while maintaining close respiratory support as well as the provision of immediate and broad-spectrum antibiotic therapy, while performing a simultaneous assessment for possible sources in order to direct targeted therapy. This time includes discussing the case with the patient and the patient’s family. This time also includes the consideration for invasive and chemical support to prevent cardiopulmonary collapse. This time does not include all procedures stated elsewhere in this record. This time also includes reviewing old records, labs and radiological studies. This time includes examining and re-examining the patient. Additionally, this time also includes arranging care with admitting and consulting physicians.
ADMISSION
This patient requires inpatient admission and ongoing acute care as their infectious symptoms have not stabilized and the patient is at risk for decompensation and/or an adverse event. Outpatient therapy is not advisable/safe due to patient’s clinical status and/or social factors. The decision to admit was made after careful consideration of the patient’s past medical history, clinical risk factors, comorbidities, and diagnostic studies.
[Patient not stable for transfer]
The patient will be admitted for further therapy, hemodynamic monitoring, careful hydration, infection/source control, further diagnostic imaging, and possible procedure].
ACCEPTING CARE TEAM:
Current data and ongoing care discussed with Dr. []
Patient accepted at [time]
Patient to be dispositioned to: []
Case discussed directly with consultants:
Pending Data: none
Code Stroke
I evaluated the patient immediately upon arrival to the ED. Symptoms were concerning for acute stroke and a Code Stroke was initiated at [***]. Last known well is [hours/minutes ago.]
NIHSS: [***]
[NO TNK: Patient is not a TNK candidate because symptom onset > 4.5 hours or at least 1 of the following:]
ABSOLUTE CONTRAINDICATIONS FOR SYMPTOMS < 4.5 HRS
IF SYMPTOMS 3-4.5 HRS, SEE ADDITIONAL WARNINGS TO TNK BELOW
ICH/SAH on CT or extensive regions of clear hypoattenuation on CT
Uncontrolled hypertension (SBP > 185 or DBP >110)
History of intracranial hemorrhage
Neurosurgery, head trauma or stroke in past 3 months
Known intra-axial neoplasm, aneurysm, or AVM
Patient has received heparin w/i 48hrs and has an elevated aPTT (greater than upper limit of normal for lab)
Current use of oral anticoagulation and INR >1.7, current use of direct thrombin inhibitors/direct factor Xa inhibitors
Platelets < 100,000
Hypoglycemia < 50 mg/dl
Active internal bleeding, known GI malignancy, or GI hemorrhage within last 21 days
Intraspinal surgery in past 3 months
Suspected/confirmed endocarditis
Stroke is known or suspected to be associated with aortic arch dissection
RELATIVE EXCLUSION CRITERIA < 4.5 HRS
Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Seizure at stroke onset
Recent lumbar puncture
Major Surgery or serious non-head Trauma in previous 14 days
Arterial Puncture at non-compressible site < 7 days
Post myocardial infarction pericarditis
History GI or urinary tract hemorrhage within 21 days
Pregnancy
ADDITIONAL WARNINGS FOR SYMPTOMS 3-4.5 HRS
Age > 80
NIHSS > 25
Any anticoagulant use (even with INR < 1.7)
History of prior CVA and DM
CT shows multilobar infarction (hypodensity > 1/3 cerebral hemisphere)
[TNK ADMINISTRATION: There were no absolute contraindications to TNK identified. The neurologist has evaluated the patient and has discussed risks and benefits of TNK with the patient and/or family members at bedside. After discussion with the neurologist, the decision was made to administer TNK.]
TNK was initiated at [***]
[DELAY IN TNK ADMINISTRATION
The following events contributed to delay in TNK administration:
Social/Religious Beliefs
Initial refusal
Care-team unable to determine eligibility
HTN requiring aggressive control with IV meds
Further diagnostic evaluation to confirm stroke for patients with hypoglycemia (glucose < 50), seizures, or major metabolic disorders
Management of concomitant emergent/acute conditions such as cardiopulmonary arrest or respiratory failure (requiring intubation)
Investigational or experimental protocol for thrombolysis
Need for additional PPE for suspected/confirmed infectious disease]
THROMBECTOMY CANDIDATE CONSIDERATION (< 24 HOURS SYMPTOM DURATION)
[Given concern for LVO, and symptoms being < 24 hours, patient underwent additional imaging.]
INTRACRANIAL HEMORRHAGE CONSIDERATION
Patient found to have an ICH defined as [***]
Active ICH management for Blood Pressure Control [was/was not]required and Nicardipine was used to maintain a systolic blood pressure between [130-150 mmHG.]
ED DISPOSITION
While in the ED patient underwent hemodynamic monitoring as well as serial neuro exams and reassessments. At time of discharge from the ED patient was reassessed and their condition was [***]
CRITICAL CARE
Time: [***] minutes
Treatments/Evaluations: Close monitoring and treatment of unstable vital signs, cardiorespiratory, and neurologic status, while maintaining tight balance of fluid, respiratory, and cardiac interventions. Continuous neurologic and cardiovascular monitoring for deterioration of neurologic function and complications, while obtaining immediate neurologic imaging. Considerations were made for TPA and invasive therapy. This time includes discussing the case with the patient and the patient’s family. This time does not include all procedures stated elsewhere in this record. This time also includes reviewing old records, labs and radiological studies. This time includes examining and re-examining the patient. Additionally, this time also includes arranging care with admitting and consulting physicians.
CXR
Chest X-Ray (Interpreted by me, Krista Moore, MD):
Trachea midline. No free air under the diaphragm, no widened mediastinum/pneumomediastinum appreciated. No pneumothorax visualized.
[]Cardiac borders and costophrenic angles clear.
[]No focal consolidations or pleural effusions appreciated.
Critical Care
Critical Care Time: [35***] minutes
Treatments/Evaluations: Close monitoring and treatment of unstable vital signs, cardiorespiratory, and neurologic status, while maintaining tight balance of fluid, respiratory, and cardiac interventions. This time includes discussing the case with the patient and the patient’s family. This time does not include all procedures stated elsewhere in this record. This time also includes reviewing old records, labs and radiological studies. This time includes examining and re-examining the patient. Additionally, this time also includes arranging care with admitting and consulting physicians.
DDX AMS
hypoglycemia, electrolyte abnormality, seizure disorder, alcohol withdrawal, metabolic abnormality, cardiac dysrhythmia, hypoxia, substance abuse, alcohol intoxication, fever, traumatic head injury, infectious process, stroke
DDX Back Pain
MSK (strain, sprain, spasm), cauda equina, renal pathology, aortic pathology, fracture (vertebral), tumor, infection (spinal epidural abscess), shingles, skin/soft tissue infection
DDX CP
ACS, aneurysm, angina, asthma, bronchitis, CHF, COPD, dissection, esophageal reflux, musculoskeletal chest pain, pneumonia, pulmonary embolism, pleurisy, pericarditis/myocarditis
DDX F abd pain
GI (gastritis, GERD, PUD, cholecystitis, pancreatitis, gastroenteritis, bowel obstruction, appendicitis, indigestion, IBD) vs genitourinary (pyelonephritis, renal colic, renal calculi, cystitis, inguinal hernia, GU infection vs vascular (AAA, aortic dissection, mesenteric ischemia, intestinal angina, portal vein thrombus) vs MSK (shingles, cellulitis, abscess) vs malignancy vs reproductive(PID, tubo-ovarian abscess, ovarian torsion, Ovarian cyst, Pregnancy related complications)
DDX M abd pain
GI (gastritis, GERD, PUD, cholecystitis, pancreatitis, gastroenteritis, bowel obstruction, appendicitis, indigestion, IBD) vs genitourinary (pyelonephritis, renal colic, renal calculi, cystitis, inguinal hernia, testicular torsion, GU infection vs vascular (AAA, aortic dissection, mesenteric ischemia, intestinal angina, portal vein thrombus) vs MSK (shingles, cellulitis, abscess) vs malignancy
DDX SOB
ACS, angina, asthma, bronchitis, CHF, COPD, dissection, esophageal reflux, MI, URI/Flu/COVID, pneumonia, pulmonary embolism, pleurisy, metabolic or electrolyte abnornality.
DDX Trauma
closed head injury, facial fractures, intracranial hemorrhage, skull fracture, cervical, thoracic or lumbar fracture, traumatic intrathoracic hemorrhage, rib fractures, pneumothorax, pulmonary contusion, traumatic intra-abdominal hemorrhage, pelvic fractures, upper/lower extremity fractures
EKG
EKG (Interpreted by me, Krista Moore, MD):
Sinus rhythm with a ventricular rate of [#]
QTc [***]ms
No ST segment elevations/depressions, T wave inversions or other ischemic changes
Exam - Basic
GENERAL: well appearing, in no apparent distress, non-diaphoretic
HEAD: normocephalic, atraumatic
EENT: EOM intact, pupils equal round and reactive to light, no scleral icterus. Hearing intact to normal conversation. Mucus membranes moist
CV: Regular rate and rhythm. Well perfused, no dependent edema
PULM: Lungs clear to auscultation bilaterally. Normal depth, rate and work of breathing
ABDOMEN: Soft, non-distended, non-tender to palpation
SKINS: Warm, dry. No active bleeding from skin.
PSYCH: Patient cooperative with normal mood and affect.
EXTREMITIES: No obvious deformities. No cyanosis
NEURO: Awake and alert, moving all extremities without focal motor deficit
Exam - Female GU
Female Pelvic Exam:
Patient consented to sensitive exam and chaperoned by [HM/RN]
EXTERNAL GENITALIA: Normal hair distribution/trimmed/shaved pubic hair [] . No lesions, normal appearance, no prolapse/cystocele.
VAGINA: Speculum placed with visualization of the cervix. Pink vaginal vault, moist with normal appearing rugae. No lesions, blood, discharge, or yeast elements in vaginal vault. No amine odor present.
CERVIX: Parous/Non-parous cervix. No lesions, discharge from os, erythema or polyps. IUD strings []
BIMANUAL: Normal size, shape and contour. No obvious masses. No CMT or adnexal tenderness.
RECTAL: No external lesions, fissures, fistulas, or external hemorrhoids.
Exam - male GU
Male Genitourinary exam:
Patient consented to sensitive exam and chaperoned by [HM/RN]
Circumcised male/Foreskin retracts easily
Pubic hair: [***]
Cremasteric reflex intact.
Testicles descended bilaterally. No testicular masses, lesions or varicoceles. Epididymis nontender.
No palpable hernias via inguinal canal or abdominal wall or LAD.
Penis without lesions, urethral meatus without discharge or blood
Exam - Neonate Infant
GENERAL: Alert, active when aroused. NAD. Appropriately interactive.
HEENT: Anterior fontanelle open and flat. Conjunctiva clear, ears have normal shape and position with no pits or tags. Nares patent. Palate intact. Mucous membranes moist. TM’s clear bilaterally.
NECK: Full range of motion.
CARDIOVASCULAR: Normal precordium, regular rate and rhythm. No murmurs. Normal femoral pulses.
RESPIRATORY: Clear to auscultation bilaterally. No retractions.
ABDOMEN: Soft, nondistended. Normal bowel sounds. Umbilical stump is clean, dry, and intact without purulent drainage or surround redness.
GENITOURINARY: Normal external [female/+/- circumcised male] genitalia. Anus externally normal.
MUSCULOSKELETAL: Spine straight. No sacral dimple or hair tuft. Leg lengths grossly symmetric.
SKIN: Warm and pink with brisk peripheral and truncal capillary refill. No jaundice.
NEUROLOGICAL: Normal tone. Moves all extremities equally. [***Normal root, suck, grasp, and Moro reflexes (3-4 months)]
Exam - Peds
GENERAL: well nourished, developmentally appropriate child in NAD, playing in exam room in
HEENT: normocephalic, atraumatic, age appropriate fontanelles,
EYES: no icterus, discharge, or conjunctivitis. EOMI, PERRLA.
EARS: Hearing intact to normal conversation. TMs clear bilaterally, no pain with pinna manipulation.
NOSE: Normal nares, no discharge
THROAT: Mucus membranes moist. Normal gums and palate. Uvula midline, no exudates
NECK: no LAD, no nuchal rigidity
CV: Regular rate and rhythm, no murmurs, rubs or gallops. Well perfused, capillary refill <3 seconds, no dependent edema
PULM: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Normal depth, rate and work of breathing.
ABDOMEN: Soft, nontender, nondistended, no rigidity, no rebound, no guarding.
GU: [circumcised/not circumcised] normal genitalia. No rash.
BACK: No CVAT
EXTREMITIES: Normal appearing extremities, moves all extremities spontaneously without difficult. No clubbing or cyanosis.
NEURO: Normal muscle strength and tone.
SKINS: Pink, warm, dry. No rashes, normal skin turgor.
Exam - Full Neuro
NEURO: CN II-XII intact. SILT & 5/5 strength in bilateral upper and lower extremities. No pronator drift. No dysarthria. Gait and balance normal. Ambulated without difficulty.
Exam - Rectal
Patient consented to sensitive exam and chaperoned by [HM/RN]
RECTAL: No external lesions, no fissures, no fistulas, no external hemorrhoids, no skin tags, no pilonidal cysts. Normal sphincter tone. No rectal masses, prostate smooth & normal in size. No blood on the glove.
