MedNote Dawson Dean

6:36 PM | BY ZeroDivide EDIT

Critical
CV/Pulm
Renal
Renal 2
Electrolytes
GI/Endo
PreExisting
Other




Chief Complaint:
History of Present Illness:


Review of Systems:
A fourteen (14) point Review of Systems was performed and is otherwise negative except as per the history above and also the following specific positive and negative findings:
Constitutional: no fevers, no weakness, no weight loss, normal appetite
Eyes: no dry eyes, no blurred vision, no vision changes
HENT: no hearing loss, no oral lesions, no rhinorrhea
Cardiovascular: no chest pain, no palpitations, no edema
Respiratory: no shortness of breath, no cough, no dyspnea on exertion, no change in sputum production
Gastrointestinal: no nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
Genitourinary: no partial voiding, no weak stream, no urinary hesitancy, no dysuria
Musculoskeletal: no back pain, no shoulder pain, no hip pain, no knee pain
Integumentary: no rashes, no lesions, no bruising
Neurological: no headaches, no dizziness, no sensation loss, no burning
Psychiatric: no depression, no anxiety, no hallucinations
Hematologic: no melena, no hematochezia, no hematemesis, no coffee ground emesis, no hematuria
Endocrine: no heat intolerance, no cold intolerance, no excessive thirst
Allergic: no allergic reactions, no recurrent infections
All other review of systems are negative.

Medical History:

Surgical History:

Social History:
- Tobacco:
- EtOH:
- Illicits: None

Family History:
Reviewed and non-contributory
Mother:
Father:

Home Medications:

Allergies: NKDA

OBJECTIVE
Physical Exam:
General: AOx3, no acute distress, well-nourished
HEENT: oral pharynx clear, mucosa moist, anicteric
Neck: supple, no thyromegaly, no JVD
Cardiovascular: regular s1/s2, no murmurs, no JVD, no lower extremity edema
Pulmonary: clear, no crackles, no wheezes, non-labored
Abdom: normal bowel sounds, soft, non-tender, non-distended
Muskuloskeletal: full RoM in BUE, full RoM in Knees, full RoM in Hips
Neurologic: no asterixis, CN II-XII grossly intact, 5/5 BUE strength, 5/5 BLE strength, Negative Babinski
Dermatologic: no rashes, no lesions, no ulcers

ASSESSMENT/PLAN
History and Physical
Review of Systems






Physical Exam

#) Chest Pain
/Assessment:
The pain is non-cardiac, with 1 properties: substernal
The patient has 2 cardiovascular risk factors: Diabetes, Hypertension
The TIMI score is 1 with: elevated Troponins
/Plan:
- Check Troponins
- Aspirin 325mg PO once then 81mg daily
- Atorvastatin 80mg
- Lisinopril 2.5mg PO daily
- Risk stratify and check HgbA1c
- Continuous bedside Telemetry
NSTEMI    

   
Age: 
  • Contraindications to NTG: Sildenafil or other erectile dysfunction med in past 7 days, Bradycardia (HR below 60), Hypotension, R-side or inferior wall MI
  • Do not anticoagulate in a Type-2 NSTEMI caused by Hypertensive Urgency, as it increases risk of hemorrhagic stroke
  • ASCVD score http://tools.cardiosource.org/ASCVD-Risk-Estimator/
  • Not clear whether to hold PPI if on Clopidogrel

#) Diabetic Ketoacidosis
Diabetic Ketoacidosis           

 

#) GI Bleed
GI Bleed           

 

#) SIRS
Sepsis           

 
WBC: 
 

#) Stroke
Stroke    

   

#) Encephalopathy
Encephalopathy           

 

#) Syncope
Syncope           

 

#) Malignancy
Oncology           


#) Hepatitis
Hepatitis           

 
PT: INR: Tbili: Cr: 

#) Pancreatitis
Pancreatitis           

 

#) Pneumonia
Pneumonia           

 

#) Coronary Artery Disease
Coronary Artery Disease    

#) Heart Failure
Heart Failure    

 
  LVEF: 

#) Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease    

 
  FEV1: 
 
 

#) Preoperative Evaluation
/Assessment:
The patient has 0 cardiac risk factors which suggests a 0.4 percent risk of of major cardiac events based on RCRI
The patient has 0 renal risk factors which suggests a 0,1 percent risk of of perioperative AKI requiring Dialysis
The patient has 0 renal risk factors which suggests a 0.2 percent risk of for any perioperative AKI with a rise of Cr over 2
Pre-Op           


#) Cirrhosis
/Ascites:
- Furosemide 40mg
- Spironolactone 100mg
/Encephalopathy Stage 0 (none):
- Lactulose 30mL PO TID, titrate for 2-3 stools daily
- Rifaximin 550mg PO BID
Cirrhosis        
 
PT INR Na Cr TBili Albumin 
  
 

#) Renal Failure on Hemodialysis
Renal Failure on Dialysis   

 

#) Renal Transplant
Renal Transplant   

 

#) Acute Kidney Injury
/Assessment:
Since admission Cr=
Baseline Cr=
This is KDIGO Stage 1 (Cr rose 0.3 or 1.5x to 2x baseline within 48hrs or urine output below 0.5 mg/kg/hr for 6 hours)
Acute Kidney Injury
Cr Baseline Cr Na Urine-NaUrine-Cr
   
 

#) Chronic Kidney Disease
Chronic Kidney Didease           

 
Cr: GFR: 
Age: U Prot: U Albumin: U Cr: 
 
 

#) Nephrotic Proteinuria
Nephrotic Proteinuria
Urine-ProtUrine-AlbUrine-CrSerum Albumin 
   
 

#) IV Contrast
IV Contrast           


#) Dysphagia
Dysphagia           


#) Metabolic Bone Disease
Mineral Bone Disease           

Ca: Phos: PTH: Albumin: 

#) Hypertension
Hypertension           

 

#) Acid Base
Acid Base
Na: Cl: Bicarb: 
Albumin: ABG pH: PaCO2: 
Urine Na: Urine K: Urine Cl: 
 
Differential
Treat

#) Hypokalemia
Hypokalemia           

K: Mg: Ur-K: Ur-Cl: 
Serum Osm: Ur-Osm: 

#) Hyperkalemia
HypERKalemia           

K: Ur-K: Serum Osm: Ur-Osm: 

#) Hyponatremia
Hyponatremia           

Na: Glucose: Bicarb: Serum Osm  
Urine Osm: Urine Na: Urine K: 
 
 
 
 
 

#) Hypernatremia
HypERNatremia           

Na: Ur-Osm: Ur-Na: Ur-K: 

#) Hypomagnesemia
HypOMagnesemia           

Mg: 

#) HypoPhosphatemia - Present on admission
HypOPhos           

Phos: Ca: iCal: PTH: 

#) HypoCalcemia - Present on admission
HypOCalcemia           

Ca: iCal: PTH: Albumin: 

#) HyperCalcemia
HypERCalcemia           

Ca: iCal: PTH: Albumin: 

#) Vitamin D Deficiency
Vit D Deficiency           

Vit D: 

#) Diabetes
Diabetes           

 
A1c: 

#) Asthma
Asthma    

 
 

#) Obstructive Sleep Apnea
Obstructive Sleep Apnea           

 
 

#) Atrial Fibrillation
Atrial Fibrillation    

   
INR: 
 
 

#) Anemia
Anemia           

 

General:

Workup:

Monitor:

Treat:

#) Hypothyroid
Hypothyroid           


#) Gout
Gout           

 
Urate: 

#) Gastroesophageal Reflux Disease
GERD           


#) Benign Prostatic Hyperplasia
BPH           


#) Alcohol Abuse
Alcohol           


#) Substance Abuse
Substance Abuse           

 

#) Tobacco Dependance
Tobbaco           

Age Started: 

#) Calorie and Protein Malnutrition (Present on admission)
Malnutrition           

 
BMI: Prealbumin: 

#) Palliative
Palliative           


#) Obesity (Present on admission)
Obesity           

 
BMI: 

#) Mood Disorder
Mood Disorder           

 
I:II:IIIIV

#) Weakness - Present on admission
Weakness           

 

#) Pressure Ulcer (Present on admission)
Pressure Ulcer           

 

#) Chronic Hepatitis C
Hep C           

 

#) Femoral neck fracture
Leg Fracture           

 

#) Nephrolithiasis
Nephrolithiasis           

 
 


#) Fluids/Electrolytes/Nutrition
- Regular diet

#) Prophylaxis
- Enoxaparin subcu

#) Discharge Planning
- Followup appointments after discharge:

#) Code Status
- FULL CODE

Common Plans           

Diet

Prophylaxis

Discharge Planning
Barriers:
PT Recs:
Discharge Meds:

Code Status
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