AKI / CKD / ESRD

#AKI on CKD***
- Cr *** on admission (baseline Cr: ***)
- Suspect ***-renal etiology 2/2 ***
- s/p ***L of IVF, f/u repeat Cr***
- No recent contrast or offending medications***
- ***
- ***
- Strict I/Os, monitor UOP
- Renal dose med, avoid nephrotoxins
[ ] f/u urine lytes & FeNa
[ ] f/u renal US
[ ] f/u PVR
- ***

For ESRD patients

#ESRD
#HyperPhosphatemia***
- HD *** via ***
- Last HD on ***
- Consult renal for HD while inpatient, no indication for emergent HD***
- c/w home Renvela TID***
- c/w home cinacalcet***
- Renal diet, renal dose meds

’murica (T2DM, HTN, HLD, obesity, OSA)

Everything is bigger in Texas

#T2DM (A1c ***)
#HTN
#HLD
- Home insulin: ***u basal daily*** + ***u TIDac

- While in-house, Levemir ***u qAM &***u qPM + aspart ***uTIDac + SSI
- While NPO***, Levemir ***u qAM &***u qPM + SSI
- Correctional insulin monotherapy*** for 24h. Tomorrow, plan to either add basal or d/c

- c/w home ARB/ACEi
- c/w home statin
- c/w home gabapentin*** for diabetic neuropathy

[ ] f/u repeat A1c
[ ] f/u fasting lipids
- Consider starting *** on discharge

#Obesity
#OSA *** on home CPAP
#Suspected*** OSA
- Patient unable to recall their home settings
- ***PAP at night
- Patient could benefit from sleep study outpatient***

Cirrhosis

#Cirrhosis 2/2 ***, ***decompensated
- History of decompensation: ***
- MELD-Na: *** on admission
- Last EGD (***): ***

- PSE: Denies h/o HE, no evidence of HE on exam, ctm***
- PSE: No*** evidence of HE on exam, c/w lactulose (titrated to 3-4BM / day)
- PSE: ***, lactulose (titrated to 3-4BM / day), Rifaximin 550 BID

- Ascites: c/w home Lasix:Spiro 40:100 *** Lasix:Spiro 80:200
- Ascites: Consult IR*** for paracentesis
- Ascites: s/p ***L para, SAAG ***

- SBP: c/w Rocephin (***-p), f/u cell count, on *** for PPx at home
- SBP: No evidence of SBP (PMNs ***)

- EV: No evidence of GIB presently, close monitoring 
- on *** for PPx at home, will continue
- EV: s/p Protonix 80 x1
- c/w octreotide gtt, PPI gtt***40 IV q12h, CTX x5 d

- HRS: Cr at baseline (***)
- HRS: Cr on admission (baseline ***), albumin challenge

- Daily CMP + INR to calculate MELD; low Na diet
- GI consult***

CIWA / Smoker / Substance use

If considering long acting benzos: 2mg Ativan \(\approx\) 50mg Librium \(\approx\) 10mg Valium, but keep in mind the hepatic metabolism

Equivalent Benzodiazepine Calculator

#EtOH abuse
- Currently drinking *** per ***
- Last drink: ***
- Withdrawal Hx: ***, no h/o seizures
- CIWA and close monitoring
- Insight*** consult placed
- Consider naltrexone on discharge

#Substance use disorder
- Pt reports ***
- UDS pending***
- HIV, hepatitis panel
- Insight*** consult placed

#Current smoker
- Current ***ppd smoker. *** pky hx
- Nicotine patch w/ PRN gum
- Insight*** consult placed
- Advised cessation

COPD +/- CAP

#COPD exacerbation
#CAP***
- Reports *** days of worsening dyspnea, increased sputum, sputum color change
- *** pky ***current smoker
- On ***L home O2
- During prior admissions required BiPAP***intubation
- VBG: *** / ***; serum HCO3 ***
- CXR: w/o*** consolidation
- Duonebs q4h
- Prednisone x5 d (*** - p)
- Three day Z-pack (*** - p)
- CTX for CAP coverage*** given ?consolidation on CXR
[ ] f/u uStrep & uLegionella

Pancytopenia / nutritional anemia / ?MDS

#Pancytopenia***
#Anemia, ***cytic
- Baseline hgb: ***
[ ] Reticulocyte count
[ ] PBS pending
- Retic index ***hypoproliferative
- Nutritional eval: MMA, homocysteine, thiamine, copper, zinc
- Iron panel c/w ***
- Empiric thiamine IV x1
- Empiric multivitamin, folate, thiamine
- No evidence of overt bleed
- Transfuse if Hgb<***

Infectious diseases

#Ulcer of the ***
- Wound is w/o*** purulent secretion and w/o*** signs of infection
- Classify the wound*** (Table 2 of IDSA guidelines helpful, so can also consider WIfI if vascular studies available)
- See photo uploaded in EMR

- Discontinue abx (.dcabx***) as wound does not appear infected
- Switch to vanc & Unasyn*** (unless h/o PsA)
- Consult surgery for deep tissue Cx &/or debridement
- ***

- Baseline XR***
[ ] f/u XR to eval potential OM
- MRI***

- ABI, TBI, arterial US
- No s/s of claudication
- Vascular consult in the AM***

- Wound care consult, PT for offloading
- Tight glycemic control
- ASA due to c/f PVD 

#Acute arthritis of the *** knee, concerning for septic arthritis***bursitis
- Joint is warm, swollen, TTP w/ limited ROM w/o*** overlying cellulitis
- Denies known trauma to the knee, PMH of gout
- No pain in other joints
- WBC ***, ESR ***, CRP ***
- XR: ***
- MRI: (If not wanting to tap the joint)***

- Ortho consulted, planning*** for tap
- c/w vanc, ***

- Follow BCx, fluid studies
- NPOpMN for washout in AM***

#Skin/soft tissue infection of the ***
- Ongoing for ***
- Reports fevers*** at home, Tm *** here
- WBC ***, ESR ***, CRP ***
- Lower*** c/f osteomyelitis
- XR: ***
- MRI: Pending***
- c/w vanc & ***
- Switch to doxy & amox ***
- ***

#HIV (CD4 *** in ***)
- Follows with ***
- Reports good*** adherence to ***
- Last CD4 ***, VL *** (***date)
- c/w home ***
- c/w *** ppx

#Asx bacteriuria
- Patient denies s/s of cystitis, inc ***
- s/p *** in ED
- Discontinue antibiotics

GI bleed

#Upper GI bleed
- DDx includes esophagitis, gastritis, AVM, Dieulafoy's lesion, PUD***
- Maintain two working large bore IVs, volume resuscitation, active T&S
- PPI drip 80mg bolus then 8mg/hr
- Octreotide drip 50mcg bolus then 50mcg/hr
- Hgb goal >7, INR <2, plat >50 with active bleeding. Do not overtransfuse in cirrhosis as it can increase portal pressures further and worsen bleeding.
- *** Diet today
- NPO***
- ***Airway protection
- Anti-emetic ***
- ABX ***
- EGD***

#Lower GI bleed
- DDx includes diverticular, hemorrhoidal, AVMs, brisk upper GI bleed.
- Maintain two working large bore IVs, volume resuscitation, active T&S
- Hgb goal >7, INR <2, plat >50 with active bleeding. 
- NPO***
- Colonoscopy***

HFrEF

Need to make a HFpEF dot phrase, but when you do add the H2FpEF score to it

#HFrEF (LVEF ***% on ***)
- Suspected exacerbation 2/2 *** 
- Dry weight: ***
- TTE (***): LVEF ***%, grade *** DD, RVSP ***
- Home diuretics: Lasix ***
- GDMT:
   *BetaB: Hold due to decompensation, was on metop *** at home
   *RAAS: c/w home ***
   *Aldo: ***
   *SGLT: c/w home ***
   *ICD: Address outpatient
- s/p *** in the ED
- Will start aggressive diuresis with *** for goal net negative ***
- Strict I/Os, daily weights
- If gut edema, consider PO bumex (L:B PO conversion 40:1)*** on discharge 

Obstructive jaundice

#Obstructive Jaundice
- Un***/known primary *** cancer
- CT A/P (***): ***
- Labs remarkable for Tbili ***, Dbili ***, AST ***, ALT *** and Alk Phos ***
- Will obtain RUQ US ***
- GI consulted for evaluation and possible ERCP
- Dis***/continue abx to cover for cholangitis

SBO

#SBO: Malignant vs benign*** 
- Imaging: ***
- Transition point: ***
- NPO, NGT to suction
- IVF & monitor electrolytes
- Antiemetics and analgesics
- Surgery ***
- Octreotide, Dex ***

Syncope

Canadian Syncope Risk Score

#***Syncope
- ***pertinent HPI/risk factors
- Suspect vasovagal***orthostatic because ***
- Low suspicion for PE (if able, PERC rule***)
- EKG: ***
- CTH: ***
- Admit w/ tele
[ ] Orthostatic VS
[ ] interrogate ICD
[ ] f/u TTE

Trop elevation

#NSTEMI
#Unstable Angina
- Risk factors: ***
- Trop trend: ***
- EKGs: ***
- TIMI score: *** (link***)

- s/p ASA load in ED, c/w daily ASA
- High intensity statin
- Heparin drip***
- Start metop 12.5 BID (***unless cardiogenic shock)
- Should probs be on ARB/ACEi (***for other reasons)
[ ] f/u TTE
[ ] f/u A1c, lipids
- Stress test ordered
- Cards consult

#Demand Ischemia / Type 2 MI
- Troponin w/o clinical history or EKG suggestive of ACS. 
- Demand ischemia most likely secondary to ***
- Low suspicion for PE, pericarditis, myocarditis
- Denies chest pain***
- EKG with ***
- Trend trops to peak

Day team do the med rec

#Transitions of care
- Unable to obtain full medication list from patient due to [mentation] [poor recall]
- Called emergency contact without success
- Will reattempt in the AM
- Will discuss with pharmacy to obtain accurate medication list

OLDER

#Anemia, ***cytic
- Baseline Hgb ***
- Reticulocyte count: ***
- r/o hemolysis: DAT ***, LDH ***, haptoglobin ***, fractionated bilirubin ***
- r/o DIC: Fibrinogen *** , D-dimer ***, Coags ***
- r/o nutritional: Iron panel ***, B12/folate ***, MMA/Homocysteine ***
- monitor and transfuse if <7

#Chest pain
-DDX: 
    - Cardiac: ACS, pericarditis, myocarditis, anomalous coronary/bridge, takutsuobo
    - Pulmonary: PE, pleuritis, pna, serositis
    - MSK: costochondritis, rib fx
    - Derm: No h/o or current rash to indicate zoster or post-herpetic neuralgia
    - Referred: GERD, liver, spleen, diaphragm 
- PE, Tamponade, dissection, ACS, PNX, esophageal rupture
- PERC negative (<50 y/o, HR<100, Sp02>95%, no hormone use, surg past mo, leg swell, hemoptysis, h/o VTE)
- EKG: ***
- Troponin: ***
- CXR: ***
- Bedside u/s ***
- Prior TTE, caths ***

#Hyponatremia
- NA trend: ***
- SOsm: ***, rule out pseudohyponatremia
- Hypovolemic (UNa, hx), euvolemic (UOsm, TSH, Cortisol), hypervolemic (Cirrhosis, CHF)
- Sx: *** (HA, gait instability, AMS, seizure, Nausea/malaise, lethargy, muscle cramps)
- Tx: ***

Capacity - No

#Capacity
In my medical opinion, at this time this patient does NOT have capacity to make a medical decision regarding ***, because:

[***] The patient is unable to communicate a choice
[***] The patient is unable to understand the relevant information
[***] The patient is unable to appreciate a situation and its consequences
[***] The patient is unable to reason rationally

Capacity is dynamic and should be re-assessed frequently to see if they regain capacity. Until that time, the patient’s proxy/surrogate decision maker(s) is/are ***.

#CODE STATUS
- Patient is PRESUMED full code***.
- Will continue to attempt to contact patient’s proxy to clarify code status

Capacity - Yes

Capacity Assessment: In my medical opinion, this patient has capacity to make medical decisions. The patient has the ability to communicate their choice to me and others, understands the information relevant to this decision, appreciates the situation itself and the consequences inherent to their choice, and can logically explain their rationale for their decision.

D/C ABX & monitor

- Discontinue antibiotics, hold antipyretics
- Monitor for further signs of infection, ***low threshold to resume abx
- Follow cultures

Death note

I was called to patient’s bedside to pronounce patient as deceased. No spontaneous movements were present. There was no response to verbal or tactile stimuli. Pupils were mid-dilated and fixed. No carotid pulses were palpable. No heart sounds were auscultated over entire precordium.

***Air movement from mechanical ventilation was heard over bilateral chest. No breath sound were heard with mechanical ventilation turned off.

Family was notified and attending physician was notified. The family has not made a decision of autopsy at the time of this note. Chaplain and postmortem services were offered. Patient was DNR at time of death. Time of death was [____] on [____].

General: unresponsive, no spontaneous movements, no response to verbal or tactile stimuli.
Eyes: pupils fixed and dilated, corneal reflexes absent.
CV: no heart sounds, no carotid pulses.
Lungs: no breath sounds, no chest wall motion.
Extremities: absent distal pulses

Negative 14 point ROS

All other systems in the 14-point ROS were reviewed and are negative (unless otherwise documented in the HPI and/or below). If there are discrepancies between what is listed in the “History of Present Illness” section and below, the HPI section takes precedence

Constitutional: (-) fever/chills, (-) recent loss of weight, (-) appetite changes, (-) night sweats.
Head: (-) headache, (-) dizziness.
Eye: (-) blurring of vision, (-) double vision, (-) redness.
Ear: (-) hearing loss, (-) discharge, (-) vertigo
Nose: (-) discharge, (-) bleeding, (-) congestion, (-) post nasal drip.
Throat: (-) sore throat, (-) hoarseness of voice, (-) odynophagia.
Cardiovascular: (-) chest pain, (-) palpitations, (-) syncope, (-) orthopnea, (-) PND, (-) leg swelling.
Respiratory: (-) shortness of breath, (-) cough, (-) wheezing, (-) hemoptysis.
Neuro: (-) weakness in extremities, (-) numbness, (-) tingling, (-) tremor.
Gastrointestinal: (-) belly pain, (-) belly distension, (-) nausea, (-) vomiting, (-) diarrhea, (-) constipation, (-) na, (-) hematemesis, (-) hematochezia, (-) bowel incontinence
Genitourinary: (-) hematuria, (-) dysuria, (-) polyuria, (-) hesitancy, (-) frequency, (-) urinary incontinence.
Musculoskeletal: (-) myalgia, (-) arthralgia.
Skin: (-) rashes.
Endocrine: (-) heat/cold intolerance.
Psychiatry: (-) depression, (-) hallucination.

Misc

Seen & staffed

Patient *** with attending Dr ***. Please see their addendum/attestation for further details

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