Critical Care Note

peeya

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Will this note justify critical care code. Patient is already in ICU when the Doctor is called..

TYPE OF CONSULTATION: Cardiology

ORDERING PHYSICIAN: Dr. ____________
CONSULTING PHYSICIAN: _____________

REASON FOR CONSULTATION: Consideration for myocardial infarction.

HISTORY OF PRESENT ILLNESS: This is a 55-year-old male patient who
was found pulseless in his place of residence in a nursing facility.
Paramedics were called, who found staff performing CPR upon arrival.
The rhythm the paramedics established per protocol was ventricular
fibrillation and he was shocked. Subsequently, asystole was noted and
after the third bolus of epinephrine, pulse was regained. He was
transferred to the Valley Presbyterian Medical Center. In the
hospital, he had multiple episodes of CPR. Pulse was regained for a
brief time and then CPR was resumed. That occurred at multiple times.
I was called due to EKG findings. EKG findings are noteworthy
for initial EKG at 8:55 which reveals ST depression and sinus rhythm.
At 8:58, ST elevations were noted in leads I, II, III, aVF, lead II,
V4, V5, and V6, with reciprocal changes in the remaining leads. At
9:03, the EKG normalized. There were no remaining ST elevations. There
are now nonspecific ST-T changes. I see the patient in the emergency
room. Earlier, immediate cardiac catheterization was considered. We
decided to hold off, giving that EKG normalized without undue
coagulation or revascularization therapy. Also in light of the fact
that the patient is completely nonreactive at the time and no
sedation was given. The patient is now on hypothermia protocol. He is
on Levophed drip.

PAST MEDICAL HISTORY: Diabetes mellitus. Arterial hypertension.
Hyperlipoproteinemia, obesity, COPD, thyroid disorder, depression.

HOME MEDICATIONS
1. Albuterol.
2. Norvasc.
3. Colace.
4. Lovenox 40 mg subcutaneous daily.
5. Atrovent.
6. Claritin.
7. Tapazole.
8. Zyprexa.
9. Protonix.
10. Zocor.
11. Prednisone.
12. Vicodin.
13. Clonidine.
14. Albuterol.
15. Ativan.
16. Fleet enema.
17. Insulin sliding scale.

SOCIAL HISTORY: Cannot be obtained.

FAMILY HISTORY: Cannot be obtained.

REVIEW OF SYSTEMS: Cannot be obtained.

PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure is 40/ ________, now 144/86, heart rate
is 122, respiratory rate is 30, pulse oximetry is 97%, temperature
94.8, on hypothermia protocol.
HEAD: The patient is intubated.
NECK: Jugular veins visible at 9 cm. There are no bruits.
CHEST: Crackles audible both lower lobes.
CARDIOVASCULAR: Irregular rate and rhythm, no murmurs.
ABDOMEN: Soft.
EXTREMITIES: 1+ pitting edema both lower extremities, 1+ pulses
dorsalis pedis and tibialis posterior bilaterally and symmetrically.

DIAGNOSTIC DATA
EKG of 9:18: Sinus rhythm, ST depressions, 134 beats per minute.
EKG at 8:55: Sinus rhythm, nonspecific ST-T changes, ST depression in
V5 and V6.
EKG at 8:58: ST elevation in leads I, II, III, aVF, reciprocal ST
depression in aVR and lead V1, ST elevation also in V3, V4, and V5
and V6.
EKG at 9:03: Sinus tachycardia, 151 beats per minute, nonspecific ST-
T changes.

LABORATORIES: White blood cells 20.4, hematocrit is 40.5, platelets
156,000. INR is 1.34. Sodium 135, potassium 4.8, creatinine is 1.3. CK
52, CK-MB 1.5. Troponin 0.23. BNP 1210.

IMPRESSIONS
1. Cardiopulmonary arrest.
2. Hypotension.
3. Coma.
4. Renal insufficiency.
5. Chronic obstructive pulmonary disease.
6. History of arterial hypertension.
7. Thyroid disorder.
8. Gastroesophageal reflux disease.
9. Diabetes mellitus.
10. Hyperlipoproteinemia.

PLAN AND COURSE: At this point, we are holding off of cardiac
catheterization given the normalization of the EKG. It is possible
that the ST elevation was seen shortly after an episode of asystole.
It is noteworthy that the patient showed marked ST elevation in
several territories, which may be suggestive of relative ischemia in
the presence of profound hypotension and clinical death. It is also
noteworthy that the patient, at this point, is not reactive to any
stimuli before sedation was initiated. I concur with hypothermia
protocol. The patient should remain on aspirin and on pressor
therapy. We will obtain a 2-dimensional echocardiogram. Will check
a repeat EKG, repeat CK, CK-MB. We will consider cardiac
catheterization, but will first initiate medical therapy.

ADDENDUM

CRITICAL CARE TIME: The total critical care time I spent with the
patient is 39 minutes without inclusion of any procedures.
 
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