tosborne
Contributor
Need help abstracting relevant HPI from Palliative Care Initial Consultation note:
This patient is a 52-year-old, unfortunate female, who was found unresponsive by her family on May 17, 2016. The patient had agonal breathing and ACLS protocol was started en route to _____________. Once arrived at ___________, the patient did have a total downtime of approximately 12 to 15 minutes. The patient does have a history of COPD and is on home oxygen at 2 L and also did have a recent admission to __________________ about a month ago for hypercapnic respiratory failure and was on the ventilator there for three days. The patient did continue to code for another 8 to 10 minutes before return of spontaneous circulation at _______. Total downtime for the patient is about 15 minutes. Patient was subsequently transferred to ________ ICU unit for further evaluation and upon arrival the patient was unresponsive and would not respond to any painful stimuli and she has been monitored in the ICU since then. Palliative Care Team has since been consulted to hold discussions with the patient's family about goals of care and code status as at this point, the patient is still unable to follow commands.
This patient is a 52-year-old, unfortunate female, who was found unresponsive by her family on May 17, 2016. The patient had agonal breathing and ACLS protocol was started en route to _____________. Once arrived at ___________, the patient did have a total downtime of approximately 12 to 15 minutes. The patient does have a history of COPD and is on home oxygen at 2 L and also did have a recent admission to __________________ about a month ago for hypercapnic respiratory failure and was on the ventilator there for three days. The patient did continue to code for another 8 to 10 minutes before return of spontaneous circulation at _______. Total downtime for the patient is about 15 minutes. Patient was subsequently transferred to ________ ICU unit for further evaluation and upon arrival the patient was unresponsive and would not respond to any painful stimuli and she has been monitored in the ICU since then. Palliative Care Team has since been consulted to hold discussions with the patient's family about goals of care and code status as at this point, the patient is still unable to follow commands.