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The documentation:
Why aren't the hypertension and smoking reported?
EMERGENCY DEPARTMENT
SEX: MALE
AGE: 60
DOS: 1/1/20XX
Code only for the ER physician
Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS:
Chief Complaint- MULTIPLE SYNCOPAL EPISODES. It has been waxing/waning. This occurred over past few weeks, 3 times this week. He has recovered. Is no longer unconscious. Event was witnessed. At time of event, he was standing. He had preceding symptoms of light-headedness. No preceding symptoms of nausea, dim vision, chest pain, warmth or abdominal pain. He lost consciousness completely. No seizure activity, incontinence or apnea noted. Did not lose pulse. Experienced repeated episodes. The episode lasted seconds. No injuries noted. The patient currently has generalized weakness. No localized weakness. Similar symptoms previously: He has had similar symptoms previously. Recent medical care: The patient was seen recently by a health care provider. REVIEW OF SYSTEMS:
The patient has had dizziness and a mild headache. He has had generalized weakness. No localized weakness. No chest pain, palpitations, abdominal pain, vomiting or diarrhea. No black stools, bloody stools, fever, sore throat or difficulty breathing. No difficulty with urination, skin rash, enlarged lymph nodes or cough. All systems otherwise negative, except as recorded above. PAST HISTORY: Hypertension. No history of a stroke or heart disease. Risk factors for heart disease-smoking and hypertension . Denies the following risk factors for heart disease - elevated cholesterol. SOCIAL HISTORY: Current smoker. No alcohol use or drug use. ADDITIONAL NOTES: The nursing notes have been reviewed. Weight: 80.7 kg. Height: 66 inches. BMI: 28.7. PHYSICAL EXAM:
Appearance: Alert. IV present X 1. EKG monitor and O2 sat monitor on the patient. Vital Signs: Have been reviewed and appear to be correct. (BP: 165/60. HR: 68. RR: 16. Temp: 96.8. O2 saturation 99%). Eyes: No nystagmus. ENT: Normal ENT inspection. Moist mucous membranes. Neck: Normal inspection. Neck supple. CVS: Normal heart rate and rhythm. Heart sounds normal. Respiratory: No respiratory distress. Breath sounds normal. Abdomen: Soft and nontender. No organomegaly. Back: Normal inspection. Skin: Skin warm and dry. Normal skin color. No rash. Normal skin turgor. Extremities: Extremities exhibit normal ROM. No lower extremity edema. Neuro: Alert. Oriented X 3. Mood/affect normal. Cranial nerves normal (as tested). No motor deficit. No sensory deficit. LABS, X-RAYS, AND EKG
EKG: 12 lead EKG time (16:34). No acute process. No acute ischemia. 12 lead EKG performed. EKG shows non-specific T-wave flattening without other abnormality. ( independently viewed and interpreted contemporaneously by me.)
Rhythm Strip: Normal rhythm strip (good tracing): (independently viewed and interpreted contemporaneously by me). Normal sinus rhythm. Normal PR interval. Normal QRS complexes. Normal STs and T waves. No ectopy.
Christopher Thomas, MD
Electronically signed by CHRISTOPHER THOMAS, MD 1/1/20XX
CT Head: (DISCUSSION: Noncontrasted CT head shows normal brain ventricles,
sulci, basal cisterns. No evidence of mass, mass effect, hemorrhage,
hematomas no acute infarction.
IMPRESSION: Normal Noncontrasted CT head.
Ronald Kramer, MD
Electronically signed by RONALD KRAMER, MD 1/1/20XX *Prior studies were not available for comparison. The study was interpreted by the radiologist (Kramer). Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process. 0525:YJ:CG00123R: (Final results)
Laboratory Test Value: HOLD TUBE FOR COAG SEE NOTE
0525:YJ:C00440S:Final results
Laboratory Test Value
SODIUM 140
POTASSIUM 3.4
CHRUTHDE 105
CARBON DIOXIDE 20.0
ANION GAP 15
GLUCOSE 54
BLOOD UREA NITROGEN 21
CREATININE 1.80
GLOMERULAR FILTRATION RATE 41
TOTAL PROTEIN 8.0
ALBUMIN 3.8
CALCIUM 9.8
BILIRUBIN TOTAL 0.30
SGOT/AST 10
SGPT/ALT 18
ALKALINE PHOSPHATASE 97
CREATINE KINASE (CK) 122
TROPONIN I 0.03
0525:YJ:H00270S: Final results
Laboratory Test Value
WHITE BLOOD CELL 12.8
RED BLOOD CELL 4.24
HEMOGLOBIN 14.0
HEMATOCRIT 42.2
MEAN CELL VOLUME 99.5
MEAN CELL HGB 32.9
MEAN CELL HGB CONCENTRATION 33.1
RED CELL DISTRIBUTION WIDTH 14.0
PLATELET COUNT 264
MEAN PLATELET VOLUME 10.2
NEUTROPHIL % 78.9
LYMPHOCYTE % 12.8
MONOCYTE % 7.7
EOSINOPHIL % 0.2
BASOPHIL % 0.4
NEUTROPHIL # 10.1
LYMPHOCYTE # 1.6
MONOCYTE # 1.0
EOSINOPHIL # 0.0
BASOPHIL # 0.1
MANUAL DIFF REQUIRED? NO
SMEAR REVIEW ? NO
NP AUTO DIFF NO . Bedside Tests: Glucose: hyperglycemia - 181 (performed pre-hospital). Pulse Oximetry: O2 saturation- 99% room air. PROGRESS AND PROCEDURES:
Course of Care: 60 year-old male presents with frequent falls/likely syncopal events. Patient reports 3 times over the past week having falls after feeling dizzy, "blacking out" briefly. No chest pain, dyspnea at any point. Patient feels generally weak and minimally dizzy at time of presentation.
EKG shows non-specific T-wave flattening without other abnormality.
CT head negative.
Labs show mild renal insufficiency without other significant abnormality.
Given several recent syncopal events, will admit Mr. Smith for further observation/workup.
Discussed patient with Dr. Andrews who will admit Mr. Smith.. Discussed case with hospitalist, (Andrews). Reviewed test results. Agreed upon treatment plan. Health care provider will see patient in hospital. Patient and family counseled in person regarding the patient's stable condition, test results, diagnosis and need for admission. IV fluid administered under direct supervision of physician. Clinical Review ECG interpretation documented. Antiplatelet medications administered. Consultation obtained from admitting physician. Disposition: Placed in observation status in Telemetry. CLINICAL IMPRESSION: Syncope of unknown cause. 12 lead EKG performed. Christopher Thomas, MD
Electronically signed by CHRISTOPHER THOMAS, MD 1/1/20XX Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.
CASE MANAGEMENT NOTE
SCREENED FOR ADMISSION
PT MET CRITERIA UNDER OBSV WITH CARDIAC/RESPIRATORY FINDINGS OF SYNCOPE, UNKNOWN ETIOLOGY.
PT PRESENTED TO ER WITH
Chief Complaint- MULTIPLE SYNCOPAL EPISODES. It has been waxing/waning. This occurred over past few weeks, 3 times this week. He has recovered. Is no longer unconscious. Event was witnessed. At time of event, he was standing. He had preceding symptoms of light-headedness. No preceding symptoms of nausea, dim vision, chest pain, warmth or abdominal pain. He lost consciousness completely. No seizure activity, incontinence or apnea noted. Did not lose pulse. Experienced repeated episodes. The episode lasted seconds. No injuries noted. The patient currently has generalized weakness. No localized weakness. Similar symptoms previously: He has had similar symptoms previously. Recent medical care: The patient was seen recently by a health care provider. The patient has had dizziness and a mild headache. He has had generalized weakness. BP 165/60, HR 68, RR 16 and T 96.8
RA O2 SAT 99 %. PAIN SCORE 0/10.
HX: DIABETES, HTN and GERD
LABS: WBC 12.8 and MAGNESIUM 1.5
GIVEN ASA and IV FLUIDS 1000 MLS.
PM RN CM Electronically signed by R., Paula RN 1/1/20XX
5/16/20XX 18:23
CASE MANAGEMENT ADDENDUM
POTASSIUM 3.4 L mMOL/L (3.5-5.1) CHRUTHDE 105 mMOL/L (98-107) CARBON DIOXIDE 20.0 L mMOL/L (23.0-32.0) ANION GAP 15 H mmol/L (4-12) GLUCOSE 54 L mg/dL (70-110) BLOOD UREA NITROGEN 21 H mg/dL (7-18) CREATININE 1.80 H mg/dL (0.6-1.3) GLOMERULAR FILTRATION RATE 41 L (60-130) PM RN CM Electronically signed by R., Paula RN 1/1/20XX
SEX: MALE
AGE: 60
DOS: 1/1/20XX
Code only for the ER physician
Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS:
Chief Complaint- MULTIPLE SYNCOPAL EPISODES. It has been waxing/waning. This occurred over past few weeks, 3 times this week. He has recovered. Is no longer unconscious. Event was witnessed. At time of event, he was standing. He had preceding symptoms of light-headedness. No preceding symptoms of nausea, dim vision, chest pain, warmth or abdominal pain. He lost consciousness completely. No seizure activity, incontinence or apnea noted. Did not lose pulse. Experienced repeated episodes. The episode lasted seconds. No injuries noted. The patient currently has generalized weakness. No localized weakness. Similar symptoms previously: He has had similar symptoms previously. Recent medical care: The patient was seen recently by a health care provider. REVIEW OF SYSTEMS:
The patient has had dizziness and a mild headache. He has had generalized weakness. No localized weakness. No chest pain, palpitations, abdominal pain, vomiting or diarrhea. No black stools, bloody stools, fever, sore throat or difficulty breathing. No difficulty with urination, skin rash, enlarged lymph nodes or cough. All systems otherwise negative, except as recorded above. PAST HISTORY: Hypertension. No history of a stroke or heart disease. Risk factors for heart disease-smoking and hypertension . Denies the following risk factors for heart disease - elevated cholesterol. SOCIAL HISTORY: Current smoker. No alcohol use or drug use. ADDITIONAL NOTES: The nursing notes have been reviewed. Weight: 80.7 kg. Height: 66 inches. BMI: 28.7. PHYSICAL EXAM:
Appearance: Alert. IV present X 1. EKG monitor and O2 sat monitor on the patient. Vital Signs: Have been reviewed and appear to be correct. (BP: 165/60. HR: 68. RR: 16. Temp: 96.8. O2 saturation 99%). Eyes: No nystagmus. ENT: Normal ENT inspection. Moist mucous membranes. Neck: Normal inspection. Neck supple. CVS: Normal heart rate and rhythm. Heart sounds normal. Respiratory: No respiratory distress. Breath sounds normal. Abdomen: Soft and nontender. No organomegaly. Back: Normal inspection. Skin: Skin warm and dry. Normal skin color. No rash. Normal skin turgor. Extremities: Extremities exhibit normal ROM. No lower extremity edema. Neuro: Alert. Oriented X 3. Mood/affect normal. Cranial nerves normal (as tested). No motor deficit. No sensory deficit. LABS, X-RAYS, AND EKG
EKG: 12 lead EKG time (16:34). No acute process. No acute ischemia. 12 lead EKG performed. EKG shows non-specific T-wave flattening without other abnormality. ( independently viewed and interpreted contemporaneously by me.)
Rhythm Strip: Normal rhythm strip (good tracing): (independently viewed and interpreted contemporaneously by me). Normal sinus rhythm. Normal PR interval. Normal QRS complexes. Normal STs and T waves. No ectopy.
Christopher Thomas, MD
Electronically signed by CHRISTOPHER THOMAS, MD 1/1/20XX
CT Head: (DISCUSSION: Noncontrasted CT head shows normal brain ventricles,
sulci, basal cisterns. No evidence of mass, mass effect, hemorrhage,
hematomas no acute infarction.
IMPRESSION: Normal Noncontrasted CT head.
Ronald Kramer, MD
Electronically signed by RONALD KRAMER, MD 1/1/20XX *Prior studies were not available for comparison. The study was interpreted by the radiologist (Kramer). Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process. 0525:YJ:CG00123R: (Final results)
Laboratory Test Value: HOLD TUBE FOR COAG SEE NOTE
0525:YJ:C00440S:Final results
Laboratory Test Value
SODIUM 140
POTASSIUM 3.4
CHRUTHDE 105
CARBON DIOXIDE 20.0
ANION GAP 15
GLUCOSE 54
BLOOD UREA NITROGEN 21
CREATININE 1.80
GLOMERULAR FILTRATION RATE 41
TOTAL PROTEIN 8.0
ALBUMIN 3.8
CALCIUM 9.8
BILIRUBIN TOTAL 0.30
SGOT/AST 10
SGPT/ALT 18
ALKALINE PHOSPHATASE 97
CREATINE KINASE (CK) 122
TROPONIN I 0.03
0525:YJ:H00270S: Final results
Laboratory Test Value
WHITE BLOOD CELL 12.8
RED BLOOD CELL 4.24
HEMOGLOBIN 14.0
HEMATOCRIT 42.2
MEAN CELL VOLUME 99.5
MEAN CELL HGB 32.9
MEAN CELL HGB CONCENTRATION 33.1
RED CELL DISTRIBUTION WIDTH 14.0
PLATELET COUNT 264
MEAN PLATELET VOLUME 10.2
NEUTROPHIL % 78.9
LYMPHOCYTE % 12.8
MONOCYTE % 7.7
EOSINOPHIL % 0.2
BASOPHIL % 0.4
NEUTROPHIL # 10.1
LYMPHOCYTE # 1.6
MONOCYTE # 1.0
EOSINOPHIL # 0.0
BASOPHIL # 0.1
MANUAL DIFF REQUIRED? NO
SMEAR REVIEW ? NO
NP AUTO DIFF NO . Bedside Tests: Glucose: hyperglycemia - 181 (performed pre-hospital). Pulse Oximetry: O2 saturation- 99% room air. PROGRESS AND PROCEDURES:
Course of Care: 60 year-old male presents with frequent falls/likely syncopal events. Patient reports 3 times over the past week having falls after feeling dizzy, "blacking out" briefly. No chest pain, dyspnea at any point. Patient feels generally weak and minimally dizzy at time of presentation.
EKG shows non-specific T-wave flattening without other abnormality.
CT head negative.
Labs show mild renal insufficiency without other significant abnormality.
Given several recent syncopal events, will admit Mr. Smith for further observation/workup.
Discussed patient with Dr. Andrews who will admit Mr. Smith.. Discussed case with hospitalist, (Andrews). Reviewed test results. Agreed upon treatment plan. Health care provider will see patient in hospital. Patient and family counseled in person regarding the patient's stable condition, test results, diagnosis and need for admission. IV fluid administered under direct supervision of physician. Clinical Review ECG interpretation documented. Antiplatelet medications administered. Consultation obtained from admitting physician. Disposition: Placed in observation status in Telemetry. CLINICAL IMPRESSION: Syncope of unknown cause. 12 lead EKG performed. Christopher Thomas, MD
Electronically signed by CHRISTOPHER THOMAS, MD 1/1/20XX Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.
CASE MANAGEMENT NOTE
SCREENED FOR ADMISSION
PT MET CRITERIA UNDER OBSV WITH CARDIAC/RESPIRATORY FINDINGS OF SYNCOPE, UNKNOWN ETIOLOGY.
PT PRESENTED TO ER WITH
Chief Complaint- MULTIPLE SYNCOPAL EPISODES. It has been waxing/waning. This occurred over past few weeks, 3 times this week. He has recovered. Is no longer unconscious. Event was witnessed. At time of event, he was standing. He had preceding symptoms of light-headedness. No preceding symptoms of nausea, dim vision, chest pain, warmth or abdominal pain. He lost consciousness completely. No seizure activity, incontinence or apnea noted. Did not lose pulse. Experienced repeated episodes. The episode lasted seconds. No injuries noted. The patient currently has generalized weakness. No localized weakness. Similar symptoms previously: He has had similar symptoms previously. Recent medical care: The patient was seen recently by a health care provider. The patient has had dizziness and a mild headache. He has had generalized weakness. BP 165/60, HR 68, RR 16 and T 96.8
RA O2 SAT 99 %. PAIN SCORE 0/10.
HX: DIABETES, HTN and GERD
LABS: WBC 12.8 and MAGNESIUM 1.5
GIVEN ASA and IV FLUIDS 1000 MLS.
PM RN CM Electronically signed by R., Paula RN 1/1/20XX
5/16/20XX 18:23
CASE MANAGEMENT ADDENDUM
POTASSIUM 3.4 L mMOL/L (3.5-5.1) CHRUTHDE 105 mMOL/L (98-107) CARBON DIOXIDE 20.0 L mMOL/L (23.0-32.0) ANION GAP 15 H mmol/L (4-12) GLUCOSE 54 L mg/dL (70-110) BLOOD UREA NITROGEN 21 H mg/dL (7-18) CREATININE 1.80 H mg/dL (0.6-1.3) GLOMERULAR FILTRATION RATE 41 L (60-130) PM RN CM Electronically signed by R., Paula RN 1/1/20XX
Why aren't the hypertension and smoking reported?