admit

STEMI Activation

MDM

This patient presents with chest pain and an EKG showing *** STEMI or STEMI equivalent (Wellens, de Winter’s, Sgarbossa criteria).*** Presentation not consistent with acute thoracic arotic dissection. No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. Plan for PCI with cardiac cath lab activation.

Plan: CODE STEMI, STEMI labs, pacer pads, cardiac monitor, Cardiology consult, Cardiac cath lab activation, ASA, heparin, dual antiplatelet agent (per Cards), CXR

Chest Pain – Admit (High Risk)

MDM

This patient presents with chest pain, with a history suggestive of ***. No evidence of volume overload or shock on exam. EKG without signs of active ischemia. EKG without evidence of STEMI. Low suspicion for acute PE (Wells low risk ***), pneumothorax, thoracic aortic dissection, cardiac effusion / tamponade. Overall, ACS is being considered given higher risk features, ***, history & physical. HEART score: ***.

Patient will require admission for inpatient risk stratification and possible provocative testing.

Plan: cardiac monitor, EKG, troponins,CXR, ASA, heparin***, pain control, reassess, Cardiology consult***

SYNCOPE – Admit

MDM

This *** patient presents with symptoms consistent with syncope, most likely due to ***. Differential diagnosis includes ***reflex syncope (i.e. vasovagal syncope). Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding diatheses. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: ***). However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry.

Plan: labs, troponin, CXR, EKG, serial reassessment

DKA – Admit

MDM

This patient presents with hyperglycemia and symptoms concerning for DKA. Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. Considered possible causes of DKA to include infection (pancreatitis, UTI, pneumonia), infarction / ischemia (acute coronary syndrome, cerebral vascular accident), medication non-compliance with insulin therapy, illicit substance abuse, iatrogenic (including prescription medications and drug-drug interactions), idiopathic causes. Most likely etiology at this time is ***. Plan to treat the hyperglycemia as below while simultaneously evaluating and treating potential underlying etiologies.

Plan: POC glucose monitoring (Q1H), BMP (Q2H), blood gas, UA, serum ketones, CBC, LFTs / lipase, infectious workup (lactate/blood cultures, CHEST X-RAY)***, IVF, IV Insulin therapy, serial reassessment, admission for treatment of hyperglycemia

COPD Exacerbation – Admit

MDM

This patient presents with symptoms most consistent with an acute COPD exacerbation. These constellation of symptoms are similar to prior flares without overt deviations from normal exacerbations. The likely precipitant is acute respiratory infection // weather change or air quality // recent beta-blocker or opiate use.*** Low suspicion for alternate etiologies such as pneumothorax, acute PE. Presentation not consistent with other acute cardiopulmonary causes including ACS / CHF / cardiac effusion.

Pseudomonas risk factors: recent hospitalization // frequent antibiotic treatment // severe COPD // previously isolated Pseudomonas.*** Plan to maintain SaO2 ~90-94% with supplemental O2. Based on current presentation, including work of breathing, patient will need NIPPV (CPAP/BiPAP) // will not need NIPPV at this time. Plan for trial of duonebs, steroids. Antibiotics ***indicated given purulent sputum // increased sputum production // trial of NIPPV // No indication for antibiotic treatment at this time.*** Will evaluate for other acute cardiopulmonary processes with a CXR.

Anticipate hospitalization given marked increase in symptoms // significant co-morbidities and age // new arrhythmias.***

Plan: supplemental O2 (goal SaO2 ~90-94%), NIPPV***, duonebs, steroids, antibiotics***, CXR***, serial reassessment

CHF – Hypertensive Pulm Edema

MDM

This is a @AGE@ @SEX@ patient with history of *** sided, ***olic CHF, presenting with likely acute decompensated heart failure and ***pulmonary edema. The etiology of his decompensation is ***unclear but is likely due to ***. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection), respiratory (COPD, PE, or PNA), medication noncompliance or dietary indiscretion, alcohol or drug abuse, endocrine (thyrotoxicosis), and anemia***. ***I considered ACS as a possible cause of the exacerbation but think this is unlikely given history and EKG without overt evidence of acute ischemia. Other acute, emergent etiologies of shortness of breath unlikely.

I plan for afterload reduction with nitrates given hypertension and possibly ACEi. Given respiratory status will also consider starting NIPPV. Will start diuresis after nitrate administration. The patient will require admission for acute management of ADHF.

Plan: labs, troponin, BNP, EKG, CXR, BUS, nitrates/diuretics, admission

CHF with Shock – Admit

MDM

This patient with a hx of ***CHF presents with acute shortness of breath and peripheral edema, most consistent with acute decompensated heart failure and concerning for cardiogenic shock. Likely etiology is medication non-compliance // dietary indiscretion // HTN // infection // fluid overload // anemia //alcohol intoxication // thyroid disease.*** I considered ACS as a possible etiology but think this less likely. EKG without overt evidence of acute ischemia. Other acute, emergent etiologies of shortness of breath are unlikely at this time.

Given tenuous systolic function and hypotension, plan includes starting ionotrope such as dobutamine +/- ionopressor (i.e. Dopamine, levophed). Will give O2; would like to avoid utilizing NIPPV or intubation due to tenuous preload status. Will require admission for acute management of ADHF.

Plan: labs, troponin, BNP, EKG, CXR, BUS, vasopressors, Cardiology consult***