cardiac

DC Inst – Palpitations

DC

You were seen today in the emergency department for palpitations. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms.

You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist.

Please return to the emergency department for chest pain, shortness of breath, lightheadedness or dizziness, or other symptoms that are concerning to you.

DC Inst – Chest Pain

DC

You were evaluated in the Emergency Department today for chest pain. Your evaluation has shown no signs of medical conditions requiring emergent intervention at this time, however we recommend that you follow up with your primary care physician or your cardiologist as soon as possible for further testing as an outpatient.

Please schedule an appointment for follow up with your primary care physician as soon as possible.

Return to the Emergency Department if you experience worsening or uncontrolled chest pain, shortness of breath, light headedness, feeling faint, nausea, vomiting, or any other concerning symptoms.

Thank you for choosing us for your care.

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, Atypical (No Troponin)

MDM

This patient presents with atypical chest pain, most likely secondary to ***. Differential diagnosis includes ***. Low suspicion for ACS, acute PE (PERC negative***), pericarditis / myocarditis, thoracic aortic dissection, pneumothorax, pneumonia or other acute infectious process. Presentation not consistent with other acute, emergent causes of chest pain at this time. No indication for cardiac enzyme testing.*** Plan to order CXR to evaluate for acute cardiopulmonary causes.***

Plan: labs***, EKG, CXR***, pain control

Chest Pain – Low Risk (Trop Out)

MDM

This patient presents with chest pain, with symptoms suggestive of noncardiac chest pain. History without high risk features (e.g., not substernal, no exertional component, not relieved with rest, *** ).

Minimal CAD risk factors (including age), recent negative stress test (<2 years).*** Exam without evidence of volume overload. EKG without signs of active ischemia. HEART score: ***. Given the timing of pain to ER presentation, plan to send single troponin // delta troponin to evaluate for NSTEMI.*** Presentation not consistent with acute PE (Wells low risk *** // PERC negative***), pneumothorax, thoracic arotic dissection, cardiac effusion or tamponade.

Plan: labs, troponin***, EKG, CXR, ASA***, pain control, serial reassessment

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***

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***