ER History and Physical Medical Transcription Sample
DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Brought in by EMS.
ADMITTING DIAGNOSES:
1. Diabetic ketoacidosis.
2. Hypokalemia.
3. Possible gastrointestinal bleed.
4. Acute renal failure.
5. Alcohol abuse.
6. Coronary artery disease, status post coronary artery bypass graft.
7. Hypertension.
8. Congestive heart failure.
9. Status post intracranial hemorrhage, bur hole was done in the past.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old male who is not able to give an accurate account of the events precipitating his presentation here to the emergency room. Per ED documentation, the patient was found by his daughter at home with high blood sugar and altered mental status. Per the daughter, she checked the patient’s fingerstick blood sugar, and it was greater than 500. She summoned EMS who subsequently brought the patient here to the emergency room for further evaluation and treatment. Incidentally, the patient has had multiple presentations and admissions here in the past for hyperglycemia and DKA. The patient was worked up here in the emergency room and was found to have a blood sugar of 2010, also a potassium level of 2.5.
The patient was not able to give an accurate account of the events, although his wife was brought into the emergency room at the same time and did admit that they have both been drinking lately, although the patient is not able to quantify the amount of alcohol that he did consume or even if he did consume alcohol prior to his presentation to the emergency room. The patient did receive 4 liters of normal saline down in the emergency room shortly after his arrival and he did eventually become a bit more alert, although still not able to give an accurate account of his events. The patient denied any current discomfort. He did mention that he has not been able to eat or drink anything the last couple of days, although once again unable to validate the patient’s information due to his underlying confusion.
With the patient’s blood sugar being 2010, the patient was started on an insulin drip in the emergency room. He was also found to have 1+ serum ketones and a pH of 7.12. The patient had an urgent central line placed due to his hypokalemia and need for an insulin drip and minimal line access. The patient was also noted to have coffee-ground emesis. An NG was inserted without difficulty, although the patient did pull it out shortly after its insertion. The patient would be admitted to the MICU for further evaluation and workup.
PAST MEDICAL HISTORY: Multiple past admissions for DKA; acute renal failure; anemia; atrial fibrillation; COPD; diabetes mellitus type 2, uncontrolled; alcohol abuse; hypertension; intracranial hemorrhage.
PAST SURGICAL HISTORY: Removal of colonic polyps, CABG in the past, bur holes in the past.
FAMILY HISTORY: Significant for cardiac disease.
SOCIAL HISTORY: The patient is an alcoholic and a smoker. Denies any illegal drug use. The patient does have a daughter who checks on the patient periodically.
ALLERGIES TO MEDICATIONS: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Taken prior to the patient’s admission to the hospital include albuterol MDI 2 puffs every 4 hours as needed, Elavil 10 mg p.o. q.h.s., aspirin 81 mg p.o. every day, clonidine 0.1 mg b.i.d., Procardia XL 60 mg every day, Lantus 16 units subcutaneously q.a.m., NovoLog 2 units with meals, metoprolol 75 mg p.o. b.i.d., Protonix 40 mg p.o. every day, Renagel 1600 mg 3 times daily with meals, vitamin B complex 1 tablet daily, Tylenol 650 mg q.4h. p.r.n.
REVIEW OF SYSTEMS: Unable to review due to the patient’s mental status.
PHYSICAL EXAMINATION: Vital Signs: Upon presentation to the emergency room, blood pressure 110/70, pulse 96, respirations 18, pulse oximetry 100%. General: The patient is a well-developed, well-nourished (XX)-year-old male who appears much older than his stated age, rather confused, not able to give an accurate account of events prior to his hospitalization. Appears ill but is not in any acute distress presently, at the time of admission. HEENT: Head normocephalic, atraumatic. Pupils equal and reactive to light. The patient does have his own teeth. He does have old blood noted on his lips at the time of admission. Neck: Neck is supple. No palpable lymphadenopathy, thyromegaly, stiffness, rigidity or carotid bruit noted. Lungs: Essentially clear throughout. No wheezes, rales, rhonchi or stridor noted. Cardiovascular: The patient’s rhythm and rate are tachycardic with a rate of 104. No murmurs, no gallops or rubs. Positive S1, S2. Negative S3, S4. No bilateral lower extremity edema noted and pulses are positive. Abdomen: Soft, nontender, nondistended. Bowel sounds positive in all four quadrants. Genitourinary: The patient does have a Foley catheter in place draining clear yellow urine. Neurological: The patient is alert to name only. He is able to answer some questions but is rather confused at baseline. The patient is able to follow instructions. Cranial nerves II through XII are intact. Musculoskeletal: The patient is able to move all his extremities without any difficulty. They are cool and dry. No cyanosis noted. Pulses are positive. No bilateral lower extremity edema noted.
LABORATORY DATA: Corrected sodium 137, potassium 2.3, chloride 69, CO2 of 20, anion gap 24, glucose 2010, creatinine 2.8, GFR 23.2, troponin 0.09, WBC is 10.7, hemoglobin 11.8, hematocrit 36.4, platelets 239, neutrophils 82.1, BUN 44, calcium 9.5, serum ketones 1+. Urinalysis; color yellow, clear, pH 6, specific gravity 1.027, protein 1+, glucose 3+, ketones negative, blood 3+. Nitrites, bilirubin negative, wbc’s 0 to 1, rbc’s 2 to 5, bacteria few. PT 14, PTT 28, INR 1.1. EKG shows normal sinus rhythm with a rate of 92.
IMPRESSION: The patient is a (XX)-year-old male with multiple presentations and admissions for diabetic ketoacidosis, who most recently had an inpatient stay for several weeks on the rehabilitation unit for strengthening and conditioning. There is a question of whether the patient was drinking after his discharge from rehabilitation or not. The patient does relate that he has not been able to eat or drink for the last couple of days. Unsure of whether the patient is taking his medications. There certainly is a safety/social issue at home. The patient was found to be in DKA at the time of presentation to the emergency room, was given 4 liters of normal saline. By the time the patient was admitted, his glucose did drop from 2010 to around 1450. He did remain hypokalemic requiring aggressive potassium replacement. The patient was placed on an insulin drip in addition to his normal saline boluses.
PLAN:
1. DKA: MICU admit. Continue with his insulin drip, titrating depending on the results of his glucose. Check an ABG. Check BMP q.2h. Check magnesium and phosphorus and continue with IV fluids with normal saline.
2. Hypokalemia: Continue with his KCl IV and check potassium with a BMP q.12h. We did start the patient on 0.9 normal saline with 40 of potassium at 200 an hour to give him some additional potassium.
3. Possible GI bleed: The patient was having coffee-ground emesis. An NG tube was placed. The patient did pull it out and refused placement. In addition, the patient was having bleeding so the NG tube was not replaced. The patient was given Protonix IV in the emergency room. He was typed and crossed 2 units of packed red blood cells in preparation for transfusion should the patient need a transfusion. We will check a CBC in the morning and we will check the coags as well.
4. Acute renal failure: We will check a BMP. His renal status is slowly improving with IV hydration.
5. Alcohol abuse: We will give him thiamine, folic and multivitamin in his IV. The patient may need some DT prophylaxis.
6. Coronary artery disease: Status post CABG. The patient was on aspirin and Procardia XL. We will hold for now due to the patient’s n.p.o. status.
7. Hypertension: The patient was on clonidine and metoprolol. We will check blood pressure per ICU routine. Antihypertensives were not ordered at the time of admission due to the patient’s n.p.o. status and also the patient is not hypertensive at the time of admission.
8. CHF: The patient did have an echo done in the past with an EF of 45-50%. We will check I and O and careful fluid resuscitation.
9. Status post intracranial hemorrhage and bur holes done in the past. Symptom management and monitor the patient’s status.
10. Protective measures: Protonix IV, SCDs for DVT prophylaxis. No heparin, Lovenox or aspirin due to the possibility of having a GI bleed.
11. Disposition: Critical care management in the MICU. Social worker to see for possible social placement issues.
Total critical care time 90 minutes. Further intervention pending clinical course and findings.
