History Presenting complaint (s) from Patient / Care: Issues
- Patient presents with acute respiratory distress and altered mental status.
- Symptoms began approximately 2 hours prior to arrival, with sudden onset of shortness of breath and confusion. The patient reports a feeling of suffocation.
- The patient reports no specific triggers or alleviating factors.
- Symptoms have rapidly worsened over the past two hours.
- No prior history of similar episodes.
- The patient is unable to perform any activities of daily living due to severe shortness of breath and confusion.
- Associated symptoms include chest pain, diaphoresis, and a cough productive of frothy, pink sputum.
Past Medical History:
- Significant for hypertension, type 2 diabetes, and a recent pneumonia treated with antibiotics.
- Smokes one pack of cigarettes per day.
- No significant family history.
- Works as a construction worker, with potential exposure to dust and chemicals.
- Up-to-date on all vaccinations.
- Other: Patient reports feeling very anxious and scared.
Objective Findings on Exam:
- Vitals signs: BP 180/100, HR 130, RR 36, SpO2 88% on room air, Temp 38.5°C.
- Physical or mental state examination findings: Patient is in acute respiratory distress, using accessory muscles to breathe. Auscultation reveals bilateral crackles and wheezes. Patient is confused and disoriented.
- Investigations with results: Chest X-ray shows bilateral infiltrates consistent with pulmonary edema. Arterial blood gas (ABG) reveals: pH 7.28, pCO2 55 mmHg, pO2 60 mmHg, HCO3 24 mEq/L.
Differential Diagnoses (Issues & Management Plan):
1. Acute Respiratory Distress Syndrome (ARDS)
- Assessment: ARDS secondary to pneumonia and possible aspiration.
- Differential diagnosis: Cardiogenic pulmonary edema, severe pneumonia, sepsis.
- Investigations planned: Repeat ABG, complete blood count (CBC), comprehensive metabolic panel (CMP), blood cultures, sputum culture.
- Treatment planned: Intubation and mechanical ventilation, intravenous fluids, broad-spectrum antibiotics, vasopressors as needed, and supportive care.
- Relevant referrals: Intensivist, respiratory therapist.
2. Possible Sepsis
- Assessment: Sepsis secondary to pneumonia.
- Differential diagnosis: Pneumonia, ARDS, cardiogenic pulmonary edema.
- Investigations planned: Repeat ABG, complete blood count (CBC), comprehensive metabolic panel (CMP), blood cultures, sputum culture.
- Treatment planned: Intravenous fluids, broad-spectrum antibiotics, vasopressors as needed, and supportive care.
- Relevant referrals: Intensivist.
3. Cardiogenic Pulmonary Edema
- Assessment: Cardiogenic pulmonary edema.
- Differential diagnosis: ARDS, severe pneumonia, sepsis.
- Investigations planned: Chest X-ray, ECG, cardiac enzymes.
- Treatment planned: Diuretics, oxygen therapy, and supportive care.
- Relevant referrals: Intensivist, cardiologist.
History Presenting complaint (s) from Patient / Care: Issues
- [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Past Medical History:
- [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
- [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Objective Findings on Exam:
- [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
Differential Diagnoses (Issues & Management Plan):
[1. Issue, problem or request 1 (issue, request, topic or condition name only)]
- [Assessment, likely diagnosis for Issue 1 (condition name only)]
- [Differential diagnosis for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant referrals for Issue 1 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[2. Issue, problem or request 2 (issue, request, topic or condition name only)]
- [Assessment, likely diagnosis for Issue 2 (condition name only)]
- [Differential diagnosis for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant referrals for Issue 2 (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
[3. Issue, problem or request 3, 4, 5 etc (issue, request, topic or condition name only)]
- [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only)]
- [Differential diagnosis for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations planned for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant referrals for Issue 3, 4, 5 etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
(Never come up with your own assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)
