* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download DOC - HCPro
Survey
Document related concepts
Childhood immunizations in the United States wikipedia , lookup
Hygiene hypothesis wikipedia , lookup
Urinary tract infection wikipedia , lookup
Gastroenteritis wikipedia , lookup
Schistosomiasis wikipedia , lookup
Diabetes mellitus type 1 wikipedia , lookup
Infection control wikipedia , lookup
Hospital-acquired infection wikipedia , lookup
Neonatal infection wikipedia , lookup
Hepatitis C wikipedia , lookup
Immunosuppressive drug wikipedia , lookup
Transcript
If You Write Consider ACS w/elevated troponin Non-Q wave MI Any Infection, Bacteremia (e.g. C.difficile colitis. Appendicitis, peritoneal abscess Sepsis if pt. has SIRS (WBC>14k, “left shift”, temp>101, HR>90, AMS, due to that infection Albumin 3.0, underweight Mild/Moderate/Severe malnutrition Altered Mental Status Document alteration (Acute confusion, delirium, psychosis, dementia, coma) any probable underlying encephalopathy (toxic, septic, metabolic, traumatic, hypoxic hypertensive) & other brain diseases present (Alzheimer’s, late effect of stroke, 1 or 2 Parkinson’s) Amiodarone/AICD use Underlying rhythm disturbance Asthmaticus, Status Acute Resp. Failure if present Azotemia, Cr from 1.0 to 2.0 mg/dl. Acute Kidney Injury Acute Renal Failure AKI criteria of acute rise of CR>0.3 mg/dl w/I 48 hr: otherwise acute renal insufficiency Blunt Abd. Trauma w/ deep injury If You Write Acute peritoneal injury + how solid organ was injured Consider CAD/ Angina Document Stable Angina, Angina at rest or Progressive Angina if present Cardiac Arrest Its cause : V-Fib/V-Tach /AMI Chest Pain CHF Closed Head Injury Cocaine/Illegal Drug Use Alcohol or Marijuana Use Type of pain (angina, pleuritic, heartburn, biliary colic), its probable cause( ie:GERD, gallstones, cocaine), & if at rest or accelerated Acute/Chronic, Systolic or Diastolic CHF (decompensated does not count!!!!!) Concussion, LOC X _____min Drug (cocaine) intoxication with continuous dependency (Document accompanying angina, psychosis, toxic encephalopathy, arrhythmias, accelerated HTN , etc.) Continuous chemical dependency (if use is recurrent w/ health consequences or if on chronic RX i.e. methadone If You Write Consider Chronic Renal Insufficiency or Failure Chronic Kidney Disease (CKD) & stage I, II,III,IV,V or ESRD based on GFR/Dialysis COPD/Chronic Bronchitis Document if stable or exacerbated Debridement of skin Describe if Excisional and deepest level excised. Diabetes Diabetes Type 1 or 2 (no more NIDDM OR IDDM) Type 2 on Insulin Diabetes, poorly controlled Uncontrolled Diabetes, if multiple BS>250, Hgb A1c >7. Hct 2 GI Bleeding/Surg Acute Blood Loss Anemia Hypertensive Emergency Accelerated or Malignant HTN Hypotension state UNDERLYING cause i.e.: hypovolemia, autonomic K+ 2.0 Hypokalemia due to__________ LLL infiltrate, TX w/ Zosyn Probable Gram-neg. pneumonia Na= 125 Hyponatremia & probable cause (i.e.: diuretics, SIADH) If You Write Consider Pneumonia Hospital/SNF/Community acquired/Ventilator-associated And UNDERLYING organism i.e.: aspiration, MRSA Seizure Describe probable Underlying cause i.e.: old CVA, Alcohol withdrawal, epilepsy Syncope LOC probably due to _________ Urosepsis Sepsis due to UTI PH 7.25 pC02 34 p02 80 Metabolic Acidosis + cause Neutropenic Fever Underlying systemic infection (sepsis) or bacterial infection for which antibiotics are prescribed. I.e.: Fungemia rx-capsofungin Rhythm Stable Underlying arrhythmia i.e.: V-Tach, PAT on monitor or treated Ranson’s Criteria met SIRS 2 to Pancreatitis + organs affected Pleural Effusion State probable underlying condition i.e.: empyema, chronic CHF or condition to be ruled out TB, Metastatic CA