# Critical Care Note



## peeya (Apr 23, 2012)

Will this note justify critical care code. Patient is already in ICU when the Doctor is called..

TYPE OF CONSULTATION: Cardiology 

ORDERING PHYSICIAN: Dr. ____________ 
CONSULTING PHYSICIAN: _____________ 

REASON FOR CONSULTATION: Consideration for myocardial infarction.

HISTORY OF PRESENT ILLNESS: This is a 55-year-old male patient who 
was found pulseless in his place of residence in a nursing facility. 
Paramedics were called, who found staff performing CPR upon arrival. 
The rhythm the paramedics established per protocol was ventricular 
fibrillation and he was shocked. Subsequently, asystole was noted and 
after the third bolus of epinephrine, pulse was regained. He was 
transferred to the Valley Presbyterian Medical Center. In the 
hospital, he had multiple episodes of CPR. Pulse was regained for a 
brief time and then CPR was resumed. That occurred at multiple times. 
I was called due to EKG findings. EKG findings are noteworthy 
for initial EKG at 8:55 which reveals ST depression and sinus rhythm. 
At 8:58, ST elevations were noted in leads I, II, III, aVF, lead II, 
V4, V5, and V6, with reciprocal changes in the remaining leads. At 
9:03, the EKG normalized. There were no remaining ST elevations. There 
are now nonspecific ST-T changes. I see the patient in the emergency 
room. Earlier, immediate cardiac catheterization was considered. We 
decided to hold off, giving that EKG normalized without undue 
coagulation or revascularization therapy. Also in light of the fact 
that the patient is completely nonreactive at the time and no 
sedation was given. The patient is now on hypothermia protocol. He is 
on Levophed drip.

PAST MEDICAL HISTORY: Diabetes mellitus. Arterial hypertension. 
Hyperlipoproteinemia, obesity, COPD, thyroid disorder, depression.

HOME MEDICATIONS  
1. Albuterol. 
2. Norvasc. 
3. Colace. 
4. Lovenox 40 mg subcutaneous daily. 
5. Atrovent. 
6. Claritin. 
7. Tapazole. 
8. Zyprexa. 
9. Protonix. 
10. Zocor. 
11. Prednisone. 
12. Vicodin. 
13. Clonidine. 
14. Albuterol. 
15. Ativan. 
16. Fleet enema. 
17. Insulin sliding scale. 

SOCIAL HISTORY: Cannot be obtained.

FAMILY HISTORY: Cannot be obtained.

REVIEW OF SYSTEMS: Cannot be obtained.

PHYSICAL EXAMINATION 
VITAL SIGNS: Blood pressure is 40/ ________, now 144/86, heart rate 
is 122, respiratory rate is 30, pulse oximetry is 97%, temperature 
94.8, on hypothermia protocol. 
HEAD: The patient is intubated. 
NECK: Jugular veins visible at 9 cm. There are no bruits. 
CHEST: Crackles audible both lower lobes. 
CARDIOVASCULAR: Irregular rate and rhythm, no murmurs. 
ABDOMEN: Soft. 
EXTREMITIES: 1+ pitting edema both lower extremities, 1+ pulses 
dorsalis pedis and tibialis posterior bilaterally and symmetrically.

DIAGNOSTIC DATA 
EKG of 9:18: Sinus rhythm, ST depressions, 134 beats per minute. 
EKG at 8:55: Sinus rhythm, nonspecific ST-T changes, ST depression in 
V5 and V6. 
EKG at 8:58: ST elevation in leads I, II, III, aVF, reciprocal ST 
depression in aVR and lead V1, ST elevation also in V3, V4, and V5 
and V6. 
EKG at 9:03: Sinus tachycardia, 151 beats per minute, nonspecific ST-
T changes.

LABORATORIES: White blood cells 20.4, hematocrit is 40.5, platelets 
156,000. INR is 1.34. Sodium 135, potassium 4.8, creatinine is 1.3. CK 
52, CK-MB 1.5. Troponin 0.23. BNP 1210.

IMPRESSIONS  
1. Cardiopulmonary arrest. 
2. Hypotension. 
3. Coma. 
4. Renal insufficiency. 
5. Chronic obstructive pulmonary disease.  
6. History of arterial hypertension. 
7. Thyroid disorder. 
8. Gastroesophageal reflux disease. 
9. Diabetes mellitus. 
10. Hyperlipoproteinemia. 

PLAN AND COURSE: At this point, we are holding off of cardiac 
catheterization given the normalization of the EKG. It is possible 
that the ST elevation was seen shortly after an episode of asystole. 
It is noteworthy that the patient showed marked ST elevation in 
several territories, which may be suggestive of relative ischemia in 
the presence of profound hypotension and clinical death. It is also 
noteworthy that the patient, at this point, is not reactive to any 
stimuli before sedation was initiated. I concur with hypothermia 
protocol. The patient should remain on aspirin and on pressor 
therapy. We will obtain a 2-dimensional echocardiogram. Will check 
a repeat EKG, repeat CK, CK-MB. We will consider cardiac 
catheterization, but will first initiate medical therapy.

ADDENDUM

CRITICAL CARE TIME:  The total critical care time I spent with the 
patient is 39 minutes without inclusion of any procedures.


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## syllingk (Apr 24, 2012)

Sounds like critical care to me. You list three or four critical dx's on there.


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