STEMI

Vital signs:

PE:

ECG:

TTE: EF, RWMA, no root dilatation/flap/AR, no pericardial effusion

CXR: 

Lab: LA, TnT

. Loading DAPT (aspirin 300mg + brilinta 180mg)
. Heparinization (Loading dose 60U/kg, max 4000U, maintenance dose 12U/kg/hr)
. Primary PCI then CCU admission
. f/u ECG and TnT Q6H until peaking
. Inform MACE and bleeding risk

. Check 4 limb BP for complaining back pain
. Risk stratification: check lipid profile, HbA1c, lipoprotein (a)
. Optimize medical therapy including beta blocker, ACEI/ARB and high intensity statin as tolerated

[PE]

E4V5M6

HEENT: Pink conjunctiva, anicteric sclera

Heart: Regular heart beat without murmur

Chest: bilateral clear breath sounds

Abdomen: Soft and flat, normoactive bowel sounds

Extremities: No pitting edema

Skin: no ecchymoses. no rash

[CAD Risk factors]

DM(-), Hypertension(-), Dyslipidemia(-), Smoking(-), Sex(-), Age>45(men)(-), Age>55(woman or postmenopause)(-), Family history(male<55, female<65), Lack of exercise(-), obesity (-), Gout (-)

Progress 範本

List

Timeline (→ ⇒ ↑ ↓)

[Baseline]
ADL/iADL dependent, ___照顧, cons clear, ECOG

[Active problems]
[Underlying]

[OPD]

[Key person]
[HD]
[Code]

[Course]

================== NTUH ER ====================================
CC:

/  [VS]
   [PE]
   [ECG]        
   [Lab]

   [CXR]    

   [Mx, Tx]

===============================================================

[Event]

[Abx]
------------------------------------

[Microbiology]

[Ventilation]
PCV //

[Inotropes/Vasopressors]

[PADIS]
F

[Nutrition]

[Image/Examination]

[CKRT]

[Code]
Full resuscitation

================ CCU ==================
[Event]

[Abx]
------------------------------------

[Microbiology]

[Ventilation]
PCV //

[Inotropes/Vasopressors] 
mcg/kg/min

[Mechanical circulatory support]

[PADIS]
F

[Nutrition]

[Image/Examination]

[CKRT]

[Code]

=== Ward ===========
[Event]

[Abx]
--------------------------------------
[Microbiology]

[Image/examination]

[Inotr./vasopr.]
Nil

[Ventilation/O2]
Nil

[Nutrition]
Normal diet

[Code]
Full resuscitation

===================================================

[Physical Examination]

E4V5M6

HEENT: Pink conjunctiva, anicteric sclera

Heart: Regular heart beat without murmur

Chest: clear breath sounds

Abdomen: Soft and flat, normoactive bowel sounds

Extremities: No pitting edema

Skin: no ecchymoses. no rash

===================================================

■ CAD Risk: 

DM(), Hypertension(), Dyslipidemia(), Smoking(), Sex(), Age>45(men)(), Age>55(woman or postmenopause)(), Family history(male<55, female<65), Lack of exercise(), obesity (BMI)

-----------------------------------------------------------------

【History of Obstetrics and Gynecology】

1. G   P   AA   SA    E (NSD*   , C/S*   ), sexual experience:    , marital status: 

2. Menarche:     years old, menopause:    , hormone therapy:   , 

  Menstrual cycle: interval/duration:   /   days,

  Amount: moderate, dysmenorrhea:(   ), 

last menstrual period: 2019/

3. Last Pap smear and result: (2021/  /  ) 

【Brief History】

1. Birth history: 

   GP, GA  wks, BBW:  gm, NSD/ C/S due to _____

   PROM(-), Perinatal asphyxia(-), Neonatal jaundice(-)

2. Feeding: on full diet

3. Vaccination: As scheduled

4. Growth and development: 

   - BW:  kg (  th percentile); 

   - BH:  cm (  th percentile);

   - Developmental milestones: within normal limits

5. Allergies: Denied drug and food allergy

6. Past history: 

   - Systemic disease: 

   - Admission history: 

   - Surgical history:

7. Current medication:

   - NTUH: 

   - Other: nil

8. Maternal history: denied any systemic disease, DM(-), HTN(-)

   Denied radiation or drug exposure during pregnancy

9. Family history: no relevant disease, HTN(-), DM(-), Allergy(-)

10.TOCC:  

 T:travel history: denied

 O:occupation    : 

 C:contact       : denied

 C:cluster       : denied

【Oncology Summary】 revised on 

■1. Initial Presentations

■2. Definite Diagnosis

■3. Disease Extent

■4. Treatment Course

■5. Effects and Side effects

■6. Plan

好用公式、計算器

• 小兒科
• CrCl：http://www.medcalc.com/crcl.html  
• Protein loss：留12hr urine Total protein (TP), 濃度*體積
• UPCR：數值/1000 (mg/mg)= daily protein loss (g/d)

急診主訴模板

[急診主訴模板]

• General 
• Fever
• Febrile neutropenia
• CV
• Chest pain, ACS
• Hypertension
• Syncope
• Chest
• Dyspnea, DOE, SOB
• GI
• Abdominal pain
• Hiccup
• Nausea, Vomiting
• GIB
• Dysphagia, odynophagia
• Foreign body
• Diarrhea
• Jaundice
• Nephro
• Flank pain, hematuria, stone
• AKI, ↓ UOP
• Dialysis patient emergency
• ID
• SSTI (Skin & soft tissue infection)
• Rheuma
• Joint pain 
• Neuro
• Consciousness disturbance
• Headache
• Dizziness, Vertigo
• Stroke
• Low back pain 
• OBGYN
• History
• Vaginal bleeding
• Pelvic pain
• Pediatrics
• Derm
• Allergy skin reaction, angioedema, drug allergy
• Skin rash 
• Herpes zoster
• ENT
• Foreign body
• Hearing loss 
• Ramsay Hunt syndrome
• Oph
• Vision change, Vision loss
• Subconjunctival hemorrhage
• Preseptal cellulitis, orbital cellulitis 
• Psy
• Hyperventilation
• Manic symptoms


• EPS


• 
  
• Trauma

急診模板: OBGYN

• History

【History of OBGYN】

1. G   P   AA   SA    E (NSD* , C/S* ), sexual experience:+, marital status:

2. Menarche:     years old, menopause:    , hormone therapy:   , 

  Menstrual cycle: interval/duration:   /   days,

  Amount: moderate, dysmenorrhea:(-), 

3. last menstrual period: 2020/

急診模板: Derm

• Allergy skin reaction, angioedema, drug allergy

CF: 

Facial swelling (-),

Itchiness (-), pain (-), tenderness (-),  

Dyspnea (-), Stridor (-), wheezing (-)

Previous experience: 

Culprit event/ medicine: probably 

Current medication, 中藥保健食品:

Allergy: 

急診模板: Oph

• Subconjunctival hemorrhage

Visual disturbance (-), Visual field defecit (-)
During lifting (-), vomiting (-), cough (-)
Previous history of trauma (-), eye surgery (-)

Current medication: anticoagulant (-), antiplatelet (-)

Past medical history: HTN (-)

• Preseptal cellulitis, orbital cellulitis

Fever (-)

EOM intact/ impaired

Visual disturbance (-), visual field deficit (-)

Conjunctiva: injected

Previous medical history: sinusitis (-), previous skin wound (-), recent ocular surgery (-), trauma (-)

急診模板: Trauma

Mechanism:
Helmet (+), head injury (-), ILOC (-)
Active and passive ROM:
Gait: steady
Amnesia (-)
GCS: EVM
Suspected open or depressed skull fracture:
Sign of basilar skull fracture: raccoon eyes (-), Battle's sign (-), CSF otorrhea (-), CSF rhinorrhea (-)
More than 2 episodes of vomoting:
Retrograde amnesia to the event more than 30 minutes:
Dangerous mechanism:
Current medication: anticoagulant (-), antiplatelet (-)
Tetanus vaccine in recent 5 years: denied
Muscle power: R/L  /

Sensory deficit: nil
Allergy: nil
Last meal: 

PH:

PE:
No visible head wound
No obvious chest and abdominal injury
No focal neurological sign, no focal weakness

=============

• 急診創傷評估、處置

• 自介
• 病人名字、這裡是哪裡、你發生啥事

• Primary ABCDE
• A：airway＋C-spine restriction，呼吸通暢？
• 困難插管：影像輔助->cricothyrotomy（ER不做氣切！）
• C-spine 可問上下肢運動、感覺
• B：breathing & ventilation，呼吸、換氣足夠？
• 呼吸pattern、換氣功能（Ambu, BiPAP, Ventilator）、氧合狀態
• C：circulation & hemorrhagic control，休克？
• Tachycardia -> ↓BP -> shock, conscious change
• D：diability，意識清楚？
• AVPU（清聲痛否）、pupil size、light reflex
• E：exposure & environmental control +保暖
• Back & perineum + DRE/Anal tone
• 保暖：輸warm fluid＋烤燈

• 4大立即致命胸部外傷
• Tension pnx
• Open pnx
• Massive hemothorax
• Flail chest
• FAST
• Morrison pouch：肝腎
• hepatospleno：肝脾
• Pericardial
• Douglas pouch

• Secondary survey
• 全身各處再檢查（孔洞：鼻、耳、NG、陰道、尿道）
• AMPLE（之前吃藥過敏）
• A：allergy過敏
• Ｍ：medicine過敏
• Ｐ：past illness/ pregnancy 過去病史、懷孕
• Ｌ：last meal上一餐啥時吃、吃啥
• Ｅ：events/ environment related to injury 發生啥事、環境如何
• 完整PE、NE、Image

• 撞到頭
• Canadian CT Head Injury/ Trauma rule
• 在正常人使用，看ICH是否需ICU、neurointervention
• New Orleans/Charity Head Trauma/ Injury rule
• 應付刁民用
• 只要頭撞到幾乎都可用
• 看任何出血
• C-spine
• Canadian C-spine
• NEXUS Criteria for C-spine imaging
• 小兒撞到頭
• PECARN Pediatric Head Injury/Trauma Algorithm

急診模板: General

• Fever

Fever to ___ °C for___days,. Headache (-), neck stiffness (-), seizure (-), change in sensorium (-)

. Cough (-), sputum (-), rhinorrhea (-), sorethroat (-), dyspnea (-)

. Dysuria (-), urinary frequency (-), urgency (-), CV angle knocking tenderness (-)

. Abdominal pain (-), diarrhea (-), tenderness (-), rebound tenderness (-)

. Myalgia (-), skin rash (-), arthralgia (-)

T:

O:

C:

C:

Host factors:

Recent ANC:

Indwelling catheters: nil

===================================================================

• Febrile neutropenia

Recent WBC: , S:/ B:, ANC: 

Fever to ___ °C for___days,

. Headache (-), neck stiffness (-), seizure (-), change in sensorium (-)

. Cough (-), sputum (-), rhinorrhea (-), sorethroat (-), dyspnea (-)

. Dysuria (-), urinary frequency (-), urgency (-), CV angle knocking tenderness (-)

. Abdominal pain (-), diarrhea (-), tenderness (-), rebound tenderness (-)

. Myalgia (-), skin rash (-), arthralgia (-)

T:

O:

C:

C:

Indwelling catheters: nil

MASCC risk index:  

急診模板: CV

• Chest pain, ACS

Chest pressure/ tightness/ pain, radiated to back/ jaw/ neck/ left arm/ right arm for____, since____

Sudden/ Gradual onset, excertional induced, dull pain/ tearing sensation /sharp pain/ stinging pain/ pleuritic pain/ burning sensation

Duration:

Aggravated by lying down/ sitting up/ walking/ exercising/ climbing stairs

Relieved by taking NTG/ taking medicine/ lying down/ sitting up/ resting

Nausea (-), vomiting (-), diaphoresis (-), exertional dyspnea (-), orthopnea (-)

Cough (-), sputum (-), color (-), rhinorrhea (-), sore throat (-)

Abdominal pain (-), constipation (-)

Dysuria(-), frequency (-), urgency (-)

Recent trauma (-), Surgery history (-)

Recent forceful vomiting after drinking alcohol (-), dysphagia (-)

CV risk factor:

-DM (-), HTN (-), Dyslipidemia (-), Obesity (-), Smoking (-), Physical inactivity (-),

-Age (-), Sex (-), FHx(-)

• Hypertension

BP, when, resistant to medication

Headache (), seizure (), stroke (), blurred vision ()

Chest pain ()/ radiation to back (), chest tightness (), dyspnea (), orthopnea (), bil leg swelling ()

Urine output (), hematuria (), dizziness (), palpitation ()

Current medication: titration (), changing ()

Change in diet ()

Use of steroids ()

Pheochromocytoma 5P:

-Pressure: hypertensive ()

-Pain: headache (), chest pain ()    

-Palpitations: tachycardia (), tremor (), weight loss (), fever ()

-Perspiration () 大量流汗

-Pallor ()

PHx:

HTN (), Aortic dissection (), ischemic stroke ()  

• Syncope

Micturition, cough, defecation, standing for too long, 打針

Turning head, shaving

Orthostatic hypotension, postural change

Seizure-like movement

Current medication:

PE:

Heart: regular/ irregular heartbeats, murmur (-),

Mx

EKG, CBC, BCS

OPD, Holter, Adm EPS