Charting Bootcamp

New-Onset Type 2 Diabetes — New-onset Type 2 Diabetes Mellitus — hyperglycemia workup

CHF Exacerbation — Acute exacerbation of congestive heart failure

Community-Acquired Pneumonia — Community-acquired pneumonia — right lower lobe

Post-Op Total Knee Replacement — Post-op Day 1 — Right Total Knee Arthroplasty

UTI With Sepsis Risk — Complicated UTI — sepsis screening

Alcohol Withdrawal — CIWA Protocol — Alcohol use disorder — inpatient detox, CIWA protocol

COPD Exacerbation — COPD exacerbation — IV steroids, scheduled nebs

New A-Fib with RVR — New-onset atrial fibrillation with rapid ventricular response — telemetry

Post-op TURP with CBI — Post-op Day 0 — Transurethral Resection of Prostate (TURP)

DKA Resolution & Insulin Transition — Diabetic Ketoacidosis — resolving

Upper GI Bleed — Transfusion — Upper GI bleed, awaiting EGD

Post-tPA Stroke — Neuro Watch — Ischemic CVA — 6 hours post-tPA

Chest Tube — Spontaneous Pneumothorax — R spontaneous pneumothorax with chest tube

Sickle Cell Vaso-occlusive Crisis — Sickle cell disease, vaso-occlusive crisis

Cellulitis with IV Antibiotics — R lower leg cellulitis with venous stasis ulcer

Total Hip Arthroplasty — POD 1 — R total hip arthroplasty, POD 1

Acute Pancreatitis — Acute gallstone pancreatitis

Heart Failure — Discharge Day — CHF exacerbation — resolved, discharge day

Sepsis — Post-op Abdominal Source — Sepsis — post-op day 3 colectomy, suspected intra-abdominal source

Post-op CABG — Day 2 — Post-op day 2 CABG ×3, chest tubes in place

Multi-Trauma — MVC — MVC — grade II splenic laceration (non-op), rib fx 4-7 right, right radius fx

Acute Respiratory Failure — BiPAP — Acute hypercapnic respiratory failure — COPD exacerbation

Traumatic Brain Injury — Neuro ICU — Moderate TBI — subdural hematoma, s/p burr hole

Postpartum Hemorrhage — PPH — uterine atony s/p vaginal delivery, EBL 1200 mL

Pediatric Asthma Exacerbation — Severe asthma exacerbation

End-of-Life — Comfort Care Transition — End-stage metastatic pancreatic cancer — comfort care

Rapid Response — Deteriorating Patient — PE — new dx during hospitalization for cellulitis

Post-op Hip Fracture — Day 1 — Post-op day 1 R hip ORIF (fall at home)

Capstone — Acute Ischemic Stroke — Acute ischemic stroke — tPA candidate, LKW 60 min ago