Description: Dyspnea dot phrase with a plan for the initial evaluation of shortness of breath.

Dyspnea smart phrase

Dyspnea: Differential diagnosis include CHF, PE, pneumothorax, pneumonia, obstructive airway disease (COPD, asthma), restrictive airway disease, neuromuscular disorder, anemia

Evaluation
– O2 sat @FLO(2078:last)@ on *** O2
– exam significant for RR=***, accessory muscles used/not used***, pulmuonary exam shows ***
– CHF history ***neg/pos with BNP of ***, S3***,
– DVT/PE risk factors (pregnancy, cancer, hormone therapy, previous DVT, immobility, recent surgery/injury, family history of DVT, inherited hypercoagulability, obesity, age>60, very tall, smoking, calf pain) – COPD history: PFTs***, smoking history***, physical exam (barrel chested, wheezes)***
– Anemia: exam findings: pallor, tachycardia, flow murmur***
– Neuromuscular disease: neuro exam shows ***
 
Plan
– CXR: PA/Lateral ***
– ECG ***
– BNP ***
– echocardiogram ***
– CT PE protocol ***
– Lower extremity dopplers ***
– ABG ***
– Pulmonary function tests ***
– tele ***
– DVT prophylaxis ***
– DuoNebs ***
– Daily CBC/BMG
– Strict I&O, dailyl weights
 

Topics #asthma #CHF #COPD #dot phrase #dyspnea #obstructive sleep apnea #shortness of breath #smart phrase #sob