วันเสาร์ที่ 18 ตุลาคม พ.ศ. 2568

Medical record

Medical record

✔️ แนะนำให้ใส่เวลาจริง (clock time) ควบคู่กับ “PTA” โดยเฉพาะในกรณี refer/transfer, critical care, legal-sensitive cases, และ procedures,

  • 48 hrs PTA (03:00 PM, 01/10): Onset of fever.
  • 24 hrs PTA (03:30 PM, 01/11): Worsening dyspnea, went to local hospital.
  • 12 hrs PTA (03:45 AM, 01/12): Received IV antibiotics; BP dropped.
  • 2 hrs PTA (04:45 AM, 01/12): Started norepinephrine infusion during transfer.
  • Arrival ED (06:00 AM): Patient drowsy, SpO₂ 90% on NRB.

ถ้าไม่สามารถระบุเวลาแน่นอนได้ สามารถใช้ “approx.” เช่น
“12 hrs PTA (approx. 4:00 PM yesterday)”

🔷 Case Example: Severe Community-Acquired Pneumonia with Sepsis – Transferred from a District Hospital

✅ A. Timeline Style (Transfer Note)

Chief Complaint:
“High fever and difficulty breathing”

Timeline HPI & Transfer Events:

  • 48 hrs PTA (At home): Patient developed high-grade fever (up to 39.5°C), productive cough with yellow sputum, malaise. Self-medicated with paracetamol.
  • 24 hrs PTA (Local clinic): Worsening dyspnea and pleuritic chest pain. Received nebulized salbutamol, minimal relief. Referred to district hospital.
  • 18 hrs PTA (District Hospital – Initial Assessment):
    • Vital signs: T 39.2°C, HR 112 bpm, BP 102/65 mmHg, RR 28/min, SpO₂ 90% RA
    • Physical Exam: Decreased breath sounds RLL, crackles R mid and lower fields
    • Labs: WBC 18,500/µL (85% neutrophils), Cr 1.3 mg/dL, Lactate 2.8 mmol/L
    • CXR: Right lower lobe consolidation with air bronchograms
    • Treatment started: IV ceftriaxone 2 g, IV azithromycin 500 mg, 1 L NS bolus, oxygen via nasal cannula 3 L/min
  • 12 hrs PTA: Persistent fever and hypotension (BP dropped to 90/60). Received second bolus NS 500 mL and IV norepinephrine started at 0.05 mcg/kg/min. Oxygen escalated to non-rebreather mask 10 L/min (SpO₂ 94%). Decision made to transfer.
  • During transport (2 hrs PTA):
    • Oxygen maintained with NRB 10 L/min
    • Norepinephrine infusion ongoing
    • Patient became drowsy but arousable (GCS 14), BP improved to 100/65 mmHg
  • Arrival to ED:
    • Vital signs: T 38.5°C, HR 118, BP 102/70 on norepinephrine, RR 30, SpO₂ 92% on NRB.
    • Physical exam: Crackles and decreased air entry over R lung; mild accessory muscle use
    • Labs pending: ABG, lactate, procalcitonin, blood cultures
    • Plan: Upgrade antibiotics to piperacillin-tazobactam + azithromycin, consider ICU admission

PMH: Hypertension, no CKD
Medications: Amlodipine 10 mg daily
Allergies: NKDA

✅ B. Narrative Style (HPI Only with transfer details)

The patient is a 58-year-old male presenting with a two-day history of high-grade fever, productive cough, and progressive dyspnea. Symptoms worsened despite outpatient treatment and he was evaluated at a district hospital where examination revealed tachypnea, hypoxia, and right lower lobe consolidation on chest radiograph. Initial management included IV ceftriaxone, azithromycin, intravenous fluids, and supplemental oxygen. The patient subsequently developed hypotension requiring initiation of norepinephrine and escalation of oxygen support to a non-rebreather mask. Due to worsening respiratory distress and concern for septic shock, he was transferred to our facility. During transport, he remained on vasopressor support with stable hemodynamics but showed increasing work of breathing. Upon arrival, he is febrile, tachycardic, hypotensive on vasopressors, and hypoxic despite high-flow oxygen, consistent with severe pneumonia and evolving sepsis.

 

Example of New case in ED

🔷 Condition 1: Acute Appendicitis

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Right lower quadrant abdominal pain”

HPI (Timeline Format):

  • 36 hours PTA: Patient began experiencing vague periumbilical abdominal discomfort, described as dull and intermittent. No associated nausea at that time.
  • 24 hours PTA: Pain migrated to the right lower quadrant, becoming sharper and constant. Patient reported decreased appetite and mild nausea without vomiting.
  • 18 hours PTA: Developed low-grade fever (subjective), attempted self-medication with acetaminophen 500 mg with minimal relief.
  • 12 hours PTA: Pain intensity increased to 7/10, aggravated by movement and coughing. Reports a single episode of vomiting. Denies diarrhea or urinary symptoms.
  • 3 hours PTA: Pain became severe, prompting visit to the emergency department. No bowel movement in 24 hours. Denies history of similar episodes.

Relevant Past Medical History:

  • No known chronic medical conditions
  • No history of gastrointestinal disorders or prior abdominal surgeries

Medications:

  • Occasional acetaminophen PRN
  • No regular prescriptions

Allergies:

  • No known drug allergies (NKDA)

B. Narrative Style (HPI Only)

The patient reports a 36-hour history of abdominal pain that initially began in the periumbilical region as a dull discomfort and later migrated to the right lower quadrant, becoming sharp and constant. The pain progressively worsened over the past 24 hours and is now exacerbated by movement and coughing. Associated symptoms include anorexia, nausea, one episode of vomiting, and subjective fever. The patient denies diarrhea, constipation, dysuria, or urinary frequency. No prior episodes of similar pain and no previous abdominal surgeries.

🔷 Condition 2: Acute Coronary Syndrome (NSTEMI)

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Chest pain”

HPI (Timeline Format):

  • 2 days PTA: Patient began noticing intermittent central chest pressure during exertion, relieved by rest. No medical attention sought.
  • 12 hours PTA: Chest pain became more frequent and now occurs at rest, described as a heavy pressure rated 6/10, radiating to the left arm. Associated with mild diaphoresis and shortness of breath.
  • 6 hours PTA: Took sublingual nitroglycerin (borrowed from spouse) with partial relief. Pain recurred within one hour.
  • 1 hour PTA: Pain worsened to 8/10 with persistent pressure, nausea, and diaphoresis, prompting ED visit. Patient denies syncope or palpitations. No history of trauma.

Relevant Past Medical History:

  • Hypertension (diagnosed 5 years ago)
  • Type 2 diabetes mellitus
  • Hyperlipidemia
  • No prior myocardial infarction or coronary interventions

Medications:

  • Metformin 500 mg BID
  • Lisinopril 20 mg daily
  • Atorvastatin 40 mg daily
  • Aspirin 81 mg daily (non-compliant)

Allergies:

  • No known drug allergies (NKDA)

B. Narrative Style (HPI Only)

The patient reports a two-day history of intermittent substernal chest pressure initially occurring with exertion and relieved by rest, which progressed to persistent chest pain at rest over the past 12 hours. The pain is described as a heavy pressure radiating to the left arm, accompanied by diaphoresis, dyspnea, and nausea. Pain severity increased despite taking nitroglycerin borrowed from a family member. There is no associated syncope, palpitations, or trauma. The patient has a history of hypertension, diabetes, and hyperlipidemia with poor medication adherence.

🔷 Condition 3: Acute Ischemic Stroke

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Right-sided weakness and slurred speech”

HPI (Timeline Format):

  • Yesterday evening (approx. 18 hours PTA): Patient experienced transient episode of right arm numbness lasting 5 minutes, which resolved spontaneously. No medical evaluation sought.
  • This morning (4 hours PTA): Sudden onset of right arm and leg weakness while eating breakfast, with difficulty speaking and facial droop on the right side. Symptoms partially persisted.
  • 3 hours PTA: Symptoms worsened, including inability to hold objects with the right hand and slurred speech. Family noted patient appeared confused.
  • 30 minutes PTA: Patient unable to ambulate independently, prompting emergency transport to the ED. Denies headache, trauma, or seizure activity.

Relevant Past Medical History:

  • Hypertension
  • Atrial fibrillation (not on anticoagulation)
  • Dyslipidemia

Medications:

  • Metoprolol succinate 50 mg daily
  • Atorvastatin 40 mg daily
  • Patient admits non-adherence to prescribed anticoagulant

Allergies:

  • No known drug allergies (NKDA)

B. Narrative Style (HPI Only)

The patient developed sudden right-sided weakness and speech difficulty approximately four hours prior to arrival. Symptoms began with right arm numbness followed by progressive weakness of the right upper and lower extremities and slurred speech. Family reports facial droop and confusion. Symptoms did not improve, and the patient was unable to ambulate. There is no associated headache, loss of consciousness, or trauma. The patient has a history of atrial fibrillation and hypertension with poor anticoagulation adherence.

🔷 Condition 4: Acute Pyelonephritis

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Fever and right flank pain”

HPI (Timeline Format):

  • 3 days PTA: Patient developed dysuria and urinary frequency with foul-smelling urine. Began self-medicating with leftover antibiotics (amoxicillin) without improvement.
  • 24 hours PTA: Onset of right flank pain, dull and constant, radiating to the groin, associated with chills.
  • 12 hours PTA: Fever up to 39.2°C (102.5°F), nausea, and two episodes of vomiting. Pain now rated 7/10.
  • 2 hours PTA: Flank pain worsened; patient developed generalized malaise and presented to the ED.

Relevant Past Medical History:

  • Recurrent urinary tract infections
  • Type 2 diabetes mellitus
  • No history of kidney stones

Medications:

  • Metformin 500 mg BID
  • Occasional use of amoxicillin (self-prescribed)

Allergies:

  • NKDA

B. Narrative Style (HPI Only)

The patient presents with a three-day history of dysuria and urinary frequency that progressed to right flank pain and fever in the past 24 hours. The pain is constant, radiates to the groin, and is associated with chills, nausea, and vomiting. Symptoms have worsened despite self-administration of leftover antibiotics. No history of nephrolithiasis, but the patient reports recurrent UTIs.

🔷 Condition 5: Acute Asthma Exacerbation

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Shortness of breath and wheezing”

HPI (Timeline Format):

  • 2 days PTA: Patient developed cough and nasal congestion following cold exposure.
  • 12 hours PTA: Onset of wheezing and chest tightness; used home albuterol inhaler with minimal relief.
  • 6 hours PTA: Increasing dyspnea, unable to sleep due to shortness of breath; using inhaler every 2 hours without improvement.
  • 1 hour PTA: Developed severe respiratory distress with difficulty speaking in full sentences, prompting ED arrival via EMS.

Relevant Past Medical History:

  • Asthma since childhood
  • No previous intubations, but 2 prior ED visits
  • Allergic rhinitis

Medications:

  • Albuterol inhaler PRN
  • Fluticasone inhaler BID

Allergies:

  • Allergic to dust mites (environmental)
  • No drug allergies

B. Narrative Style (HPI Only)

The patient reports progressively worsening shortness of breath and wheezing over the past 12 hours, unresponsive to frequent albuterol inhaler use. Symptoms began after a viral upper respiratory infection and cold exposure. The patient now experiences chest tightness and difficulty speaking in full sentences, consistent with an acute asthma exacerbation.

🔷 Condition 6: Diabetic Ketoacidosis (DKA)

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Nausea, vomiting, and weakness”

HPI (Timeline Format):

  • 3 days PTA: Patient experienced polyuria, polydipsia, and fatigue; glucose readings >300 mg/dL.
  • 24 hours PTA: Onset of nausea and abdominal pain. Began missing insulin doses due to poor appetite.
  • 12 hours PTA: Multiple episodes of vomiting, generalized weakness, and rapid breathing.
  • Arrival to ED: Patient reports confusion and inability to keep fluids down.

Relevant Past Medical History:

  • Type 1 diabetes mellitus (diagnosed 8 years ago)
  • Recent upper respiratory infection

Medications:

  • Insulin glargine (Lantus) 20 units at bedtime
  • Insulin lispro with meals (often missed doses recently)

Allergies:

  • NKDA

B. Narrative Style (HPI Only)

The patient presents with a three-day history of fatigue, excessive thirst, and polyuria, followed by nausea, abdominal pain, and progressive vomiting over the past 24 hours. He has missed several insulin doses due to poor appetite. On arrival, he reports weakness and confusion, consistent with possible diabetic ketoacidosis.

🔷 Condition 7: Acute Gastroenteritis with Dehydration

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Vomiting and diarrhea”

HPI (Timeline Format):

  • 2 days PTA: Patient developed watery diarrhea 4–5 times per day after eating at a restaurant.
  • 24 hours PTA: Onset of nausea and vomiting; unable to tolerate oral intake.
  • 12 hours PTA: Increasing weakness, dry mouth, decreased urination.
  • Arrival to ED: Persistent vomiting and diarrhea; patient feels dizzy upon standing.

Relevant Past Medical History:

  • No chronic medical conditions

Medications:

  • None regularly

Allergies:

  • NKDA

B. Narrative Style (HPI Only)

The patient reports a two-day history of profuse watery diarrhea and a one-day history of persistent vomiting. He has been unable to tolerate oral intake and notes decreased urine output, dizziness, and generalized weakness, suggesting dehydration from acute gastroenteritis.

🔷 Condition 8: Upper GI Bleed

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Vomiting blood”

HPI (Timeline Format):

  • 1 week PTA: Patient experienced epigastric burning pain; self-treated with OTC ibuprofen.
  • 24 hours PTA: Developed nausea and dark-colored emesis.
  • 6 hours PTA: Multiple episodes of hematemesis with bright red blood. Reports dizziness and weakness.
  • Arrival to ED: Continues to have epigastric pain and lightheadedness.

Relevant Past Medical History:

  • Peptic ulcer disease
  • GERD

Medications:

  • Omeprazole (intermittent use)
  • NSAID overuse (ibuprofen daily for 1 week)

Allergies:

  • NKDA

B. Narrative Style (HPI Only)

The patient presents with acute-onset hematemesis following one week of worsening epigastric discomfort and NSAID use. The vomiting progressed from coffee-ground material to bright red blood. Associated symptoms include dizziness and generalized weakness.

🔷 Condition 9: COPD Exacerbation

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Increasing shortness of breath”

HPI (Timeline Format):

  • 3 days PTA: Patient developed productive cough with yellow sputum.
  • 24 hours PTA: Increased dyspnea, wheezing, and fatigue.
  • 8 hours PTA: Required increased use of home nebulizer without adequate relief.
  • Arrival to ED: Severe dyspnea at rest, difficulty speaking full sentences.

Relevant Past Medical History:

  • COPD (GOLD stage III)
  • 40 pack-year smoking history

Medications:

  • Tiotropium inhaler daily
  • Albuterol nebulizer PRN
  • Home oxygen at night

Allergies:

  • NKDA

B. Narrative Style (HPI Only)

The patient reports a three-day history of productive cough and progressive dyspnea, unrelieved by increased use of home bronchodilators. Symptoms worsened significantly overnight, and he is now short of breath at rest with difficulty speaking, consistent with a COPD exacerbation.

🔷 Condition 10: Migraine Headache

A. Timeline Style (US-ED Standard)

Chief Complaint:
“Severe headache”

HPI (Timeline Format):

  • 2 days PTA: Patient reports onset of unilateral throbbing headache associated with photophobia.
  • 24 hours PTA: Pain intensified, accompanied by nausea and vomiting. OTC analgesics provided no relief.
  • 4 hours PTA: Headache worsened to 9/10 intensity with visual aura and increased sensitivity to light and sound.
  • Arrival to ED: Continues to vomit; unable to tolerate PO intake.

Relevant Past Medical History:

  • Recurrent migraines (diagnosed 5 years ago)
  • No recent trauma

Medications:

  • Sumatriptan PRN (ran out of medication)

Allergies:

  • NKDA

B. Narrative Style (HPI Only)

The patient presents with a two-day history of unilateral throbbing headache associated with photophobia and nausea, which progressed in severity over the past 24 hours. The headache is now severe and accompanied by vomiting and visual aura, consistent with a migraine exacerbation.

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