Clinical: ED Case Summaries - yina/2025-catalyzing-health-promptathon GitHub Wiki
| Type | Example |
|---|---|
| Summarization | Ask for a description of why the patient was admitted to the hospital. Example prompt (cut and paste): Using the ED case summary below, please provide me a short description of why the patient was admitted to the hospital and the contributing factors that led to their hospitalization. |
| Clinical Judgment | Prioritization. Example prompt (cut and paste): You are a hospitalist - what is the priority for this patient, upon receiving handoff? |
Note: 8 total de-identified cases are available here. One case is available for copy/pasting into GPT, below.
Perelman ED, Admission to General Medicine, Resident Provider Note with no attestation
Smartlink Summary
This patient is a 62 y.o. male who presents to the ED today with Chest Pain and Weakness
Triage note:
Chest Pain (DM, ESRD on HD MWF, last session 05/30. BIBEMS for SBS 200s, left sided CP, weakness, and SOB X 1 week. +vomiting x 1 today. ) and Weakness
Past medical history and elements of social history:
Past Medical History:
Diagnosis Date
• Anemia
per patient report
• Chronic kidney disease
• Dialysis patient
• Hypertension
Social History
Substance and Sexual Activity
Drug Use Not Currently
• Types: Cocaine, Heroin
Comment: Currently on methadone
Social History
Tobacco Use
Smoking Status Every Day
• Packs/day: 0.25
• Types: Cigarettes
Smokeless Tobacco Never
In the Emergency Department, the following vital signs were noted:
Vital Signs:
06/05/21 1348 06/05/21 1504 06/05/21 1619 06/05/21 1734
BP: (!) 199/80 (!) 200/91 (!) 190/88 (!) 196/88
Pulse: 77 74 66 64
Resp: 18 15 15 17
Temp: 36.8 ∞C (98.3 ∞F)
06/05/21 2018 06/05/21 2148 06/05/21 2246
BP: (!) 186/81 (!) 204/97 (!) 209/101
Pulse: 68 72 65
Resp: 18 12 17
Temp:
The following labs were obtained recently:
Results for orders placed or performed during the hospital encounter of 06/05/21 (from the past 24 hour(s))
BASIC METABOLIC PANEL
Collection Time: 06/05/21 2:15 PM
Result Value
SODIUM 138
POTASSIUM 6.8 (Critical Hi)
CHLORIDE 105
CARBON DIOXIDE 16 (L)
BLOOD UREA NITROGEN 88 (H)
CREATININE 19.74 (H)
GLUCOSE 80
CALCIUM 9.0
eGFR (CKD-EPI 2021) 2.4 (L)
ANION GAP 17 (H)
HEPATIC PANEL
Collection Time: 06/05/21 2:15 PM
Result Value
ALBUMIN 4.0
PROTEIN, TOTAL 7.5
BILIRUBIN DIRECT 0.2
BILIRUBIN TOTAL 0.5
AST 13
ALT <9
ALKALINE PHOSPHATASE 215 (H)
TROPONIN I, HIGH SENSITIVITY
Collection Time: 06/05/21 2:15 PM
Result Value
TROPONIN I, HIGH SENSITIVITY 44 (Critical Hi)
TROPONIN I HS ABSOLUTE DELTA Baseline Troponin
TROPONIN I HS PERCENT DELTA Baseline Troponin
B-TYPE NATRIURETIC (BNP)
Collection Time: 06/05/21 2:15 PM
Result Value
B-TYPE NATRIURETIC PEPTIDE 765 (H)
MAGNESIUM
Collection Time: 06/05/21 2:15 PM
Result Value
MAGNESIUM 2.4
CBC WITH DIFFERENTIAL
Collection Time: 06/05/21 2:15 PM
Result Value
WHITE BLOOD CELL COUNT 9.0
NUCLEATED RED BLOOD CELLS % 0
NUCLEATED RBC,ABSOLUTE 0.02 (H)
RED BLOOD CELL COUNT 4.42 (L)
HEMOGLOBIN 12.2 (L)
HEMATOCRIT 40.0
MEAN CORPUSCULAR VOLUME 90.5
MEAN CORPUSCULAR HEMOGLOBIN 27.6
MEAN CORPUSCULAR HEMOGLOBIN CONC 30.5 (L)
RDW-CV 17.5 (H)
RDW-SD 57.0 (H)
PLATELET COUNT 185
MEAN PLATELET VOLUME 10.3
IMMATURE PLATELET FRACTION, % 1.5
IMMATURE PLATELET FRACTION, ABSOLUTE 2.8 (L)
DIFFERENTIAL TYPE AUTOMATED
NEUTROPHILS % 74 (H)
LYMPHOCYTES % 13 (L)
MONOCYTES % 8
EOSINOPHILS % 5
BASOPHILS % 0
GRANULOCYTES, IMMATURE % 0
NEUTROPHILS ABSOLUTE 6.6 (H)
LYMPHOCYTES ABSOLUTE 1.2 (L)
MONOCYTES ABSOLUTE 0.7
EOSINOPHILS, ABSOLUTE 0.5
BASOPHILS ABSOLUTE 0.0
GRANULOCYTES IMMATURE , ABSOLUTE 0.0
POCT VENOUS BLOOD GAS COMPLETE PANEL WITH LACTATE
Collection Time: 06/05/21 2:34 PM
Result Value
PH, VBG 7.26 (L)
PCO2, VBG 45
PO2, VBG 46
HCO3, VBG 20.2 (L)
BASE DEFICIT, VBG 7 (H)
O2 CONTENT (SAT), VBG 68
HEMOGLOBIN, VBG 12.8
OXYHEMOGLOBIN, VBG 65.8
CARBOXYHEMOGLOBIN, VBG 3.1 (H)
METHEMOGLOBIN, VBG 0.8 (H)
SODIUM, VBG 133 (L)
POTASSIUM, VBG 7.1 (Critical Hi)
IONIZED CALCIUM, VBG 1.12
GLUCOSE, VBG 84
TEMPERATURE, VBG 37.0
LACTATE, VBG 0.8
CHLORIDE, VBG 103
COVID-19 BY NAAT (PCR,TMA) - AT HOSPITAL ONLY
Collection Time: 06/05/21 3:12 PM
Result Value
SARS-COV-2 RNA, NAAT Detected (A)
SARS-COV-2 TARGET 1 CYCLE THRESHOLD 0.0
SARS-COV-2 TARGET 2 CYCLE THRESHOLD 37.7
SARS-COV-2 TARGET 3 CYCLE THRESHOLD 40.9
SARS-COV-2 COMMENT See note below
POCT VENOUS BLOOD GAS COMPLETE PANEL WITH LACTATE
Collection Time: 06/05/21 5:00 PM
Result Value
PH, VBG 7.26 (L)
PCO2, VBG 46
PO2, VBG 35
HCO3, VBG 20.6 (L)
BASE DEFICIT, VBG 6 (H)
O2 CONTENT (SAT), VBG 49
HEMOGLOBIN, VBG 12.0
OXYHEMOGLOBIN, VBG 47.8
CARBOXYHEMOGLOBIN, VBG 2.4
METHEMOGLOBIN, VBG 0.3
SODIUM, VBG 134 (L)
POTASSIUM, VBG 6.8 (Critical Hi)
IONIZED CALCIUM, VBG 1.15
GLUCOSE, VBG 117 (H)
TEMPERATURE, VBG 37.0
LACTATE, VBG 1.1
CHLORIDE, VBG 102
BASIC METABOLIC PANEL
Collection Time: 06/05/21 5:03 PM
Result Value
SODIUM 138
POTASSIUM 6.6 (Critical Hi)
CHLORIDE 105
CARBON DIOXIDE 16 (L)
BLOOD UREA NITROGEN 90 (H)
CREATININE 19.11 (H)
GLUCOSE 117 (H)
CALCIUM 8.9
eGFR (CKD-EPI 2021) 2.5 (L)
ANION GAP 17 (H)
POCT GLUCOSE
Collection Time: 06/05/21 8:06 PM
Result Value
GLUCOSE, POC 74
HEPATITIS B VIRUS CORE ANTIBODY, TOTAL
Collection Time: 06/05/21 8:18 PM
Result Value
HEPATITIS B CORE TOTAL ANTIBODY Reactive (A)
HEPATITIS B VIRUS SURFACE ANTIGEN
Collection Time: 06/05/21 8:18 PM
Result Value
HEPATITIS B SURFACE ANTIGEN Nonreactive
HEPATITIS C VIRUS ANTIBODY, REFLEX TO RNA QUANT
Collection Time: 06/05/21 8:18 PM
Result Value
HEPATITIS C VIRUS ANTIBODY, TOTAL Reactive (A)
HEPATITIS B VIRUS SURFACE ANTIBODY QUANTITATIVE
Collection Time: 06/05/21 8:18 PM
Result Value
HEPATITIS B SURFACE ANTIBODY 55.72 (H)
POCT GLUCOSE
Collection Time: 06/05/21 9:45 PM
Result Value
GLUCOSE, POC 96
The following imaging has been obtained recently:
No results found.
Meds given in the ED:
Medications
dextrose (GLUTOSE) 40 % oral gel 15 g (has no administration in time range)
dextrose 50 % injection 50 mL (has no administration in time range)
glucagon (GLUCAGEN) injection 1 mg (has no administration in time range)
Followed by
dextrose 5 % infusion (has no administration in time range)
dextrose 50 % injection 50 mL (has no administration in time range)
dextrose 50 % injection 25 g (has no administration in time range)
Or
dextrose (GLUTOSE) 40 % oral gel 15 g (has no administration in time range)
sodium chloride 0.9 % flush (PF) injection (has no administration in time range)
sodium chloride 0.9 % (NS) bolus 400 mL (has no administration in time range)
sodium chloride 0.9 % (NS) bolus 200 mL (has no administration in time range)
sodium chloride 0.9 % flush (PF) injection (has no administration in time range)
heparin (porcine) injection 10,000 Units (has no administration in time range)
dextrose 50 % injection 25 g (has no administration in time range)
Or
dextrose (GLUTOSE) 40 % oral gel 15 g (has no administration in time range)
carvediloL (COREG) tablet 12.5 mg (12.5 mg Oral Given 6/3/21 2213)
albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulizer solution 2.5 mg (2.5 mg Nebulization Given 6/3/21 1503)
ipratropium (ATROVENT) 0.02 % nebulizer solution 0.5 mg (0.5 mg Nebulization Given 6/3/21 1503)
methadone (DOLOPHINE) 10 mg/mL oral CONCENTRATE 10 mg (10 mg Oral Given 6/3/21 1531)
prochlorperazine (COMPAZINE) injection 5 mg (5 mg Intravenous Given 6/3/21 1503)
calcium gluconate 2,000 mg in sodium chloride 0.9 % 100 mL IVPB (0 mg Intravenous Stopped 6/3/21 1514)
albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulizer solution 10 mg (10 mg Nebulization Given 6/3/21 1537)
sodium zirconium cyclosilicate (LOKELMA) oral powder packet for suspension 10 g (10 g Oral Given 6/3/21 1618)
dextrose 50 % injection 25 g (25 g Intravenous Given 6/3/21 1615)
Followed by
insulin regular (HumuLIN R) (U-100) injection 5 Units (5 Units Intravenous Given 6/3/21 1615)
calcium gluconate 2,000 mg in sodium chloride 0.9 % 100 mL IVPB (0 mg Intravenous Stopped 6/3/21 2200)
dextrose 50 % injection 25 g (25 g Intravenous Given 6/3/21 2024)
Followed by
insulin regular (HumuLIN R) (U-100) injection 5 Units (5 Units Intravenous Given 6/3/21 2024)
albuterol (PROVENTIL) 2.5 mg /3 mL (0.083 %) nebulizer solution 10 mg (10 mg Nebulization Given 6/3/21 2011)
furosemide (LASIX) 10 mg/mL injection 40 mg (40 mg Intravenous Given 6/3/21 2010)
Consults completed in the ED: No data recorded
Diagnosis in the ED was: Hyperkalemia
Provider Note
Mary Green Gold, MD
Resident
Emergency Medicine
ED Provider Notes
Cosign Needed
Creation Time: 6/3/2021 2:04 PM
Cosigner Requested
Steven Silver, MD
Expand All Collapse All
NYU Langone - ED Provider Note
Triage and Provider History
Registration Arrival Complaint:
Triage Chief Complaint:
Chest Pain (DM, ESRD on HD MWF, last session 05/30. BIBEMS for SBS 200s, left sided CP, weakness, and SOB X 1 week. +vomiting x 1 today. ) and Weakness
Nursing HPI:
History of Present Illness:
Roger Denmark is a 62 y.o. male:
62yo M with hx OUD on methadone (120mg, goes to Harmony Life Plan Clinic 212-555-1212), ESRD on hemodialysis Monday Wednesday Friday, hypertension presenting with shortness of breath and tachypnea after missed dialysis. He reports he last got dialysis on Friday and since then has had difficulty breathing, cough, weakness. He also has some mild chest pain located in the mid chest that he gets along with palpitations when his potassium is high. He also states that he has missed his methadone dose for the last couple days and endorses nausea, vomiting, diaphoresis, abdominal pain, myalgias, anxiety, chills. He denies fevers, dysuria (still makes a small amount of urine), diarrhea, constipation. He has multiple prior hospitalizations for emergent dialysis in the setting of similar missing dialysis episodes.
Attempted to confirm methadone dosing with clinic; methadone clinic ID: 1234567 Harmony life plan 212-555-1212, left Vmail and did not receive call back.
Chest Pain
I have reviewed, verified, and updated the following clinical documentation in the chart as appropriate: Available allergies, PMH, PSH, SH, FH, and prior to arrival medications. Findings related to the current presentation are included in the HPI.
I have also reviewed the following clinical documentation: ED Nursing notes and vital signs corresponding to time patient was under my care.
Review of Systems
Cardiovascular: Positive for chest pain.
Physical Exam
Initial Vitals: | BP: (!) 199/80 | Heart Rate: 77 | Resp: 18 | Temp: 36.8 °C (98.3 °F) | SpO2: 97 %, O2 Device: None (Room air) | | |
Physical Exam
Vitals and nursing note reviewed.
Constitutional:
General: He is not in acute distress.
Appearance: Normal appearance. He is not toxic-appearing.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.
Eyes:
Extraocular Movements: Extraocular movements intact.
Conjunctiva/sclera: Conjunctivae normal.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Heart sounds: Normal heart sounds. No murmur heard.
No friction rub. No gallop.
Pulmonary:
Effort: No respiratory distress.
Breath sounds: Wheezing and rales present. No rhonchi.
Abdominal:
General: Abdomen is flat. Bowel sounds are normal. There is no distension.
Palpations: Abdomen is soft.
Tenderness: There is no abdominal tenderness. There is no guarding.
Musculoskeletal:
General: No swelling, tenderness, deformity or signs of injury. Normal range of motion.
Cervical back: Normal range of motion and neck supple.
Right lower leg: No edema.
Left lower leg: No edema.
Skin:
General: Skin is warm and dry.
Capillary Refill: Capillary refill takes less than 2 seconds.
Coloration: Skin is not jaundiced.
Findings: No bruising, erythema, lesion or rash.
Neurological:
General: No focal deficit present.
Mental Status: He is alert and oriented to person, place, and time.
Assessment & Plan
62-year-old man with a history of opioid use disorder on methadone, ESRD now presenting with crackles and tachypnea as well as chest pain in the setting of 3 missed dialysis sessions, concerning for pulmonary edema and hyperkalemia. Plan for EKG, labs, likely hyperkalemia meds, chest x-ray, possible admission. Also with evidence of opioid withdrawal with COWS score of 12, so will give 10mg of methadone and titrate to symptoms.
The patient’s current pain assessment and goals for pain management are: Goals have been discussed and the patient declines medication.
Mary Green Gold, MD
Resident
06/05/21 1951