Illness Script

81 y/o
y/o male ,Presented w/ hematuria General:
Presentation Extra details: Problem Presentation (DDx)

HEENT:
Stabilization
Vitals
Airway/ O2 Supp.: Positive pressure
BP 125 / 76 Breathing Exertional SoB CV:
He was primarily diagnosed with bladder
HR 86 cancer and planned to have a urethroscopy
(cystoscopy) procedure. during procedure
Pulm.:

Physical Examination
RR 18 Circulation CV-line | large-bore IV×2
Leg raising test
SpO2 % Room air IV fluid therapy? Yes No Abd.:
Baseline: 15 Type? Choose an item
GCS
NT domain: none Neuro.:
Volume? Vol. in mLmL

Any extra details Extra:

Temp: 36.5
Extremities:
Initial U/ output: 700ml

Encounter

Disability Skin: Final Dx:

(CNS)

30-word Summary:
HPI: Lab Value Lab Value Lab Value
Exertional SoB Hb (28th morning) 12.5 CRP (27th morning) 3+ pH (CPR) 7.39
He was primarily diagnosed with bladder cancer and planned to have a urethroscopy (cystoscopy) procedure. during procedure
WBC (28th morning) 6 LDH(27th morning) 1518 PCO2 (CPR) 41.9
cystoscopy the tumor had active bleeding.
Preoperative assessment: LVEF of 55-60% and LV diastolic function grade I Plt (28th morning) 269 ESR(27th morning) 28 HCO3 (CPR) 25.7
during urethroscopy (cystoscopy) , patient got bradicadic. 50mg of ephedrin & 1mg of atropine administered. HR did not raise and
Labs
his his position corrected to supine and recieved epinephrine was administered and he was intubated. CPR started (12:35') Urea (28th morning) 20 Troponin(27th mor Neg K (CPR) 4.55
immediately upon patient became asystolic. epinephrine injection was repeated each 3-5 min. he got ×3 synchronized electroshock at BUN (28th morning) 9.3 SO2 (CPR) 42.2
200, 250 and 300J. Magnesium carbonate administered. 150 mg amiodarone administered. ABG sample was taken. after 60 min of
CPR (13:40') the patient death was announced. Cr (28th morning) 1.2 Ca (ionized) (CPR) 0.64

BS (28th morning) 114 BE (CPR) 0.4

✔ HTN | ✔ DM | IHD US: (Esfand 4th 1402) Previous Pathology: (Shahrivar 27th 1402)

Procedures
Medical Hx: Prostate cancer hydroureter TURP: Poorly differentiated carcinoma (IHC panel Recom.)

Imaging
DJ tube left side
PMH bladder thickness: trabecular irregular 5.3mm; before urination
Surgical Hx: 590cc and after 485cc.
Prostate: 112cc highly projected into bladder

Illness Script Summary:

Meds Disease Who? When? What? Why?

Family Hx

Social Hx

Allergies

Created by S. Ahmadreza Saeed

 Detailed Management Chart
Primary
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Dx

EvaluatIons
Treatment

Final
Dx
Take Home Messages: Extra notes:

Follow-up

Created by S. Ahmadreza Saeed