Kathryn Ferch

A 74-year-old female presented to the ED with complaints of left-sided weakness for 24-36 hours. EMS reports they have been to the house three times in the past 2 days for lift assist. She denies any injury from falls, says they were all from trying to stand and sliding back down the couch. The patient says she had COVID several months ago and has had generalized weakness, brain fog, and malaise that have persisted. She complains of a right frontal headache. She was nauseous and vomited several times today. She denies numbness or tingling, no vision or speech changes. She developed a productive cough the day prior and had occasional wheezing. History- asthma, HTN, morbid obesity. Nonsmoker, non-drinker. Lives with daughter and SIL. Retired. Vitals BP 172/91, P 64, T 97.8, R 22, SpO2 96% on RA. Exam- Gen- no acute distress; HEENT- unremarkable; CV- regular with 3/6 systolic murmur; Pulm- clear bilat; Abd- soft, obese, ND/NT; Neuro- left facial droop, mild dysarthria. Weakness R leg > R arm and distal > proximal. Pronator drift on the right. Ataxia right arm and leg Labs- WBC 11.8, Alk phos 121. Lactic, TSH, trop, INR, COVID/flu, UA normal Rad- CTA head/neck- 5 cm rim enhancing lesion right frontal lobe with 1.9 cm left shift and subfalcine herniation concerning for malignancy, metastasis, or abscess On chart review, patient had been seen multiple times prior to arrival at our facility: She was seen at an ED in Spokane almost 2 months prior for facial pressure and ear pain, diagnosed with acute sinusitis and otitis media and treated with 7 days of Augmentin, ENT referral sent. She was seen at different outside hospital 5 days later with fatigue, persistent headache, and difficulty getting dressed. Afebrile, VSS, recommended complete abx, Flonase, saline rinses, Tylenol, get ENT…

Chief Complaint “Confusion and weakness” History of Present Illness A 72-year-old male with a history of diabetes and hypertension is brought in by EMS for altered mental status. Patient unable to give a history due to current mental status. Family reports 2 days of fever, decreased oral intake, and progressive confusion. Today he became difficult to arouse. Brief Physical Exam Initial Vitals Temp: 39.2°C, HR: 128 bpm, BP: 78/46 mmHg, RR: 26, SpO₂: 91% on room air General: Ill-appearing, obtunded HEENT: Dry mucous membranes Heart: Tachycardic, weak pulses, no murmurs, rubs or Gallops, Delayed capillary refill Lungs: coarse breath sounds, no wheezes, increased rate Skin: mottled, cool to touch, no rashes Brief ED Course / Medical Decision Making Patient identified as being in septic shock with acute organ dysfunction (altered mental status, hypotension). Immediate interventions: Rapid IV fluid resuscitation (30 mL/kg crystalloid) Broad-spectrum IV antibiotics within 1 hour Initiation of vasopressors (e.g., norepinephrine) for persistent hypotension Continuous cardiac and hemodynamic monitoring Frequent reassessments of perfusion and mental status Diagnostics: Blood cultures ×2 prior to antibiotics Lactate elevated at 5.2 mmol/L CBC: leukocytosis CMP: acute kidney injury Chest X-ray: right lower lobe pneumonia Why This Qualifies for Critical Care Time This patient meets criteria because: High probability of imminent life-threatening deterioration (shock, organ failure) Active physician management required to prevent death Multiple organ systems involved (cardiovascular, neurologic, renal) Time-intensive interventions and reassessments Example Critical Care Documentation Statement “The patient was critically ill with septic shock and acute organ dysfunction. I was immediately available and provided direct management including aggressive fluid resuscitation, initiation of vasopressors, interpretation of diagnostic studies, and continuous reassessment. The patient was at high risk for cardiovascular collapse and death. A total of 45 minutes of critical care time was provided, exclusive of separately billable procedures.” Critical care is the direct delivery of medical care by a physician or qualified healthcare professional to a critically ill or injured patient, involving high-complexity decision-making to treat or prevent life-threatening organ system failure. CMS…