Date:
Patient:
MRN:
Clincian: (Emergency Physician, Urgent Care Physician)
Reason for Visit:
Evaluation for suspected heat-related illness (heat cramps, heat exhaustion, heat stroke)
Assessment of symptoms and vital signs
Implementation of cooling measures and supportive treatment
Determination of disposition (hospital admission, home recovery)
History of Present Illness:
Briefly describe the circumstances of the exposure:
Duration and intensity of heat exposure (environmental temperature, humidity, exertion level)
Access to fluids and shade
Time of symptom onset (during or after heat exposure)
Symptoms upon presentation:
Heat cramps (painful muscle spasms)
Heat exhaustion (nausea, vomiting, headache, dizziness, fatigue, profuse sweating)
Heat stroke (altered mental status, confusion, seizures, coma)
Past Medical History:
Underlying medical conditions (increased risk for complications)
Previous episodes of heat-related illness
Social History:
Medications (certain medications can increase heat sensitivity)
Alcohol or illicit drug use (can impair thermoregulation)
Physical Exam:
Vital Signs:
Elevated core body temperature (critical in diagnosing heat stroke)
Increased heart rate and respiratory rate (tachycardia, tachypnea)
Elevated blood pressure (may be present in early stages)
Decreased blood pressure (symptomatic of dehydration or shock)
Skin exam:
Moist or dry skin depending on severity
Flushed skin (heat exhaustion)
Pale, clammy skin (heat stroke)
Neurologic exam:
Assess mental status (alertness, confusion, disorientation)
Evaluate for seizures (heat stroke)
Labs:
Electrolytes (potassium, sodium) to assess for imbalances due to sweating.
Kidney function tests (creatinine, BUN) to assess for dehydration or potential kidney injury.
Complete blood count (CBC) may be ordered to rule out infection.
Consider mentioning other labs ordered as needed (coagulation studies if risk of bleeding).
Imaging:
Imaging studies are not typically needed for initial diagnosis.
Consider mentioning a head CT scan if seizures occurred or altered mental status persists to rule out other causes.
Assessment:
Summarize the diagnosis of specific heat-related illness (heat cramps, heat exhaustion, heat stroke) based on presenting symptoms and clinical findings.
Identify any contributing factors (underlying medical conditions, medications, dehydration).
Plan:
Outline the treatment plan based on the severity of illness:
Immediate cooling measures:
Move patient to a cool, shaded environment.
Remove excess clothing.
Immerse in cool water (avoid ice baths) or apply cool towels.
Fan the patient to promote evaporation.
Fluid resuscitation:
Intravenous fluids for moderate to severe illness or altered mental status.
Oral rehydration solution for mild heat exhaustion with intact mental status.
Electrolyte replacement:
May be necessary based on laboratory results.
Medications:
Anti-emetics for nausea and vomiting.
Antipyretics for fever control.
Seizure medications if indicated.
Hospital admission:
Consider admission for patients with severe heat stroke, altered mental status, underlying medical conditions, or those unable to tolerate oral intake.
Disposition instructions:
Continued cooling measures at home if appropriate.
Monitor for signs of worsening and seek immediate medical attention if needed.
Gradual return to activity in cool environments and adequate hydration.
Education:
Document any education provided to the patient regarding:
The dangers of heat exposure and preventive measures (hydration, shade, avoiding peak heat hours).
Warning signs and symptoms of heat-related illness.
Importance of seeking medical attention promptly for suspected heat stroke.
Importance of rehydration and continued monitoring at home if discharged.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about recovery or future heat exposure.
Emphasize the importance of preventing future episodes through education and behavioral changes.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a physician