Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Encounter:
Suspected malignant hyperthermia (MH) episode during surgery/anesthesia
Confirmed malignant hyperthermia diagnosis
Evaluation for risk of malignant hyperthermia (MH)
History of Present Illness:
For suspected MH episode: Describe the details of the event during surgery/anesthesia, including:
Triggering agents (inhalational anesthetics, succinylcholine)
Signs and symptoms (rapid increase in heart rate and temperature, muscle rigidity, metabolic acidosis)
Management course (dantrolane administration, supportive measures)
For confirmed MH diagnosis: Summarize the basis for diagnosis (genetic testing, previous episode).
For MH risk evaluation:
Inquire about personal or family history of MH susceptibility (siblings, parents, children).
Mention any previous anesthetic exposures without complications (if applicable).
Past Medical History:
Underlying surgical procedure that triggered the suspected MH episode (if applicable).
Previous surgeries with or without anesthesia (mention any complications).
Personal or family history of muscle disorders (e.g., Duchenne muscular dystrophy).
Medications:
List all current medications, particularly medications used during the surgery/anesthesia that may have triggered MH.
Allergies:
Mention any allergies to medications, particularly medications used during anesthesia.
Family History:
Inquire about a detailed family history of MH susceptibility in first-degree relatives (parents, siblings, children).
Social History:
Occupation (some professions with physical exertion may increase MH risk).
Physical Exam:
For suspected MH episode: Describe any relevant physical findings after the event (muscle tenderness, weakness).
For MH risk evaluation: General physical exam focusing on normal muscle tone and absence of suggestive features of muscle disorders.
Laboratory Tests:
For confirmed or suspected MH episode:
Serum creatine kinase (CK): Elevated levels may indicate muscle damage.
Arterial blood gas (ABG): May show metabolic acidosis during an MH episode.
Electrolytes: May show abnormalities due to the metabolic derangement.
For MH risk evaluation: Consider genetic testing for known MH susceptibility mutations (especially if family history is suggestive).
Imaging Studies:
Not routinely used for MH diagnosis or risk evaluation.
Assessment:
Malignant hyperthermia status: State whether MH is suspected, confirmed, or unlikely based on clinical presentation, history, and testing results (if available).
Severity (if applicable): Briefly describe the severity of the suspected MH episode.
Plan:
For suspected MH episode:
Document the event thoroughly, including management details and response to treatment.
Consider referral to a specialist center for MH for further evaluation and confirmation of diagnosis.
For confirmed MH diagnosis: Provide the patient with an MH identification card or bracelet for future healthcare encounters. Discuss the importance of communicating MH susceptibility to all healthcare providers before undergoing surgery or anesthesia.
For MH risk evaluation:
If MH risk is suspected based on family history or genetic testing, advise the patient to wear an MH identification bracelet and inform all healthcare providers about their risk before any surgery or anesthesia. Consider referral to a specialist center for MH for further risk stratification and counseling.
Anesthesia plan for future procedures: Discuss the importance of using MH-safe anesthetic techniques for future surgeries. Collaboration with anesthesiologists experienced in MH management is crucial.
Education:
Educate the patient about malignant hyperthermia, symptoms, risk factors, and the importance of wearing an MH identification bracelet.
Discuss the need to inform all healthcare providers about MH susceptibility before any surgery or anesthesia.
Provide resources for additional information on MH support groups or patient advocacy organizations.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Malignant hyperthermia is a rare but serious condition. Early diagnosis and appropriate management are crucial. It is recommended to consult with relevant medical resources and MH management guidelines for comprehensive care planning.