Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
Near-drowning event (witnessed or suspected)
(Specify) This will depend on the severity of the event and the patient’s current state.
For a critically ill patient: “Altered mental status following near-drowning event”.
For a more stable patient: “Near-drowning event with [brief description of
symptoms]”.
History of Present Illness:
Details of the near-drowning event:
Location (e.g., pool, bathtub, open water)
Duration of submersion (estimated or confirmed)
Witnessed or unwitnessed event
Rescue efforts (if any)
Current symptoms:
Respiratory distress (cough, shortness of breath, wheezing)
Altered mental status (confusion, lethargy, coma)
Fever
Nausea and vomiting
Chest pain
Seizures (less common)
Past Medical History:
Underlying medical conditions (e.g., asthma, epilepsy)
Prior history of near-drowning (if any)
Social History:
(For children) Supervision practices in and around water.
(For adults) Alcohol or drug use at the time of the event (if applicable).
Physical Exam:
General examination: Vital signs (temperature, heart rate, respiratory rate, oxygen saturation). Assess for skin color (cyanosis suggestive of hypoxia) and signs of dehydration.
Respiratory examination: Listen for lung sounds (rales or wheezing suggestive of fluid in the lungs).
Neurological examination: Assess level of consciousness, orientation, and pupillary reflexes.
Laboratory Tests:
Arterial blood gas (ABG): To assess oxygen and carbon dioxide levels in the blood,
indicating respiratory function.
Complete blood count (CBC): May show elevated white blood cells if there is infection.
Electrolytes: May be checked to assess for imbalances due to resuscitation fluids.
Chest X-ray: May show signs of fluid in the lungs (pulmonary edema).
Imaging Studies:
Head CT scan: May be indicated if there is concern for head injury or altered mental status.
Assessment:
Near-drowning event: Confirmed based on history and potential presence of supportive clinical findings (e.g., hypoxia, pulmonary edema).
Severity of near-drowning: Classified based on the level of consciousness (coma, stupor, alertness) and respiratory status (need for ventilator support).
Potential complications:
Pneumonia (infection of the lungs)
Acute respiratory distress syndrome (ARDS)
Hypoxic brain injury (damage to brain cells from lack of oxygen)
Seizures
Plan:
The plan will depend on the severity of the near-drowning event and the patient’s current condition. Possible elements include:
Supportive care: Oxygen therapy, mechanical ventilation (if needed), intravenous fluids, medications to improve breathing or circulation.
Antibiotics: To prevent or treat pneumonia.
Neurological monitoring: To assess for signs of brain injury.
Pulmonary function testing: May be done later to assess for long-term lung damage.
Follow-up with specialists: Respiratory therapist, neurologist (if brain injury is suspected).
Disposition:
Admit to intensive care unit (ICU) for close monitoring and aggressive treatment (for critically ill patients).
Admit to general medical/surgical floor for continued monitoring and treatment (for less severe cases).
Discharge home with close follow-up (for stable patients with minimal complications).
Education:
(For all patients/families) Importance of water safety and supervision around water.
(For patients with risk factors) Strategies to prevent future near-drowning events (e.g., swimming lessons for children, pool fencing)