(Instructions: click on the checkbox to expand the decision tree and suggested options below. Click on the submit button a chart will be generated below in the text box). *Has yet to be sufficiently peer reviewed for clinical purposes.

CC:

  • Chief compliant:
  • Hx:
  • ROS:
    • 10 Point Review of System negative unless otherwise specified in the HPI
    • Constitutional: no lethargy
    • Eyes: no recent changes in vision
    • Nose/Mouth/Throat: no sore throat, rhinorrhea, otalgia
    • Cardiovascular: no chest pain, no palpitations
    • Respiratory: no SOB, no new cough
    • Gastrointestinal: no n/v/d. no BRBPR/melana
    • Genitourinary: no dysuria
    • MSK: no trauma to extremities
    • Neurological: no confusion
    • Psychiatric: no disorganized thinking
  • PMH/PSH:
    • Reviewed, pertinents as noted in HPI.
  • PFSH
    •  SH:
      • Denies tob/etoh/illicits
      • Endorses tob. Denies etoh/illicits
      • Endorses etoh. Denies tob/illicits
      • Endorses tob/etoh/illicits
    • FH:
      • Reviewed and non-contributory to patient’s chief complaint.
  • Exam (Complaint relevant additional components of the exam)
    • 8 System Physical Exam:
    • Constitutional:
    • mild distress, appears stated age
    • moderate distress, appears stated age
    • severe distress, appears stated age
    • HEENT: vision grossly intact, EOM intact
    • CardioVascular: RRR, No r/m/g
    • Pulmonary: non-labored breathing, no rhonchi, no rales
    • Abdomen: soft, non-tender
    • Extremities: no edema, no deformities
    • Neurologically: normal speech, no focal deficits
    • Psychiatrically: cooperative, linear
    • Skin: no rashes, warm and dry
    • Additional complaint specific aspects of examination:
  • ED Course:
    • DDx:
    • Diagnostically:
      • Point of Care Testing:
        • Pregnancy Test
          • negative
        • POC gluc
          • wnl
        • POC Hg
          • wnl
        • Guiac
          • non-red, non-melanotic stool in vault, guiac negative
        • Interpretation of Pulse Oximetry:
          • No evidence of hypoxia on pulse oximetry in emergency department
      • Laboratory Results Reviewed. Analysis/Interpretation:
        • Basic Labs:
          • CBC:
            • No significant luekocytosis/neutropenia, no unexpected anemia, no thrombocytopenia.
            • Mild leukocytosis suggestive of infectious process
          • BMP:
            • No significant pathologic electrolyte derangements.
          • Basic laboratory analyses does not suggest more pathologic process in patient at this time.
        • Complete Laboratory Analysis:
          • CBC:
            • No luekocytosis, no unexpected anemia, no thrombocytopenia.
            • Mild luekocytosis suggestive of infectious process or acute demarginalization.
          • BMP:
            • No significant pathologic electrolyte derangements.
          • LFTs/lipase:
            • No laboratory evidence of hepato-biliiary pathology.
          • UA:
            • No consistent with urinary tract infection
            • in conjunction with clinical context.
      • EKG Interpretation:
        • Normal EKG (Indication: eval for ischemia):
          • EKG: NSR, regular rate, normal axis, normal intervals, no abnormal TWI, no ST elevation/depression.
          • Interpretation: No clear evidence of active ischemia on EKG
        • Normal EKG (Eval for arrhythmia/syncope):
          • EKG: Normal Sinus Rhythm. No arrythmia (no PACs, no PVCs), no brugada wave, no prolonged QTc, no delta wave/no shortened PR, no episilon wave, no evidence of ischemia.
          • Interpretation: No cardiogenic etiology for syncope obvious on EKG.
        • Abnormal EKG
          • Sinus tachycardia, no abnormal TWI, no significant ST elevation/depression
          • Non-specific repolarization abnormalities. No ST elevation/depression.
          • Evidence of previous or active myocardial ischemia by abnormal TWI. NSR.
          • Evidence of previous myocardial ischemia by pathologic Q waves.
          • ST elevation concerning for active myocardial ischemia/infarct.
      • Radiograph Interpretation:
        • CXR
          • Normal CXR. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema. Lung markings throughout – no radiographic evidence of pneumothorax.
          • Cardiomegaly. Otherwise non-remarkable CXR. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema.. Lung markings throughout – no radiographic evidence of pneumothorax.
          • Pulmonary edema. Evidenced radio-opacities consistent with fluid in pulmonary parachyma.
          • Pneumonia. Evidenced by consolidation concerning for pneumonia.
          • Non-specific diffuse opacities. Concerning for diffuse infectious process verses pulmonary edema.
          • Not indicated. Given patient is not comorbid, not other extremes of age, there are no abnormal vital signs-specifically no tachycardia, no tachypnea, no fever, and the pulmonary exam is unremarkable, bacterial pneumonia is sufficiently unlikely that a chest radiograph is not indicated at this time. Patient was advised to return precautions in case of subsequent development of superimposed bacterial infection.
  • Medical Decision Making:
    • Suspect (most consistent with)
    • Considered the following however pt does not meet sufficient criteria for reasonable further pursuit of these entities (risks outwiegh benefits).
  • Disposition:
    • Discharged from Emergent Department with prompt PMD follow up.
      • The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an illness, an initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and the patient understands that worsening, changing or persistent symptoms should prompt an immediate call or follow up with their primary physician or return for reevaluation. More extensive discharge instructions were given in the patient’s discharge paperwork.  Discharge Instructions included: Follow Up: Patient/family advised for prompt follow up with primary care physician. I explained the importance of follow up given the limitations of a one time emergency department visit and the importance of continued care and diagnoses that may only be elucidated by serial evaluations. Should the patient have difficulty finding primary care follow up, the patient was advised of community health resources as well as advised that they always could return to the Emergency Department for re-evaluation. Return precautions – both general and specific to the patient’s evaluation were discussed with the patient.
    • Placed on Observation given
      • In my medical opinion, the patient warrants admission for further telemetric monitoring, and workup as deemed necessary by the inpatient treatment team. The patient remained clinically stable during care in ED.
    • Admitted given above findings/rationale
  • Counseling: Patient/family was counseled on the above evaluation, findings, assessment, and plan and were in agreement with plan. All questions answers. Reiterated understanding.