Abdominal Pain (Lower) SNDN nfm

Reviewed triage note:

  • CC: year old with pertinent PMH/PSH presents with
  • HPI (on my evaluation of patient):
    • vomiting
    • no hx of abd surgeries
    • Female specific HPI:
      • no hx of gallstones
      • no recent fevers
      • no vomiting
      • not worse after eating
      • no hx of ulcers
      • no BRBPR/tarry stool
      • hx of heavy etoh use
      • hx of high dose/prolonged NSAIDS
      • no suspicious foods/sick contacts/recent travel
  • Review of Systems:
    • Constitutional: no recent fever
    • Integument: no rashes
    • Eye: no acute vision changes
    • ENT: no current rhinorrhea/sore throat
    • CV: no chest pain, no syncope
    • Resp: no SOB, no new productive cough
    • GI: as detailed above in HPI
    • MSK: no recent trauma/fall to any extremity
    • Neuro: no focal weakness
    • Psych: no confusion
  • PMH/PSH: as noted in HPI
    • FH: reviewed, non-contributory to patient's current complaint
  • Physical Examination:
    • General: NAD, Alert,
    • Skin: No rash, warm, dry
    • Eye: PEERL, EOM intact
    • CV: RRR, no r/m/g
    • Resp: Lungs CBTA, respirations non-labored
    • GI: Abd soft, non-tender
    • LEs:No LE sweling, palpable pulses
    • Neuro: Alert and oriented, normal mentation, no focal motor/sensory deficit
    • Psych: Normal speech, linear
    • MSK: No deformities, normal ROM
    • Pelvic exam: on bi-manual exam no CMT, no adnexal tenderness, no abnormal discharge, no vaginal bleeding. No masses palpable.
    • Chaperoned by female RN for patient's comfort:
  • ED Course/MDM/A/P:
  • Diagnostically:
    • cbc (to eval for luekocytosis or significant anemia)
    • bmp (to eval for electrolyte derangements)
    • LFT's, lipase (to eval for labratorial evidence of hepato-biliary pathology)
    • UA (to eval for atypical presentation of UTI/pyelo)
    • upreg
    • EKG (eval for atypical anginal presentation)
    • RUQ US: no sonographic evidence cholecytitis
    • CT (eval for acute surgical abdominal processes)
  • Therapeutically:
    • analgesia/anti-emetics
  • MDM:
  • DDx:
  • Gyn:
    • Doubt pregnancy related complications (e.g. ectopic, abruption, etc) given upreg neg.
    • Doubt PID given no CMT, no adnexal tenderness on pelvic exam.
    • Dobut UTI given non-infectious UA.
  • Testicular:
    • Doubt testicular torsion given pt denies testicular pain and GU exam reveals non-tender testicle, normal lie.
    • Doubt ure
  • GI:
    • Doubt diverticulitis given age make pre-test probability less likely, no diarrhea, no hx of diverticulitis.
    • Unlikely appendicitis given low pre-test probability based upon hx, exam (no RLQ pain), risks of radiation related malignancy outweigh potential benefits of CT.
    • Considered gastritis (infectious or ulcerative). Pt advised to f/u with PMD and if sx persists, to request GI referral for endocscopy to start empiric trial of famotidine (OTC).
    • Dobut bleeding ulcer given no hx of BRBPR/melena, no signs of anemia on exam nor significant anemia on cbc.
    • Doubt perforated viscus given abd exam bening, pt well appearing, no significant labratorial abnormalities, non-severe pain, and tolerance of PO challenge in ED.
    • Doubt incarcerated hernia given no hernia on exam, no tender/non-reducible hernia on exam.
  • GU:
    • Doubt atypical presentation for nephrolithiasis given no CVA tenderness, no hematuria on UA.
    • Doubt pyleonephritis given no CVA tenderness, systemically well.
  • Hepato-Biliary:
    • Doubt cholecystitis given lower abd pain atypical for hepato-biliary pathology, LFTs not c/w cholecystitis. Pt advised if worsening of symptoms to return given possibility of interval development of cholecystitis.
    • Doubt cholelithiasis given above rationale.
    • Doubt pancretitis given lipase wnl.
  • Endocrine:
    • Doubt DKA given no elevated glucose with anion gap.
  • Vascular:
    • Doubt AAA given age, low likelihood based upon lack of risk factors, no palpable pulsitile mass.
  • Diagnosis:
  •   Assessment/Plan:
    • year old with PMH/PSH of
    • presented with  
    • evaluation is most consistent with
    •  Concurrent evaluation for secondary problem is consistent with
    • DDx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing)
    • Plan:
  • Diposition:
    • home.  
      • Counseled patient on assessment, impression, plan. 
        • Discussed disposition options with patient after counseling as above and included option for continued observation in medical setting however shared decision making yielded joint decision for disposition to home with self and family observation, prompt follow up with PCP, and return to ED precautions.  Counseled patient on complaint specific return precautions given that there are pathologies that, while sufficiently unlikely to warrant further investigation at this time, may develop/worsen after discharge.  Counseled that early in a disease progress, a work up can be falsely non-revealing of more significant pathology however this does not exclude the possibility of developing serious pathology thereby underscoring the importance of prompt follow-up with PMD and low threshold for return to ED as needed. 
    • Observation
      • Indication:
    • Admitted, 
      • transfer of care kindly assumed by admitting team  
      • at
      • level of care, 
      • with service.
    • Sign out at change of shift, transition of care kindly assumed by oncoming ED team
      • to
      • pending
      • at
    • Eloped.
      • Patient eloped prior to my full evaluation of patient. Patient noted by nursing staff to be walking, in no apparent distress and no suggestion of intoxication or altered mental status or psychiatric impairment that would suggest that patient does not have capacity. Therefore while I was unable to complete evaluation, it appears that patient has capacity based upon collateral to make decision to leave and ability to return should the patient desire medical evaluation. Therefore policy of calling patient overhead multiple times to encourage patient to return for eval started however patient did not return
    • AMA.
      • Documentation of AMA. 
      • The patient insisted to leave AMA (against medical advice).    The patient exhibits: 
      •   Capacity. 
        • The patient was clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has demonstrated capacity to make this medical decision to leave AMA. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient"s condition given that a full evaluation and treatment had not occurred.
      • Articulates understanding of symptoms and signs and my concerns as the provider. 
        • The patient and I have discussed the need for further evaluation to determine if their symptoms and signs are caused by a condition that would cause permanent disability, long term pain/suffering, development of morbidity which could in addition could require advanced medical care, hospitalization, and procedures that could be very costly and possibly averted by full evaluation and treatment at this time.  I explained that these could cause problems which would prevent them from being able to work or care for themselves independently, and even lead to death.  The patient demonstrated understanding of these risks to me. 
      • Exhibits understanding of limitations of evaluation. 
        • I explained that the limited evaluation performed was not conclusive nor sufficiently able to exclude pathological processes and that by being partially evaluated, this could lead to a false reassurance of well-being when in fact serious pathology had not yet been elucidated. 
      • Exhibits understanding of advised treatment plan
        • which includes remaining in the ED for additional evaluation, diagnostics, and treatment.
        •  
      • Exhibits understanding of foregoing additional evaluation/treatment.
        • The risks of leaving that I explained and the patient verbalized back (I included a broad set of complications given that the work up was incomplete and definitive diagnosis was not know) including: immediate deterioration of health, long term disability (both neurological and physical), infection with sepsis, loss of limb or ability, loss of ability work, organ failure leading to death, and death without preceding symptoms to allow patient to get back to an Emergency Department quickly enough to treat
      • Was offered alternatives to advised plan. 
        • Treatments to mitigate risk for patient (given with uncertainty from incomplete work up):
          • Empiric treatment based upon presumptive suspicion of etiology though this was balanced with risk of causing harm from treating the incorrect etiology of the patient"s s/s given diagnostic uncertainty at that point in the work up. 
          • I attempted to offer alternative treatments even with the patient leaving (while being very clear that the treatment would be suboptimal care and thereby place the patient at risk for the same morbidity/mortality as described (I used non-medical words to describe these concepts).  This was my hope that the patient may be amenable to partial or empiric treatment contingent upon it being safe and less likely to cause harm that help patient even if they insisted against our strongest medical advice to stay.
          • Additionally, I tried offering alternative options or options for patient comfort (sandwich, water,warm blanket, turning off alarms in pt"s room, offer for SW to come and assist with any psychosocial issues or financial concerns, and also offered analgesia or other symptomatic relief), in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient. 
        • AMA form:
          • pt signed, placed in chart.
          • pt refused to sign secondary, had ability to sign but was unfortunately unwilling
        • Questions. I addressed all questions, implored importance of follow up, and re-iterated return precautions.
          • Unfortunately despite all attempts, the patient declined and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation/treatment regardless of how they feel but especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation and we would welcome their return to continue their evaluation at any time. I strongly encouraged the patient to return to this or any Emergency Department at any time if they are not willing to do so, at least to contact their PMD in hopes that the patient may at least have as much care to reduce risk to the extent that they are willing to do so.
        • Witness to this interaction and patient"s departure against my medical advice:
        • It is my dear hope that the patient will return to my care, the care of one of my colleagues, or to the care of another physician to order to ensure the safety of the patient. 
    • DIAGNOSIS:
    • COUNSELING:
      • Patient/family educated to the extent possible in terminology matched to their understanding on diagnostics, assessment, and treatment plan along with the risks inherent to the diagnostics and therapeutics and plan. Patient/family amendable and in agreement with above plan. All questions and concerns addressed and answered.
      • Attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible.
      • Attempted to explain and obtain patient"s approval for plan however unable to do so secondary to patient"s condition and the requirement of emergent evaluation and interventions.
    • SUPERVISION:
      • With attending MD. Discussed and obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician
      • With resident physician. I have evaluated the patient and discussed the patient"s history, exam, diagnostics, and plan with the resident physician and agree with plan as stated by resident physician.  
  • Supplemental Documentation:
    • OBSERVATION NOTE:
      • Total observation time
      • Start of observation time
      • End of observation time
      • Decision for disposition made after observation. Disposition to
      • Observation performed in order to attempt to safely preclude an inpatient admission.
      •    Observation was performed given
        • diagnostic uncertainty (i.e. serial examinations and assessments by me to elucidate likelihood of a pathologic process).  
        • to determine intensity therapy required (i.e. there was a reasonable possibility that by observing the patient"s response to therapy, an admission may be abated and safely discharged). 
      • Observation by me in ED.
      • The observation was utilized as the primary diagnostic tool during that time.
      •   Of note, additional history was obtained at this time and there was no family history contributory to the patient"s current condition. 
      • Given patient had initial complaint concerning for significant deterioration resulting in severe morbidity and potential mortality, patient required direct observation and monitoring in the emergency department with trending of vital signs, telemetric monitoring reviewed by me, frequent reassessments by nursing with communication with me of status, re-accessments in addition by me, which were all required for patient"s safety during that time (monitoring while administering medications with risk for CNS/cardiac/pulmonary adverse reactions) and to determine patient"s disposition by assessing for response to interventions/treatment. Patient was observed under my supervision.
      • Revenue code: 0762.  HCPCS Code G0378
    •  CRITICAL CARE PROCEDURE NOTE:
      • Authorized and performed by: Attending physician
      •  Total critical time:
        • minutes.
          • CPT Code
      • Indication for critical care including pt has exhibited risk factors for and symptoms and signs concerning for impending deterioration included compromise of
        • airway,
        • respiratory stability,
        • cardiovascular collapse,
        • CNS irreversible damage,
        • metabolic derangements
        • renal failure
        • fulminant hepatic failure
      • PRIMARY DIAGNOSIS:
        • ((primary diagnosis must be one of these for critical care time to be documented))
      • Due to patient having a presentation that is concerning for a potentially pathologic process causing an resulting in significant morbidity and potential mortality, the patient required emergent evaluation in the emergency department including emergent diagnostics, emergent assessment and evaluation, and emergent and directed treatment in order to mitigate risk for life-threatening deterioration. The critical care time as indicated above included discussing history with patient, examining patient, interpreting vital signs including pulse oximetry, initiating and interpreting diagnostics, and clinical acumen in order to synthesize patient"s presentation to develop treatment plan and emergently implement the requisite steps. This part of my care the patient is exclusive of other billable procedures, specifically procedures, treating other patients, and any educational time. Please refer to the above rationale for further documentation regarding the critical nature of the patient during my care.
      • This critical care time is separate from teaching or other separately billable procedures or treating other patients.
    •  COUNSELING:
      • Patient/family educated to the extent possible in terminology matched to their understanding on diagnostics, assessment, and treatment plan along with the risks inherent to the diagnostics and therapeutics and plan. Patient/family amendable and in agreement with above plan. All questions and concerns addressed and answered.
      • Attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible.
      • Attempted to explain and obtain patient"s approval for plan however unable to do so secondary to patient"s condition and the requirement of emergent evaluation and interventions.
    • SUPERVISION:
      • Discussed with attending.  Obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician
      •  Evaluated patient with resident physician. I have evaluated the patient and discussed the patient"s history, exam, diagnostics, and plan with the resident physician and agree with plan as stated by resident physician.
    • Of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics.

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