0CCChief compliant:Hx:ROS:10 Point Review of System negative unless otherwise specified in the HPIConstitutional: no lethargyEyes: no recent changes in visionNose/Mouth/Throat: no sore throat, rhinorrhea, otalgiaCardiovascular: no chest pain, no palpitationsRespiratory: no SOB, no new coughGastrointestinal: no n/v/d. no BRBPR/melanaGenitourinary: no dysuriaMSK: no trauma to extremitiesNeurological: no confusionPsychiatric: no disorganized thinkingPMH/PSH:Reviewed, pertinents as noted in HPI.PFSH SH:Denies tob/etoh/illicitsEndorses tob. Denies etoh/illicitsEndorses etoh. Denies tob/illicitsEndorses tob/etoh/illicitsFH: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 agemoderate distress, appears stated agesevere distress, appears stated ageHEENT: vision grossly intact, EOM intactCardioVascular: RRR, No r/m/gPulmonary: non-labored breathing, no rhonchi, no ralesAbdomen: soft, non-tenderExtremities: no edema, no deformitiesNeurologically: normal speech, no focal deficitsPsychiatrically: cooperative, linearSkin: no rashes, warm and dryAdditional complaint specific aspects of examination:not symptomatic on ambulation in EDED Course:DDx:Diagnostically:Point of Care Testing:Pregnancy TestnegativePOC glucwnlPOC HgwnlGuiacnon-red, non-melanotic stool in vault, guiac negativeInterpretation of Pulse Oximetry:No evidence of hypoxia on pulse oximetry in emergency departmentLaboratory Results Reviewed. Analysis/Interpretation:Basic Labs:CBC:No significant luekocytosis/neutropenia, no unexpected anemia, no thrombocytopenia.Mild leukocytosis suggestive of infectious processBMP: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 infectionin 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 EKGNormal 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 EKGSinus tachycardia, no abnormal TWI, no significant ST elevation/depressionNon-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:CXRNormal 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:SuspectDDx (I considered that there is a small but finite risk for the following processes. The patient’s presentation does NOT meet our criteria for being reasonable for additional pursuit of these entities at this time (i.e. reasonable level of consistency with characteristic findings as detailed parenthetically below):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 givenIn 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/rationaleCounseling: Patient/family was counseled on the above evaluation, findings, assessment, and plan. All questions were answers. Verbal expression by patient/family provided of understanding.