MDM

  • MDM: GENERAL MDM
    • CC:
      • year old with pertinent PMH/PSH
      • presents with
      • Onset of symptoms ,
      • Reason for coming to ED today and trend of symptoms: ,
      • Locations of symptoms ,
      • Associated symptoms ,
      • History of prior symptoms: ,
    • ED Course:
    • Working diagnosis:
    • Ddx: (evaluation includes but was not limited to)
      • , , ,
    • Pertinent Notable Aspects of Evaluation particularly contributory to MDM: :
    • On Clinically Eval:
      • Cx
        • HPI:
          • Qualitatively symptoms are ,
            • painful,
              • sharp,
              • dull,
              • pressure,
              • burning,
          • located at ,
          • with durationof symptoms
            • acute,
              • starting minutes ago,
              • starting hoursago,
            • subacute,
              • starting hoursago,
              • starting approximately a day ago,
              • starting approximately a days ago,
            • chronic,
              • starting approximately weeksago,
              • starting approximately months ago,
              • starting approximately years ago,
          • withassociated symptoms of .
          • with no associated symptoms.
          • Reason for patient coming to the ED today (context) was ,
          • since onset
            • acutely worsening,
            • constant,
            • intermittent,
            • resolved, asymptomaticat this time,
            • improving,
          • Historically, of similar symptoms inpast
            • never
          • Previously
            • patient has never had thesesymptoms,
            • had these symptoms and was evaluated by a clinician ,
            • resolved,
            • has been constant,
          • The circumstances at time of onset of symptoms were
            • pt unable to recall
          • Alleviating factors include
          • Aggrevated by .
          • Provocation by
            • nothing that patient can identify,
            • over the counter analgesics,
              • though refractory to those medications,
              • though wanted to come to ED given concern for cause rather than severity of symptoms,
          • Pertinentpositives:
          • Pertinent negatives:
          • History obtain from
            • interview with patient.
            • via collateral
              • History unfortunately limited
                • secondary
                  • to patient's condition,
                  • to requirement of emergent diagnostics/interventions that take precedence over extensive history,
                  • to patient's lack of understanding of their medical conditions,
                  • to patient's lack of cooperative with interview,
                  • to lack of medical records for this patient available in our system,
                  • to lack of patient bringing medical information
            • via best attempt to obtain from patient and available collateral at this time.
              • History unfortunately limited
                • secondary
                  • to patient's condition,
                  • to requirement of emergent diagnostics/interventions that take precedence over extensive history,
                  • to patient's lack of understanding of their medical conditions,
                  • to patient's lack of cooperative with interview,
                  • to lack of medical records for this patient available in our system,
                  • to lack of patient bringing medical information
    • On Exam:
      • exam
        • EXAM:
          • VITALS:
            • vitals
              • (Interpratation ofvital signs by me to inform medical decision making. Repeat vitals in chartwithRNs re-assessment ofpatient).
              • Concise Summary/Intetpration ofVitals Signs
                • Vital signs in/near range of normal, not suggestive of acute emergent pathology.
                • Elevated BP: Advised patient to follow up for recheck/eval with PMD for elevated BP, asymptomatic.
              • Interpretation ofEach Vital Sign
                • HR:
                  • normal rate,
                  • tachycardic,
                    • hemodynamicsstable,
                    • no acute symptoms suspected to be 2/2 to tachycardia
                    • interpretted to likely beatrial, suspectedsinus source,
                      • based upon my evaluation of telemetry
                        • with narrow complex and regular rhythm,
                      • based upon my evaluation of EKG,
                  • bradycardia,
                    • good chronotropic response
                    • asymptomatic,
                  • placed on pulse oximetry and telemetric monitoring,
                • BP:
                  • normotensive.
                  • elevated blood pressure
                    • (attempted to inform pt to advise to f/u with PMD).
                  • hypotensive,
                    • emergently evaluated for etiology and interventions started,
                    • will frequently reacess for signs of hypoperfusion, critical intervenionsPRN,
                • Oxygenation:
                  • hypoxia on my interpretation of pulse oximetry,
                  • peri baseline O2 sat,
                  • hypoxia,
                    • requiring
                      • supplemental oxygenation via nasal canula,with monitoring for need for intubation
                      • nasal airway,with monitoring for need for intubation
                      • oropharyngeal airway,with monitoring for need for intubation
                      • BIPAP, with monitoring for need for intubation
                      • intubation,
                        • for oxygenation,
                        • for anticipated clincal course,
                        • for airway protection,
                        • presumed prior to ED. required emergent intubation for suspected severe hypercarbia,
                    • unable to obtain O2 sat initially, given condition presumed to be severly hypoxic and requiring emergent intubation for oxygenation,
                  • placed on pulse oximetry and telemetric monitoring,
                • RR:
                  • respiratory rate,
                    • required emergent
                      • intubation,
                        • for oxygenation,
                        • for anticipated clincal course,
                        • for airway protection,
                        • presumed prior to ED. required emergent intubation for suspected severe hypercarbia,
                      • BIPAP, with monitoring for need for intubation
                      • oropharyngeal airway,with monitoring for need for intubation
                      • nasal airway,with monitoring for need for intubation
                      • supplemental oxygenation via nasal canula,with monitoring for need for intubation
          • PHYSICAL EXAM:
            • gen exam
              • PHYSICAL EXAM:
                • Constitutional:
                  • well-nourished,
                  • well-developed,
                  • appears stated age in chart,
                  • distress,
                • Integumentary (skin):
                  • warm, dry,
                  • no rashes on face/neck/back/abd/back/extremities,
                • Eyes:
                  • vision grossly intact,
                  • no conjunctival infection
                  • PERRL
                  • abbreviated eye exam
                    • vision
                      • 20/20 bilaterally,
                    • EOM intact,
                    • PERRLA pupils equal, round, reactive to light and accommodation
                    • intraocular pressures wnl, normal pressures under 20
                    • confrontation visual fields intact, check for no visual field defect
                    • external examination non-remarkable,
                    • slit lamp exam:
                      • lids/lashes lacrimal system without lesions,
                      • conjunctiva/sclera: white and quiet, no injections,
                      • cornea: clear,
                      • anterior chamber: no cell or flare,
                      • iris: round pupil,
                      • lens: clear, no cataracts,
                      • anterior vitreous: no inflammation/hemorrhage,
                    • fundoscopic exam:
                      • no papillary edema,
                      • no splinter hemorrhage,
                    • fluorescein exam:
                      • no areas of uptake,
                  • detailed ocular exam
                    • Visual Acuity:
                      • OD
                        • 20/20
                      • OS
                        • 20/20
                      • wearing glasses/contacts
                      • finger counting,
                      • motion,
                      • light perception
                      • Visual Fields:
                        • OD intact x 4
                        • OS intact x 4
                      • Extraocular movements: OD intact w/o diplopia; OS intact w/o diplopia
                      • Lids/Lashes/Lacrimal: OD no lesions; OS no lesions
                      • Conjunctiva & Sclera: OD white and quiet; OS white and quiet
                      • Cornea:
                        • OD no fluorescein uptake;OS no fluorescein uptake
                      • Anterior chamber: OD deep and quiet; OS deep and quiet
                      • Iris: OD round and reactive; OS round and reactive
                      • Lens: OD clear; OS clear
                      • Retina:
                        • OD sharp disc margins
                        • OD (unable to visualize)
                        • OS sharp disc margins
                        • OS (unable to visualize)
                      • Intraocular pressure:
                        • OD ,
                        • OS ,
                      • ,
                • HENT:
                  • neck supple
                  • hearing grossly intact,
                  • ,
                • Cardiovascular:
                  • regular rhythm, no r/m/g
                  • no LE swelling,
                  • regular rate, no r/m/g.
                  • tachycardic,
                  • no LE asymmetry,
                  • no JVP,
                • Pulmonary:
                  • Lungs CBTA,
                  • No respiratory distress, non-labored breathing,
                  • Speaking comfortably in full sentences,
                  • symmetric breath sounds,
                  • wheezing,
                    • (inspiratory and expiratory),
                    • (expiratory only),
                  • significant decreased aeration
                  • rales,
                    • throughout,
                    • at bases bilaterally,
                  • rhonchi,
                  • respiratory distress,
                    • mild,
                    • moderate,
                    • severe,
                • GI:
                  • abdomen soft,
                  • abdomen non-tender in all 4 quadrants,
                  • TTP
                    • diffusely
                    • RUQ,
                    • RLQ,
                    • LLQ,
                    • LUQ,
                    • epigastric region,
                • Neuro:
                  • Normal ALOC,
                  • Somnolent though protecting airway.
                  • Moves all extremities,
                  • Ambulatory,
                    • with steady gate
                  • AO x3
                  • AO x1
                  • CN II-XII intact,
                  • no facialasymmetry
                  • PERRL,
                  • strength intact throughout,
                  • sensation grossly intact throughout,
                  • normal reflexes,
                  • ambulatory,
                  • with steady gate,
                  • no dysmetria,
                  • no dysarthria,
                  • detailed neuro exam
                    • Mental status: A/Ox3
                    • CN II-XII tested and intact.
                    • Sensation intact to sharp/dull differentiation in all extremities.
                    • Motor: Normal tone and bulk. No abnormal movements appreciated.
                    • No pronator drift.
                    • Strength tested and 5/5 in bilateral wrist flexion/extension, elbow flexion/extension, shoulder abduction, straight leg raise, knee flexion/extension, ankle dorsiflexion/plantarflexion.
                    • Patient ambulates with a steady gait.
                    • Coordination: Finger to nose and heel to shin testing intact bilaterally.
                    • Reflexes: Brachioradialis, biceps, and patellar reflexes WNL and symmetric bilaterally.
                    • Babinski with downgoing toes bilaterally.
                    • Rectal exam:
                      • Examchaperoned
                        • by
                      • Able to squeeze buttock,
                      • Good rectal tone on digital rectal exam,
                      • Symmetric intact sharp/dull differentiation to both sides of perineum.
                      • Rectal vault:
                        • no stool,
                        • with stool,
                • MSK:
                  • no deformities,
                  • moving all extremities,
                  • ambulation:
                    • with steady gate,
                    • without steady gate, though stands,
                    • non ambulatory,
                  • Focused exam at affected area
                    • nuero intact
                    • muscular intact
                    • vascular intact
                    • no deformities,
                    • id="dds-335-exam_bonettp" name="exam_bonettp" class="bracket-drop-down" style="margin: 0; padding: 0 10px;"> type="text" value=" " selected="selected"> type="text" value="no">no bony tenderness to palpitation
                    • id="dds-336-exam_range" name="exam_range" class="bracket-drop-down" style="margin: 0; padding: 0 10px;"> type="text" value=" " selected="selected"> type="text" value="no">no full range of motion,
                  • Hand exam:
                    • On
                      • left,
                      • right,
                      • bilateral exam,
                    • Symmetrically palpable radial and ulnar pulses.
                    • Capillary refill <2 seconds to all digits.
                    • Intact sensation to light touch of the radial, median and ulnar nerves demonstrated by testing in the dorsal web space of the thumb, the distal palmar aspect of the index finger, and the lateral surface of the fifth finger.
                    • 2 point discrimination intact to 5mm of discrimination in the affected digit.
                      • up to 6mm can be normal in digits 3-5
                    • Intact motor function of the radial, median and ulnar nerves demonstrated by strength of extension of the isolated distal joint of the index finger, hand grip, and spreading of the 2nd through 5th digits. Intact recurrent median nerve as demonstrated by ability to move thumb fully through opposition, abduction and flexion.
                    • No snuffbox tenderness.
                • Pysch:
                  • Normal speech,
                  • Demonstrates linear thinking,
                  • SI,
                  • HI.
                  • Exam, appearance, presentation consistent with gravely disabled.
                  • Confused.
                    • Pulling at treatments (monitor, IV, etc) thereby interfering with ability to care for patient and diagnose/treat patient's condition.
                      • Required soft restraints, utilized as minimally as possible to allow patient maximum mobility while prevent patient from interfering with care or patient.
                      • Patient does not appear to have understanding of condition, poor insight, unable to redirect verbally, does not have capacity for decision of receiving medical initial diagnostics at this time.
                  • No AH/VH.
                  • Agitated.
                  • Combative.
                    • Not able to redirected/calmedwith multiple attempts by multiple staff.
                    • Not able to elucidate any particular reason why patient is agitated that is reasonable and could be reversed.
                    • Thrashing posing danger to self and staff.
                    • Required restraints, minimal restraints that adequately ensured safety utilized.
                      • Chemically sedation for patient and surrounding person'ssafety,
                      • Physical restraints required given patient poses immediate threat to self and surrounding,
                      • Sitter requested to be at bedside to monitor patient continuously until patient is awake, oriented, not agitated,
                      • Patient does not have capacity at this time of understanding that we are concerned about a potentially morbid condition and that patient requires diagnostics/monitoring,
                  • AOx3.
                  • Normal detailed psych exam
                    • Appearance: Well kempt
                    • Behavior: Calm, good eye contact, in no acute distress
                    • Mood:
                      • good,
                      • sad,
                    • Affect:
                      • pleasant,
                      • sad,
                      • (blunted,
                      • angry
                    • Mood is congruent with affect.
                    • Speech: Appropriate rate, quantity and volume.
                    • Thought process: Linear
                    • Thought content:
                      • unwilling to answer,
                      • (what is on patient ismind).
                    • Denies SI/HI.
                    • Cognition: Normal
                    • Insight: Good
                    • Judgment: Good
                • GU exam:
                  • Male specific exam:
                    • Exam chaperoned
                      • by
                    • Testicular exam:
                      • no testicular tenderness,
                      • normal testicular lie,
                      • able to elicit cremaster reflex,
                    • Penile exam:
                      • no discharge at meatus
                      • non-erect
                    • Prostate exam:
                      • enlarged prostate
                      • bogginess and tenderness
                  • Female specific exam:
                    • Exam chaperoned,
                      • by ,
                    • no CMT,
                    • no adnexal TTP,
                    • no abnomral discharge
                    • no active vaginal bleeding,
                    • vaginal bleeding from os,
                    • atraumatic, no cervical lacerations
                    • Exam for infection
                      • External genitalia unremarkable.
                      • Speculum exam with normal appearing whitish vaginal discharge.
                      • Vaginal wall mucosa is unremarkable.
                      • Cervix visualized and is unremarkable (closed in appearance without any protruding material).
                      • Bimanual exam without cervical motion tenderness, adnexal tenderness or any masses appreciated.
                      • Swabs for testing for gonorrhea, chlamydia and wet prep were obtained.
                        • Follow up mechanism in place for follow up on test results.
                        • Patient counseled on risks of unprotected sexual intercourse may lead to STI,
                  • Rectal exam:
                    • Examchaperoned
                      • by
                    • guiac
                    • brown stool in vault,
                    • no visible external hermorroids,
                    • no palpable internal hemorroids,
                    • thoughappreciate limited sensitivity of DRE,
    • On Diagnostics:
      • diagnostically
        • Diagnostics:
          • Labs:
            • Ordered, pending at this time, including:
              • CBC,
              • BMP,
              • LFTs/lipase,
              • UA,
              • Urine Cx
              • lactate
              • Blood Cx
                • x2
              • CK,
              • EtOH level,
              • Ingestion labs (acetaminophen, ASA),
              • Troponin,
              • Delta troponin,
              • BNP,
              • HIV,
              • Influenza,
              • Urine toxicological screen,
              • CRP,
              • ESR,
            • Reviewed and interpreted/correlated to clinical scenario to inform diagnosis and plan by me.
              • No significant labratory abnormalities contributoryto patient's presentation.
              • Non-emergent abnormalities which I informed the patient about and advised for prompt outpatient follow up for outpatient care.
              • Specifically:
              • CBC:
                • No significant unexpected anemia,No significant leukocytosis, No thrombocytopenia.
                • Notable for
                • Hg:
                  • anemia,
                    • transfusion indicated given
                      • symptomatic
                      • < 7 Hg (6-8 range from restrictive transfusion strategy)
                      • active significant bleeding
                    • transfusion not indicated (considered)
                    • peri-baseline,
                    • significantly lower than baseline
                    • unknown baseline,
                    • suspected iron deficiency contributory, will advise/rxFerrous sulfate 325mg daily w/ vit C.
                • wbc's:
                  • luekocytosis
                    • suspect demarginalization given lack of infectious findings on hx/exam,
                    • suggestive of infectious process,
                    • concerning for malignancy, advised to for follow up
                  • leukopenic
                    • neutropenic
                      • ((ANC < 500))
                • platelets:
                  • thrombocytopenic
                    • ((platelets < 150k))
                    • transfusion not indicated
                      • given suspected consumptive process
                      • ((ITP, TTP, HIT))
                  • transfusion indicated given
                    • <10 k (regardless that pt is asymptomatic)
                    • <20k and and planned CVP or pt febrile
                    • <50k and planned LP or neurosurgicalprocedure
                • pancytopeniac
                  • likely 2/2 chemo
                  • likely 2/2 HIV
                  • likely 2/2 hep C
                  • unclear etiology, will initiate eval w/ completion of eval and monitoring/treatment to be continef as outpatientafter ED
              • BMP:
                • No significant pathologic electrolyte derangements.
                • AKI,
                  • 50% increase from baseline
                  • BUN/Cr >20 suggestive of prerenal process,
                    • will administer IVF
                    • and recheck
                • CKD,
                  • grossly unchanged from prior,
                • Hyperkalemia,
                • Anion gap
                  • ((> 12))
                • acidotic suggested by low bicarb,
              • LFTs/lipase:
                • No laboratory evidence of hepato-biliary pathology.
                • Transaminitis without elevated bilirubin, suggestive of hepatic pathology
                • Elevated direct bilirubin suggestive of biliary pathology
                • Elevated indirect bilirubin suggestive of increased rbc breakdown
              • UA:
                • Not consistent with urinary tract infection.
                • Urine Cx sent with follow mechanism in place
                • Equivocal for infection
                  • Empirically treated.
                  • UCx sent with f/u mechanism in place
              • Cardiac Labs:
                • Troponin:
                  • undetectable
                  • <99th percentile
                  • >99th percentile but under cut off for positive
                  • positive
                • Delta troponin
                  • pending, pt under care of other service at time of delta troponin,
                  • undetectable,
                  • <99th percentile,
                  • >99th percentile but under cut off for positive,
                  • positive,
                • BNP:
                  • please note that greater than 500 suggests CHF, under suggests not CHF
                  • not suggestive of CHF exacerbation
                  • suggestive of CHF exacerbation
                  • non-diagnostic
              • HIV:
                • negative,
                • positive,
                  • I discussedthis finding with patient in sensitive private manner, educated on treatment options, offered resources, answered all questions, advised to have partner evaluated and advised to refrain from any of the common modes of transmission.
                • Prior to test sent, pt was informed that we advise for testing for HIV. Pt did not opt out.
                • Pending, to be followed up by accepting team.
              • Influenza
                • negative
              • CK:
                • significantly elevated, requires trending, usually for >500-1000k
                • mildly elevated, not anticipated to rise given negated precipitant,
                • not high enough to suggest concern for pathology,
              • Ingestion labs:
                • acetaminophen
                  • non-detectable,
                • ASA:
                  • non-detectable,
                • etoh
                  • non-detectable,
                  • positive
              • Urine toxicological screen:
                • negative
                • postive for
              • Markers of inflammation
                • CRP suggestive of more acute inflammation
                  • wnl
                  • elevated
                • ESR suggestive of more chronic inflammation
                  • wnl
                  • elevated
          • EKG:
            • synthesized interpretations
              • (interpreted by me as ED interpretation)
              • Non-remarkable EKG. No evidence of ischemia. NSR, regular rate, pertinent intervals normal, no abnormal TWI, no ST elevation/depression.
              • Sinus tachycardia. Otherwise non-remarkable EKG. No evidence of ischemia. Sinus rhythm, pertinent intervals normal, no abnormal TWI, no ST elevation/depression.
            • Notable for:
            • systematic approach
              • Rate
                • normal,
                • bradycardic,
                • tachycardic,
              • ST-segment morphology:
                • TWaves:
                  • No abnormal TWI,
                  • Abnormal TWI,
                  • Non-specific repolarization abnormalities,
                  • No ST depression, ST depression,
                  • No ST elevation, ST elevation but does not meet STEMI criteria, meets STEMI criteria and cath lab activated,
              • Comparison to prior:
                • Unchanged when compared to prior,
                • Attempted but no prior EKG available in emergent time frame for comparison,
                • ,
              • Summary to pt's clinical condition:
                • Normal EKG - not suggestive any pathology elucidated on EKG, Non-specific repolarization abnormalities - no definitive evidence of active ischemia on EKG, Evidence on EKG concerning for active ischemia.
              • Rhythm:
                • Regularly regular:
                  • NSR,
                  • Sinus tachycardia,
                  • Sinus bradycardia,
                • Irregularly irregular:
                  • Atrial fibrillation with normal ventricular rate,
                  • Atrial fibrillation with RVR,
                • Regularly irregular:
                  • tachycardic,
                    • Atrial flutter with RVR,
                  • bradycardic,
                    • Heart block,
                      • Type: ,
              • Intervals: QRS
                • Narrow QRS,
                  • supraventricular:
                    • irregular:
                      • AVRT(considering pre-excitation, considering WPW, etc),
                        • Tx: Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min.
                        • Tx: Synchronized cardioversion.
                          • Per ACLS 120-200J.
                    • regular:
                      • AVNRT (considering supraventricular tachycardia),
                        • Tx: Adenosine 6mg IV push,
                          • Refractory, therefore second dose 12mg IV push
                        • Synchronized cardioverson.
                          • 100 J
                          • per ACLS for narrow regular 50-100J
                • Wide QRS,
                  • bradycardic:
                    • low junctional escape/ventricular origin,
                  • tachycardic:
                    • regular:
                      • stable,
                        • Amiodarone 150mg IV / 10 min
                          • Refractory, repeated PRN recurrence of VT.
                          • Maintenance 1mg/min x 6 hrs.
                        • Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min.
                        • synchronized cardioversion
                          • 100 J (per ACLS)
                      • unstable:
                        • with pulse. Therefore Unstable Ventricular Tachycardia with Pulse.
                          • Synchronized cardioversion (per ACLS 100J).
                      • pulseless. Therefore pulseless ventricular tachycardia. ACLS initiated: (CPR. Defibrillation 200 J Biphasic. Epi 1mg. Continuation of ACLS.)
          • CXR:
            • Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.
            • Notable findings on CXR:
              • widened mediastinum,
              • pulmonary edema,
              • cardiomegaly,
              • lobar opacity,
              • diffuse radio-opacity,
              • pneumothorax
                • on right
                • on left
                • mediastenium midline
              • radio-lucency concerning for hemothorax,
                • on left
                • on right
              • clavicular fracture
                • on right
                • on left
              • rib fracture
            • Comparison to prior:
              • grossly unchanged,
              • worsened,
              • improved,
            • No rib fracture clearly appreciable however appreciate limited sensitivity of this study for rib fracture.
            • (This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads, findings of pulmonary nodules, changes, critical reads).
          • imaging
            • Advanced Radiographs: Considered the following (and applied diagnostic clinical decision rules and clinical gestalt/evaluation (and shared decision making when possible) to inform appropriate use of radiographic diagnostics i.e. image as indicated, not image when risk of radiation exceeds diagnostic benefit):
              • Imaging not indicated.
              • FAST
                • negative
                • indeterminate
                • not indicated
                • performed and interpreted by ED team
                  • (me)
                  • by Dr
              • eFAST (extended FAST)
                • negative
                • indeterminate
                • not indicated
                • performed and interpreted by ED team
                  • (me)
                  • by Dr
              • CXR and PXR indicated
                • negative for acute traumatic pathology
                  • on formal radiology read.
                • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
              • Intracranial injury:
                • plan for admission
                  • Appreciate that while patient was evaluated for traumatic pathology requiring emergent pathology, all possible traumatic injuries cannot be excluded until tertiary evaluation performed, to be performed by team accepting care of patient.
                • plan for discharge
                  • Of note, pt will be queriedfor any development of pain, re-examined with tertiary trauma exam, and ambulation trial prior to discharge and if any new findings revealed, as is my common practice, will pursue further diagnostics at that time.
                • Extremity injury
                  • XRs of extremities with signs of trauma or pain obtained.
                  • Not indicated to obtain XRs of extremities given
                    • no deformities,
                    • no signs of trauma,
                    • no elicitable pain bone/joint on secondary examination,
                    • pulses intact,
                    • full ROM.
                    • per my standard practice, ambulation trial to be performed to ensure does not incite extremity pain,
                    • and pt denies development of any extremity pain during ED stay,
                  • CTA of extremity
                    • CTA not indicated given 2+ pulses, neuro intact, cap refil <2 sec, no evidence of arterial injury.
                    • CTA performed given concern for possible arterial injury
                • Spinal injury
                  • negative for acute traumatic pathology
                    • on formal radiology read.
                  • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                  • Imaging not indicated. Risks outweigh benefits. Employed risk stratification to inform appropriate use of diagnostics. Not indicated given
                    • no TTP on spinal processes,
                    • neurologicallyintact,
                    • able to squeeze buttock
                    • good rectal tone
                • Pelvic injury
                  • CT A/P
                    • negative for acute traumatic pathology
                      • on formal radiology read.
                    • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                    • Imaging not indicated. Risks outweigh benefits. Employed risk stratification to inform appropriate use of diagnostics. Not indicated given
                      • pelvis stable to rock on exam,
                      • no signs of pelvic trauma on inspection,
                      • pt denies pelvic pain,
                      • mechanism not severe,
                      • mechanism not typical for intra-abdominal injury,
                      • pt ambulatory ensured to be ambulatory prior to discharge without inciting pelvic pain,
                  • PXR
                    • negative for acute traumatic pathology
                      • on formal radiology read.
                    • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                    • Imaging not indicated. Risks outweigh benefits. Employed risk stratification to inform appropriate use of diagnostics. Not indicated given
                      • pelvis stable to rock on exam,
                      • no signs of pelvic trauma on inspection,
                      • pt denies pelvic pain,
                      • mechanism not severe,
                      • mechanism not typical for intra-abdominal injury,
                      • per my standard practice, ambulatory to be ensured to be ambulatory prior to discharge to ensure does not incite any pelvic pain,
                  • Not indicated given sufficiently low suspicionof pelvic bony/vascular injury.
                • Abdominal injury
                  • FAST
                    • negative
                    • indeterminate
                    • not indicated
                    • performed and interpreted by ED team
                      • (me)
                      • by Dr
                  • CT A/P
                    • negative for acute traumatic pathology
                      • on formal radiology read.
                    • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                    • Imaging not indicated. Risks outweigh benefits. Employed risk stratification to inform appropriate use of diagnostics. Not indicated given
                      • benign abdominal exam,
                      • no signs of abdominal trauma on inspection,
                      • pt denies abdominalpain,
                      • mechanism not severe,
                      • mechanism not typical for intra-abdominal injury,
                      • benign serial abdominalexam,
                • Thoracic injury
                  • CXR
                    • negative for acute traumatic pathology. No cardiomegaly. 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. No obvious multiple rib fractures.
                      • on formal radiology read.
                    • Normal study. no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.
                    • Abnormal CXR:
                      • Pulmonary edema,
                      • Cardiomegaly,
                      • lobar opacity,
                      • diffuse radio-opacities
                      • pneumothorax
                        • on right
                        • on left
                        • mediastenium midline
                    • Comparison to prior:
                      • grossly unchanged,
                      • worsened,
                      • improved,
                  • CT chest
                    • negative for acute traumatic pathology
                      • on formal radiology read.
                    • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                    • Imaging not indicated. Risks outweigh benefits. Employed risk stratification to inform appropriate use of diagnostics. Not indicated given no severe mechanism c/w intra-thoracic injury, no signs of chest wall trauma, not extremes of age, no cardio-pulmonary distress),
                  • CT max/face
                    • negative for acute traumatic pathology
                      • on formal radiology read.
                    • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                    • Imaging not indicated. Risks outweigh benefits. Employed risk stratification to inform appropriate use of diagnostics. Not indicated given no signs of facial trauma,
                      • patient denies symptoms of facial pain,
                • Vascular neck injury
                  • CT Angio Neck
                    • negative for acute traumatic pathology
                      • on formal radiology read.
                    • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                  • Not indicated. Risks outweigh benefits. Reviewed indications, applied to eval for Blunt Cerebral Vascular Injury (BCVI) with Denver Screening Criteria and given none of the following:
                    • signs/symptoms
                      • focal neurological deficit
                      • arterial hemorrhage
                      • cervical bruit/thrill (if pt <50 y/o)
                      • infarct on head CT
                      • expanding neck hematoma
                      • neuro exam inconsisten with head CT
                    • risk factors
                      • midface fractures
                      • cervical spine injuries
                      • basical skull fracture
                      • GCS <8
                      • hanging w/ anxoic brain injury
                      • sealt belt abrasion WITH swelling or AMS
                • Cervical spine injury:
                  • CT neck
                    • negative for acute traumatic pathology
                      • on formal radiology read.
                    • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                  • Not indicated. Risks outweigh benefit. Reviewed indications, applied Canadian head criteria to this patient to inform appropriate use of diagnostics.
                    • Not indications given GCS<15, intoxication/distracting injury, 16>age<65, parathesias, previous spine dz/surgeries, no dangerous mechanism (MVC>60mph, rollover, ejection, recreational motor vehicle, bike-MVC, then CT. If none of above, then if any low risk factors (no neck pain, simple rear end MVC, sitting position, ambulatory, delayed neck pain), then safe for ROM. No pain w/ ROM.
                • CT head
                  • negative for acute traumatic pathology
                    • on formal radiology read.
                  • No clear emergent pathology requiring emergent intervention on ED prelim interpretation (be me).
                • Not indicated. Risks outweigh benefit. Reviewed indications, applied Canadian head criteria to this patient to inform appropriate use of diagnostics.
                  • Not indicated given no dangerous mechanism (PMVT, ejection, fall>3ft), GCS>=13, no coagulopathy, no open skull fxr, 1630.
    • Therapeutically:
      • therapeutically
        • Therapeutically:
          • Empirically:
            • Anti-platelet agent: ASA
              • Empirically administered given ddx includes ACS and potential benefit outweighs potential harm
              • 162mg PO chewed
              • 325mg PO chewed
            • IVF
              • 30 cc/kg,
              • 250cc,
              • 500cc,
              • 1 L,
              • 2 L,
            • Analgesia:
              • acetaminophen,
              • ibuprofen,
              • hydrocodone/acetaminophen (pt informed not to drive/drink/take fall precautions/not make significant decisions for remainder of day)
              • morphine,
              • ketorolac,
              • hydromorphone
              • haloperidol (haldol)
                • indication:
                  • sx refractory to other analgesia,
                  • side effect profile of opioids likely to exacerbate symptoms,
                • 3mg
                  • IV
                  • IM
                • 5 mg
                  • IM
                  • IV
                • 10mg
                  • IM
            • Anti-emetics
              • ondansetron (zofran),
                • IV,
                • ODT oral dissolving tablet
              • metoclopramide (reglan),
                • 5 mg,
                • 10mg,
                • PO,
                • IV,
                • IM,
              • lorazepam,
                • indication:
                  • prolonged QTC make risk of other similar medications that would prolong QTC prudent to avoid,
                  • sx refractory to other anti-emetics,
              • haloperidol (haldol)
                • indication:
                  • sx refractory to other anti-emetics,
                  • pain refractory to other analgesia,
                  • suspected to have quality of component of pain that may benefit from analgesic effects,
                • 3mg
                  • IV
                  • IM
                • 5 mg
                  • IM
                  • IV
                • 10mg
                  • IM
            • Anxiolytic
              • lorazepam
                • 0.5 mg
                • 1 mg
                • 2mg
                • PO
                • IV
                • IM
          • Anti-biotics:
            • Timing:
              • administeredas promptlyas source identified with sufficient likelihoodto inform appropriate antibiotics (goal directed)
              • administered when source identified
              • administered within 1 hrs from triage
              • administered within 3 hrs from triage
            • Regimen:
              • ceftriaxone 1 g IV
              • ceftriaxone 1g IV /azithromycin 500mg IV
              • vancomycin IV / cefepime 1 g IV / azithromycin 500mg IV
              • ceftriaxone 1g IV / metronidazole500mg IV
              • Unasyn
              • vancomycin / zosyn
              • cefazoline (ancef) 1 g IV
    • MDM:
      • Suspect (diagnosis)
      • Evaluation was not sufficiently consistent the followingentities to meet threshold for ED further diagnostics/interventionsmaking risks outweigh benefit of further diagnostics/interventions for the patient i.e. not consistent with these etiologies (consideration included but limited to these conditions):
    • Dispo:
      • dispo
        • 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 howeverpatient 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 causepermanent 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 therapeuticsand 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.
          • Of note, please excuse typos and brevity of documentation as priority of note being done contemporaneously to patient's work up and treatment (for potential use by consulting services, in case of change of status, etc) and emphasis for effective communication of care.

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