mdmgeneric

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    • – DDx.Given nature of presenting complaint (CC), pt was evaluated emergently for the following to determine if need for emergent diagnostics/interventions. When upon my eval, the hx/exam was exceeding clear that more emergent morbid/mortal pathologies were not in any reasonable refined ddx to this pt's presentation,further work up was not unnecessarily pursued to prevent putting pt at – in my professional opinion – were not indicated risks and outweighedbenefit. Guidance was by consideration and appreciation for pt's best interest.
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    • – A/P:
      • – ED Course:
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      • – Diagnostically:(aspects of evaluation emphasized given significant contribution to MDM):
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      • – Therapeutically:
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    • – MDM:
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    • – Diagnosis:
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        • – (most consistent with dx above wth understanding for diagnostic limitations due to emergent setting of encounter)
      • – Doubt:(evaluation was not sufficiently consistent the following entities to meet threshold for ED further diagnostics/interventions making 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:
      • – Admitted
      • – Discharged

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