MSE (Medical Screening Exam) – © MedTx, LLC 2017

 
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  • Medical Screening Exam Chief Complaint:
    • CC: year old with pertinent PMH/PSH presents with
    • HPI:
    • Onset:
      • acute,
      • subacute,
      • chronic,
    • History of similar symptom is past
      • never
    • 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
    • VITALS:
      • Generally in normal limits, no indication of emergent pathology.
      • Abnormalities significantly abnormal enough to inform diagnostics/interventions notes:
    • A/P: Suspicion for (though appreciate this is not sufficient eval for a diagnosis).
    • Ddx includes but not limited to:
    • Initial Plan:
    • ((General))
    • chest pain
    • HPI:
    • Abbreviated HPI
      • Onset
      • Quality
      • Cardiac risk factors
        • HTN
        • HLD
        • tob
        • obesity
        • DM
        • CAD
        • Pacemaker
      • Exam:
        • NAD, no obvious remarkable cardio-pulmonary findings
      • Ddx includes but not limited to acute cardio-pulmonary processes
      • Concern for
      • Plan
        • Diagnostically:
          • upreg
          • EKG/trop/CXR/cbc/bmp
          • BNP given may assist with challenging diagnostic dilemma on CHF (appreciation of limited utility)
        • Therapeutically:
          • ASA
          • Nitro deferred given unknown if contra-indication in inferior STEMI. Per discretion of accepting team after EKG.
    • RUQ/epigastric pain
      • p/w RUQ pain
      • p/w epigastric pain
      • HPI (limited 2/2 to triage setting)
        • hx of gallstones
        • unknown hx of gallstones
        • Provocation
          • worse with eating
          • not worse with eating
        • Emesis
        • No emesis
        • Nausea
        • Fevers
        • heavy etoh use
        • NSAID use
      • Exam (limited 2/2 to triage setting)
        • NAD
        • Moderate distress
        • RUQ TTP
        • + Murphy's sign
        • Neg Murphy's sign
        • TTP in epigastrum
        • Abd benign
        • No flank pain.
      • DDx includes but not limited to hepato-biliary pathology, gastric pathology. Less likely renal patholgy
      • Plan
        • Diagnostically:
          • upreg
          • EKG (while not highest on ddx, given possible anginal equivalent)
          • Trop (while not highest on ddx, given possible anginal equivalent)
          • ASA
          • Labs:
            • cbc, bmp, LFTs, lipase
            • UA
          • Imaging:
          • RUQ per discretion of accepting team and formal v. bedside ED US per discretion of accepting team to maximize expeditious care.
          • RUQ (Formal ordered given suspicion bedside US will not suffice and attempt maximize expeditious care).
        • Therapeutically:
          • Zofran
          • Norco
          • Tylenol
          • Pt deferred pain meds
    • shortness of breath
      • p/w SOB
      • p/w
      • HPI (limited by triage setting)
        • onset
        • known respiratory pre-existing pathology:
        • assoc sx
          • cough
          • no cough
          • chest pain
          • no chest pain
          • fevers
          • no fever
          • tob use
          • no tob use
        • DDx includes but not limited to respiratory pathology
        • Respiratory exam (limited by triage setting):
          • NAD
          • Moderate distress
          • CBTA
          • rales
          • rhonchi
          • coarse breath sounds
        • Plan:
          • upreg
          • CXR
          • EKG
          • duonebs
          • steroids
    • syncope
      • p/w syncope
      • p/w pre-syncope
      • Plan
        • Diagnostically:
          • POC gluc
          • EKG, trop, cbc, bmp, CXR
          • bnp
    • lower extremity swelling – bilaterally
      • p/w bilateral LE edema
      • HPI (Limited by triage setting)
        • Onset
        • Assoc features
        • DDx includes but not limited to: CHF, nephrotic syndrome, hypo-albuminemia, chronic venous stasis, bilateral LE infection/cellulitis, less likely bilateral LE DVTs.
          • Clinically not c/w nec fasc or NSTI at this time.
        • Exam:
          • NAD
          • C/w cellulitis in LEs
          • Not c/w cellulitis in LEs
          • Lesions c/f infection
        • Plan
          • Diagnostically:
            • upreg
            • EKG
            • cbc, bmp, LFTs, UA
            • ESR
          • Therapeutically:
    • lower extremity swelling – unilateral
      • p/w unilateral LE swelling
    • laceration
      • p/w laceration
        • Location:
      • Exam
        • nuero-vasc-motor intact, hemostatic
      • Plan
        • upreg
        • imaging for FB
        • tetanus deferred (already UTD)
        • tetanus updated (unknown last, but suspected fully immunized)
        • Laceration exploration/exam/repair per accepting MD
    • trauma
      • p/w trauma
        • NAD, Normal cognitive status
        • Imaging:
          • CT head
          • CT
          • Tetanus
        • Labs:
          • upreg
          • CBC, BMP
          • LFTs, UA
    • head strike
    • back pain
    • headache
      • p/w headache
        • HPI
          • hx of prior
          • no red flag symptoms
        • Exam:
          • Nuero grossly intact, no signs of trauma
        • Plan
          • upreg
          • CT deferred at this time
          • compazine
          • IVF
          • zofran
          • toradol (exceeding low suspicion for hemorrhage)
          • tylenol
    • joint pain
      • p/w joint pain
        • HPI
          • location
        • Exam:
          • nuero-vasc-motor intact
          • no pain on passive ROM
        • Plan
          • XRs
          • labs
          • Analgesia
    • vision problem
      • p/w vision problem
        • HPI
          • bilateral
          • unilateral
            • left
            • right
          • No hx of caustic irritants
          • Caustic irritants, threfore immediately moved to room for irrigation.
        • Exam (perintent to complaint):
          • nuero intact grossly
          • external ocular exam
        • Plan
          • visual acuity
          • full ocular exam/eval by accepting MD
    • request for refill on medications
      • p/w request for refill on controlled substances.
      • p/w request for refill on non-controlled substances.
      • Has PMD
      • Does not have PMD
    • request to establish care
      • p/w request to establish PMD for intake/eval of chronic conditions
      • advised to follow up here for establishment of follow up care
    • intoxication
      • p/w intoxication.
      • Suspected substance
        • etoh
        • amphetamines
        • cocaine
        • marijuna
        • opiods
      • Exam (pertinent to complaint)
        • somulent
        • protecting airway, satting well
        • agitated, redirectable
        • agitated, refractory to verbal de-escalation attempts, requiring sedation, restraints for pt and staff safety
        • evidence of etoh withdrawal
        • no evidence of etoh withdrawal
    • suicidal ideation
      • hx of prior
      • no hx of prior
      • has active plan,
      • does not have active plan
      • hx of pysch d/o
      • no hx of psych d/o
      • POC gluc wnl
      • Plan
          • "Medically cleared." The patient does not have any acute medical emergency requiring medical intervention prior to psychiatric evaluation.medically cleared for psychiatric evaluation.
          • The medical screening evaluation did not reveal any clear medical conditions which are thought to be more likely as causative to the patient's psychiatric complaints than primarily psychiatric pathology.
          • Given the most likely etiology for the patient's symptoms at this time would require an emergent psych evaluation and the risks of delayed psychiatric evaluation outweigh the benefit of additional medical evaluation, the patient is to be evaluated by psychiatry.
          • This emergency medical screening examination does exclude all underlying medical conditions which may be contributory or exacerbating the patient's psychiatric complaints (as this is not feasible to be done in an medical screening exam). Additionally, the patient may have additional comorbidities/medical need which will need to be addressed on an non-emergent basis.
          • Patient transferred to care of psychiatrist with safety-sitter for evaluation of patient's psychiatrist complaints.
          • To assist accepting team (and to be followed up by accping team):
            • Utox
            • Upreg
        • Cannot medically clear until more thorough medical evaluation given
        • Suspicion for
        • Plan to faciliate ellucidation of medical etiology or clearance for psych:
          • POC gluc
          • upreg
          • EKG
          • labs: cbc, bmp,
          • trop, CK
          • ingestion labs (ASA, tylenol level)
          • CT head
          • CXR
          • UA
          • utox (to be followed up by psych team)
    • vaginal bleeding (pt doubts pregnancy)
      • No anemic sx (no CP/SOB/sycnope/fatigue)
      • Dx:
        • upreg
        • POC Hg
        • cbc, bmp, type/screen
        • UA
        • Pelvic US deferred given hx/exam not c/w torsion, necotric fibroid, TOA, ovarian cyst
    • vaginal bleeding in pregnancy
      • EGA
        • by LMP
        • by US which shows IUP
        • has not had US confirmed IUP
      • serum hcg
      • cbc, bmp, type/screen
      • pelvic US
      • UA, UCx
    • dysuria
      • upreg
      • UA
      • UCx given age and/or morbidity and/or microbiological history
      • Labs: cbc, bmp
      • lab deferred given no systemic sx of infection, no flank pain. Contingent upon exam of accepting MD showing solely UTI, labs may be deferred.
    • infectious systems
      • Meets SIRS criteria
      • BP
        • normotensive
        • hypotensive
      • Hx of immunocompromise:
      • Suspected source
      • Plan
        • Septic work-up: cbc, bmp, LFTs, lipase, BCx x2, lactate, UA, UCx, trop
        • IVF
        • Abx deferred for accepting team to iniate based upon suspected source.
    • cough
      • Exam:
        • abnormal breath sounds
        • wheezing
        • rales
        • rhonchi
          • CXR
          • duonebs
          • steroids
          • magnesium
          • magnesium deferred given well appearing
          • labs: cbc, bmp
          • EKG/trop/ASA
    • URI systems
      • No hx of immunocompromise.
      • Well appearing.
      • Vitals not severe deranged suggestive of more malignant process.
      • Plan for symptomatic relief, full eval by accepting practitioner.
    • fever
      • Given well appearing and no e/o bacterial infection on triage exam, will defer further diagnostic to accepting practioner.
        • upreg
        • Symptomatic relief
      • Given ill appearing and/or comorbid, will pursue full septic work up:
        • upreg
        • cbc, bmp, LFTs, lipase, UA, BCx x2, lactate, trop, CXR
        • IVF
        • Abx per accepting team based upon suspected source.
        • Additional imaging given suspected source:
      • Suspected source
  • Dispo:
    • Stable for Fast Track/Rapid Medical Evaluation/Urgent Care (based upon evaluation at this time).
    • Awaiting bed
    • Next back
    • Bring back now, additional screening evaluation deferred given necessity to transport patient to ED bed, mobilize ED team emergently.
  • Of note, this is a limited medical screening exam. The history/exam is insufficient for complete eval in the ED given the limitations of time and the intention of this exam is to determine initial diagnostics to expedite care by AED/RME team assuming care of patient. Further history and exam to be obtained per protocol by AED/RME team that subsequent to this examination assumes care of patient. As such, there is recognition that aspects of the history or exam may be incomplete given time limitations and inability to derobe nor keep patient on monitor for full evaluation. Patient educated that this is not a complete evaluation and the necessity of staying for full evaluation by AED/RME team.

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