test module

  • # Medical Screening Evaluation
  • Generic
    • CC:
      • Given well appearing and no e/o bacterial infection on triage exam, will defer further diagnostic to accepting practioner.
      • Given ill appearing and/or comorbid, will pursue full septic work up:
      • Suspected source
    • Onset:
      • acute,
      • subacute,
      • chronic,
    • History of similar symptom is past
    • History unfortunately limited
    • VITALS:
    • A/P: Suspicion for
    • Ddx includes but not limited to:
    • InitialPlan:
    • lower extremity swelling - bilaterally,
    • lower extremity swelling - unilateral,
    • laceration,
    • trauma
    • joint pain
    • vision problem
    • request for refill on medications
    • request to establish care
    • intoxication
    • suicidal ideation
    • vaginal bleeding (pt doubts pregnancy)
    • vaginal bleeding in pregnancy
    • dysuria
    • infectious systems
    • cough
    • URI systems
    • fever
  • Dispo:
    • Stable for Fast Track/Rapid Medical Evaluation/Urgent Care (based upon evaluation at this time).
    • Awaiting bed,
      • for fast track,
      • for rapid medical screening,
      • in emergency department,
    • Next back given precarious status,
    • Bring back now, additional screening evaluation deferredgiven necessity to transport patient to ED bed, mobilize ED team emergently.
  • Of note, given patient"s symptoms a medication with cognitive side effects was offered to patient contingent upon patient"s agreement to not drive for the remainder of day and to exercise extreme caution for fall risk and to call upon friend/family to pick up and observe until effects had worn off.
  • Of note, this is a limited medical screening exam. The patient was informed that this did NOT constitute a full evaluation in the ED and as such needs to remain here waiting for a room for a full evaluation. I explained there are non-trivial risks of leaving without being fully evaluated given they may misinterpret it to be reassuring when a more complex emergent pathologic process in occurring. Specifically, the history/exam is insufficient for complete eval in the ED given the limitations of time, the lack of patient privacy in the screening setting,and the intention of this evaluation is solelyto determine some of theinitial diagnostics to expedite care by ED team assuming care of patient. Further history and exam to be obtained per protocol by ED team that subsequent to this examination assumes care of patient. As such, there is recognition with understanding between our providers and also as communicated to the patientthat aspects of the evaluationwill likely be incompletegiven above rationaltime limitations, inability to fullyaerobe,nor keep patient on monitor for full evaluation. Patient again explainedthat this is not a complete evaluation and the necessity of staying for full evaluation by ED team.

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