EM Macros

CARDIOLOGY

CHEST PAIN

GENERIC CHEST PAIN MDM
Cardiac risk factors, labs, EKG and imaging were reviewed. EKG shows no acute ischemic changes. Trop x 1 is negative, symptom onset > 6 hrs PTA. /// Troponin x 2 negative. /// HEART Score is XXXX therefore patient is considered low risk for MACE within 30 days and is thus safe for d/c with outpatient cardiac f/u. Unlikely PE as pt is PERC negative///dimer is negative///CTA chest is negative. Unlikely PTX as pt has b/l breath sounds and CXR is negative for ptx. Unlikely PNA as pt is afebrile with no PNA seen on CXR and without PE findings c/w PNA. Unlikely tamponade as there is no low voltage on EKG or CM on CXR. Unlikely pericarditis, endocarditis or myocarditis based on risk factor analysis, EKG and lab findings and the lack of fever. Unlikely aortic dissection or aneurysm based on history (not abrupt in onset, no tearing/ripping), physical exam (pulses symmetric), and lack of mediastinal widening on CXR. Unlikely Esophageal rupture as the CXR is unremarkable and there is no dysphagia. Unlikely zoster as there is no appreciable rash.

New Onset AFIB MDM
Given their history and exam it is likely this patient is spontaneously reverting to a rate controlled rhythm but necessitates a thorough workup for their new arrhythmia.
Workup: ECG, CXR, CBC, BMP, UA, Troponin, BNP, TSH, Ca-Mag-Phos
Findings: ECG:
Interventions: Defer Cardioversion (uncertain historical reliability with time of onset, increased risk of thromboembolic stroke).
CHADS VASC score: ___
Patient’s presentation not consistent with Pneumothorax, Pneumonia, Pulmonary Embolus, Tamponade, ACS, Thyrotoxicosis. No history or evidence decompensated heart failure.
Reassessment: Patient maintained NSR during multi-hour observation in ED.
Rx: Xarelto 20mg Daily (Denies hemophilia, recent GI or other ongoing bleeding), Metoprolol 25mg BID, Aspirin 81mg daily
Disposition: Discharge home with prompt PCP follow up and cardiology referral.

CHEST PAIN D/C INSTRUCTIONS
You have been evaluated in the Emergency Department today for chest pain. Your evaluation was not suggestive of any emergent condition requiring medical intervention at this time. Your EKG did not show any acute changes. 
Please follow up with your primary care physician as needed. If you do not have a primary doctor, you can call your insurance company to find one.  If you do not have insurance, you can go to the finance/registration department for more assistance.
Return to the ER immediately for worsening chest pain, palpitations, shortness of breath, persistent vomiting, fainting, or for any other concerning symptoms. 
HYPERTENSION

Elevated BP was addressed with the patient. Will refer to PCP for continued BP monitoring and management. I also recommended several lifestyle modifications (weight loss, dietary sodium restriction, increase physical activity and moderate alcohol consumption).
SYNCOPE

This patient has a low risk of a significant etiology causing their syncope given that their age less than 60, they have no family history of sudden death, and have no history of CHF, CAD, congenital heart disease or ventricular arrhythmias. Also, the circumstances surrounding the syncopal event are not consistent with ACS and there is no current evidence of CHF or valvular heart disease, no significantly abnormal ECG, nor exertional syncope. Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. 
STEMI

The patient was immediately placed in monitored bed, and IV was placed, oxygen was administered, and the EKG was evaluated. The ECG revealed an acute ST elevation myocardial infarction. A code STEMI was called XXX time and the cath lab was activated. I spoke with DR. XXX of cardiology who agreed to take this patient directly to cardiac catheterization. Defibrillator pads were placed on the patient. The patient was given Aspirin and Plavix. After a chest x-ray was performed which showed no mediastinal widening IV heparin was given based on the patients weight. The patient had normal hemodynamics during the ED course and was taken directly to the cardiac cath lab.


CRITICAL CARE

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Code Procedure Note

Initial Rhythm:  
Description of Code:
CPR was initiated and conducted as per ACLS protocol.
Total duration of CPR: 
Drugs:
– Epinephrine x ***
– Insulin + D50 as well as calcium gluconate for hyperkalemia as potential etiology of cardiac arrest
– Sodium bicarb for treatment of acidosis
– Fluid bolus
– Atropine 
– Pressors initiated – ***
Intubation: Performed by me
Lines Placed: 
Result of Code: ROSC/Death
Next of kin notified: Yes
Primary attending notified: Yes
Cardiac Arrest

During the code, possible causes of asystole were reviewed, including hypoxia (100% oxygen via XXX tube), hypothermia, hypo/hyperkalemia, hypomagnesemia, hydrogen ion acidosis (calcium given for membrane stabilization, sodium bicarb given for acidemia), hypovolemia (IV fluids running). Trauma (none reported, no evidence of on phys exam), toxins (no history), tension pneumothorax (bilateral breath sounds present), cardiac tamponade (no pericardial effusion noted on ultrasound), acute myocardial infarction and pulmonary embolism. Cannot rule our acute myocardial infarction or pulmonary embolus as causes in this patient's course and they may likely provide most reasonable etiology.
Expiration

Patient had no spontaneous respirations, heart sounds, response to any stimulus including noxious stimuli. Patient's pupil were fixed and dilated at 8mm and with no response to light, no corneal reflexes, no gag reflex, and no oculocephalic reflex. Patient was pronounced at __________. Patient's family was contacted and did not desire autopsy, chaplain services were offered, and funeral arrangements were discussed.

DERMATOLOGY

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Cellulitis Discharge

Take all of your antibiotics as ordered. Please call your primary care doctor within 2 days of discharge and follow-up with them in one week. If the affected cellulitic area increases in redness, warmth, pain or swelling call your primary care doctor. If you develop fever, chills, and/or malaise, call your primary care doctor.
Rash Discharge

Does not appear at this time to be erythema multiforme, bullous, SJS, TEN; no evidence at this time to suggest RMSF or endocarditis or Lyme disease; patient looks well, nontoxic and is tolerating oral intake; no neurologic signs or symptoms; no headache or photophobia or neck pain; no ev of sepsis; question viral exanthema; afebrile; appropriate for initial o/p tx; d/w pt importance of f/u and pt agrees/understands; told pt to return to nearest ER immediately for any worsening ssx incl but not limited to: fever, spreading rash, pain, sore throat, headache, dizziness, chest pain, trouble breathing, or any ssx concerning to the patient. I did d/w pt the aforementioned ddx as possibilities and pt understands to f/u even if better and to return to ER if un-changed/worse. Pt understands these instructions on d/c and is comfortable with discharge plan.

GASTROENTEROLOGY

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Abdominal Pain

ABDOMINAL EXAM RE-EVAL
The patient appears comfortable and states that pain is improved. Tolerating oral intake. Vital signs reviewed and are normal. On repeat physical exam, the abdomen is soft and nontender All diagnostics tests reviewed and discussed with the patient.

ABDOMINAL PAIN DISCHARGE RE-EVAL
On repeat examination prior to discharge, the patient has a soft abdomen with no peritoneal findings. The patient was able to tolerate oral intake. The patient was advised that even though there is no evidence of a surgical emergency at this time, sometimes this is not visible on ***IMAGING*** or in the labs early in a disease course and that if there is additional pain they are to return for repeat evaluation. The patient stated understanding of this, has decisional making capacity and is discharged in stable condition. The patient was instructed to return to the emergency department for re-evaluation in 8-12 hours and sooner if they feel worse in any way.

ABDOMINAL PAIN D/C INSTRUCTIONS
Please return to the emergency department immediately should you feel worse in any way or have any of the following symptoms: increasing or different abdominal pain, persistent vomiting, fevers or shaking chills. Please return to the emergency department for a recheck in 8-12 hours if the pain is persistent or worse so we can re-evaluate you and ensure that you are not developing a problem that would require surgery or hospitalization.
CT Abdomen Shared Decision Making

I had a discussion with the patient and we shared decision making regarding emergent CT of the abdomen. Risks and benefits were reviewed and discussed and radiation exposure vs. diagnostic uncertainty were reviewed. Based on overall clinical presentation and diagnostic data, it was felt the risk of life-threatening or serious pathology was low. Importance of strict follow up was stressed. The patient was warned to return to the ED with worsening or recurrent pain or if their condition worsened in any way.

GENERAL

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General

GENERAL DISCHARGE
All lab work, imaging and diagnostic studies were reviewed by me. The patient was counseled extensively on my clinical impression, diagnosis, expected course of the disease, and plan, including their follow-up care. The patient agreed to call their primary care physician immediately for a follow up appointment. The patient was given the opportunity to ask questions and all questions were answered by myself and the nursing staff. The patient verbally expressed understanding of the discharge instructions, including the reasons to return to the Emergency Department.

TIMING
The times in the chart may not be reflective of actual patient care times, interventions, or procedures. Documentation occurs after the physical care of the patient.
AMA

The patient has requested to leave the ED against medical advice. The patient reason(s) for leaving include, but are not limited to, the following: XXXX. I believe this patient is of sound mind and competent to refuse medical care. The patient is responding and asking questions appropriately. The patient is oriented to person, place and time. The patient is not psychotic, delusional, suicidal, homicidal or hallucinating. The patient demonstrates a normal mental capacity to make decisions regarding their healthcare. The patient is clinically sober and does not appear to be under the influence of any illicit drugs at this time. The patient has been advised of the risks, in layman terms, of leaving AMA which include, but are not limited to death, coma, permanent disability, loss of current lifestyle, delay in diagnosis. Alternatives have been offered - the patient remains steadfast in their wish to leave. The patient has been advised that should they change their mind they are welcome to return to this hospital, or any other, at any time. The patient understands that in no way does an AMA discharge mean that I do not want them to have the best medical care available. To this end, I have provided appropriate prescriptions, referrals, and discharge instructions. The patient ***did/did not*** sign AMA paperwork. The above discussion was witnessed by another member of staff.
Smoking Cessation

Due to patients current smoking history I had an extensive discussion lasting more than 3 minutes about the need to quit smoking.
Drug/Alcohol

INTOXICATION DISCHARGE
The patient is clinically sober. The patient is alert and oriented x 3, is clear and coherent in conversation and has a normal gait and shows no signs of acute intoxication. The patient is safe for discharge.

OPIOID DISCHARGE
Will discharge patient with a short course of opiates. Went over the risks of the medication. Advised patient to not mix with other products containing acetaminophen, to not combine with alcohol, or other illicit drugs, to not drive or operate machinery, and to refrain from any activity that will require complete attention while taking this medication.

DRUG SEEKING
The patient is manifesting multiple drug seeking attributes. Prior medical records, if available, were reviewed. Discussed with the patient that opioid pain medication will not be given during the ED visit. Alternative analgesia is offered and REFUSED/ACCEPTED.
Sign Out

The patient was signed out to the incoming physician. All decisions regarding the progression of care and interpretation of tests will be made at their discretion.
Pain Med Discharge

Patient was counseled to not drive, operate heavy machinery and/or make important decisions while on taking prescribed medications. The patient expresses understanding that these medications can impair their judgment.
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INFECTIOUS DISEASE

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Cellulitis MDM

Pt seen w initial presentation of local erythema, warmth, swelling to ____. Sensitivity/pain to light touch around the erythematous area. Nontoxic appearing, VSS. No lymphangitic spread visible and no fluid pockets or fluctuance c/f abscess noted. Low c/f osteomyelitis or DVT. No immune compromise, bullae, pain out of proportion, or rapid progression c/f necrotizing fasciitis. No purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS c/f MRSA infection. No h/o prior tx failure, fever, chronic leg ulcers, chronic edema/lyphedema c/f treatment failure. Plan tx w Reflex 500mg PO q8hrs outpt. Erythema outlined. DC home w return precautions discussed
Cellulitis Discharge

Take all of your antibiotics as ordered. Please call your primary care doctor within 2 days of discharge and follow-up with them in one week. If the affected cellulitic area increases in redness, warmth, pain or swelling call your primary care doctor. If you develop fever, chills, and/or malaise, call your primary care doctor.
GC/Chlamydia Discharge

Will empirically treat for GC/Chlamydia with Ceftriaxone IM and Azithromycin. GC culture sent. Abstinence and safe sex precautions were provided and the patient demonstrated understanding.
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EPHROLOGY

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Kidney Stones

Clinically the patient presents with nephrolithasis. IV pain medications, antiemetics, and IV fluids were given. A CT Abdomen/Pelvis was obtained for concern for a possible obstructing kidney stone and to rule out other pathologic conditions. The CT confirmed revealed a stone at XXX. The patient's labs were significant for XXX. With pain medication the patient improved significantly. The patient is referred to the on-call urologist for follow up and is discharged with XXX for pain control, +/- Flomax, antiemetics, and given the following return precautions: Fever > 100.5, pain not controlled with narcotics, vomiting or any other concerns and to strain the urine
CT Dye Consent

This patient was found to have an elevated creatinine and may be at risk for contrast induced nephropathy. Discussed risks/benefits with patient, agrees w/ scan. The patient will receive IV hydration prior to the CT scan and immediately after. Will continue to monitor.

NEUROLOGY

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Headache

HEADACHE MDM
Based on the patient's history and physical there is very low clinical suspicion for significant intracranial pathology. The headache was NOT sudden onset, NOT maximal at onset, there are NO neurologic findings, the patient does NOT have a fever, the patient does NOT have any jaw claudication, the patient does NOT endorse a clotting disorder, patient DENIES any trauma or eye pain and the headache is NOT associated with dizziness or ataxia. Will treatment the patient symptomatically and reassess.

HEADACHE MDM #2
XXXX who presents with Headache.  Most likely 2/2 tension headache, migraine, or headache of non-emergent etiology. No focal neurological symptoms. Neuro exam is benign. Pt is nontoxic. VSS.
Unlikely SAH: headache is non thunderclap. Headache is gradual, non-maximal at onset and similar to headaches in the past.
Unlikely Subdural/epidural hematoma: no history of trauma, no anticoagulation.
Unlikely Meningitis: afebrile, no meningismus,  mild photophobia.
Unlikely Temporal arteritis: pt < 60 years old.  no tenderness in temporal area
Unlikely Acute angle glaucoma: PERRL, no eye pain.
Unlikely Carbon Monoxide Poisoning: no other house members with similar symptoms.
Plan: Will give pain medication and reexamine
CT Head Shared Decision Making

I had a discussion with the patient and we shared decision making regarding emergent CT of the head. Risks and benefits were reviewed and discussed and radiation exposure vs. diagnostic uncertainty were reviewed. Based on overall clinical presentation and diagnostic data, it was felt the risk of life-threatening or serious pathology was low. Clinical decision tools for imaging were considered. Importance of strict follow up was stressed. The patient was warned to return to the ED with worsening or recurrent pain, neurologic symptoms, vomiting, altered mentation or if their condition worsened in any way.
Neuro Re-eval MDM

Patient is alert, attentive, and oriented. Speech is clear and fluent. PERRL and there is no facial droop. There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally. SILT in all four extremities. Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. Gait is steady with normal steps.
Seizure Discharge

Please follow up with Neurology in the next 1-2 days as an outpatient. Please continue taking your medications as prescribed. Do not drive until you are cleared by the Neurologist. If your seizures are not well controlled, avoid high-risk sports such as skiing and scuba diving. Avoid high-risk jobs that involve heavy or fast-moving equipment, heights, bodies of water, or other situations where you or others might be injured if you have a seizure. Avoid swimming. Return for worsening condition or any other emergencies.

OB/GYN

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Diclegis

Please take 10 mg of Pyridoxine and 10mg of Doxylamine at bedtime. If that does not work increase to 20mg of each medicine on a daily basis at bedtime; if symptoms not adequately controlled, increase dose to 40mg tablets each day (10mg of each pill in AM, 10mg of each pill in the mid-afternoon, and 20mg of each pill at bedtime).

ORTHOPEDICS

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Chronic Back Pain

___ year old patient presents with worsening of chronic low back pain for the past ___ days of non-emergent etiology. I feel this is likely secondary to musculoskeletal etiology vs non-emergent disc herniation. Unlikely spinal cord compression syndrome based on PE. The patient denies all RED FLAGS including fevers, chills, recent spinal procedures, bowel/bladder incontinence, IV drug use, cancer, age > 70 yo, recent weight loss, immunosuppression, prolonged steroid use, osteoporosis, acute trauma, weakness, numbness, tingling, dysuria, or hematuria. Low suspicion for AAA or renal stone. Unlikely vertebral malignancy/metastasis, fracture, or infection. Unlikely epidural abscess or osteomyelitis. I will attempt to manage pts pain and defer imaging and labwork for outpatient follow up at this time.

EDIATRICS

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Pediatric Fever Discharge

The patient was evaluated by myself and was noted to be completely nontoxic in appearance at time of discharge. The child was smiling, taking oral fluids without any difficulty and well appearing. There is no evidence of systemic toxicity at this time, but the child's parents were advised that the condition could change, and that if the child gets worse in any way to return to the emergency department immediately for reevaluation. They were specifically counselled in signs and symptoms of toxicity to look for: inability to tolerate oral fluids, lethargy, delayed capillary refill, alteration in mental status, or petechial rash.

PSYCHIATRY

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Psych Discharge

At present, protective factors outweigh the risk factors. The patient does not appear to be at imminent danger to self/ others at present, denies suicidal thoughts and will be referred to outpatient psychiatrist/ therapist.
Verbal De-escalation

I was called to the bedside by the RN to evaluate the patient. The patient is agitated, aggressive, verbally threatening. I established verbal contact with patient, being concise, attempted verbal de-escalation techniques however the patient could not be re-directed. The patient required physical restraint and chemical sedation to ensure their safety as well as the safety of those around them, including other patients and staff. I will continue to monitor the patient closely. 
Psych Differential

Adjustment reaction, alcohol abuse, anxiety, depression, substance abuse, eating disorder, hyperventilation syndrome, personality disorder, schizophrenia, bipolar d

ROLOGY

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Kidney Stone MDM

Clinically the patient presents with nephrolithasis. IV pain medications, antiemetics, and IV fluids were given. A CT Abdomen/Pelvis was obtained for concern for a possible obstructing kidney stone and to rule out other pathologic conditions. The CT confirmed revealed a stone at XXX. The patient's labs were significant for XXX. With pain medication the patient improved significantly. The patient is referred to the on-call urologist for follow up and is discharged with oral narcotics for pain control, Flomax, antiemetics, and given the following return precautions: Fever > 100.5, pain not controlled with narcotics, vomiting or any other concerns and to strain the urine
Kidney Stone Discharge

Follow up with your primary doctor within 2-3 days. Follow up with a Urologist this week, number provided with your discharge paper. Please call as soon as possible for an appointment. Use Motrin (also called Ibuprofen or Advil) 400 mg every 6 hours as needed for pain. If you have any stomach discomfort while taking Motrin, you can use TUMS to help. All of these medications can be purchased without a prescription. Drink plenty of fluids, avoid caffeine & alcohol. Please continue taking your home medications as directed. Do not use alcohol when taking any medication (especially antibiotics, tylenol or other pain medication) unless you check with the doctor or pharmacist. Any worsening pain, fever, chills, difficulty urinating, or any other concerns, please see your doctor immediately or return to Emergency Department right away.

RASOUND

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EFAST

EFAST Exam
Limited Diagnostic Exam: Limited Abdomen, Limited Chest, Limited Cardiac 
76705-26, 93308-26, 76604-26
Patient Identity confirmed: Yes
Indication for exam: Trauma
Hepatorenal (RUQ): No Free Fluid Identified 
Right Pleural Space: No Free Fluid Identified 
Perisplenic (LUQ): No Free Fluid Identified 
Left Pleural Space: No Free Fluid Identified 
Suprapubic:  No Free Fluid Identified 
Pericardium: No Pericardial Effusion Identified  
Right Anterior Chest Wall: Pleural Sliding Present 
Left Anterior Chest Wall: Pleural Sliding Present 
Other Findings: None
Performed by ED Physician (me)
FAST

FAST Exam
Limited Diagnostic Exam: Limited Abdomen, Limited Cardiac 
76705-26, 93308-26
Patient Identity confirmed: Yes
Indication for exam: Trauma
Hepatorenal (RUQ): No Free Fluid Identified 
Perisplenic (LUQ): No Free Fluid Identified 
Suprapubic:  No Free Fluid Identified 
Pericardium: No Pericardial Effusion Identified  
Other Findings: None
Performed by ED Physician (me)
CARDIO

Limited Transthoracic Echocardiogram (TTE)
Limited Diagnostic Exam: Cardiac (TTE)
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: ***
Pericardium: No effusion noted
Left Ventricular Function: Grossly normal EF by EPSS and global function 
RV size: RV size is grossly normal 
Other Findings: none
Comments: No pathology noted.
AORTA

Limited Retroperitoneal Ultrasound Exam: Abdominal Aorta 
Limited Diagnostic Exam: Retroperitoneal 
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: ***
Transverse view of proximal abdominal aorta measures < 3 cm
Transverse view of distal abdominal aorta measures < 3 cm
Long Axis view of the abdominal aorta: No evidence of fusiform or saccular aneurysm
Other findings: No abdominal aortic pathology noted 
Comments: none
LUNG

Limited Diagnostic Exam: Limited Chest
76604-26
Patient Identity confirmed: Yes
Indication for exam: SOB
Right Lung Sliding: Present 
Right Lung B-Lines: No B-Lines noted
Right Pleural Free Fluid: No free fluid noted
Left Lung Sliding: Present
Left Lung B-Lines: No B-Lines noted
Left Pleural Free Fluid: No free fluid noted
Additional Findings: none
Performed by ED Physician (me)
Peripheral IV

Peripheral Venous Access US Guidance
Limited Diagnostic Exam: Venipuncture requiring physician skill with ultrasound guidance
Performed by: ED Physician (me)
Patient Identity confirmed: Yes
Risks, benefits and alternatives were discussed
Consent obtained verbally
Indication for Exam: Vascular Access 
Vein/Location: ***
Normal Compressibility and Visualized Patency 
Catheter Size: 20 g
Number of Attempts: 1
Successful Catheter Insertion: yes
Complications: none
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Soft Tissue

Limited Soft Tissue Ultrasound
Limited Diagnostic Exam: Soft Tissue
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: ***
Location: ***
Findings: ***
Ocular US

Ocular Ultrasound 
Limited Diagnostic Exam: Ocular
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: ***
Right Eye: anatomy identified, no pathology noted 
Right Retinal Contour: no abnormalities noted, normal contour 
Right Lens: Lens in normal position
Right vitreous body: clear vitreous body, no abnormalities noted 
Right optic nerve sheath diameter (mm): less than 5.5mm
Right Ocular Foreign Body: none noted 
Left Eye: anatomy identified, no pathology noted 
Left Retinal Contour: no abnormalities noted, normal contour 
Left Lens: Lens in normal position
Left vitreous body: clear vitreous body, no abnormalities noted
Left optic nerve sheath diameter (mm): less than 5.5mm
Left Ocular Foreign Body: none noted 
Comments: none
Bladder

Limited Diagnostic Exam: Bladder 
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: Post Void Residual Volume 
Bladder Volume: *** ml
Comments: ***
CARDIOLOGY

CHEST PAIN

GENERIC CHEST PAIN MDM
Cardiac risk factors, labs, EKG and imaging were reviewed. EKG shows no acute ischemic changes. Trop x 1 is negative, symptom onset > 6 hrs PTA. /// Troponin x 2 negative. /// HEART Score is XXXX therefore patient is considered low risk for MACE within 30 days and is thus safe for d/c with outpatient cardiac f/u. Unlikely PE as pt is PERC negative///dimer is negative///CTA chest is negative. Unlikely PTX as pt has b/l breath sounds and CXR is negative for ptx. Unlikely PNA as pt is afebrile with no PNA seen on CXR and without PE findings c/w PNA. Unlikely tamponade as there is no low voltage on EKG or CM on CXR. Unlikely pericarditis, endocarditis or myocarditis based on risk factor analysis, EKG and lab findings and the lack of fever. Unlikely aortic dissection or aneurysm based on history (not abrupt in onset, no tearing/ripping), physical exam (pulses symmetric), and lack of mediastinal widening on CXR. Unlikely Esophageal rupture as the CXR is unremarkable and there is no dysphagia. Unlikely zoster as there is no appreciable rash.

New Onset AFIB MDM
Given their history and exam it is likely this patient is spontaneously reverting to a rate controlled rhythm but necessitates a thorough workup for their new arrhythmia.
Workup: ECG, CXR, CBC, BMP, UA, Troponin, BNP, TSH, Ca-Mag-Phos
Findings: ECG:
Interventions: Defer Cardioversion (uncertain historical reliability with time of onset, increased risk of thromboembolic stroke).
CHADS VASC score: ___
Patient’s presentation not consistent with Pneumothorax, Pneumonia, Pulmonary Embolus, Tamponade, ACS, Thyrotoxicosis. No history or evidence decompensated heart failure.
Reassessment: Patient maintained NSR during multi-hour observation in ED.
Rx: Xarelto 20mg Daily (Denies hemophilia, recent GI or other ongoing bleeding), Metoprolol 25mg BID, Aspirin 81mg daily
Disposition: Discharge home with prompt PCP follow up and cardiology referral.

CHEST PAIN D/C INSTRUCTIONS
You have been evaluated in the Emergency Department today for chest pain. Your evaluation was not suggestive of any emergent condition requiring medical intervention at this time. Your EKG did not show any acute changes.
Please follow up with your primary care physician as needed. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can go to the finance/registration department for more assistance.
Return to the ER immediately for worsening chest pain, palpitations, shortness of breath, persistent vomiting, fainting, or for any other concerning symptoms.
HYPERTENSION

Elevated BP was addressed with the patient. Will refer to PCP for continued BP monitoring and management. I also recommended several lifestyle modifications (weight loss, dietary sodium restriction, increase physical activity and moderate alcohol consumption).
SYNCOPE

This patient has a low risk of a significant etiology causing their syncope given that their age less than 60, they have no family history of sudden death, and have no history of CHF, CAD, congenital heart disease or ventricular arrhythmias. Also, the circumstances surrounding the syncopal event are not consistent with ACS and there is no current evidence of CHF or valvular heart disease, no significantly abnormal ECG, nor exertional syncope. Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation.
STEMI

The patient was immediately placed in monitored bed, and IV was placed, oxygen was administered, and the EKG was evaluated. The ECG revealed an acute ST elevation myocardial infarction. A code STEMI was called XXX time and the cath lab was activated. I spoke with DR. XXX of cardiology who agreed to take this patient directly to cardiac catheterization. Defibrillator pads were placed on the patient. The patient was given Aspirin and Plavix. After a chest x-ray was performed which showed no mediastinal widening IV heparin was given based on the patients weight. The patient had normal hemodynamics during the ED course and was taken directly to the cardiac cath lab.


CRITICAL CARE

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Code Procedure Note

Initial Rhythm:
Description of Code:
CPR was initiated and conducted as per ACLS protocol.
Total duration of CPR:
Drugs:
– Epinephrine x ***
– Insulin + D50 as well as calcium gluconate for hyperkalemia as potential etiology of cardiac arrest
– Sodium bicarb for treatment of acidosis
– Fluid bolus
– Atropine
– Pressors initiated – ***
Intubation: Performed by me
Lines Placed:
Result of Code: ROSC/Death
Next of kin notified: Yes
Primary attending notified: Yes
Cardiac Arrest

During the code, possible causes of asystole were reviewed, including hypoxia (100% oxygen via XXX tube), hypothermia, hypo/hyperkalemia, hypomagnesemia, hydrogen ion acidosis (calcium given for membrane stabilization, sodium bicarb given for acidemia), hypovolemia (IV fluids running). Trauma (none reported, no evidence of on phys exam), toxins (no history), tension pneumothorax (bilateral breath sounds present), cardiac tamponade (no pericardial effusion noted on ultrasound), acute myocardial infarction and pulmonary embolism. Cannot rule our acute myocardial infarction or pulmonary embolus as causes in this patient's course and they may likely provide most reasonable etiology.
Expiration

Patient had no spontaneous respirations, heart sounds, response to any stimulus including noxious stimuli. Patient's pupil were fixed and dilated at 8mm and with no response to light, no corneal reflexes, no gag reflex, and no oculocephalic reflex. Patient was pronounced at __________. Patient's family was contacted and did not desire autopsy, chaplain services were offered, and funeral arrangements were discussed.

DERMATOLOGY

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Cellulitis Discharge

Take all of your antibiotics as ordered. Please call your primary care doctor within 2 days of discharge and follow-up with them in one week. If the affected cellulitic area increases in redness, warmth, pain or swelling call your primary care doctor. If you develop fever, chills, and/or malaise, call your primary care doctor.
Rash Discharge

Does not appear at this time to be erythema multiforme, bullous, SJS, TEN; no evidence at this time to suggest RMSF or endocarditis or Lyme disease; patient looks well, nontoxic and is tolerating oral intake; no neurologic signs or symptoms; no headache or photophobia or neck pain; no ev of sepsis; question viral exanthema; afebrile; appropriate for initial o/p tx; d/w pt importance of f/u and pt agrees/understands; told pt to return to nearest ER immediately for any worsening ssx incl but not limited to: fever, spreading rash, pain, sore throat, headache, dizziness, chest pain, trouble breathing, or any ssx concerning to the patient. I did d/w pt the aforementioned ddx as possibilities and pt understands to f/u even if better and to return to ER if un-changed/worse. Pt understands these instructions on d/c and is comfortable with discharge plan.

GASTROENTEROLOGY

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Abdominal Pain

ABDOMINAL EXAM RE-EVAL
The patient appears comfortable and states that pain is improved. Tolerating oral intake. Vital signs reviewed and are normal. On repeat physical exam, the abdomen is soft and nontender All diagnostics tests reviewed and discussed with the patient.

ABDOMINAL PAIN DISCHARGE RE-EVAL
On repeat examination prior to discharge, the patient has a soft abdomen with no peritoneal findings. The patient was able to tolerate oral intake. The patient was advised that even though there is no evidence of a surgical emergency at this time, sometimes this is not visible on ***IMAGING*** or in the labs early in a disease course and that if there is additional pain they are to return for repeat evaluation. The patient stated understanding of this, has decisional making capacity and is discharged in stable condition. The patient was instructed to return to the emergency department for re-evaluation in 8-12 hours and sooner if they feel worse in any way.

ABDOMINAL PAIN D/C INSTRUCTIONS
Please return to the emergency department immediately should you feel worse in any way or have any of the following symptoms: increasing or different abdominal pain, persistent vomiting, fevers or shaking chills. Please return to the emergency department for a recheck in 8-12 hours if the pain is persistent or worse so we can re-evaluate you and ensure that you are not developing a problem that would require surgery or hospitalization.
CT Abdomen Shared Decision Making

I had a discussion with the patient and we shared decision making regarding emergent CT of the abdomen. Risks and benefits were reviewed and discussed and radiation exposure vs. diagnostic uncertainty were reviewed. Based on overall clinical presentation and diagnostic data, it was felt the risk of life-threatening or serious pathology was low. Importance of strict follow up was stressed. The patient was warned to return to the ED with worsening or recurrent pain or if their condition worsened in any way.

GENERAL

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General

GENERAL DISCHARGE
All lab work, imaging and diagnostic studies were reviewed by me. The patient was counseled extensively on my clinical impression, diagnosis, expected course of the disease, and plan, including their follow-up care. The patient agreed to call their primary care physician immediately for a follow up appointment. The patient was given the opportunity to ask questions and all questions were answered by myself and the nursing staff. The patient verbally expressed understanding of the discharge instructions, including the reasons to return to the Emergency Department.

TIMING
The times in the chart may not be reflective of actual patient care times, interventions, or procedures. Documentation occurs after the physical care of the patient.
AMA

The patient has requested to leave the ED against medical advice. The patient reason(s) for leaving include, but are not limited to, the following: XXXX. I believe this patient is of sound mind and competent to refuse medical care. The patient is responding and asking questions appropriately. The patient is oriented to person, place and time. The patient is not psychotic, delusional, suicidal, homicidal or hallucinating. The patient demonstrates a normal mental capacity to make decisions regarding their healthcare. The patient is clinically sober and does not appear to be under the influence of any illicit drugs at this time. The patient has been advised of the risks, in layman terms, of leaving AMA which include, but are not limited to death, coma, permanent disability, loss of current lifestyle, delay in diagnosis. Alternatives have been offered - the patient remains steadfast in their wish to leave. The patient has been advised that should they change their mind they are welcome to return to this hospital, or any other, at any time. The patient understands that in no way does an AMA discharge mean that I do not want them to have the best medical care available. To this end, I have provided appropriate prescriptions, referrals, and discharge instructions. The patient ***did/did not*** sign AMA paperwork. The above discussion was witnessed by another member of staff.
Smoking Cessation

Due to patients current smoking history I had an extensive discussion lasting more than 3 minutes about the need to quit smoking.
Drug/Alcohol

INTOXICATION DISCHARGE
The patient is clinically sober. The patient is alert and oriented x 3, is clear and coherent in conversation and has a normal gait and shows no signs of acute intoxication. The patient is safe for discharge.

OPIOID DISCHARGE
Will discharge patient with a short course of opiates. Went over the risks of the medication. Advised patient to not mix with other products containing acetaminophen, to not combine with alcohol, or other illicit drugs, to not drive or operate machinery, and to refrain from any activity that will require complete attention while taking this medication.

DRUG SEEKING
The patient is manifesting multiple drug seeking attributes. Prior medical records, if available, were reviewed. Discussed with the patient that opioid pain medication will not be given during the ED visit. Alternative analgesia is offered and REFUSED/ACCEPTED.
Sign Out

The patient was signed out to the incoming physician. All decisions regarding the progression of care and interpretation of tests will be made at their discretion.
Pain Med Discharge

Patient was counseled to not drive, operate heavy machinery and/or make important decisions while on taking prescribed medications. The patient expresses understanding that these medications can impair their judgment.
Copyright © 2018 ED Macros - All Rights Reserved.

INFECTIOUS DISEASE

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Cellulitis MDM

Pt seen w initial presentation of local erythema, warmth, swelling to ____. Sensitivity/pain to light touch around the erythematous area. Nontoxic appearing, VSS. No lymphangitic spread visible and no fluid pockets or fluctuance c/f abscess noted. Low c/f osteomyelitis or DVT. No immune compromise, bullae, pain out of proportion, or rapid progression c/f necrotizing fasciitis. No purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS c/f MRSA infection. No h/o prior tx failure, fever, chronic leg ulcers, chronic edema/lyphedema c/f treatment failure. Plan tx w Reflex 500mg PO q8hrs outpt. Erythema outlined. DC home w return precautions discussed
Cellulitis Discharge

Take all of your antibiotics as ordered. Please call your primary care doctor within 2 days of discharge and follow-up with them in one week. If the affected cellulitic area increases in redness, warmth, pain or swelling call your primary care doctor. If you develop fever, chills, and/or malaise, call your primary care doctor.
GC/Chlamydia Discharge

Will empirically treat for GC/Chlamydia with Ceftriaxone IM and Azithromycin. GC culture sent. Abstinence and safe sex precautions were provided and the patient demonstrated understanding.
Copyright © 2018 ED Macros - All Rights Reserved.

EPHROLOGY

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Kidney Stones

Clinically the patient presents with nephrolithasis. IV pain medications, antiemetics, and IV fluids were given. A CT Abdomen/Pelvis was obtained for concern for a possible obstructing kidney stone and to rule out other pathologic conditions. The CT confirmed revealed a stone at XXX. The patient's labs were significant for XXX. With pain medication the patient improved significantly. The patient is referred to the on-call urologist for follow up and is discharged with XXX for pain control, +/- Flomax, antiemetics, and given the following return precautions: Fever > 100.5, pain not controlled with narcotics, vomiting or any other concerns and to strain the urine
CT Dye Consent

This patient was found to have an elevated creatinine and may be at risk for contrast induced nephropathy. Discussed risks/benefits with patient, agrees w/ scan. The patient will receive IV hydration prior to the CT scan and immediately after. Will continue to monitor.

NEUROLOGY

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Headache

HEADACHE MDM
Based on the patient's history and physical there is very low clinical suspicion for significant intracranial pathology. The headache was NOT sudden onset, NOT maximal at onset, there are NO neurologic findings, the patient does NOT have a fever, the patient does NOT have any jaw claudication, the patient does NOT endorse a clotting disorder, patient DENIES any trauma or eye pain and the headache is NOT associated with dizziness or ataxia. Will treatment the patient symptomatically and reassess.

HEADACHE MDM #2
XXXX who presents with Headache. Most likely 2/2 tension headache, migraine, or headache of non-emergent etiology. No focal neurological symptoms. Neuro exam is benign. Pt is nontoxic. VSS.
Unlikely SAH: headache is non thunderclap. Headache is gradual, non-maximal at onset and similar to headaches in the past.
Unlikely Subdural/epidural hematoma: no history of trauma, no anticoagulation.
Unlikely Meningitis: afebrile, no meningismus, mild photophobia.
Unlikely Temporal arteritis: pt < 60 years old. no tenderness in temporal area
Unlikely Acute angle glaucoma: PERRL, no eye pain.
Unlikely Carbon Monoxide Poisoning: no other house members with similar symptoms.
Plan: Will give pain medication and reexamine
CT Head Shared Decision Making

I had a discussion with the patient and we shared decision making regarding emergent CT of the head. Risks and benefits were reviewed and discussed and radiation exposure vs. diagnostic uncertainty were reviewed. Based on overall clinical presentation and diagnostic data, it was felt the risk of life-threatening or serious pathology was low. Clinical decision tools for imaging were considered. Importance of strict follow up was stressed. The patient was warned to return to the ED with worsening or recurrent pain, neurologic symptoms, vomiting, altered mentation or if their condition worsened in any way.
Neuro Re-eval MDM

Patient is alert, attentive, and oriented. Speech is clear and fluent. PERRL and there is no facial droop. There is no pronator drift of out-stretched arms. Muscle bulk and tone are normal. Strength is full bilaterally. SILT in all four extremities. Rapid alternating movements and fine finger movements are intact. There is no dysmetria on finger-to-nose and heel-knee-shin. Gait is steady with normal steps.
Seizure Discharge

Please follow up with Neurology in the next 1-2 days as an outpatient. Please continue taking your medications as prescribed. Do not drive until you are cleared by the Neurologist. If your seizures are not well controlled, avoid high-risk sports such as skiing and scuba diving. Avoid high-risk jobs that involve heavy or fast-moving equipment, heights, bodies of water, or other situations where you or others might be injured if you have a seizure. Avoid swimming. Return for worsening condition or any other emergencies.

OB/GYN

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Diclegis

Please take 10 mg of Pyridoxine and 10mg of Doxylamine at bedtime. If that does not work increase to 20mg of each medicine on a daily basis at bedtime; if symptoms not adequately controlled, increase dose to 40mg tablets each day (10mg of each pill in AM, 10mg of each pill in the mid-afternoon, and 20mg of each pill at bedtime).

ORTHOPEDICS

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Chronic Back Pain

___ year old patient presents with worsening of chronic low back pain for the past ___ days of non-emergent etiology. I feel this is likely secondary to musculoskeletal etiology vs non-emergent disc herniation. Unlikely spinal cord compression syndrome based on PE. The patient denies all RED FLAGS including fevers, chills, recent spinal procedures, bowel/bladder incontinence, IV drug use, cancer, age > 70 yo, recent weight loss, immunosuppression, prolonged steroid use, osteoporosis, acute trauma, weakness, numbness, tingling, dysuria, or hematuria. Low suspicion for AAA or renal stone. Unlikely vertebral malignancy/metastasis, fracture, or infection. Unlikely epidural abscess or osteomyelitis. I will attempt to manage pts pain and defer imaging and labwork for outpatient follow up at this time.

EDIATRICS

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Pediatric Fever Discharge

The patient was evaluated by myself and was noted to be completely nontoxic in appearance at time of discharge. The child was smiling, taking oral fluids without any difficulty and well appearing. There is no evidence of systemic toxicity at this time, but the child's parents were advised that the condition could change, and that if the child gets worse in any way to return to the emergency department immediately for reevaluation. They were specifically counselled in signs and symptoms of toxicity to look for: inability to tolerate oral fluids, lethargy, delayed capillary refill, alteration in mental status, or petechial rash.

PSYCHIATRY

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Psych Discharge

At present, protective factors outweigh the risk factors. The patient does not appear to be at imminent danger to self/ others at present, denies suicidal thoughts and will be referred to outpatient psychiatrist/ therapist.
Verbal De-escalation

I was called to the bedside by the RN to evaluate the patient. The patient is agitated, aggressive, verbally threatening. I established verbal contact with patient, being concise, attempted verbal de-escalation techniques however the patient could not be re-directed. The patient required physical restraint and chemical sedation to ensure their safety as well as the safety of those around them, including other patients and staff. I will continue to monitor the patient closely.
Psych Differential

Adjustment reaction, alcohol abuse, anxiety, depression, substance abuse, eating disorder, hyperventilation syndrome, personality disorder, schizophrenia, bipolar d

ROLOGY

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Kidney Stone MDM

Clinically the patient presents with nephrolithasis. IV pain medications, antiemetics, and IV fluids were given. A CT Abdomen/Pelvis was obtained for concern for a possible obstructing kidney stone and to rule out other pathologic conditions. The CT confirmed revealed a stone at XXX. The patient's labs were significant for XXX. With pain medication the patient improved significantly. The patient is referred to the on-call urologist for follow up and is discharged with oral narcotics for pain control, Flomax, antiemetics, and given the following return precautions: Fever > 100.5, pain not controlled with narcotics, vomiting or any other concerns and to strain the urine
Kidney Stone Discharge

Follow up with your primary doctor within 2-3 days. Follow up with a Urologist this week, number provided with your discharge paper. Please call as soon as possible for an appointment. Use Motrin (also called Ibuprofen or Advil) 400 mg every 6 hours as needed for pain. If you have any stomach discomfort while taking Motrin, you can use TUMS to help. All of these medications can be purchased without a prescription. Drink plenty of fluids, avoid caffeine & alcohol. Please continue taking your home medications as directed. Do not use alcohol when taking any medication (especially antibiotics, tylenol or other pain medication) unless you check with the doctor or pharmacist. Any worsening pain, fever, chills, difficulty urinating, or any other concerns, please see your doctor immediately or return to Emergency Department right away.

RASOUND

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EFAST

EFAST Exam
Limited Diagnostic Exam: Limited Abdomen, Limited Chest, Limited Cardiac
76705-26, 93308-26, 76604-26
Patient Identity confirmed: Yes
Indication for exam: Trauma
Hepatorenal (RUQ): No Free Fluid Identified
Right Pleural Space: No Free Fluid Identified
Perisplenic (LUQ): No Free Fluid Identified
Left Pleural Space: No Free Fluid Identified
Suprapubic: No Free Fluid Identified
Pericardium: No Pericardial Effusion Identified
Right Anterior Chest Wall: Pleural Sliding Present
Left Anterior Chest Wall: Pleural Sliding Present
Other Findings: None
Performed by ED Physician (me)
FAST

FAST Exam
Limited Diagnostic Exam: Limited Abdomen, Limited Cardiac
76705-26, 93308-26
Patient Identity confirmed: Yes
Indication for exam: Trauma
Hepatorenal (RUQ): No Free Fluid Identified
Perisplenic (LUQ): No Free Fluid Identified
Suprapubic: No Free Fluid Identified
Pericardium: No Pericardial Effusion Identified
Other Findings: None
Performed by ED Physician (me)
CARDIO

Limited Transthoracic Echocardiogram (TTE)
Limited Diagnostic Exam: Cardiac (TTE)
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: ***
Pericardium: No effusion noted
Left Ventricular Function: Grossly normal EF by EPSS and global function
RV size: RV size is grossly normal
Other Findings: none
Comments: No pathology noted.
AORTA

Limited Retroperitoneal Ultrasound Exam: Abdominal Aorta
Limited Diagnostic Exam: Retroperitoneal
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: ***
Transverse view of proximal abdominal aorta measures < 3 cm
Transverse view of distal abdominal aorta measures < 3 cm
Long Axis view of the abdominal aorta: No evidence of fusiform or saccular aneurysm
Other findings: No abdominal aortic pathology noted
Comments: none
LUNG

Limited Diagnostic Exam: Limited Chest
76604-26
Patient Identity confirmed: Yes
Indication for exam: SOB
Right Lung Sliding: Present
Right Lung B-Lines: No B-Lines noted
Right Pleural Free Fluid: No free fluid noted
Left Lung Sliding: Present
Left Lung B-Lines: No B-Lines noted
Left Pleural Free Fluid: No free fluid noted
Additional Findings: none
Performed by ED Physician (me)
Peripheral IV

Peripheral Venous Access US Guidance
Limited Diagnostic Exam: Venipuncture requiring physician skill with ultrasound guidance
Performed by: ED Physician (me)
Patient Identity confirmed: Yes
Risks, benefits and alternatives were discussed
Consent obtained verbally
Indication for Exam: Vascular Access
Vein/Location: ***
Normal Compressibility and Visualized Patency
Catheter Size: 20 g
Number of Attempts: 1
Successful Catheter Insertion: yes
Complications: none
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Soft Tissue

Limited Soft Tissue Ultrasound
Limited Diagnostic Exam: Soft Tissue
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: ***
Location: ***
Findings: ***
Ocular US

Ocular Ultrasound
Limited Diagnostic Exam: Ocular
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: ***
Right Eye: anatomy identified, no pathology noted
Right Retinal Contour: no abnormalities noted, normal contour
Right Lens: Lens in normal position
Right vitreous body: clear vitreous body, no abnormalities noted
Right optic nerve sheath diameter (mm): less than 5.5mm
Right Ocular Foreign Body: none noted
Left Eye: anatomy identified, no pathology noted
Left Retinal Contour: no abnormalities noted, normal contour
Left Lens: Lens in normal position
Left vitreous body: clear vitreous body, no abnormalities noted
Left optic nerve sheath diameter (mm): less than 5.5mm
Left Ocular Foreign Body: none noted
Comments: none
Bladder

Limited Diagnostic Exam: Bladder
Patient Identity confirmed: Yes
Performed by ED Physician (me)
Indication for Exam: Post Void Residual Volume
Bladder Volume: *** ml
Comments: ***

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