Medical note contents

P-Plan
Continue tx ___min #x/wk for # wks to work on ____________(skills/activities/intervention) for _____ (goal/occupations).

Referrals and Recommendations
OR Discharge plan

MDM
Differential diagnosis includes: ***.
Abdominal exam without peritoneal signs. No evidence of [[Acute Abdomen]] at this time. Well appearing. Low suspicion for acute hepatobiliary disease (includng [[Acute Cholecystitis]]), [[Acute Pancreatitis]], PUD (including perforation), acute infectious processes (pneumonia, [[Hepatitis]], [[Pyelonephritis]]), [[Acute Appendicitis]], vascular catastrophe, bowel obstruction or viscus perforation. Presentation not consistent with other acute, emergent causes of [[Abdominal Pain]] at this time.
Plan: labs, UA, CT AP***, [[Pain Control]], serial reassessment
January 3, 2018 Tagged [[Abdominal Pain]]](https://natedotphrase.com/tag/abdominal-pain/), MDM Leave a comment