MDM Master List BB

[checkbox memo="Ddx abd pain LLQ" name="BA" value=""][conditional field="BA" condition="(BA).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes diverticulitis, perforation, abscess, colitis, IBD, GU pathology, among others."][/conditional][checkbox memo="Ddx abd pain lower female " name="D" value=""][conditional field="D" condition="(D).is('')"][textarea cols=80 rows=5 default="Differential diagnosis entertained was broad with potential high acuity and includes appendicitis, diverticulitis, ectopic pregnancy, ovarian torsion, hemorrhagic ovarian cyst, kidney stone, UTI, small bowel obstruction, volvulus, AAA, pancreatitis, among others. Considering pt’s lack of risk factors for AAA, normal dorsalis pedis pulses, no radiation of pain to the back, and no pulsatile mass felt on exam, the patient's profile was overall low risk for AAA and definitive workup was not pursued. Pt has no significant risk factors for PID, such as multiple sexual partners, history of STDs, vaginal discharge, or any cervical motion tenderness. Pregnancy test is negative, ruling out ectopic pregnancy. Presentation is not consistent with ovarian torsion or hemorrhagic ovarian cyst, pain was not sudden onset, not associated with vomiting, and has no significant tenderness on exam. The patient denies any bloody stool and has no pain out of proportion to exam, and no significant risk factors for mesenteric ischemia such as atrial fibrillation or severe PAD/PVD (peripheral arterial / vascular disease), thus definitive workup to rule out mesenteric ischemia was not pursued. "][/conditional][checkbox memo="ddx abd pain lower male" name="G" value=""][conditional field="G" condition="(G).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes appendicitis, diverticulitis, testicular torsion, kidney stone, small bowel obstruction, volvulus, AAA, pancreatitis, among others. The patient has no significant risk factors for AAA (abdominal aortic aneurysm) such as age over 50 with history of hypertension, connective tissue disorder, or 1st degree relative with AAA. In addition, the patient has normal dorsalis pedis pulses, no radiation of pain to the back, and no pulsatile mass felt on exam. The patient's profile was overall low risk for AAA and definitive workup was not pursued. The patient's presentation is not consistent with testicular torsion. The patient denies any testicular pain, pain was not sudden onset or associated with vomiting. Testicular exam is normal without any evidence of torsion. The patient denies any bloody stool and has no pain out of proportion to exam, and no significant risk factors for mesenteric ischemia such as atrial fibrillation or severe PAD/PVD (peripheral arterial / vascular disease), thus definitive workup to rule out mesenteric ischemia was not pursued."][/conditional][checkbox memo="ddx abd pain rlq" name="H" value=""][conditional field="H" condition="(H).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes appendicitis, mesenteric adenitis, obstruction/volvulus, crohn's disease, gastroenteritis, UTI/pyelo, kidney stone, GU pathology, among others."][/conditional][checkbox memo="ddx abd pain ruq" name="I" value=""][conditional field="I" condition="(I).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cholecystitis, cholelithiasis, biliary obstruction, hepatitis, pancreatitis, obstruction, GERD/PUD, gastroparesis, dehydration."][/conditional][checkbox memo="ddx abd pain upper" name="J" value=""][conditional field="J" condition="(J).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cholecystitis, choledocholithiasis, hepatitis, small bowel obstruction, volvulus,AAA, atypical appendicitis, pancreatitis, gastritis, peptic ulcer disease, among others."][/conditional] [checkbox memo="ddx ams / weakness" name="K" value=""][conditional field="K" condition="(K).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes infection/sepsis, dehydration, anemia, renal failure, electrolyte abnormality, endocrine abnormalities, rheumatologic disorders, tox, neurologic disease."][/conditional] [checkbox memo="ddx asthma" name="L" value=""][conditional field="L" condition="(L).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes asthma/copd, ptx, pneumomediastinum, pneumonia, pleural effusions, bronchitis, restrictive lung disease."][/conditional][checkbox memo="ddx back pain" name="M" value=""][conditional field="M" condition="(M).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes most likely musculoskeletal pain, muscle spasm / sprain, spinal stenosis, vertebral fracture, spinal epidural abscess, spinal epidural hematoma, pyelonephritis, kidney stone, AAA, aortic dissection among others."][/conditional][checkbox memo="ddx bronchitis" name="N" value=""][conditional field="N" condition="(N).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes influenza like illness, bronchitis, pneumonia, dehydration, pharyngitis."][/conditional][checkbox memo="ddx cough/wheezing" name="P" value=""][conditional field="P" condition="(P).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes pneumonia, pleural effusions, ptx, bronchospasm, restrictive lung disease, PE, CHF, pericardial effusion, atypical ACS"][/conditional] [checkbox memo="Ddx Chest Pain" name="A" value=""][conditional field="A" condition="(A).is('')"][textarea cols=80 rows=5 default="Differential includes acute coronary syndrome, pulmonary embolism, pneumonia, aortic dissection, pericardial tamponade, musculoskeletal chest pain, among others. EKG, chest xray and cardiac workup obtained. Final disposition pending results of tests and pt's ED course."][/conditional] [checkbox memo="ddx dysuria female" name="Q" value=""][conditional field="Q" condition="(Q).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cystitis, pyelonephritis, ureterolithiasis, PID/TOA, vaginitis, among others."][/conditional] [checkbox memo="ddx dysuria male" name="R" value=""][conditional field="R" condition="(R).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cystitis, pyelonephritis, ureterolithiasis, prostatitis, urethritis, among others."][/conditional] [checkbox memo="ddx extremity injury / joint pain" name="S" value=""][conditional field="S" condition="(S).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes fracture, dislocation, ligamentous rupture, sprain/strain, contusion/hematoma."][/conditional] [checkbox memo="ddx flank pain left" name="T" value=""][conditional field="T" condition="(T).is('')"][textarea cols=80 rows=5 default="Differential diagnosis kidney stone, pyelonephritis, cystitis, pancreatitis, diverticulitis, colitis, aortic dissection, AAA among others."][/conditional] [checkbox memo="ddx flank pain right" name="U" value=""][conditional field="U" condition="(U).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes cystitis, pyelonephritis, ureterolithiasis, prostatitis, urethritis, aortic dissection, AAA among others."][/conditional] [checkbox memo="ddx general admit" name="V" value=""][conditional field="V" condition="(V).is('')"][textarea cols=80 rows=5 default="The patient's presentation appears most consistent with a diagnosis of ******"][/conditional] [checkbox memo="ddx gi bleed lower" name="X" value=""][conditional field="X" condition="(X).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes lower GI bleeding from diverticulosis, arteriovenous malformation, colon cancer, colonic polyps, mesenteric ischemia, hemorrhoids, varices, anal fissures, among others."][/conditional] [checkbox memo="ddx gi bleed upper" name="Y" value=""][conditional field="Y" condition="(Y).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes upper GI bleed from bleeding peptic ulcer, bleeding duodenal ulcer, gastritis, esophageal varices, gastric varices, among others."][/conditional] [checkbox memo="ddx headache" name="Z" value=""][conditional field="Z" condition="(Z).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes primary headache, ICH, central venous sinus thrombosis, meningitis/encephalitis, sinusitis, tumor, and temporal arteritis, among others."][/conditional] [checkbox memo="ddx hyperglycemia / dka" name="AA" value=""][conditional field="AA" condition="(AA).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes DKA, HHNKC, hyperglycemia w/o other complication, dehydration, medication/dietary noncompliance, infectious process, renal failure, electrolyte abnormalities, AKA, uremia, starvation ketosis."][/conditional] [checkbox memo="ddx lightheaded/syncope" name="AB" value=""][conditional field="AB" condition="(AB).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes vasovagal, dehydration, arrhythmia, structural cardiac disease, heart failure, autonomic dysfxn, anemia, seizure, metabolic disorders."][/conditional] [checkbox memo="ddx missed dialysis" name="AC" value=""][conditional field="AC" condition="(AC).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes hyperkalemia, arrhythmia, acidosis, fluid overload, uremia."][/conditional] [checkbox memo="ddx psychiatric" name="AD" value=""][conditional field="AD" condition="(AD).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes suicidal ideation, primary psychiatric disorder such as depression/schizophrenia/bipolar disorder, supratherapeutic ingestion of RX or OTC meds, intoxication, substance induced mood disorder."][/conditional] [checkbox memo="ddx sepsis" name="AE" value=""][conditional field="AE" condition="(AE).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes sepsis/severe sepsis/septic shock,meningitis, UTI, pneumonia, cellulitis, endocarditis, gastroenteritis, emergent abdominal infection, among others."][/conditional] [checkbox memo="ddx vag bleed" name="AF" value=""][conditional field="AF" condition="(AF).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes pregnancy, dysfunctional uterine bleeding, fibroids, cervical/endometrial polyps, vaginal/cervical trauma, cervicitis, coagulopathy, symptomatic anemia."][/conditional] [checkbox memo="ddx vag bleed pregnant" name="AG" value=""][conditional field="AG" condition="(AG).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes threatened abortion, complete abortion, incomplete abortion, inevitable abortion, fetal demise, septic abortion, ectopic pregnancy, molar pregnancy, placental abruption, placental previa, vasa previa, cervicitis, bleeding disorders."][/conditional] [checkbox memo="ddx vague neuro sx" name="AH" value=""][conditional field="AH" condition="(AH).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes ICH, ischemic stroke, TIA, hypoglycemia, seizure or Todd's paralysis, neoplasm, MS, meningitis/encephalitis, intracranial abscess, complicated migraine."][/conditional] [checkbox memo="ddx vertigo" name="AI" value=""][conditional field="AI" condition="(AI).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes BPPV, vestibular neuritis, acute labyrinthitis, meniere's disease, acoustic neuroma, ototoxic drugs, vertebrobasilar insufficiency, cerebellar infarct/hemorrhage, MS, hypertensive encephalopathy."][/conditional]

[checkbox memo="ED Course" name="AZ" value=""][conditional field="AZ" condition="(AZ).is('')"][textarea cols=80 rows=5 default=""][/conditional]
 
[checkbox memo="MDM ABD PAIN W/ IMAGING + LABS" name="1" value=""][conditional field="1" condition="(1).is('')"][textarea cols=80 rows=5 default="The patient had * ordered to evaluate for an emergent etiology related to the abdomen. Over the course of their emergency department stay, serial abdominal exams were performed. The patient's abdominal imaging did not show any evidence of any emergent process or condition requiring immediate surgery. The patient's labs and serial abdominal exams were reassuring, without any peritoneal signs, and without any obvious source of the patient's symptoms. The patient's symptoms significantly improved, exam upon discharge revealed a benign abdomen, and tolerating oral fluids. The patient appears stable for discharge to follow up with their primary medical doctor in 1-2 days, and understand to return to the ED immediately if symptoms change or worsen. "][/conditional][checkbox memo="MDM ABD PAIN W/O IMAGING + LABS" name="2" value=""][conditional field="2" condition="(2).is('')"][textarea cols=80 rows=5 default="The patient's current symptoms and exam do not appear to be from an emergent process or condition requiring immediate surgery. Although I considered abdominal imaging, given the patient's benign exam, the patient's presentation does not warrant urgent / immediate imaging. At this time, the risk of CT scan and associated radiation likely outweigh the benefits, and thus CT imaging was deferred. The patient also had labs drawn. Results were reassuring, without any identified dangerous source of the patient's symptoms. The patient's symptoms significantly improved, exam upon discharge revealed a benign abdomen without any surgical or peritoneal signs , and tolerating oral fluids. The patient appears stable for discharge with abdominal recheck in 24 hours, and understand to return to the ED immediately if symptoms change or worsen."][/conditional][checkbox memo="MDM ALLERGIC REACTION" name="3" value=""][conditional field="3" condition="(3).is('')"][textarea cols=80 rows=5 default="Pt appears to have an allergic reaction. Pt reported sx consistent with possible angioedema earlier however, the airway is patent and intact and does not appear involved currently. Epinephrine deferred. The patient denies any difficulty breathing. The patient is tolerating po without any difficulty. The symptoms are not worsening and appear resolved. The patient looks great, the findings are minimal and due to nonprogression of symptoms here and loading of antihistamine and steroid medications in the ED, the patient is safe to discharge home. The patient feels comfortable with plan and will return immediately if symptoms begin to worsen. No visible rash or urticaria. The patient is to continue histamine 1 and 2 blockade as well as steroids. The patient was instructed to avoid potential precipitating factor and to follow up with their regular physician and or follow up."][/conditional][checkbox memo="Ddx MDM ANXIETY" name="4" value=""][conditional field="4" condition="(4).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes anxiety attack, generalized anxiety disorder, stress reaction, acute psychiatric break, drug abuse, drug intoxication, drug overdose, among others. The patient denies any suicide attempt, overdose, or ingestion. They exhibit no signs of any severe toxic syndrome or drug / alcohol withdrawal. The patient was observed for a period of time in the ED with serial exams. After serial exams in the emergency department, the patient remains sober and without any suicidal ideation, homicidal ideation or evidence of grave disability.They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. The patient's presentation seems to be consistent with anxiety, without any  evidence of dangerous arrhythmias, thyrotoxicosis, metabolic / endocrinologic emergency, or indication for emergency psychiatric evaluation. The patient appears to be stable for dc home and follow with psychiatry as an outpatient."][/conditional][checkbox memo="MDM ASTHMA ADMIT" name="5" value=""][conditional field="5" condition="(5).is('')"][textarea cols=80 rows=5 default="The patient's presentation seems most consistent with an asthma exacerbation given their wheezing on exam with a history of asthma. Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments. Although the patient has had some minimal improvement in their symptoms, they still have persistent severe dyspnea and their symptoms are unlikely to resolve with typical outpatient therapy so the patient will be admitted for further intensive serial treatments with bronchodilators and close observation.<br><br>"][/conditional][checkbox memo="MDM ASTHMA DC HOME W/ X-RAY" name="6" value=""][conditional field="6" condition="(6).is('')"][textarea cols=80 rows=5 default="The patient's presentation seems most consistent with an asthma exacerbation given their wheezing on exam with a history of asthma. Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.   The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids, as well as a refill of their inhaler if needed.<br><br>"][/conditional][checkbox memo="MDM ASTHMA DC HOME W/O X-RAY" name="7" value=""][conditional field="7" condition="(7).is('')"][textarea cols=80 rows=5 default="The patient's presentation seems most consistent with an asthma exacerbation given their wheezing on exam with a history of asthma. The patient had wheezing symmetrically on exam, without any rales, fever, hypoxic, productive cough, or evidence of peripheral edema. Chest Xray was not ordered given that pneumonia, pneumothorax, pulmonary edema appear to be extremely unlikely. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.<br><br>The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids, as well as a refill of their inhaler if needed.<br><br>"][/conditional][checkbox memo="MDM BACK PAIN" name="8" value=""][conditional field="8" condition="(8).is('')"][textarea cols=80 rows=5 default="The patient has normal dorsalis pedis pulses, and no pulsatile mass felt on exam. The patient's profile was overall low risk for AAA and definitive workup was not pursued. The patient has no significant red flags on history or exam. Patient has no history of malignancy, active or distant history. Patient has no fever or midline tenderness making epidural abscess or fracture unlikely.  Patient has no vertebral deformity or midline tenderness and has a normal gait. No mechanism for significant trauma. Presentation not consistent with a vertebral fracture, so definitive imaging not pursued.<br><br>Patient has no significant risk factors for spinal epidural emergency such as fever, IVDU, HIV, or anticoagulant use. Patient is neurologically intact without any lower extremity weakness / numbness, saddle anesthesia, urinary retention or fecal incontinence. No evidence of any emergent process of the spinal cord or cauda equina at this time.<br><br>No sx of UTI and no CVAT/fever and history is not suggestive of kidney stone.<br><br>The patient's symptoms appear consistent with a musculoskeletal origin. Given morphine and flexeril with relief. Remains neuro intact, appears stable for dc home.<br><br>The patient was counseled and understand that they need to see their primary medical doctor in the next 1-2 days for reevaluation and further treatment, and to return immediately if symptoms change or worsen. Pt agrees with plan.<br><br>"][/conditional][checkbox memo="MDM BACK PAIN MSK BRIEF" name="9" value=""][conditional field="9" condition="(9).is('')"][textarea cols=80 rows=5 default="Patient likely with MSK back pain, will treat with gentle exercise and stretching, heat, NSAIDs, short course of norco, and have f/u with PMD. Given strict return precautions.<br><br>Doubt spinal epidural abscess / hematoma, as no risk factors, afebrile.<br><br>Doubt fracture as no steroid use, no recent trauma, and age <70.<br><br>Doubt cauda equina as no urinary retention and no neuro deficits.<br><br>No hx of cancer to suggest metastatic lesions. "][/conditional][checkbox memo="MDM BRONCHITIS, Neg xray" name="10" value=""][conditional field="10" condition="(10).is('')"][textarea cols=80 rows=5 default="Likely bronchitis given duration less than 3 weeks, absence of chronic lung disease, normal vital signs, and no abnormalities on pulmonary examination or imaging. Antibiotics not indicated at this time. Return precautions given and patient to follow up with pmd."][/conditional][checkbox memo="MDM CHEST PAIN ADMIT" name="11" value=""][conditional field="11" condition="(11).is('')"][textarea cols=80 rows=5 default="EKG shows no evidence of STEMI, and initial troponin is negative, however given patient's presentation and risk factors, patient will be admitted for serial troponins and risk stratification and evaluation for likely stress testing.     Aspirin given. However, given that chest pain is currently resolved, risks likely outweigh benefits of IV heparin at this time, so deferred."][/conditional][checkbox memo="Ddx/MDM CHEST PAIN ATYPICAL home" name="12" value=""][conditional field="12" condition="(12).is('')"][textarea cols=80 rows=5 default="Differential includes acute coronary syndrome, pulmonary embolism, pneumonia, aortic dissection, pericardial tamponade, musculoskeletal chest pain, among others.<br><br>Acute coronary syndrome is unlikely and the patient is low risk, pain is atypical, nonexertional, and troponin is negative with over 6 hrs of symptoms. EKG without any obvious signs of ischemia. The pain is not classic for pericarditis or myocarditis, and the patient has no significant risk factors for a pericardial effusion and has stable vitals signs, unlikely to have tamponade. Chest xray shows no evidence of pneumothorax, pneumonia, or significant pleural effusion. Pain is not likely to be pulmonary embolism (PERC negative), and no significant PE risk factors. The patient has no significant risk factors for aortic dissection, no history of connective tissue disorder, and the patient's pain is not severe, radiating to the back, or tearing in nature. They have normal bilateral radial and pedal pulses. Currently well appearing with stable vitals.<br><br>Initial plan: patient observed for several hours in the ED, ECG with no emergent findings, patient discharged with no dangerous vital signs, patient instructed to follow up with PMD in the next 1-2 days to be referred for a treadmill stress test within the next 48-72 hours. Upon calculating the patient's HEART score, they were found to have a HEART score less than four, which indicates low risk, so the patient can be safely discharged with the understanding that they need to make an appointment with a primary care doctor to be referred for a stress test within the next 48-72 hours, or if they cannot arrange that they are to return to the ED, or sooner than that if they have any changing, persistent, or worsening symptoms.<br><br> "][/conditional][checkbox memo="Ddx/MDM CHEST PAIN MSK (NO TROP)" name="13" value=""][conditional field="13" condition="(13).is('')"][textarea cols=80 rows=5 default="Differential includes acute coronary syndrome, pulmonary embolism, pneumonia, aortic dissection, pericardial tamponade, musculoskeletal chest pain, among others. However, acute coronary syndrome is unlikely and the patient is low risk, pain is atypical, nonexertional. EKG without any obvious signs of ischemia. The pain is not classic for pericarditis or myocarditis, and the patient has no significant risk factors for a pericardial effusion and has stable vitals signs, unlikely to have tamponade. Chest xray shows no evidence of pneumothorax, pneumonia, or significant pleural effusion. Pain is not likely to be pulmonary embolism (PERC negative), and no significant PE risk factors. The patient has no significant risk factors for aortic dissection, no history of connective tissue disorder, and the patient's pain is not severe, radiating to the back, or tearing in nature. They have normal bilateral radial and pedal pulses. Currently well appearing with stable vitals.<br><br>The patient's pain appears consistent with a musculoskeletal origin. Pain is reproducible with palpation.<br><br>Initial plan: Given that the patient's pain appears to clearly be musculoskeletal in nature, and has no significant coronary artery disease risk factors, a troponin was not ordered as part of the workup, since the patient's presentation is not consistent with acute coronary syndrome.<br><br> "][/conditional][checkbox memo="MDM CHF ADMIT,bipap" name="14" value=""][conditional field="14" condition="(14).is('')"][textarea cols=80 rows=5 default="Differential includes CHF, pulmonary edema, pulmonary embolism, pneumonia, pleural effusions, pneumothorax, among others.<br><br>EKG without any obvious signs of ischemia. Chest xray shows no evidence of pneumonia, but does have findings consistent with vascular congestion from CHF. Symptoms are not likely to be due to pulmonary embolism, the patient has no significant PE risk factors and has a more likely alternate cause of their symptoms, given their chest xray findings, lung exam and presentation so workup was deferred and not pursued. The patient appears to be in decompensated CHF in exacerbation and not a suitable candidate for outpatient treatment so will be admitted for inpatient diuresis and further evaluation and treatment.<br><br>I spent ___ minutes of critical care time. This time excludes any separately billable procedures. <br>Treatments/Evaluations: Emergent and rapid respiratory assessment and management with continuous monitoring. Advanced airway equipment at the ready, while the patient's respiratory symptoms were stabilized.<br><br>Given the patient's presentation with CHF requiring BiPAP/ hypoxic respiratory failure, there existed the potential for imminent deterioration in the patient's condition due to respiratory compromise. Organ systems at risk for failure without immediate intervention include pulmonary / respiratory. This time was spent reviewing the patient's records, reviewing vital signs, reassessing the patient's clinical status, discussing the case and care with staff and consultants, and performing high-complexity medical decision making. <br><br>I considered the possibility of intubation, but at this time the patient is protecting their airway and maintaining their saturation on supplemental oxygen so will defer intubation at this time, although they will be closely monitored for any further deterioration.<br>"][/conditional][checkbox memo="MDM CHF DC HOME" name="15" value=""][conditional field="15" condition="(15).is('')"][textarea cols=80 rows=5 default="Differential includes CHF, pulmonary edema, pulmonary embolism, pneumonia, pleural effusions, pneumothorax, among others.<br><br>EKG without any obvious signs of ischemia. Chest xray shows no evidence of pneumonia, but does have findings consistent with mild vascular congestion from CHF. Symptoms are not likely to be due to pulmonary embolism, the patient has no significant PE risk factors and has a more likely alternate cause of their symptoms, given their chest xray findings, lung exam and presentation so workup was deferred and not pursued. The patient appears to be in CHF in exacerbation, which improved with treatment in the ED, appears to be a suitable candidate for outpatient treatment and understands to f/u with PMD in 2-3 days. <br>"][/conditional][checkbox memo="MDM CLOSED HEAD INJURY W/ CT" name="16" value=""][conditional field="16" condition="(16).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes closed head injury, scalp contusion, neck muscle spasm / strain, vs less likely skull fracture, intracranial bleeding, vertebral fracture, spinal cord compression / injury, among others.<br>Given the patient's mechanism, CT scans of the head were immediately obtained and showed no evidence of any emergent findings.<br>The patient is Nexus negative, no indication for imaging of the spine<br>There was no evidence of any wounds that required repair<br>The patient's tetanus status was.<br>Plain films were within normal limits<br>Hips have no tenderness or significant pain with range of motion and the patient is able to ambulate without difficulty, no evidence of hip fracture.<br>The patient is non-toxic, well appearing and significantly improved with observation and serial exams in the emergency department. <br>They are neurologically intact and able to ambulate, no evidence of spinal cord injury. <br>They appear to be stable for discharge home and follow up with their regular doctor in 2-3 days.<br>"][/conditional][checkbox memo="MDM CLOSED HEAD INJURY W/O CT" name="17" value=""][conditional field="17" condition="(17).is('')"][textarea cols=80 rows=5 default=""][/conditional][checkbox memo="MDM COPD ADMIT" name="18" value=""][conditional field="18" condition="(18).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes: COPD exacerbation, pneumonia, bronchitis, pneumothorax, pulmonary embolism, pulmonary edema, CHF, among others.<br><br>The patient's presentation seems most consistent with a COPD exacerbation given their wheezing on exam with a history of COPD . Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments. Although the patient has had some minimal improvement in their symptoms, they still have persistent severe dyspnea and their symptoms are unlikely to resolve with typical outpatient therapy so the patient will be admitted for further intensive serial treatments with bronchodilators and close observation.<br>"][/conditional][checkbox memo="MDM COPD DC HOME W/ X-RAY" name="19" value=""][conditional field="19" condition="(19).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes: COPD exacerbation, pneumonia, bronchitis, pneumothorax, pulmonary embolism, pulmonary edema, CHF, among others.<br><br>The patient's presentation seems most consistent with a COPD exacerbation given their wheezing on exam with a history of COPD . Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.<br><br>Given the patient's productive cough, and change in the color/amount of sputum, empiric antibiotics are indicated and were prescribed.<br><br>The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids, as well as a refill of their inhaler if needed. <br> <br>"][/conditional][checkbox memo="MDM COPD DC HOME W/O X-RAY" name="20" value=""][conditional field="20" condition="(20).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes: COPD exacerbation, pneumonia, bronchitis, pneumothorax, pulmonary embolism, pulmonary edema, CHF, among others. <br> <br>The patient's presentation seems most consistent with a COPD exacerbation given their wheezing on exam with a history of COPD . The patient had wheezing symmetrically on exam, without any rales, fever, hypoxic, productive cough, or evidence of peripheral edema. Chest Xray was not ordered given that pneumonia, pneumothorax, pulmonary edema appear to be extremely unlikely. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms. <br> <br>Given the patient's productive cough, and change in the color/amount of sputum, empiric antibiotics are indicated and were prescribed. <br> <br>The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids, as well as a refill of their inhaler if needed<br><br>"][/conditional][checkbox memo="MDM CORNEAL ABRASION" name="21" value=""][conditional field="21" condition="(21).is('')"][textarea cols=80 rows=5 default="Differential includes conjunctivitis, glaucoma, corneal abrasion, corneal ulceration, foreign body, among others. <br> <br>Patient's presentation c/w corneal abrasion. <br>No evidence of foreign body by history or exam. <br>No evidence of corneal ulceration as well. <br>There is no evidence of iritis, glaucoma, preseptal cellulitis, periorbital or orbital cellulitis. <br>Will place patient on polytrim for prophylaxis of infection in corneal abrasion.This was discussed with the patient. <br>The patient was also instructed to stop wearing all contacts and use their prescription eyeglasses. <br>The patient was instructed to follow up with their ophthalmologist or return here if worsened, increased pain, decreased vision, swelling around the eye or as needed. The patient agreed with plan<br><br>"][/conditional][checkbox memo="MDM DIARRHEA" name="22" value=""][conditional field="22" condition="(22).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes viral gastroenteritis, bacterial gastroenteritis, norovirus, Clostridium difficile infection, hemolytic uremic syndrome, food poisoning, colitis (infectious, ischemic, inflammatory), Celiac disease, dehydration, among others. <br> <br>On exam, the patient's abdomen is benign, no e/o abdominal surgical emergency. Patient appears well hydrated. The stool is watery, nonbloody, without any evidence of GI bleed. No significant risk factors for mesenteric ischemia, patient without any pain out of proportion or bloody stool. <br>The patient has no significant risk factors for Clostridium difficile infection, no recent antibiotics use, hospitalization, or bloody stool. <br> <br>The patient's current symptoms and exam do not appear to be from an emergent process or condition requiring immediate surgery. Although I considered abdominal imaging, given the patient's benign exam, the patient's presentation does not warrant urgent / immediate imaging. At this time, the risk of CT scan and associated radiation likely outweigh the benefits, and thus CT imaging was deferred. The patient's symptoms significantly improved, exam upon discharge revealed a benign abdomen without any surgical or peritoneal signs, and patient tolerating oral fluids. The patient appears stable for discharge with abdominal recheck in 24 hours, and understand to return to the ED immediately if symptoms change or worsen<br><br>"][/conditional][checkbox memo="MDM DIZZY ADMIT" name="23" value=""][conditional field="23" condition="(23).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's symptoms include causes of peripheral vertigo (including BPPV, vestibular neuritis, Meniere's disease, viral labyrinthitis), causes of central vertigo (including cerebellar ischemic stroke, hemorrhagic stroke, acoustic neuroma, vertebrobasilar insufficiency), malignant arrhythmias, obstructive heart disease (critical aortic stenosis, hypertrophic cardiomyopathy), acute anemia, severe dehydration, electrolyte abnormalities, among others. <br> <br>The patient denies any external blood loss and has no significant pallor or evidence of acute anemia as a cause of their symptoms. Hemoglobin is not severely low, and acute blood transfusion is not indicated. EKG shows no signs of malignant arrhythmia such as Brugada syndrome, delta wave, significant heart block, or QTc >500. In addition, the patient has no loud murmur or evidence of significant obstructive heart disease, symptoms are not in the setting of exertion. Labs show no severe electrolyte derangement such as severe hyponatremia, hypokalemia, acidosis, or hypoglycemia. The patient is neurologically intact, with normal cerebellar exam, without any evidence of central vertigo as a cause of their symptoms. They appear well hydrated without any evidence of severe dehydration or acute hypovolemia. <br> <br>However, given the patient's risk factors, the patient would benefit from admission to observation for continuous cardiac monitoring, given the possibility of cardiac syncope<br><br>"][/conditional][checkbox memo="MDM DIZZY DC HOME" name="24" value=""][conditional field="24" condition="(24).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's symptoms include causes of peripheral vertigo (including BPPV, vestibular neuritis, Meniere's disease, viral labyrinthitis), causes of central vertigo (including cerebellar ischemic stroke, hemorrhagic stroke, acoustic neuroma, vertebrobasilar insufficiency), malignant arrhythmias, obstructive heart disease (critical aortic stenosis, hypertrophic cardiomyopathy), acute anemia, severe dehydration, electrolyte abnormalities, among others. <br> <br>The patient denies any external blood loss and has no significant pallor or evidence of acute anemia as a cause of their symptoms. Hemoglobin is not severely low, and acute blood transfusion is not indicated. EKG shows no signs of malignant arrhythmia such as Brugada syndrome, delta wave, significant heart block, or QTc >500. In addition, the patient has no loud murmur or evidence of significant obstructive heart disease, symptoms are not in the setting of exertion. Labs show no severe electrolyte derangement such as severe hyponatremia, hypokalemia, acidosis, or hypoglycemia. The patient is neurologically intact, with normal cerebellar exam, without any evidence of central vertigo as a cause of their symptoms. They appear well hydrated without any evidence of severe dehydration or acute hypovolemia. <br> <br>The patient was observed for a period of time, with symptoms improved, and no emergent cause of their symptoms. The patient appears stable for discharge and to follow up with their regular doctor<br><br>"][/conditional][checkbox memo="MDM DVT" name="25" value=""][conditional field="25" condition="(25).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes DVT, musculoskeletal pain, without evidence of fracture, dislocation, soft tissue infection such as cellulitis or abscess, necrotizing fasciitis, compartment syndrome, septic arthritis, arterial occlusion, among others. <br> <br>Distally the patient has capillary refill <2 seconds and strong pulses. There is no pallor or pain out of proportion to exam. No evidence of arterial occlusion The associated joints have full range of motion without any significant pain or restriction in mobility. There is no crepitus or pain out of proportion to exam and the patient is afebrile and nontoxic. There is no overlying redness, induration, tenderness, pus, or evidence of drainable fluid collection. No evidence of septic arthritis, necrotizing fasciitis, or soft tissue infection such as abscess or cellulitis. compartments are soft, the patient is able to bear weight and has no neurologic deficits. No evidence of fracture, dislocation or compartment syndrome at this time. There is no swelling so vascular US to evaluate for DVT was obatined which did reveal an acute DVT of the L leg. The patient was prescribed Lovenox 1mg/kg SQ BID x 1 week, and given the 1st dose here and taught how to self administer. They understand to f/u with their PMD tomorrow to be transitioned to oral anticoagulation, and understands to return immediately to the ER if they are about to run out of Lovenox and have not been able to see the PMD<br><br>"][/conditional][checkbox memo="MDM ETOH INTOX W/ CT/LABS" name="26" value=""][conditional field="26" condition="(26).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes alcohol intoxication, alcohol withdrawal, hypoglycemia, drug intoxication or overdose, head injury, epidural hematoma, subdural hematoma, among others. <br> <br>Upon arrival the patient's fingerstick glucose was normal with no evidence of hypoglycemia. Because of the patient's symptoms imaging of the brain / spine was obtained to rule out intracranial bleeding and / or vertebral fractures although the patient does not currently exhibit any focal neurologic deficits. The patient has no significant tremors or tachycardia, and their presentation seems most consistent with alcohol intoxication without withdrawal. The patient will be observed in the emergency department with serial neurologic exams for improvement in their mental status. <br> <br>After serial neurologic exams in the emergency department, the patient's mental status significantly improved. The patient was able to follow commands and is clinically sober. Imaging did not reveal any acute findings, and the patient is now able to fully participate in the neurologic exam. They are fully alert oriented and conversant have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. The patient's presentation seems to be consistent with alcohol intoxication, which has resolved, without any complications such as alcohol withdrawal, GI bleeding, or intracranial bleeding. Lab results were reassuring with no evidence of significant metabolic derangement. The patient appears to be safe for discharge home. Patient understands not to drive and appears able to care for themselves<br><br>"][/conditional][checkbox memo="MDM ETOH INTOX W/O CT/LABS" name="27" value=""][conditional field="27" condition="(27).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes alcohol intoxication, alcohol withdrawal, hypoglycemia, drug intoxication or overdose, head injury, among others. Upon arrival the patient's fingerstick glucose was normal with no evidence of hypoglycemia. <br> <br>The patient has no evidence of injury or tenderness of the head or neck, thus immediate imaging of the brain and spine was not felt to be necessary. The patient has no significant tremors or tachycardia, and their presentation seems most consistent with alcohol intoxication without withdrawal. The patient will be observed in the emergency department with serial neurologic exams for improvement in their mental status. <br> <br>After serial neurologic exams in the emergency department, the patient's mental status significantly improved. The patient was able to follow commands and is clinically sober. They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. The patient's presentation seems to be consistent with alcohol intoxication, which has resolved, without any complications such as alcohol withdrawal, head injury, GI bleeding, or intracranial bleeding. The patient appears to be safe for discharge home. Patient understands not to drive and appears able to care for themselves<br><br>"][/conditional][checkbox memo="MDM ETOH WITHDRAWAL ADMIT" name="28" value=""][conditional field="28" condition="(28).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes alcohol intoxication, alcohol withdrawal, hypoglycemia, drug intoxication or overdose, head injury, among others. Upon arrival the patient's fingerstick glucose was normal with no evidence of hypoglycemia. <br> <br>The patient has no evidence of injury or tenderness of the head or neck, thus immediate imaging of the brain and spine was not felt to be necessary. The patient had tremors and tachycardia, and their presentation seems most consistent with alcohol withdrawal. The patient was given Ativan and will be observed in the emergency department with serial neurologic exams for improvement in their mental status. The patient's presentation seems to be consistent with alcohol withdrawal,, without any complications such as alcohol intoxication, head injury, GI bleeding, or intracranial bleeding. <br> <br>After serial neurologic exams in the emergency department, the patient improved but still has evidence of persistent alcohol withdrawal requiring admission to prevent delirium tremens<br><br>"][/conditional][checkbox memo="MDM ETOH WITHDRAWAL DC HOME" name="29" value=""][conditional field="29" condition="(29).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes alcohol intoxication, alcohol withdrawal, hypoglycemia, drug intoxication or overdose, head injury, among others. Upon arrival the patient's fingerstick glucose was normal with no evidence of hypoglycemia. <br> <br>The patient has no evidence of injury or tenderness of the head or neck, thus immediate imaging of the brain and spine was not felt to be necessary. The patient had mild tremors and tachycardia, and their presentation seems most consistent with mild alcohol withdrawal. The patient was given Ativan and will be observed in the emergency department with serial neurologic exams for improvement in their mental status. <br> <br>After serial neurologic exams in the emergency department, the patient significantly improved. The patient's tachycardia and tremor have resolved. They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. The patient's presentation seems to be consistent with mild alcohol withdrawal, which has resolved, without any complications such as alcohol intoxication, head injury, GI bleeding or intracranial bleeding. The patient appears to be safe for discharge home. Patient understands not to drive and appears able to care for themselves<br><br>"][/conditional][checkbox memo="MDM EXTREMITY INJURY" name="30" value=""][conditional field="30" condition="(30).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes musculoskeletal pain, fracture, dislocation, compartment syndrome, arterial occlusion, nerve damage, among others. <br> <br>Distally the patient has capillary refill <2 seconds and strong pulses. There is no pallor or pain out of proportion to exam. There is no significant swelling, deformity, or report of significant dislocation that subsequently reduced.. No evidence of arterial occlusion or injury. The associated joints have full range of motion without any significant pain or restriction in mobility. No evidence at this time of major ligamentous disruption. <br> <br>Xrays of the __ are within normal limits, compartments are soft, the patient is able to bear weight and has no neurologic deficits. No evidence of fracture, dislocation, foreign body, significant nerve damage, compartment syndrome at this time. <br> <br>However, the patient was informed that occult fractures or foreign bodies are not always apparent on their first visit and understand to follow up with their regular doctor for a reevaluation within the next 2-3 days, to ensure their symptoms completely resolve<br><br>"][/conditional][checkbox memo="MDM EXTREMITY PAIN" name="31" value=""][conditional field="31" condition="(31).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes musculoskeletal pain, fracture, dislocation, soft tissue infection such as cellulitis or abscess, necrotizing fasciitis, compartment syndrome, septic arthritis, arterial occlusion, deep venous thrombosis, among others. <br> <br>Distally the patient has capillary refill <2 seconds and strong pulses. There is no pallor or pain out of proportion to exam. There is no significant swelling or venous engorgement. The patient has no significant DVT risk factors or known hypercoagulable disorder. No evidence of arterial occlusion or deep venous thrombosis. <br> <br>The associated joints have full range of motion without any significant pain or restriction in mobility. There is no crepitus or pain out of proportion to exam and the patient is afebrile and nontoxic. There is no overlying redness, induration, tenderness, pus, or evidence of drainable fluid collection. No evidence of septic arthritis, necrotizing fasciitis, or soft tissue infection such as abscess or cellulitis. <br> <br>Xrays of the __ are within normal limits, compartments are soft, the patient is able to bear weight and has no neurologic deficits. No evidence of fracture, dislocation or compartment syndrome at this time. <br> <br>However, the patient was informed that occult fractures or foreign bodies are not always apparent on their first visit and understand to follow up with their regular doctor for a reevaluation within the next 2-3 days for a reevaluation, to ensure their symptoms completely resolve<br><br>"][/conditional][checkbox memo="MDM FOLEY REPLACEMENT" name="32" value=""][conditional field="32" condition="(32).is('')"][textarea cols=80 rows=5 default="Patient with history of chronic urinary retention and chronic indwelling foley presents with catheter dysfunction, leading to urinary retention and abdominal swelling with discomfort. Differential includes foley dysfunction, UTI, BPH, AKI, among others. Pt was afebrile, nontoxic. No e/o sepsis. Catheter was replaced and drained 2L of clear urine, obstruction relieved.. UA shows no evidence of UTI. Labs shows no evidence of development of renal failure. Patient appears stable for discharge home and understand to f/u with PMD in 1-2 days. Patient will be discharged home with antibiotics<br><br>"][/conditional][checkbox memo="MDM GENERAL WEAKNESS ADMIT" name="33" value=""][conditional field="33" condition="(33).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes dehydration, hypovolemia, electrolyte derangement such as hyponatremia / hypoglycemia, neuromuscular junction disorder such as myasthenia gravis, GI bleed, anemia, UTI, sepsis, among others. <br> <br>The patient feels generally weak but has no focal neurologic deficits, abnormal muscle tone, hypo/hyperreflexia, or fatigability. No evidence of stroke, spinal cord emergency, neuromuscular junction disorder, or multiple sclerosis at this time. <br> <br>Lab results were reassuring without any evidence of severe sepsis, UTI, acute anemia requiring transfusion, or severe metabolic derangement such as significant hyponatremia or severe hypoglycemia. <br> <br>The patient appears well hydrated and has normal vitals, no evidence of significant dehydration / hypovolemia at this time. Although the patient does not have any evidence of an emergent cause of their symptoms, they do appear to be significantly generally weak and deconditioned with failure to thrive. The patient will therefore be admitted for rehabilitation, physical therapy, and potential placement into a facility with increased resources for care given the patient's inability to adequately perform their activities of daily living which would be required to be safely discharged home<br><br>"][/conditional][checkbox memo="MDM GENERAL WEAKNESS DC HOME" name="34" value=""][conditional field="34" condition="(34).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes dehydration, hypovolemia, electrolyte derangement such as hyponatremia / hypoglycemia, neuromuscular junction disorder such as myasthenia gravis, GI bleed, anemia, UTI, sepsis, among others. <br> <br>The patient feels generally weak but has no focal neurologic deficits, abnormal muscle tone, hypo/hyperreflexia, or fatigability. No evidence of stroke, spinal cord emergency, neuromuscular junction disorder, or multiple sclerosis at this time. <br> <br>Lab results were reassuring without any evidence of severe sepsis, UTI, acute anemia requiring transfusion, or severe metabolic derangement such as significant hyponatremia or severe hypoglycemia. <br> <br>The patient appears well hydrated and has normal vitals, no evidence of significant dehydration / hypovolemia at this time. The patient has no evidence of any emergent cause of their symptoms at this time, and appear stable for discharge home and follow up with their regular doctor for reevaluation, further workup, and continued care in 2-3 days<br><br>"][/conditional][checkbox memo="MDM GI BLEED" name="35" value=""][conditional field="35" condition="(35).is('')"][textarea cols=80 rows=5 default="Given the possibility of a bleeding peptic ulcer, Protonix IV was immediately started. Because of __, the patient is at risk for portal hypertension and varices from cirrhosis, so octreotide IV was also started and Ceftriaxone IV also given. <br> <br>Because of __, the patient will immediately be transfused __ units of PRBC, and admitted for further care and management. The patient does not require any emergent anticoagulation reversal at this time point, although it was considered. Gastroenterology on-call, Dr. __ was consulted and will evaluate the patient for endoscopy. <br> <br>The patient is currently hemodynamically stable, and stable for transfer to the floor at this time. <br> <br>Because the patient's hemoglobin is stable, emergent transfusion was not started; however, the patient will need to be admitted for serial hemoglobin checks, and if downtrending, transfusion may be indicated at a later time. <br> <br>Patient is protecting their airway, no active vomiting, no need for NG tube or intubation at this time<br><br>"][/conditional][checkbox memo="MDM HEADACHE W/ CT" name="36" value=""][conditional field="36" condition="(36).is('')"][textarea cols=80 rows=5 default="Differential for the patient's headache includes primary headache (migraine, tension, cluster), subarachnoid hemorrhage, intracranial mass / tumor, meningitis, encephalitis, increased intracranial pressure, mastoiditis, acute sinusitis, dural venous thrombosis, temporal arteritis, acute angle closure glaucoma, among others. <br> <br>Headache not sudden and severe, not worst headache of life, no family hx of SAH, neurologically intact without any persistent vomiting. Not consistent with subarachnoid hemorrhage, dural venous thrombosis, increased intracranial pressure, or significant tumor at this time. <br> <br>Patient without meningismus, mastoid / sinus tenderness, altered mental status or seizure. Doubt subdural abscess, meningitis, encephalitis, mastoiditis. <br> <br>No significant trauma mechanism, not anticoagulated. No evidence of subdural / epidural hematoma. Canadian CT head criteria negative. <br> <br>No temporal tenderness, jaw claudication or vision loss. Eyes are reactive, with normal appearing anterior chambers. No evidence of temporal arteritis or acute angle closure glaucoma. <br> <br>Given the patient's presentation, with new type of headache and vomiting, despite normal neurologic exam, advanced imaging of the head with CT was felt to indicated and was obtained after weighing the risks and benefits of radiation to rule out cause of increased intracranial pressure such as tumor or mass which was negative. CT negative for tumor / mass. remains neuro intact, all sx resolved after compazine / toradol / benadryl. Patient appears stable for discharge home and f/u with PMD<br><br>"][/conditional][checkbox memo="MDM HEADACHE W/O CT" name="37" value=""][conditional field="37" condition="(37).is('')"][textarea cols=80 rows=5 default="Differential for the patient's headache includes primary headache (migraine, tension, cluster), subarachnoid hemorrhage, intracranial mass / tumor, meningitis, encephalitis, increased intracranial pressure, mastoiditis, acute sinusitis, dural venous thrombosis, temporal arteritis, acute angle closure glaucoma, among others. <br> <br>Headache not sudden and severe, not worst headache of life, no family hx of SAH, neurologically intact without any persistent vomiting. Not consistent with subarachnoid hemorrhage, dural venous thrombosis, increased intracranial pressure, or significant tumor at this time. <br> <br>Patient without meningismus, mastoid / sinus tenderness, altered mental status or seizure. Doubt subdural abscess, meningitis, encephalitis, mastoiditis. <br> <br>No significant trauma mechanism, not anticoagulated. No evidence of subdural / epidural hematoma. Canadian CT head criteria negative. <br> <br>No temporal tenderness, jaw claudication or vision loss. Eyes are reactive, with normal appearing anterior chambers. No evidence of temporal arteritis or acute angle closure glaucoma. <br> <br>Given the patient's presentation, and normal neurologic exam, advanced imaging of the head with CT was not felt to be necessary or indicated and not pursued after weighing the risks and benefits of radiation<br><br>"][/conditional][checkbox memo="MDM HYPERKALEMIA" name="38" value=""][conditional field="38" condition="(38).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes Hyperkalemia, arrhythmia, acidosis, fluid overload, uremia, among others.<br><br>Initial Plan: <br>The patient's presentation appears most consistent with a diagnosis of hyperkalemia related to their end stage renal disease.<br><br>They were given Insulin, D50W, Albuterol, Kayexalate, Calcium_Gluconate and will also need emergent dialysis.<br>Currently stable with no malignant arrhythmias or hypotension, but has a critically high potassium<br><br>"][/conditional][checkbox memo="MDM HYPERTENSION W/ LABS" name="39" value=""][conditional field="39" condition="(39).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes essential hypertension, malignant hypertension, hypertensive emergency, end-organ damage (such as renal failure, cardiac ischemia, pulmonary edema, hypertensive encephalopathy, intracranial hemorrhage, among others), medication noncompliance, among others. Alert and oriented, no neuro deficits, no severe headache, no evidence of hypertensive encephalopathy or intracranial bleeding. No volume overload, chest pain, or shortness of breath, no evidence of cardiac ischemia or CHF. On history and exam and labs, the patient exhibits no features of end-organ damage. They have no no chest pain, shortness of breath, or evidence of volume overload. The patient was given a new prescription for amlodipine and appears to be stable for discharge home, and blood pressure recheck with their PMD in 1-2 days as instructed.<br><br>"][/conditional][checkbox memo="MDM HYPERTENSION W/O LABS" name="40" value=""][conditional field="40" condition="(40).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes essential hypertension, malignant hypertension, hypertensive emergency, end-organ damage (such as renal failure, cardiac ischemia, pulmonary edema, hypertensive encephalopathy, intracranial hemorrhage, among others), medication noncompliance, among others. Alert and oriented, no neuro deficits, no severe headache, no evidence of hypertensive encephalopathy or intracranial bleeding. No volume overload, chest pain, or shortness of breath, no evidence of cardiac ischemia or CHF. On history and exam , the patient exhibits no features of end-organ damage. They have no no chest pain, shortness of breath, or evidence of volume overload. The patient was given a new prescription for *amlodipine and appears to be stable for discharge home, and blood pressure recheck with their PMD in 1-2 days as instructed. .<br><br>"][/conditional][checkbox memo="MDM HYPOGLYCEMIA ADMIT" name="41" value=""][conditional field="41" condition="(41).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's hypoglycemia includes relative overdose of the pt's insulin, acute renal failure, poor PO intake, insulin secreting tumor, among others.<br><br>Given that *, the patient will be admitted for further serial blood glucose monitoring, as well as further evaluation and management. <br><br>Patient was fed  *and placed on D5 1/2 NS to prevent further hypoglycemic episodes.<br><br>Because of the patient's altered level of consciousness related to poor glucose control, this may be an area of risk should it recur while the patient is driving. The patient was instructed not to drive until cleared by their doctor and a DMV form was submitted. <br><br>"][/conditional][checkbox memo="MDM HYPOGLYCEMIA DC HOME" name="42" value=""][conditional field="42" condition="(42).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's hypoglycemia include relative overdose of the pt's insulin, acute renal failure, poor PO intake, insulin secreting tumor, among others. Patient had serial blood glucose checks while in the ED, and was fed.<br><br>Serial blood glucose checks remain normal and stable in the ED. Symptoms appear to be from insulin use with poor Po intake, which is now resolved and unlikely to recur now that the patient has received further education regarding his insulin use. Appears stable for discharge home and follow up with their PMD in 2-3 days. <br><br>Because of the patient's altered level of consciousness related to poor glucose control, this may be an area of risk should it recur while the patient is driving. The patient was instructed not to drive until cleared by their doctor and a DMV form was submitted. <br><br>"][/conditional][checkbox memo="MDM METHADONE" name="43" value=""][conditional field="43" condition="(43).is('')"][textarea cols=80 rows=5 default=""][/conditional][checkbox memo="MDM OTITIS MEDIA (NO ABX)" name="44" value=""][conditional field="44" condition="(44).is('')"][textarea cols=80 rows=5 default="Diagnosis includes viral otitis media, bacterial otitis media, otitis externa, mastoiditis, among others. <br>Patient is nontoxic and well appearing. The patient is tolerating fluids and is well hydrated. <br>No evidence of mastoiditis, perforated tympanic membrane or otitis externa on exam.<br>Presentation appears consistent with viral otitis media, no indications for antibiotics.<br>No clinical evidence by history or evaluation to suspect meningitis and/or sepsis. The lung exam is normal with normal respirations and clear lung sounds. I discussed with the diagnosis, plan of care and to follow up with the patient's primary medical doctor within the next 1-2 days. Instructed to return if the patient worsens in anyway, especially if not tolerating fluids, decreased activity, increased irritability or as needed. They agreed with plan. .<br><br>"][/conditional][checkbox memo="MDM OTITIS MEDIA W/ ABX" name="45" value=""][conditional field="45" condition="(45).is('')"][textarea cols=80 rows=5 default="Diagnosis includes viral otitis media, bacterial otitis media, otitis externa, mastoiditis, among others. <br><br>Patient is nontoxic and well appearing. The patient is tolerating fluids and is well hydrated. <br><br>No evidence of mastoiditis, perforated tympanic membrane or otitis externa on exam.<br><br>Presentation appears consistent with bacterial otitis media, and will be prescribed antibiotics<br><br>No clinical evidence by history or evaluation to suspect meningitis and/or sepsis. The lung exam is normal with normal respirations and clear lung sounds. I discussed with the diagnosis, plan of care and to follow up with the patient's primary medical doctor within the next 1-2 days. Instructed to return if the patient worsens in anyway, especially if not tolerating fluids, decreased activity, increased irritability or as needed. They agreed with plan.<br><br>"][/conditional][checkbox memo="MDM PEDS CRYING" name="46" value=""][conditional field="46" condition="(46).is('')"][textarea cols=80 rows=5 default="The patient presented with parent complaining of crying and fussiness. There is no history to suggest an obvious source of <br>discomfort. There has not been any fever, rash, vomiting, diarrhea or bloody stools. <br>There has not been any recent change in formula or diet.<br>The patient has been tolerating feeds and stooling well. There has not been any URI symptoms, recent illness or known ill contacts. Exam is similar and without findings. Vitals are within normal limits and no fever. There is no rash and the patient is nontoxic and well appearing. Ears and throat are normal. Chest, abdomen and genitalia exams are unremarkable without tenderness, mass or herniations. Extremity exam reveals no infection, injury, edema, erythema, effusions or hair tourniquets or tenderness. There is no evidence to suggest nonaccidental trauma. During the course of the evaluation the patient improved and was not crying and was tolerating fluids without difficulty. Plan of care was discussed with the parent and the patient was referred to their primary pediatrician. Warnings were discussed with the parent such as fever, vomiting, blood in stool, develops rash, not tolerating fluids or if worsens. Parent agreed with plan. <br><br>"][/conditional][checkbox memo="MDM PEDS UTI" name="47" value=""][conditional field="47" condition="(47).is('')"][textarea cols=80 rows=5 default="Differential includes UTI, PNA, URI, among others. No clinical evidence by history or evaluation to suspect meningitis and/or severe sepsis.The lung exam is normal with normal respirations and clear lung sounds. Chest xray negative for any PNA, but UA c/w UTI. Pt given CTX IM, and Rx for Cefpodoxime. I discussed with the parent, diagnosis, plan of care and to follow up with the patient's primary pediatrician within the next 3 days and to take Cefpodoxime (preferred atbx), but that if they are not able to buy it (from either availability or insurance refusal), prescription for keflex was provided as second option.. The parent was instructed to return if the patient worsens in anyway, especially if not tolerating fluids, decreased activity, increased irritability or as needed. The parent agreed with plan. <br><br>"][/conditional][checkbox memo="MDM PID" name="48" value=""][conditional field="48" condition="(48).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes UTI, pelvic inflammatory disease, yeast infection, bacterial vaginosis, trichomonas infection, chlamydia infection, gonorrhea infection, among others.<br>UA negative for_UTI. <br>Chlamydia / Gonorrhea testing obtained and patient will receive telephone follow up to confirm if positive. <br>No evidence of yeast infection, BV or trichomonas on wet mount. <br>Patient appears stable for discharge home and follow up with PMD. Pelvic exam notable for cervical motion tenderness, so consistent with PID, but no rebound or guarding, patient nontoxic and well appearing, no evidence of TOA. <br>Patient given empiric Ceftriaxone 250mg IM and will be given Doxycycline x 2 weeks. <br>Pt instructed to f/u with PMD as outpatient for remainder of STD testing, including syphilis and HIV. <br><br>"][/conditional][checkbox memo="MDM PNEUMONIA ADMIT" name="49" value=""][conditional field="49" condition="(49).is('')"][textarea cols=80 rows=5 default="Differential includes pneumonia, bronchitis, CHF, pulmonary edema, pulmonary embolism, pleural effusion among others. Symptoms are not likely to be pulmonary embolism, patient no significant PE risk factors, and has more likely alternate cause of symptoms. <br>Chest xray seems to be consistent with pneumonia, rather than CHF. <br>Presentation not consistent with ischemia / ACS. <br>Based on  *the patient's PSI/PORT score, has high enough mortality risk that inpatient admission for IV antibiotics and clinical observation is most appropriate. <br>Patient given *Ceftriaxone / Azithromycin. <br>No evidence of severe sepsis at this time<br><br>"][/conditional][checkbox memo="MDM PNEUMONIA DC HOME" name="50" value=""][conditional field="50" condition="(50).is('')"][textarea cols=80 rows=5 default="Differential includes pneumonia, bronchitis, CHF, pulmonary edema, pulmonary embolism, pleural effusion among others. Symptoms are not likely to be pulmonary embolism, patient no significant PE risk factors, and has more likely alternate cause of symptoms. *Additionally, PERC score is negative, very low risk for PE<br>Chest xray seems to be consistent with pneumonia, rather than CHF. <br>Presentation not consistent with ischemia / ACS. <br>Based on the patient's PSI/PORT score, seems reasonable for outpatient therapy. <br>Stable for discharge home and follow up with PMD in 1-2 days. <br>Patient given prescription for Azithromycin. <br><br>"][/conditional][checkbox memo="MDM POSSIBLE ECTOPIC" name="51" value=""][conditional field="51" condition="(51).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes, ectopic pregnancy, miscarriage, hemorrhagic ovarian cyst, threatened abortion, inevitable abortion, fibroids, severe anemia, dysfunctional uterine bleeding, vaginal / uterine mass, among others. <br><br>Pregnancy test is POSITIVE. <br>Ultrasound was obtained but was indeterminate, not able to identify a definitive IUP, no yolk sac or fetal heart activity found<br>Possibilities still include ectopic pregnancy vs miscarriage<br>Rh status is *, Rhogam was not indicated.<br>Unlikely ruptured ectopic at this time point, patient's abdomen is not peritoneal, no significant tenderness.<br>The patient's presentation is not consistent with hemorrhagic ovarian cyst or torsion, and has no significant tenderness on exam. <br>Patient's hemoglobin is not severely low, vitals are hemodynamically stable, and no symptoms of severe anemia (near syncope, lightheadedness, severe fatigue), no indication for blood transfusion at this time. <br><br>The patient appears stable for discharge home and follow up here in the ED in 48 hrs for repeat HCG quant testing, reevaluation and further treatment.<br><br>"][/conditional][checkbox memo="MDM PSYCH 5150 AGITATION" name="52" value=""][conditional field="52" condition="(52).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes severe depression, suicidal ideation, bipolar disorder, psychosis, delusions, paranoid schizophrenia, drug abuse, drug intoxication, drug overdose, among others. <br>The patient denies any suicide attempt, overdose, or ingestion. <br>They exhibit no signs of any toxic syndrome or drug / alcohol withdrawal. <br>Labs were ordered for evaluation, and results are reassuring with no evidence of occult overdose, or severe metabolic derangement.<br>EKG shows no obvious signs of TCA overdose. <br>The patient was observed for a period of time in the ED with serial neurologic exams.<br><br>After serial neurologic exams in the emergency department, the patient remains clinically sober. <br>They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. <br>The patient's presentation seems to be consistent with agitation / psychosis, without any complications such as suicide attempt or overdose. <br>They meet psychiatric hold criteria because of *danger to others / grave disability.<br>The patient appears to be stable for transfer to a psychiatric facility for further psychiatric evaluation and care, without any obvious medical etiology for their symptoms.<br>Social worker was consulted to assist with placement into an inpatient psychiatric team, and the patient is awaiting evaluation and placement on a psychiatric hold by the PET team. <br><br>"][/conditional][checkbox memo="MDM PSYCH 5150 SI/DEPRESSION" name="53" value=""][conditional field="53" condition="(53).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes severe depression, suicidal ideation, bipolar disorder, schizophrenia, drug abuse, drug overdose,among others. <br>The patient denies any suicide attempt, overdose, or ingestion. <br>They exhibit no signs of any toxic syndrome or drug / alcohol withdrawal. <br>Labs were ordered for evaluation, and results are reassuring with no evidence of occult overdose, or severe metabolic derangement. <br>EKG shows no obvious signs of TCA overdose.<br>The patient was observed for a period of time in the ED with serial neurologic exams.<br><br>After serial neurologic exams in the emergency department, the patient remains clinically sober. <br>They have no focal neurologic deficits and were able to ambulate with a steady gait without assistance. <br>The patient's presentation seems to be consistent with suicidal ideation, without any complications such as suicide attempt or overdose. <br>The patient appears to be stable for transfer to a psychiatric facility for further psychiatric evaluation and care, without any obvious medical etiology for their symptoms.<br>Social worker was consulted to assist with placement into an inpatient psychiatric team, and the patient is awaiting evaluation and placement on a psychiatric hold by the PET team. <br><br>"][/conditional][checkbox memo="MDM REACTIVE AIRWAY DISEASE" name="54" value=""][conditional field="54" condition="(54).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes: reactive airway disease, asthma exacerbation, pneumonia, bronchitis, pneumothorax, pulmonary embolism, pulmonary edema, CHF, among others.<br><br>The patient's presentation seems most consistent with reactive airway disease given their wheezing on exam without a history of asthma. Chest x ray shows no evidence of pneumonia, pneumothorax, or pulmonary edema. The patient has no significant risk factors for pulmonary embolism, and has a more likely alternate cause given their wheezing on exam, thus further workup was deferred given that PE is unlikely. The patient was given albuterol, atrovent, steroids, and had serial reassessments which demonstrated significant improvement in their symptoms.<br><br>The patient is now stable to be discharged home safely for further outpatient management and reevaluation by their primary medical doctor. The patient will be discharged with a prescription for steroids and albuterol inhaler. <br><br>Differential includes new onset seizure, epilepsy, brain tumor, intracranial bleeding, metabolic encephalopathy, hyponatremia, hypoglycemia, among others.<br>Labs were checked, which were reassuring, no evidence of severe acidosis, or significant metabolic derangement.<br>CT was ordered, given that patient that this is the patient's first reported seizure. <br>Patient is back to their baseline neurologic status, no focal deficits, no e/o brain tumor, bleed. <br>No headache, not consistent with subarachnoid hemorrhage , no indication for LP.<br>Pt is very low risk for subarachnoid hemorrhage - CT negative for any blood within 6 hours of symptoms.<br>Patient had serial neurologic exams in the ER, and is back to baseline, no neuro deficits, ambulating steadily without any assistance, and stable for dc home and f/u with PMD. <br>Patient instructed not to drive until cleared by PMD, and DMV form faxed. <br><br>"][/conditional][checkbox memo="MDM SEIZURE (NEW ONSET - NEG CT)" name="55" value=""][conditional field="55" condition="(55).is('')"][textarea cols=80 rows=5 default=""][/conditional][checkbox memo="MDM SEIZURE (NO CT)" name="56" value=""][conditional field="56" condition="(56).is('')"][textarea cols=80 rows=5 default="Differential includes noncompliance with medication, brain tumor, intracranial bleeding, metabolic encephalopathy, hyponatremia, hypoglycemia, among others.<br>Labs were checked, which were reassuring, no evidence of hypoglycemia, severe acidosis, or significant metabolic derangement.<br>CT was not ordered, given that patient has history of seizures, is back to baseline neuro status, no focal deficits, no e/o brain tumor, bleed.<br>Dilantin level was noted to be subtherapeutic, patient was loaded with Dilantin in the ED. <br>The patient will be discharged with a refill of their maintenance medication.<br>Patient had serial neurologic exams in the ER, and is back to baseline, no neuro deficits, ambulating steadily without any assistance, understands to take their antiepileptics, and stable for dc home and f/u with PMD. <br>Patient instructed not to drive until cleared by PMD, and DMV form faxed. <br><br>"][/conditional][checkbox memo="MDM SEPSIS" name="57" value=""][conditional field="57" condition="(57).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes sepsis / severe sepsis, septic shock, meningitis, cellulitis, UTI, pneumonia , viral syndrome, gastroenteritis, emergent abdominal infection, among others. <br>Patient abdomen is benign, no evidence of emergent abdominal condition. <br>UA is clear, and without evidence of UTI.<br>No meningismus, not altered, no neuro deficits, not consistent with meningitis or encephalitis. <br>Chest xray with no evidence of infiltrate / pneumonia. <br>Presentation not consistent with severe sepsis / septic shock. <br>Sepsis bundle initiated on arrival. <br>Blood cultures, lactate drawn. <br>Lactate was elevated, patient given 30 cc/kg IV fluids by bolus and empiric antibiotics were started. <br>Patient will be admitted to the hospital for further care and evaluation.<br><br>Critical Care Statement<br>Critical care performed 35 minutes) Time is exclusive of separately billable procedures. <br>Time includes: direct patient care, patient reassessment, coordination of patient care, review of patient's medical records, medical consultation, family consultation regarding treatment decisions and documentation of patient care. <br>Organ systems at risk: Cardiac / circulatory.<br><br>"][/conditional][checkbox memo="MDM STROKE (NO TPA)" name="58" value=""][conditional field="58" condition="(58).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others.<br>The patient's presentation appears most consistent with a diagnosis of ischemic stroke.. <br>CT shows no evidence of bleed or mass.<br>However the patient is not a tPa candidate because * The patient is not an interventional candidate because *<br>The patient will be admitted to the hospital to a telemetry bed for further workup and treatment. <br>Aspirin was given and <br>Patient is protecting their own airway, no indication for intubation.<br><br>"][/conditional][checkbox memo="MDM STROKE (TPA GIVEN)" name="59" value=""][conditional field="59" condition="(59).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others.<br>The patient's presentation appears most consistent with a diagnosis of ischemic stroke. <br>The patient is a tPa candidate because they have deficits and presented within 4.5 hours. <br>They do not meet any exclusion criteria. <br>The stroke neurologist on-call, Dr Zangiabadi was immediately consulted upon arrival and CT scans were performed. <br>No evidence on CT of hemorrhagic stroke, so stroke neurologist ordered to start tPA over the phone.<br>BP elevated but no high enough to contraindicate tPA.<br>The patient will be admitted to the hospital to ICU for further workup and treatment. <br>Patient is protecting their own airway, no indication for intubation at this time.<br><br>"][/conditional][checkbox memo="MDM SYNCOPE ADMIT" name="60" value=""][conditional field="60" condition="(60).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's symptoms include , malignant arrhythmias, obstructive heart disease (critical aortic stenosis, hypertrophic cardiomyopathy), acute anemia, severe dehydration, electrolyte abnormalities, among others. <br><br>The patient denies any external blood loss and has no significant pallor or evidence of acute anemia as a cause of their symptoms. <br>Hemoglobin is not severely low, and acute blood transfusion is not indicated. <br><br>EKG shows no signs of malignant arrhythmia such as Brugada syndrome, delta wave, significant heart block, or QTc >500. In addition, the patient has no loud murmur or evidence of significant obstructive heart disease, symptoms are not in the setting of exertion. <br><br>Labs show no severe electrolyte derangement such as severe hyponatremia, hypokalemia, acidosis, or hypoglycemia. <br>The patient is neurologically intact, with normal cerebellar exam, without any evidence of central vertigo as a cause of their symptoms. <br><br>No report of seizure activity. <br><br>They appear well hydrated without any evidence of severe dehydration or acute hypovolemia. Denies any headache or neck pain. NEXUS negative, so CT scans not indicated and deferred.<br><br>Patient instructed not to drive until cleared by PMD, and DMV form faxed.<br><br>Considering the patient's presentation, risk factors, and lack of an obvious cause of their syncope, there is concern for possible cardiac cause of syncope, so the patient will be admitted to telemetry for further workup and risk stratification. <br><br>"][/conditional][checkbox memo="MDM SYNCOPE DC HOME" name="61" value=""][conditional field="61" condition="(61).is('')"][textarea cols=80 rows=5 default="Differential diagnosis for the patient's symptoms include , malignant arrhythmias, obstructive heart disease (critical aortic stenosis, hypertrophic cardiomyopathy), acute anemia, severe dehydration, electrolyte abnormalities, seizure, among others. <br><br>Patient presents with syncope. Preceded by nausea, vomiting, tunnel vision, pallor.<br>No associated headache, chest pain, shortness of breath, abdominal pain, back pain, blood in stool.<br>No family history of sudden cardiac death. with stable vital signs.<br>Pt without any risk factors for PE, coronary artery disease, or CVA and has reassuring exam.<br><br>-EKG shows: NSR rate. Normal axis and intervals. No ectopic beats, No ST elevation or depression. No overt tachy or bradydysrhythmias. No evidence of WPW, Brugada, or dagger like q waves to suggest HOCM. No murmur. Not provoked by exertion.<br>-The patient denies any external blood loss and has no significant pallor or evidence of acute anemia as a cause of their symptoms. Hemoglobin is not severely low, and acute blood transfusion is not indicated.<br>-Labs show no severe electrolyte derangement such as severe hyponatremia, hypokalemia, acidosis, or hypoglycemia.<br>-No report of seizure activity. Pt now back at baseline.<br><br>They appear well hydrated without any evidence of severe dehydration or acute hypovolemia.<br>The patient was observed for a period of time, with symptoms improved, and no emergent cause of their symptoms at time time<br>The patient appears stable for discharge and to follow up with their regular doctor. <br>- Will get CBC to rule out anemia, urine pregnancy to rule out pregnancy as contributory.<br><br>"][/conditional][checkbox memo="MDM THREATENED AB" name="62" value=""][conditional field="62" condition="(62).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes, ectopic pregnancy, hemorrhagic ovarian cyst, threatened abortion, inevitable abortion, fibroids, severe anemia, dysfunctional uterine bleeding, vaginal / uterine mass, among others. <br><br>Pregnancy test is POSITIVE. <br>Ultrasound was obtained which revealed an intrauterine pregnancy, with a viable fetus. <br>Patient was diagnosed with threatened abortion. <br>No evidence of trauma or severe bleeding or fetal distress that would be concerning for placenta previa or placental abruption.<br>Rh status is *, Rhogam was not indicated.<br><br>The patient's presentation is not consistent with hemorrhagic ovarian cyst, and has no significant tenderness on exam. <br>Patient's hemoglobin is not severely low, vitals are hemodynamically stable, and no symptoms of severe anemia (near syncope, lightheadedness, severe fatigue), no indication for blood transfusion at this time. <br><br>The patient appears stable for discharge home and follow with PMD in 2-3 days for reevaluation and further treatment.<br><br>"][/conditional][checkbox memo="MDM TIA" name="63" value=""][conditional field="63" condition="(63).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes TIA, ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others.<br>The patient's presentation appears most consistent with a diagnosis of TIA given transient neurologic symptoms that have completely resolved in_a_potential_vascular_distribution. <br>CT shows no evidence of bleed or mass.<br>The patient is not a tPa candidate because their NIH stroke scale is zero. They have a normal neurologic exam, all symptoms resolved and back to baseline<br>The patient will be admitted to the hospital to a telemetry bed for further workup and treatment. <br>Aspirin was given and care transitioned to the admitting physician<br><br>"][/conditional][checkbox memo="MDM TRAUMA" name="64" value=""][conditional field="64" condition="(64).is('')"][textarea cols=80 rows=5 default=""][/conditional][checkbox memo="MDM TRAUMA MAJOR MECHANISM" name="65" value=""][conditional field="65" condition="(65).is('')"][textarea cols=80 rows=5 default=""][/conditional][checkbox memo="MDM VAG BLEED NON-PREGNANT" name="66" value=""][conditional field="66" condition="(66).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes, ectopic pregnancy, hemorrhagic ovarian cyst, threatened abortion, fibroids, severe anemia, dysfunctional uterine bleeding, vaginal / uterine mass, among others. <br><br>Pregnancy test is negative, ruling out ectopic pregnancy, or threatened / inevitable abortion. <br>The patient's presentation is not consistent with hemorrhagic ovarian cyst, and has no significant tenderness on exam. <br>Patient's hemoglobin is not severely low, vitals are hemodynamically stable, and no symptoms of severe anemia (near syncope, lightheadedness, severe fatigue), no indication for blood transfusion at this time. <br>The patient appears stable for discharge home and follow with PMD in 2-3 days for reevaluation and further treatment. <br><br>"][/conditional][checkbox memo="MDM VAG DISCHARGE W/ TREATMENT" name="67" value=""][conditional field="67" condition="(67).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes yeast infection, bacterial vaginosis, trichomonas infection, chlamydia infection, gonorrhea infection, among others.<br>UA *negative for_UTI. <br>Chlamydia / Gonorrhea testing obtained and patient will receive telephone follow up if testing is positive <br>No evidence of yeast infection, BV or trichomonas on wet mount. <br>Pelvic exam without any evidence of PID.<br>Patient appears stable for discharge home and follow up with PMD. <br>Because patient does have risk factors for chlamydia / gonorrhea, was empirically treated with Ceftriaxone and Azithromycin. <br>Pt instructed to f/u with PMD as outpatient for remainder of STD testing, including syphilis and HIV. <br><br>"][/conditional][checkbox memo="MDM VAG DISCHARGE W/O TREATMENT" name="68" value=""][conditional field="68" condition="(68).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes yeast infection, bacterial vaginosis, trichomonas infection, chlamydia infection, gonorrhea infection, among others.<br>UA  *negative for_UTI. <br>Patient has NO risk factors for STD. <br>Chlamydia / Gonorrhea testing obtained and patient will receive telephone follow up if testing is positive and to have treatment started. <br>No evidence of yeast infection, BV or trichomonas on wet mount. <br>Pelvic exam without any evidence of PID.<br>Patient appears stable for discharge home and follow up with PMD. <br>Pt instructed to f/u with PMD as outpatient for remainder of STD testing, including syphilis and HIV. <br><br>"][/conditional][checkbox memo="STROKE TEMPLATE" name="69" value=""][conditional field="69" condition="(69).is('')"][textarea cols=80 rows=5 default="Pt presented with "][/conditional][checkbox memo="LKWT" name="70" value=""][conditional field="70" condition="(70).is('')"][textarea cols=80 rows=5 default="Last known well time was "][/conditional][checkbox memo="NIHSS" name="71" value=""][conditional field="71" condition="(71).is('')"][textarea cols=80 rows=5 default="NIHSS is "][/conditional][checkbox memo="tPA MDM" name="72" value=""][conditional field="72" condition="(72).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others.<br>The patient's presentation appears most consistent with a diagnosis of ischemic stroke. <br>The patient is a tPa candidate because they have deficits and presented within 4.5 hours. <br>They do not meet any exclusion criteria. <br>The stroke neurologist on-call, Dr Zangiabadi was immediately consulted upon arrival and CT scans were performed. <br>No evidence on CT of hemorrhagic stroke, so stroke neurologist ordered to start tPA over the phone.<br>BP elevated but no high enough to contraindicate tPA.<br>The patient will be admitted to the hospital to ICU for further workup and treatment. <br>Patient is protecting their own airway, no indication for intubation at this time.<br><br>"][/conditional]