MDM Master

[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="1 step sciatica" name="E" value=""][conditional field="E" condition="(E).is('')"][textarea cols=80 rows=5 default="The patient presents with acute onset of atraumatic back pain radiating down ***.No risk factors or findings concerning for epidural abscess, diskitis, vertebral osteomyelitis, cord compression, cauda equina, vertebral fracture or bone malignancy, AAA, or pyelonephritis. 
Clinically this patient can be ruled out for serious pathology given there is a completely normal neurological exam, no history of IV drug use, and no history of bowel or bladder incontinence, no perianal numbness/tingling, no constipation or urinary retention. Once the patient's pain was adequately controlled, the patient was able to ambulate and be discharged in stable condition with anticipatory guidance - to consider further imaging and workup through their primary care physician as an outpatient if symptoms persist."][/conditional][checkbox memo="Ddx Low Back Pain" name="C" value=""][conditional field="C" condition="(C).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes most likely musculoskeletal pain, muscle spasm / sprain, without e/o vertebral fracture, spinal epidural abscess, spinal epidural hematoma, pyelonephritis, kidney stone, AAA, among others."][/conditional]
[checkbox memo="ED Course" name="D" value=""][conditional field="D" condition="(D).is('')"][textarea cols=80 rows=5 default=""][/conditional]

[checkbox memo="MDM Chest Pain" name="B" value=""][conditional field="B" condition="(B).is('')"][textarea cols=80 rows=5 default="Acute coronary syndrome is unlikely and the patient is low risk, pain is atypical, nonexertional, and serial troponins x2 are negative. 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 , no SOB or tachycardia, 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.

Results discussed with patient. Pt agreeable to outpatient follow up and continued workup as necessary. Return indications discussed. Stable for discharge  home."][/conditional]
Ddx Chest Pain 1 step sciatica Ddx Low Back Pain
ED Course

MDM Chest Pain

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.5, 15 form elements, 5 text areas, 5 checkboxes, 5 conditionals, 10 total clicks
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: