Assessment & Plan Elements
Loading Add to Favorites
Share
Tweet
Cite
ASSESSMENT:
[text name="variable_1"] with a history of [text name="variable_2"] presenting with [text name="variable_3"] for [text name="variable_4"].<BR> History was notable for [textarea name="variable_5"][/textarea]<BR> Physical exam was notable for [textarea name="variable_6"][/textarea].<BR>[checkbox memo="Differential diagnosis includes and Plan" name="8" value=""][conditional field="8" condition="(8).is('')"][textarea cols=80 rows=5 default="Differential diagnosis includes but is not limited to.<br><br>"][/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.<br>"][/conditional]

[comment memo="Plan/ED Course"]
[textarea name="variable_1" default=""]


[checkbox memo="MDM ASTHMA ADMIT" name="5" value=""][conditional field="5" condition="(5).is('')"][textarea cols=80 rows=10 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=10 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=10 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]

Diagnostic rationale, follow up instructions, and return indications were discussed with the patient and patient is agreeable with plan. See DCI.

[comment memo="DCI"]
[checkbox memo="ASTHMA DCI" name="9" value=""][conditional field="9" condition="(9).is('')"][textarea cols=80 rows=10 default="Use your inhaler as needed every four hours for shortness of breath/wheeze and take the prednisone as directed.
Follow up with your primary care doctor in 2-3 days.
Return to the ER for worsened shortness of breath, cough, fever, chest pain or other concerns.
********************************************************************************
Use su inhalador como necesario cada cuatro horas para la brevedad del aliento/resuello y tome el prednisone como dirigido.
Siga a su doctor de cuidado primario en 2-3 días.
Vuelva al ER para falta de aliento empeorada, tos, fiebre, dolor de pecho u otras preocupaciones.<br><br>"][/conditional]



Read the following information and attached handout about your diagnosis, treatment and/or prevention of symptoms, and indications for return.
** Take any medications prescribed as directed.
** Follow up with your doctor [checkbox value="tomorrow|as needed|in 1-2 days for a recheck|in 2-3 days for a recheck|in 3-5 days for a recheck|within a week for a recheck|You will need a referral to see a specialist:"] [text]
[checkbox value="** If you do not have a primary physician follow-up at the county hospital or one of the clinics listed. (Phone and/or address for referrals can be found above)"]

** Bring your exam results to your follow up appointments. Keep a copy for your records as well.
** ALWAYS have a list of your current medications with you.
** Return to the ER for:
[checkbox value="worsened or uncontrolled pain, particularly if the pain localizes to the right lower part of your abdomen, for fever, vomiting|worsened or uncontrolled pain, fever, excessive vomiting, bloody diarrhea|signs of dehydration - decreased tears, decreased urination, lethargy|fever lasting longer than 5 days|vaginal bleeding (more than 1 pad an hour for 2-3 consecutive hours),lightheadedness, fainting|Worsened chest pain, shortness of breath, dizziness, fainting, swelling|bleeding that does not stop with simple pressure within 10 minutes|worsened symptoms, failure to improve, or for any other concerns.|or for any other concerns."]
ASSESSMENT:
with a history of presenting with for .<BR> History was notable for <BR> Physical exam was notable for .<BR> Differential diagnosis includes and Plan ddx asthma

Plan/ED Course



MDM ASTHMA ADMIT MDM ASTHMA DC HOME W/ X-RAY MDM ASTHMA DC HOME W/O X-RAY

Diagnostic rationale, follow up instructions, and return indications were discussed with the patient and patient is agreeable with plan. See DCI.

DCI
ASTHMA DCI



Read the following information and attached handout about your diagnosis, treatment and/or prevention of symptoms, and indications for return.
** Take any medications prescribed as directed.
** Follow up with your doctor


** Bring your exam results to your follow up appointments. Keep a copy for your records as well.
** ALWAYS have a list of your current medications with you.
** Return to the ER for:
Result - Copy and paste this output: