Dictation

Chest Pain

Past medical history:

Nil

Medication:

Nil

Allergies:

NKA

HPI:

The Pain was not exertional not pleuritic, not positional

The Pain Not associated with nausea or vomiting or diaphoresis.

No Palpitation no light-headedness or syncope

there was no shortness of breath, no infectious symptoms like cough, phlegm, or fever, runny nose or any signs of a respiratory tract infection in the last two weeks. No contact with sick patients

No history of trauma

No PE risk factor perk negative, and no history of hemoptysis, calf pain or swelling or recent travel, or hormonal medication

No GI or GU symptoms

No focal neurological symptoms

No other symptoms

On examination

The Patient was alert oriented not in distress during the examination

All vital sign reviewed

Chest: good air entry bilateral no wheeze. S1, S2 no murmurs.

Abdomen: soft no organomegaly no tenderness no Mass no CVA tenderness

No rush

No calf swelling or tenderness no leg edema

Neurological exam grossly normal

The rest of the exam was normal

Investigation:

Troponin with EKG nil acute

D Dimer [normal]

Chest x-ray: Nil Acute

Assessment and Plan:

After a thorough history, examination and work up, I think it´s

- Less likely to be cardiac chest pain with normal troponin and EKG with low HEART Score.

- Less likely to be PE.

- Less likely to be due to aortic dissection with no Marfanoid features with equal bilateral radial pulse and blood pressure.

- No sign of pneumothorax

- Less likely to be pneumonia

- Less likely to be pericarditis or Myocarditis according to the History, physical exam and CXR.

The patient was clinically well at the time of discharge home, return to ER instructions explained Provide clear instructions that include specific reasons to return to the ED for any return of pain, change in character, increased severity, SOB, sweating, palpitations, or any other concern)

I asked the patient to follow up with his family physician within two days to arrange for reassessment, stress test and Holter monitor.

And return to ED for any concerns.

The patient discharged home with normal vital signs and no chest pain. questions answered, patient happy with the plan

It has been a pleasure to be involved in the care of this patient

Notes: Error may exist despite proofreading since its voice generated

Abdominal Pain – Full - NYD

PAST MEDICAL HISTORY:

Nil

MEDICATION:

Nil

ALLERGY:

NKA

History of present illness:

The Patient [] chest pain, shortness of breath, dyspnea on exertion,

The Patient [] headache, vision changes, denies lightheadedness,

The Patient [] abdominal pain, nausea or vomiting, back pain,

The Patient [] urinary symptoms,

The Patient [] fever, chills/sweats

The Patient [] sore throat, cough, or phlegm

The Patient [] leg pain or swelling,

The Patient [] Genital pain, discharge or bleeding,

The Patient [] ETOH abuse,

The Patient [] any Trauma,

No other symptoms.

PHYSICAL EXAMINATION:

Alert, Oriented x3, is not distressed.

Vital Sign reviewed

Chest: Lungs are clear, normal heart sounds with no extra heart sounds and no murmurs. Equal bilateral radial pulses

Abdomen:

Soft, non-tender, no organomegaly, no pulsatile mass.

Genital exam: Normal no tenderness, no mass

Extremities: No Calf Swelling or tender. No peripheral edema.

Back: No tenderness No CVA Tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

The rest of the exam is Normal.

INVESTIGATIONS:

IMPRESSION AND PLAN:

After thorough history examination and work up My clinical impression at this time; This pain is less likely to be due to Acute abdomen causes like:

- Acute appendicitis

- Diverticulitis

- Acute cholecystitis, cholangitis, or pancreatitis

- Perforated viscus

- Bowel obstruction

- Ischemic bowel

- Rupture AAA

- Intra-thoracic pathology like MI or Basel pneumonia

- Renal colic, or pyelonephritis

- [testicular torsion/Ectopic pregnancy or ovarian torsion]

It could be due to []

Treatments provided included []

[Patient will be admitted. Discussed case with Dr. *** who will admit.]

The patient discharged home

Recommend over the counter []

Monitor for new or worsening symptoms.

The Patient advised on continued fluid hydration

The Patient prescribed []

The patient was stable at the time of discharge home, return to ED instruction given, questions answered, and the patient was happy with the plan. I asked him to visit his family physician within two days. and I asked him to return to the emergency department for any concerns.

It has been my pleasure to involve in the care of the patient

Note: Error may exist despite proofreading since it's a voice-generated dictation.

Abdominal Pain

History of Present Illness

Patient presenting for evaluation of [abdominal pain, RLQ abdominal pain, LLQ abdominal pain, RUQ abdominal pain, LUQ abdominal pain, suprapubic abdominal pain, epigastric abdominal pain, vomiting, nausea, acid reflux, diarrhea, constipation, fever, urinary symptoms, hematuria, constipation].

Onset of symptoms was @@@ days ago.

Patient describes a [constant, intermittent],

[mild, sharp, heaviness, cramping, pressure, achy, burning],

[anterior, epigastric, left sided, right sided, bilateral pain].

Radiation of pain is [not present, chest, flank, to back, down leg, to left shoulder, to right shoulder].

Pain is [mild, moderate, severe], [@/10] in severity.

Patient has associated symptoms of [nausea, vomiting, diarrhea, chest pain, shortness of breath, diaphoresis, lightheadedness, belching, frequency, dysuria].

Patient does not have symptoms of [nausea, vomiting, diarrhea, chest pain, shortness of breath, diaphoresis, lightheadedness, belching, abd discomfort, frequency, dysuria].

Aggravating symptoms include [nothing, exercise, eating, drinking, movement, deep breaths, palpation, sitting forward, lying flat].

Treatment prior to arrival includes [nothing, rest, aspirin, nitroglycerin, acid reflux medications, OTC Medications],

[with improvement, without improvement].

Patient has history of [no prior abdominal surgeries, appendectomy, cholecystectomy, hernia repair, hysterectomy, oophorectomy, prior small bowel obstruction, gastric bypass].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

denies [chest pain, shortness of breath, dyspnea on exertion, headache, vision changes, denies lightheadedness, abdominal pain, nausea or vomiting, back pain, urinary symptoms, leg swelling, fever, chills/sweats, weight gain, weight loss, sore throat, cough,]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Abdomen:

soft, nontender,

[bowel sounds normal, bowel sounds hyperactive, bowel sounds hypoactive,

distended, nondistended],

[tenderness, tenderness RUQ, tenderness RLQ, tenderness LLQ, tenderness LUQ, tenderness epigastric, tenderness suprapubic],

[no rebound or guarding, rebound, guarding],

[positive Murphy's sign, negative Murphy's sign],

[positive McBurney's tenderness, negative McBurney's tenderness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Vital signs revealed [no major abnormalities, no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time is most consistent with [LLQ Pain, LUQ Pain, RLQ Pain, RUQ Pain, appendicitis, diverticulitis., diverticulitis, appendicitis, GERD, gastritis, peptic ulcer disease, cholelithiasis, abdominal wall strain, UTI, cystitis, pregnancy, ovarian cyst, nephrolithiasis, urolithiasis, SBO, pancreatitis, gastroenteritis, diarrhea, nausea, vomiting, generalized abdominal pain, ***].

Differential diagnosis considered including [GERD, gastritis, peptic ulcer disease, esophagitis, cholelithiasis, cholecystitis, abdominal wall strain, UTI, cystitis, pregnancy, ovarian cyst, ovarian torsion, nephrolithiasis, urolithiasis, diverticulitis, SBO, pancreatitis, gastroenteritis, diarrhea, nausea, vomiting, generalized abdominal pain, ACS, angina, pulmonary embolism, AAA, aortic dissection, ***].

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

[EKG shows normal sinus rhythm without acute ST elevation/depression.],

[WBC elevated, WBC normal],

[metabolic panel normal, lipase normal, liver function tests normal],

[urinalysis shows signs of infection, urinalysis does not show infection],

[CT of the abdomen showed pathology consitent with that of the diagnosis,

CT of the abdomen shows no acute findings],

[Abdominal Xray reveals no evidence of pneumonia or other acute process],

[lactate normal, procalcitonin normal, troponin normal, ***].

Treatments provided included [normal saline, dilaudid, morphine, GI Cocktail, ibuprofen, tylenol[,

[with improvement in symptoms, without improvement in symptoms].

[Patient will be admitted. Discussed case with Dr. *** who will admit.]

Recommend over the counter [Tylenol and Ibuprofen for fever/general discomfort].

Monitor for new or worsening symptoms.

Patient advised on bland diet.

Patient advised on continued fluid hydration

Patient prescribed [ciprofloxacin, Flagyl, Augmentin, doxycycline, Keflex, amoxicillin, macrobid, Hydrocodone, Naproxen, Ibuprofen].

Follow up in one or two days,

return to ER with new or worsening symptoms.

Abdominal Pain Appendicitis

History of Present Illness

Patient presenting for evaluation of [abdominal pain. abdominal cramping, abdominal discomfort, nausea, vomiting, diarrhea, constipation, fever, decreased appetite, urinary symptoms, flank pain, bright red blood per rectum, chest pain, shortness of breath, dehydration]

Patient describes the pain as [constant, intermittent], occurring in increased frequency, [sharp, colicky, pressure, diffuse, epigastric, RUQ, LUQ, RLQ, LLQ, suprapubic] in nature.

Onset of symptoms was [@@@ hours ago].

Patient reports pain is [5/10] in severity.

Radiation of pain is [not present, to back, to RUQ, to LUQ, to RLQ, to LLQ, to epigastrium].

Patient reports associated symptoms of [nothing, fever, nausea, emesis, constipation, diarrhea, dysuria, hematuria, melena, hematochezia].

Patient denies symptoms of [fever, nausea, emesis, constipation, diarrhea, dysuria, hematuria, melena, hematochezia].

Aggravating factors include [nothing, movement, eating, alcohol, fatty foods, urination, bowel movements, NSAIDs].

Alleviating factors include nothing, [movement, eating, Antacids, position changes, belching, bowel movements, urination, Acetaminophen, Opioid pain medications].

Treatment prior to arrival includes [nothing, Antacids, NSAIDs, Acetaminophen, Opioid pain medications],

[with no improvement of symptoms, with mild improvement of symptoms].

Previous abdominal surgery and procedures

includes nothing.

Review of Systems:

All other systems reviewed and are negative,

vital signs reviewed,

The patient [denies chest pain, shortness of breath, dyspnea on exertion,

denies headache, vision changes, light-headedness,

denies abdominal pain, nausea or vomiting, back pain, urinary symptoms, leg swelling, Denied fever, chills/sweats, weight gain, weight loss, sore throat, cough]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Abdomen:

[soft, nontender, bowel sounds normal]

[No organomegaly no Mass]

bowel sounds [hyperactive, bowel sounds hypoactive, distended]

[tenderness, tenderness RUQ, tenderness RLQ, tenderness LLQ, tenderness LUQ, tenderness epigastric, tenderness suprapubic]

[no rebound or guarding, rebound, guarding]

[positive Murphy's sign, negative Murphy's sign]

[positive McBurney's tenderness, negative McBurney's tenderness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with abdominal pain.

Differential included [appendicitis, diverticulitis, nephrolithiasis, UTI]. Also considered but less likely given history and physical exam included [constipation, bowel perforation, gastritis, pancreatitis, pyelonephritis, mesenteric ischemia].

EKG shows normal sinus rhythm without acute ST elevation/depression.,

WBC [elevated, WBC normal], White blood count was ***.

Metabolic panel normal, lipase normal, liver function tests normal,

Urinalysis shows [signs of infection, does not show infection], No significant amount of blood in urine, less likely nephrolithiasis.

CT of the abdomen showed [pathology consitent with that of the diagnosis],

CT of the abdomen and pelvis showed appendicitis without perforation.

CT of the abdomen shows [no acute findings],

US of the abdomen shows [diagnosis],

US of the abdomen shows [no acute abnormalities],

Abdominal X ray reveals [no evidence of pneumonia or other acute process],

lactate normal, troponin normal, ***.

Patient provided *** for pain control.

Antibiotics *** provided. General Surgery consulted.

They will admit patient for operative management.

Impression

Appendicitis

Plan

Admit to General Surgery

Abdominal Pain Cholelithiasis / Gallbladder

History of Present Illness

Patient presenting for evaluation of [RUQ abdominal pain, abdominal pain, RLQ abdominal pain, LLQ abdominal pain, LUQ abdominal pain, suprapubic abdominal pain, epigastric abdominal pain, vomiting, nausea, acid reflux, diarrhea, constipation, fever, urinary symptoms, hematuria, constipation].

Onset of symptoms was [@@@ hours ago].

Patient describes a [constant, intermittent],

[mild, sharp, heaviness, cramping, pressure, achy, burning],

[anterior, epigastric, left sided, right sided, bilateral pain].

Radiation of pain is [not present, chest, flank, to back, down leg, to left shoulder, to right shoulder].

Pain is [mild, moderate, severe], [5/10] in severity.

Patient has associated symptoms of [nausea, vomiting, diarrhea, chest pain, shortness of breath, diaphoresis, lightheadedness, belching, frequency, dysuria].

Patient does not have symptoms of nausea, vomiting, diarrhea, chest pain, shortness of breath, diaphoresis, lightheadedness, belching, abd discomfort, frequency, dysuria.

Aggravating symptoms include [nothing, exercise, eating, drinking, movement, deep breaths, palpation, sitting forward, lying flat]

Treatment prior to arrival includes [nothing, rest, aspirin, nitroglycerin, acid reflux medications, OTC Medications]

[with improvement, without improvement]

Patient has history of no prior abdominal surgeries.

Review of Systems:

All other systems reviewed and are [negative]

vital signs reviewed,

denies [chest pain, shortness of breath, dyspnea on exertion],

denies [headache, vision changes, lightheadedness],

denies [abdominal pain, nausea or vomiting, back pain, urinary symptoms, leg swelling], denies [fever, chills/sweats, weight gain, weight loss, sore throat, cough]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Abdomen:

[soft, nontender, bowel sounds normal]

[No organomegaly no Mass]

bowel sounds [hyperactive, bowel sounds hypoactive, distended]

[tenderness, tenderness RUQ, tenderness RLQ, tenderness LLQ, tenderness LUQ, tenderness epigastric, tenderness suprapubic]

[no rebound or guarding, rebound, guarding]

[positive Murphy's sign, negative Murphy's sign]

[positive McBurney's tenderness, negative McBurney's tenderness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with right upper quadrant abdominal pain. Differential included [cholelithiasis, nephrolithiasis, urinary tract infection, cholecystitis, hepatitis, pancreatitis].

Formal ultrasound reveals gallstones with no evidence of gallbladder wall thickening pericholecystic fluid consistent with cholelithiasis. Given these findings, less likely to be [cholecystitis, choledocholithiasis, or pancreatitis].

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

EKG shows normal sinus rhythm without acute ST elevation/depression.,

WBC [elevated, WBC normal],

Metabolic panel normal, lipase normal, liver function tests normal,

Urinalysis shows [signs of infection, does not show infection],

CT of the abdomen showed [pathology consitent with that of the diagnosis],

CT of the abdomen shows [no acute findings],

US of the abdomen shows [diagnosis],

US of the abdomen shows [no acute abnormalities],

Abdominal X ray reveals [no evidence of pneumonia or other acute process],

lactate normal, troponin normal, ***.

Treatments provided included [normal saline, dilaudid, morphine, fentanyl, toradol, hydrocodone, GI Cocktail, ibuprofen, tylenol,]

[with improvement in symptoms, without improvement in symptoms].

Discussed with patient to cut down on fatty foods.

Discussed warning Discussed signs of cholecystitis and choledocholithiasis, including fevers, worsening pain, uncontrolled vomiting, yellowing of skin or eyes.

Provided prescription for pain medication.

Present to emergency department urgently if new or worsening symptoms develop.

Patient prescribed [Tylenol, Ibuprofen, Hydrocodone, Oxycodone, Naproxen, ranitidine, Omeprazole, Famotidine].

Follow up in one or two days, return to clinic or urgent care with new or worsening symptoms, present to ER with new or worsening symptoms,

follow up with general surgery Done.

Abdominal Pain Diverticulitis

History of Present Illness

Patient describes the pain as [constant, intermittent], occurring in increased frequency, [sharp, colicky, pressure, diffuse, epigastric, RUQ, LUQ, RLQ, LLQ, suprapubic] in nature.

Onset of symptoms was [@@@ hours ago].

Patient reports pain is [5/10] in severity.

Radiation of pain is [not present, to back, to RUQ, to LUQ, to RLQ, to LLQ, to epigastrium].

Patient reports associated symptoms of [nothing, fever, nausea, emesis, constipation, diarrhea, dysuria, hematuria, melena, hematochezia].

Patient denies symptoms of [fever, nausea, emesis, constipation, diarrhea, dysuria, hematuria, melena, hematochezia].

Aggravating factors include [nothing, movement, eating, alcohol, fatty foods, urination, bowel movements, NSAIDs].

Alleviating factors include nothing, [movement, eating, Antacids, position changes, belching, bowel movements, urination, Acetaminophen, Opioid pain medications].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, zofran, OTC Medications, Pepto-Bismol, Imodium, Miralax, stool softeners, hydrocodone, oxycodone].

[with no improvement of symptoms, with mild improvement of symptoms].

Previous abdominal surgery and procedures

includes nothing.

Review of Systems:

All other systems reviewed and are negative,

vital signs reviewed,

The patient [denies chest pain, shortness of breath, dyspnea on exertion,

denies headache, vision changes, light-headedness,

denies abdominal pain, nausea or vomiting, back pain, urinary symptoms, leg swelling, Denied fever, chills/sweats, weight gain, weight loss, sore throat, cough]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Abdomen:

[soft, nontender, bowel sounds normal]

[No organomegaly no Mass]

bowel sounds [hyperactive, bowel sounds hypoactive, distended]

[tenderness, tenderness RUQ, tenderness RLQ, tenderness LLQ, tenderness LUQ, tenderness epigastric, tenderness suprapubic]

[no rebound or guarding, rebound, guarding]

[positive Murphy's sign, negative Murphy's sign]

[positive McBurney's tenderness, negative McBurney's tenderness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with LLQ abdominal pain.

Differential included [diverticulitis, nephrolithiasis, UTI].

Also considered but less likely given history and physical exam included [constipation, bowel perforation, gastritis, pancreatitis, pyelonephritis, mesenteric ischemia].

EKG shows normal sinus rhythm without acute ST elevation/depression.,

WBC [elevated, WBC normal],

Metabolic panel normal, lipase normal, liver function tests normal,

Urinalysis shows [signs of infection, does not show infection],

CT of the abdomen showed [pathology consitent with that of the diagnosis],

CT of the abdomen and pelvis showed diverticulitis without perforation

CT of the abdomen shows [no acute findings],

US of the abdomen shows [diagnosis],

US of the abdomen shows [no acute abnormalities],

Abdominal X ray reveals [no evidence of pneumonia or other acute process],

lactate normal, troponin normal, ***.

Patient provided *** for pain control.

Time given for questions and all questions answered to patient satisfaction.

Patient is to return if having worsening pain, fevers, vomiting, inability to tolerate PO, inability to stool, or any other concern.

[Patient will be admitted. Discussed case with Dr *** who will admit].

Impression: Diverticulitis

Plan

- Ciprofloxacin

- augmentin

- Metronidazole

- *** for pain control

Maintain Fluid Intake: Pedialyte/Gatorade, Juice, Non-caffenated Pop

F/U with PC. Clear liquid diet to start before advancing over the next few days.

Informed to return if unable to tolerate PO intake, high fever, uncontrolled pain, or any other concerns. Patient understanding of and agreement with plan and all questions answered.

Dermatology Hives (Urticaria)

History of Present Illness

Patient presenting for evaluation of [hives, allergic reaction, rash, itching, erythema] Symptoms located on the [left, right, bilateral], [face, neck, upper arm, hand, trunk, abdomen, back, buttock, hip, thigh, foot].

Onset of symptoms was @@@@@ ago.

Pain is [mild, moderate, severe in severity]

Patient has associated symptoms of [pain, bruising, swelling, redness, warmth, bleeding, ulcers, drainage, itching, numbness, tingling, weakness]

Patient [denies any new exposures]

Patient reports exposure to [pets, metals, plants, new foods, new laundry detergent, allergens, new medications]

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, benadryl, antibiotic ointment, epinephrine, steroid cream, ice.]

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Patient denies chest pain, shortness of breath, dyspnea on exertion, headache, denies vision changes, light-headedness, abdominal pain, back pain, urinary symptoms, leg swelling, fever, chills/sweats, sore throat, cough

Physical Exam:

Constitutional: A Ox3, No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: warm, dry, [rash present, erythema present, laceration, abrasion, bruising, urticarial rash present, pustules present, macular rash present, maculopapular rash present, vesicular rash present, no purpura, no skin breakdown, no drainage]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with hives.

Treatments provided included [benadryl, prednisone, Cetirizine (Zyrtec), Loratadine (Claritin), Ranitidine (Zantac)]

[with improvement in symptoms, without improvement in symptoms]

Patient is to follow up with primary care provider to further discuss anaphylactic treatment and allergen testing as needed. Return to emergency department urgently if new or worsening symptoms develop including oral swelling, difficulty breathing, chest pain, shortness of breath, worsening rash, headache, or other worrisome symptoms.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Monitor for new or worsening symptoms.

Patient prescribed Prednisone, Benadryl, epipen, Ranitidine (Zantac), Loratadine (Claritin).

ENT Bacterial Sinusitis

History of Present Illness

Patient presenting for evaluation of [ear pain, ear drainage, fever, cough, nasal congestion, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, abdominal pain, rash, irritability, fatigue].

Onset of symptoms was [@@@ hours ago].

Patient has associated symptoms of [ear pain, pulling at ears, fever, cough, shortness of breath, nasal congestion, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, abdominal pain, rash, irritability, fatigue].

Patient does not have symptoms of [ear pain, pulling at ears, fever, cough, shortness of breath, nasal congestion, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, abdominal pain, rash, irritability, fatigue].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, OTC cough medications, OTC cold medications, decongestants, antibiotics].

Patient has history of [prior ear infections, Patient does not have history of prior ear infections], [ear drainage, no ear drainage],

[recent swimming, no recent swimming],

[recent antibiotic use, no recent anbiotic use].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

denies [chest pain, shortness of breath, dyspnea on exertion, headache, vision changes, lightheadedness, abdominal pain, nausea or vomiting, back pain, urinary symptoms, denies leg swelling, fever, chills/sweats, weight gain, weight loss, sore throat, cough]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

HEENT:

[TM normal bilaterally]

[right TM erythematous, right TM normal],

[left TM erythematous, left TM normal],

[effusion present, no effusion present],

[oropharynx clear, pharyngeal erythema, tonsillar erythema, tonsillar enlargement],

uvula midline,

[normal voice, hoarse voice],

[no trismus, neck supple],

[maxillary sinus tenderness, frontal sinus tenderness, no sinus tenderness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

· Presentation consistent with bacterial sinusitis.

· No evidence of other bacterial infections including [pneumonia, meningitis, pharyngitis, otitis media].

· Discussed that this fits picture of viral vs bacterial sinusitis and that due to type and duration of symptoms and exam findings,

· we will treat as bacterial sinusitis. Antibiotics prescribed.

· Advised to continue ibuprofen and Tylenol at home.

· Patient is to followup with primary physician if having continued symptoms.

· Advised patient on supportive therapies, including using a [cool-mist vaporizer/humidifer/steam from hot showers, OTC throat lozenges, advancement of fluids as tolerated, nasal saline sprays, rest, OTC acetaminophen or ibuprofen for pain control, frequent handwashing].

Patient prescribed an antibiotic.

Will have patient/family use wait and watch approach and only use antibiotics if symptoms not improving, [Tamiflu, Amoxicillin, Amoxicillin and clavulanate (Augmentin), Cefprozil (Cefzil), Cefuroxime (Ceftin), Cefpodoxime (Vantin), Cefdinir, Azithromycin (Zithromax), Trimethoprim/sulfamethoxazole (Bactrim DS), phenylephrine, Sudafed, oxymetazoline (Afrin), fluticasone (Flonase), Mucinex, prednisone, Robitussin, Tessalon Perles, Phenergan-Codeine].

Follow up in one or two days,

present to ER with new or worsening symptoms.

ENT Epistaxis / Nosebleed

History of Present Illness

Patient presenting for evaluation of [left sided epistaxis, right sided epistaxis, bilateral epistaxis, recurrent epistaxis, nasal trauma, nasal pain].

Onset of symptoms was @@@ hours ago.

Patient has associated symptoms of [fever, cough, shortness of breath, nasal congestion, ear pain, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, abdominal pain, nausea, vomiting, diarrhea, rash, lightheadedness].

Patient does not have symptoms of [fever, cough, shortness of breath, nasal congestion, ear pain, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, abdominal pain, nausea, vomiting, diarrhea, rash, lightheadedness, weakness].

Treatment prior to arrival includes [nothing, compression, Afrin, OTC cough medications, OTC cold medications, decongestants, prior cautery, nasal packing].

Patient takes no blood thinning medications, [aspirin, Plavix, coumadin, Pradaxa, xarelto, Eliquis, brilinta].

Review of Systems:

All other systems reviewed and are negative,

vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

HEENT:

normocephalic, muscous membranes moist

atraumatic, [oozing bleeding right nare, oozing bleeding left nare, bilateral nare bleeding], clots present,

[oropharynx normal, blood within the oropharynx, bleeding from anterior septum],

[active bleeding, no active bleeding],

[nasal tenderness, no nasal tenderness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [epistaxis, left nare epistaxis, right nare epistaxis, nasal pain, nasal trauma].

Vital signs revealed no major abnormalities,

[no fever, fever, ]

[no hypoxia, hypoxia, ]

[no tachycardia, tachycardia, ]

[no tachypnea, ]

[hypotension, no hypotension].

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed]

[Hemoglobin stable, Hemoglobin low]

[INR normal, INR elevated]

[WBC elevated, WBC normal]

[head CT unremarkable, facial CT unremarkable]

[nasal Xray shows nasal fracture, nasal Xray shows no nasal fracture].

Adequate cessation of bleeding achieved through direct pressure,

[Afrin, chemical cautery, Murocel, Rhino Rocket, TXA, nasal packing, cocaine, phenylephrine, lidocaine, at which time patient was asymptomatic].

Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Epistaxis first-aid, including sitting upright and leaning forward to prevent blood from passing into the throat, pinching the nose gently but firmly between the thumb and index finger just below the nasal bones and hold forŅmin, and repeat until coagulation.

Supportive therapies discussed, including using saline nasal spray or saline nose drops to keep the turbinates moist, application of petroleum jelly inside the noise, refrain from blowing the nose.

Patient prescribed [Afrin, nasal saline, Keflex, Amoxicillin, Amoxicillin and clavulanate (Augmentin), Cefprozil (Cefzil), Penicillin, Lortab, Percocet, Tylenol, Ibuprofen].

Follow up in one or two days, return to clinic or urgent care with new or worsening symptoms, present to ER with new or worsening symptoms, follow up with ENT.

ENT Otitis Externa

History of Present Illness

Onset of symptoms was [@@@ hours ago].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, OTC cough medications, OTC cold medications, decongestants, antibiotics].

Patient has history of [prior ear infections, Patient does not have history of prior ear infections], [ear drainage, no ear drainage],

[recent swimming, no recent swimming],

[recent antibiotic use, no recent anbiotic use].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

HEENT:

[TM normal bilaterally, right TM erythematous, right TM normal],

[left TM erythematous, left TM normal],

[effusion present, no effusion present],

[oropharynx clear, pharyngeal erythema, tonsillar erythema, tonsillar enlargement],

[, R tympanic canal edematous with drainage noted, L tympanic canal edematous with drainage noted, tubes present],

no mastoid tenderness

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with ear pain and drainage. Given history and physical exam findings, presentation most consistent with otitis externa. The differential also included [pneumonia, sinusitis, pharyngitis, upper respiratory infection, otitis media, mastoiditis, dental infection] however these are less likely given data presented thus far.

Antibiotics were prescribed as below.

Advised to use Tylenol/ibuprofen for discomfort.

Informed to return for new or worsening symptoms such as persistent fevers, persistent vomiting, dehydration, altered mental status.

Patient prescribed an antibiotic.

Will have family use wait and watch approach and only use antibiotics if symptoms not improving., [Acetic acid otic solution, Cortisporin, Ofloxacin, Ciprofloxacin, Gentamicin, Tobramycin, Azithromycin (Zithromax), amoxicillin, augmentin, Tylenol, Ibuprofen].

Follow up in one or two days, return to clinic or urgent care with new or worsening symptoms, present to ER with new or worsening symptoms.

ENT Otitis Media

History of Present Illness

Onset of symptoms was [@@@ hours ago].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, OTC cough medications, OTC cold medications, decongestants, antibiotics].

Patient has history of [prior ear infections, Patient does not have history of prior ear infections], [ear drainage, no ear drainage],

[recent swimming, no recent swimming],

[recent antibiotic use, no recent anbiotic use].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

HEENT:

[TM normal bilaterally, right TM erythematous, right TM normal],

[left TM erythematous, left TM normal],

[effusion present, no effusion present],

[oropharynx clear, pharyngeal erythema,

[tonsillar erythema, tonsillar enlargement],

uvula midline,

[normal voice, hoarse voice],

[sinus tenderness, no sinus tenderness]

no trismus, neck supple,

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with ear pain. Given history and physical exam findings, presentation most consistent with otitis media.

The differential also included [pneumonia, sinusitis, pharyngitis, upper respiratory infection, otitis externa, mastoiditis, dental infection] however these are less likely given data presented thus far.

Antibiotics were prescribed as below.

Advised to use Tylenol/ibuprofen for fevers.

Informed to return for new or worsening symptoms such as persistent fevers, persistent vomiting, dehydration, altered mental status.

Patient prescribed an antibiotic.

Will have family use wait and watch approach and only use antibiotics if symptoms not improving., [Auralgan, Amoxicillin, Amoxicillin and clavulanate (Augmentin), Cefprozil (Cefzil), Cefuroxime (Ceftin), Cefpodoxime (Vantin), Cefdinir, Azithromycin (Zithromax), Trimethoprim/sulfamethoxazole (Bactrim DS), albuterol inhaler, albuterol nebulizer, Tylenol, Ibuprofen].

Follow up in one or two days, return to clinic or urgent care with new or worsening symptoms, present to ER with new or worsening symptoms.

ENT Sinus Pain / Viral Sinusitis

History of Present Illness

Onset of symptoms was [@@@ hours ago].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, OTC cough medications, OTC cold medications, decongestants, antibiotics].

Patient has history of [prior ear infections, Patient does not have history of prior ear infections], [ear drainage, no ear drainage],

[recent swimming, no recent swimming],

[recent antibiotic use, no recent anbiotic use].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

HEENT:

[TM normal bilaterally]

[right TM erythematous, right TM normal],

[left TM erythematous, left TM normal],

[effusion present, no effusion present],

[oropharynx clear, pharyngeal erythema, tonsillar erythema, tonsillar enlargement],

uvula midline,

[normal voice, hoarse voice],

[no trismus, neck supple],

[maxillary sinus tenderness, frontal sinus tenderness, no sinus tenderness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

· Presentation consistent with viral sinusitis.

· No evidence of bacterial infections including [pneumonia, meningitis, pharyngitis, otitis media].

· Discussed with patient that this fits picture of viral vs bacterial sinusitis and that due to type and duration of symptoms and exam findings, it is likely this is viral.

· However, discussed that if symptoms do not improve in several days with symptomatic measures, it may be worthwhile to try an antibiotic as determined by your primary care provider.

· Advised to continue ibuprofen and Tylenol at home.

· Patient is to followup with primary physician if having continued symptoms.

Advised patient on supportive therapies, including using [a cool-mist vaporizer/humidifer/steam from hot showers, OTC throat lozenges, advancement of fluids as tolerated, nasal saline sprays, rest, OTC acetaminophen or ibuprofen for pain control, frequent handwashing.]

Patient prescribed an antibiotic.

Follow up in one or two days, return to ER with new or worsening symptoms.

ENT Strep Pharyngitis / Tonsillitis

History of Present Illness

Onset of symptoms was [@@@ hours ago].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, OTC cough medications, OTC cold medications, decongestants, antibiotics].

Patient has history of [prior ear infections, Patient does not have history of prior ear infections], [ear drainage, no ear drainage],

[recent swimming, no recent swimming],

[recent antibiotic use, no recent anbiotic use].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

HEENT:

[TM normal bilaterally, right TM erythematous, right TM normal],

[left TM erythematous, left TM normal],

[effusion present, no effusion present],

[oropharynx clear, pharyngeal erythema, tonsillar erythema, tonsillar enlargement],

[, R tympanic canal edematous with drainage noted, L tympanic canal edematous with drainage noted, tubes present],

no mastoid tenderness

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with sore throat consistent with bacterial pharyngitis.

Strep test is positive.

The patient did not have trismus, hot potato voice, uvula deviation, unilateral tonsillar swelling, toxic appearance, drooling or pain with movement of the trachea to suggest peritonsillar abscess or epiglottitis.

No evidence of bacterial infections including peritonsillar abscess, retropharyngeal abscess, epiglottitis. Patient advised to continue ibuprofen and Tylenol at home.

Further symptomatic measures discussed.

Advised Pt on supportive therapies, including using [a cool-mist vaporizer/humidifer/steam from hot showers, limit talking, OTC throat lozenges and mouthwashes, gargling w/ warm saltwater, advancement of fluids as tolerated, nasal saline sprays, rest, OTC acetaminophen or ibuprofen as directed prn for pain control, frequent handwashing, and boiling/disposing of contaminated toothbrushes. ]

Patient prescribed an antibiotic.

Will have family use wait and watch approach and only use antibiotics if symptoms not improving., [Amoxicillin, Amoxicillin and clavulanate (Augmentin), Cefprozil (Cefzil), Cefuroxime (Ceftin), Cefpodoxime (Vantin), Cefdinir, Azithromycin (Zithromax), Trimethoprim/sulfamethoxazole (Bactrim DS), chloraseptic throat spray, viscous lidocaine, magic mouth wash, prednisone, Tylenol, Ibuprofen].

Follow up in one or two days,

return to ER with new or worsening symptoms.

ENT Viral Pharyngitis

History of Present Illness

Onset of symptoms was [@@@ hours ago].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, OTC cough medications, OTC cold medications, decongestants, antibiotics].

Patient has history of [prior ear infections, Patient does not have history of prior ear infections], [ear drainage, no ear drainage],

[recent swimming, no recent swimming],

[recent antibiotic use, no recent anbiotic use].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

HEENT:

[TM normal bilaterally, right TM erythematous, right TM normal],

[left TM erythematous, left TM normal],

[effusion present, no effusion present],

[oropharynx clear, pharyngeal erythema, tonsillar erythema, tonsillar enlargement],

[, R tympanic canal edematous with drainage noted, L tympanic canal edematous with drainage noted, tubes present],

no mastoid tenderness

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with sore throat consistent with viral pharyngitis.

· The patient did not have trismus, hot potato voice, uvula deviation, unilateral tonsillar swelling, toxic appearance, drooling or pain with movement of the trachea to suggest peritonsillar abscess or epiglottitis.

· No evidence of bacterial infections including peritonsillar abscess, retropharyngeal abscess, epiglottitis.

· Rapid strep was obtained and was negative.

· Patient advised to continue ibuprofen and Tylenol at home.

· Further symptomatic measures discussed.

Advised patient on supportive therapies, including using [a cool-mist vaporizer/humidifer/steam from hot showers, limit talking, OTC throat lozenges and mouthwashes, gargling w/ warm saltwater, advancement of fluids as tolerated, nasal saline sprays, rest, OTC acetaminophen or ibuprofen as directed prn for pain control, frequent handwashing, and boiling/disposing of contaminated toothbrushes].

Patient prescribed an antibiotic.

Follow up in one or two days,

return to clinic or urgent care with new or worsening symptoms,

present to ER with new or worsening symptoms.

Eye Conjunctivitis

History of Present Illness

Patient presenting for evaluation of [eye pain, eye foreign body sensation, eye swelling, eye redness, eye drainage, eye itching, mattering of the eye, tearing, vision change, blurry vision, pink eye].

Symptoms affect the [right eye, the left eye, both eyes]

Onset of symptoms was @@@ hours ago.

Pain is [mild, moderate, severe],

@/10 in severity.

Patient has associated symptoms of [eye pain, eye foreign body sensation, eye swelling, eye redness, eye drainage, eye itching, mattering of the eye, tearing, vision change, blurry vision, pink eye].

Patient does not have symptoms of [eye pain, eye foreign body sensation, eye swelling, eye redness, eye drainage, eye itching, mattering of the eye, tearing, vision change, blurry vision, pink eye].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, irrigation, removing contacting, antibiotic ointment, warm compresses].

Patient does [wear glasses, Patient does not wear glasses, patient does wear contacts, patient does not wear contacts]

[Tetanus up to date, Tetanus not up to date].

Review of Systems:

All other systems reviewed and are negative,

vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Eyes:

Left eye normal, Right eye normal,

vision intact, L *** / ***, R *** / ***,

[Left eye examined, Right eye examined],

[sclera normal, sclera injected]

[conjunctiva normal, conjunctiva injected]

no discharge,

[fluorescein exam reveal no corneal abrasions or foreign bodies,

corneal abrasion noted on fluorescein exam]

[foreign body seen, no foreign body seen]

negative Seidel sign

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of eye pain.

Vital signs revealed no major abnormalities.

Diagnosis at this time most consistent with conjunctivitis based on history and physical exam.

Differential diagnosis considered including [corneal abrasion, allergic conjunctivitis, corneal foreign body, eye irritation, blepharitis, sty/hordeolum, iritis, glaucoma, corneal ulcer, herpes keratitis, open globe]. These were thought to be less likely given the history, exam, and workup.

Natural course of conjunctivitis discussed with the patient. Symptomatic measures discussed. Advised on supportive therapies, including gently wiping d/c from eye w/ tissue from medial to lateral, changing pillowcases daily, refraining from wearing contact lenses and eye make-up, disposing of contact lenses and eye make-up, refraining from swimming, refraining from sharing hand towels, and thorough handwashing w/ soap and water. I have instructed the patient to return at any time if there are any new or worsening symptoms. Follow up with eye care provider if symptoms persist.

Patient prescribed [Tylenol, Ibuprofen, Vigamox Trimethoprim/polymyxin B ophthalmic (Polytrim)].

Eye Corneal Abrasion

History of Present Illness

Symptoms affect the [right eye, the left eye, both eyes]

Onset of symptoms was @@@ hours ago.

Pain is [mild, moderate, severe],

@/10 in severity.

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, irrigation, removing contacting, antibiotic ointment, warm compresses].

Patient does [wear glasses, Patient does not wear glasses, patient does wear contacts, patient does not wear contacts]

[Tetanus up to date, Tetanus not up to date].

Review of Systems:

All other systems reviewed and are negative,

vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Eyes:

Left eye normal, Right eye normal,

vision intact, L *** / ***, R *** / ***,

[Left eye examined, Right eye examined],

[sclera normal, sclera injected]

[conjunctiva normal, conjunctiva injected]

no discharge,

[fluorescein exam reveal no corneal abrasions or foreign bodies,

corneal abrasion noted on fluorescein exam]

[foreign body seen, no foreign body seen]

negative Seidel sign

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of eye pain.

Vital signs revealed no major abnormalities.

Diagnosis at this time most consistent with corneal abrasion based on history and physical exam.

Differential diagnosis considered including [conjunctivitis, allergic conjunctivitis, corneal foreign body, eye irritation, blepharitis, sty/hordeolum, iritis, glaucoma, corneal ulcer, herpes keratitis, open globe]. These were thought to be less likely given the history, exam, and workup.

Natural course of corneal abrasions discussed with the patient. I have instructed the patient to return at any time if there are any new or worsening symptoms. Follow up with eye care provider if symptoms persist. The patient expressed understanding of and agreement with this plan.

Patient prescribed [Tylenol, Ibuprofen, Vigamox, Cyclogyle 1%, Bion tear, Celluvisc]

Follow up in one or two days, return to clinic or urgent care with new or worsening symptoms, present to ER with new or worsening symptoms, follow up with ophthalmologist or eye provider.

Eye Eye Foreign Body

History of Present Illness

Symptoms affect the [right eye, the left eye, both eyes]

Onset of symptoms was @@@ hours ago.

Pain is [mild, moderate, severe],

@/10 in severity.

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, irrigation, removing contacting, antibiotic ointment, warm compresses].

Patient does [wear glasses, Patient does not wear glasses, patient does wear contacts, patient does not wear contacts]

[Tetanus up to date, Tetanus not up to date].

Review of Systems:

All other systems reviewed and are negative,

vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Eyes:

Left eye normal, Right eye normal,

vision intact, L *** / ***, R *** / ***,

[Left eye examined, Right eye examined],

[sclera normal, sclera injected]

[conjunctiva normal, conjunctiva injected]

no discharge,

[fluorescein exam reveal no corneal abrasions or foreign bodies,

corneal abrasion noted on fluorescein exam]

[foreign body seen, no foreign body seen]

negative Seidel sign

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of eye pain.

Vital signs revealed no major abnormalities.

Diagnosis at this time most consistent with eye foreign body based on history and physical exam. Foreign body removed.

Differential diagnosis considered including [conjunctivitis, allergic conjunctivitis, retained foreign body, eye irritation, blepharitis, sty/hordeolum, iritis, glaucoma, corneal ulcer, herpes keratitis, open globe]. These were thought to be less likely given the history, exam, and workup

I have instructed the patient to return at any time if there are any new or worsening symptoms. The patient expressed understanding of and agreement with this plan.

Patient prescribed [Trimethoprim/polymyxin B ophthalmic (Polytrim), Ciprofloxacin, Tylenol, Ibuprofen].

Follow up in one or two days, Follow up as needed, return to clinic or urgent care with new or worsening symptoms, present to ER with new or worsening symptoms, follow up with ophthalmologist or eye provider.

Eye Hordeolum / Stye

History of Present Illness

Symptoms affect the [right eye, the left eye, both eyes]

Onset of symptoms was @@@ hours ago.

Pain is [mild, moderate, severe],

@/10 in severity.

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, irrigation, removing contacting, antibiotic ointment, warm compresses].

Patient does [wear glasses, Patient does not wear glasses, patient does wear contacts, patient does not wear contacts]

[Tetanus up to date, Tetanus not up to date].

Review of Systems:

All other systems reviewed and are negative,

vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, nontender

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Eyes:

Left eye normal, Right eye normal,

vision intact, L *** / ***, R *** / ***,

[Left eye examined, Right eye examined],

[sclera normal, sclera injected]

[conjunctiva normal, conjunctiva injected]

no discharge,

[fluorescein exam reveal no corneal abrasions or foreign bodies,

corneal abrasion noted on fluorescein exam]

[foreign body seen, no foreign body seen]

negative Seidel sign

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of eye pain.

Vital signs revealed no major abnormalities.

Diagnosis at this time most consistent with a hordeolum based on history and physical exam.

Differential diagnosis considered including [corneal abrasion, allergic conjunctivitis, corneal foreign body, eye irritation, blepharitis, conjunctivitis, iritis, glaucoma, corneal ulcer, herpes keratitis, open globe]. These were thought to be less likely given the history, exam, and workup.

Natural course of illness was discussed with the patient. Symptomatic measures discussed. Advised on supportive therapies, including warm compresses, gently wiping d/c from eye w/ tissue from medial to lateral, changing pillowcases daily, refraining from wearing contact lenses and eye make-up, disposing of contact lenses and eye make-up, refraining from swimming, refraining from sharing hand towels, and thorough handwashing w/ soap and water. I have instructed the patient to return at any time if there are any new or worsening symptoms. Follow up with eye care provider if symptoms persist.

Patient prescribed Trimethoprim/polymyxin B ophthalmic (Polytrim)

Follow up in one or two days, return to clinic or urgent care with new or worsening symptoms, present to ER with new or worsening symptoms, follow up with ophthalmologist or eye provider.

GU UTI / Cystitis / Pyelonephritis

History of Present Illness

Patient presenting for evaluation of [urinary symptoms, dysuria, frequency, flank pain, hematuria, urgency, RLQ abdominal pain, LLQ abdominal pain, RUQ abdominal pain, LUQ abdominal pain, suprapubic abdominal pain, epigastric abdominal pain, vomiting, nausea, fever, vaginal bleeding, vaginal discharge].

Onset of symptoms was @@@ days ago.

Patient describes a [constant, intermittent],

[mild, sharp, heaviness, cramping, pressure, achy, burning, anterior, epigastric, left sided, right sided, bilateral pain].

Radiation of pain is [not present, chest, flank, to back, groin].

Pain is [mild, moderate, severe in severity].

Patient has associated symptoms of [nausea, vomiting, diarrhea, chest pain, shortness of breath, lightheadedness, flank pain].

Patient does not have symptoms of [nausea, vomiting, diarrhea, chest pain, shortness of breath, diaphoresis, lightheadedness, abd discomfort, flank pain].

Aggravating symptoms include [nothing, exercise, eating, drinking, movement, intercourse, menstrual period, urination].

Treatment prior to arrival includes [nothing, rest, cranberry juice, acid reflux medications, OTC Medications],

[with improvement, without improvement].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed.

denies [chest pain, shortness of breath, dyspnea on exertion, headache, vision changes, lightheadedness, abdominal pain, nausea or vomiting, back pain, urinary symptoms, leg swelling, fever, chills/sweats, weight gain, weight loss, sore throat, cough, suicidal thoughts]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Extremities: Non-tender. No peripheral edema.

Back: No tenderness

Neuro: No gross motor deficits

Skin: Normal color. Warm and Dry

Abdomen:

soft, nontender,

[bowel sounds normal, bowel sounds hyperactive, bowel sounds hypoactive],

[distended, nondistended],

[tenderness, tenderness RUQ, tenderness RLQ, tenderness LLQ, tenderness LUQ, tenderness epigastric, tenderness suprapubic],

[no rebound or guarding, rebound, guarding],

[positive Murphy's sign, negative Murphy's sign],

[positive McBurney's tenderness, negative McBurney's tenderness]

Pelvic Exam:

pelvic exam performed with chaperone present,

(Normal) external female genitalia. Normal vaginal mucosal without lesions.

Cervix is visualized, normal in appearance without lesions or erythema.

There is a small amount of white, thin vaginal discharge. GC/C obtained.

Bimannual reveals a normal sized uterus with no adnexal fullness or cervical motion tenderness.,

[normal external genitalia, external genitalia rash present],

[normal vaginal mucosal without lesions, erythematous vaginal mucosa],

[cervix is visualized, normal in appearance without lesions or erythema, cervix not visualized, cervix friable, cervix erythematous],

[no discharge, physiologic discharge present, bloody discharge, whitish discharge,

cultures obtained],

[normal sized uterus, enlarged uterus, no masses palpated],

[no adnexal tenderness, left adnexal tenderness, right adnexal tenderness],

[no cervical motion tenderness, cervical motion tenderness present]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [urinary symptoms, abdominal pain, dysuria, frequency, urgency, hematuria, abdominal cramping, abdominal discomfort, nausea, vomiting, diarrhea, flank pain, fever, decreased appetite, vaginal bleeding, vaginal discharge].

Vital signs revealed no major abnormalities, [no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time most consistent with [urinary tract infection, dysuria, sexually transmitted infection, cystitis, yeast infection, vaginitis, nausea, vomiting, diarrhea, constipation, pyelonephritis, HSV].

Differential diagnosis considered including [nausea, vomiting, diarrhea, constipation, gastroenteritis, viral illness, urinary tract infection, pyelonephritis, abdominal gas cramping, appendicitis, biliary colic, pancreatitis, bowel obstruction, diverticulitis, dysmenorrhea, pregnancy, ovarian cyst, pelvic inflammatory disease, sexually transmitted infection, vulvovaginitis, yeast infection, ***]. These were thought to be less likely given the history, exam, and workup.

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

[urinalysis appears infected, urinalysis without signs of infection],

urine pregnancy test negative,

Abd Xray reveals no evidence of pneumonia or other acute process,

[WBC elevated, WBC normal],

liver functions normal, lipase normal,

wet prep negative,

sexually transmitted infection testing pending.

Treatments provided included [tylenol, ibuprofen, Ondansetron (Zofran), IV Fluids, oral hydration, enema, suppository],

[with improvement in symptoms, without improvement in symptoms].

Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Drink plenty of fluids. Can use cranberry juice. Applying a heating pad can help soothe the area.

Monitor for new or worsening symptoms.

Patient prescribed [Amoxicillin, Cefotaxime (Claforan), Amoxicillin and clavulanate (Augmentin), Sulfamethoxazole and trimethoprim (Bactrim), Cephalexin (Keflex), Nitrofurantoin (Macrobid), Pyridium, naproxen, Zofran].

Follow up in one or two days,

present to ER with new or worsening symptoms.

Medical Decision Making

Patient presenting for evaluation of [urinary symptoms, abdominal pain, fever, dysuria, frequency, urgency, hematuria, abdominal cramping, abdominal discomfort, nausea, vomiting, diarrhea, constipation, decreased appetite, vaginal bleeding, vaginal discharge].

Vital signs revealed no major abnormalities.

Diagnosis at this time is most consistent with [pyelonephritis, urinary tract infection, dysuria, sexually transmitted infection, cystitis, yeast infection, vaginitis, nausea, vomiting, diarrhea, constipation, HSV].

Differential diagnosis considered including [nausea, vomiting, diarrhea, constipation, gastroenteritis, viral illness, urinary tract infection, pyelonephritis, dysuria, abdominal gas cramping, appendicitis, biliary colic, pancreatitis, bowel obstruction, diverticulitis, dysmenorrhea, pregnancy, ovarian cyst, pelvic inflammatory disease, sexually transmitted infection, vulvovaginitis, yeast infection, ***].

These were thought to be less likely given the history, exam, and workup.

Diagnostic testing performed:

Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed,

Abd Xray reveals no evidence of pneumonia or other acute process,

WBC elevated, WBC normal,

liver functions normal, lipase normal,

urinalysis appears infected, urinalysis without signs of infection,

urine pregnancy test negative,

wet prep negative,

sexually transmitted infection testing pending,

pelvic ultrasound unremarkable.

Treatments provided included [tylenol, ibuprofen, Ondansetron (Zofran), IV Fluids, oral hydration, dilaudid, morphine, fentanyl, rocephin],

[with improvement in symptoms, without improvement in symptoms].

Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Drink plenty of fluids. Can use cranberry juice. Applying a heating pad can help soothe the area.

Monitor for new or worsening symptoms.

Follow up in one or two days,

return to ER with new or worsening symptoms.

MSK Ankle Pain / Sprain

History of Present Illness

Patient presenting for evaluation of left ankle pain, right ankle pain, hip pain, thigh pain, knee pain, lower leg pain, foot pain, toe pain, fall, injury, motor vehicle accident, bicycle accident, laceration. Onset of symptoms was @@@ hours ago. Patient describes left, right, 1st, 2nd, 3rd, 4th, 5th, hip, thigh, knee, lower leg, ankle, foot, toe, nail pain. Pain is mild, moderate, severe, 5/10 in severity. Patient has associated symptoms of pain, brusing, swelling, redness, warmth, bleeding, numbness, tingling, weakness, inability to bear weight. Patient does not have symptoms of pain, bruising, swelling, redness, warmth, bleeding, numbness, tingling, weakness, loss of consciousness. Treatment prior to arrival includes nothing, Tylenol, Ibuprofen, compression, splinting, elevation, rest, ice.

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed, denies chest pain, denies shortness of breath, denies dyspnea on exertion, denies headache, denies vision changes, denies lightheadedness, denies abdominal pain, denies back pain, denies urinary symptoms, denies leg swelling, denies fever, denies chills/sweats, denies weight gain, denies weight loss, denies sore throat, denies cough, denies suicidal thoughts

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Back: No tenderness

Skin: Warm, dry

Neuro: No deficits

Ankle Exam:

No bony or soft tissue deformity. There is no soft tissue swelling. No pain on palpation., tenderness along the medial malleolus, tenderness along the lateral malleolus, fifth metatarsal tenderness, anterior ankle tenderness, no swelling, bruising, or warmth, swelling present, bruising present, warmth present, no laxity, neurovascularly intact

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [ankle pain, extremity pain, hip pain, thigh pain, knee pain, lower leg pain, foot pain, toe pain, motor vehicle accident, bicycle accident, laceration, abrasion, wound].

Vital signs revealed no major abnormalities, [no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time most consistent with [sprain, strain, contusion, bruise, fracture, dislocation, tendinitis, extremity pain, hip strain, knee sprain, ankle sprain, ***.]

Differential diagnosis considered including [contusion, bruise, trauma, extremity pain, head trauma, fracture, fall, motor vehicle accident, bike accident, gout, septic joint, arthritis, ***.] These were thought to be less likely given the history, exam, and workup.

Diagnostic testing performed:

Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed,

[Xray imaging shows no evidence of fracture, Xray shows fracture,

head CT showed no acute findings,

CT cervical shows no evidence of acute injury,

CT maxillofacial shows no acute findings.]

Treatments provided included [tylenol, ibuprofen, morphine, dilaudid, toradol, naproxen, crutches, ACE wrap, sling placement, splint placement, walking boot, ice],

[with improvement in symptoms, without improvement in symptoms.]

Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Recommend rest, ice, elevation, and compression.

Monitor for new or worsening symptoms.

Follow up with orthopedic povider

Patient prescribed Tylenol, Ibuprofen, crutches, physical therapy.

Follow up in one or two days,

present to ER with new or worsening symptoms,

Follow up with orthopedic provider.

MSK Back Pain

History of Present Illness

Patient presenting for evaluation of [back pain, low back pain, muscle spasm, pain down leg, neck pain, shoulder pain, fall, motor vehicle accident, bicycle accident, extremity pain, hip pain, knee pain, laceration, abrasion, wound, injury, chronic back pain].

Onset of symptoms was @@@ days ago.

Patient describes [left, right, low, middle, back, cervical, thoracic, lumbar, mid, flank, chest, abdomen, groin, shoulder, upper arm, forearm, wrist, hand, finger, hip, knee, lower leg, ankle, foot, toe, nail, tailbone pain].

Pain is [mild, moderate, severe],[ 5/10] in severity.

Patient has associated symptoms of [pain, brusing, swelling, redness, warmth, bleeding, numbness, tingling, weakness, shooting pain down leg].

Patient does not have symptoms of [pain, bruising, swelling, redness, warmth, bleeding, numbness, tingling, weakness, bowel / bladder incontinence, fever, weight loss, radicular symptoms].

Patient has had no reported [trauma to the neck, no prior history of pain at this site, history of prior back surgery, had no prior back surgeries, has history of prior herniated disc, has history of prior radicular symptoms].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, hydrocodone, muscle relaxer, rest, ice, heat].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

denies [chest pain, shortness of breath, dyspnea on exertion, headache, vision changes, denies lightheadedness, abdominal pain, back pain, urinary symptoms, leg swelling, fever, denies chills/sweats, weight gain, weight loss, sore throat, cough, suicidal thoughts]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Skin: Warm, dry

Neuro: No deficits

Musculoskeletal:

[normal ROM, decreased ROM],

[nontender, tenderness mid back, tenderness thoracic spine, tenderness lumbar spine, midline tenderness],

[bruising, no bruising, swelling, no swelling],

normal gluteal tone,

[negative straight leg raise bilaterally, positive straight leg raise on the right, positive straight leg raise left,]

normal rectal tone, normal strength in lower extremities, normal reflexes, normal sensation

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [back pain, back spasm, chronic back pain, neck pain, fall, head trauma, motor vehicle accident, bicycle accident, extremity pain, finger pain, foot pain, toe pain, laceration, abrasion.]

Vital signs revealed no major abnormalities,

[no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time most consistent with [back pain, lumbar strain, muscle spasm, Lumbar radiculopathy, herniated disc, sciatica, gluteal strain, neck pain, fall, contusion, bruise, injury, ***.]

Differential diagnosis considered including [back pain, lumbar strain, muscle spasm, herniated disc, cauda equina, malignancy, fracture, fall, contusion, bruise, motor vehicle accident, injury, ***]. These were thought to be less likely given the history, exam, and workup.

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

[Xray imaging shows no evidence of fracture, Xray shows fracture],

[head CT showed no acute findings, CT lumbar shows no evidence of acute injury, MRI shows no acute findings].

Treatments provided included [tylenol, ibuprofen, morphine, fentanyl, dilaudid, toradol, naproxen, valium, flexeril, heat, ice],

[with improvement in symptoms, without improvement in symptoms].

Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Recommend rest, ice, elevation, and compression.

Monitor for new or worsening symptoms.

Follow up with orthopedic povider

Patient prescribed [Tylenol, Ibuprofen, Tylenol with Codeine, Naproxen, Robaxin, Gabapentin, valium, prednisone, medrol dose pack, physical therapy.]

Follow up in one or two days,

present to ER with new or worsening symptoms,

Follow up with orthopedic provider.

MSK Back pain (Top)

Mr./Mrs. XXX XX years old [male/female] presented today to our emergency department for the evaluation of his back pain.

Past medical history

Past surgical history

Medication allergy

Social history

History of present illness:

The patient states that he developed [right/left] [Upper/lower] back pain for XX days duration.

the pain start [gradually/suddenly], [mild/moderate/severe], [X/10] in severity, the pain aggravated with [movement/exercise/walking], decreased with [rest/ nothing]. The pain is [intermittent/persistent worse at night]. The pain is [Buttock dominant/leg dominant]

There is no fever, rigor no history of IVDU, No history of urinary or bowel incontinence or retention, No change in bowel habits

No history of diabetes, Chemo or radiotherapy, No Hx of cancer or Wt loss or trauma.

No G.I. or GU symptoms no respiratory symptoms like shortness of breath or chest pain.

No history of vaginal bleeding or discharge patient is sexually [active/inactive] no history of spinal injection steroid injection or instrumentation recently.

On examination:

The patient was alert, oriented x3, [not in distress/in distress/in pain].

Viral Signs reviewed

Chest: Good air entry bilaterally noise S1 S2 no murmur

Abdomen soft no tenderness no organomegaly no Mas no positive mass not come waters no CVA tenderness.

Back and lower limbs: The visual inspection of the back is grossly a remarkable, free of redness or eccemosis, no swelling. Patient half [tenderness/no tenderness] to palpation of the thoracic and lumbar sacral spine with no palpable defect. The patient has no other bone or joint line tenderness. The patient has [normal/limited] flexion of the waist. [Normal/limited] extension of the back of the waist, and [normal/limited] rotation of the back. Range of motion is [normal/limited].

Strength is five over five both lower limbs sensation is intact in bilateral lower limbs

Dorsalis pedis and posterior tibial artery walls are 2+ and symmetrical,

ankle and Knee reflex 2+ and symmetrical

Babinski test was normal the patient was able to walk on his heel and his toes, Normal Gait no Ataxia.

Straight leg test is [normal/abnormal] at xx degree.

Faber test [normal/positive]

Normal sensation at the intergluteal cleft and the saddle area the perineum rectal tone normal.

Workup

Bedside ultrasound done no sign of AAA

EKG Nil acute , CBC and electrolytes and ESR/CRP are within normal range. BHcG -ve

lumbosacral and pelvic x-ray Nil acute. CT scan Nil accurate

Post void residual bladder scan less than 150 mL.

Assessment and plan:

Mr./Mrs. XXX presents today for the evaluation of [his/her] back pain for the last xx days.

With normal physical exam except XXX with no red flags for Cauda Equina or Spinal Abscess.

After thorough history, physical exam, and workup. I don’t think the back pain due to AAA or dissecting abdominal aneurism,

less likely to be a Cauda Equina or a spinal abscess.

less likely to be due to the renal cause like pylo or renal stone.

with normal abdominal panel and soft abdomen, it’s less likely to be in Abdominal pathology like pancreatitis

with normal ECG and top troponin is likely to be an ACS and

we exclude ectopic by doing BHcg.

I think at the time of the evaluation the working diagnosis is [non-specific mechanical back pain / radiculopathy / spinal stenosis]

the patient receives pain medication Tylenol 1 g PO and Toradol 15 mg IV, with improvement after one hour.

I discussed the findings and result of the work up with the patients and the plan is:

- Discharge home

- Rest but I Encourage early mobilisation and remaining physically active

- Pain medication:

o Tylenol PO 1g, orally, q4-6h (Max 4g/d)

o Ibuprofen PO 400mg, orally q6-8h

o Oxycodone PO 5-10mg, orally, q4-6h PRN (Max 30mg/d)

o Or Oxycodone 2.5mg, orally, q4-6h, in elderly, > 75 years

o PPI

o Gabapentin – 100-300mg, orally, nocte; increase dose gradually over 3-7 day

- follow up with the family physician within two days to arrange for physiotherapy and follow.

- Referral to the Back-pain Clinic

The patient was clinically stable at the time of discharge home return to ED instruction explained questions answered and the patient was happy with the plan. I asked the patient to follow up with the FP within two days and return to ED if develop new symptoms, such as fever, leg weakness, Saddle area numbness, difficulty with or loss of control of your urine or bowels, abdominal pain, or more severe pain or any other concern.

It has been a pleasure to be involved in the care of Mr./Mrs. XXX

Note: get out of my exist despite proof reading since it’s a voice generated dictation

MSK Orthopaedic Physical Examination Templates

Neck

Visual inspection of The patient neck is grossly unremarkable, free of erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation of ***. There are no palpable defects. There is no other bony and/or joint line tenderness to palpation of the neck.
The patient has *** flexion of the neck, *** extension of the neck, and *** rotation of the neck. Range of motion is ***. Resisted range of motion is ***. Strength is *** out of 5 with the aforementioned movements.
Sensation is intact in the bilateral upper extremities.
Radial pulses are 2+ and symmetric.
Brachioradialis and triceps tendon reflexes are 2+ and symmetric.
Spurling's testing is ***.

Shoulder

Visual inspection of the *** shoulder is grossly unremarkable, free of erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation ***. There are no palpable defects. There is no other bony and/or joint line tenderness to palpation.
The patient has *** degrees of forward flexion, *** degrees of abduction, *** degrees of external rotation, and *** internal rotation.
Range of motion is ***. Resisted range of motion ***. Strength is *** out of 5 with the aforementioned movements.
Sensation is intact in the bilateral upper extremities.
Radial pulses are 2+ and symmetric.
Empty can, full can, O'Brien's, Hawkins, Neers, Yergason's, Speeds, bear hugger, belly press, scapular lift off, and crossbody adduction testing is negative.
The patient has *** apprehension. Modified dynamic sheer testing is ***.

Elbow

Visual inspection of the *** elbow reveals no gross deformities, including erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation ***. There are no palpable defects. No other bony and/or joint line tenderness to palpation is appreciated.
The patient has full flexion, extension, supination, and pronation of the *** elbow compared to the *** elbow. Range of motion is smooth and painless. The patient has *** pain with resisted ***. Strength is *** out of 5 with the aforementioned movements.
Sensation is intact in the bilateral upper extremities.
Radial pulses are 2+ and symmetric.
Floating valgus, varus, and milking maneuver testing is negative.
Hook test is negative.
Cozen's test is ***.
Mill's test is ***.
Maudsley's test is ***.

Wrist

Visual inspection of the *** wrist is grossly unremarkable, free of erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation ***. No palpable defects are noted. There is no other bony and/or joint line tenderness to palpation.
The patient has *** flexion and *** extension of the *** wrist. Ulnar and radial deviation are *** compared to the *** wrist.
The patient range of motion is ***. Strength is *** out of 5 with the aforementioned movements.
Sensation is intact in the bilateral upper extremities.
Radial pulses are 2+ and symmetric.
There is *** laxity with radial and/or ulnar deviation.
The patient's grip strength is appropriate and symmetric.
Scaphoid shift testing is ***.
Shuck testing is ***.
TFCC compression testing is ***.

Hand

Visual inspection of the *** hand is grossly unremarkable, free of erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation ***. No palpable defects are noted. There is no other bony and/or joint line tenderness to palpation.
The patient has *** flexion and *** extension of the ***. Thumb opposition is ***. Ulnar and radial deviation of the *** wrist are *** compared to the *** wrist.
The patient range of motion is ***. Strength is *** out of 5 with the aforementioned movements.
Sensation is intact in the bilateral upper extremities.
Radial pulses are 2+ and symmetric. There is *** laxity with radial and/or ulnar deviation of the wrist.
The patient has *** angulation of the fingers while making a fist.
The patient's grip strength is appropriate and symmetric.
Finkelstein’s test is ***.

Back

Visual inspection of @HIS@ back is grossly unremarkable, free of erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation of ***. There are no palpable defects.
There is no other bony and/or joint line tenderness to palpation of the back.
The patient has *** flexion at the waist, *** extension of the back at the waist, and *** rotation of the back.
Range of motion is ***. Resisted range of motion is ***.
Strength is *** out of 5 with the aforementioned movements.
Sensation is intact in the bilateral lower extremities.
Dorsalis pedis and posterior tibial pulses are 2+ and symmetric.
Achilles and patellar tendon reflexes are 2+ and symmetric.
Seated slump testing is ***.
Straight leg raise testing is ***.
The patient has *** pain with Stork testing ***.
The patient's single leg stance ***.

Hip

Visual inspection of the *** hip is grossly unremarkable, free of erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation ***.
There is no other bony and/or joint line tenderness to palpation.
The patient has full and symmetric flexion, extension, internal rotation, external rotation, abduction, and adduction of the *** hip compared to the *** hip.
Range of motion is ***. @CAPHE@ *** pain with resisted *** of the *** hip. Strength is *** out of 5 with the aforementioned movements.
Sensation is intact in the bilateral lower extremities.
Dorsalis pedis and posterior tibial pulses are 2+ and symmetric in the bilateral lower extremities.
FABER, FADIR, and resisted logroll maneuvers are negative.
Scour testing is ***. Ober testing is ***.

Knee

Visual inspection of the *** knee reveals no erythema, ecchymosis, effusion, and/or atrophy.
The patient has *** tenderness to palpation ***. There are no palpable defects noted. There is no other joint line or other bony tenderness to palpation.
The patient has *** flexion and *** extension of the *** knee compared to the *** knee. Range of motion is ***. Resisted range of motion is ***.
Strength is *** out of 5 with the aforementioned movements.
Sensation is intact in the bilateral lower extremities.
Dorsalis pedis and posterior tibial pulses are 2+ and symmetric in the lower extremities.
Anterior drawer, Lachman's, lever, posterior drawer, McMurray's, Thessaly, valgus stress testing at 0° and 30°, and varus stress testing at 0° and 30° is negative.
Deep knee flexion testing is ***.
Duck walking is ***. Patellar grind, quadriceps inhibition, and patellar apprehension testing are negative.

Ankle

Visual inspection of the *** ankle is grossly unremarkable, free of erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation ***. There are no palpable defects. There is no other bony and/or joint line tenderness to palpation.
The patient has full and symmetric plantar flexion, dorsiflexion, inversion, and eversion of the *** ankle compared to the *** ankle. Resisted *** is not painful for the patient. Strength is *** out of 5 with all of the aforementioned movements.
Sensation is intact in the bilateral lower extremities.
Dorsalis pedis and posterior tibial pulses are 2+ and symmetric.
The patient subtalar motion is smooth. Anterior drawer, talar tilt, and hop testing is negative.
The patient has *** pain with external rotation and resisted dorsiflexion.
The patient has *** pain with external rotation and resisted plantar flexion (Kleiger’s test).
Thompson testing is ***.
Single legged stance reveals ***.

Foot

Visual inspection of the *** foot is grossly unremarkable, free of erythema, ecchymosis, swelling, and/or atrophy.
The patient has *** tenderness to palpation ***. There are no palpable defects. There is no other bony and/or joint line tenderness to palpation.
The patient has *** flexion and extension of the toes bilaterally.
The patient also has *** plantar flexion, dorsiflexion, inversion, and eversion of the *** ankle compared to the *** ankle. Resisted range of motion is ***.
Strength is *** out of 5 with all of the aforementioned movements.
Sensation was intact in the bilateral lower extremities.
Dorsalis pedis and posterior tibial pulses were 2+ and symmetric.
The patient subtalar motion is smooth.
Hop testing is ***.
The patient has *** pain with plantar flexion and abduction of the great toe.
The patient's gait ***.

Neuro Headache/Migraine

History of Present Illness

Patient presenting for evaluation of [migraine, headache, trauma related headache, eye pain, nausea, vomiting, neck pain, fever, vision changes, photophobia, sinus pain].

Onset of symptoms was @@@ hours ago.

Patient describes a [left sided, right sided],

[acute, constant, intermittent],

[mild, sharp, recurrent, pressure, diffuse, frontal, temporal, occipital, orbital pain].

Pain is [mild, moderate, severe],

[5/10] in severity.

Patient has associated symptoms of [nausea, vomiting, vision changes, aura, photophobia, phonophobia, eye pain, dizziness, weakness, fever, neck pain, chest pain, shortness of breath, abdominal pain].

Patient does not have symptoms of [nausea, vomiting, vision changes, aura, photophobia, phonophobia, eye pain, dizziness, weakness, fever, neck pain, chest pain, shortness of breath, abdominal pain].

Aggravating symptoms include [nothing, stress, menstruation, lack of sleep, certain foods, hunger, exercise, light, loud noises].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, OTC headache medications, OTC Medications, imitrex, rest, sleep, ice].

Patient has had [history of headaches, no history of headaches],

[history of migraines, no history of migraines],

[recent head trauma, no recent head trauma].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

denies [chest pain, shortness of breath, dyspnea on exertion, headache, vision changes, lightheadedness, abdominal pain, back pain, urinary symptoms, leg swelling, fever, chills/sweats, weight gain, weight loss, sore throat, cough, suicidal thoughts]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Skin: Warm, dry

Neurological:

[alert, oriented x3, CN II-XII intact, normal strength throughout, normal sensation throughout, no pronator drift, no abnormal coordination, normal gait],

[left facial droop, right facial droop],

[left upper extremity weakness, right upper extremity weakness],

[left lower extremity weakness, right lower extremity weakness, diffuse weakness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with headache.

Patient has a normal neurologic exam.

No evidence of [acute intracranial hemorrhage, venous sinus thrombosis, central nervous system infection, ocular disease to warrant imaging at this time].

DDx also included [sinus disease, intracranial bleed, stroke, cluster headache, trigeminal neuralgia, tension headache], but there were felt to be less likely based on history and exam.

Presentation most consistent with migraine.

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed,]

[head CT showed no acute findings],

[MRI head showed no acute findings],

Chest Xray reveals no evidence of pneumonia or other acute process,

WBC elevated, WBC normal,

electrolytes normal, urinalysis without signs of infection, urine pregnancy test negative.

Treatments provided included [tylenol, ibuprofen, IV Fluids, Metoclopramide (Reglan), Promethazine (Phenergan), Chlorpromazine, magnesium, IV dihydroergotamine, zofran, benadryl, toradol, naproxen, Sumatriptan],

[with improvement in symptoms, without improvement in symptoms].

Patient prescribed [Tylenol, Ibuprofen, Tylenol with Codeine, Hydrocodone, Oxycodone, Naproxen, Etodolac, Lodine, Reglan, Sumatriptan].

Advised patient on supportive therapies, including resting in a dark quiet place, relaxation techniques, hydrating w/ >8cups of H2O/d and uncaffeinated and EtOH beverages, heat application, refrain from smoking and smoke exposures.

Advised Pt to monitor for worrisome signs and symptoms, including neurosensory/motor deficits, difficulty articulating, visual disturbances, dizziness, neck stiffness, decreased cognition, worsening pain, and N/V/F/C. Follow up with primary provider. Present to ER with new or worsening symptoms.

Follow up in one or two days, return to ER with new or worsening symptoms.

Neuro Seizure

History of Present Illness

Patient presenting for evaluation of [seizure, seizure like activity, shaking episode, dizziness, vertigo, syncope, head trauma, nausea, vomiting, fall].

Patient was noted to have a [loss of consciousness, noted to have tonic clonic movements, noted to have staring episodes, incontinent, noted to bite their tongue, post-ictal following the event].

Patient has associated symptoms of [headache, nausea, vomiting, diaphoresis, lightheadedness, chest pain, abdominal pain, abd discomfort, leg swelling, leg pain, dizziness].

Patient does not have symptoms of [headache, nausea, vomiting, diaphoresis, lightheadedness, chest pain, abdominal pain, abd discomfort, dizziness, numbness, weakness, tingling].

Treatment prior to arrival includes [nothing, ativan, valium, versed, IV fluids, home seizure medications],

[with improvement, without improvement].

Patient has a history of [seizures, had no prior seizures],

[previously been prescribed seizure medications],

a history of being [non-compliant with seizure medications, a history of alcohol withdrawal seizures].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

denies [chest pain, shortness of breath, dyspnea on exertion, headache, vision changes, denies lightheadedness, abdominal pain, back pain, urinary symptoms, leg swelling, denies fever, chills/sweats, weight gain, weight loss, sore throat, cough, suicidal thoughts]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Skin: Warm, dry

Neurological:

alert, oriented x3, CN II-XII intact, normal strength throughout, normal sensation throughout, no pronator drift, no abnormal coordination, normal gait,

[left facial droop, right facial droop],

[left upper extremity weakness, right upper extremity weakness],

[left lower extremity weakness, right lower extremity weakness, diffuse weakness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of seizure.

No evidence of [cranial nerve deficits, neurologic deficits, ataxia].

No evidence of [acute intracranial hemorrhage, venous sinus thrombosis, central nervous system infection].

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

EKG shows normal sinus rhythm without acute ST elevation/depression. No acute T-wave changes,

Chest Xray reveals no evidence of pneumonia or other acute process,

CT of the head shows no acute findings,

[WBC elevated, WBC normal, metabolic panel normal, D-Dimer Elevated, D-Dimer normal, troponin normal, urinalysis without signs of infection, pregnancy test negative, lactate normal, lactate normal, therapeutic drug levels pending, ***.]

Treatments provided included [IV fluids, ativan, valium, versed, keppra, fosphenytoin, Phenytoin, Zofran],

[with improvement in symptoms, without improvement in symptoms].

Patient prescribed [ativan, valium, librium, keppra, Tylenol, Ibuprofen, zofran, ***.]

Patient will be discharged home.

Patient advised to return to ER if [repeat seizures, alteration in mental status, onset of fevers, visual changes, or peripheral weakness/numbness/tingling].

First Aid Seizure Treatment was discussed.

Instructed Pt to monitor for neurologic symptoms, repeat seizures, alteration in mental status, onset of fevers, visual changes, or peripheral weakness/numbness/tingling.

No driving for 6 months after last episode of loss of consciousness. Avoid high place, open flames, and open water. No swimming or bathing unsupervised. We encourage you to take showers instead of baths.

Follow up in one or two days,

present to ER with new or worsening symptoms,

Referral placed to neurology.

Neuro Stroke / TIA

History of Present Illness

Patient presenting for evaluation of [dizziness, vertigo, syncope, slurred speech, weakness, unilateral weakness, altered mental status, gait instability, vision changes].

Onset of symptoms was @@@ minutes ago.

Symptoms [stable since onset, worsening since onset, progressive since onset, resolved since onset].

Aggravating symptoms include [nothing, movement, walking, eating, drinking, deep breaths, turning head, sitting forward, lying flat, standing up].

Patient has associated symptoms of [Fever, headache, nausea, vomiting, shortness of breath, lightheadedness, Neck pain, chest pain, abdominal pain, abd discomfort, leg swelling, leg pain, dizziness, room spinning sensation, tinnitus].

Patient does not have symptoms of [Fever, headache, nausea, vomiting, shortness of breath, lightheadedness, Neck pain, chest pain, abdominal pain, abd discomfort, leg swelling, leg pain, dizziness, vision changes, speech changes].

Patient has had [recent aspirin, no recent aspirin, recent blood thinning medications, no recent blood thinning medications, recent head trauma, no recent head trauma, prior episodes of vertigo, no prior episodes of vertigo, a history of seizures, no prior seizures].

Patient has history of [none of the major cardiac / CVA risk factors, coronary artery disease, hypertension, hyperlipidemia, tobacco use, prior MI, prior stroke, family history of coronary disease].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

denies [chest pain, shortness of breath, dyspnea on exertion, headache, vision changes, lightheadedness, abdominal pain, back pain, urinary symptoms, leg swelling, fever, denies chills/sweats, weight gain, weight loss, sore throat, cough]

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Skin: Warm, dry

Neurological:

alert, oriented x3, CN II-XII intact,

[normal strength throughout, normal sensation throughout, no pronator drift, no abnormal coordination, normal gait]

[left facial droop, right facial droop],

[left upper extremity weakness, right upper extremity weakness,]

[left lower extremity weakness, right lower extremity weakness,]

[diffuse weakness]

Past Medical History: none

Past Surgical History: non

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with neurologic changes concerning for stroke. Patient sent for emergent head CT. This showed no acute evidence of hemorrhage or intracranial mass. Patient was felt to not be a candidate for tPA. Patient remained neurologically stable while in ER.

Symptoms at this time most consistent with the diagnosis of transient ischemic attack. Other differential considered including [CVA, head bleed, intracranial mass, MS, aortic dissection, ACS, PE], but these were thought to be less likely based on history, exam, and workup.

Symptoms at this time most consistent with the diagnosis of stroke. Other differential considered including [TIA, head bleed, intracranial mass, MS, aortic dissection, ACS, PE], but these were thought to be less likely based on history, exam, and workup.

Diagnostic testing performed:

Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed,

EKG shows normal sinus rhythm without acute ST elevation/depression. No acute T-wave changes,

[Chest Xray reveals no evidence of pneumonia or other acute process, ]

[CT of the head shows no acute findings, ]

[MRI of the head shows no acute pathology, ***, ]

[WBC elevated, WBC normal, ]

[metabolic panel normal, troponin normal, urinalysis without signs of infection, ***].

Treatments provided included [IV fluids, meclizine, valium, ativan, Zofran],

[with improvement in symptoms, without improvement in symptoms].

Patient to be admitted for further workup and treatment.

Neuro Vertigo / Dizziness

History of Present Illness

Patient presenting for evaluation of [dizziness, vertigo, disequalibirum, , near syncope, syncope, lightheadedness, weakness, chest pain, chest pressure, chest wall pain, shortness of breath, nausea, vomiting, diaphoresis, palpitations, dehydration, fall].

Onset of symptoms was @@@ hours ago.

Aggravating symptoms include [nothing, movement, exercise, eating, drinking, deep breaths, turning head, sitting forward, lying flat, standing up].

Patient has associated symptoms of [nausea, vomiting, diaphoresis, shortness of breath, lightheadedness, chest pain, abdominal pain, abd discomfort, leg swelling, leg pain, dizziness, room spinning sensation, tinnitus].

Patient does not have symptoms of [nausea, vomiting, diaphoresis, shortness of breath, lightheadedness, chest pain, abdominal pain, abd discomfort, leg swelling, leg pain, dizziness, room spinning sensation, tinnitus].

Treatment prior to arrival includes [nothing, rest, aspirin, nitroglycerin, acid reflux medications, OTC Medications, meclizine],

[with improvement, without improvement].

Patient has had [recent travel, no recent travel], [recent surgery, no recent surgery], [leg swelling/pain, no leg swelling/pain], [estrogen containing medications, no estrogen containing medications], [prior episodes of vertigo, no prior episodes of vertigo], [a history of seizures, no prior seizures].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Skin: Warm, dry

Neurological:

alert, oriented x3, CN II-XII intact, normal strength throughout, normal sensation throughout, no pronator drift, no abnormal coordination, normal gait,

[left facial droop, right facial droop],

[left upper extremity weakness, right upper extremity weakness,]

[left lower extremity weakness, right lower extremity weakness, diffuse weakness]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting with dizziness. [Neurologic exam within normal limits].

Diagnostic testing performed:

Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

EKG shows normal sinus rhythm without acute ST elevation/depression. No acute T-wave changes,

Chest Xray reveals no evidence of pneumonia or other acute process,

CT of the head shows no acute findings,

[WBC elevated, WBC normal], metabolic panel normal,

[D-Dimer Elevated, D-Dimer normal], troponin normal,

[urinalysis without signs of infection, ]

[patient is orthostatic, patient is not orthostatic, ***.]

Treatments provided included [IV fluids, aspirin, meclizine, valium, ativan, zofran, Epley Manuever],

[with improvement in symptoms, without improvement in symptoms].

At this time, it is felt that the most likely explanation for the patient's symptoms is peripheral vertigo. I also considered [stroke, cerebellar mass, Ménière's disease, vestibular neuritis, labyrinthitis, atypical migraine] but this appears less likely considering the data gathered thus far. The patient expressed understanding of and agreement with this plan.

Opportunity was given for questions prior to discharge and all stated questions were answered to the patient's satisfaction. Home care instructions provided. Symptomatic measures were discussed.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Monitor for new or worsening symptoms.

Patient encourage to rest,increase fluid hydration.

Patient prescribed [meclizine, zofran, valium, nitroglycerin, aspirin, Tylenol, Ibuprofen, Aleve].

Follow up in one or two days, return to ER with new or worsening symptoms.

Patient will be admitted. Discussed case with [Dr. ***] who will admit.

Psyc Alcohol Abuse / Intoxication

History of Present Illness:

Patient presenting for evaluation of [alcohol intoxication, alcohol abuse, drug abuse, drug intoxication, anxiety, panic attacks, depression, insomnia, hallucinations, suicidality without plan, suicidality with plan, agitation, medical clearance].

Onset of symptoms was @@@ hours ago.

Patient reports symptoms of [confusion, falls, weakness, nausea, vomiting, abdominal pain, head trauma, depressed mood, anxiety, thoughts of suicide, hallucinations].

Patient denies symptoms of [confusion, Falls, weakness, nausea, vomiting, abdominal pain, head trauma, depressed mood, anxiety, thoughts of suicide, hallucinations].

Previous treatments include [nothing, medications, group therapy, individual therapy, counseling, rehab, hospitalization],

[with improvement, without improvement].

Patient has had [no thoughts of suicide, thoughts of suicide without plan, thoughts of suicide with plan], [no recent alcohol use, recent alcohol use], [no drug use, recent drug use], [no recent stressors, recent stressful events].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Neuro: No gross motor deficits

Psychiatric:

normal affect, normal behavior,

[depressed mood, denies depression], [anxious, denies anxiety], [judgement normal, agitated], [suicidal thoughts, no suidical thoughts], no hallucinations, [normal sleep patterns, decreased sleep, increased sleep], [normal concentration, decreased concentration], [poor eye contact, good eye contact]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [alcohol abuse, alcohol intoxication, drug abuse, drug intoxication, anxiety, depression, insomnia, hallucinations, suicidal w/o plan, suicidal w/ plan, agitation, medical clearance].

Vital signs revealed no major abnormalities, [no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time most consistent with [alcohol abuse, alcohol intoxication, drug intoxication, depression, drug abuse, suicidal, anxiety, insomnia, depressed mood, stress, ***.]

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

EKG shows normal sinus rhythm without acute ST elevation/depression. No acute T-wave changes],

[drug screen negative, drug screen positive],

[alcohol negative, alcohol positive],

WBC normal, metabolic panel normal, Acetaminophen normal, salicylates normal, pregnancy test negative, ***.]

Treatments provided included [IV fluids, ativan, vistaril, benadryl, haldol, zyprexa, Geodon, banana bag, Zofran],

[with improvement in symptoms, without improvement in symptoms].

Patient will be admitted. Discussed case with Dr. *** who will admit.

Monitor for new or worsening symptoms.

Patient to be placed on hour hold.

Referral to behavioral health.

Patient transferred to Detox

Patient medically cleared.

Patient to be discharged home with sober friend/relative.

Patient prescribed [Ativan, Vistaril, Librium Taper, Valium, multivitamin, Zofran].

Follow up in one or two days,

present to ER with new or worsening symptoms.

Psyc Anxiety

History of Present Illness:

Onset of symptoms was @@@ hours ago.

Patient reports symptoms of [confusion, falls, weakness, nausea, vomiting, abdominal pain, head trauma, depressed mood, anxiety, thoughts of suicide, hallucinations].

Patient denies symptoms of [confusion, Falls, weakness, nausea, vomiting, abdominal pain, head trauma, depressed mood, anxiety, thoughts of suicide, hallucinations].

Previous treatments include [nothing, medications, group therapy, individual therapy, counseling, rehab, hospitalization],

[with improvement, without improvement].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Neuro: No gross motor deficits

Psychiatric:

normal affect, normal behavior,

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Vital signs revealed no major abnormalities, [no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time most consistent with [alcohol abuse, alcohol intoxication, drug intoxication, depression, drug abuse, suicidal, anxiety, insomnia, depressed mood, stress, ***.]

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

EKG shows normal sinus rhythm without acute ST elevation/depression. No acute T-wave changes],

[drug screen negative, drug screen positive],

[alcohol negative, alcohol positive],

WBC normal, metabolic panel normal, Acetaminophen normal, salicylates normal, pregnancy test negative, ***.]

Treatments provided included [IV fluids, ativan, vistaril, benadryl, haldol, zyprexa, Geodon, banana bag, Zofran],

[with improvement in symptoms, without improvement in symptoms].

Patient will be admitted. Discussed case with Dr. *** who will admit.

Monitor for new or worsening symptoms.

Patient to be placed on hour hold.

Referral to behavioral health.

Patient transferred to Detox

Patient medically cleared.

Patient prescribed [Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline, Duloxetine, Bupropion, Trazodone, Ativan, Vistaril, Zyprexa.]

Follow up in one or two days,

present to ER with new or worsening symptoms.

Psyc Depression

History of Present Illness

Patient presenting for evaluation of [depression, anxiety, insomnia, psychosis, hallucinations, suicidality without plan, suicidality with plan, alcohol abuse, alcohol intoxication, drug abuse, agitation, medical clearance].

Onset of symptoms was @@@ days ago.

Patient reports symptoms of [depressed mood, poor concentraction, poor sleep, increased sleep, weight loss, weight gain, worthlessness, anxiety, fatigue, thoughts of suicide, hallucinations].

Patient denies symptoms of [depressed mood, poor concentraction, poor sleep, increased sleep, weight loss, weight gain, worthlessness, anxiety, fatigue, thoughts of suicide, hallucinations].

Previous treatments include [nothing, medications, group therapy, individual therapy, counseling, ETC, hospitalization],

[with improvement, without improvement].

Patient has had [no thoughts of suicide, thoughts of suicide without plan, thoughts of suicide with plan],

[no recent alcohol use, recent alcohol use,]

[no drug use, recent drug use],

[no recent stressors, recent stressful events].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Neuro: No gross motor deficits

Psychiatric:

normal affect, normal behavior,

[depressed mood, denies depression], [anxious, denies anxiety], [judgement normal, agitated], [suicidal thoughts, no suidical thoughts], no hallucinations, [normal sleep patterns, decreased sleep, increased sleep], [normal concentration, decreased concentration], [poor eye contact, good eye contact]

Past Medical History: none,

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [depression, anxiety, insomnia, psychosis, hallucinations, suicidal w/o plan, suicidal w/ plan, alcohol abuse, alcohol intoxication, drug abuse, agitation, medical clearance].

Vital signs revealed no major abnormalities, [no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension.]

Diagnosis at this time most consistent with [depression, suicidal, anxiety, insomnia, depressed mood, stress, alcohol intoxication, alcohol abuse, drug intoxication, drug abuse, ***.]

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

[EKG shows normal sinus rhythm without acute ST elevation/depression. No acute T-wave changes, ]

[drug screen negative, drug screen positive, ]

[alcohol negative, alcohol positive, ]

[WBC normal, metabolic panel normal, ]

[Acetaminophen normal, salicylates normal, pregnancy test negative, ***.]

Treatments provided included [IV fluids, ativan, vistaril, haldol, zyprexa, Geodon, banana bag, Zofran],

[with improvement in symptoms, without improvement in symptoms].

Patient will be admitted. Discussed case with Dr. *** who will admit.

Monitor for new or worsening symptoms.

Patient to be placed on @ hour hold.

Referral to behavioral health.

Patient medically cleared.

Patient prescribed [Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline, Duloxetine, Bupropion, Trazodone, Ativan, Vistaril, Zyprexa].

Follow up in one or two days,

present to ER with new or worsening symptoms.

Psyc Drug Abuse / Intoxication

History of Present Illness

Patient presenting for evaluation of [drug abuse, drug intoxication, alcohol intoxication, alcohol abuse, anxiety, panic attacks, depression, insomnia, hallucinations, suicidality without plan, suicidality with plan, agitation, medical clearance.]

Onset of symptoms was @@@ hours ago.

Patient reports symptoms of [confusion, falls, weakness, nausea, vomiting, abdominal pain, head trauma, depressed mood, anxiety, thoughts of suicide, hallucinations].

Patient denies symptoms of [confusion, Falls, weakness, nausea, vomiting, abdominal pain, head trauma, depressed mood, anxiety, thoughts of suicide, hallucinations].

Previous treatments include [nothing, medications, group therapy, individual therapy, counseling, rehab, hospitalization],

[with improvement, without improvement].

Patient has had

[no thoughts of suicide, thoughts of suicide without plan, thoughts of suicide with plan],

[no recent alcohol use, recent alcohol use],

[no drug use, recent drug use],

[no recent stressors, recent stressful events].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Extremities: Non-tender. No pedal edema.

Back: No tenderness

Neuro: No gross motor deficits

Psychiatric:

[normal affect, normal behavior, depressed mood, denies depression],

[anxious, denies anxiety],

[ judgement normal, agitated],

[suicidal thoughts, no suidical thoughts], no hallucinations,

[normal sleep patterns, decreased sleep, increased sleep],

[normal concentration, decreased concentration],

[poor eye contact, good eye contact]

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [ drug abuse, drug intoxication, alcohol abuse, alcohol intoxication, anxiety, depression, insomnia, hallucinations, suicidal w/o plan, suicidal w/ plan, agitation, medical clearance].

Vital signs revealed no major abnormalities, [no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time most consistent with [alcohol abuse, alcohol intoxication, drug intoxication, depression, drug abuse, suicidal, anxiety, insomnia, depressed mood, stress, ***.]

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

EKG shows normal sinus rhythm without acute ST elevation/depression. No acute T-wave changes,

[drug screen negative, drug screen positive],

[alcohol negative, alcohol positive],

[WBC normal, metabolic panel normal],

Acetaminophen normal, salicylates normal,

pregnancy test negative, ***.

Treatments provided included [IV fluids, ativan, vistaril, benadryl, haldol, zyprexa, Geodon, banana bag, Zofran],

[with improvement in symptoms, without improvement in symptoms].

Patient will be admitted. Discussed case with Dr. *** who will admit.

Monitor for new or worsening symptoms.

Patient to be placed on@ hour hold.

Referral to behavioral health.

Patient transferred to Detox

Patient medically cleared.

Patient to be discharged home with sober friend/relative.

Patient prescribed [Ativan, Vistaril, Librium Taper, Valium, multivitamin, Zofran].

Follow up in one or two days, present to ER with new or worsening symptoms.

Psyc Suicidal – Passive/ Active

History of Present Illness

Patient presenting for evaluation of [suicidal thoughts, depression, anxiety, bipolar disorder, psychosis, hallucinations, agitation, insomnia. Patient has a plan on how to harm themselves including ***].

Onset of symptoms was @@@ days ago.

Patient denies symptoms of [suicidal thoughts, homicidal thoughts, lack of concentration, insomnia, palpitations, diaphoresis, paresthesias, anxiety, depression, hallucinations]. Possible organic causes of patient include [none determined, substance abuse, medication side effects, tobacco use, caffeine , endocrine/metabolic, poor nutrition].

Previous/current treatment includes [no prior medication trials or therapy, therapy sessions, SSRIs, Benzodiazepines, ETC, inpatient hospitalizations].

Patient has [relatives with a history of problems with depression].

Patient reports history of [previous suicide attempts. No previous suicide attempts].

REVIEW OF SYSTEMS:

All other systems reviewed and negative except as stated above in the HPI,

[No chest pain, No shortness of breath, No abdominal pain, No dysuria, No joint swelling, No headache, No tremor, No increased or abnormal bleeding, No epistaxis , No unintential weight loss, No depression symptoms]

Past medical history: None.

No Medications or allergies.

Tobacco use: None

Alcohol Use: Yes

PHYSICAL EXAM:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic. PERRL, EOMI. No scleral icterus or erythema. Pharynx moist without erythema or exudate.

CV: Regular rate and rhythm. No murmur. Peripheral pulses intact.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender, non-distended.

Back: No CVA or vertebral tenderness

Skin: Normal color. Warm and Dry

Extremities: Non-tender. No pedal edema.

Neuro: Oriented x3. No gross motor deficits

Psych:

Cooperative.

There is / No active suicidal ideation.

There is / No homicidal ideations or hallucinations.

Appears anxious.

There is / No diaphoresis or tremor noted.

Attention span [decreased/ Normal].

There is / No agitation, aggression, or irritability noted during exam.

Thought process is linear and logical.

Recent and remote memory appear to be intact to conversation.

Insight and judgment [normal/ abnormal].

For Passive for Discharge

Medical Decision Making

Patient presenting with depression and concern for suicidal ideation.

Review of systems negative, no obvious disease on medical screening exam.

Obtained laboratory evaluation which showed ***.

Consulted psychiatry who ***.

In my clinical opinion, the current suicide risk for this patient is low.

There is no evidence to suggest the patient is experiencing significantly [low mood, hopelessness, relentless anxiety/panic, agitation, severe anhedonia, global insomnia, active or passive suicidal thinking].

Pt denies suicidal and homicidal ideation.

In addition, the patient has adequate social support from ***.

Impression:

Depression

***

Plan:

Discharge from ED

Patient instructed that if having thoughts of suicide, please call a doctor, friend, or family member and report to the nearest ER or hospital.

If you need to talk, you may also contact (DCO) Distress Centre Oakville Ontario

Hotline: +1 (905) 849 4541

For Active / Admission

Medical Decision Making

Patient presenting with depression and concern for suicidal ideation.

Review of systems negative, no obvious disease on medical screening exam.

Obtained laboratory evaluation which showed ***.

Urine drug screen with ***. Ethanol ***. Acetaminophen ***, salicylate ***. Consulted psychiatry who ***.

VSS during ED course.

Impression:

Suicidal Ideations with Significant Concern for Self Harm, ***

Plan:

FORM 1 issues , and Admit to Psychiatry for further evaluation and treatment

SOB Asthma

History of Present Illness

Patient presenting for evaluation of cough, shortness of breath, wheezing, fever, respiratory distress. Onset of symptoms was XXX hours ago. Patient reports shortness of breath with Cough and sputum production, wheezing. Patient denies symptoms of fever, chest pain, postnasal drip, hemoptysis. Treatment prior to arrival includes inhalers. Current treatment regimen includes albuterol prn, inhaled corticosteroid.

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed

Physical Exam:

Alert, oriented, No acute distress

HEENT: Head normocephalic and atraumatic. PERRL, EOMI. No scleral icterus or erythema. Pharynx moist without erythema or exudate.

GAEB bilateral, wheeze, accessory muscle use, no respiratory distress, speaking in full sentence

CV: Regular rate and rhythm. No murmurs, gallops, rubs.

Abdomen: Soft, non-tender.

Extremities: Non-tender. No edema.

Back: No tenderness

Neuro: No gross motor deficits

Past Medical History: asthma

Past Surgical History: none

Social History: no tobacco use, no alcohol use, no drug use

Medical Decision Making

· Patient presenting for evaluation of shortness of breath, cough, wheezing, respiratory distress.

· Vital signs revealed no fever, hypoxia, tachypnea, no tachycardia, no hypotension.

· Diagnosis at this time is most consistent with Asthma Exacerbation.

· Differential diagnosis considered including COPD Exacerbation, Pneumonia, bronchospasm, reactive airway disease, CHF, Pulmonary embolus, ACS.

· Diagnostic testing performed: EKG shows normal sinus rhythm without acute ST elevation/depression., WBC normal, Chest Xray reveals no evidence of pneumonia or other acute process, troponin normal.

· Treatments provided included oxygen, albuterol nebulizer, with improvement in symptoms.

· Patient prescribed albuterol inhaler, Prednisone.

· Patient prescribed Amoxicillin–clavulanate (Augmentin).

Follow up in one or two days, return to clinic or urgent care with new or worsening symptoms, present to ER with new or worsening

SOB CHF

History of Present Illness

Patient presenting for evaluation of shortness of breath, cough, leg swelling, weight gain, wheezing, chest tightness, respiratory distress. Onset of symptoms was XXX hours ago. Patient reports shortness of breath, wheezing, weight gain, orthopnea, PND. Patient denies symptoms of chest pain, hemoptysis. Aggrevating symptoms include exercise, lying flat. Treatment prior to arrival includes nothing. Patient has a history of congestive heart failure, no tobacco use or structural lung disease.

Past Medical History: hypertension, CAD, CHF

Past Surgical History:none

Social History: no tobacco use, occasional alcohol use, no drug use

Family History: no pertinent family history

Physical Exam

Alert, Oriented, in acute distress

HEENT: Head normocephalic and atraumatic. PERRL, EOMI. No scleral icterus or erythema. Pharynx moist without erythema or exudate.

CV: Regular rate and rhythm. No murmur. Peripheral pulses intact.

Respiratory: breath sounds normal, speaking in full sentences, wheezes, crackles bilateral, with accessory muscle use

Abdomen: Soft, non-tender, non-distended.

Back: No CVA or vertebral tenderness

Skin: Normal color. Warm and Dry

Extremities: Non-tender. No pedal edema.

Neuro: Oriented x3. No gross motor deficits

Medical Decision Making

· Patient presenting for evaluation of shortness of breath, chest tightness.

· Vital signs revealed hypoxia, tachycardia, no tachypnea, hypotension.

· Diagnosis at this time is most consistent with congestive heart failure.

· Differential diagnosis considered including Asthma Exacerbation, COPD Exacerbation, Pneumonia, bronchospasm, Pulmonary embolus, ACS, Pneumothorax.

· Diagnostic testing performed: EKG shows normal sinus rhythm without acute ST elevation/depression., WBC normal, metabolic panel normal, CT of the chest shows no acute findings, Chest Xray reveals findings consistent with CHF, BNP elevated, troponin normal.

· Treatments provided included oxygen, NTG, lasix, BiPap, with improvement in symptoms.

· Patient will be admitted. Discussed case with Dr. *** who will admit.

SOB COPD

History of Present Illness

Patient presenting for evaluation of cough, shortness of breath, wheezing, chest tightness, respiratory distress. Onset of symptoms was XXX hours ago. Patient symptoms of cough, sputum production, shortness of breath, fever, wheezing. Patient denies symptoms of chest pain, postnasal drip, hemoptysis. Aggrevating symptoms include exercise, smoke. Treatment prior to arrival includes inhalers. Patient has a history of tobacco abuse, COPD. Current treatment regimen includes albuterol prn, inhaled corticosteroid, oral steroids.

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed

Physical Exam:

Alert, Oriented, No acute distress

HEENT: Head normocephalic and atraumatic. PERRL, EOMI. No scleral icterus or erythema. Pharynx moist without erythema or exudate.

GAEB Bilaterally lung, wheeze, accessory muscle use, respiratory distress, speaking in full sentence

CV: Regular rate and rhythm. No murmurs

Abdomen: Soft, non-tender.

Extremities: No calf tenderness or swelling. No edema.

Back: No tenderness

Neuro: No gross motor deficits

Past Medical History: COPD

Past Surgical History: none

Social History: tobacco use, occasional alcohol use, no drug use

Family History: no pertinent family history

Medical Decision Making

· Patient presenting for evaluation of cough, shortness of breath, wheezing, chest tightness.

· Vital signs revealed no fever, hypoxia, no tachycardia, no tachypnea, no hypotension.

· Diagnosis at this time is most consistent with COPD Exacerbation.

· Differential diagnosis considered including viral bronchitis, Asthma Exacerbation, Pneumonia, CHF, Pulmonary embolus, ACS, Pneumothorax.

· Diagnostic testing performed: EKG shows normal sinus rhythm without acute ST elevation/depression., WBC elevated, CT of the chest shows no acute findings, Chest Xray reveals no evidence of pneumonia or other acute process, troponin normal.

· Treatments provided included oxygen, duoneb, albuterol nebulizer, Prednisone, with improvement in symptoms.

· Patient will be admitted. Discussed case with Dr. *** who will admit.

· Patient prescribed Amoxicillin–clavulanate (Augmentin).

SOB / Fever Viral Upper Resp Illness

History of Present Illness

Patient presenting for evaluation of [fever, cough, shortness of breath, increased work of breathing, nasal congestion, ear pain, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, nausea, vomiting, diarrhea, rash, irritability, fatigue].

Onset of symptoms was @@@ days ago.

Patient has associated symptoms of [fever, cough, shortness of breath, nasal congestion, ear pain, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, abdominal pain, nausea, vomiting, diarrhea, rash].

Patient does not have symptoms of [fever, cough, shortness of breath, nasal congestion, ear pain, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, abdominal pain, nausea, vomiting, diarrhea, rash].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, OTC cough medications, OTC cold medications, decongestants, inhaler therapies, nebulizer treatments].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmurs, gallops, rubs.

Abdomen: Soft, non-tender.

Extremities: Non-tender. No edema.

Back: No tenderness

Neuro: No gross motor deficits

Lungs clear to auscultation bilaterally. No wheeze, crackles, or rales.,

[left lung clear, right lung clear, left lung, right lung, bilateral, upper lobe, middle lobe, lower lobe],

[crackles, wheeze, rales, stridor],

chest wall tenderness,

[accessory muscle use, no accessory muscle use],

[respiratory distress, no respiratory distress],

speaking in full sentence

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [fever, cough, shortness of breath, nasal congestion, ear pain, sinus pain, sore throat, decreased appetite, weakness, headache, neck pain, abdominal pain, nausea, vomiting, diarrhea, rash, irritability, fatigue].

Vital signs revealed no major abnormalities,

[no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension, child non toxic appearing, child ill appearing, but not toxic, child toxic appearing].

Diagnosis at this time most consistent with [viral upper respiratory infection, cough, bronchitis, viral illness, viral fever, viral pharyngitis, strep throat, otitis media, RSV, influenza, influenza like illness, croup, bronchiolitis, pneumonia, gastroenteritis, nausea and vomiting, diarrhea, UTI, mononucleosis.]

Differential diagnosis considered including [viral upper respiratory infection, viral illness, viral fever, viral pharyngitis, strep throat, otitis media, RSV, influenza, influenza like illness, croup, bronchiolitis, congestion, pneumonia, gastroenteritis, nausea and vomiting, diarrhea, UTI, cough, mononucleosis.] These were thought to be less likely given the history, exam, and workup.

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

[Chest Xray reveals no evidence of pneumonia or other acute process, CXR shows infiltrate, CXR shows findings consistent with viral process],

[RSV positive, RSV negative, influenza positive, influenza negative],

[WBC elevated, WBC normal],

[rapid strep test positive, rapid strep test negative]

[urinalysis shows signs of infection, urinalysis does not appear to be infection], [mononucleosis positive, mononucleosis negative].

Treatments provided included [tylenol, ibuprofen, IV fluid bolus, prednisone, decadron, first dose of antibiotics, tamiflu, Ceftriaxone (Rocephin), albuterol inhalor, albuterol nebulizer, duoneb nebulizer],

[without improvement in symptoms, with improvement in symptoms].

Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Symptomatic cares discussed including staying hydrated, using humidified air, warm fluids, cough drops, or OTC cough medicines.

Symptomatic cares discussed including staying hydrated, using humidified air, warm fluids, cough drops, or honey

(if Patient prescribed an antibiotic). Will have patient/family use wait and watch approach and only use antibiotics if symptoms not improving, [Tamiflu, Amoxicillin, Amoxicillin and clavulanate (Augmentin), Cefprozil (Cefzil), Cefuroxime (Ceftin), Cefpodoxime (Vantin), Cefdinir, Azithromycin (Zithromax), Trimethoprim/sulfamethoxazole (Bactrim DS), albuterol inhaler, albuterol nebulizer, Tylenol, Ibuprofen, prednisone, cough medicine, Robitussin, Tessalon Perles, Phenergan-Codeine].

Follow up in one or two days,

present to ER with new or worsening symptoms.

SOB / Fever Pneumonia

History of Present Illness

Patient presenting for evaluation of [cough, shortness of breath, wheezing, chest tightness, chest pain, pleuritic chest pain, fever, asthma symptoms, COPD Symptoms, respiratory distress].

Onset of symptoms was @@@ days ago.

Patient reports pain and symptoms of [cough, sputum production, shortness of breath, fever, chest pain, chest pain with cough, wheezing, postnasal drip, dyspnea on exertion, hemoptysis].

Patient denies symptoms of [dyspnea, fever, chest pain, wheezing, postnasal drip, night sweats, weight loss, hemoptysis, dyspnea, fever, chest pain, wheezing, postnasal drip, DOE, hemoptysis].

Aggravating symptoms include [nothing, exercise, dust, pets, pollen, cold air, upper respiratory infections, smoke, odors, deep breaths].

Treatment prior to arrival includes [nothing, inhalers, nebulizer treatments, OTC cough medications, steroids, Tylenol/Ibuprofen].

Current treatment regimen includes [nothing, albuterol prn, inhaled corticosteroid, inhaled LABA, leukotriene modifier, ipratropium inhaler, oral steroids].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

HEENT: Head normocephalic and atraumatic.

CV: Regular rate and rhythm. No murmurs, gallops, rubs.

Abdomen: Soft, non-tender.

Extremities: Non-tender. No edema.

Back: No tenderness

Neuro: No gross motor deficits

Lungs clear to auscultation bilaterally. No wheeze, crackles, or rales., left lung clear, right lung clear,

[left lung, right lung, bilateral, upper lobe, middle lobe, lower lobe], [crackles, wheeze, rales, stridor],

chest wall tenderness,

[accessory muscle use, no accessory muscle use],

[respiratory distress, no respiratory distress],

speaking in full sentence

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [cough, fever, shortness of breath, wheezing, chest tightness, chest pain, pleuritic chest pain, asthma symptoms, COPD Symptoms, respiratory distress].

Vital signs revealed no major abnormalities, [no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time is most consistent with [Pneumonia, community acquired pneumonia, healthcare associated pneumonia, aspiration pneumonia, shortness of breath, Bronchitis, Cough, Asthma Exacerbation, COPD Exacerbation, bronchospasm, reactive airway disease, CHF, Croup, ***.]

Differential diagnosis considered including [shortness of breath, Bronchitis, viral bronchitis, Cough, Asthma Exacerbation, COPD Exacerbation, Pneumonia, bronchospasm, reactive airway disease, CHF, Pulmonary embolus, Croup, ACS, ***.] These were thought to be less likely given the history, exam, and workup.

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed,]

EKG shows normal sinus rhythm without acute ST elevation/depression.,

[WBC elevated, WBC normal],

metabolic panel normal, lipase normal, liver function tests normal,

[urinalysis shows signs of infection, urinalysis does not show infection],

[CT of the chest showed pathology consitent with that of the diagnosis,

CT of the chest shows no acute findings],

[Chest Xray reveals pneumonia, Chest Xray reveals no evidence of pneumonia or other acute process],

[lactate normal, lactate elevated,]

[procalcitonin normal, pro-calcitonin elevated,]

troponin normal,

blood cultures obtained, ***.

Treatments provided included [oxygen, duoneb, albuterol nebulizer, racemic epinephrine, Magnesium, Methylprednisolone, Tylenol, ibuprofen, IV fluids, tylenol, Levaquin, Rocephin, azithromycin, doxycycline, Zosyn, vancomycin],

[with improvement in symptoms, without improvement in symptoms].

Patient will be admitted. Discussed case with Dr. *** who will admit.

Monitor for new or worsening symptoms.

Patient prescribed albuterol inhaler, albuterol nebulizer, Ipratropium bromide nebulizer, Prednisone, Prednisone Taper, Phenergan with codeine, Robitussin, Tessalon Perles.

Patient prescribed [Azithromycin, Doxycycline, Amoxicillin–clavulanate (Augmentin), Levofloxacin, Ciprofloxacin, Amoxicillin, Cefpodoxime, Keflex].

Follow up in one or two days,

present to ER with new or worsening symptoms.

Trauma Head Injury / Concussion / Fall

History of Present Illness

Patient presenting for evaluation of [fall, head trauma, neck pain, injury, motor vehicle accident, bicycle accident, extremity pain, hand pain, shoulder pain, hip pain, knee pain, laceration, abrasion, wound, injury, loss of consciousness, dizziness, nausea, vomiting, headache].

Onset of symptoms was @@@ hours ago.

Patient describes [left, right, anterior, posterior, frontal, occipital, parietal, head, face, scalp, neck, back pain].

Pain is [mild, moderate, severe], [5/10] in severity.

Patient has associated symptoms of [pain, bruising, swelling, redness, warmth, bleeding, numbness, tingling, weakness, loss of consciousness, dizziness, headache, nausea, vomiting, confusion].

Patient does not have symptoms of [pain, bruising, swelling, redness, warmth, bleeding, numbness, tingling, weakness, loss of consciousness, dizziness, headache, nausea, vomiting, confusion].

Patient did [lose consciousness during this episode, did not lose consciousness, is unsure whether they lost consciousness or not].

Patient is on [no blood thinners, aspirin, coumadin, Pradaxa, Xeralto, Eliquis].

Treatment prior to arrival includes [nothing, Tylenol, Ibuprofen, compression, splinting, elevation, rest, ice].

Review of Systems:

All other systems reviewed and are negative, vital signs reviewed,

Physical Exam:

Constitutional: No acute distress

CV: Regular rate and rhythm. No murmur.

Respiratory: Lungs clear to auscultation bilaterally

Abdomen: Soft, non-tender.

Back: No tenderness

Skin: Warm, dry

Neuro: No deficits

Head Exam:

atraumatic, normocephalic, no hematoma, pupils equal round and reactive, extraocular movements intact,

[no tenderness, tenderness], [left, right, frontal, parietal, temporal, occipital, facial, orbital],

[contusion, hematoma, abrasion, dental trauma, no dental trauma, no midface instability, TMs clear bilaterally, no raccoon eyes or Battle sign]

Musculoskeletal:

[normal ROM, decreased ROM], [tenderness, nontender], [swelling, no swelling], [bruising, no bruising],

intact pulses, sensation intact

Past Medical History: none

Past Surgical History: none

Social History: no tobacco use

Family History: no pertinent family history

Medical Decision Making

Patient presenting for evaluation of [head trauma, fall, pain, injury, motor vehicle accident, bicycle accident, extremity pain, loss of consciousness, dizziness, nausea, vomiting].

Vital signs revealed no major abnormalities, [no fever, fever, no hypoxia, hypoxia, no tachycardia, tachycardia, no tachypnea, hypotension, no hypotension].

Diagnosis at this time most consistent with [head trauma, concussion, neck pain, fall, contusion, bruise, extremity pain, fracture, motor vehicle accident, bike accident, sports related injury, injury, ***].

Differential diagnosis considered including [contusion, bruise, trauma, extremity pain, head trauma, fracture, fall, motor vehicle accident, bike accident, skull fracture, SAH, SDH, ***]. These were thought to be less likely given the history, exam, and workup.

Diagnostic testing performed:

[Based on history and exam, discussed that further testing at this time would likely not be of benefit and therefore no further testing was performed],

Xray imaging shows [no evidence of fracture, Xray shows fracture],

head CT showed [no acute findings, CT cervical shows no evidence of acute injury,

CT maxillofacial shows no acute findings].

Treatments provided included [tylenol, ibuprofen, hydrocodone, oxycodone, morphine, fentanyl, dilaudid, toradol, naproxen, crutches, ACE wrap, sling placement, splint placement, brace placement, ice],

[with improvement in symptoms, without improvement in symptoms].

Rest, fluids, and over-the-counter symptomatic treatments were recommended.

Recommend over the counter Tylenol and Ibuprofen for fever/general discomfort.

Recommend rest, ice, elevation, and compression.

Monitor for new or worsening symptoms.

Follow up with orthopedic povider

Patient prescribed [Tylenol, Ibuprofen, Tylenol with Codeine, Hydrocodone, Oxycodone, Naproxen, Etodolac, Lodine, crutches, physical therapy].

Follow up in one or two days, present to ER with new or worsening symptoms, Follow up with orthopedic provider.

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