ABDOMINAL PAIN
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: Patient
Location: [***]
Time course: [Gradual]
Onset was [***] prior to arrival, Episodes [***]
Currently Symptomatic: [Worse]
Complicating Factors: Quality [Aching, Dull]
Severity: Maximum [Severe]; Current severity [Moderate].
Associated with: [No Flank pain, Groin pain, No Trauma, No Recent travel, No UTI]. [Abdominal distention, Vomiting, Diarrhea, Fever].
[Pregnancy risks: Status post hysterectomy, LMP
Ectopic pregnancy risk: Prior ectopics, History of PID, IUD]
Exacerbated by
Movement
Relieved by
Nothing
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: Abdominal pain as described, No nausea, No vomiting.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal inspection.
HEENT: normocephalic, atraumatic , normal ENT inspection.
ORAL: Moist
NECK: supple , normal inspection.
CARD: regular rate and rhythm, heart sounds normal.
RESP: no respiratory distress, breath sounds normal.
ABD: soft, tender to palpation [***], BS present, soft, no organomegaly or masses .
BACK: non-tender. No CVA tenderness.
MUSC: normal ROM, non-tender , no pedal edema .
SKIN: color normal, no rash, warm, dry .
NEURO: awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: mood/affect normal.
ASSESSMENT:
GI upset. No gross pain to suggest an acute abdomen, but will discuss signs and symtoms for return to an emergency department and consideration of further studies. Will consider studies as appropriate and discuss with the patient.
Will assist with oral or IV hydration as the patient tolerates. I feel a pulmonary or cardiac component is unlikely at this time base on the history and exam.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
ABSCESS
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: Patient
Location: [***]
Onset was [***] prior to arrival
Time course: [Gradual]
Currently Symptomatic: [Worse]
Complicating Factors: [None]
Maximum Severity: [Severe]; Current Severity: [Moderate]
Associated with: [Swelling, Pain]
Tetanus status: [Tetanus up-to-date]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: No Abdominal pain, No nausea, No vomiting.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: As described
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid. EYES: Normal inspection.
Eyes: Normal to inspection
HEENT: normocephalic, atraumatic , normal ENT inspection.
NECK: Supple , normal inspection. No meningismis.
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal.
BACK: Normal inspection
MUSC: Normal ROM, non-tender.
SKIN: Abscess: [***]. Otherwise, color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
History and exam is consistent with an abscess. As the patient has [fluctuance/induration], an incision and drainage with culture of the wound is appropriate. No evidence for sepsis, bacteremia, necrotizing fasciitis. No proximal streaking or symptoms of systemic infection. Will treat with oral antibiotics as an outpatient, covering for Streptococcus and Staphylococcal infections (including MRSA) pending culture results. Tetanus status is addressed
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@DIAG@
@EDPTMEDSTART@
BACK-NECK PAIN
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Location: [***]
Occurred: [***] prior to arrival.
Historian: Patient
Mechanism: [Injury]
Patient currently has symptoms. Symptoms are [Worse, Persistent]
Maximum Severity: Severe
Current Severity: Moderate
Quality: [Aching, Dull]
Location of pain:
Associated with: [No Urine changes, Decreased ROM]
No Radiation.
Exacerbated by: [Walking, Movement]
Relieved by: [Nothing]
Risk Factors: [No Recent Surgery]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills, No weakness.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: No abdominal pain, No nausea, No vomiting.
GENITOURINARY: No incontinence, No retention.
MUSCULOSKELETAL: Pain, as described
SKIN: No Rash.
NEUROLOGIC: No headache, No paralysis, No focal weakness, No sensory changes.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEAD: Normocephalic, atraumatic
ENT: Normal ENT inspection. OP Moist
NECK: Supple, normal inspection. No meningismis. No pain on palpation of the spine. Normal ROM
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal.
BACK: No CVA tenderness, Normal inspection, No scoliosis, [No] Pain with straight leg raise. Pain on [***]. No pain on palpation of the spine.
SKIN: Color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
Findings are consistent with strain, sprain, or contusion. No mechanism to suggest fracture or subluxation, no point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. No evidence for cauda equina syndrome. No indication for imaging. No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. Nothing in the history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
CHEST PAIN
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: Patient
Chest Pain: [Ongoing]
No localizing symptoms, No Radiation
Change in location over time: None
Quality: [Pressure, Heaviness]
Associated with: [Nothing]
Exacerbated by: [Palpation of chest, Movement, Walking, Cough., Deep breath]
Relieved: [Nothing]
Risk factors coronary artery disease: [***]
Thoracic aneurysm dissection risk: [None]
PE risk: [None]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: Chest pain as detailed.
RESPIRATORY: No Cough, No SOB.
GI: No Abdominal pain, No nausea, No vomiting.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEENT: normocephalic, atraumatic , normal ENT inspection.
ORAL: Moist
NECK: supple , normal inspection. No meningismis.
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal. [Unable to reproduce chest pain with palpation or compression of the chest wall.]
ABD: Soft, nontender, BS present, soft, no organomegaly or masses.
BACK: Non-tender. No CVA tenderness.
MUSC: Normal ROM, non-tender , no pedal edema .
SKIN: Color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
Chest pain evaluation contains a wide differential diagnosis. Will consider initiating testing in the urgent care versus transfer.
The patient will receive a prophylactic aspirin.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
DENTAL PAIN
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Dental Pain. Associated Symptoms [none]
No trauma, No recent dental procedure
Symptoms began [***] prior to arrival. Patient currently has symptoms. Symptoms are [worse].
Severity: Maximum: [Severe]
Current: [Moderate]
Exacerbated by: [Eating, Chewing]
Relieved by: [minimal with OTC medicines]
Historian:
[Patient]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Subjective fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
ENT: No Rhinorrhea, + Dental pain.
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Vital signs and temperature reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Eyes are normal to inspection, Extraocular muscles intact.
ENT: External ears normal to inspection, Nares patent. Tympanic membranes clear bilaterally. Oropharynx is moist with posterior erythema and exudate. Pain at tooth # [***]
NECK: Normal ROM, No meningeal signs. Cervical chain lymphadenopathy.RESPIRATORY: No Cough, No SOB.
CV: RRR, No murmurs, Normal S1 S2
Pulm: Breath sounds normal. Chest is grossly nontender.
NEURO: No focal motor deficits, No focal sensory deficits, Speech normal, Gait normal, Memory normal.
SKIN: Skin is warm, Skin is dry, Skin is normal color.
PSYCH: Normal affect, Normal insight, Normal concentration.
ASSESSMENT:
Patient with Dental pain. No evidence of facial cellulitis or abscess. No sinus component. No evidence of strep pharyngitis. Will treat with dental block and a timely follow up with dental services
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Procedure: The patient verbally consents to a dental block The tooth is prepped with viscous lidocaine. It is then injected with Bupivicaine 0.5% and epinephrine, approximately 1.5 cc. The patient tolerates this well and has near complete resolution of pain.
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
DEPRESSION-ANXIETY
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: [Patient]
PRECIPITATING FACTORS
[[***] stress, Drug abuse, Alcohol abuse, Change in medication]
Occurred: [***] prior to arrival
Just prior to presentation Patient currently has symptoms.
Quality: [Dysphoric, Somatic complaints]
Associated with: [Alcohol use, Dysphoria, School/work problems, Self injury]
Symptoms are: [Worse]
Severity: Maximum: [Severe]
Risk Factors: [Previous suicide attempts, Alcohol abuse, Substance abuse, Access to firearm]
Time course: [Gradual]
Currently Symptomatic: [worse]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: No Abdominal pain, No nausea, No vomiting.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PSYCH: As described
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid. EYES: Normal inspection.
Eyes: Normal to inspection.
HEENT: normocephalic, atraumatic , normal ENT inspection. Oral pharynx moist.
NECK: supple , normal inspection.
CARD: regular rate and rhythm, heart sounds normal.
RESP: no respiratory distress, breath sounds normal.
MUSC: normal ROM, non-tender.
SKIN: color normal, no rash, warm, dry.
NEURO: awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: [mood/affect normal, Normal insight and concentration].
ASSESSMENT:
The patient’s history reveals significant [anxiety, depression]. The patient denies stimulant or substance abuse which could cause anxiety. No rapid cycling between mania and depression, making bipolar disorder unlikely. No signs or symptoms suggestive of psychosis. With no suicidal or homicidal ideation, or hallucinations, this patient is safe for outpatient management. Will start with a primary care provider, consideration of thyroid testing, electrolyte evaluations, and a baseline CBC may be appropriate. The patient understands that psychiatric evaluation may also be helpful.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
DERM
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Chief complaint: [Rash, Cellulitis, Allergic reaction]
Location [***]
Description: [Skin intact, Ulcerated, Draining]
Associated with: [Injury, Swelling, Pain, Itching, Tenderness, F.B., Fever, Allergen, Lesions]
Historian: Patient
Mechanism: [None, Allergen, Bite, Unknown]
Complicating factors: None [DM, Steroids, Prior episodes, IV Drug use, Obesity]
Occurred: [***] prior to arrival
Symptoms are: Worse
Quality: [Itching, Red, Raised]
Severity
Maximum: Moderate.
Current: Severe.
Quality: [***]
[Pressure, Aching, Dull]
Exacerbated by
[Nothing Scratching Heat]
Relieved by: [***]
Notes:
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: No Abdominal pain, No nausea, No vomiting.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: Rash as described.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEENT: normocephalic, atraumatic , normal ENT inspection.
ORAL: Moist
NECK: supple , normal inspection. No meningismis.
CARD: regular rate and rhythm, heart sounds normal.
RESP: no respiratory distress, breath sounds normal.
MUSC: normal ROM, non-tender
SKIN: Rash description: [***]. Otherwise, color normal, no rash, warm, dry .
NEURO: awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: mood/affect normal.
ASSESSMENT:
Patient reports rash consistent with unclear etiology. The patient has no systemic symptoms to suggest viral xanthem, no headache or other symptoms suggestive of meningococcal infection. Rash does not resemble urticarial vasculitis. The patient has taken taken no medications to cause a drug eruption. No evidence for respiratory involvement.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
EAR PAIN
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: Patient.
Associated with: No sore throat, is present. No Nasal Congestion, No Cough, No Fevers
Associated Symptoms [none]
Quality: [Achy, Fullness]
Symptoms began [***] prior to arrival. Patient currently has symptoms. Symptoms are [worse].
Severity: Maximum: [Severe]
Current: [Moderate]
Exacerbated by: [Nothing]
Relieved by: [minimal with OTC medicines]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Subjective fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
ENT: As Described
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Eyes are normal to inspection, Extraocular muscles intact
ENT: External ears pain management patient, and exudates in the affected ear., Nares patent. Tympanic membranes clear bilaterally. Oropharynx is moist. No trismus. Mouth normal to inspection. No tenderness on palpation of the sinuses
NECK: Normal ROM, No meningeal signs. Cervical chain lymphadenopathy.
CV: RRR, No murmurs, Normal S1 S2.
PULM: Breath sounds normal. Chest is grossly nontender.
NEURO: No focal motor deficits, No focal sensory deficits, Speech normal, Gait normal, Memory normal.
SKIN: Skin is warm, Skin is dry, Skin is normal color.
PSYCH: Normal affect, Normal insight, Normal concentration.
ASSESSMENT:
History and exam consistent with otitis media. No evidence on exam for peritonsilar abscess or cellulitis without radicular pain to the ear. No tap tenderness to teeth to suggest dental infection or pain. Pt has no diabetes or immunocompromise. Will discuss symptomatic management, and the ineffectiveness of antibiotics.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
EYE COMPLAINT
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: Patient.
[Right] side
[Crusting is present]
Associated with: [no vision loss, No URI symptoms].Patient [does not wear glasses or contact lenses].
[No Trauma]
Quality: [Achy, Fullness]
Symptoms began [***] prior to arrival. Patient currently has symptoms. Symptoms are [Worse].
Severity: Maximum: [Severe]
Current: [Moderate]
Exacerbated by: [Eye opening]
Relieved by: [nothing]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Subjective fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
ENT: No rhinorrhea or ear pain.
Eyes: As described
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
EYES: Eyes are injected. Pupils are equal and reactive to light, Extraocular muscles intact. Vision grossly intact.
ENT: External ears pain management patient, and exudates in the affected ear., Nares patent. Tympanic membranes clear bilaterally. Oropharynx is moist. No trismus. Mouth normal to inspection. No tenderness on palpation of the sinuses
NECK: Normal ROM, No meningeal signs. Cervical chain lymphadenopathy.
CV: RRR, No murmurs, Normal S1 S2.
PULM: Breath sounds normal. Chest is grossly nontender.
NEURO: No focal motor deficits, No focal sensory deficits, Speech normal, Gait normal, Memory normal.
SKIN: Skin is warm, Skin is dry, Skin is normal color.
PSYCH: Normal affect, Normal insight, Normal concentration.
ASSESSMENT:
Patient presents with complaints of red eyes and exam consistent with [conjunctivitis], which will be treated with topical antibiotics. No evidence for visual disturbance, no evidence of foreign body by history. Will consider followup with ophthalmology in a timely fashion if not improving.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
GENERAL
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: Patient
Location: [***]
Time course: [Sudden, Gradual, Unknown]
Onset was [***] prior to arrival.
Episodes Lasting [***]
Currently Symptomatic: [Worse]
Complicating Factors: Quality [Aching, Dull]
Severity
Maximum: [Severe]
Current severity: [Moderate]
Associated with: [Nothing]
Exacerbated by: [***]
Relieved by: [***]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: No Abdominal pain, No nausea, No vomiting.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid. EYES: Normal inspection.
EYES: Normal to inspection
HEENT: Normocephalic, atraumatic , normal ENT inspection. OP Moist.
NECK: Supple , normal inspection. No meningismis.
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal.
ABD: Soft, nontender, BS present, soft, no organomegaly or masses .
BACK: Non-tender. No CVA tenderness.
MUSC: Normal ROM, non-tender , no pedal edema .
SKIN: Color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
HEAD PAIN
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Injury Location: [***]
Historian: Patient
Mechanism: [Sharp Object]
Complicating Factors: None
Occurred: [***] prior to arrival. Patient currently has symptoms. Symptoms are [Worse, Persistent]
Severity: Maximum: Severe
Current: Moderate
Quality: [Straight]
Bleeding: [Controlled]
Exacerbated by: [Nothing]
Relieved by: [Nothing]
Tetanus: [up-to date]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Patient in a good state of baseline health
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
MUSCULOSKELETAL: Some pain associated with injury
SKIN: Laceration.
NEUROLOGIC: No sensory changes. No Head injury
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEAD: Normocephalic, atraumatic
ENT: Normal ENT inspection. OP Moist
NECK: Supple, normal inspection. No pain on palpation of the spine. Normal ROM
LOWER EXTREMITY: No clubbing, edema, or cyanosis.
BACK: Normal inspection
SKIN: Color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
Differential diagnoses: [Scalp, Facial] Contusion. Closed Head Injury. In the setting of no loss of consciousness and normal neurologic exam, I did not feel a CT scan of the head was needed. The patient will return with changes in behavior, decreased level of consciousness, or increased pain. The patient may also return for nausea, vomiting, or dizziness.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
LOWER LAC
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @SEX@ @AGE@ [***]
Injury Location: [***]
Historian: Patient
Mechanism: [Sharp Object]
Complicating Factors: None
Occurred: [***] prior to arrival. Patient currently has symptoms. Symptoms are [Worse, Persistent]
Severity: Maximum: Severe
Current: Moderate
Quality: [Straight]
Bleeding: [Controlled]
Exacerbated by: [Nothing]
Relieved by: [Nothing]
Tetanus: [up-to date]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Patient in a good state of baseline health
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
MUSCULOSKELETAL: Some pain associated with injury
SKIN: Laceration.
HEME: No Easy bleeding or brusing.
NEUROLOGIC: No sensory changes. No Head injury
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEAD: Normocephalic, atraumatic
ENT: Normal ENT inspection. OP Moist
NECK: Supple, normal inspection. No pain on palpation of the spine. Normal ROM
LOWER EXTREMITY: Laceration [***]. Bleeding is controlled. No foreign bodies are appreciated. Surrounding sensation is intact. Otherwise, Inspection normal, Normal range of motion, Distal cap refill and sharp/dull differentiation is intact.
BACK: Normal inspection
SKIN: As described, Otherwise, Color normal, no rash, warm, dry.
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
Laceration will require closure to achieve and maintain hemostasis and to promote optimal wound healing. No evidence for tendon damage or neurovascular compromise, nor for bony injury (xrays not indicated). Tetanus status is [up to date].
EMERGENCY DEPARTMENT COURSE:
The patient verbally consents to a wound repair. Side and sight are verified. Patient identification is verified. The wound is anesthetized with [marcaine 0.5%] for a [regional] block. It is then copiously irrigated.
It is approximated using simple interrupted sutures with [4-0] Ethilon. Total number [3]. Good approximation is achieved. Hemostasis is maintained. It is dressed with Bacitracin and a bulky dressing.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
UPPER LAC
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Injury Location: [***]
Historian: Patient
Mechanism: [Sharp Object]
Complicating Factors: None
Occurred: [***] prior to arrival. Patient currently has symptoms. Symptoms are [Worse, Persistent]
Severity: Maximum: Severe
Current: Moderate
Quality: [Straight]
Bleeding: [Controlled]
Exacerbated by: [Nothing]
Relieved by: [Nothing]
Tetanus: [up-to date]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Patient in a good state of baseline health.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
MUSCULOSKELETAL: No arthralgias.
SKIN: Laceration as described.
HEME: No easy bleeding or bruising.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEAD: Normocephalic, atraumatic
ENT: Normal ENT inspection. OP Moist
NECK: Supple, normal inspection. No pain on palpation of the spine. Normal ROM
UPPER EXTREMITY: Laceration [[***] size,location]. Bleeding is controlled. No foreign bodies are appreciated. Surrounding sensation is intact. Otherwise, Inspection normal, Normal range of motion, Distal cap refill and sharp/dull differentiation is intact.
BACK: Normal inspection
SKIN: As described, Otherwise, Color normal, no rash, warm, dry.
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
Laceration will require closure to achieve and maintain hemostasis and to promote optimal wound healing. No evidence for tendon damage or neurovascular compromise, nor for bony injury (xrays not indicated). Tetanus status is [up to date].
EMERGENCY DEPARTMENT COURSE:
The patient verbally consents to a wound repair. Side and sight are verified. Patient identification is verified. The wound is anesthetized with [marcaine 0.5%] for a [regional] block. It is then copiously irrigated.
It is approximated using simple interrupted sutures with [5-0] Ethilon. Total number [3]. Good approximation is achieved. Hemostasis is maintained. It is dressed with Bacitracin and a bulky dressing.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
LOWER EXT PAIN
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Location: [***]
Historian: Patient
Mechanism: [Body motion, Vehicle, Fall, Unknown]
[Injury, Pain, Decreased ROM]
Occurred: [***] prior to arrival. Patient currently has symptoms. Symptoms are [Worse, Persistent]
Severity: Maximum: Severe
Current: Moderate
Quality: [Aching, Dull]
Exacerbated by: [Movement]
Relieved by: [Nothing]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Patient in a good state of baseline health
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
MUSCULOSKELETAL: Lower extremity issues, as described
SKIN: No Laceration.
NEUROLOGIC: No sensory changes. No Head injury
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEAD: Normocephalic, atraumatic
ENT: Normal ENT inspection. OP Moist
NECK: Supple, normal inspection. No pain on palpation of the spine. Normal ROM
LOWER Extremity: Pain on palpation: [***]. Distal Cap refill and Gross sensation is intact.
BACK: Normal inspection
SKIN: Color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
Differential diagnosis: Contusion, strain, sprain, or fracture [of the joint]. X-ray indicated to rule out the latter. No evidence of neurovascular compromise of the extremity.
@EDORD@
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Xray is unremarkable on my interpretation, confirmed on radiology over read.. Patient to follow up with primary care provider in 2-3 days, or orthopedics in 1-2 weeks if not improving.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
MVA
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Position: [***], [No Damage to the windshield, Dashboard, Steering wheel, No Intrusion, No Air Bag deployment]
Historian, Patient
Location of pain:[***]
Associated with: [No LOC, No Alcohol, GCS 15 current and on the scene]
Occurred: [***] prior to arrival
Symptoms are persistent, Increased
Risk Factors:
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills, No weakness.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: No abdominal pain, No nausea, No vomiting.
GENITOURINARY: No incontinence, No retention.
MUSCULOSKELETAL: Back pain, as described
SKIN: No Rash.
NEUROLOGIC: No headache, No paralysis, No focal weakness, No sensory changes.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEAD: Normocephalic, atraumatic
ENT: Normal ENT inspection. OP Moist
NECK: Supple , normal inspection. No pain on palpation of the spine. Normal ROM.
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal.
ABDOMEN: Abdomen is nontender, No masses, Bowel sounds normal, No distension, No peritoneal signs.
UPPER EXTREMITIES: Normal to inspection. No gross pain on palpation. Normal range of motion.
LOWER EXTREMITIES: Normal to inspection. No gross pain on palpation. Normal range of motion.
BACK: No CVA tenderness, Normal inspection, No scoliosis, [No] pain with straight leg raise. No pain on palpation of the spine.
SKIN: Color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
Findings are consistent with strain, sprain, or contusion. No mechanism to suggest fracture or subluxation, no point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. No evidence for cauda equina syndrome. No indication for imaging. No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. Nothing in the history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.
@EDORD@
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Xray is unremarkable on my interpretation, confirmed on radiology over read.. Patient to follow up with primary care provider in 2-3 days, or orthopedics in 1-2 weeks if not improving.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
NAUSEA-VOMITING-DIARRHEA
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian:
Patient
Any pain
Time course:
Gradual
Onset was [***] prior to arrival
Currently Symptomatic:
[worse]
Complicating Factors:
Quality [aching, crampy]
Associated with [ abdominal pain, Blood in stool, Antibiotic use recently, Diarrhea, Fever, Hematemesis, Nausea, Recent travel, UTI symptoms, Vomiting, Vaginal discharge/bleeding]
[Pregnancy risks
Status post hysterectomy
LMP
Ectopic pregnancy risk
Prior ectopics
History of PID
IUD
Exacerbated by
Movement]
Relieved by
Nothing
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: Abdominal pain as described, No nausea, No vomiting.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid. EYES: Normal inspection.
Eyes: Normal to inspection
HEENT: normocephalic, atraumatic , normal ENT inspection.
ORAL: Moist
NECK: supple , normal inspection. No meningismis.
CARD: regular rate and rhythm, heart sounds normal.
RESP: no respiratory distress, breath sounds normal.
ABD: soft, Non tender, BS present, soft, no organomegaly or masses .
BACK: non-tender. No CVA tenderness.
MUSC: normal ROM, non-tender , no pedal edema .
SKIN: color normal, no rash, warm, dry .
NEURO: awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: mood/affect normal.
ASSESSMENT:
Differential diagnosis: Vomiting and diarrhea. Without frank abdominal pain, likely viral syndrome (gastroenteritis). Cannot exclude food poisoning, Escherichia coli, shigella, some are not. No evidence of the headache, head injury, changes in medication, alcohol or diabetic concerns. Will perform a CBC and electrolytes to evaluate for evidence of infection or electrolyte imbalance.
No history or suggestion of inflammatory bowel disease, dietary changes were factors, medications, irritable bowel syndrome, or surgical concerns. No evidence of obstruction. Stool testing where appropriate. Consider further work up if abdominal pain presents.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
PEDS
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: Parent
Time course:
[Gradual, Unknown]
Onset was [***] prior to arrival
Currently Symptomatic: [Worse]
Exacerbated by: Nothing
Relieved by: [Minimal relief with OTC medications]
@ALLERGY@
@PMH@
@SURGICALHX@
Social: Presents with parent.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: No syncope.
RESPIRATORY: No Cough, No SOB.
ENT: No rhinorrhea, no sore throat, no ear tugging.
GI: No vomiting. No change in bowel movement
GU: No urine changes
MUSCULOSKELETAL: No muscle dysfunction.
SKIN: No rash.
NEUROLOGIC: No weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, comfortable, consolable
HEENT: Normocephalic, atraumatic , normal ENT inspection
EYES: Normal inspection.
ORAL: Moist
NECK: Supple , normal inspection. No meningismis.
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal.
ABD: Soft, nontender, BS present, soft, no organomegaly or masses .
BACK: Non-tender.
MUSC: Normal ROM, non-tender , no pedal edema .
SKIN: Color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, Responsive
PSYCH: Age appropriate affect.
ASSESSMENT:
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
I discussed with the patient’s family the diagnosis, treatment plan, indications for return to the emergency department, and the expected follow-up. The patient’s family member verbalized understanding. The patient’s family was asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the family’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
STREP
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @SEX@ @AGE@ [***]
History: Patient.
Sore throat, is present. No Nasal Congestion, No Cough.
Subjective Fevers
No Sick contacts
Associated Symptoms [none]
Symptoms began [***] prior to arrival. Patient currently has symptoms. Symptoms are [worse].
Severity: Maximum: [Severe]
Current: [Moderate]
Exacerbated by: [Nothing]
Relieved by: [minimal with OTC medicines]
Historian:
[Patient]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Subjective fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
ENT: No Rhinorrhea, + sore throat. No ear pain.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Vital signs and temperature reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Eyes are normal to inspection, Extraocular muscles intact.
ENT: External ears normal to inspection, Nares patent. Tympanic membranes clear bilaterally. Oropharynx is moist with posterior erythema and exudate. Equivocal trismus. Mouth normal to inspection. No tenderness on palpation of the sinuses
NECK: Normal ROM, No meningeal signs. Cervical chain lymphadenopathy.
CV: RRR, No murmurs, Normal S1 S2.
Pulm: Breath sounds normal. Chest is grossly nontender.
NEURO: No focal motor deficits, No focal sensory deficits, Speech normal, Gait normal, Memory normal.
SKIN: Skin is warm, Skin is dry, Skin is normal color.
PSYCH: Normal affect, Normal insight, Normal concentration.
ASSESSMENT:
Differential diagnoses: viral or strep pharyngitis. No lesions to suggest coxsackie infection, oral herpes. No evidence for peritonsilar cellulitis or abscess. No evidence of dehydration due to poor po intake. With trismus, Sore throat, isolated symptoms, Cervical adenopathy, and vocal changes, will treat empirically.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
UPPER EXT PAIN
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Location: [***]
Historian: Patient
Mechanism: [Body motion, Vehicle, Fall, Unknown]
[Injury, Pain, Decreased ROM]
Occurred: [***] prior to arrival. Patient currently has symptoms. Symptoms are [Worse, Persistent]
Severity: Maximum: Severe
Current: Moderate
Quality: [Aching, Dull]
Exacerbated by: [Movement]
Relieved by: [Nothing]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Patient in a good state of baseline health
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
MUSCULOSKELETAL: As Described
SKIN: No Laceration.
NEUROLOGIC: No sensory changes. No Head injury
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection
HEAD: Normocephalic, atraumatic
ENT: Normal ENT inspection. OP Moist
NECK: Supple, normal inspection. No pain on palpation of the spine. Normal ROM
Upper Extremity: Pain on palpation: [***]. Distal Cap refill and Gross sensation is intact.
BACK: Normal inspection
SKIN: Color normal, no rash, warm, dry .
NEURO: Awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: Mood/affect normal.
ASSESSMENT:
Differential diagnosis: Contusion, strain, sprain, or fracture [of the joint]. X-ray indicated to rule out the latter. No evidence of neurovascular compromise of the extremity.
@EDORD@
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
Xray is unremarkable on my interpretation, confirmed on radiology over read.. Patient to follow up with primary care provider in 2-3 days, or orthopedics in 1-2 weeks if not improving.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
URI
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian: Patient.
No Sore throat, is present. No Nasal Congestion, No Cough.
No Subjective Fevers
No Sick contacts
Associated Symptoms [none]
Symptoms began [several days] prior to arrival. Patient currently has symptoms. Symptoms are [worse].
Severity: Maximum: [Severe]
Current: [Moderate]
Exacerbated by: [Nothing]
Relieved by: [minimal with OTC medicines]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Subjective fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: Cough, non productive, No SOB.
ENT: As Described
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Vital Signs and temperature reviewed, Well appearing, Patient appears comfortable, Alert and lucid
EYES: Eyes are normal to inspection, Extraocular muscles intact.
ENT: External ears normal to inspection, Nares patent. Tympanic membranes clear bilaterally. Oropharynx is moist no erythema or exudate. No trismus. Mouth normal to inspection. No tenderness on palpation of the sinuses
NECK: ROM, No meningeal signs. No Cervical chain lymphadenopathy.
CV: RRR, No murmurs, Normal S1 S2.
PULM: Breath sounds normal. Chest is grossly nontender
NEURO: No focal motor deficits, No focal sensory deficits, Speech normal, Gait normal, Memory normal.
SKIN: Skin is warm, Skin is dry, Skin is normal color
PSYCH: Normal affect, Normal insight, Normal concentration.
ASSESSMENT:
Upper respiration infection . Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, sinusitis, pneumonia, otitis. Presentation is consistent with viral URI which will be treated symptomatically. No indication for diagnostic testing.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
UTI
CHIEF COMPLAINT: @CHIEFCOMPLAINT@
Notes:
This is a @AGE@ @SEX@ [***]
Historian:
Patient
Time course:
Gradual
Onset was [***] prior to arrival
Currently Symptomatic:
[worse]
Complicating Factors: [None]
Quality: Burning, Frequency
Associated with No Vaginal Discharge. [Abdominal pain, Blood in stool, Antibiotic use recently, Diarrhea, Fever, Hematemesis, Nausea, Recent travel, UTI symptoms, Vomiting, Vaginal discharge/bleeding]
[Pregnancy risks: Status post hysterectomy, LMP
Ectopic pregnancy risk: Prior ectopics, History of PID, IUD]
Exacerbated by: Urination
Relieved by: [Nothing]
@ALLERGY@
@PMH@
@SURGICALHX@
@SOC@
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever, No chills.
CARDIOVASCULAR: No chest pain.
RESPIRATORY: No Cough, No SOB.
GI: Abdominal pain as described, No nausea, No vomiting.
GU: No dysuria, frequency
MUSCULOSKELETAL: No arthralgias.
SKIN: No rash.
NEUROLOGIC: No headaches or weakness.
PHYSICAL EXAM:
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid. EYES: Normal inspection.
Eyes: Normal to inspection
HEENT: normocephalic, atraumatic , normal ENT inspection.
ORAL: Moist
NECK: supple , normal inspection. No meningismis.
CARD: regular rate and rhythm, heart sounds normal.
RESP: no respiratory distress, breath sounds normal.
ABD: soft, Non tender, BS present, soft, no organomegaly or masses .
BACK: non-tender. No CVA tenderness.
MUSC: normal ROM, non-tender , no pedal edema .
SKIN: color normal, no rash, warm, dry .
NEURO: awake & alert, lucid, no motor/sensory deficit. Gait stable.
PSYCH: mood/affect normal.
ASSESSMENT:
Lower urinary tract irritation suggestive of possible urinary tract infection. No evidence of polynephritis or symptoms to suggest vaginitis. Urinalysis is indicated. Pregnancy is considered.
Given the [low/high-evidence] for infection, we’ll monitor for changes to suggest kidney problems, or other source of dysuria. Patient understands to followup in 2-3 if not improving, and immediately with significant changes or worsening symptoms.
@RESULTRCNT(24h)@
EMERGENCY DEPARTMENT COURSE:
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient’s satisfaction.
@MEDADMIN@
@DIAG@
@EDPTMEDSTART@
rosskln 