HPI
Headache red flags
Not maximal at onset, onset over >15 minutes. No dysarthria, no dystaxia, no diplopia, no dizziness, no dysphagia. No fever, no IVDU, no immune suppression, no trauma, no anticoagulation, no personal history of cancer.
Back pain red flags
No fever, no IVDU, no immune suppression, no trauma, no hx cancer, no saddle anesthesia, no bowel/bladder incontinence
CP PERC/HEART Questions
No unilateral leg swelling, no hemoptysis, no trauma/surgery/immobilization last 4 weeks, no prior DVT/PE, no exogenous estrogens
Exams
Door (No-Touch) Exam
General: No acute distress
Neck: Supple
Respiratory: Normal nonlabored respirations
Cardiovascular: Normal peripheral perfusion
Extremities: No deformity
Integumentary: Normal for ethnicity
Neurologic: Alert, normal speech
ENT: MMM
Psych: Cooperative
Touch Exam
General: No acute distress
Neck: Supple
Respiratory: Normal nonlabored respirations. CTAB.
GI: NTND, no masses.
Cardiovascular: Normal peripheral perfusion
Extremities: No deformity
Integumentary: Normal for ethnicity
Neurologic: Alert, normal speech
ENT: MMM
Psych: Cooperative
Peds Exam
General: No acute distress
Neck: Supple
ENT: Normal TMs without retraction or bulging.. Posterior pharynx clear without erythema/edema/cobblestoning/tonsillar enlargement or exudates.
Respiratory: Normal nonlabored respirations. CTAB.
GI: NTND, no masses.
Cardiovascular: Normal peripheral perfusion
Extremities: No deformity
Integumentary: Normal for ethnicity
Neurologic: Alert, appropriate verbalization/sounds for age
ENT: MMM
Psych: Interactive
Infant Exam
General: Alert, supine, smiling.
HENT: Head atraumatic, oropharynx clear, mucus membranes moist, fontanelle open and flat.
Eyes: Anicteric, non-injected. PERRL, red reflex intact.
Cards: RRR, clear S1/S2, no murmurs, capillary refill <2s, periphery warm and well-perfused.
Chest: Clear and equal bilaterally, breathing comfortably on room air, no wheezes or crackles.
Abd: Sounds normoactive, soft, non-tender, no masses or guarding.
Msk: Full range of motion, non-tender, no swelling or deformities in four extremities.
Neuro: Alert, responds to parents' requests. Moving all extremities spontaneously, good muscle bulk and tone, good dexterity.
Skin: Warm, dry, no rashes.
Psych: Appropriately interactive, preferential towards parents.
Testicle Exam
GU: bilateral cremasteric reflexes intact, no testicular tenderness, no discomfort with elevation of the testes, no erythema, edema or blue dot, no obvious hernias noted, no discharge or blood at the meatus. Exam chaperoned by nurse.
Trauma Exam
CONST: Well-nourished, normally developed. Looks Well.
RESP: States name. Breath sounds bilateral. Unlabored. Clear to auscultation bilaterally.
ENMT: Atraumatic external nose and ears. Eyelids and periorbital areas atraumatic. Moist mucous membranes. No hemotympanum or septal hematoma. No mid-face instability. Oropharynx clear.
NECK: No neck deformities or hematomas. Trachea midline.
CVS/CHEST: Chest appears atraumatic. Symmetric chest rise. +S1/S2 no m/r/g. No chest wall tenderness or instability.
ABD: Soft, NTND. No pelvic instability.
VASC: Radial pulses L/R 2+/2+, DP pulses L/R 2+/2+. Cap refill <2s. No significant external bleeding.
NEURO: _ C-collar in place. GCS E4 (spontaneous opening)/V5 (oriented)/M6 (obeys commands). Spinal stepoffs or tenderness C/T/L-spine: none/none/none. No incontinence. Eyes symmetric, reactive, 3-5mm. EOM intact. Sensation to light touch present in all extremities.
MSK:
No deformity or tenderness of the head or extremities except as noted in the lines above.
Demonstrates full active RoM at shoulder, elbow, wrist, and digits unless exceptions noted in the lines above.
Demonstrates full active RoM at hips, knees, and ankles unless exceptions noted in the lines above.
SKIN:
No lacerations, abrasions, or other skin lesions including examination of groin except as noted in the lines above.
Back Exam
Back: Pain reproduced by flexion or extension at the spine or bending at the waist. No saddle anesthesia. Patellar reflexes 2+ and symmetric. Ambulatory. Normal cap refill in both legs. Compartments soft.
Breast Exam
Breast: Female chaperone present. No suspicious masses, skin or nipple changes. No tenderness. No axillary nodes. The nipples are normal without lesions or discharge.
Neuro Exam
Neurologic: Awake, alert. Normal speech. Cranial nerves II through XII intact. Moving all extremities. Grip strength 5 out of 5, symmetric. Normal finger-to-nose testing. Leg raise 5 out of 5, symmetric. Normal heel-shin testing. Sensation to light touch intact all extremities.
Ortho Exam
LUE/RUE: no deformities noted. normal muscle tone. skin intact. no tenderness along clavicle, scapula, shoulder, elbow, FA, wrist, digits. FRoM in all joints. No pain with ROM. No instability of shoulder, elbow, wrist. ax/m/r/u sens/motor intact. Firing FPL, EPL, IO, OP, wrist extensors. 2+RP. BCR in all digits
LLE/RLE: no deformities. normal muscle tone. skin intact. no TTP hip, thigh, knee, tibia, ankle, or foot. Full ROM in all joints. No pain with ROM. No instability of hip/knee/ankle. knee extensor mechanism intact, patient able to perform straight leg raise. quad/TA/GSC/EHL motor intact. s/s/sp/dp/t sens intact. 2+DP/PT. BCR in all digits. No localized calf pain/tenderness. No compartment syndrome.
Differentials
Headache
ICH, Neoplasm, IIH, hydrocephalus, Meningitis/encephalitis, retropharyngeal abscess, temporal arteritis, cerebral venous/cavernous thrombosis, carotid/basilar dissection, ischemic stroke, symptomatic HTN/hypertensive emergency, CO poisoning, acute angle closure glaucoma, zoster opthalmicys/oticus, benign headache (migraine/tension/cluster), TMJ syndrome, trigeminal neuralgia
Abdominal Pain
ACS, aortic dissection/aneurysm, pneumonia, esophageal spasm, GERD, cholelithiasis, cholecystitis, dulcocholelithiasis, ascending cholangitis, bowel perforation, appendicitis, colitis (ulcerative, inflammatory, and infectious), diverticulitis, torsion of teste/ovary, musculoskeletal pain, gastritis, PUD, anxiety, UTI, kidney/ureteral stone, STD, genital infection.
Blunt Trauma
Penetrating Trauma
Extremity Trauma
Compartment syndrome, Contusion, Crush syndrome, Degloving injury, Morel-Lavallée lesion, Ring avulsion injury, Fracture, Open fracture, Laceration, Myositis ossificans, Open joint injury, Peripheral nerve injury, Rhabdomyolysis, Tendon injury, Vascular injury
Fever
Respiratory Tract: PNA, PTA, RPA, Epiglottis, Otitis, Sinusitis, Pharyngitis (viral, strep, fungal), Viral URI (influenza, Covid-19, RSV, cold, etc).
Cardiovascular: Endocarditis, Myocarditis, Pericarditis
Gastrointestinal: Peritonitis, abscess, appendicitis, cholecystitis, diverticulitis, hepatitis, colitis, enteritis
Genitourinary: pyelonephritis, TOA, PID, cystitis, prostatitis, epididymitis, orchitis
Central Nervous: Meningitis, CVT, encephalitis, abscess
Neurological: ACS, arrhythmia, electrolyte derangement, vasovagal syncope, orthostatic syncope, neurogenic syncope, serious head injury for complicated laceration
Sore Throat
Chest Pain/Dyspnea
ACS, PE, aortic dissection, esophageal rupture, pneumonia, pneumothorax, costochondritis, other musculoskeletal chest pain, GERD, anxiety
AMS
Hypoxic encephalopathy, Acute toxic-metabolic encephalopathy, Hypoglycemia, Hyperosmolar state , Electrolyte Abnormalities, Organ system failure, Hepatic Encephalopathy, Uremia/Renal Failure, Addison's disease, Cushing syndrome, hypothyroidism, myxedema coma, thyroid storm, Hypoxia, CO2 narcosis, Hypertensive Encephalopathy, Toxins, TTP / Thrombotic thrombocytopenic purpura, Alcohol withdrawal, NMS, Serotonin Syndrome, Environmental causes, Hypothermia, Hyperthermia, Deficiency state, Wernicke encephalopathy,, Subacute Combined Degeneration of Spinal Cord , B12 deficiency, Vitamin D Deficiency, Zinc Deficiency, Sepsis, Osmotic demyelination syndrome central pontine myelinolysis, Encephalitis, Diffuse axonal injury, Subdural/epidural hematoma, Intraparenchymal hemorrhage, SAH, Stroke,, Meningitis, Neoplasms, Paraneoplastic Limbic encephalitis, Malignant Meningitis, Pancreatic Insulinoma, Seizures, Nonconvulsive status epilepticus, Postictal state, Unspecified Dementia, Alzheimer's, Lewy Body Dementia, Frontotemporal Dementia
Maculopapular Rash
Adenovirus,Arbovirus, Chikungunya, EBV, Ehrlichiosis, Enterovirus, Fifths disease, HSV 6, Leptospirosis, Lyme, Measles, Meningococcemia, Mycoplasma, Parvovirus (B19), Primary HIV, Psittacosis, Rickettsia, Rubella, Rubeola, Scabies, Secondary syphilis, Streptobacillus moniliformis, Typhoid fever/typhus, Psoriasis, Bowen disease, Discoid lupus erythematosus, Drug eruption, Erythema annulare centrifugum, Lichen planus, Lichen simplex chronicus, Nummular dermatitis (nummular eczema), Parapsoriasis, Pityriasis rosea, Seborrheic dermatitis
Leg pain/swelling
Syncope
WPW, Torsaders/Long QT, Brugada, VTach, 2nd/3rd AV block, Afib/aflutter, Sick sinus syndrome, ARVD, Short QT syndrome, AS, MS, tricuspid stenosis, Aortic Dissection, Myocardial Infarction, CHF, HCM, PE, Pericardial Tamponade, Myxoma, Pulmonary Hypertension, Pacemaker malfunction, Vasovagal, Orthostatic hypotension, Volume depletion, Stroke/TIA, SAH, Vertebrobasilar Insufficiency, Subclavian steal, Heat syncope, Hypoglycemia, Hyperventilation, Asphyxiation, Seizure, Narcolepsy, Psychogenic (anxiety, conversion disorder, somatic symptom disorder), Toxic (drugs, carbon monoxide, etc.)
Hearing loss
Red eye
Acute angle-closure glaucoma, Anterior uveitis, Conjunctivitis, Corneal erosion, Corneal ulcer, Endophthalmitis, Episcleritis, Herpes zoster ophthalmicus, Inflamed pinguecula, Inflamed pterygium, Keratoconjunctivitis, Keratoconus, Nontraumatic iritis, Scleritis, Subconjunctival hemorrhage
Psych
AMA
AMA Note
The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. The patient speaks coherently and exhibits no evidence of having an altered level of consciousness or alcohol or drug intoxication to a point that would impair judgment. They respond knowingly to questions about recommended treatment and alternate treatments including no further testing or treatment; participate in diagnostic and treatment decisions by means of rational thought processes; and understand the items of minimum basic medical treatment information with respect to that treatment (the nature and seriousness of the illness, the nature of the treatment, the probable degree and duration of any benefits and risks of any medical intervention that is being recommended, and the consequences of lack of treatment, and the nature, risks, and benefits of any reasonable alternatives).
I have reviewed the relevant issues with the patient. They are aware of the suspected diagnosis suggested by screening exam, _, based upon the initiated medical screening exam. The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. The recommended medical care being refused has been discussed with the patient and is _. The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death.
The patient understands the relevant information of the nature of their medical condition, as well as the risks, benefits, and treatment alternatives (including non-treatment), consequences of refusing care, and can competently communicate a rational explanation about their choice of care options.
_▼. The patient understands they are welcome to return to the hospital at any time to receive the recommended care or any other care at any time, regardless of their ability to pay for such care.
Procedures
General Template
PROCEDURE: _
Date/Time of Procedure: [Current Date Time]
Performed By: Self
Consent:
Discussion of the risks, benefits, and alternatives to the procedure, along with informed consent .
Consent was precluded by the urgency of the procedure and the patient condition.
Universal Protocol: Time out was performed. Patient, side, site and procedure was verified.
Pre-Procedure Diagnosis: _
Post-Procedure Diagnosis: Same
Anesthesia and Sedation: See MAR for record of administered analgesics and sedatives.
Technique: _
Estimated Blood Loss: Less than 5 mls▼
The patient tolerated the procedure without complications.
Cardioversion
PROCEDURE: CARDIOVERSION/DEFIBRILATION
Performed by: self
Time: _
Consent:
Discussion of the risks, benefits, and alternatives to the procedure, along with informed consent .
Consent was precluded by the urgency of the procedure and the patient condition.
Timeout: A timeout to verify the correct patient, procedure, and site was performed.
Indication: Initial Rhythm: _
Anesthesia: See MAR for details.
Description:
Patch/paddle position: Anterior/Posterior left chest
Synchronized cardioversion at 100 Joules.
Post Cardioversion Rhythm: _
Post-Procedure: Patient tolerated the procedure well with no immediate complications _.
Central Line
PROCEDURE: CENTRAL LINE PLACEMENT
Performed by the emergency provider
Time: ***
Consent:
Discussion of the risks, benefits, and alternatives to the procedure, along with informed consent .
Consent was precluded by the urgency of the procedure and the patient condition.
Timeout: A timeout to verify the correct patient, procedure, and site was performed.
Indication: ***
Anesthesia: See MAR for details.
Skin Preparation: Hand hygiene performed prior to central venous catheter insertion. Sterile field, sterile drape, sterile technique, and cap and gown were used. The area was cleansed with 2% Chlorhexidine.
Patient position: ***
Location: ***
Ultrasound Guidance: YES/NO
Technique: The landmarks for the line placement were identified. The vessel was cannulated and a non-tunneled 7.0 Fr triple lumen *** was placed using the Seldinger technique.
Successful placement: YES/NO. Line sutured with silk and appropriate dressing applied.
Assessment: Good patency and blood return through all three lumens. The ports were appropriately flushed. See post procedure X-Ray interpretation.
Post-procedure: Patient tolerated the procedure well with no immediate complications.
Ultrasound IV Placement
PROCEDURE NOTE: IV Placement under Ultrasound Guidance
Performed by: self
Indication: IV access required. Multiple attempts at peripheral IV placement were made by the nursing staff without success
Procedure: The area was prepped in the usual fashion. The _ was cannulated with a _ gauge angiocath with use of dynamic ultrasound to identify the vein. IV draws blood and flushed without complication. The patient tolerated the procedure well.
Complications: None
Outcome: Successful IV Placement
Discussion of the risks, benefits, and alternatives to the procedure, along with informed consent .
Consent was precluded by the urgency of the procedure and the patient condition.
Dental Block
PROCEDURE: Dental Nerve Block (Periosteal)
Performed by the emergency provider
Consent: Informed consent, after discussion of the risks, benefits, and alternatives to the procedure, was obtained
Indication: Pain control
Location: Periosteal
Procedure: The appropriate site was identified. The mucosal space {ABOVE/BELOW:16086} tooth number *** was injected with approximately *** mL of {LOCAL ANESTHETIC:15382}.
Post-Procedure: The patient reported adequate analgesia, tolerated the procedure well, and there were no complications.
Discharges
Tylenol
You may take 650mg of tylenol every 6 hours for pain and inflammation.
Ibuprofen
You may take 600mg of ibuprofen and 650mg of tylenol every 6 hours for pain and inflammation.
Peds Trauma
It is common to have multiple bruises and sore muscles after a motor vehicle collision (MVC). These tend to feel worse for the first 24 hours. Your child may have the most stiffness and soreness over the first several hours. Your child may also feel worse when you wake up the first morning after your collision. After this point, you will usually begin to improve with each day. The speed of improvement often depends on the severity of the collision, the number of injuries, and the location and nature of these injuries.
HOME CARE INSTRUCTIONS
• Drink enough fluids to keep your urine clear or pale yellow.
• Take a warm shower or bath once or twice a day. This will increase blood flow to sore muscles.
• You may return to activities as directed by your caregiver. Be careful when lifting, as this may aggravate neck or back pain.
• Only take over-the-counter or prescription medicines for pain, discomfort, or fever as directed by your caregiver.
SEEK IMMEDIATE MEDICAL CARE IF:
• Your child has numbness, tingling, or weakness in the arms or legs.
• Your child develops severe headaches not relieved with medicine.
• Your child has severe neck pain, especially tenderness in the middle of the back of your neck.
• Your child has changes in bowel or bladder control.
• There is increasing pain in any area of the body.
• Your child has shortness of breath, lightheadedness, dizziness, or fainting.
• Your child has chest pain.
• Your child has increasing abdominal discomfort.
• There is blood in your child's urine, stool, or vomit.
• You feel your symptoms are getting worse.
If symptoms are not improving after 2-3 days, please followup with your primary care physician for reevaluation.
* For better pain control, you can alternate between Tylenol and Ibuprofen every 3 hours.
Misc Documentation
Resident Attestation
I personally saw and examined the patient. I have reviewed and agree with the resident's findings, including all diagnostic interpretations and treatment plans as written. I was present for the key portions of procedures performed and the inclusive time noted for any critical care statement.
AMA
Patient insists on going home. Expressed an understanding of the risks involved, including life-threatening illness, permanent disability and death. Discussed at length and multiple attempts to sway patient were unsuccessful. The patient is alert and oriented, not under the influence of drugs or alcohol, and is competent to make decisions about their medical care. Detailed instructions were provided to the patient.
Critical Care Time
The high probability of sudden, clinically significant deterioration in the patient's condition required the highest level of my preparedness to intervene urgently. The services I provided to this patient were to treat and/or prevent clinically significant deterioration that could result in: hemodynamic collapse, permanent disability, or death. Services included the following: chart data review, reviewing nurses notes an/or old charts, documentation time, consultant collaboration regarding findings and treatment options, vital sign assessments and ordering, interpreting and reviewing diagnostic studies/lab test.
Aggregate critical care time was 45 minutes, which includes only time during which I was engaged in work directly related to the patient's care, as described above, whether at the bedside or elsewhere in the Emergency Department. It did not include time spent performing other reported procedures or the services of residents, students, nurses or physician assistants.
MDM Template
In summary, this is a _
Chronic conditions affecting care: _
Social determinants affecting care: _
Independent test interpretation: _
Escalation of care considered: _
Provider discussions: _
Non-ED records review: _
Additional history sources: _
Tests considered but not performed: _
Prescriptions considered but not given: _
DDx includes but not limited to: _