Medical Decision Making

Patient with [-generalized-] abdominal pain.

Abdominal pain contains a wide differential diagnosis to include appendicitis, bowel dysfunction, renal colic, infection, hernia, hepatic, gastric, or gallbladder dysfunction.

CBC to evaluate for infection or anemia, urinalysis for infection or hematuria. Electrolytes to evaluate for an imbalance. Liver function tests and lipase to evaluate for end organ pathology.

[-Pregnancy testing to evaluate for pregnancy pathology, including ectopic pregnancy.-] [-Patient denies testicular pain, swelling, or tenderness to suggest testicular torsion.-] [-Ovarian torsion unlikely given lack of sudden unilateral onset.-]

[-Will perform advanced imaging-]

[-Will provide antiemetics.-] [-Will provide IV fluids for possible dehydration.-] [-Will provide analgesia with reassessment.-]

Patient with [-generalized-] abdominal pain. Exam and history are not consistent with an acute abdominal process. Patient to return with worsening or changing symptoms. Will return in 12-24 hours if not improving.

The abrasion is irrigated and cleaned. [-Will offer wound debridement.-] Wound is not amenable to suture repair.

Dressing appropriate. Will discuss wound care and infection precautions.

Tetanus prophylaxis [-is up-to-date-].

Patient presents with fluctuance/induration on on examination consistent with abscess.

[-Will offer incision and drainage.-]

Surrounding cellulitis and will provide antibiotics for broad strep and staph coverage.

Strict return precautions for spreading redness, fever, or worsening pain.

Tetanus prophylaxis [-is up-to-date-].

Patient presents with a rash consistent with allergic response. Allergen [-of unclear etiology-]. The patient will follow up with an Allergist if symptoms are not resolving, or if they recur after initial management.

The patient has no systemic symptoms to suggest viral exanthem, no headache or other symptoms suggestive of meningococcal infection. Rash does not resemble urticarial vasculitis. The patient has taken no medications to cause a drug eruption. No evidence of respiratory involvement. Will treat with histamine blockers. Will prescribe steroids and discuss timing of use with the patient.

The patient presents with associated anxiety. [-The patient denies substance abuse-]. No rapid cycling behavior. No signs or symptoms suggestive of psychosis. With no suicidal or homicidal ideation, or hallucinations, this patient is safe for outpatient management.

Consider thyroid testing, electrolyte evaluations, and a baseline CBC as an inpatient or with a primary care provider. The patient understands that psychiatric evaluation may also be helpful.

Patient with a history of asthma presents with signs and symptoms consistent with an exacerbation.

Patient is afebrile, no productive cough, tachypnea, or chest pain. Pneumonia is unlikely, but we will discuss obtaining a chest-x-ray. No suggestion of a cardiac etiology by history.

[-Will provide nebulizer treatment for symptomatic relief and reassess.-] [-Will review medical management and provide steroid treatment.-]

Pain is most consistent with muscle strain, sprain, or contusion. No mechanism or exam to suggest fracture or subluxation.

No point tenderness to suggest osteomyelitis or other infection. Timing does not suggest a malignant process. [-No evidence for cauda equina syndrome.-] No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. Nothing in history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain. No indication for emergent imaging.

Symptomatic management and follow up with [-physical medicine-] if not significantly improved in 1-2 weeks.

Pain is most consistent with muscle strain, sprain, or contusion. No mechanism or exam to suggest fracture or subluxation.

Given the significant mechanism, [-we will perform imaging-]. Nothing in history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.

Symptomatic management and follow up with [-physical medicine-] if not significantly improved in 1-2 weeks.

Direct bat contact or bite; per public health guidance this is a high-risk rabies exposure.

Bat exposure, bat unavailable for testing, so must be treated as exposed [-though there is no evident bite wound-]. Will need HRIG and HR vaccine. Current recommendation for rabies vaccination at day 0, 3, 7, and 14. No evidence of infection from a wound. Medical records are reviewed and tetanus [-is up-to-date-].

Follow up will be needed to complete treatment.

Patient with suspected insect or bee sting. Patient is without prior history of bee sting allergy, but with similar local reaction. Timing and lack of proximal streaking or fever argue against secondary infection. No evidence of systemic allergic reaction or impending respiratory difficulty.

Will treat with histamine blockers. [-Will consider steroids if not improving.-]

The patient presents with a new diagnosis of Bell's Palsy.

There is unilateral facial weakness including the mouth and forehead, an isolated deficit without other neurologic findings on exam or by history. This is unlikely to represent tumor given the fairly rapid onset, lack of hearing change, ataxia, nystagmus or other neurologic symptoms or findings.

Will treat with prednisone.

Currently, there is equivocal benefit for use of antivirals. Will review eye precautions, including avoidance of contact lenses and saline drops. Will provide a neurology referral.

Body fluid exposure via [-needle stick-]

Source patient status [-unknown-]. Risk sufficient to warrant prophylaxis. (or Source patient known HIV positive.) (or Source patient testing arranged.) Baseline HIV, hepatitis B, and hepatitis C testing appropriate.

HIV post-exposure prophylaxis is appropriate within 72 hours (ideally within 24 hours). Will discuss the 28-day course, side effects, adherence, and infectious disease follow-up. [-Patient states Hepatitis B immunity is up to date.-]

Will discuss interim precautions and the follow-up testing schedule at 4 to 6 weeks, 3 months, and up to 4 to 6 months post-exposure. Tetanus prophylaxis [-is up-to-date-].

Patient presents with productive cough and general malaise.

Although patient has no evidence of respiratory distress or significant hypoxia, I will discuss chest x-ray to screen for infiltrate and pneumonia.

[-If symptoms are related to bronchitis, No indication for antibiotics at this time. I will provide patient with symptomatic relief. No other evidence of serious bacterial illness to include meningitis.-]

Patient appears well-hydrated and is able to tolerate fluids. I do not feel IV fluid hydration is needed at this time.

[-Partial-thickness (second-degree) burn with blistering.-] Estimated total body surface area involved: [-*** %.-]

Does not involve face, hands, feet, genitalia, or major joints. The wounds are not circumferential. No inhalation concern and no high-voltage electrical mechanism, so reasonable for outpatient management.

The burn was cooled, cleansed, and dressed. [-Debridement of loose devitalized tissue and ruptured blisters appropriate.-] [-Topical antimicrobial appropriate.-] Will discuss wound care instructions and infection precautions. Tetanus prophylaxis [-is up-to-date-].

Puncture wounds to be cleaned. Patient is informed of high infection risk of feline bites. [-Splinting to decrease spread of infection via movement.-] [-Signs of infection include erythema.-]

Full range of motion and sensation intact distally. The wound is not overlying a joint or tendon and no neurovascular involvement.

Amoxicillin-clavulanate treatment is appropriate given the high infection rate of cat bites.

Tetanus prophylaxis [-is up to date-].

The patient presents with a localized rash. Appearance is most consistent with cellulitic reaction.

No medication changes or contact with new soaps, perfumes, detergents, or plants to suggest an allergic component. No identifiable target lesion. Viral xanthem unlikely in absence of viral symptoms.

No signs of abscess. The patient is immunocompetent, and outpatient oral therapy is appropriate. [-IV antibiotics appropriate.-] Hot soaks and hot compresses are reviewed. [-Splinting to decrease spread of infection.-]

Patient to return immediately if having red streaks, increased pain, new fever, or drainage.

Tetanus prophylaxis [-is up-to-date-].

History and exam consistent with cerumen impaction.

No recent upper respiratory infection symptoms to suggest otitis media. No ear canal sensitivity to suggest otitis externa.

Will attempt removal of cerumen. Will discuss ear hygiene.

Chest pain after injury. Differential diagnoses include rib contusion, intercostal contusion, rib fracture, or pneumothorax.

Will discuss chest x-ray to rule out pneumothorax and to help clarify whether there is rib fracture.

A cardiac event is unlikely, as the pain is reproducible, intermittent, and associated with an injury.

[-Chest pain-] evaluation contains a wide differential diagnosis. [-D-dimer to screen for pulmonary embolism-]. Ordered electrolytes for baseline assessment and to guide management if CT scan becomes necessary. CBC to assess for infection or anemia that may contribute to presentation. [-BNP to evaluate for congestive heart failure. -] Chest x-ray to evaluate for pneumonia, pulmonary edema, or signs of CHF.

EKG and troponin to evaluate for cardiac injury. [-Will consider serial studies for evolving cardiac injury.-]

No sudden or severe pain, no tearing or ripping sensation radiating to the back, and radial pulses are equal bilaterally

[-Will consider aspirin, nitroglycerin, diuretic, nebulizer.-]

Patient presents with carbon monoxide exposure, bedside screening demonstrates this is higher than normal.

Will consider ABG, CO pulse oximetry. CBC to look for evidence of anemia. Electrolytes to look for imbalance. Will screen with an EKG and troponin for cardiac event.

We will treat with high dose oxygen.

Mechanism with exam suggests coccygeal contusion or fracture.

[-No evidence for cauda equina syndrome.-] No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. No hematochezia to suggest rectal injury.

[-Imaging would not change medical management.-]

Will utilize stool softeners, donut pillow, and will discuss additional management for pain.

Fluorescein examination demonstrates [-conjunctivitis-] which will be treated with topical antibiotics. No evidence for visual disturbance and no evidence of foreign body by history.

Lids everted without foreign body, no rust ring and no high-velocity or penetrating mechanism[-, and no hyphema or Seidel sign-], so retained foreign body and globe injury are unlikely.

[-Ofloxacin-] appropriate[-, with ophthalmology follow-up in 24 to 48 hours-]. Return immediately for worsening pain or vision change.

Patient presents with a barking cough and a history consistent with croup.

No suggestion of foreign body ingestion. No trismus and epiglottis easily visualized. Patient has no other evidence of serious bacterial illnesses including meningitis. No hypoxia to suggest a need for admission.

Will consider dexamethasone 0.6 mg/kg for treatment. [-Racemic epinephrine to be used in the setting of significant disease. Patient will require observation.-]

Patient presents with signs of a neurological ischemic event. Will obtain a CT scan of the brain to evaluate for stroke or hemorrhagic. We will monitor patient's stability and treat as needed. Time of event is [-unclear-]. Will assess with the stroke scale.

Will evaluate for hypoglycemia and monitor Oxygen saturation.

Will monitor for other pathology. No evidence of seizure. No presentation that suggests migraine. [-Blood pressure does not suggest hypertensive encephalopathy.-] No report of syncope or evidence of systemic infection.

Electrocardiogram and Cardiac enzymes with troponin to evaluate for concomitant or atypical presentation of a cardiac event. Complete blood count including platelets to look for infection, anemia, poor platelet function. Electrolytes to look for imbalance or end organ damage. [-Prothrombin time and international normalized ratio (INR), Activated partial thromboplastin time as a screen for possible anticoagulation dysfunction.-]

Patient presents with dehydration.

Dental pain without evidence on exam for peri-apical or other abscess, nor for facial cellulitis/abscess.

No floor-of-mouth or submandibular swelling, tongue elevation, drooling, muffled voice, dysphagia, or dyspnea to suggest deep neck-space infection or Ludwig angina. No fever, tachycardia, hypotension, rigors, or rapidly spreading edema to suggest systemic toxicity. [-Pain distribution is consistent with an odontogenic source rather than temporomandibular disorder, sinusitis, neuralgia, or referred otologic pain.-]

[-Will offer pain management with a dental block.-] Will discuss pain management options with the patient.

[-Antibiotics are appropriate given flair of symptoms and involvement. Patient understands they do not replace definitive management and dental follow up.-]

Given resources for a timely follow up with a dentist. Patient to return with fever, worsening swelling, dysphagia, drooling, voice change, dyspnea, or trismus.

Pruritic eruption consistent with contact dermatitis. Trigger is [-unknown-]

Extensive involvement. No purulence and afebrile as such, secondary infection is not suspected.

[-Will utilize antihistamines for itching.-] [-and discuss oral corticosteroid.-] Dermatology, allergist, or primary care follow-up if not improving.

Patient with dizziness/lightheaded symptoms. Wide differential diagnosis.

[-No recent medication changes.-] [-Vasovagal reaction possible, but no prior history of similar events.-]

Dehydration is a common cause, will hydrate with normal saline.

Electrolytes and liver function testing to look for evidence of end organ damage. [-EKG and monitor to screen for cardiac arrhythmia, enzymes to screen for a cardiac event. CBC to look for evidence of infection or anemia.-]

No murmur on exam to suggest valvular disease. [-No dyspnea, hemoptysis, or tachycardia.-]

We will put the patient on continuous cardiac monitoring here in the emergency department. [-Will arrange for a CAM monitor.-]

The patient presents with lower extremity pain. [-The patient presents with edema, calf tenderness, a positive Homans sign.-]

[-Risk factors include trauma, surgery, smoking, prior history of DVT, first-degree family member with a history of DVT or PE. Estrogen birth control, tachycardia-]

Differential does include muscle strain or myalgia, however, it also includes deep vein thrombosis.

[-Will proceed to ultrasound.-] [-Will screen with D-dimer.-]

[-Dyspnea-] evaluation contains a wide differential diagnosis. [-D-dimer to screen for pulmonary embolism-]. Ordered electrolytes for baseline assessment [-and to guide management if CT scan becomes necessary.-] CBC to assess for infection or anemia that may contribute to presentation. [-BNP to evaluate for congestive heart failure. -] Chest x-ray to evaluate for pneumonia, pulmonary edema, or signs of CHF.

EKG and troponin to evaluate for cardiac injury. [-Will consider serial studies for evolving cardiac injury.-]

No sudden or severe pain, no tearing or ripping sensation radiating to the back, and radial pulses are equal bilaterally

[-Will consider aspirin, nitroglycerin, diuretic, nebulizer.-]

Epistaxis. [-No-] history of trauma. [-No-] URI symptoms exacerbating the process.

Will attempt to clear blood clots, and if the location is anterior or septal, attempts at silver nitrate cautery will be undertaken. Packing may be considered if persistent bleeding.

Differential diagnosis: contusion, strain, sprain, dislocation or fracture [-of the joint-]. X-ray indicated to rule out fracture or dislocation. No evidence of neurovascular compromise of the extremity.

Acute monoarticular arthritis consistent with gout:

Afebrile without systemic toxicity. [-Classic prior identical episodes and no overlying wound or recent instrumentation-][-, and demonstrates range of motion making septic arthritis unlikely-]. Arthrocentesis [-deferred-].

Diagnosis made clinically based on classic presentation and history. Will consider Uric Acid level. Treatment with [-NSAIDS, Colchicine, Steroids-].

Will discuss return precautions for fever or spreading redness.

Head injury evaluation:

GCS 15 with normal mentation, no vomiting, no anticoagulant or antiplatelet use, no focal neurologic deficit and no signs of skull fracture[-, no loss of consciousness-][-, and low-risk mechanism-], so by validated head CT decision rules imaging is not indicated. [-Will observe with serial neurologic examinations.-]

Patient to return with any significant changes or worsening symptoms.

Head injury evaluation:

CT of the head obtained [-given anticoagulation, loss of consciousness, uncontrolled vomiting, focal findings-]. [-CT of the cervical spine appropriate given mechanism and examination.-] Patient to return with any significant changes or worsening symptoms.

Patient is here for [-migraine.-] [-No significant change in character from previous headaches and-] with a benign exam. [-There is no indication for CT or further radiographic study at this time.-]

There is no evidence for an infectious process such as sinusitis, meningitis/encephalitis, inflammatory process such as temporal arteritis, increased cranial pressure, trauma, intracranial hemorrhage, or chronic process such as tumor formation. No recent trauma to cause SDH or post-concussive syndrome. No recent chiropractic neck manipulation to cause vertebral or carotid artery dissection.

Will medicate for pain and nausea.

Signs and symptoms consistent with an external hemorrhoid. Differential also includes perirectal fissure and abscess.

No significant ongoing bleeding and no fever or perianal induration to suggest abscess[-, and no mass suspicious for malignancy-], so significant hemorrhage or alternative pathology is unlikely.

[-With thrombosis, incision offered; patient declines, preferring conservative management initially.-]

[-With the small size and the patient's minimal discomfort, there is no urgent need for surgical consult-]

Will review sitz baths, hygiene, use of Anusol, stool softeners and fiber. [-Will review a donut pillow.-]

Physical examination findings are consistent with an [-inguinal-] hernia.

The hernia appears reducible based on the benign abdominal exam findings. There are no signs of incarceration or strangulation. No fever, nausea, vomiting, severe pain.

[-Patient may require imaging to confirm the diagnosis.-]

Activity modification: avoid heavy lifting and strenuous activities that exacerbate symptoms. Surgical referral for evaluation for hernia repair, as some hernias typically do not resolve spontaneously. [-Consider surgical consultation for definitive management.-]

Patient education regarding warning signs of incarceration or strangulation requiring emergency evaluation: severe pain, nausea, vomiting, and inability to reduce hernia.

This patient presents with an elevated blood pressure. I have discussed with the patient the possible reasons for why there is an elevation in blood pressure today. Patient understands this may be in part because of anxiety or discomfort related to today's visit. The patient also understands the need for follow-up and repeat blood pressure readings in the future, and that chronic blood pressure without treatment can lead to strokes or heart attacks.

[- This patient presents with a concerning elevated blood pressure. Will try an intervention, consideration of anxiolytic versus hypertension medications in case this is situational. CBC to look for anemia, electrolytes to look for renal function. Timely follow-up is indicated.-]

No chest pain or other indications for cardiac evaluation.

Patient presents with concerns for a viral illness. [-Will offer viral testing-] Lungs clear to auscultation and no hypoxia[-, and no pleuritic chest pain-], making secondary pneumonia unlikely.

Supportive care with hydration, antipyretics, rest, and household precautions. Will discuss return precautions for shortness of breath, chest pain, or inability to maintain hydration.

Acute intoxication:

Patient is chronically inebriated. Patient demonstrates no desire to stop the use of alcohol. Is chronically at risk for injury and alcohol related complications.

[-Will consider blood alcohol testing, glucose-]

No signs of head trauma on examination, moving all extremities spontaneously and protecting airway[-, and no evidence of assault or fall by history or exam, so occult trauma is unlikely and observation is appropriate. -]

I feel that an enforced stay in the emergency department places the patient at risk for withdrawal and will not improve the patient's care. Patient would like to go [-home-]. Will wait until the patient is able to demonstrate ambulation unassisted. Today's visit demonstrates the patient is able to obtain medical care.

[-Will consider providing vitamin supplements by mouth or IV.-]

Patient with presentation concerning for nephrolithiasis: Differential diagnosis includes AAA, pyelonephritis, renal infarct, or renal cancer. Possible muscular causes including lumbar strain, lumbar radiculopathy, trauma.

Other considerations including radiating pain from cholelithiasis, PUD, or abdominal causes. [-No Evidence of pulmonary involvement.-]

Urinalysis appropriate. CBC to look for evidence of infection or dehydration. Electrolytes with liver function testing to look for evidence of end organ damage.

[-Will perform a CT scan. -]Urinalysis is appropriate to exclude infected stone or pyelonephritis.

Laceration will require closure to achieve and maintain hemostasis and to promote optimal wound healing; see separate procedure note for repair details.

No evidence of tendon damage or neurovascular compromise on examination. No clinical concern for underlying fracture or retained foreign body; imaging is not indicated. [-X-ray obtained to evaluate for underlying fracture or foreign body.-]

Tetanus prophylaxis is [-up-to-date-].

Headache with infectious features - meningitis evaluation:

No neck rigidity, normal mentation and nontoxic appearance[-, and immunocompetent-][-. Headache consistent with a benign pattern-][-, and given the timing, not consistent with bacterial meningitis-]. Lumbar puncture is deferred with close return precautions.

[-Empiric antibiotics not indicated at this time-]

Patient presents with heavy menstruation. [-***Recurring monthly, worse than usual, previously diagnosed.-] Pregnancy to be performed.

[-Will screen for uterine fibroids, polyps, and cancerous changes with ultrasound.-]

No history of coagulopathy. [-Complicated by ***[e.g. IUD].-]

Age does not suggest endometrial or vaginal atrophy.

[-Pelvic exam without evidence of polyps or vaginal wall bleed.-]

Patient does not use hormone therapy, tamoxifen, or anticoagulation.

[-Will treat with 35 mcg ethinyl estradiol and 1.0 mg norethindrone acetate, 1 tab by mouth three times daily for 7 days, then 20 mcg ethinyl estradiol and 1 mg norethindrone, 1 tab daily for 21 days.-][- Will treat with medroxyprogesterone 10 mg, 2 tabs by mouth three times daily for 7 days, then medroxyprogesterone acetate 10 mg, 2 tabs daily for 21 days.)-]

The patient's history reveals significant [-depression.-] The patient [-denies stimulant or substance abuse-]. No rapid cycling between mania and depression, making bipolar disorder unlikely. No signs or symptoms suggestive of psychosis. Given the presentation, is appropriate for social work screening.

Laboratory evaluation to include blood alcohol and drug screen, thyroid testing, electrolyte evaluations and a baseline CBC. Urine tox screen, BAL and TSH screening indicated.

[-The patient does contract for safety.-] [-There is risk for involuntary departure.-]

Precautions in place: belongings secured, room safety check, and continuous observation. Will consider restraints, safe environment, and medical management only if appropriate for patient and staff safety.

The patient's history reveals [-depression.-] Denies suicidal ideation, plan, or intent. Denies homicidal ideation, active planning, and resources are in place. This supports safe discharge with an outpatient plan.

Will discuss a safety plan with the patient. Crisis line and emergency return instructions provided.

Patient presents with neck strain or sprain. No mechanism to suggest fracture or subluxation, no point tenderness to suggest osteomyelitis or other infection.

No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. No recent chiropractic manipulations.

Timing does not suggest a malignant process. [-No evidence for cauda equina syndrome.-] No URI symptoms or sore throat.

Symptomatic management and follow up with [-physical medicine-] if not significantly improved in 1-2 weeks.

Nasal trauma evaluation:

Septum examined directly[-, and nares patent bilaterally-], so septal hematoma is unlikely.

Epistaxis is controlled with direct pressure. Nasal fracture is a clinical diagnosis; imaging does not change acute management [-and is not indicated-].

ENT follow-up in 5 to 7 days, after swelling subsides, for cosmetic or functional deformity assessment.

History and physical is consistent with a nursemaid's elbow/subluxation of the radial head. No evidence of neurovascular damage. No gross evidence of fracture. [-Given lack of trauma, will defer imaging at this time.-]

Will attempt reduction.

History and exam consistent with otitis externa.

No recent upper respiratory infection symptoms to suggest otitis media. No evidence for peritonsillar cellulitis or abscess. Patient has no diabetes or immunocompromise.

Will discuss treatment with topical antibiotics.

History and exam consistent with otitis media.

No evidence for peritonsillar cellulitis or abscess. No exam findings of sinusitis. Patient has no diabetes or immunocompromise.

Will discuss symptomatic management, and the equivocal effectiveness of antibiotics.

Patient presents with facial swelling. History and exam are consistent with parotitis.

No evidence of dental infection or abscess. No recent exposure to similarly ill patients, and patient immunized making mumps unlikely. No immunocompromise. Rapid onset makes a cancerous process less likely.

[-Ultrasound appropriate for initial evaluation.-]

[-Unknown status of mononucleosis, and will perform testing.-] [-CBC to look for evidence of bacterial infection or lymphocytosis. Electrolytes to evaluate for evidence of end organ damage, and to prepare for potential CT scan.-]

Patient presents with an exam suggesting peritonsillar abscess. [-Will consider CT scan to confirm.-]

Vocal changes are present. Strep pharyngitis is presumed and will be treated.

Patient is able to breathe easily and swallow their own secretions.

No evidence for acute bronchitis, sinusitis, pneumonia, otitis. Labs to establish an infection baseline and to evaluate for electrolyte imbalance.

Will arrange ENT referral and consultation. [-Will provide IV hydration.-] [-Will provide pain management.-]

Puncture wound evaluation:

Full range of motion and sensation intact distally[-, and no pain with tendon loading-], so deep structure injury is unlikely. [-No clinical concern for bony involvement and/or foreign body so low yield from x-ray.-]

Puncture wound with hemostasis. Neurovascularly intact. No evidence for tendon injury.

Wound irrigated. Wound left open; closure is not indicated for this wound. [-Plantar puncture through footwear noted. Coverage for staph and strep appropriate and will monitor for pseudomonas.-]

Tetanus prophylaxis is [-up-to-date.-]

Healthy domestic animal [-available for 10-day observation and provoked bite and species low-risk in this region-][-, and no direct contact with a bat-], so rabies post-exposure prophylaxis is not indicated per public health guidance.

Potential rabies exposure, with animal unavailable for testing. His must be treated as an exposure, although there is no evident bite wound. Will need HRIG and HR vaccine. Follow-up with infectious disease. Will receive further injections through the infusion center at day 3, 7, 14. Tetanus status is [-up-to-date-].

History and exam support the diagnosis for [-lumbar-] radiculopathy. [-No evidence for cauda equina syndrome.-]

No mechanism or exam to suggest fracture or subluxation. No evidence of osteomyelitis, bone lesion, or tumor.

[-No acute requirements for imaging. If symptoms persist or worsen, an outpatient MRI may be appropriate.-]

[-Will medicate with steroids and consider pain management options.-]

The patient's vague history, inconsistencies in history, and registration data raise concern regarding possible secondary goals of Emergency Department visit.

[-Additionally, patient displayed advanced knowledge of narcotic medications and dosing, and requests specific medication and dosage-]. Secondary gain must be considered in the differential diagnosis.

I discussed this with the patient and indicated that I would not provide controlled substances until I'm able to confirm or refute variances in data/history.

Patient with reported seizure activity.

The patient to receive evaluation for point-of-care glucose. To evaluate for metabolic abnormalities, will perform electrolytes, liver function testing, renal function. [-Will consider toxicology screening.-] [-To screen for a seizure, will perform prolactin levels.-]

[-Will consider imaging.-] [-Will consider EEG.-]

No infectious process such as meningitis to suggest need for lumbar puncture.

Will provide benzodiazepine medication. Seizure precautions to be initiated.

Sepsis evaluation contains a broad differential diagnosis. qSOFA is not used as a sole screening tool; will assess trajectory, perfusion, mental status, respiratory status, renal function, and lactate.

CBC with differential, comprehensive metabolic panel, liver testing, lactate with repeat when elevated, blood gas, coagulation studies, and bedside glucose appropriate. Urinalysis appropriate to screen for a urinary source. Blood cultures from two sites are appropriate before antimicrobial therapy when this does not delay treatment. [-Urine, respiratory, sputum, wound, CSF, or device cultures appropriate per the suspected source.-] [-Pregnancy testing appropriate.-]

ECG and troponin appropriate. Chest x-ray appropriate to screen for a pulmonary source. [-Bedside cardiac, lung, and abdominal ultrasound appropriate to assess ventricular function, RV strain, pulmonary edema, free fluid, biliary disease, and urinary obstruction.-]

[-Balanced crystalloid appropriate in measured boluses, commonly up to 30 mL/kg within the first 3 hours, with reassessment of MAP, mental status, capillary refill, urine output, and lactate trend between boluses.-]

Prompt empiric IV antibiotics appropriate, tailored to local resistance patterns, allergy history, prior cultures, healthcare exposure, immune status, and suspected source. [-Urgent source control appropriate: drainage, surgery, device removal, or biliary or urinary decompression as indicated.-]

Will reassess perfusion, mental status, and lactate serially; deterioration may occur after an initially non-severe presentation.

[-Will prioritize pulmonary, urinary, abdominal, skin and soft tissue, vascular-device, and CNS sources.-]

Sinusitis evaluation:

No periorbital swelling or pain with eye movement, no vision change and normal mentation without severe headache[-, and no meningismus-], so orbital or intracranial extension is not suspected.

Symptom duration and pattern are consistent with viral rhinosinusitis; antibiotics are not indicated and supportive care is recommended.

[-Will consider saline irrigation, steroids, analgesia. Return precautions for eye swelling, vision change, severe headache, or persistent fever are reviewed.-]

Patient with concerns for sexually transmitted infection. Cannot exclude urinary tract infection. Urinalysis to be performed. [-Will perform screening test for pregnancy.-]

Screening tests performed for gonorrhea and chlamydia. [-Patient agrees to treatment while awaiting results, usually ceftriaxone and doxycycline, with results returning in 1 to 3 days.-]

Recommend screening for HIV, HPV, hepatitis, and patient understands they will need follow-up.

[-No current lesions are present with concerns for herpes-]

[-Patient is not at high risk for syphilis, including no history of HIV.-]

Patient at risk for sexually transmitted disease. Will perform screening. Will perform testing for gonorrhea and chlamydia. [-Patient agrees to treatment while awaiting results, usually ceftriaxone and doxycycline, with results returning in 1 to 3 days.-]

Recommend screening for HIV, HPV, hepatitis, and patient understands they will need follow-up.

[-No current lesions are present with concerns for herpes. Patient may consider screening with primary care provider. (or Lesions present; will start an antiviral given timing less than 72 hours or new lesions.) (or Patient declines antiviral treatment.)-]

[-No current lesions are present with concerns for herpes-]

[-Patient is not at high risk for syphilis, including no history of HIV.-]

Pharyngitis with [-isolated symptoms, cervical adenopathy, equivocal trismus, fever-]

No lesions to suggest coxsackie infection or oral herpes. No evidence for peritonsillar cellulitis or abscess. [-No evidence for acute bronchitis, sinusitis, pneumonia, otitis.-]

No evidence of dehydration due to poor po intake. [-CBC to look for baseline evidence of infection. Electrolytes to look for an imbalance. Liver function testing and lipase to look for end organ damage.-] [-Will screen for mono.-]

Patient with history of swallowed foreign body. There is risk for impaction in the esophagus[- and will perform imaging-].

No evidence of a sharp foreign body ingestion. Based on history, there is no concern for ingestion material containing toxic metals. No demonstration of breathing problems to suggest aspiration. No reports of magnets swallowing. No reports of a swallowed battery.

Syncope evaluation - transient loss of consciousness with spontaneous recovery:

There are no risk factors such as family history of sudden cardiac death, abnormal EKG, persistently low blood pressure, history of cardiac disease or heart failure, shortness of breath with the event or during evaluation, age related or associated comorbidities and hematocrit less than 30.

Not exertional, rapid complete recovery without confusion and clear prodrome of [-lightheadedness, warmth, diaphoresis. -][-No associated chest pain or palpitations preceding the event. -][-No significant injury from the event-].

EKG appropriate to evaluate for dysrhythmia, conduction disease, and ischemic changes. [-Will place on cardiac monitoring in the department.-] No tongue injury or incontinence to suggest seizure. Bilateral radial pulses are equal. [-Will consider CT scan as a screen for a neurological event.-]

Laboratory evaluation selective: glucose and hematocrit. [-Will screen for pregnancy. -][-CBC to look for anemia or evidence of infection. Electrolytes to look for evidence of end organ damage or acidosis.-] [-Anxiety does not appear to be a source of the patient's symptoms by history.-] [-Will check a TSH to look for an atypical cause.-]

Common but with less mortality can include a neurocardiogenic, carotid sinus sensitivity, orthostasis, and medication-related or substance abuse process. [-No evidence for this on history or physical exam.-]

Tachycardia. Differential diagnosis includes dehydration, and the patient will receive 1 L of normal saline IV.

Cardiac component will be evaluated by an EKG. [-Troponin appropriate to test for myocardial injury-] [-CBC appropriate to test for infection or anemia.-] [-Electrolyte imbalance will be evaluated with laboratory testing.-] [-Will perform a urinalysis to evaluate for infection or drug use.-] [-Hyperthyroidism will be screened with a TSH.-] [-Negative for pulmonary embolism by PERC criteria.-] [-No viral symptoms-] [-Will consider Antipyretics.-]

[-Will evaluate for sepsis.-]

[-Anxiety or pain considered as a possible source.-]

Testicular pain. Differential diagnosis: epididymitis, orchitis. Consideration for torsion and testicular mass is appropriate for doppler ultrasound.

No reports of trauma. Urinalysis pathology to be investigated for infection.

[-Patient declines screening for STD.-]

Symptoms consistent with upper respiratory infection. Likely a viral process which will be treated symptomatically.

[-Given the timing, testing would not change management for the patient and is not performed.-] [-Will offer viral testing.-]

Urinary retention. Foley catheter to be placed and effect monitored.

[-Considerations include BPH.-]

[-Will consider lab studies-]

Lower urinary tract symptoms are suggestive of a simple urinary tract infection. Urinalysis is indicated to look for evidence of infection.

[-No evidence for pyelonephritis.-] [-Will screen for vaginitis and STD.-] [-Will check urine pregnancy.-]

Patient with bleeding in pregnancy. Differential diagnosis: threatened abortion, missed abortion, fetal demise, consideration for ectopic.

Nothing in the history or exam to suggest UTI, sepsis, DIC, or significant hypovolemia.

CBC to look for evidence of infection. Electrolytes to look for an imbalance. Liver function testing and lipase to look for end organ damage. Urinalysis to look for infection. [-Quantitative Hcg as a baseline-]

[-Discussed wide differential for abdominal pain, and patient understands we will start evaluation for pregnancy related concerns. -]

Imaging with pelvic ultrasound. [-Quantitative beta HCG.-] [-Will perform Blood typing-]

Patient presents with vertigo, spinning-type.

No lightheadedness to suggest decreased cerebral perfusion such as TIA, dysrhythmia, or hypovolemia. Abrupt onset and associated with head movement consistent with peripheral origin. No recent URI symptoms suggesting labyrinthitis.

Positional signs and symptoms consistent with benign positional vertigo.

Will perform the Epley maneuver. Significant relief would strongly argue against a central process. Will consider advanced workup if not improving.

Differential diagnosis [-vomiting and diarrhea-]. Cannot exclude food poisoning, Escherichia coli, shigella, or Salmonella.

No evidence of the headache, head injury, changes in medication, alcohol or diabetic concerns. No evidence of obstruction. No history or suggestion of inflammatory bowel disease, dietary changes as factors, medications, or surgical concerns.

No blood in stool or emesis. No focal or significant peritoneal abdominal tenderness. [-Will discuss hydrationand laboratory evaluation.-] The presentation is consistent with uncomplicated gastroenteritis.

The patient presents with a painful rash, appearance and location consistent with zoster. There are no recent upper respiratory infective symptoms that suggest a viral exanthem. No new ingestions or exposures to suggest allergic or drug reaction. No purpura or petechia to suggest vasculitis. No other symptoms to suggest systemic illness. Distribution of the pain and lesions are consistent with herpes zoster.

No evidence of secondary infection.

[-Patient presents within 72 hours of rash onset, so we will utilize antiviral therapy for reduction of symptoms and posttherpetic neuralgia risk.-]

Will discuss pain management.