Abdominal Pain

Abdominal pain contains a wide differential diagnosis, and at present remains undiagnosed. 

[- This presentation meets criteria for an acute abdominal process, and will discuss emergency department management. Patient to be considered for advanced imaging.-] 

[-Patient does not present with suggestion of acute abdominal process at this time. Patient understands that with an unknown source of abdominal pain, we should monitor closely for significant changes (Location, radiation, associated symptoms, or other concerns) as well as worsening of pain. Patient is also to go to the emergency department in 12-24 hours if not improving.-]

[-I would like to avoid narcotic pain medications at this time, so as not to mask development of an acute abdominal process.-]

Abscess

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 consider treating with oral antibiotics as an outpatient, with broad coverage.-] 

[-Culture to be performed as a unique study. Will change treatment if needed based on result interpretation-]. Record review and patient history show tetanus is [-up to date-]

Abrasion

Abrasions are superficial, well approximated, and hemostasis is intact. They are not conducive to suture repair. Will manage the wound with conservative management, using antibiotic ointment and bandaging. No evidence for tendon damage or neurovascular compromise, nor for bony injury (xrays not indicated). Records reviewed and tetanus prophylaxis is [-up-to-date-].

This is an acute injury [-complicated by foreign body debris, possible fracture, location-]

Allergic Reaction

Patient presents with a rash consistent with allergic response. Allergen [-of unclear etiology-]. Currently, the source is undiagnosed and 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 xanthem, 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 for respiratory involvement. Will treat with histamine blockers. Will prescribe steroids and discuss timing of use with the patient.

Asthma

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 unlikely[-, but chest x-ray will help rule this out-].  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.-]

Anxiety

The patient presents with anxiety.  [-***This is a chronic illness with exacerbation-] [-***This is a currently undiagnosed new problem with uncertain prognosis-]

[-The patient denies stimulant or substance abuse which could cause anxiety.-]  No rapid cycling alternations with depression.  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.

[-Will Discuss anxiolytics and follow up for long term management-]

Back Pain

Tenderness consistent with a muscle strain or sprain of the back.  [-***This is a chronic illness with exacerbation-] [-***This is a currently undiagnosed new problem with uncertain prognosis-]

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 history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.

[-Over the counter medications and prescription medications for pain are discussed with the patient.-]

Back X-ray

Tenderness consistent with a muscle strain or sprain of the back.  [-***This is a chronic illness with exacerbation-] [-***This is a currently undiagnosed new problem with uncertain prognosis-]

Given the significant mechanism, [-we will perform imaging-]. No point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. No evidence for cauda equina syndrome. No radicular pain or focal neurologic finding to suggest disc injury or nerve impingement. Nothing in history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain. 

[-Over the counter medications and prescription medications for pain are discussed with the patient.-]

Bat Bite

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-]. No pain. 

Follow up will be needed to complete treatment.

Bell’s Palsy

The patient presents with a new diagnosis of Bell’s Palsy. There is unilateral facial weakness, 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. I will treat with prednisone. Currently, there is equivocal benefit for use of antivirals. I reviewed eye precautions (including avoidance of contact lenses, and saline drops), and provided a neurology referral.

 Bee Sting

Patient 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. 

This is an acute injury with complication of an allergic response. Will discuss antihistamines and steroids. 

Body Fluid Exposure Without PEP

The patient was counseled regarding HIV and hepatitis testing, and given informed consent. The patient was counseled regarding postexposure prophylaxis and declines. 

Patient understands the outcome of this exposure is unclear. 

Patient understands changes in plan can occur, but timeliness is important. I discussed at length with the patient the diagnosis and expected follow-up with infectious disease.

Body Fluid Exposure PEP Treatment

Patient presents with [-percutaneous, mucous membrane, skin-] body fluid exposure does present with some risk. 

There is an high risk diagnosis with unclear outcome. 

Postexposure chemoprophylaxis with Truvada and TIVICAY is reviewed. HIV and hepatitis testing indicated to establish baseline. [-Hepatitis B is up-to-date.-] Records reviewed and tetanus prophylaxis is [-up-to-date-].Will provide infectious disease referral for follow-up.

Bronchitis

Patient presents with productive cough and general malaise. Although patient has no evidence of respiratory distress or significant hypoxia, I will obtain chest x-ray to help rule out infiltrate and pneumonia. 

Patient’s symptoms are likely related to bronchitis and without evidence of infiltrate; I will not use antibiotics at this time. I will, however, provide patient with symptomatic relief. Patient has no other evidence of serious bacterial illness to include meningitis.

This is a new diagnosis with systemic symptoms. 

Burn

History and exam consistent with first and second-degree burns. [-Will debride ruptured blisters/Will pad existing Blisters/No blisters requiring padding-]. Will treat with topical antibiotics, and consider narcotic analgesia for breakthrough pain. Records reviewed and tetanus prophylaxis is [-up-to-date-].

Cat Bite

Patient with a cat bite injury. Exam concerning for infection. There is no puncture over a flexor tendon, no circumferential swelling and no tenderness over the tendons. No evidence for neurovascular compromise. The patient has no immunocompromise or impaired wound healing, therefore will treat as an outpatient with oral antibiotics [-(Augmentin to cover for P. multocida)-]. Will consider splinting for comfort and to slow spread of infection. Records reviewed and tetanus prophylaxis is [-up-to-date-].

This is an acute high risk injury due to potential rapid spread of infection.

Cellulitis 

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 allergic component. No identifiable target lesion. Viral xanthem unlikely in absence of viral symptoms. 

Will treat with broad antibiotic coverage. [-Source of infection from a wound with complication of infection.-]

Records reviewed and tetanus prophylaxis is [-up-to-date-]. 

Patient will return with increased redness, red streaks, drainage, or increased pain.

Chest Pain 

Chest pain evaluation contains a wide differential diagnosis. 

EKG Ordered and interpreted:

Aspirin 324mg is administered.

Reviewed with the Emergency Department, notation available to accepting provider.

This is an acute illness that is potentially life threatening or may cause permanent disability.

Coccyx Contusion

Mechanism and exam suggest coccygeal contusion or fracture. No evidence for cauda equina syndrome. No radicular pain or focal neurologic finding to suggest disc injury or nerve impingement. No hematochezia to suggest rectal injury. Nothing in history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.

This remains an undiagnosed problem with unclear prognosis (1-2 week recovery for contusion, 4-6 week recovery for fracture)

Will discuss prescription medications for pain and stool softener. 

Patient presents with concerns for viral process. Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, sinusitis, pneumonia.

Covid 19

Patient presents with concerns for a viral process. Has been in public during a pandemic. [-No discrete contact-]. Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, sinusitis, pneumonia, otitis. Symptoms consistent with viral URI which will be treated symptomatically. 

Will offer Covid-19 testing. 

[-Patient is not a candidate for bamlanivimab-]

Croup

Patient presents with a barking cough and a history consistent with croup. No suggestion of foreign body ingestion. No trismis arguing against epiglottitis or strep.  

I will treat and encourage strong monitoring. 

No hypoxia to suggest a need for admission or racemic epinephrine. Will offer steroids.

This is an acute illness with airway involvement/systemic symptoms.

Cerumen Impaction

History and exam consistent with cerumen impaction. This is an acute presentation of a chronic process and we will review hygiene of the ear. 

No recent upper respiratory infection symptoms to suggest otitis media and no evidence on exam for peritonsilar abscess or cellulitis. No ear canal sensitivity to suggest otitis externa. No tap tenderness to teeth to suggest dental infection or pain. Patient has no diabetes or immunocompromise. Will attempt at removal of cerumen. Patient trained on hygiene of the ear.

As there was significant cerumen and now instrumentation leading to possible trauma, there is risk for otitis externa. Patient to monitor closely. I would like to avoid Cortisporin otic drops at this time, but patient understands this may be necessary in the near future.

Chest Contusion 

Chest pain after injury. Differential diagnoses includes rib contusion, intercostal contusion, rib fracture, or pneumothorax. We will perform a chest x-ray to rule out pneumothorax and to help clarify whether there is rib fracture. Cardiac event is unlikely, as the pain is reproducible, intermittent, and associated with an injury.

Potential complication of developing pneumonia, and will review breathing exercises with the patient.

Will discuss prescription pain management with the patient. 

Conjunctivitis

Patient presents with complaints of red eyes and exam consistent with [-conjunctivitis-], which will be treated with topical antibiotics.  Persistent infection without treatment could lead to iritis or long term vision problems.

No current evidence for visual disturbance, no evidence of foreign body by history. Will have the patient follow-up with ophthalmology if not improving in 2-4 days.

Corneal Abrasion

Patient presents with complaints of eye discomfort and exam consistent with [-corneal abrasion-], which will be treated with topical antibiotics.  Persistent injury or subsequent infection without treatment could lead to iritis or long term vision problems. Will require follow-up with ophthalmology if not improving in 2-4 days.

No current evidence for visual disturbance, no evidence of foreign body by history. 

Dermatitis

Patient presents with a rash consistent with allergic response. Allergen [-of unclear etiology-]. Currently, the source is undiagnosed and 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 xanthem, 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 for respiratory involvement. Will treat with histamine blockers. Will prescribe steroids and discuss timing of use with the patient.

With wide differential diagnoses, timely followup is appropriate if not improving within one week. 

DVT 

The patient presents with lower extremity pain [-edema, calf tenderness, positive Homans sign-].  No history of recent trauma.  Differential does include muscle strain or myalgia, however, it also includes deep vein thrombosis.  [-Will proceed to Venous Doppler Ultrasound-].

Progression of DVT to Pulmonary Embolism can be life threatening or lead to permanent cardiac and/or pulmonary dysfunction.

Epistaxis

Epistaxis. Attempted to clear blood clots. Location remains unclear, but not grossly evident at the anterior septal region. 

Cautery at this time would be non-focal, and risks outweigh benefits. Will discuss packing with the patient, and consider this strongly with any persistent bleeding. Will require observation. 

Conservative management with antibiotic ointment to decrease risk of recurrent bleeding due to dryness.

Fracture vs Sprain

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.

Imaging is ordered by myself, and I will perform and independent review.

Gastroenteritis

Vomiting and diarrhea. Without frank abdominal pain, likely viral syndrome (gastroenteritis). [-No diet changes to suggest food poisoning-] No drinking water from possibly contaminated sources. No recent antibiotic use to suggest c. difficile. 

No history or suggestion of inflammatory bowel disease, dietary changes, medication changes, irritable bowel syndrome. No evidence of obstruction 

[-With no blood in the stool and given the timing, no indication for stool studies currently-] [-Will perform a CBC to look for evidence of dehydration or infection. Will perform electrolytes.-] [-Will provide hydration-]

At this time, there are no surgical concerns. [-Patient to be provided probiotics for diarrhea and Zofran ODT for nausea/Vomiting-]

At present, the diagnosis remains unclear, and patient will closely monitor to look for progression of symptoms requiring re-evaluation or Emergency Department evaluation. 

Gout

Differential diagnosis: gout given past history of same, presence of focal pain [-area-], positive risk factors including [-family history, obesity, hypertension, past history-]. Lack of point of entry for infection, lack of fever makes cellulitis less likely. No history or calcium dysfunction to suggest pseudogout.

No risk factors for osteomyelitis. No bleeding disorder or anticoagulation to cause hemarthropathy. No recent STD, tick exposure, immunocompromise, [-diabetes-], arthritis, recent joint injury or joint prosthesis to place patient at risk for septic arthritis. [-Will consider consider arthrocentesis-]. Other acute arthritides unlikely given abrupt onset. [-Will order a Uric Acid level-].

[-This is a chronic illness with an exacerbation.-] [-I have prescribed medication-]

Head Injury (with imaging)

Differential diagnoses: [-Scalp, Facial-] Contusion. Concussion. Due to [-loss of consciousness, symptoms, age, anticoagulants-], I felt we should consider CT scan imaging. The patient will continue to monitor for, and return with, changes in behavior, decreased level of consciousness, or increased pain. The patient should also return with poorly controlled nausea, vomiting, or dizziness.

This is an acute injury with systemic symptoms [-Nausea, lightheaded, body aches-]. [-Prescription medications are ordered.

Head Injury  (no imaging)

Differential diagnoses: [-Scalp, Facial-] Contusion. [-Evidence for Mild-] Concussion. In the setting of no loss of consciousness, Glascow coma scale of 15 and normal neurologic exam, I did not feel a CT scan of the head was needed.  The patient is instructed to return with changes in behavior, decreased level of consciousness, or increased pain. The patient may also return with poorly controlled nausea, vomiting, or dizziness.

This is an acute injury with systemic symptoms [-Nausea, lightheaded, body aches-]. [-Prescription medications are ordered.

Hemorrhoid

Signs and symptoms consistent with an external hemorrhoid. No hematochezia prompting further workup. With thrombosis, patient was offered an incision, [-and declines-].  Conservative management to be followed. Will consider surgical consult in follow up, especially if there are worsening symptoms. I spent a significant amount of time reviewing sitz baths, hygiene, and prescription cream. Patient may consider using a donut pillow.

This is a chronic issue with exacerbation. Will prescribe Anusol.

Hypertension

Hypertension is either related to pain, anxiousness, chronic, or a combination of conditions. Patient is advised that long term elevations in blood pressure can lead to complications such as heart disease or stroke.

This is not a hypertensive crisis and without additional monitoring, prescribing antihypertensive medication at this time would not be appropriate. Patient is to check their  blood pressure, or follow-up with their primary doctor in the next 2-3 weeks for reevaluation. [-***The source of the elevated blood pressure is unclear at this time, as well as the required care-] [-***This is an established diagnosis with an exacerbation-].

Influenza

Presumed seasonal flu. Strep pharyngitis unlikely based on exam and symptom. No evidence for acute bronchitis, sinusitis, pneumonia, otitis. Symptoms consistent with viral URI which will be treated symptomatically. [-Testing for influenza is of limited value with a high error margin, and little change in most patients care-]. Will counsel the patient regarding isolation.

This is an acute illness with systemic symptoms. Prescription medications [-are discussed-].

Intoxicated

Patient is a chronically inebriated. Will perform blood alcohol testing. Patient demonstrates no desire to stop the use of alcohol. Is chronically at risk for injury and alcohol related complications. 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. [-***Will order and interpret lab results.-] Patient has clearly demonstrated the ability to obtain medical care. Will consider providing vitamin supplements by mouth or IV.

This is a chronic problem with an exacerbation.

Laceration

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)-]. Records reviewed and tetanus prophylaxis is [-up-to-date-].

This is an acute injury [-complicated by foreign body debris, possible fracture, location-]

Laceration Without Repair

Laceration is [-superficial, well approximated, presents too late for wound care-] and hemostasis is intact. There would likely be minimal improvement with suture repair. Will manage the wound with conservative management, using good wound care. No evidence for tendon damage or neurovascular compromise, nor for bony injury (xrays not indicated). Records reviewed and tetanus prophylaxis is [-up-to-date-].

This is an acute injury [-complicated by foreign body debris, possible fracture, location, risk of infection-]

Meningitis

Patient is here for worse headache of life. This is a change in character from previous headaches but with a benign neurologic exam. There is evidence for an infectious process such as meningitis or encephalitis, with notable meningismus. No evidence for an inflammatory process such as temporal arteritis, increased cranial pressure, trauma, or chronic process such as tumor formation. No recent trauma to cause SDH or post-concussive syndrome. [-CT or fundal exam-] with subsequent LP is indicated to rule out SAH or other intracranial process.

Will require antibiotic treatment. 

Viral testing, CBC and additional chemistries may be useful to differentiate this type of headache.

This is a life threatening process. Discussed with the Emergency Department.

Mental Health Inpatient

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 [-suicidal/homicidal ideation/hallucinations-] this patient requires screening for inpatient management. Will perform [-blood alcohol and drug screen-] and consider supplemental testing for organic cause with [-thyroid testing, electrolyte evaluations, and a baseline CBC-]. The patient [-does/does not-] contract for safety. There is risk for involuntary departure. Will consider restraints, safe enviroment, and medical management only if appropriate for patient and staff safety.

[-***This is a chronic problem with an acute exacerbation.-][-*** This is an undiagnosed new problem with uncertain prognosis.-]

[-Will defer medical management a primary care provider to ensure good follow-up.-]

Mental Health Outpatient

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.

[-***This is a chronic problem with an acute exacerbation.-][-*** This is an undiagnosed new problem with uncertain prognosis.-]

[-Will defer medical management for a primary care provider to ensure good follow-up.-]

Migraine

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

[-***This is a chronic problem with acute exacerbation.-][-***This is a new problem with a presumed diagnosis and unclear prognosis.-]

Neck Pain 

Neck sprain or strain. No recent upper respiratory infection symptoms to suggest infectious cause for pain. No direct blow or midline tenderness, as such x-rays are not indicated. No radicular pain or focal neurologic finding to suggest disc herniation or nerve impingement. History and exam consistent with a strain or sprain.

No point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. 

[-Over the counter medications and prescription medications for pain are discussed with the patient.-]

[-***This is a chronic illness with exacerbation-] [-***This is a currently undiagnosed new problem with uncertain prognosis-]

Nose Injury 

Patient presents with probable nasal fracture with associated soft tissue swelling. Patient has no other identifiable facial trauma, and at this point, I do not feel that further imaging is necessary. Patient has no evidence of septal hematoma or ongoing significant epistaxis. Patient may need referral to otolaryngology for definitive management for probable fracture after swelling has subsided. [-I will consider antibiotics at this time due to the possibility of an open fracture-]. Records reviewed and tetanus prophylaxis is [-up-to-date-].

Nursemaid’s Elbow

History and physical consistent with a nursemaid’s elbow/subluxation of the radial head. No evidence of neurovascular damage. No gross evidence of fracture. Will attempt reduction.

This is an acute injury complicated by subluxation. Discussion of management takes place with the patient’s parents. Review of outside records do not demonstrate previous similar injury.

Otitis Media Medical

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. Patient has no diabetes or immunocompromise. Will discuss antibiotic use and their equivocal effectiveness.

[-***This is a chronic illness with exacerbation-] [-***This is a currently undiagnosed new problem with uncertain prognosis-]

Otitis Externa Medical 

History and exam consistent with otitis externa, nonmalignant. No recent URI symptoms to suggest 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. Patient has no diabetes or immunocompromise.

[-This is a currently undiagnosed new problem with uncertain prognosis. Patient informed that progression could occur, requiring an ear wick or otolaryngology referral-]

Puncture Wound 

Puncture wound with hemostasis, no evidence of bony injury and no history for FB. X-rays would likely not be helpful. This wound is not amenable to copious irrigation. No repair is indicated. The patient is neurovascularly intact. No evidence for tendon injury. Records reviewed and tetanus prophylaxis is [-up-to-date-]. 

Will not use antibiotics at this time, but patient monitor closely for signs of infection. This is an acute injury, with a complication of possible retained foreign body material. 

Rabies

Potential rabies exposure, with animal unavailable for testing. This 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 on day 3, 7, 14. Records reviewed and tetanus prophylaxis is [-up-to-date-]. 

Patient is at risk for injury complicated by rabies infection.

Sciatica

History and exam support the diagnosis for sciatica. No evidence for cauda  syndrome. No mechanism to suggest fracture or subluxation. No evidence of osteomyelitis or other infection, bone lesion, or tumor. Nothing in history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.

No acute requirements for imaging. If symptoms persist or worsen, an outpatient MRI may be appropriate. Will medicate with steroids and consider prescription pain management options.

[-***This is a chronic illness with exacerbation-] [-***This is a currently undiagnosed new problem with uncertain prognosis-] 

Sexually Transmitted Disease

Patient with concern for sexually transmitted disease. [-For evaluation of urine infection, urinalysis is to be performed.-][- Will perform screening test for pregnancy.-][- Will screen with vaginal DNA probe for bacterial vaginitis or yeast infection.-]

Will perform testing for gonorrhea and chlamydia (an independent order that will require interpretation and management by our team). [-Patient agrees to treatment while awaiting results.-]

Will discuss screening in our clinic versus follow-up with with primary care provider for concerns of HIV, HPV, hepatitis.

[-No current lesions are present with concerns for herpes. Patient may consider screening with primary care provider.-]

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

Sinusitis

Signs and symptoms are consistent with sinusitis. Will discuss treatment with sinus irrigation, nasal/oral steroids, decongestants and pain management for breakthrough discomfort.

Will review antibiotics with the patient, and explained limited role in the setting of sinusitis.

Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, pneumonia, otitis. 

[-***This is a chronic illness with exacerbation-] [-***This is a currently undiagnosed new problem with uncertain prognosis, and will provide otolaryngology referral should symptoms persist.-] 

Strep Throat

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 using antibiotics.

This is an acute illness with systemic symptoms (fever). 

Stroke

Patient presents with signs of an ischemic event. Will require emergency evaluation. We will monitor patient’s stability and treat as needed. Time of event is [-unclear-]. Will assess with the stroke scale.

Will immediately evaluate for hypoglycemia and monitor Oxygen saturation.

Will monitor for other pathology. No evidence for seizure. No presentation that suggests migraine. Blood pressure does not suggest hypertensive encephalopathy. No global symptoms to suggest syncope or systemic infection. Consideration for potential complication from a cardiac event such as atrial fibrillation.

This is an acute illness that is life-threatening. We will not provide aspirin at this time, as there is risk for hemorrhagic event.

Syncope 

There are [-no risk factors such as: Abnormal EKG, history of cardiac disease/heart failure, Persistently low blood pressure, shortness of breath with event or during evaluation, no hematocrit less than 30, no age related or associated comorbidities, and no family history of sudden cardiac death.-] 

[-Will consider EKG and cardiac chemistry evaluation to evaluate for a cardiac component.-]

No tongue injury or incontinence to suggest seizure

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 of syncope.

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.-]

Syncope is undiagnosed, and prognosis is unclear. Independent tests are ordered, and will require interpretation management by our team. 

Tachycardia 

Tachycardia. Possibly secondary to [-subclinical-] fever. 

Differential diagnosis includes dehydration, and the patient will receive IV hydration. Cardiac component will be evaluated by an EKG. [-Hyperthyroidism will be screened with a TSH.-] Electrolyte imbalance will be evaluated with laboratory testing. A CBC will be performed to look for anemia or infection. 

Will perform a urinalysis to evaluate for infection or drug use.

Untreated tachycardia is a life-threatening process. Will discuss antipyretic management with the patient and Emergency Department evaluation.

Testicular Pain Medical

Testicular Pain. Differential diagnosis: Epididymitis, orchitis. Consideration for torsion and consider doppler ultrasound. Trauma is a consideration. Less likely would be referred pain from renal colic. Also consider testicular mass as possibility as well. Urine tract pathology to be investigated with urine dip. For younger males with risk factors, consider STD.

This is an unclear diagnosis with uncertain prognosis. Will require follow-up with urology. Will discuss prescription pain management with the patient.

Upper Respiratory Infection (Cold)

Upper respiratory infection symptoms are consistent with viral process which will be treated symptomatically.  Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, sinusitis, pneumonia, otitis. No indication for diagnostic testing.

This is an acute illness with systemic involvement. Symptomatic prescription management is discussed with the patient.

UTI

Lower urinary tract or symptoms are suggestive of a simple urinary tract infection. Urinalysis is indicated. No evidence for pyelonephritis [-or symptoms to suggest vaginitis.-] [-Will perform urine pregnancy.-]

[-Will require a test interpretation for culture after results are obtained.-]

Will require an ordering of unique tests [-***Urine Culture, Vaginal Pathogens, Chlamydia/Gonorrhea-]

Vertigo

Vertigo. Of unclear diagnosis with uncertain prognosis. 

No evidence for otitis media on exam. Decreased risk of central process, as patient can ambulate, age is not over 50, and no cranial nerve dysfunction is noted.

Atypical differential to include pre-syncope, dehydration, anemia, medication reaction, trauma, head injury, viral syndromes.

[-Medication is prescribed for the patient-]

Zoster

The patient presents with a painful rash, no systemic symptoms.  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 and pain palliation for reduction of symptoms and post herpetic neuralgia risk. Current studies do not endorse corticosteroid use.

This is a chronic condition of underlying varicella with an acute exacerbation. Medications are prescribed.