EPIC Templates

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Complaint: ***
Time course: Sudden, Gradual, Unknown, Onset was *** prior to arrival.
Lasting ***
Currently Symptomatic: Worse, Quality Aching, Dull
Severity - Maximum: Severe, Current severity: Moderate
Associated with: Nothing
Exacerbated by: ***
Relieved by: ***-]
[-No fever-]
[-No Chest Pain-]
[-No SOB-]
[-Abdominal pain as described, No nausea, No vomiting.-]
[-No dysuria-]
[-No easy bleeding-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, well appearing, Patient appears [-comfortable-], Alert and lucid.
ENT: OP moist, Nares patent
CARD: [-Regular rate and rhythm, heart sounds normal-]
RESP: [-No respiratory distress, breath sounds normal-]
ABD: Soft, [-tender to palpation ***-], [-negative Murphy's Sign, Negative Obturator and Rovsing sign, No peritonitis-]. BS present, no organomegaly or masses.
BACK: non-tender. [-No CVA tenderness-].
SKIN: Color normal
NEURO: Awake, alert, and lucid. No motor deficits.
PSYCH: Mood/ affect normal
MEDICAL DECISION MAKING
Differential Diagnosis: Abdominal pain includes: diverticulitis, colitis, non-specific abdominal pain, constipation, inflammatory bowel, irritable bowel. Other considerations include renal colic, pyelonephritis, inguinal hernia.
Anterior abdominal wall pain, pain of unclear etiology/functional abdominal pain, atypical appendicitis, obstruction, mesenteric ischemia, AAA. Also may include hepatitis, cholilithiasis, GERD, Gastritis.
[-In males: consideration for testicular torsion. In females consideration for ovarian cyst, torsion, pregnancy including ectopic or corpus luteum cyst. Consider pregnancy testing-]
Work Up Includes: CBC to evaluate for infection or anemia. Electrolytes and liver function testing with lipase to look for evidence of endorgan damage. Urine test will be obtained to rule out infection, renal stone, hematuria. [-Will consider advanced imaging.-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
[-EKG: ***-]
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
[-I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
[-Escalation of care including admission/observation considered. ***-]
[-Case Reviewed with ***-]
[-Records reviewed and summary***-]
[-EKG Interpretation/imaging interpretation-]
[-I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient's satisfaction
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
DIAGNOSIS
@DIAGX@
Medications on Discharge
@EDPTMEDSTART@
@FUP@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Location: ***
Onset was *** prior to arrival
Time course: Gradual
Currently Symptomatic: Worse
Complicating Factors: None
Maximum Severity: Severe; Current Severity: Moderate
Associated with: Swelling, Pain-]
Tetanus status: [-Tetanus up-to-date-]
[-No fever-]
[-No arthralgia-]
[-No easy bleeding-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Vital signs reviewed, well appearing, Patient appears [-comfortable-], Alert and lucid.
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal
SKIN: Abscess: [-***-]. Otherwise, color normal, no rash, warm, dry.
NEURO: Awake, alert, and lucid. No motor deficits. Gait stable
PSYCH: Mood/ affect normal
MEDICAL DECISION MAKING
History and exam is consistent with [-an abscess-]. As the patient has [-fluctuance/induration-], an incision and drainage is appropriate. No evidence for sepsis, bacteremia, necrotizing fasciitis. No proximal streaking or symptoms of systemic infection. Will review antibiotic risks and benefits with the patient. Tetanus status is [-up-to-date-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
EMERGENCY DEPARTMENT COURSE
[-***-]
Medications given in ED:
@EDMEDS@
The abscess is anesthetized in a field block with [-0.5% Sensorcaine-]. Good analgesia is obtained. The wound is incised with an 11 blade scalpel. Approximately [-30 cc-] of purulent material was expelled. [-This is sent for culture.-] The wound is then explored. [-It is then packed with quarter inch gauze.-] It is covered with 4 x 4 dressings and a bulky fashion. The patient tolerates this well.
I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.
DIAGNOSIS
@DIAGX@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Complaint: ***
Time course: Sudden, Gradual, Unknown, Onset was *** prior to arrival.
Lasting ***
Currently Symptomatic: Worse, Quality Aching, Dull
Severity - Maximum: Severe, Current severity: Moderate
Associated with: Nothing
Exacerbated by: ***
Relieved by: ***
No change in bowel movement, urination. No radiation of the pain to the groin. Patient is able to ambulate.-]
[-No fever-]
[-No SOB-]
[-No Abdominal pain, no vomiting. No incontinence of stool-]
[-No urine changes-]
[-No Rash-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Vital signs reviewed, well appearing, Patient appears [-comfortable-], Alert and lucid-]
NECK: Normal inspection. [-No pain on palpation of the spine-]. Normal ROM
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal
BACK: No CVA tenderness, Normal inspection, no scoliosis, [-Negative straight leg raise testing-]. [-Pain on palpation ***-]. [-No pain on palpation of the spine.-]
NEURO: Awake, alert, and lucid. No motor deficits. Gait [-stable, but causes pain-]
MEDICAL DECISION MAKING
[-Findings are consistent with strain, sprain, or contusion. No mechanism to suggest fracture or subluxation, no point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. No evidence for cauda equina syndrome. No indication for imaging. No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. Nothing in the history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
Chest Pain: [-Ongoing-]
[-No localizing symptoms, No Radiation-]
Change in location over time: [-None-]
Quality: [-Pressure, Heaviness-], Associated with: [-Nothing-]
Exacerbated by: [-Palpation of chest, Movement, Walking, Cough, Deep breath-]
Relieved: [-Nothing-]
Risk factors coronary artery disease: [-***-], Thoracic aneurysm dissection risk: [-None-]. PE risk: [-none-]
[-No fever
Chest pain as detailed
No Cough, No SOB
No Abdominal pain, no vomiting
No dysuria
No arthralgia
No rash
No easy bleeding
No anxiety-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, well appearing, Patient appears comfortable, Alert and lucid
HEAD: Atraumatic
EYES: Normal to inspection
ENT: OP moist, Nares patent
NECK: Normal inspection, No JVD.
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal. [-Chest pain not reproducible-]
ABD: Soft, non-tender
BACK: Normal Inspection.
MUSC: Normal ROM, [-no pedal edema-]
SKIN: Color normal
NEURO: Awake, alert, and lucid. No motor deficits
PSYCH: Mood and affect normal
MEDICAL DECISION MAKING
[-Chest pain-] evaluation contains a wide differential diagnosis. [-For evaluation of pulmonary embolism, will perform a d-dimer.-] Will perform electrolytes, for baseline evaluation, and to screen renal function. Chest x-ray, CBC will help to evaluate for pneumonia. Will evaluate for CHF chest x-ray[- and BNP-]. Will perform an EKG and cardiac enzymes to evaluate for a cardiac event. [-Will consider serial studies.-]
[-The patient will receive a prophylactic aspirin, nitroglycerin. For possible reactive airway process, the patient will receive a nebulizer treatment.-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
@EDABNLABSONLY@
[-EKG: ***-]
[-***-]
[-Escalation of care including admission/observation considered. ***-]
[-Case Reviewed with ***-]
[-Records reviewed and summay***-]
[-EKG Interpretation/imaging interpretation-]
[-I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient's satisfaction
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Complaint: ***
Time course: Sudden, Gradual, Unknown, Onset was *** prior to arrival.
Lasting ***
Currently Symptomatic: Worse, Quality Aching, Dull
Severity - Maximum: Severe, Current severity: Moderate
Associated with: Nothing
Exacerbated by: ***
Relieved by: ***-]
[-No fever/chills
No cough
No shortness of breath/difficulty breathing
No fatigue
No muscle aches or body aches
No headache
No Redness/itchy eyes
No new loss of taste or smell
No sore throat
No congestion/runny nose
No nausea/vomiting/diarrhea-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Vital Signs and temperature reviewed, well appearing, Patient appears comfortable, Alert and lucid
HEAD: Atraumatic
EYES: Normal to inspection
ENT: External ears normal to inspection, Nares patent. Oropharynx is moist no erythema or exudate. Mouth normal to inspection.
NECK: Normal inspection, No Cervical chain lymphadenopathy.
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal. No pain with compression of the chest wall.
BACK: Normal Inspection
MUSC: Normal ROM
SKIN: Color normal
NEURO: Awake, alert, and lucid. No motor deficits
PSYCH: Mood and affect normal
MEDICAL DECISION MAKING
Patient presents with concerns for viral process. Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, sinusitis, pneumonia.
[-Will offer Covid-19 testing. Patient is not a candidate for advanced treatment treatment.-]
@EDABNLABSONLY@
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
[-I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

CRITICAL CARE NOTEPerformed by: Ross Klein PA-C
- Critical findings: ***
- Critical interventions to stabilize the patient and prevent further decompensation: ***
- Critical care time includes time spent directly with patient for interview/physical exam, repeat patient evaluations to assess response to treatments, reviewing laboratory testing, radiographic studies (including discussion with radiology where appropriate), reviewing old records and discussion with family.
In addition, consultation with admitting attendings and coordination of care is included.- Critical care time was exclusive of separately billable procedures and treating other patients.
CRITICAL CARE ELEMENTS
TIME (minutes)
Initial patient history & exam
5
Repeat patient examinations
5
Review of prehospital care, nursing notes and PMH
10
Ordering diagnostic studies and interventions
5
Diagnostic study interpretation and therapeutic interventions
10
Discussion with patient and family
5
Discussion with physicians
5
TOTAL CRITICAL CARE TIME :
45 min

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@
@HPISEC@
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
@PESEC@
MEDICAL DECISION MAKING
[-@APSEC@-]
[-***-]
RESULTS
Labs:
@EDABNLABSONLY@
Imaging:
@EDORD@
@EDMEDS@
EMERGENCY DEPARTMENT COURSE
[-***-]
[-EKG: ***-]
DAX Verbal Consent: Verbal consent given by patient to allow for recording and processing by DAX software.
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
[-I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient's satisfaction.-]
Follow up plan per the discharge instructions and follow-up with emergency department in the next 12-24hrs if increasing symptoms, significant changes, pain, or concerns.
DIAGNOSIS
@DIAGX@
@EDPTMEDSTART@
@FUP@
@MEMD@
@NOW@, @TD@

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Dental Pain. Associated Symptoms none
No trauma, No recent dental procedure
Symptoms began *** prior to arrival. Patient currently has symptoms. Symptoms are worse.
Severity: Maximum: Severe
Current: Moderate
Exacerbated by: Eating, Chewing
Relieved by: minimal with OTC medicines-]
[-No fever.
No sore throat..
No headaches-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Alert and lucid.
ENT: External ears normal to inspection, Nares patent. Oropharynx is moist without posterior erythema and exudate. Pain at tooth # [-***-]. No pain on palpation of the sinuses.
SKIN: Color normal
PSYCH: Mood/affect normal.
MEDICAL DECISION MAKING
Patient with dental pain. No evidence of facial cellulitis or abscess. No sinus component. No evidence of strep pharyngitis. Will discuss short term management and a timely follow up with dental service.
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
[-EKG: ***-]
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
EMERGENCY DEPARTMENT COURSE
[-***-]
Medications given in ED:
@EDMEDS@
I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Location ***
Description: Skin intact, Ulcerated, Draining
Associated with: Injury, Swelling, Pain, Itching, Tenderness, F.B., Fever, Allergen, Lesions-]
Mechanism: [-None, Allergen, Bite, Unknown-]
Complicating factors: None [-DM, Steroids, Prior episodes, IV Drug use, Obesity-]
Occurred: [-***-] prior to arrival. Onset [-Gradual-]. Symptoms are: Worse
Quality: [-Itching, Red, Raised-]
Severity Maximum: [-Moderate-]. Current: [-Moderate-].
Exacerbated by: [-Nothing Scratching Heat-]
[-Relieved by: Nothing
No fever
No itchy eyes
No rhinorrhea. No problems swallowing, No drooling
No nausea, No vomiting.
No easy bleeding or bruising.-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection. Extraocular movements are intact.
ENT: OP moist. Nares patent.
NECK: Supple, normal inspection. Normal Range of Motion.
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal.
SKIN: [-Rash description: ***-]. Otherwise, color normal, no rash, warm, dry.
NEURO: Awake & alert, lucid, no motor/sensory deficit.
MEDICAL DECISION MAKING
Patient reports rash consistent with [-unclear etiology-]. The patient has no systemic symptoms to suggest viral xanthem, no headache or other symptoms suggestive of meningococcal infection. Rash does not resemble urticarial vasculitis. The patient has taken taken no medications to cause a drug eruption. No evidence for respiratory involvement.
Will treat [-***-]
@EDMEDS@
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns-]
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Associated with: No sore throat, is present. No Nasal Congestion, No Cough, No Fevers
Associated Symptoms none
Quality: Achy, Fullness
Symptoms began *** prior to arrival. Patient currently has symptoms. Symptoms are worse.
Severity: Maximum: Severe. Current: Moderate
Exacerbated by: Nothing
Relieved by: minimal with OTC medicines-]
[-No fever.
No itchy eyes
No Cough, No SOB.
No Rash.
No headaches-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Normal to inspection.
ENT: [-External ear with exudate and pain on instrumentation *** side, opposite side is unremarkable-] [-Tympanic membrane with no erythema or bulging-], Nares patent. Oropharynx is moist. No trismus. Mouth normal to inspection. No tenderness on palpation of the sinuses
NECK: Normal ROM, No nuchal rigidity. [-No lymphadenopathy.-]
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal.
SKIN: Color normal
NEURO: Awake & alert, lucid, no motor/sensory deficit.
PSYCH: Mood/affect normal.
MEDICAL DECISION MAKING
[-***History and exam consistent with otitis externa nonmalignant. No recent URI symptoms to suggest otitis media and 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.-]
[-***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 symptomatic management, and the equivocal effectiveness of antibiotics.-]
@EDMEDS@
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
[-***-]
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by medical assistant and reviewed by myself.
[-I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient's satisfaction.
Follow up plan per the discharge instructions including returning to the urgent care or emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
@MEDADMIN@
DIAGNOSIS
@DIAGX@
@EDPTMEDSTART@
@MEMD@
@NOW@, @TD@

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Location: ***
Mechanism: Body motion, Vehicle, Fall, Unknown, Injury, Pain, Decreased ROM-]
Occurred: [-***-] prior to arrival. Patient currently has symptoms. Symptoms are [-Worse, Persistent-]
[-Severity: Maximum: Severe , Current: Moderate
Quality: Aching, Dull-]
Exacerbated by: [-Movement-]
Relieved by: [-Nothing-]
[-No Chest Pain-]
[-No SOB-]
[-No laceration-]
[-No easy bleeding-]
[-No head injury-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL : Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
[-UPPER EXTREMITY, LOWER EXTREMITY-] : [-Pain on palpation ***-] Otherwise, Inspection normal, Normal range of motion, Distal cap refill and sharp/dull differentiation is intact.
SKIN : As described, Otherwise, Color normal, no rash, warm, dry.
PSYCH : Mood/affect normal.
MEDICAL DECISION MAKING
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.
@EDMEDS@
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
[-X-rays are negative on my interpretation, confirmed on radiology over read.-]
Patient to follow up with orthopedics in one to 2 weeks if needed. Return to activities as symptoms allow.
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient's satisfaction.
Patient's PCP is @PCP@.
DIAGNOSIS
@DIAGX@
@EDPTMEDSTART@
Follow up:
@FUP@
@EDRM@
@MEMD@
@NOW@, @TD@

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Injury Location: ***. Mechanism: Sharp Object
Complicating Factors: none-]
Occurred: [-***-] prior to arrival. Patient currently has symptoms. Symptoms are [-Worse, Persistent-]. Bleeding: [-Controlled-]
Tetanus: [-up-to date-]
[-No Easy bleeding or brusing-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL : Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
UPPER EXTREMITY: Laceration [-***-]. Bleeding is controlled. No foreign bodies are appreciated. Surrounding sensation is intact. Otherwise, Inspection normal, Normal range of motion, Distal cap refill and sharp/dull differentiation is intact.
SKIN : As described, Otherwise, Color normal, no rash, warm, dry.
NEURO : Awake & alert, lucid, no motor/sensory deficit. Gait stable.
MEDICAL DECISION MAKING
Laceration will require closure to achieve and maintain hemostasis and to promote optimal wound healing. No evidence for tendon damage or neurovascular compromise, nor for bony injury (xrays not indicated). Tetanus status is [-up to date-].
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
[-***-]
Procedure : The patient verbally consents to a wound repair. Sterile procedures observed. Side and sight are verified. Patient identification is verified. The wound is anesthetized with [-marcaine 0.5%-] for a [-regional-] block. It is then copiously irrigated.
Wound Measured at [-*** cm-]. It is approximated using simple interrupted sutures with [-5-0-] Ethilon. Total number [-3-]. Good approximation is achieved. Hemostasis is maintained. It is dressed with Bacitracin and a bulky dressing.
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient's satisfaction.
Patient's PCP is @PCP@.
DIAGNOSIS
@DIAGX@
@EDPTMEDSTART@
Follow up: @FUP@
@EDRM@
@MEMD@
@NOW@, @TD@

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Right side
Crusting is present
Associated with: no vision loss, No URI symptoms.Patient does not wear glasses or contact lenses.
No Trauma
Quality: Achy, Fullness
Symptoms began *** prior to arrival. Patient currently has symptoms. Symptoms are Worse.
Severity: Maximum: Severe, Current: Moderate
Exacerbated by: Eye opening
Relieved by: nothing-]
[-No fever-]
[-No sore throat. No rhinorrhea.-]
[-No Chest Pain-]
[-No rash-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES: Injected at [-The conjunctiva-]. Pupils are equal and reactive to light, Extraocular muscles intact. [-Vision grossly intact.-] [-Tonometry pressure ***, abnormal fluorescein uptake ***, negative Seidel sign. Visual acuity as per staff notes.-]
ENT: Nares patent. Tympanic membranes clear bilaterally. Oropharynx is moist. No trismus. Mouth normal to inspection. No tenderness on palpation of the sinuses.
CARD: Regular rate and rhythm, heart sounds normal.
RESP: No respiratory distress, breath sounds normal.
SKIN: Color normal
NEURO: Awake & alert, lucid, no motor/sensory deficit.
PSYCH: Mood/affect normal.
MEDICAL DECISION MAKING
Patient presents with complaints of red eyes and exam consistent with [-conjunctivitis-], which will be treated with topical antibiotics. No evidence for visual disturbance, no evidence of foreign body by history. [-Follow-up with ophthalmology in a timely fashion if not improving.-]
RESULTS
Labs: @EDABNLABSONLY@
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
[-I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns-]
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
Notes: [-***-]
[-No fever-]
[-No Chest Pain-]
[-No SOB-]
[-No Abdominal pain, no vomiting-]
[-No dysuria-]
[-No arthralgia-]
[-No rash-]
[-No easy bleeding-]
[-No anxiety-]
[-No headaches-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: [-Patient is afebrile, Vital signs reviewed, well appearing, Patient appears comfortable, Alert and lucid-]
HEAD: [-Atraumatic-]
EYES: [-Normal to inspection-]
ENT: [-OP moist, Nares patent-]
NECK: [-Normal inspection, Normal Range of Motion. No Nuchal rigidity-]
CARD: [-Regular rate and rhythm, heart sounds normal-]
RESP: [-No respiratory distress, breath sounds normal-]
ABD: [-Soft, non-tender-]
BACK: [-Non-tender-]
MUSC: [-Normal ROM, no pedal edema-]
SKIN: [-Color normal-]
NEURO: [-Awake, alert, and lucid. No motor deficits. Gait stable-]
PSYCH: [-Mood/ affect normal-]
MEDICAL DECISION MAKING
[-***-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
[-I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient's satisfaction.-]
Follow up plan per the discharge instructions including returning to the emergency department or urgent care in the next 12-24hrs if there are increasing symptoms, pain, fevers, or concerns.
Patient's PCP is @PCP@.
DIAGNOSIS
@DIAGX@
@EDPTMEDSTART@
Follow up:
@FUP@
@MEMD@
@NOW@, @TD@

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Pain Location: Diffuse. Mechanism: Direct blow Recent Head Injury No
Complicating Factors: None Occurred: *** prior to arrival. Patient currently has symptoms. Symptoms are Worse, Persistent-]
[-Severity: Maximum: Severe, Current: Moderate
Quality: Achy, Pressure Associated with: Injury as described, Headache, No Nausea or Vomiting
Exacerbated by: Nothing Relieved by: Nothing
Intracranial Bleeding risks: Age, Blood thinners, Mechanism, Alcohol-]
[-No vision changes-]
[-No Epistaxis or facial pain-]
[-No nausea, no vomiting-]
[-No arthralgia-]
[-No Laceration-]
[-No easy bleeding-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Vital signs reviewed, well appearing, Patient appears [-comfortable-], Alert and lucid
HEAD: [-Normocephalic, atraumatic.-]
EYES: Normal to inspection
ENT: Normal ENT inspection. OP Moist. [-No pain on palpation of the bony prominences of the face-]
NECK: Supple, normal inspection. [-Pain on palpation ***.-] No pain on palpation of the spine. Normal ROM
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal
BACK: [-Normal Inspection-]
MUSC: [-Normal ROM-]
SKIN: [-Color normal-]
NEURO: Patient is alert, lucid and oriented times 3. EOMI, facial and jaw muscle strength intact, hearing grossly intact, speech is without dysarthria, and shoulder shrug is strong. No focal motor, sensory or cerebellar deficits are noted. Speech and gait are normal. Patient has 5/5 muscle strength in the upper and lower extremities. Sensory exam is intact to lite touch on arms and legs bilaterally. [-Cerebellar exam is intact on "finger to nose" ,"heel shin" and gait is stable.-] [-Patient has no pronator drift. Romberg signs are absent.-]
PSYCH: Mood/ affect normal.
MEDICAL DECISION MAKING
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.
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Pain Location: Diffuse
Worst Headache of life: No
Change in character from prior HA No
Complicating Factors: None-]
Occurred: [-***-] prior to arrival. Patient currently has symptoms. Symptoms are [-Worse, Persistent-]
[-Severity: Maximum: Severe, Current: Moderate
Quality: Achy, Pressure
Associated with: No injury, no URI symptoms-]
[-Exacerbated by: Nothing
Relieved by: Nothing-]
[-No fever-]
[-Photophobia-]
[-No Cough-]
[-Nausea, no vomiting-]
[-No arthralgia-]
[-No rash-]
[-No easy bleeding-]
[-No anxiety-]
Historian: Patient
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: [-Patient is afebrile, Vital signs reviewed, well appearing, Patient appears comfortable, Alert and lucid-]
HEAD: Atraumatic
EYES: Normal to inspection
ENT: OP moist, Nares patent
NECK: Normal inspection, Normal Range of Motion. No Nuchal rigidity
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal
BACK: [-Normal Inspection-]
MUSC: [-Normal ROM-]
SKIN: [-Color normal-]
NEURO: Patient is alert, lucid and oriented times 3. EOMI, facial and jaw muscle strength intact, hearing grossly intact, speech is without dysarthria, and shoulder shrug is strong. No focal motor, sensory or cerebellar deficits are noted. Speech and gait are normal. Patient has 5/5 muscle strength in the upper and lower extremities. Sensory exam is intact to lite touch on arms and legs bilaterally. [-Cerebellar exam is intact on "finger to nose" ,"heel shin" and gait is stable.-] [-Patient has no pronator drift. Romberg signs are absent.-]
PSYCH: [-Mood/ affect normal-]
MEDICAL DECISION MAKING
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 or 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 discuss management with the patient.-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
PRECIPITATING FACTORS: [-*** stress, Drug abuse, Alcohol abuse, Change in medication-]
Occurred: [-***-] prior to arrival. Time course: [-Gradual-]
Quality: [-Dysphoric, Somatic complaints-]
Associated with: [-Alcohol use, Dysphoria, School/work problems, Self injury-]
Symptoms are: [-Worse-], Currently Symptomatic [-Persistent-].
Severity: Maximum: [-Severe-]
Risk Factors: [-Previous suicide attempts, Alcohol abuse, Substance abuse, Access to firearm-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Vital signs reviewed, well appearing, Patient appears comfortable, Alert and lucid
HEAD: Atraumatic
EYES: Normal to inspection
ENT: OP moist, Nares patent
NECK: Normal inspection, No JVD. No thyromegaly. Normal Range of Motion.
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal
BACK: Normal Inspection
MUSC: Normal ROM
SKIN: Color normal
NEURO: Awake, alert, and lucid. No motor deficits
PSYCH: [-mood/affect normal, Normal insight and concentration-].
MEDICAL DECISION MAKING
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. 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.
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
[-I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider
Past Month
Have you wished you were dead or wished you could go to sleep and not wake up?
[-No-]
Have you actually had any thoughts about killing yourself?
[-No-]
If YES to 2, answer questions 3, 4, 5 and 6 If NO to 2, go directly to question 6
Have you thought about how you might do this?
[--]
Have you had any intention of acting on these thoughts of killing yourself, as opposed to you have the thoughts but you definitely would not act on them?
High Risk
[--]
Have you started to work out or worked out the details of how to kill yourself?
High Risk
[--]
Always Ask Question 6
Lifetime
Past
Month
Have you done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, held a gun but changed your mind, cut yourself, tried to hang yourself, etc.
[-No-]
High Risk
[-No-]

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Time course: Sudden, Gradual, Unknown, Onset was *** prior to arrival. Lasting ***
Currently Symptomatic: Worse, Quality Aching, Dull
Associated with: Nothing
Exacerbated by: ***. Relieved by: ***-]
[-No fever-]
[-No syncope-]
[-No SOB, No cough-]
[-No Abdominal pain, no vomiting-]
[-No urine change-]
[-No rash-]
Historian: [-Patient's parent-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
Presents with parent.
PHYSICAL EXAMINATION
@VS@
GENERAL : Patient is afebrile, Vital signs reviewed, Well appearing, comfortable, consolable
HEENT : Normocephalic, atraumatic , normal ENT inspection. OP moist.
EYES : Normal inspection. Extraocular movements are intact.
NECK : Supple , normal inspection. No nuchal rigidity.
CARD : Regular rate and rhythm, heart sounds normal.
RESP : No respiratory distress, breath sounds normal.
ABD : Soft, nontender, BS present, soft, no organomegaly or masses.
BACK : Non-tender.
MUSC : Normal ROM, non-tender , no pedal edema .
SKIN : Color normal, no rash, warm, dry .
NEURO : Awake & alert, lucid, Responsive
PSYCH : Age appropriate affect.
MEDICAL DECISION MAKING
[-***-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
[-***-]
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
I discussed with the patient's family the diagnosis, treatment plan, indications for return to the emergency department, and the expected follow-up. The patient's family member verbalized understanding. The patient's family was asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the family's satisfaction.
DIAGNOSIS
@DIAGX@
@EDPTMEDSTART@
Follow up:
@FUP@
@EDRM@
@MEMD@
@NOW@, @TD@

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Complaint: ***
Time course: Sudden, Gradual, Unknown, Onset was *** prior to arrival.
Lasting ***
Currently Symptomatic: Worse, Quality Aching, Dull
Severity - Maximum: Severe, Current severity: Moderate
Associated with: Nothing
Exacerbated by: ***
Relieved by: ***
No change in bowel movement, urination. No radiation of the pain to the groin. Patient is able to ambulate.-]
[-No fever-]
[-No SOB-]
[-No Abdominal pain, no vomiting. No incontinence of stool-]
[-No urine changes-]
[-No Rash-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Vital signs reviewed, well appearing, Patient appears [-comfortable-], Alert and lucid-]
NECK: Normal inspection. [-No pain on palpation of the spine-]. Normal ROM
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal
BACK: No CVA tenderness, Normal inspection, no scoliosis, [-Negative straight leg raise testing-]. [-Pain on palpation ***-]. [-No pain on palpation of the spine.-]
NEURO: Awake, alert, and lucid. No motor deficits. Gait [-stable, but causes pain-]
MEDICAL DECISION MAKING
[-Findings are consistent with strain, sprain, or contusion. No mechanism to suggest fracture or subluxation, no point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. No evidence for cauda equina syndrome. No indication for imaging. No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. Nothing in the history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
Medications, medical history, allergies, surgical history, hospitalizations, family history, social history, ROS and vitals entered by nursing staff and reviewed by myself.
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
Location: [-***-] Occurred: [-Suddenly, ***-] prior to arrival.
Mechanism: [-Injury-]
Patient currently has symptoms. Symptoms are [-Worse, Persistent-]
[-Maximum Severity: Severe Current Severity: Moderate
Quality: Aching, Dull-]
Associated with: [-No Urine changes, Decreased ROM-], [-No Radiation-].
Exacerbated by: [-Walking, Movement-]
Relieved by: [-Nothing-]
[-Risk Factors: No Recent Surgery
No Chest Pain
No SOB
No Abdominal pain, no vomiting
No urine changes. No incontinence or retention.
No lacerations
No easy bleeding
No anxiety
No headaches-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL : Patient is afebrile, Vital signs reviewed, Well appearing, Patient appears comfortable, Alert and lucid.
EYES : Normal to inspection. Extraocular movements are intact.
HEAD : Normocephalic, atraumatic
ENT : Normal ENT inspection. OP Moist
NECK : [-Pain on palpation***.-] No pain on palpation of the spine. Normal ROM
CARD : Regular rate and rhythm, heart sounds normal.
RESP : No respiratory distress, breath sounds normal.
BACK : No CVA tenderness, Normal inspection, No scoliosis, [-No-] Pain with straight leg raise. [-Pain on palpation ***-]. [-No pain on palpation of the spine.-]
ABD : soft, non tender. BS present, no organomegaly or masses.
UPPER EXTREMITY : No pain at the bony prominences of the shoulder, elbow, wrist. Normal range of motion.
LOWER EXTREMITY : No pain on palpation of the hips, pelvis, knees, ankles at the bony prominences. No edema. Normal range of motion.
SKIN : Color normal, no rash, warm, dry .
NEURO : Awake & alert, lucid, no motor/sensory deficit. Gait [-stable-].
PSYCH : Mood/affect normal.
MEDICAL DECISION MAKING
[-Findings are consistent with strain, sprain, or contusion. No mechanism to suggest fracture or subluxation, no point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. No evidence for cauda equina syndrome. No indication for imaging. No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. Nothing in the history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.-]
@EDMEDS@
[-EKG :***-]
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
[-***-]
[-Escalation of care including admission/observation considered. ***-]
[-Case Reviewed with ***-]
[-Records reviewed and summay***-]
[-EKG Interpretation/imaging interpretation-]
[-I discussed with the patient the diagnosis, treatment plan, indications for return to the emergency department, and for expected follow-up. The patient verbalized an understanding. The patient is asked if there are any questions or concerns. We discuss the case, until all issues are addressed to the patient's satisfaction
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
Patient's PCP is @PCP@.
DIAGNOSIS
@DIAGX@
@EDPTMEDSTART@
Follow up:
@FUP@
@EDRM@
@MEMD@
@NOW@, @TD@

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
[-Complaint: ***
Time course: Sudden, Gradual, Unknown, Onset was *** prior to arrival.
Lasting ***
Currently Symptomatic: Worse, Quality Aching, Dull
Severity - Maximum: Severe, Current severity: Moderate
Associated with: Nothing
Exacerbated by: ***
Relieved by: ***-]
[-No fever/chills
No cough
No shortness of breath/difficulty breathing
No fatigue
No muscle aches or body aches
No headache
No Redness/itchy eyes
No new loss of taste or smell
No sore throat
No congestion/runny nose
No nausea/vomiting/diarrhea-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Vital Signs and temperature reviewed, well appearing, Patient appears comfortable, Alert and lucid
HEAD: Atraumatic
EYES: Normal to inspection
ENT: External ears normal to inspection, Nares patent. Oropharynx is moist no erythema or exudate. Mouth normal to inspection.
NECK: Normal inspection, No Cervical chain lymphadenopathy.
CARD: Regular rate and rhythm, heart sounds normal
RESP: No respiratory distress, breath sounds normal. No pain with compression of the chest wall.
BACK: Normal Inspection
MUSC: Normal ROM
SKIN: Color normal
NEURO: Awake, alert, and lucid. No motor deficits
PSYCH: Mood and affect normal
MEDICAL DECISION MAKING
Patient presents with concerns for viral process. Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, sinusitis, pneumonia.
[-Will offer Covid-19 testing. Patient is not a candidate for advanced treatment treatment.-]
@EDABNLABSONLY@
RESULTS
Labs: @EDABNLABSONLY@
Imaging: @EDORD@
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
[-I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider

Primary Care Provider: @PCP@
@CHIEFCOMPLAINT@
HPI
This is a @AGE@ @SEX@ [-***-]
Associated with: No Vaginal Discharge. [-Abdominal pain, Blood in stool, Antibiotic use recently, Diarrhea, Fever, Hematemesis, Nausea, Recent travel, UTI symptoms, Vomiting, Vaginal discharge/bleeding-]
[-Pregnancy risks: Status post hysterectomy, LMP
Ectopic pregnancy risk: Prior ectopics, History of PID, IUD-]
Exacerbated by: Urination
Relieved by: [-Nothing-]
[-No fever-]
[-No Abdominal pain, no vomiting-]
[-No back pain-]
[-No rash-]
Historian: [-Patient-]
[-Records reviewed and updated below-]
PMH
@HXPMH@
@PROB@
Past Surg: @HXPSH@
Allergies: @ALG@
Meds: @EDPTMEDCONT@
Social: [-***-]
@SOCX@
PHYSICAL EXAMINATION
@VS@
GENERAL: Vital Signs and temperature reviewed, Well appearing, Patient appears comfortable, Alert and lucid
CARD: [-Regular rate and rhythm, heart sounds normal-]
RESP: [-No respiratory distress, breath sounds normal-]
ABD: [-Soft, non-tender-]
BACK: non-tender. [-No CVA tenderness-].
SKIN: Color normal
MEDICAL DECISION MAKING
Lower urinary tract irritation suggestive of possible urinary tract infection. No evidence of pyelonephritis[- or symptoms to suggest vaginitis-]. Urinalysis is indicated. [-Pregnancy testing is ordered.-]
RESULTS
Labs: @EDABNLABSONLY@
EMERGENCY DEPARTMENT COURSE
Medications given in ED:
@EDMEDS@
[-***-]
[-I discussed with the patient the diagnosis, treatment, plan, and indications for return to the emergency department. The patient verbalized an understanding. The patient is asked if there are any questions or additional concerns
Follow up plan per the discharge instructions including returning to the emergency department in the next 12-24hrs if increasing symptoms, pain, fevers, or concerns.-]
DIAGNOSIS
@DIAGX@
Follow up: @FUP@
Medications on Discharge
@EDPTMEDSTART@
@EDRM@
@MEMD@
@NOW@ @TD@
Attending Provider