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Isolated Extremity Injury

HPI: Patient is a [x-old male/female with past medical history significant for] who presents with [ deformity / pain to x extremity].  Pain is describes as [X /10], [achy] pain that has been constant.  Patient reports [no numbness or weakness]. Incident occurred [x time ago] and is described as [falling off of a ladder]. Alleviating factors to pain include [x medication given by ems] and exacerbating factors include movement. Patient arrives [in mothers arms, via EMS],and reports [no LOC or trauma to other parts of patient's body]. Associated symptoms include [abrasion / ecchymosis to x extremity].  Patient does not report any [fever, chills, sweats].

MDM: Patient is a [x-old male/female with past medical history significant for] who presents with [ deformity / pain to x extremity].  Vital signs are remarkable for [tachycardia] and physical exam is notable for [x deformity / tenderness to x regions]. No evidence of weakness, numbness and patient is neuro intact. Given history and physical, differential is above. Will obtain labs including CBC, BMP, type and screen, coags, [LFTs, Lactic Acid]. Will obtain plain film x rays of [chest, humerus, elbow] and treat patient's pain with [morphine].

– Patient attached to the monitor, [Vital signs still unremarkable]. Patient reporting pain relief with analgesic medications.

– X-rays [notable for x fracture]. [Will consult orthopaedics, consent for conscious sedation with ketamine and reduction]

– Lab work [Largely unremarkable].

– Patient consented for conscious sedation and closed reduction. Patient placed in a room with suction, end-tidal CO2 monitoring, and emergency airway supplies at the ready. Patient placed on supplemental O2.  Conscious sedation achieved [with ketamine] and patient successfully reduced.  Procedure note below.

Dispo: [Patient PO challenged, will be admitted to hospitalist per ortho service for continued observation]

Child URI / Low Grade Fever

HPI: Patient is a [x-old male/female with past medical history significant for] who presents with [fever, dyspnea, cough, congestion].  Patient's symptoms started [x days ago] and have [progressed, stayed the same, improved] and are associated with [associated symptoms, fever, cough, congestion, inability to eat or drink]. Alleviating factors include [] and aggravating factors include [].  Patient's PO intake is [decreased, unchanged] and urinary output is [decreased, unchanged]. Patient does not report any [fever, chills, sweats].

MDM: Patient is a healthy [x year old female/male] presenting with fever likely secondary to urinary source of viral syndrome.  No localizing symptoms of bacterial URI or intra abdominal pathology.  Low suspicion for serious bacterial infection given nontoxic appearance and otherwise healthy child with no major medical problems.  I have a low clinical suspicion for pneumonia, pyelonephritis, meningitis or appendicitis.

Plan: Plan for [straight cath for urine}, antipyretic instructions, reassurance and reassessment, and discharged with pediatric follow-up.  Patient is instructed to return if symptoms progress, fevers uncontrolled with antipyretics increased work of breathing.

Sickle Cell Crisis

Patient is a [x-old male/female] with [past medical history significant for] who presents to the emergency department for [X/10] [location: substernal] [character] pain [consistent with prior sickle cell crises]. Symptoms started [x hours ago], have [progressed, been constant or intermittent] and associated symptoms include [shortness of breath, vomitting]. [Patient states that he has / has not been admitted for this in the past]. [Patient states he has been taking all of his medications] Alleviating factors include [nitroglycerin, Tylenol] and exacerbating factors include [Exercise, movement, breathing].

Vital signs are [unremarkable, notable for] and physical exam is remarkable for [chest wall tenderness].  Initial bedside ultrasound shows [normal EF]. Given history and physical, the differential is above. Considered [PE] but less likely due to [perc negative***]. Especially concerned for [x diagnosis given history / physical exam finding]. Will obtain CBC, Reticulocyte Count, Type and Screen, BMP, LFTs, LDH, UA, blood cultures, EKG, Troponin, Chest X-ray [D-dimer, CT PE, ***].  Will establish IV access and initiate pain management with [morphine/dilaudid] [and will give fluid bolus/IV antibiotics].

- Patient attached to the monitor, [Vital signs still unremarkable / responded well to initial resuscitation].

- EKG [shows unchanged bundle branch block morphology]

- Chest X-ray [demonstrates / does not demonstrate new infiltrate. Is suggestive or not suggestive of acute chest]

- Labwork [L Reticulocyte count, hemoglobin, largely unremarkable/notable for urinary tract infection], [Reticulocyte count], [hemoglobin].

- Given the above, [will consult hematology, will take patient to the OR]

Dispo: [Patient PO challenged, ambulated, will be admitted to x service for x diagnosis service for x diagnosis]

FEBRILE SEIZURE

The patient presents with generalized tonic-clonic activity lasting [] concerning for a suspected simple febrile seizure in the setting of []. The Pt is otherwise well-appearing and at mental status baseline without evidence of status or subclinical status. No history of afebrile seizures, history of immunosuppression, toxic exposures including no antihyperglycemic intake, unilateral weakness or recent trauma. Given the patient’s concurrent fevers, the differential for underlying cause of fever is the above and includes viral illness, UTI and potential pneumonia. I have low suspicion for other emergent causes of seizures including sepsis, meningitis or intracranial hemorrhage. The patient’s initial evaluation is [unrevealing for a source of infxn and does not show evidence of AOM, strep pharyngitis, deep space neck infxn, pneumonia, SSTI, or intra-abdominal infxn]. Will obtain [UA, CXR, PO Trial] and treat the underlying fever with Motrin/Tylenol.

- Patient attached to the monitor, vital signs [significant for]

- Workup thus far revealing for []

- Patient returned to a normal baseline and was henceforth observed for 4 hours in the ED without recurrence.

- Normal mental status, normal neuro exam, SpO2 >95% on room air, tolerating PO.

- Patient was discharged with PCP followup in 24 hours. Patient given  with strict return precautions if there is any progression of symptoms, fever, shortness of breath, chest pain, palpitations, abdominal pain, vomiting, headache, mental status changes or other worrisome symptoms. Follow up with pediatrician within next 24 hours.

Shortness of breath (.MDMSOB)

Patient is a *** who presents to the emergency department for shortness of breath. Patient was brought in via ***. Symptoms started *** and associated symptoms include ***. Exacerbating factors include *** and exacerbating factors include ***.

 Vital signs are *** and physical exam is remarkable for ***.  Initial bedside ultrasound remarkable for ***. Given history and physical, the differential includes obstructive lung disease (COPD, Asthma, RAD), flash pulmonary edema, restrictive lung disease (Pulm Fibrosis, etc.), CHF/ CHF exacerbation, ACS, PE, pneumothorax, pulmonary HTN, pneumonia, anxiety. Considered *** but less likely due to ***. Will obtain CBC, BMP, EKG, Troponin, Chest Xray and ***.  Will treat with ***.

-       Patient attached to the monitor, vital signs remarkable for ***

Trauma MDM (.MDMGeneric)

Patient is a *** who presents to the emergency department for ***. Patient was brought in via ***. Patient had *** LOC, is on *** blood thinning medications for ***. Patient is alert and oriented *** Symptoms started *** and associated symptoms include ***. Exacerbating factors include *** and exacerbating factors include ***.

Vital signs are *** and primary survey is ***. Secondary survey is remarkable for ***.  Given history and physical, the differential includes ICH, fracture, spinal cord injury. Will obtain CBC, BMP, EKG, Chest Xray, CT *** and Xrays of ***.

-       Patient attached to the monitor, vital signs remarkable for ***