This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. No localizing symptoms of URI or intraabdominal pathology, low suspicion for serious bacterial infection given nontoxic appearance and otherwise healthy child with no major medical problems. Doubt pneumonia or pyelonephritis. Doubt meningitis or appendicitis.
Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u
LOW RISK, <2 y old
This pediatric patient presents with head trauma. Given mechanism, history, and physical exam findings, we have a low probability of serious injury to include intracranial bleed or skull fracture, DAI, or high risk of decompensation. Given lack of a severe mechanism, GCS 15 or lack of AMS, no occipital/parietal scalp hematoma, and no LOC, risk of obtaining a CT scan outweighs the potential benefit. Will observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up.
LOW RISK, >2 y old
This pediatric patient presents with head trauma. Given mechanism, history, and physical exam findings, we have a low probability of serious injury to include intracranial bleed or skull fracture, DAI, or high risk of decompensation. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. The mechanism is of low energy. In this group, PECARN rules demonstrate an exceptionally low risk of serious intracranial injury and obtaining further imaging is likely to be of little or no benefit.
Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge
HIGH RISK:
This pediatric patient presents with a history concerning for a serious intracranial injury. Unable to clear patient with PECARN rules given ***. Will obtain CT imaging to rule out intracranial injury or skull fracture. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey.
Plan: CT scan head/neck, pain control, reassess
This is an ill-appearing *** who presents with lethargy. Differential includes sepsis, congenital heart disease, hypovolemia and hypoxemic states, endocrine emergencies like CAH or thyroiditis, trauma, inborn errors of metabolism, seizures, electrolyte derangements, or intestinal catastrophe. Given this undifferentiated sick neonate, will work up broadly, empiric broad-spectrum antibiotics***, trial of 10cc/kg fluid bolus, resuscitative measures and will consider early airway intervention.
Pearls: For a sick kid use THE MISFITS:
Trauma: consider FAST and CTH
– consider vitamin K and Ca if bleeding
Heart disease, hypovolemia, hypoxia
Endocrine (CAH, thyrotoxicosis)
Metabolic – lytes
Inborn errors
Seizures
Formula mishaps
Intestinal catastrophes (volvulus, intuss, NEC)
Toxins
Sepsis
Differential diagnosis includes VPS malfunction or infection producing increased ICP. Other dagnerous causes of acute vomiting are also on the differential including pyloric stenosis, intussusception, appendicitis or SBO although in this patient they are unlikely. Considered viral syndromes (URI, gastritis, gastroenteritis) as well as other non-emergent causes of vomiting.
Given this patient’s shunt, will evaluate with shunt series // CT // limited MRI, discuss with neurosurgery for possible tap, supportive care, reassess.
Differential Diagnosis: Cough, wheezing, asthma exacerbation, pneumonia, seasonal allergies, viral syndrome, Pneumothorax.
Rationale: Given the history of cough, difficulty breathing, wheeze and history of asthma, the patient’s symptoms may be attributed to either viral syndrome, pneumonia, acute asthma exacerbation or pneumothorax. Most likely, this represents an acute asthma exacerbation.
1) STAT bronchodilator therapy and steroids will be given, with re-assessments between nebulized treatments.
2) If worsening or persistent symptoms occur, the patient may require critical care management or admission to the hospital.
This patient presents with wrist pain after a trauma, suspicious for a Salter-Harris fracture. Will obtain plain films to evaluate; ortho consultation for high-grade or unstable fracture patterns, pain control, reassessment. Will likely splint with follow up in ortho clinic pending reassessment.
Pearls: SALTR
Grade 1: Straight: usually can’t see on XR
Grade 2: Above the physis (away from the joint)
Grade 3: Lower – below the physis (near the joint)
Grade 4: Through – through the physis. Unstable; will need operative repair.
Grade 5: Crush/Compression injury. Rare; difficult to pick up on initial XR. Usually from axial load force to extremity. Must consult ortho ASAP.
All updates courtesy Steve Lai and Brian Truong
MEDICAL DECISION MAKING
Patient presents with acute alcohol intoxication without evidence of co-ingestion or trauma per history and exam. Will observe patient in ED with frequent monitoring and reassessment. Plan to PO trial, reassess mental status, and assess gait when more stable. No evidence of withdrawal currently.
After extensive discussion of R/B/A per routine with patient, patient electing to leave against medical advice. As prior, risks explained to patient with understanding and full capacity. Patient encouraged to return to ED if patient decided to change mind regarding care or if any new concerning symptoms arise.
Neurovascularly intact. Query likely ankle sprain. Discussed conservative measures including rest, elevation, alternating application of ice, pain control and early ambulation as tolerated. No gross ankle instability. No evidence of maison-neue. Discussed follow up with PMD and given resources for ortho/sports medicine follow up as needed. Discussed strict return precautions for neurovascular insufficiency or need for repeat imaging/evaluation if pain not vastly improved in 5-7 days for possible occult fracture.
Patient with likely acute otitis media given history and exam. No overt e/o mastoiditis or malignant otitis externa. Nontoxic appearing with low suspicion for intracranial extension. Tolerating PO, low suspicion for concurrent serious bacterial infection. Will discharge home with amoxicillin (high dose), auralgan, tylenol, follow up peds_. Cautious return precautions discussed w/ full understanding.
Patient presenting with shortness of breath. Given exam and history, suspect likely acute asthma exacerbation without_ status asthmaticus. These constellation of symptoms are similar to prior flares without overt deviations from normal exacerbations. Given clinical findings and history, low suspicion for pneumonia, pneumothorax, or acute valvular failure. Patient with minimal risk factors for pulmonary embolism and atypical ACS. As such, will trial bronchodilators, steroids, monitor respiratory status closely, reassess.
Patient presents with several days_ of lower back pain, atraumatic, afebrile. Given history and exam, suspect likely musculoskeletal etiology_. Nontoxic appearing and no overt risk factors for epidural hematoma or abscess. No overt e/o cauda equina or acute critical cord compression with nonfocal neuro exam. Neurovascularly intact distally. No e/o prostatitis or Fournier’s. No peritoneal signs or abdominal pain on exam with low suspicion for AAA.
Patient presents with abdominal pain and ultrasound demonstrates visible gallstones. Given exam and history, suspect likely uncomplicated_ biliary colic. Patient is afebrile without overt thickening of the gallbladder wall, CBD dilation or pericholecystic fluid suggests the absence of acute cholecystitis or acute biliary obstruction. Patient is tolerating PO_ and suspicion for acute pancreatic involvement is low. After serial abdominal exams, history and observation, low suspicion at this time for other acute intraabdominal processes, including aortic aneurysm, atypical appendicitis, diverticulitis, or bowel obstruction. Given resolution of pain and no peritoneal signs on serial exams, will discharge patient home with general surgery follow up and strict return precautions.
Wound inspected under direct bright light with good visualization. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. No overt foreign body. Area hemostatic. Neurovascular exam congruent with above. Area extensively irrigated with sterile normal saline under pressure. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Patient tolerated procedure well and neurovascular exam intact and unchanged post repair with intact distal pulses and cap refill_. Cautious return precautions discussed w/ full understanding. Wound care discussed. Prompt follow up with primary care physician discussed and return for suture removal.
history of hypertension presents for hypertension with SBP _ sent in by PMD with concern for possible pre-eclampsia. Of note, patient without severe range BP in ED. Patient without neuro or ocular concerns at this time. No RUQ and no frank proteinuria. No seizure activity and without cardiothoracic symptoms.. Benign abdominal exam and non-focal neuro exam. Labs largely reassuring_. Therefore, given history and exam, low suspicion at this time for fulminant pre-eclampsia requiring admission. No overt evidence of HELLP, acute cholestasis of pregnancy, or eclampsia at this time. Discussed case with OB and after evaluation, will _. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician/OB arranged and discussed_.
Patient presenting with constellation of symptoms concerning for vitreous hemorrhage vs retinal detachment. Not contact lens wearer_. No prior ocular history_. Patient is headache free and visual acuity intact with low suspicion for temporal arteritis or CRAO/CRVO. No vision changes or conjunctival injection with low suspicion for acute angle closure glaucoma. No trauma to the eye and no sensation of foreign body with low suspicion for corneal ulceration or globe injury. No evidence of overt hyphema or hypopyon on exam. No ocular pain or consensual photophobia with low suspicion for scleritis or iritis. Plan to discuss case with ophthalmology for dilated exam and further assessment.
Patient is currently at baseline mental status and activity level per family. Patient does not have evidence of palpable skull fractures or step offs. Patient does not have an occipital, parietal or temporal hematoma. Denies LOC > 5 seconds. No signs of basilar skull injury including raccoon eyes, battle’s sign, CSF rhinorrhea or hemotympanum. No nasal hematoma. Denies vomiting or headache. Denies severe mechanism of injury.
After extensive discussion with patient regarding PEP versus observation/follow up and risks and benefits of both, mutual decision making to provide first dose of PEP and follow up promptly with outpatient testing and further treatment as needed at this time per most recent CDC HIV PEP guidelines for unknown relatively high risk exposures_. Discussed that single dose of PEP is not a substitute for follow up and further care/evaluation. Discussed need for concurrent testing of other STI including, but not limited to, G/C and RPR. Discussed safe sex practices_. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
Denies any ingestions and denies any other medical complaints. Does not endorse any alcohol withdrawal symptoms. Engages with conversation. Mood and affect are congruent. Thoughts are linear and organized, and has no AH or HI. Plan admit to psychiatry for further management of symptoms. Will consult psychiatry to evaluate Patient for potential hold for danger to self. Clinically no overt toxidrome, well appearing, low suspicion for ingestion given history and exam.
_ with bat exposure who presents for immunoglobulin administration. Patient without obvious wound but given duration of exposure, high risk nature and possible incubation period (of up to 1-3 months), mutual decision making with patient re: R/B/A to give dose of RiG. Per most recent CDC/ACIP guidelines re: PEP for human rabies, patient with 1st of 4-dose rabies vaccination regimen prior to arrival (0, 3, 7, 14; HDCV or PCECV). Discussed need for subsequent doses. Patient without altered immune competence. No obvious inoculation wound, as such, will infiltrate weight based RIG IM_. Patient currently largely asymptomatic with non-focal exam with no symptoms of cerebral dysfunction, anxiety, confusion, agitation, delirium, abnormal behavior, hallucinations, and insomnia. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
Patient presents with flank pain consistent with previous kidney stone pain. Patient otherwise well-appearing with low suspicion for sepsis, dissection or infected obstructed renal colic. US w/ mild hydronephrosis on affected side_. Low suspicion for atypical appendicitis, torsion, acute chole, or intraabdominal infection. Discussed conservative management, strict return precautions and follow up with urology. Will discharge with Flomax_, NSAIDs, opiates for breakthrough, strainer, and antiemetics. Patient tolerating PO and pain controlled prior to discharge. Strict return precautions for infected stone or PO intolerance discussed. Low suspicion for AKI, obstructive nephropathy given exam and history.
Given exam and history, low suspicion for septic arthritis at this time given location of pain (not over knee joint but superior to area), subacute nature, and relative comfort to range of motion and axial loading. Nontoxic appearing and no overt systemic symptoms. Atraumatic with low suspicion for fracture or dislocation. No overt e/o necrotizing fasciitis. Given tenderness and area of erythema, will treat for cellulitis. Neurovascularly intact per routine as above with no overt e/o compartment syndrome.
After extensive discussion with patient and wife regarding observation and treatment of possible cellulitis versus arthrocentesis and risks (overlying cellulitis, lower pretest probability of septic arthritis, risk of inoculation of joint) and benefits of both, mutual decision making to trial antibiotics and not pursue further arthrocentesis at this time. Patient tolerating discomfort, continue to be at baseline and well appearing. As above, does not have signs of systemic symptoms or neurovascular compromise. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Family agreeing to bring patient back if any concern including if patient with increase in pain, inability to range or bear weight, or fevers.
Patient presents after ground level fall, currently in c-spine precautions with likely LOC_. Unwitnessed fall, with unclear etiology, possible mechanical but cannot r/o syncope at this time. Patient without any prodromal symptoms with low suspicion at this time for ACS, dissection or malignant arrhythmia. Will check labs for electrolyte protuberances, will obtain CT brain and C-spine to evaluate for ICH as patient is anticoagulated_. Given history, low suspicion for ACS, but will obtain troponin and EKG for cardiac evaluation and reassess_. Currently at baseline mental status. No respiratory distress or hypoxia with low suspicion for massive PE at this time. Serial neurologic exams and monitor in interim.
Patient otherwise healthy_, fully vaccinated_ with anterior neck swelling likely secondary to significant lymphadenopathy of limited duration with suspicion for likely viral etiology. BUS with visualization of LAD without frank abscess. Mild trismus on exam but no overt e/o PTA or RPA. No overt e/o deep space infection; nontoxic appearing and tolerating PO. Non-focal neuro exam with low suspicion for Lemierre’s. Vaccinated with low suspicion for mumps. Low suspicion for malignancy or goiter formation at this time given duration but discussed prompt follow up to reassess. Trial antibiotics_ and steroids_ with cautious return precautions discussed w/ full understanding. Airway fully patent.
Patient presents with epigastric_ abdominal pain most likely secondary to dyspepsia or non-acute abdominal etiology. No peritoneal signs on abdominal exam. Patient’s symptoms near resolved with GI cocktail. Patient remains PO tolerant. Serial abdominal exam without increase in abdominal pain. Given exam and history, low suspicion for acute abdominal process, such as acute cholecystitis, pancreatitis, perforated viscus, atypical appendicitis or torsion. Extensive conversation about return precautions and need for follow-up.
Patient with rash likely allergic or contact dermatitis in nature given history, temporal nature and appearance. No mucous membrane involvement with low suspicion for SJS/TEN. No wheezing or difficulty breathing with low suspicion for systemic involvement. Unclear trigger but discussed close monitoring for progression. Will prescribe single dose of steroid given extent of rash and hydrocortisone cream_. Cautious return precautions discussed w/ full understanding. No overt e/o superinfection. Prompt follow up with primary care physician discussed.
Patient with _ apical abscess over _lower right posterior molar presenting for pain control. Patient well appearing, no trismus or airway involvement. No systemic symptoms and no overt e/o deep space extension. Mutual decision making to perform inferior alveolar nerve block for temporary relief and continued control with short course of NSAIDs and opiates as outpatient_. Apical abscess I+D extended and small amount of pus expressed with decompression of lesion. Low cost dental resources given. Cautious return precautions discussed w/ full understanding.
Patient with abdominal pain and vomiting, now resolved_. No peritoneal signs with low suspicion for acute intraabdominal process including torsion, SBO, intussusception or atypical appendicitis. Serial abdominal exams throughout course without increase in pain or migration of pain. Tolerating PO in ED. US appendix inconclusive_. After extensive discussion with family regarding observation versus CT versus return for recheck in 8-12 hours if not resolved and risks and benefits of options, mutual decision making to return for recheck given relative improvement and well appearing child with alternative diagnoses (_) for fever and malaise and not pursue further workup at this time. Patient tolerating PO, continue to be at baseline and well appearing. As above, does not have signs of peritoneal involvement. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Family agreeing to bring patient back if any concern including if patient with recurrent vomiting, increase in abdominal pain, or altered behavior. Will discuss prompt follow up with PMD and strict return precautions discussed.
Patient with _ bartholin’s cyst infection with concurrent abscess formation. No overt evidence of fournier’s or deep space involvement. No systemic symptoms. Small medial incision made with copious drainage of pus. Insertion of word catheter to maintain tract and follow up with OB/GYN discussed. Wound care and return precautions discussed.
Patient with possible latrodectus envenomation to dominant hand_ several hours prior. Now with constellation of symptoms, potentially consistent with mild envenomation including diffuse pain in extremity. Hand with possible area of early cellulitis but no frank abscess formation. Will treat with doxy given allergy profile after conversation with pharmacist. Area of inoculation without local diaphoresis. No overt evidence of necrosis or abscess. No cardiothoracic symptoms, no peritoneal signs. At this time, will trial pain control and muscle relaxants. Will continue to monitor and will hold antivenom at this time. TDAP up to date.
with no previous medical history presents brought in by parents for superficial scattered burns primarily to torso_ with minimal BSA involved. Burns superficial, consistent with history and given interaction observed between parents, low suspicion at this time for NAT. Parents and patient appropriate. Patient undressed fully without any suspicious lesions. Discussed wound care, pain control and follow up with PMD. Return precautions for superinfection. Patient at baseline currently without significant burns over scalp, face, groin or distal extremities. Cautious return precautions discussed w/ full understanding.
with atypical chest discomfort and now resolved palpitations in the setting of Adderall_ use. No overt risk factors for early cardiac disease; no family history of early cardiac death. Patient well appearing, nontoxic. Low Wells score with low s/f PE; no overt hypoxia. Given history and exam, low suspicion for ACS, dissection, or pneumothorax. Discussed cessation of Adderall_ and follow up with PMD for further evaluation as needed. Cautious return precautions discussed w/ full understanding.
with history of tobacco abuse, otherwise healthy, p/w atypical chest pain, subacute worsening of chronic pain. No overt risk factors for ACS and serial EKGs and troponins without overt e/o NSTEMI. Pain reproducible on exam with likely musculoskeletal component. Low Wells score with low risk for PE and no significant hypoxia_. Given chronicity, low s/f dissection. Pain controlled, well appearing. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
p/w atypical chest pain, subacute onset of atypical chest pain. No overt risk factors for ACS aside from HLD_ and EKG w/o overt e/o acute ischemia. Pain reproducible on exam with likely musculoskeletal component. Low Wells score and PERC negative with low risk for PE and no significant hypoxia. Given duration, low s/f dissection. Pain controlled, well appearing. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
Patient presents with chest pain without signs of acute ischemia on ECG. Patient given aspirin and is currently chest pain free. Low Wells score with low risk for PE and no significant hypoxia_. Given exam and history, low suspicion for dissection. No ectopy noted on monitor and patient well appearing. Had conversation with pt at length regarding risks vs benefits of admission to obs for chest pain. Mutual decision making for patient to be admitted to obs, and agrees to workup. Low suspicion for overt ACS but given age and persistence of symptoms, plan to admit to obs for serial troponins, serial EKGs, and risk stratification as inpatient.
with worsening shortness of breath over the past few weeks with constellation of symptoms concerning for possible CHF exacerbation. Patient not overtly hypoxic with minimal respiratory distress. No overt evidence of acute ischemia on EKG. Will trial nitroglycerin for afterload reduction, diuresis with strict I/O presuming no evidence of AKI or cardiorenal syndrome_. Trend troponin although low suspicion for acute ischemia given history and exam_. Low suspicion for acute PE given exam and history. Given decline in functional status, consider admission for diuresis and further cardiac evaluation_.
Patient with L_ minimally displaced clavicular fracture after falling onto L side. Distally neurovascularly intact in extremities. No overt evidence of significant head trauma. Mentating well with non-focal neurologic exam. Placed in sling and adhesive capsulitis precautions discussed. Follow up with pediatric orthopedics. Return precautions.
presenting s/p minor head trauma with headache, lightheadedness, and nausea_. Given mechanism and nonfocal neurologic exam, low suspicion at this time for ICH or significant C-spine injury. Concussion care and precautions discussed. After extensive discussion with patient and family_ regarding observation versus CT and risks and benefits of both, mutual decision making to observe and not pursue further workup at this time. Patient tolerating PO, continue to be at baseline and well appearing. As above, does not have signs of altered mental status or basilar skull fracture. Patient with nonfocal neurologic exam and with low suspicion for overt ICH. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Family agreeing to bring patient back if any concern including if patient with recurrent vomiting or altered behavior.
presenting with 1 day of left eye pain_ after irritation yesterday. Patient is a contact lens-wearer. Visual acuity otherwise preserved. Given exam and history, no overt evidence of scleritis, purulent conversion, or corneal ulceration. Patient does however have small corneal abrasion, which will be treated with antibiotic eyedrops_. Patient to avoid wearing contacts in interim and prompt follow up with ophthalmology discussed.
Patient without overt maloccusion and given mechanism and history, low suspicion at this time for significant mandibular or maxillary fracture and will defer imaging at this time. Prompt follow up with plastics arranged and discussed. In regards to fractured dentition, likely Ellis II_, patient with access to dentist in 24 hours and after R/B/A discussed, patient deferred antibiotics and cementing of tooth which is reasonable given degree of fracture and prompt follow up. Strict return precautions discussed.
with isolated episode of binocular_ diplopia now resolved with nonfocal neuro exam with low suspicion for TIA. Patient with minimal neurovascular/CVA risk factors and with prompt follow up with neurology already arranged. Low suspicion given exam and history for CNS or facial infection including meningitis or cavernous sinus thrombosis (no facial tenderness, ptosis and no limitation of CN III, IV, V, VI) , aneursym (no e/o CN III palsy, headache, no personal or family history). No e/o Horner’s syndrome or inflammatory process (i.e. GBS/MF, myasthenia, or temporal arteritis). Exam and history with no overt e/o monocular diplopia with low suspicion for acute media or refractive pathology, optic neuritis, or uveitis.
with elbow pain after fall. X-ray does not reveal any overt fractures. Discussed discharge instructions with patient and return precautions. Given sling for comfort and adhesive capsulitis precautions discussed. No overt e/o compartment syndrome or supracondylar fracture. Distally NVI per routine. Patient is well-appearing, in no apparent distress, and vital signs stable for discharge home. Return precautions for occult fracture and return for repeat imaging if needed discussed.
Patient with ground level fall _ without frank head trauma and non-focal neurologic exam. Patient with multiple abrasions but no lacerations requiring repair_. Affected areas inspected, irrigated and dressings applied. Wound care discussed. TDAP up to date. Patient initially with mild headache_, single episode of emesis_ without frank abdominal injury and shoulder pain, now resolved_. Given nonfocal exam and currently well appearing, query possible mild concussive symptoms_. As above, given mechanism and nonfocal neurologic exam, low suspicion at this time for ICH or significant C-spine injury. Concussion care and precautions discussed. After extensive discussion with patient and companion regarding observation versus CT and risks and benefits of both, mutual decision making to observe and not pursue further workup at this time. Patient tolerating PO, continue to be at baseline and well appearing. As above, does not have signs of altered mental status or basilar skull fracture. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Friend agreeing to bring patient back if any concern including if patient with recurrent vomiting or altered behavior.
otherwise healthy, full term, brought in by parents for 1 day_ of increased fussiness. Afebrile, full term, currently well appearing, nontoxic. Given history and exam, low suspicion for serious bacterial infection including meningitis, pneumonia, UTI or bacteremia. Tolerating PO and appearing euvolemic with appropriate linear weight gain since birth. No meningismus, otherwise at baseline activity level with low suspicion for CNS infection. Patient wearing mittens_, no excessive tearing or redness, and without long nails with low suspicion for corneal abrasion. No overt evidence of NAT or hair tourniquets. No malignant rashes noted and improving diaper rash per parents on exam. Discussed strict return precautions for worsening of symptoms, increased respiratory effort, signs of CNS infection including but not limited to changes in mental status or vomiting, or fever. Discussed prompt follow up with primary pediatrician in 24-48 hours for recheck or return to ED sooner if concern or if cannot schedule appointment.
presenting with 3 days_ of vomiting and diarrhea. Currently euvolemic without any abdominal tenderness or peritoneal signs. Nontoxic appearing; query possible gastroenteritis. Patient also with URI symptoms and a cough over past several days – suspect viral etiology and will low suspicion for pneumonia at this time_. Nausea control, rehydrate, serial abdominal exam, reassess. At this time, given initial history and exam, low suspicion for torsion, PID, atypical appendicitis or cholecystitis.
not on anticoagulation_ with resultant laceration requiring simple repair. TDAP updated. NVI distally. Relatively clean wound, irrigated copiously and repaired in simple fashion with dermabond. No antibiotics indicated at this time. Given mechanism and nonfocal neurologic exam, low suspicion for ICH or significant c-spine injury. Discussed strict return precautions and wound care.
otherwise healthy with moderate risk HIV exposure (unprotected vaginal sex with HIV+ patient albeit with unclear last CD4 + VL)_. Extensive discussion with patient regarding risk of transmission in regards to Hep B/C, RPR, G/C and HIV and relative rates given source patient and mechanism. Patient declining vaginal exam to evaluate for tears at this time after risks discussed with full understanding and capacity. Discussed PEP at length with patients and after review of primary risks, benefits and alternative, given risk of transmission, mutual decision making to use PEP at this time. Discussed prompt follow up with clinic for bloodwork and serial serologies. Discussed at length regarding consensual nature of sex and patient does not feel that encounter was not consensual. Discussed that if patient changes mind, given STI treatment center resources. Patient contracts to safety and feels safe at home.
Given history, per CDC (2013) and NYSDOH (2014), patient not pregnant and will treat with Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily + Either Raltegravir 400 mg PO twice daily. Discussed post exposure testing at baseline6 weeks post-exposure, 12 weeks post-exposure. 6 months post-exposure at clinic. Will provide 5 days of PEP_ but discussed prompt need for follow up and full course being at least 4 weeks. Cautious return precautions discussed w/ full understanding.
subacute worsening of chronic right knee pain. Atraumatic. Neurovascularly intact distally. Given focal tenderness, query possible MCL strain vs bursitis. No systemic symptoms and nontoxic; given exam and history, low suspicion for septic arthritis, pyomyositis or necrotizing fascitis. No e/o compartment syndrome or DVT.
with R_ knee pain and mild swelling after injury. Neurovascularly intact distally. Given focal tenderness, query possible ligamentous injury however no gross instability. No tibial plateau tenderness. XR without frank fracture. Low suspicion for vascular injury with dislocation-relocation. No ankle or hip pain. No back pain with low supicion for significant axial load. No systemic symptoms and nontoxic; given exam and history, low suspicion for septic arthritis, pyomyositis or necrotizing fascitis. No e/o compartment syndrome or DVT. Pain control. Follow up with PMD and ortho as needed. Cautious return precautions discussed w/ full understanding.
with chin injury and superficial arm abrasions s/p fall from scooter_ prior to arrival. Pt with resultant chin laceration requiring simple repair. TDAP UTD. No maloccusion with low suspicion for mandibular fracture. No LOC and low suspicion for ICH. Relatively clean wound, irrigated copiously and repaired in simple fashion with sutures. No antibiotics indicated at this time. Discussed strict return precautions, follow up for suture removal and wound care. Extremity exam with full range of motion, no bony tenderness and distally neurovascularly intact.
with resultant laceration requiring simple repair. TDAP updated. XR w/o overt e/o fracture. NVI distally. Relatively clean wound, irrigated copiously and repaired in simple fashion with staples_. No antibiotics indicated at this time. NVI per routine post repair. No overt e/o compartment syndrome. Discussed strict return precautions, follow up for staple removal and wound care.
with history of chronic intermittent migraines, recently started on triptan_, now presenting with similar constellation of symptoms without overt evidence and low suspicion for intracranial hemorrhage, subarachnoid hemorrhage, or CNS affection. Patient with non-focal neuro exam. Patient not immunocompromised and no family history of bleeding dyscrasias or aneursymal rupture. Headache slow onset and similar to prior exacerbations. Will attempt pain control, serial neuro exams, and reassess.
otherwise healthy involved in restrained MVA with airbag deployment. Patient with pain predominantly to L paraspinal and L clavicular area_. Hemodynamically appropriate with nonfocal neurologic exam. Given exam and history, low suspicion for traumatic dissection or ICH. CT c-spine without overt fracture or dislocation with low suspicion for ligamentous injury on re-examination. Serial abdominal exam without tenderness and FAST initially unremarkable. Observed for several hours in ED with clinical improvement. Stable gait and tolerating PO. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
with no pertinent history presents with now resolving R_ paraspinal neck pain. No acute findings on exam; in particular, no midline spinal tenderness to palpation. Non-focal neuro exam with sensation and strength intact and equal bilaterally. Low suspicion for cervical ligamentous or vascular injury. Intact grips and UE exam with low suspicion for central cord. Discussed pain control, observation of symptoms. Cautious return precautions discussed w/ full understanding.
Patient denies severe mechanism of injury. Patient does not have overt evidence of abdominal wall trauma or seat belt sign. Patient is currently alert and at baseline mental status and activity level per family. Patient denies any abdominal tenderness and does not have evidence of thoracic wall trauma. Breath sounds remain equal bilaterally. Denies nausea or vomiting.
with vaccinations up to date_, full term, otherwise healthy boy presenting with fever and constellation of upper respiratory symptoms. Currently well appearing, nontoxic. Given history and exam, low suspicion for serious bacterial infection including meningitis, pneumonia, UTI or bacteremia. Tolerating PO and appearing euvolemic. Mild fever and well appearing after ibuprofen administration. No meningismus, otherwise at baseline activity level with low suspicion for CNS infection. Query likely viral etiology. Discussed low risk but possible UTI and offered catherterized urine sampling, but mutual decision making at this time to defer after discussion with parents_. Discussed alternating tylenol and ibuprofen as directed over the counter for antipyresis. Discussed strict return precautions for worsening of symptoms, increased respiratory effort, signs of CNS infection including but not limited to changes in mental status or vomiting, or fever for more than 5 days. Discussed prompt follow up with primary pediatrician in 24-48 hours for recheck or return to ED sooner if concern or if cannot schedule appointment.
immunizations UTD_, otherwise healthy, not immunocompromised, presenting with fever and malaise. Constellation of symptoms and history concerning for possible UTI_. Patient is extremely well appearing, mentating well, at baseline per parents, lucid and without meningismus. Nonfocal neuro exam with low suspicion for CNS infection. No respiratory distress with low suspicion for pneumonia. No abdominal pain and benign abdominal exam with low suspicion for atypical appendicitis. No overt findings for vulvovaginitis_. UA with some WBC and + LE_. Given symptoms, will treat with Keflex_ for possible upper tract infection. Tolerating PO including juice and crackers in ED. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Appendicitis return precautions discussed.
with positional chest pain for the past 2 days_. Recent mild cough, sore throat_. EKG obtained consistent with pericarditis. BUS w/o overt tamponade or significant effusion. Query possible recent URI as trigger. No overt e/o AKI or CKD, malignancy, HIV, TB. No overt high risk factors for complicated pericarditis including fever, no e/o large pericardial effusion or tamponade, no immunosuppression, anticoagulation, or trauma. Low suspicion given history and exam for concurrent myocarditis, ACS or PE. Discussed activity restriction until symptom resolution. Discussed treatment with NSAIDS (ibuprofen TID per ESC guidelines) with low risk for GIB (no history of PUD, age < 65, and no concurrent anticoagulation) and cotreatment with colchicine given lack of risk factors for toxicity (low suspicion for CKD given age) and potential benefits (significant reduction in the risk of recurrence – ICAP trial NEJM 2013)_. Discussed need for close follow up with ASHE and cardiology referral as well as strict return precautions for worsening chest pain, signs of CHF/fluid overload/tamponade, or infection.
presenting with increased anxiety with clear trigger now resolved. Given exam and history, low suspicion for acute cardiopulmonary process including dissection, ACS, or PE. Denies any acute ingestions and denies any other medical complaints at this time. Does not endorse any alcohol withdrawal symptoms. Engages with conversation. Mood and affect are congruent. Thoughts are linear and organized, and has no AH or HI. No acute need for psychiatric consultation and patient without SI or HI. Clinically no overt toxidrome, well appearing, low suspicion for ingestion given history and exam. Contracted for safety as well as demonstration of significant insight for finding homeless shelter and follow up. Cautious return precautions discussed w/ full understanding.
fully immunized, otherwise healthy, p/w isolated rash likely due to viral exantham_ given history, temporal nature and appearance. No mucous membrane involvement with low suspicion for SJS/TEN. No wheezing or difficulty breathing with low suspicion for systemic involvement. Low suspicion for scabies given history and exam. Discussed close monitoring for progression. Cautious return precautions discussed w/ full understanding. No overt e/o superinfection. Prompt follow up with primary care physician discussed.
subacute rash over months_. Given distribution, characteristics and associated symptoms, likely secondary to scabies vs bedbugs. No overt mucosal involvement w/ low s/f TEN/SJS/EM. No e/o superinfection. Discussed hygiene/decontamination measures, continue ivermectin and permethrin_; symptomatic t/w benadryl and steroid burst. F/u w/ dermatology as discussed. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
s/p renal transplant_ and s/p OHT_ who presents with fever for past several days and intermittent productive cough_. Despite patient being well appearing, will perform septic workup with concern for possible CAP. Will obtain CXR, labs, blood cultures, urine cultures, UA. Will also get troponin (to evaluate for myocarditis), BNP (to trend for possible rejection). No overt evidence of fluid overload at this time. No overt hospital acquired risk factors but given immunosuppression and concern for pulmonary cause, will empirically treat with vanc/cefepime/azithromycin_ and will defer to medicine team to narrow. Although grafts working well on prior visit, as patient not overtly septic, will gently hydrate with NS given hemodynamic stability and propensity for possible graft dysfunction/fluid overload_.
who presents with fever and ¾_ SIRS criteria. Resuscitation via EGDT with 30 cc/kg NS bolus with stabilization in vitals. Empiric antibiotic therapy, albeit with modified regimen given suspected intraabdominal source_ and allergy profile_. CXR, cultures, and UA. Consider Norepinephrine if patient not fluid responsive. Monitor hemodynamic status. Admit to medicine for further care.
with history of SSD Hb SS_, functionally asplenic_, immunizations for encapsulated organisms reportedly up to date, complicated prior by_ avascular necrosis of humerus and femur, and acute chest syndrome_, last transfusion several months prior_, baseline hgb _ now presenting with constellation of symptoms similar to prior acute vasooclusive pain crises without overt trigger. Patient is afebrile, not hypoxic and without dyspnea with low suspicion at this time for acute chest syndrome. Will trend hemoglobin and reticulocyte count to evaluate for possible hemolytic vs aplastic crisis, although low suspicion at this time. No overt worsening of avascular necrosis or osteomyelitis on exam. Nonfocal neuro exam with low suspicion at this time for end organ dysfunction from VOC including CVA, ACS, AKI or hepatobiliary complications. Will continue to monitor, pain control, gentle hydration, and follow up labs.
with stye vs chalazion to right upper eyelid. Patient well appearing without overt evidence of septal or pre-septal cellulitis. No overt evidence of cavernous sinus thrombosis. Will discharge with recommended warm compresses at home and optho follow-up this week. Low suspicion for foreign body or corneal abrasion given history and exam.
who presents with syncope prior to arrival. Witnessed syncope, likely vasovagal in etiology given history and exam. Patient currently at baseline mental status. No chest pain with low s/f dissection or ACS. No hypoxia or tachypnea with no risk factors for PE. No overt e/o malignant arrhythmia on serial EKG. Patient not pregnant_. PO challenge. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed for further workup as needed.
with otherwise healthy, fully vaccinated with sore throat likely secondary to viral URI vs strep pharyngitis. No trismus on exam and no overt e/o PTA or RPA. No overt e/o deep space infection; nontoxic appearing and tolerating PO. Centor _. Non-focal neuro exam with low suspicion for Lemierre’s. Trial antibiotics and steroids with cautious return precautions discussed w/ full understanding. Tolerating PO and otherwise well appearing.
otherwise healthy presenting with constellation of symptoms likely representing uncomplicated viral upper respiratory symptoms as characterized by mild pharyngitis without overt evidence of RPA/PTA, deep space infection/Ludwig’s, or bacterial superinfection_. Low suspicion for CNS infection bacterial sinuitis, or pneumonia given exam and history. Will attempt to alleviate symptoms conservatively; no overt indications at this time for antibiotics. No respiratory distress, otherwise relatively well appearing and nontoxic. No peritoneal signs with low suspicion for acute intraabdominal process. Will discuss prompt follow up with PMD and strict return precautions discussed.
with with no significant medical history who presents with UTI without overt e/o infected stone or prostatitis. BUS w/o overt e/o hydronephrosis_. Rectal w/o e/o abscess formation, deep space infection or prostatitis_. No e/o epididymo-orchitis on exam. Abdomen benign with minimal suprapubic TTP. No CVAT. Febrile, but otherwise well appearing and reliable. Given dose of ceftriaxone and d/c w/ Cipro_. Cautious return precautions discussed w/ full understanding. Appendicitis and abdominal pain precautions given for return. Prompt follow up with primary care physician discussed.
| Physical Exam |
NVI per routine with appropriate cap refill, extension and flexion of digits, sensation intact to FT throughout
No pain over 1st and 5th MTP
No medial or lateral malleolar tenderness
No proximal tib/fib pain
(+) small _ cm abscess over interdental papilla of right lower premolar_ between teeth 29 and 30_ with mild gingival thickening, otherwise gingival tissues pink and stipple and firm. No discharge, no blood visualized.
Otherwise, patient with no exudate to bilateral tonsillar beds and no erythema to upper palate or tonsillar beds. No uvular deviation. Full range of motion of neck. No evidence of overt RPA or PTA on exam. Non-elevated tongue with soft lower palate. No carotid bruit heard in neck. No petechiae around face or neck. No LAD appreciated. Supple.
Comfortably resting, lying in bed, NAD, nondiaphoretic, lucid, fully conversant, no respiratory distress, alert and oriented.
Testicular exam with normal lie and CMR bilaterally, no significant erythema, tenderness or swelling appreciated. No appreciable inguinal hernia bilaterally. No rashes or lesions. No penile discharge. No blood at meatus.
2+ RP symmetric bilaterally. CR < 2 seconds bilaterally. Neurovascularly intact to radian, median, ulnar per routine to both fine touch and motor in distal hands.
Right hand:
FPL intact per routine. FDS and FDP grossly intact per routine. Extensor mechanisms grossly intact per routine. Able to oppose thumb to pinky. No overt evidence of malrotation. Median recurrent nerve intact to fine touch per routine.
Left hand:
FPL intact per routine. FDS and FDP grossly intact per routine. Extensor mechanisms grossly intact per routine. Able to oppose thumb to pinky. No overt evidence of malrotation. Median recurrent nerve intact to fine touch per routine.
No septal hematoma, TM x2 clear w/o e/o hemotypanum or CSF rhinorrhea, no battle sign, raccoon eyes or csf rhinorrhea, no e/o entrapment, no diplopia on EOM, PERRL, EOMI. No facial tenderness over zygoma, mandible or maxilla. No malocclusion or trismus. TMJ grossly intact. Midface stable. Nose midline without significant deviation. No ML C-spine TTP.
Full range of motion of right ankle, right knee without pain, (-) right patellar tenderness. Negative mcburney’s, negative Lachman’s, posterior drawer test. 5/5 strength of ankle, knee and hip with stable gait. No effusion appreciated.
No lower extremity edema, asymmetry, erythema or pain. 2+ DP.
Mental status: oriented, alert, lucid, cooperative, appropriate.
Cranial nerves: CN 2-12 intact
Motor: 5+ UE and LE, flexors and extensors symmetric.
Sensation: Grossly intact to fine touch UE and LE symmetrically.
Cerebellar: normal FTN bilaterally. No tremor noted.
Gait: normal gait
Tone: normal bulk and tone in upper and lower extremities. No atrophy noted.
Visual Acuity:
OD: 20/20
OS: 20/20
OU: 20/20
No pinhole, no lens
Pupils:
OD: 4à2
OS: 4à2
APD: none
Intraocular pressure –
Tp OD: 15
Tp OS: 15
Extraocular motility: FULL OU
Confrontational fields: intact in all fields OU.
Slit lamp exam:
Lids and lashes: No edema and no periorbital erythema
Conjunctiva and Sclera: no injection OU
Cornea: no stromal edema, no ED OU
Anterior chamber: no cell, no flare OU
Iris: round and reactive OU
Lens: IOL OU
At baseline, well appearing, smiling, interactive, playing with mother. Nontoxic appearing. No tripoding, no drooling. Verbalization at baseline.
12.PEPULM
No overt respiratory distress. No tripoding or accessory muscle use. No cyanosis. No clubbing. No stridor or audible wheezing. No visualizable foreign body or mass in upper airway.
Full range of motion of left ankle_, (+) _ patellar tenderness. 5/5 strength of left ankle, knee and hip but limited by pain. Possible small knee effusion on ballotment_. Mild erythema over anterior superior knee _. No pain out of proportion; area traced out and observed throughout ED stay without extension. No pain on axial loading. Passive and active ROM to 120 degrees without significant discomfort. + TTP over area of erythema w/o fluctuance. 2+ DP.
No tenderness to shoulder, no limited flexion and abduction of shoulder secondary to pain, rotator cuff tests are negative. Able to touch opposite shoulder with hand. No deformities. Radian, medial, and ulnar nerves intact to motor and sensation. Good distal pulses and good cap refill.
There is no bruising and no laceration of the skin. The clavicle is not elevated, and the skin is not tented. No sulcus sign when palpating the humeral head and scapula. No scapular tenderness. He has intact axillary nerve sensation. He has no pain or limitation to ROM of elbow, or wrist. He has intact motor distal but limited ROM of the shoulder due to pain.
Patient with no exudate to bilateral tonsillar beds and no erythema to upper palate or tonsillar beds. No uvula deviation. Full range of motion of neck. No evidence of overt RPA or PTA on exam. Non-elevated tongue with soft lower palate. No trismus. No carotid bruit heard in neck. No petechiae around face or neck. No LAD appreciated. FROM, supple.
(+) blanching nontender mildly pruritic maculopapular centrally confluent rash with satellite lesions over _. Negative nikolsky’s. No perineal, scrotal or mucosal involvement_. No discharge or crusting.
No TTP over C/T/L/S midline
Diffuse nonconfluent pinpoint erythematous blanching papular rash predominately over thorax, extremities_. Pruritic, nontender, non discharge, some with overlying excoriations without evidence of cellulitis or superinfection. No tenderness to palpation. Negative nikolsky’s. No predominance over flexor creases. No involvement of nails or web spaces of hands.
Pelvic Exam: Closed Os, no purulent mucopurulent cervical exudate. no cervical friability, no cervical erythema, edema. No Adnexal Tenderness, no CMT. No Vaginal Vault Discharge or lacerations.
| History and Physical |
Patient has no history of malignancy, active or distant history. Patient is not less than 16 or greater than 50. Patient has no unexplained weight loss. No recent fevers, rigors, malaise, or recent infection. No history of IVDU or skin-popping. Patient does not have any saddle anesthesia/perianal sensory loss or complaining of decreased rectal tone. Patient does not have urinary retention or inability to control urine from overflow. Patient has no tenderness overlying spinous process. Patient has normal gait and able to walk on heels/ toes. Patient has no focal weakness on examination. Patient does not have hyperreflexia on examination.
Patient has a history significant for _.
Chest discomfort is described as a pressure/sharp/dull sensation without/with radiation to neck/arm/back. Patient has had this chest pain before. Chest pain is nonexertional. Chest pain started at _ and has been intermittent/constant/progressive/nonprogressive. Patient last chest pain was at _.
Chest pain is non-pleuritic and not positional_. Chest pain is not associated with food.
Patient endorses the following symptoms: _
Patient denies any associated symptoms, including near syncope, syncope, palpitations, shortness of breath, nausea, vomiting, diaphoresis._
Denies orthopnea, PND, or LEE.
Denies upper respiratory symptoms or productive cough.
Patient denies any lower extremity edema, pain, asymmetry, or swelling.
Denies prior DVT/PE or history of malignancy or known hypercoagulable state.
Patient has had no decline in their exercise tolerance.
Patient denies any tearing chest pain.
Patient denies any early family history of cardiac death or MI.
Patient has been compliant with home medications
No dysphagia, dysarthria, diplopia. No difficulty with gait or coordination.
_ presents with altered mental status.
Patient’s history is notable for: _.
Patient was brought in by _. Patient was found at _.
Denies ingestion. _
Patient without history of similar in past._
Glucose in field was _.
Denies seizure history. No seizure activity witnessed. Denies incontinence or tongue biting._
Denies falls or recent trauma._
Patient presents with abdominal pain.
Patient’s history is notable for: _.
Patient first noted the abdominal pain _. Pain is at diffuse/RUQ/LUQ/RLQ/LLQ/epigastric _. Discomfort is described as a pressure/sharp/dull_ sensation without/with _ radiation to groin/back. Patient has had this abdominal pain before_. Pain is nonexertional and not positional_.
Pain is not associated with food_. Pain is alleviated by _ and worsened by _.
Patient denies past abdominal surgeries. Last bowel movement was _. Endorses flatus._
Denies nausea or vomiting. Able to tolerate PO without difficulty._
Denies diarrhea, BRBPR, or melena._
Denies dysuria or hematuria. Denies flank pain. _
Denies recent travel._
Denies recent antibiotics or hospitalizations._
vaccinations up to date_, full term, otherwise healthy boy_ who presents with upper respiratory symptoms including a nonproductive cough, congestion and coryza for 2-3_ days. Patient also with fever for 2 days_. Endorse sick contact_ in father with similar symptoms. Stable UOP. No nausea or vomiting. Normal PO intake. No rashes. At baseline mental status and activity level without lethargy. No recent travel. No overt abdominal pain, headache, ear pain, or shortness of breath. No increase in respiratory effort.
Patient is asymptomatic currently and at baseline_. Patient was seen in clinic today by primary OB and patient had two mildly elevated blood pressure readings_. Patient denies known personal and family history of hypertension_. Denies headache or vision changes, including photophobia, blurred vision, and scotomas. Denies abdominal pain, nausea, vomiting, focal weakness or parasthesias. Endorses persistent, although stable, intermittent lower extremity edema without further asymmetry or pain. Denies chest pain or shortness of breath. Denies PND or DOE. Denies oozing with brushing teeth or new easy bruising. Denies vaginal bleeding, loss of fluid, contractions. Endorses stable and active movement of fetus.
_who presents with SI_.
Patient’s history is notable for: _. Patient was brought in voluntarily/by family/by police_. A temporary hold was/was not placed prior to arrival. _
Patient was in normal state of health until approximately _ days ago. At this time, patient noted _. Patient came in today due to _.
Patient endorses SI with plan to _.
Denies previous suicide attempt. Patient has been compliant with his medications._
Patient denies any ingestions including tylenol or aspirin._
Denies illicit substances including IVDU, amphetamines, marijuana, or alcohol. _
Patient is seen by Dr. _.
Denies previous hospitalizations._
Denies hallucinations, auditory or visual._
Denies HI/HA._
Patient is able to perform daily functions and contracts to safety._
fully vaccinated, otherwise healthy M_ who presents with rash for past day_. Rash started centripetally_ and is scattered papular mildly pruritic over chest and face_ with no oral involvement. Patient with mild URI symptoms several days prior and fever, now resolved. Patient otherwise at baseline with baseline mental status, activity level, UOP and PO intake intact. Denies sick contacts. Denies other family members with rash. Denies discharge, fevers, recent travel/hospitalizations/antibiotics.
presents with shortness of breath. Patient’s history is significant for _.
Patient first noticed increased shortness of breath _. Shortness of breath has been progressive_. Denies alleviating or exacerbating factors_. Denies similar episodes in past. Denies changes in position. Denies pleurisy.
Denies chest pain, abdominal pain, nausea or vomiting. Denies fevers._
Denies home oxygen requirement or increase in oxygen requirement._
Denies recent travel. Denies sick contacts_.
Denies upper respiratory symptoms, including productive cough, hematemesis, sore throat or runny nose._
Denies lower extremity edema, swelling, asymmetry or pain._
Denies history of DVT/PE. Denies known malignancy or hypercoagulable state.
Denies smoking or OCP use.
Patient has been compliant with home medications.
otherwise healthy p/w four_ days of productive cough without hemoptysis, mild chills now resolved, no overt fever, also associated with concurrent coryza and congestion_. Denies chest pain or shortness of breath. Denies LE edema, asymmetry or pain. Denies AP, n/v. Denies headache, fevers or chills. Denies orthopnea or PND. + sick contact also with similar constellation of symptoms. No travel.
| Progress Notes |
Serial abdominal exam without increased tenderness; no peritoneal signs. Patient with increased lucidity, tolerating PO, interactive with staff. Hemodynamically stable.
Trialed gait after several hours of observation in the ED with improvement in mental status to baseline and with stable gait. Cautious return precautions discussed w/ full understanding.
After extensive discussion of R/B/A per routine with patient, patient electing to leave against medical advice. As prior, risks explained to patient with understanding and full capacity. Patient encouraged to return to ED if patient decided to change mind regarding care or if any new concerning symptoms arise.
X-ray does not reveal any fractures, likely ankle sprain. Discussed discharge instructions with parents and return precautions. Parents expressed verbal understanding and agreement with care plan. All questions answered. Given crutches and an ankle brace. Patient is well-appearing, in no apparent distress, and vital signs stable for discharge home.
Patient reassessed and respiratory status has stabilized while in the department and appears appropriate for outpatient work up. Exam and work up not consistent w/ impending respiratory failure or cardiovascular collapse. Afebrile with low suspicion for acute pneumonia. Patient not hypoxic, fully ambulatory without respiratory distress. Medications refilled and strict return precautions discussed.
EKG reviewed, no overt evidence of contiguous ST segment elevations, low suspicion for acute MI. No overt tachy- or bradydysrhythmias. Low suspicion for WPW, long QT, HOCM, Brugada after EKG review.
As above, patient with unchanged neurovascular exam post procedure. No foreign body sensation after repair but discussed possible smaller fragments being retained despite close inspection under bright field and copious irrigation with saline_. Cautious return precautions discussed w/ full understanding.
After extensive discussion with family regarding observation versus CT and risks and benefits of both, mutual decision making to observe and not pursue further workup at this time_. Patient tolerating PO, continue to be at baseline and well appearing. As above, does not have signs of altered mental status or basilar skull fracture. Patient with nonfocal neurologic exam and with low suspicion for overt intracranial hemorrhage. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed. Family agreeing to bring patient back if any concern including if patient with recurrent vomiting or altered behavior.
Serial neuro exam without new focal neuro signs or altered mental status, has been at baseline mental status; seen running and walking around ER smiling and playful. No emesis. Patient well appearing, tolerating PO. Hemodynamically stable. Discussed case at length with parents and requesting to go home. Given reliability of parents (both father, mother, and grandmother at bedside with appropriate concern and interaction), low suspicion for NAT and seems reliable to monitor and bring back patient if any changes or concerns. Mutual decision to discharge home with strict return precautions.
Serial abdominal exam without increased tenderness; no peritoneal signs. Patient well appearing, tolerating PO. Hemodynamically stable.
This was assessed during the medical interview. Capacity to make one’s own medical decisions is based upon a patient’s ability to understand the decision that is being made, the possible options, the risks and benefits of those options, demonstrate understanding of this information and the ability to apply it to themselves, and ultimately the ability to communicate a decision. Capacity is dynamic over time, and the threshold for capacity is different dependent on the specific decision and its risks and benefits. Given our conversation, the patient at this time does appear to have the ability to communicate a preference to leave the hospital rather than stay and have medical workup_. The patient does understand the benefits of their decision, which include personal autonomy and the ability to seek care elsewhere, as well as the risks, which include delay in medical workup and possible worsening of symptoms. Given their ability to reason through this decision, and the risk of leaving the hospital _, the patient does appear to have capacity at this time_. Therefore, we will respect the patient’s autonomy to make their own decisions, which at this time is expressed as a desire for discharge.
Of note, at this time, it the patient does not seem to meet criteria for an involuntary hold based on grave disability. Patient is able to state a clear and viable plan for obtaining her own food, clothing, and shelter._
Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
Serial neuro exam without new focal neuro signs or AMS, has been at baseline mental status; seen running and walking around ER smiling and playful. No emesis. Patient well appearing, tolerating PO. Hemodynamically stable. Discussed case at length with parents and requesting to go home. Given reliability of parents (both father, mother, and grandmother at bedside with appropriate concern and interaction), low suspicion for NAT and seems reliable to monitor and bring back patient if any changes or concerns. Mutual decision to discharge home with strict return precautions.
ED Sign Out
The patient’s care was signed out to Dr. *** at 20:00***.
Items Pending at sign out: ***
Impression at the time of sign out: ***
Expected disposition: ***
(I spoke to the physician taking over care about the plan for this patient, but the final disposition will depend on the results of the patient’s studies/labs and condition upon re-evaluation. The original plan may alter depending on the patient’s medical needs.)
| Discharge Instructions |
You have been evaluated in the Olive View-UCLA Emergency Department today for abdominal pain. Your evaluation was not suggestive of any emergent condition requiring medical intervention at this time. However, some abdominal problems make take more time to appear. Therefore, it is important for you to watch for any new symptoms or worsening of your current condition.
Return to the ER if your pain does not resolve within 8-12 hours or worsens. Please follow up with your primary care physician within one to two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening pain, persistent fevers greater than 100.4, recurrent vomiting, blood in vomit, blood in stool, dark tarry stool, chest pain, difficulty breathing, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your allergic reaction. You have been given medications including steroids, epinephrine, and benadryl to control your swelling. You have been observed in the Emergency Department and it appears that your symptoms will not return.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience difficulty breathing or swallowing, recurrent vomiting, rashes, lip/mouth/tongue swelling, persistent fevers or for any other concerning symptoms.
Thank you for choosing Olive-ViewUCLA for your care.
You were evaluated in the Olive View-UCLA Emergency Department for an abscess. Your abscess was incised and drained in the Emergency Department. We have inserted a loose gauze in the abscess pocket to promote drainage and applied a clean dressing over it. You will need to change the dressing every 24 hours. Please keep the areas surrounding the abscess clean and dry. Take the antibiotics prescribed to you in full as directed.
Follow up with your primary care physician within 2 days for a wound check. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening pain, persistent fevers greater than 100.4, an increase in area of redness, increased tenderness/warmth around the abscess, foul smelling discharge from the abscess, or any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department for an abscess. You should soak the area in warm water for 20-30 minutes 3-4 times daily. Contact your doctor when the abscess comes to a head and needs to be drained. Please keep the areas surrounding the abscess clean and dry. Take the antibiotics prescribed to you in full as directed.
Follow up with your primary care physician within 2 days for a wound check. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening pain, persistent fevers greater than 100.4, an increase in area of redness, increased tenderness/warmth around the abscess, foul smelling discharge from the abscess, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today. You are refusing further testing, imaging, and further admission and choosing to leave against medical advice. You were advised of your risks of leaving and understand that permanent harm, or even death, can occur from failing to follow the recommendations of the physician.
Please follow up with your primary care physician within one day. If you do not have a primary doctor, you can go to the finance/registration department or call (818) 364-1555 to find a primary care physician.
Return to the Emergency Department immediately if you experience worsening or uncontrolled pain, persistent fevers, recurrent vomiting, blood in vomit, blood in stool, dark tarry stool, chest pain, shortness of breath, or for any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for ankle pain. The x-ray of your ankle _.
You can alternate Tylenol and Motrin every 4-6 hours to help control your pain. Please also rest, ice, and elevate your ankle to control your pain.
Please follow up with your primary care physician within two days as needed. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening pain, numbness/tingling, change of color in your toes, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your anxiety. Your symptoms have resolved in the Emergency Department.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience new or worsening anxiety, depression, thoughts of harming yourself or others, or for any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for an acute exacerbation of your asthma. Your symptoms improved receiving an albuterol breathing treatment.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening shortness of breath, chest pain, palpitations, headache, light headedness, nausea/vomiting, or any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for back pain. Your evaluation suggests no acute abnormalities which require further intervention at this time.
You should alternate Tylenol and Motrin every 4-6 hours to help control your pain. You should continue doing back exercises which could include going to physical therapy.
Please follow up with your primary care physician within three days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening back pain, incontinence, numbness/tingling, weakness, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for a skin infection. Please take the prescribed antibiotics as directed for the full course of the medication.
Follow up with your primary care physician within 2 days for a re-evaluation of the skin infection to make sure it has not spread and is getting better. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience an increase in area of redness, persistent fevers, increased tenderness/warmth around the skin infection, or any other concerning symptoms
You have been evaluated in the Olive View-UCLA Emergency Department today for chest pain. Your evaluation was not suggestive of any emergent condition requiring medical intervention at this time. Your EKG did not show any acute changes.
Please follow up with your primary care doctor in 2 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the ER immediately for worsening chest pain, palpitations, shortness of breath, persistent vomiting, fainting, or for any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for a cough. Your evaluation suggests _.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening cough, fever, shortness of breath, recurrent vomiting, lethargy, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your dental pain. Your pain has been controlled with __. Your physical exam suggests no acute abnormalities which require further intervention at this time.
Please follow up with your dentist tomorrow. Call to schedule an appointment with a dentistry clinic.
Return to the Emergency Department if you experience worsening or uncontrolled pain, fevers 100.4°F or greater, vomiting, tongue swelling, throat swelling, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for dizziness. Your evaluation suggests _.
You have been prescribed _ to help relieve your symptoms. Please take your prescription as directed.
Please follow up with your primary care doctor in 2-3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the ER immediately for worsening or uncontrolled symptoms, worsening headache, chest pain, shortness of breath, persistent vomiting, vision changes, fainting, or for any other concerning symptoms
You were evaluated in the Olive View-UCLA Emergency Department today for problems urinating. Your urine suggests that you have a urinary tract infection_. Please drink plenty of clear liquids. You will be given a prescription for antibiotics, please take as directed in full_.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening problems urinating, back pain, blood in your urine, fevers, recurrent vomiting, or any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for ear pain. Your physical exam suggests that you have an ear infection_. Please take the antibiotics in full as directed_.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience hearing loss, discharge from your ear, headaches, fevers, recurrent vomiting, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for elbow pain. Your evaluation, including physical exam and x-rays, were unremarkable// reveal a fracture_.
Please use the sling for comfort_. You can alternate Tylenol and Motrin every 4-6 hours to help control your pain. Take norco as needed for severe pain. Do not drive or operate heavy machinery when taking norco_.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Please follow up with an orthopedic surgeon in about 1 week. If we referred you to the olive view specialists, please follow up with your appointment. Please call 818-364-3676 if you do not receive a call for an appointment time.
Return to the Emergency Department if you experience worsening pain, numbness/tingling, change of color in your arm, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for a nosebleed. The bleeding was controlled in the Emergency Department and your examination reveals no active bleeding at this time.
Please follow up with your primary care physician in 2-3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the ER immediately if you experience worsening bleeding, worsening or uncontrolled pain, difficulty breathing, or for any other concerning symptoms.
You have been evaluated in the Olive View UCLA Emergency Department today for alcohol intoxication. You are now able to walk on your own and are tolerating fluids/food.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience inability to keep down fluids, worsening or uncontrolled pain, confusion, or for any other concerning symptoms.
LA Country Drug Abuse and Prevention
http://publichealth.lacounty.gov/sapc/findtreatment.htm
Call: 800-564-6600
You were evaluated in the Olive view-UCLA Emergency Department today for eye redness. Your physical exam suggests _.
Call (818)-364-3538 to schedule an appointment with the eye specialist within one week for a repeat eye exam._
Please follow up with your primary care physician within two days.If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience discharge from your eye, worsening eye redness, eye pain, vision changes, headache, fever, vomiting, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for finger pain. Your evaluation, including physical exam and x-ray, has revealed that you have a fracture of your _// no evidence of any acute fractures or dislocations_. Your finger was splinted in the Emergency Department_. Keep the splint clean and dry.
You can alternate Tylenol and Motrin every 4-6 hours to help control your pain as directed on the package.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience any new or worsening finger pain, numbness, weakness, discoloration, fevers, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for foot pain. The x-ray of your foot shows _.
You can alternate Tylenol and Motrin every 4-6 hours to help control your pain. Please also rest, ice, and elevate your foot to control your pain.
Please follow up with your primary care physician within two days as needed. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Please follow up with a podiatrist in about 1 week. You can find an podiatrist by calling (818) 364-3676.
Return to the Emergency Department if you experience worsening pain, numbness/tingling, change of color in your toes, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your injury while _. Your evaluation, including an x-ray of your _, have revealed a fracture of your _. Your __has been splinted in the ER.
Please rest, ice, and elevate your __to control pain and inflammation. Please take Tylenol of Motrin as needed for pain. Take vicodin for as needed for severe pain. Do not drive or operate heavy machinery while taking vicodin.
Please follow up with your primary care physician in 2-3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Please follow up with an orthopedic surgeon in about 1 week. You can go to your primary care doctor or follow up with the referral we have given you. Please call (818) 364-3676 if you do not receive a call for your appointment time.
Return to the ER immediately for worsening or uncontrolled pain, numbness or weakness to your _, color change to your _, or for any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for abdominal pain. Your evaluation suggests that your pain is due to gallstones. It is not emergent at this time but it is recommended that you make an appointment at a surgery clinic to be evaluated to have your gallbladder removed.
We will give you a referral to general surgery at olive view. They will call you with an appointment time in the future to discuss elective surgery. P lease call (818) 364-3129 if you do not receive an appointment date.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening pain, fever, recurrent vomiting, blood in vomit, blood in stool, dark tarry stool, shortness of breath, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for general weakness. Your evaluation, including _, were within normal limits and not suggestive of any emergent condition requiring medical intervention at this time.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening or uncontrolled pain, difficulty walking or moving your arms or legs, slurred speech, difficulty with normal activities, abnormal behavior, vision changes, or for any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for headache. Your evaluation suggests _. Your pain improved with medication.
Please control your pain by alternating Tylenol and Motrin every 4-6 hours as directed on the package.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can go to the finance/registration department or call (818) 364-1555 to find a primary care physician.
Return to the Emergency Department if you experience worsening or uncontrolled pain, vision changes, recurrent vomiting, difficulty with normal activities, abnormal behavior, difficulty walking, numbness/tingling, weakness, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for head trauma. Your evaluation suggests _.
You will likely feel a little worse tomorrow due to the trauma please rest and control your pain by alternating Tylenol and Motrin every 4-6 hours as directed on the package. You should avoid contact sports, running, playing video games and studying for long periods of time.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience severe headache, vision changes, recurrent vomiting, difficulty with normal activities, abnormal behavior, difficulty walking, numbness, weakness, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for hemorrhoids. You were given a prescription for topical cream_ and stool softeners to help with your symptoms. Use a sitz bath and rest to help control your pain (instructions can be found at http://www.webmd.com/digestive-disorders/sitz-bath). Drink plenty of fluids.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening pain, worsening bleeding in your stool, recurrent vomiting, blood in vomit, shortness of breath, fevers or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for pain secondary to your hernia. Your evaluation suggests that you do not need any emergent surgery to repair your hernia today.
Please follow up with your primary care physician within the next week. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Please arrange to see a general surgeon for elective surgery through your primary care doctor. If you do not have a primary care doctor, we will refer to surgery here, you will receive a phone call for an appointment time. If you do not get an appointment, you can call Outpatient Surgery Clinic, (818) 364-3129.
Return to the Emergency Department if you experience worsening pain, fever, recurrent vomiting, blood in vomit, blood in stool, dark tarry stool, shortness of breath, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for toe pain from an ingrown toe nail.
You can alternate Tylenol and Motrin every 4-6 hours to help control your pain. Please also rest, ice, and elevate your foot to control your pain, as well as soak your foot in water 1-2 times daily and place an antibiotic ointment in the corner of your toenail and cover with a bandage.
Please follow up with a podiatrist to treat your ingrown toenail. You can call 818- 364- 3676 to find a podiatry appointment at Olive View-UCLA.
Return to the Emergency Department if you experience worsening pain, worsening swelling, fevers 100.4°F or greater, numbness/tingling, change of color in your toes, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for a kidney stone. The stone will pass on its own and will be expelled in the urine. Please use the strainer as directed to strain your urine until your stone passes. Please read the information provided to you on discharge.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening pain, fever, painful urination, blood in urine, weakness, chest pain, difficulty breathing or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for knee pain. The x-ray of your knee shows_.
You can alternate Tylenol and Motrin every 4-6 hours to help control your pain. Please also rest, ice, and elevate your leg to control your pain.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening pain, numbness/tingling, or any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for a laceration of your _. Your laceration was closed with sutures_ in the Emergency Department. Please keep the area surrounding the laceration clean and dry.
Please follow up with your primary care physician in 7-10 days to get your sutures removed. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience discharge from your laceration, redness around your laceration, warmth around your laceration, fever, vomiting, numbness, tingling, or any other concerning symptoms.
You were evaluated in the UCLA Emergency Department today for leg swelling. Your physical exam and _ reveal _.
Please rest and keep your leg elevated. Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience shortness of breath, chest pain, palpitations, nausea/vomiting or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your injuries after a mechanical fall. Your evaluation has revealed ___. Please be aware that musculoskeletal pain commonly worsens a day or two after a fall before it gets better.
Please take Tylenol or Motrin as needed for pain using the directions on the box. Take norco only as needed for severe pain. Do not drive or operate heavy machinery while taking norco.
Please follow up with your primary care physician in 2-3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the ER immediately for worsening or uncontrolled pain, difficulty walking, numbness or weakness in your arms or legs, chest pain, shortness of breath, confusion, vomiting, or for any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for a medication refill.
It is very important that you establish primary care with a physician if you have not already done so to gain an optimal regimen for your medical conditions. Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience chest pain, shortness of breath, numbness/tingling, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your __ pain after _. Your pain is most likely muscle strain which will improve on its own.
Please rest, ice, and elevate your _to control pain and inflammation.
Please follow up with your primary care physician in 2-3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the ER immediately for worsening or uncontrolled pain, numbness or weakness to your _, color change to your _, or for any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your injuries after a motor vehicle collision. Your evaluation has revealed __. Please be aware that musculoskeletal pain commonly worsens a day or two after a collision before it gets better.
Please take Tylenol or Motrin as needed for pain using the directions on the box. Take norco as needed for severe pain. Do not drive or operate heavy machinery while taking norco.
Please follow up with your primary care physician in 2-3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the ER immediately for worsening or uncontrolled pain, difficulty walking, numbness or weakness in your arms or legs, chest pain, shortness of breath, confusion, vomiting, or for any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your nausea and vomiting. Your evaluation suggests that your symptoms are most likely due to a viral gastroenterological infection which will improve on its own.
Remember to drink plenty of clear fluids at home and eat a bland diet.
Please follow up with your primary care physician within two days.If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening or uncontrolled pain, inability to tolerate fluids by mouth, recurrent vomiting, blood in your vomit, difficulty breathing, fevers 100.4°F or greater, or any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for neck pain. Your _ suggests no acute abnormalities which require further intervention at this time.
You should alternate Tylenol and Motrin every 4-6 hours to help control your pain.
Please follow up with your primary care physician within three days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening neck pain, incontinence, numbness/tingling, weakness, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for numbness in your _. Your evaluation, including labs and imaging_, suggests that your symptoms are due to __.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can go to the finance/registration department or call (818) 364-1555 to find a primary care physician.
Return to the Emergency Department if you experience worsening or uncontrolled pain, difficulty walking or moving your arms or legs, slurred speech, difficulty with normal activities, abnormal behavior, vision changes, or for any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for palpitations. Your evaluation suggests _.
Please follow up with your primary care doctor in 2-3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the ER immediately for persistent periods of very rapid heart rate that is associated with shortness of breath, worsening fatigue with trouble exercising, chest pain, dizziness, fainting, or for any other concerning symptoms.
Your child has been evaluated in the Olive View-UCLA Emergency Department today. Their evaluation was not suggestive of any emergent condition requiring medical intervention at this time. However, some abdominal problems make take more time to appear. Therefore, it is important for you to watch for any new symptoms or worsening of the current condition.
Please follow up with your pediatrician within one to two days. If you do not have a Pediatrician, you can walk into the pediatric clinic on the scheduled clinic days to establish a doctor for you child. Please call (818) 364-3141 if you have any problems finding the clinic.
Return to the Emergency Department immediately if your child has worsening abdominal pain, persistent fevers of 100.4°F or greater, recurrent vomiting, blood in vomit, blood in stool, dark tarry stool, or any other concerning symptoms.
Your child was evaluated in the Olive View-UCLA Emergency Department today for cough. Their physical exam suggests that their symptoms are likely due to a viral illness. Viral illnesses should resolve on their own over time. You should give tylenol or motrin as needed using the directions provided to you and give plenty of fluids.
Please follow up with their pediatrician within three days. If you do not have a Pediatrician, you can walk into the pediatric clinic on the scheduled clinic days to establish a doctor for you child. Please call (818) 364-3141 if you have any problems finding the clinic.
Return to the Emergency Department if XXXX experiences worsening cough, trouble breathing, fever, recurrent vomiting, lethargy, or any other concerning symptoms.
Your child was evaluated in the Olive View-UCLA Emergency Department today for a fever. Their evaluation suggests that the symptoms are likely due to a viral illness_. Viral illnesses should resolve on their own_.
Please alternate Tylenol and Motrin every 4-6 hours to help control fever and give plenty of fluids.
Please follow up with your pediatrician within three days. If you do not have a Pediatrician, you can walk into the pediatric clinic on the scheduled clinic days to establish a doctor for you child. Please call (818) 364-3141 if you have any problems finding the clinic.
Return to the Emergency Department immediately if your child experiences persistent fevers greater than 100.4°F that cannot be controlled with Tylenol/Motrin, recurrent vomiting, lethargy, seizures, difficulty breathing, or any other concerning symptoms.
Your child has been evaluated in the Olive View-UCLA Emergency Department today for head trauma. Your child’s evaluation was not suggestive of any emergent condition requiring medical intervention at this time. Your child was observed in the ED without any evidence of neurological instability.
Please follow up with your child’s pediatrician within two days. If you do not have a Pediatrician, you can walk into the pediatric clinic on the scheduled clinic days to establish a doctor for you child. Please call (818) 364-3141 if you have any problems finding the clinic.
Return to the Emergency Department if your child experiences worsening headaches, vision changes, recurrent vomiting, difficulty with normal activities, lethargy, abnormal behavior, difficulty walking, weakness, persistent fevers, or any other concerning symptoms.
Your child was evaluated in the Olive View-UCLA Emergency Department today for a laceration. Their laceration was closed with sutures in the Emergency Department. Please keep the area surrounding the laceration clean and dry. To minimize scarring reduce sun exposure for the next year by wearing sunscreen, hats and long clothing.
Please follow up with your pediatrician within two days for a wound check. If you do not have a Pediatrician, you can walk into the pediatric clinic on the scheduled clinic days to establish a doctor for you child. Please call (818) 364-3141 if you have any problems finding the clinic.
Return to the Emergency Department if your child experiences discharge from the laceration, redness around the laceration, warmth around the laceration, persistent fevers, recurrent vomiting, or any other concerning symptoms.
Your child has been evaluated in the Olive View-UCLA Emergency Department today for _ pain. Their evaluation, including physical exam and x-rays, were unremarkable_.
Please rest, ice, and elevate to control pain and inflammation. Please give your child tylenol/motrin as directed in the attached dosing instructions for discomfort.
Please follow up with your Pediatrician within two days. If you do not have a Pediatrician, you can walk into the pediatric clinic on the scheduled clinic days to establish a doctor for you child. Please call (818) 364-3141 if you have any problems finding the clinic.
Please follow up with a pediatric orthopedic surgeon in about 1 week. You can find a pediatric by follow up with a pediatrician.
Return to the Emergency Department if your child experiences worsening pain, change of color in their _, persistent fevers, recurrent vomiting, or any other concerning symptoms.
Your child was evaluated in the Olive View-UCLA Emergency Department today for a rash. Their evaluation suggests _.
Please follow up with your pediatrician within three days. If you do not have a Pediatrician, you can walk into the pediatric clinic on the scheduled clinic days to establish a doctor for you child. Please call (818) 364-3141 if you have any problems finding the clinic.
Return to the Emergency Department if your child experiences difficulty breathing or swallowing, lip/mouth/tongue swelling, persistent fevers >100.4 that cannot be controlled with tylenol/motrin, recurrent vomiting, lethargy, seizures, discharge from his rash, or any other concerning symptoms.
You were examined in the Olive View-UCLA Emergency Department today for penile pain. Your physical exam suggests that _.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Please follow up with your primary care doctor for an appointment with a urologist. Call (818) 364-3129 if you were not given an appointment time over the phone with an Olive View-UCLA urologist.
Return to the Emergency Department immediately if you experience worsening penile pain, increasing redness or discharge from the penis, fevers or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your psychiatric complaint. You were evaluated by both Emergency Medicine and Psychiatry staff_ and have been cleared to go home.
Please follow up with your psychiatrist within 2-3 days. Please use the resources given to you in the Emergency Department.
Psychiatric Urgent Care
14659 Olive View Dr.
Sylmar, CA 91342
(818) 485-0888
HRS M-F 8am-10pm Sat-Sun 9am-5:30pm
Return to the Emergency Department immediately if you experience thoughts of hurting yourself or others, audio or visual hallucinations, or for any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for problems urinating. Your urine suggests that you have a kidney infection (pyelonephritis). Please drink plenty of clear liquids. You will be given a prescription for antibiotics, please take in full as directed.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening problems urinating, back pain, blood in your urine, fevers, recurrent vomiting, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for a seizure. Your evaluation, including labs and CT of your brain, were unremarkable_.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Follow up with your primary care doctor to make an appointment with a neurologist. If you were referred to a neurologic here at Olive View-UCLA, please follow up with that appointment which you will be called for.
Return to the Emergency Department if you experience recurrent seizures, difficulty walking or moving your arms or legs, slurred speech, difficulty with normal activities, abnormal behavior, vision changes, or for any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for shortness of breath. Your symptoms improved with Albuterol and Prednisone_.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening shortness of breath, chest pain, palpitations, headache, light headedness, nausea/vomiting, or any other concerning symptoms
You have been evaluated in the Olive View UCLA Emergency Department today for shoulder pain. Your evaluation, including physical exam and x-rays, were unremarkable// reveal a shoulder dislocation_. We have reduced your shoulder, please use the sling for comfort_.
You can alternate Tylenol and Motrin every 4-6 hours to help control your pain. Take norco as needed for severe pain. Do not drive or operate heavy machinery when taking norco_.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Please follow up with an orthopedic surgeon in about 1 week with your primary care doctor. If you were referred to one from Olive View, please follow up with your scheduled appointment that you should receive a phone call for.
Return to the Emergency Department if you experience worsening pain, numbness/tingling, change of color in your arm, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your sore throat. Your evaluation suggests__.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening or uncontrolled pain, tongue swelling, difficulty swallowing, difficulty breathing, fevers 100.4°F or greater, recurrent vomiting, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for your genital ulcer_. Your gonorrhea and chlamydia tests are still pending_; you have been given treatment for these infections presumptively _.
Please take your prescribed antibiotics for the full course of the medication as directed.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience fevers 100.4° or greater, worsening or uncontrolled pain, rashes, sores, vomiting, or for any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today after a syncopal episode. Your evaluation suggests that your symptoms are due to vasovagal syncope_. Your physical exam was not suggestive of any emergent condition requiring medical intervention. Your EKG was normal_.
Please take tylenol or motrin as needed for pain using the directions on the box.
Please follow up with your primary care doctor in 2-3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the ER immediately for worsening or uncontrolled symptoms, worsening headache, chest pain, shortness of breath, persistent vomiting, vision changes, recurrent fainting, or for any other concerning symptoms.
You were examined in the Olive View-UCLA Emergency Department today for testicular pain. The ultrasound of your testicles did not show torsion_.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Follow up with your primary doctor to make an appointment with a urologist or follow up with the referral given to you. You should receive a telephone call with an appointment time if you were referred to UCLA-Olive View
Return to the Emergency Department immediately if you experience worsening testicular pain, penile pain, redness or discharge from your penis, fevers or any other concerning symptoms.
You have been evaluated in the Olive View UCLA Emergency Department today for your sore throat, cough, runny nose, fevers, and body aches. Your evaluation suggests that your symptoms are most likely to due a viral upper respiratory infection which will improve on its own.
Drink plenty of fluids at home. Take Tylenol/Motrin as needed using the directions on the box.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening or uncontrolled pain, tongue swelling, difficulty swallowing, difficulty breathing, fevers 100.4°F or greater, recurrent vomiting, or any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for urinary retention. We have placed a foley catheter_. Keep the bag attached to your leg and empty when full. If you do not have any urine output, or if the urine is cloudy or bloody, call your primary doctor or return to the ER.
Please follow up with your primary care physician within two days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening problems urinating, back pain, blood in your urine, fevers, recurrent vomiting, or any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for problems urinating. Your urine suggests that you have a urinary tract infection_. Please drink plenty of clear liquids. You will be given a prescription for antibiotics, please take in full as directed_.
Please follow up with your primary care physician within two days. Please follow up with your primary care physician in 3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening problems urinating, back pain, blood in your urine, fevers, recurrent vomiting, or any other concerning symptoms.
You were evaluated in the Olive View-UCLA Emergency Department today for vaginal bleeding. Your ultrasound and labs show _.
Please follow up with your OB/GYN within two days. If you do not have an OB/GYN doctor, please arrange to see a specialist with your primary doctor or follow up with the referral with a Olive View-UCLA OB/GYN.
Return to the Emergency Department if you experience severe abdominal pain, worsening vaginal bleeding, dizziness, fevers, recurrent vomiting, or any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for a wound check. Your wound appears to be healing well; there is no evidence of infection_.
Please follow up with your primary care physician in 3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Return to the Emergency Department if you experience worsening or uncontrolled pain, spreading redness from your wound, pus from your wound, fevers 100.4° of greater, numbness/tingling or weakness, or for any other concerning symptoms.
You have been evaluated in the Olive View-UCLA Emergency Department today for wrist pain. Your evaluation, including physical exam and x-ray, has revealed that you have a fracture of your _ OR _ no evidence of any acute fractures or dislocations_.
You can alternate Tylenol and Motrin every 4-6 hours to help control your pain as directed on the package.
Please also rest, ice, and elevate your arm to control pain and inflammation.
Please follow up with your primary care physician within two days. Please follow up with your primary care physician in 3 days. If you do not have a primary doctor, you can call your insurance company to find one. If you do not have insurance, you can look for one on this of local clinics or go to the finance/registration department for more assistance.
Please follow up with a hand surgeon within 1 week by calling (818) 364-3132.
Return to the Emergency Department if you experience worsening or uncontrolled pain, numbness or weakness to your hand, color change to your hand, or any other concerning symptoms
| Memory Tools |
who presents with right hand paraesthesias s/p possible exposure to HF 14 hours ago. Given duration of symptoms and history of exposure, likely low risk dermal exposure. In brief, hydrofluoric acid is usually found as a rust remover, used in glass etching or in the manufacture of silicon chips. While there is a higher risk of co-exposure with other acids in the workplace, this was likely not the case in regards to our patient. HF is both a dermal and respiratory irritant, however in our case, as patient was using a hood and given the questionable exposure, there is a low suspicion for cardiopulmonary symptoms at this time. As such, our patient currently does not demonstrate any overt inhalational symptoms including chemical pneumonitis or noncardiogenic pulmonary edema. While the concentration of HF exposure is unknown, if an exposure were to have happened, it is likely a weak or intermediate concentration as there currently is no overt signs of dermal injury. However, in weaker concentrations, there may be a delay of symptoms owning to the penetration of deeper tissues by the cytotoxic fluoride ions. As above, despite the low risk nature of exposure and relatively benign exam, after further discussion with poison control, we will obtain labs to evaluate for systemic hypocalcemia, hypomagnesemia and hyperkalemia. In the interim, the potential affected area will be irrigated extensively and if labs are unremarkable, given the time frame and history, will likely recommend continuation of topical calcium gluconate gel using a rubber glove to enhance skin penetration. At this time, given the constellation of symptoms, duration, non-progressive nature and unclear history of exposure, there is no acute indication for subcutaneous or systemic calcium administration.
with altered mental status and ingestion of multiple medications as above_. Patient appearing dry (dry MM, anhidrotic), tachycardic (sinus on EKG with largely normal intervals), flushed peripherally with mydriasis and delirium with high suspicion for anticholinergic component, potentially from _. Given hyperpyrexia, likely secondary to anhydrotic hyperthermia and less likely encephalitis or CNS infection given exam and history, will start with evaporative cooling measures. Given myoclonus and agitation, will give benzodiazepines, which will also aid to prevent seizures secondary to possible sodium channel blockade (no electrocardiographic evidence thus far) or alcohol withdrawal. Will place foley given AMS and possible urinary retention. Given AMS and unclear history, will obtain CT brain and C-spine to evaluate for ICH_. Given limited exam, will obtain XR chest to evaluate for concretions_. Given likely intentional overdose, will check acetaminophen level and provide sitter with medical detainment until formal psychiatric evaluation_. Accucheck, Chem 7, and CBC to evaluate for possible metabolic perturbances_. Seizure precautions for possible alcohol withdrawal and monitor for respiratory and mental status for _ overdose. Given temporal nature of ingestion and AMS, no acute indication for whole bowel irrigation or charcoal. Finally, will contact poison control; continue fluid rehydration, trend CK given period of immobilization_. Reassess.
Given beta blocker overdose, will continue cardiac monitor although no initial evidence of PR prolongation or any bradydysrhythmia; also not bradycardic or hypotensive; will check lytes for possible mild hyperkalemia and hypoglycemia. No acute indication at this time for beta blocker overdose treatment including atropine, glucagon, calcium, vasopressor, high-dose insulin (with glucose), or lipid emulsion therapy. Given temporal nature of ingestion and AMS, no acute indication for whole bowel irrigation or charcoal. Will contact poison control; continue fluid rehydration. Reassess.
with occupational work exposure with relatively low risk of transmission. Extensive discussion with patient regarding risk of transmission in regards to Hep B, C and HIV and relative rates given source patient and mechanism. Immunizations UTD as above, specifically TDAP and Hep B vaccinations. Discussed PEP at length with patients and after review of primary risks, benefits and alternative, given relatively low risk of transmission, mutual decision making to defer PEP at this time. Discussed prompt follow up with occupational health for bloodwork and serial serologies as needed.
___________________
NYSDOH AI Recommendations (2014)
Indication: Percutaneous or mucocutaneous exposure with blood or visibly bloody fluid or other potentially infectious material.
Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily or Lamivudine 300 mg PO daily plus Either Raltegravir 400 mg PO twice daily or Dolutegravir 50 mg PO daily
HIV Antibody Testing of Healthcare Worker
Baseline
4 weeks post-exposure
12 weeks post-exposure
When a potential occupational exposure to HIV occurs, every effort should be made to initiate PEP, as soon as possible, ideally within 2 hours. A first dose of PEP should be offered to the exposed worker while the evaluation is underway. In addition, PEP should not be delayed while awaiting information about the source or results of the exposed individual’s baseline HIV test.
Decisions regarding initiation of PEP beyond 36 hours post exposure should be made on a case-by-case basis with the understanding of diminished efficacy when timing of initiation is prolonged.
CDC Recommendations (2013)
* Kuhar DT, Henderson DK, Struble KA, et al. Updated U.S. Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013;34: 875-892. Available at: http://stacks.cdc.gov/view/cdc/20711
Indications: Percutaneous injury or contact of mucous membrane or nonintact skin with blood, tissue, or potentially infectious body fluids, such as semen, vaginal secretions, and visibly bloody fluids and reasonable suspicion that the source patient is HIV-infected.
Source Testing:
Although concerns have been expressed regarding HIV-negative sources being in the window period for seroconversion, no case of transmission involving an exposure source during the window period has been reported in the United States. Rapid HIV testing of source patients can facilitate making timely decisions regarding use of HIV PEP after occupational exposures to sources of unknown HIV status.
Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily + Raltegravir 400 mg PO twice daily
Duration of PEP: 4 weeks
HIV Antibody Testing of Healthcare Worker
Baseline
6 weeks post-exposure
12 weeks post-exposure
6 months post-exposure
Alternatively, if the clinician is certain that a fourth-generation antibody/antigen combination assay is being used, then HIV testing could be performed at baseline, 6 weeks, and concluded at 4 months post-exposure.
PEP should be initiated as soon as possible, preferably within hours rather than days of exposure. Initiation of PEP should not be delayed while awaiting the results of a source patient’s HIV test, nor should it be delayed during consultation with experts to determine ideal PEP regimens.
Rationale:
Several clinical studies have demonstrated that HIV transmission can be significantly reduced by the post-exposure administration of antiretroviral agents. A dramatic decline in vertical transmission was observed in the AIDS Clinical Trial Group (ACTG) 076 study,1 in which pregnant women and their newborns received monotherapy with zidovudine (ZDV), and in the HIVNET 012 study,2 in which single-dose nevirapine was compared with ZDV. A CDC retrospective case-control study3 of ZDV use after occupational HIV exposure in healthcare workers (HCWs) showed an 81% reduction in risk of HIV infection in persons who received ZDV.
Because the ultimate goals of PEP are to maximally suppress any limited viral replication that may occur and to shift the biologic advantage to the host cellular immune system to prevent or abort early infection, the Committee recommends the use of a three-drug PEP regimen for all significant risk exposures.
Relative Risks:
Estimated Per-Act Probability of Acquiring HIV From a Known HIV-Infected Source by Exposure Act
Type of Exposure Risk per 10,000 Exposures
Parenteral
Blood Transfusion 9,000
Percutaneous (needlestick) 30
Sexual
Receptive anal intercourse 138
Insertive anal intercourse 11
Receptive penile-vaginal intercourse 8
Insertive penile-vaginal intercourse 4
Receptive oral intercourse low
Insertive oral intercourse low
Other
Biting Negligible
Spitting Negligible
Throwing body fluids Negligible
(including semen or saliva)
http://www.cdc.gov/hiv/law/transmission.htm.
Factors that increase the risk of HIV transmission include early and late-stage HIV infection and a high level of HIV in the blood. Factors that reduce the risk of HIV transmission include low level of HIV in the blood and the use of ART.
NIH Stroke Scale:
Interval: {NIHSS interval:17994}
Time: {Time; 0100-2400:14903} ***
Person Administering Scale: ***
| 1a. Level of consciousness: | {exam; consciousness neuro:31423} |
| 1b. LOC questions: (month; age) | *** 0 – answers both questions correctly *** 1 – one question correctly *** 2 – neither question correctly |
| 1c. LOC commands: [open/close eyes; grip/ release hand or other 1-step command] | {Loc commands neuro:31401} |
| 2. Best Gaze: [test horizontal only. Isolated peripheral CN 3,4,6 palsy =1] | {exam; best gaze neuro:31402} |
| 3. Visual: [upper & lower VF quadrants] | {Visual neuro:31403} |
| 4. Facial Palsy: [show teeth, raise eyebrows, close eyes] | {Exam; neuro facial palsy:31404} |
| 5a. Motor left arm: [extend arms] | {Motor arm:27865} |
| 5b. Motor right arm: | {Motor arm:27865} |
| 6a. Motor left leg: [hold 30 degrees supine] | {Motor leg:27866} |
| 6b. Motor right leg: [hold 30 degrees supine] | {Motor leg:27866} |
| 7. Limb Ataxia: [w/ eyes open. (B) Finger to nose; (B) heel to shin. ‘0’ if paralyzed or does not understand] | {Limb ataxia neuro:31406} |
| 8. Sensory: [to pinprick. If coma-> 2] | {SENSORY:18028} |
| 9. Best Language: [describe picture; name items in picture; read sentences] | {exam; best language neuro:31408} |
| 10. Dysarthria:[read or repeat words] | {dysarthria neuro:31409} |
| 11. Extinction and Inattention: | {findings; extinction neuro:31410} |
Total: {0-42:17997}
Note:
A patient with a completely normal neurological exam and normal mental status
will have an NIHSS of 0. The maximum recordable NIHSS score is 42. However,
since acute ischemic stroke causes unilateral paralysis and blindness, the maximum
score actually is 31 for a stroke patient with complete hemiparesis, hemianopia,
hemineglect, and aphasia.
Patients with an NIHSS score greater than 15-20 are considered to have a severe
stroke clinically.
Exclusion Criteria
Significant head trauma or prior stroke in previous 3 months
Symptoms suggest subarachnoid hemorrhage
History of previous intracranial hemorrhage
Intracranial neoplasm, arteriovenous malformation, or aneurysm
Recent intracranial or intraspinal surgery
Arterial puncture at noncompressible site in previous 7 days
Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
Active internal bleeding
Blood glucose concentration <50mg/dl (2.7mmol/L)
Acute bleeding diathesis, including but not limited to: Platelet count <100 000/mm³ (In patients without history of thrombocytopenia,
treatment with IV rtPA can be initiated before availability of platelet count but should be discontinued if platelet count is <100 000/mm³.)
Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
Current use of anticoagulant with INR >1.7 or PT >15 seconds (In patients without recent use of oral anticoagulants or heparin, treatment with
IV rtPA can be initiated before availability of coagulation test results but should be discontinued if INR is >1.7 or PT
is abnormally elevated by local laboratory standards.)
Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet
count, and ECT; TT; or appropriate factor Xa activity assays)
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)
Relative Exclusion Criteria
Recent experience suggests that under some circumstances—with careful consideration and weighting of risk to benefit—patients may receive
fibrinolytic therapy despite 1 or more relative contraindications. Consider risk to benefit of IV rtPA administration carefully if any of these relative
contraindications are present:
Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Seizure at onset with postictal residual neurological impairments
Major surgery or serious trauma within previous 14 days
Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
Pregnancy
http://www.mdcalc.com/heart-score-for-major-cardiac-events/
Upon calculating the patient’s HEART score, they were found to have a score of 0-3, which indicates low risk, so the patient can be safely discharged with the understanding that they need to make an appointment with a primary care doctor to be referred for a stress test within the next 48-72 hours, or if they cannot arrange that they are to return to the ED, or sooner than that if they have any changing, persistent, or worsening symptoms.
In the studies referenced below, the patients in the low risk group were discharged and found to have a 0.9-1.7% change of having a major adverse cardiac event (defined as revascularization, myocardial infarction, or all-cause mortality) within 6 weeks when studied both retrospectively and prospectively.
Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart J. 2008 Jun;16(6):191-6. PMID: 18665203
Backus BE, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. PMID: 23465250.
| Resources |
COMMUNITY PSYCHIATRY REFERRALS
Suicide Hotline: 877-727-4747 or 800-273-TALK (273-8255) or 888-628-9454 (Spanish)
Los Angeles County Psychiatric Emergency Team/PMRT:
310-618-9687 or 800-854-7771
LAPD SMART Team:
(213) 485-3300
Call your insurance for a list of psychiatrists and psychotherapists and outpatient programs.
Exodus Urgent Care Center:
Culver City: (310) 253-9494, 3828 Delmas Terrace, Culver City
Downtown Los Angeles: 323-276-6400, 1920 Marengo Street, Los Angeles
Fresno: 559-512-8335, 4411 East Kings Canyon Road
Open 24 hours per day, 365 days per year, on a walk-in basis
individuals in crisis can be assessed for stabilization services, medication refills/ evaluation and management, or hospitalization if necessary.
Los Angeles County Mental Health Clinics: must present to the clinic designated for service area. Call 24/7 Access Line: 1-800-854-7771 for clinic locations, hours, etc.
Antelope Valley: 661-723-4260, 349 East Avenue K-6, Lancaster 93535
Arcadia: 626-821-5858, 330 E. Live Oak Avenue, Arcadia 91006
Augustus Hawkins: 310-668-4271, 1720 E. 120th Street, Los Angeles, 90059
Compton: (310) 668-6800, 1600 E. Compton Blvd, Compton, CA 90220
Culver City: Didi Hirsch (310) 390-6612, 4760 Sepulveda Blvd.
Downtown: 213-430-6700, 529 Maple Avenue, Los Angeles 90013
Glendale: 818-244-7257, 1538 Colorado Blvd
Hollywood: (323) 769-6100, 1224 Vine Street, Los Angeles 90038
La Puente: 818-961-8971, 160 S. 7th St
Long Beach: (562) 599-9280, 1975 Long Beach Blvd., Long Beach 90806
North East: 323-478-8200, 5321 Via Marisol, Los Angeles, CA, 90042
Palmdale: 661-575-1800, 1529 E. Palmdale Blvd, Suite 150, Palmdale 93550
Rio Hondo: 562-402-0688, 17707 Studebaker Road, Cerritos 90703
San Fernando: 818-832-2400, 10605 Balboa Blvd, Suite 100, Granada Hills 91344
San Pedro: 310-519-6100, 150 West 7th Street, San Pedro, 90731
Santa Clarita: 661-288-4800, 23501 Cinema Drive, Valencia 91355
South Bay: 323-241-6730, 2311 W. El Segundo Boulevard, Hawthorne 90250
Sylmar: Hillview Mental Health Center (818) 896-1161 X211, 11500 Eldridge Ave.
West Central: 323-298-3680, 3751 Stocker Street, Los Angeles 90008
West LA: Edelman (310) 966-6500, 11080 West Olympic Boulevard, Los Angeles, CA 90064
West Valley: 818-598-6967, 7621 Canoga Avenue, Canoga Park 91304
Venice Family Clinic: (310) 392-8636
Walk-in appointments:
604 Rose Ave. 10-11:30 M, W-F or 2-3:30 M, T, F
2509 Pico Blvd. 10-11:30 M/F or 2-3:30 T, W, F
905 Venice Blvd. (teens only) 2-5 M-W
4700 Inglewood Blvd. Th 3:30-4:30
Other County Mental Health Clinics:
Orange County Mental Health: (714) 568-4463
Riverside County Mental Health: (909) 358-4705
San Bernadino County Mental Health (909) 387-7171
Santa Barbara County Mental Health (805) 681-5220
Tri-City Mental Health (909) 623-6131
Ventura County Mental Health (805) 652-6737
Los Angeles Gay & Lesbian Center
(323) 993-7500 1625 North Schrader Boulevard, Los Angeles
Counseling offered on a sliding fee scale basis. Support groups, HIV care, anger management, case management and other services also available.
HIV/AIDS Resources
APLA-AIDS Project Los Angeles- (213) 201-1388
AHF-AIDS Healthcare Foundation- (323) 860-5200
CHIRPLA-Housing- (213) 741-1951
Oasis Clinic-Medical Issues- (310) 668-5033
UCLA CARE Clinic-(310) 557-2273
Homeless Shelters (below are contact numbers to inform you of available local shelters)
Access Center 800-854-7771-will inform of available shelters in local areas
Cold Weather Shelters 800-548-6047
United Way 310-603-8962
Homeless Drop-In Centers:
OPCC Access Center: 1616 7th Street, Santa Monica (310) 450-4050
Drop-in center for clothing, showers, sack lunches, and referrals to shelters
St. Joseph’s Homeless Service Center 404 Lincoln Boulevard, Venice (310) 399-6878 x407
Emergency services, including shower, laundry, mail, clothing, counseling, and case management. All services provided free of charge. Orientation 8am M-F.
Step-Up on Second 2701 Ocean Park Boulevard, #150B Santa Monica (310) 392-9474
Psychotherapy, groups, case management, meals, drop-in center, and other services.
Homeless Health Care (HHCLA) 2330 Beverly Boulevard, Los Angeles, CA (213) 744-0724
Wide ranging outpatient services—therapy, psychiatry, groups, case management, referrals. All qualify for services.
Beyond Shelter 1200 Wilshire Boulevard, Los Angeles (213) 252-0772
Cornerstone 14000 Oxnard Street, Van Nuys (818) 901-4836
Walk-in drop-in center. Assistance with housing, groups, therapy, psychiatry. Meals
Long Beach Multi-Service Center
1301 W. 12th Street, Long Beach, (562) 733-1147
Outreach, case management and housing placement services. laundry, showers.
Domestic Violence Shelters
Domestic Violence Drop-In and Resource Center (310) 464-6281
Jewish Family Service DV Program (818) 505-0900, Los Angeles
Angel Step Inn (323) 780-7285, Los Angeles
STAR House (women and children) (323) 461-4118
Sojourn (310) 264-6644 X235, Los Angeles
1736 Family Crisis Center (213) 745-6434, Redondo Beach
Good Shepherd (323) 737-6111, Los Angeles
Haven Hills (818) 887-7481, Canoga Park
House of Ruth (909) 623-4364, Pomona
Valley Oasis (800) 945-6736, Antelope Valley
Financial Assistance:
L.A. County Department of Public Social Services (General Relief, CalWORKS, Medi-Cal etc.) (866) 613-3777
Local Office: 11110 W Pico Blvd, Los Angeles 866-613-3777
Medi-Cal (800) 541-5555
Social Security Administration (SSI, SDI, SSDI) – 24-hour Info Line (800) 772-1213
Local Office: 11500 W Olympic Blvd, Suite 300, Los Angeles 90064
You were evaluated in the Emergency Department today for a cough. Your chest xray did not show evidence of a pneumonia- your cough is most likely due to a viral illness which will improve on its own with rest and fluids. You can take over the counter medications such as dextromethorphan to help manage your symptoms.
Please schedule an appointment for follow up with your primary care physician within two days.
Return to the Emergency Department if you experience worsening cough, fever 100.4 ° F or greater, recurrent vomiting, chest pain, shortness of breath, or any other concerning symptoms.
Thank you for choosing us for your care
Your child has been evaluated in the Emergency Department today for a rash. Your child’s rash is most likely due to ***.
Please follow up with your child’s pediatrician within three days.
Return to the Emergency Department immediately if your child has worsening rash, rash that spreads to the mouth or the palms of the hands or soles of the feet, fevers that cannot be controlled with tylenol or motrin, behavior changes, or any other concerning symptoms.
Thank you for choosing us for your child’s care.
Your child has been evaluated in the Emergency Department today for *** pain. Your child’s evaluation, including X-rays, did not find signs of any concerning conditions such as fractures or dislocations.
Please rest, ice, and elevate your child’s ***, and resume normal activities as tolerated.
Give your child Tylenol and Ibuprofen per the attached dosing instructions for pain.
Please schedule an appointment with your child’s pediatrician for follow up this week.
Return to the Emergency Department if your child experiences worsening pain, numbness, tingling, change of color in your child’s extremity, or any other concerning symptoms.
Thank you for choosing us for your child’s care.
EM DOT PHRASES 