DC Inst: Abdominal Pain

DC

You have been evaluated in the Emergency Department today for abdominal pain. Your evaluation did not show evidence of medical conditions requiring emergent intervention at this time.

Please schedule an appointment with your primary care physician.

Return to the Emergency Department if you experience worsening or uncontrolled pain, fevers 100.4°F or greater, recurrent vomiting, inability to tolerate food or fluids by mouth, bloody stools or vomit, black or tarry stools, or any other concerning symptoms.

Thank you for choosing us for your care.

Pyelonephritis – General

MDM

Patient presenting with flank pain and fever. Differential included UTI, pyelonephritis, diverticulitis, nephrolithiasis, appendicitis. Also considered but less likely given history and physical exam included constipation, bowel perforation, gastritis, pancreatitis, mesenteric ischemia. Patient febrile and provided with tylenol.

Plan: labs, UA/cx, bedside ultrasound for hydro/stone, ***CT A/P, pain control, reassessment, antibiotics, anticipate admission/discharge

Benign Rash – Derm – General

MDM

This is a @AGE@ @SEX@ patient who presents with rash for ***, consistent with ***. Differential diagnosis includes contact//atopic//eczematous dermatitis, psoriasis, ***. History and exam findings not consistent with dangerous etiologies of rash such as SJS/TEN, or secondary dangerous causes such as petechial rashes from thrombocytopenia or rickettsial infections. Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN.

Plan: ***

About

Uncategorized

For when you just can’t access your dot phrase library like you’re used to.

Created by a gruntled resident who just wants to click a couple fewer boxes.

If only there was a way to ‘dot phrase’ the Depart screen…

PE – Infant Basic

Peds

General Appearance: alert, no apparent distress, appropriately interactive with examiner
Skin: no lesions, no jaundice
Head/Fontanelles: normocephalic, AF_____x_______,  RR normal bilaterally
EENT: conjunctiva clear, nares patent, normal oral mucosa, ears normal placement, TM’s clear bilaterally
Neck: full range of motion
Lungs:  CTA bilaterally, no adventitious breath sounds
CV: normal S1, S2, RRR without murmur normal femoral pulses
Abdomen: soft, no hepatosplenomegaly or masses
Extremities: no deformities
Hips: negative Barlow/Ortolani, > 60° abduction
Genitourinary: Male: testes descended, circ/uncirc    //  Female: normal external genitalia
Neurologic: moves all extremities symmetrically, normal tone, responds to clap, positive moro, grasp/suck/root/toe grasp

PE – Peds Basic (Non-Infant)

Physical Exam

General- well-appearing developmentally-appropriate child in NAD, playing in exam room
Head: atraumatic, normocephalic,
Eyes: no icterus, no discharge, no conjunctivitis
Ears: no discharge, tympanic membranes nml bilat
Nose: no discharge, moist nasal mucosa
Throat: moist oral mucosa, no exudates, uvula midline
Neck: no lymphadenopathy, no nuchal rigidity
CV- RRR, nml S1, S2 w no murmurs
Respiratory- CTAB, no wheezing or crackles
Abdomen- Soft, NTND, no rigidity, no rebound, no guarding,
Extremities- warm, symmetric tone, nml muscle development and strength
Skin- moist; without rash or erythema

PE – Basic

Physical Exam
GENERAL APPEARANCE:  AxOx4, generally well-appearing ***M/F, no acute distress.
HEENT:  NC, AT. MMM. EOMI, clear conjunctiva, oropharynx clear.
NECK:  Supple without lymphadenopathy.  No stiffness or restricted ROM.
HEART:  Normal rate and regular rhythm, normal S1/S1, no m/r/g
LUNGS:  CTAB, moving air well. No crackles or wheezes are heard.
ABDOMEN:  Soft, nontender, nondistended with good bowel sounds heard.
BACK: No CVAT, no obvious deformity.
EXTREMITIES:  Without cyanosis, clubbing or edema.
NEUROLOGICAL:  Grossly nonfocal. Alert and oriented, moving all 4 extremities. CN not formally tested but appear grossly intact. Observed to ambulate with normal gait.
Skin:  Warm and dry without any rash.

STEMI Activation

MDM

This patient presents with chest pain and an EKG showing *** STEMI or STEMI equivalent (Wellens, de Winter’s, Sgarbossa criteria).*** Presentation not consistent with acute thoracic arotic dissection. No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. Plan for PCI with cardiac cath lab activation.

Plan: CODE STEMI, STEMI labs, pacer pads, cardiac monitor, Cardiology consult, Cardiac cath lab activation, ASA, heparin, dual antiplatelet agent (per Cards), CXR

Chest Pain, Atypical (No Troponin)

MDM

This patient presents with atypical chest pain, most likely secondary to ***. Differential diagnosis includes ***. Low suspicion for ACS, acute PE (PERC negative***), pericarditis / myocarditis, thoracic aortic dissection, pneumothorax, pneumonia or other acute infectious process. Presentation not consistent with other acute, emergent causes of chest pain at this time. No indication for cardiac enzyme testing.*** Plan to order CXR to evaluate for acute cardiopulmonary causes.***

Plan: labs***, EKG, CXR***, pain control

Chest Pain – Low Risk (Trop Out)

MDM

This patient presents with chest pain, with symptoms suggestive of noncardiac chest pain. History without high risk features (e.g., not substernal, no exertional component, not relieved with rest, *** ).

Minimal CAD risk factors (including age), recent negative stress test (<2 years).*** Exam without evidence of volume overload. EKG without signs of active ischemia. HEART score: ***. Given the timing of pain to ER presentation, plan to send single troponin // delta troponin to evaluate for NSTEMI.*** Presentation not consistent with acute PE (Wells low risk *** // PERC negative***), pneumothorax, thoracic arotic dissection, cardiac effusion or tamponade.

Plan: labs, troponin***, EKG, CXR, ASA***, pain control, serial reassessment