You have been evaluated in the Emergency Department today for ***. Your evaluation, including ***, suggests that your symptoms are due to ***.
Please follow up with your primary care physician within two days.
Return to the Emergency Department if you experience ***.
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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: ***
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
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
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
This patient presents with dyspnea, most likely secondary to ***. Differential diagnosis includes ***. Presentation not consistent with acute cardiac etiologies to include ACS (HEART score ***), CHF, pericardial effusion / tamponade . Presentation not consistent with acute respiratory etiologies to include acute PE (Wells low risk ***), pneumothorax , asthma, COPD exacerbation, allergic etiologies, or infectious etiologies such as PNA. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. demyelinating diseases).
Plan: supplemental O2, NIPPV ***, CXR, labs, troponin, close hemodynamic monitoring, serial reassessment
This patient presents with symptoms consistent with acute seizure, most likely due to ***. I considered, but think less likely, secondary etiologies of epileptic seizures to include drug / toxin etiologies (ETOH, stimulants, medication side effects), metabolic disturbances (glucose, Na), acute CNS infections (meningitis, encephalitis, abscess), ICH / tumor / CVA. Presentation not consistent with non-epileptic type seizure to include syncope, neurologic etiologies (vertebrobasilar insufficiency, movement disorder, migraine), impact seizure related to head trauma.
Plan: BZDs, labs***, CT brain***, seizure precautions, Neurology consult***, reassess
Pearls
Consider nonconvulsive status: persistent change in behavior that lasts 30 minutes after a seizure. Look for positive symptoms (twitching, eye deviation, jerking) and negative (aphasia, catatonia, mutism). Many patients will just not respond. Think about this in head trauma patients with a decreased GCS and a negative initial CT. Also consider this in a “septic” altered patient with a borderline positive UA that isn’t that convincing.
This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely ***. Differential diagnosis includes ***. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). Given the H&P, I suspect this patient is ***suicidal/homicidal/gravely disabled and will require psychiatric care. Will consult psychiatry to evaluate the patient for potential hold for ***. Will also obtain labs for medical clearance.
Plan: labs***, EKG***, ASA/APAP levels***, ETOH level***, UDS***, ICON***, Psych consult, medical detainment, reassess
This patient with *** presents with symptoms concerning for acute, upper GI bleed, likely secondary to ***.
Differential diagnoses includes peptic ulcer disease (PUD = most common) versus less likely gastritis versus Mallory-Weiss tear versus AVM. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaave’s syndrome. Presentation not consistent with other etiologies upper GI bleeding at this time. No red flag features or high risk bleeding. No evidence of hemorrhagic shock. Glasgow-Blatchford Bleeding (GBS) score: ***. Based on this well validated study, the patient can safely be discharged for outpatient therapy // is “high risk” for needing a medical intervention to include transfusion, endoscopy or surgery. Plan to check labs to evaluate the extent of bleeding, including H/H. Will initiate treatment with PPI. No indication for octreotide or antibiotics given low likelihood of variceal bleeding from portal hypertension and cirrhosis.*** No indication for abdominal imaging at this time.
Plan: labs, LFTs, close hemodynamic monitoring, serial reassessment, PPI therapy, Octrotide/CTX***
EM DOT PHRASES 