MDM

AMA Documentation

MDM

This patient has elected to leave against medical advice. In my opinion, the patient has capacity to leave AMA. The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason, and in my opinion has capacity to make decisions. I explained to the patient that his symptoms may represent *** and the patient verbalized understanding of my concerns.

I had a discussion with the patient about their workup and results, and that they may still have *** despite ***. I informed the patient that the next step in diagnosis and treatment would be ***, and they verbalized understanding of this as well. I explained the risks of leaving without further workup or treatment, which included reasonably foreseeable complications such as death, serious injury, permanent disability, and ***. I also offered alternatives to departing AMA such as assigning the patient a different provider or an alternate workup pathway.

The patient is refusing any further care, specifically ***, and is leaving against medical advice. I am unable to convince the patient to stay. I have asked them to return as soon as possible to complete their evaluation, and also explained that they were welcome to return to the ER for further evaluation whenever they choose. I have asked the patient to follow up with their primary doctor as soon as possible. I have answered all their questions. Patient signed***did not sign AMA paperwork.

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: ***

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

Chest Pain – Admit (High Risk)

MDM

This patient presents with chest pain, with a history suggestive of ***. No evidence of volume overload or shock on exam. EKG without signs of active ischemia. EKG without evidence of STEMI. Low suspicion for acute PE (Wells low risk ***), pneumothorax, thoracic aortic dissection, cardiac effusion / tamponade. Overall, ACS is being considered given higher risk features, ***, history & physical. HEART score: ***.

Patient will require admission for inpatient risk stratification and possible provocative testing.

Plan: cardiac monitor, EKG, troponins,CXR, ASA, heparin***, pain control, reassess, Cardiology consult***

SYNCOPE – Admit

MDM

This *** patient presents with symptoms consistent with syncope, most likely due to ***. Differential diagnosis includes ***reflex syncope (i.e. vasovagal syncope). Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding diatheses. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: ***). However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry.

Plan: labs, troponin, CXR, EKG, serial reassessment

STROKE – Code Activation

MDM

This *** patient presents with symptoms concerning for acute CVA versus TIA.***. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todd’s paralysis. However, presentation most concerning for a CVA. EKG without evidence of STEMI or ischemia, fingerstick BS not hypoglycemic, and clinical picture does not suggest other stroke mimic. Plan to workup for acute CVA / TIA.

Plan: Code stroke protocol, MRI/MRA stroke protocol, stroke labs, Neurology stroke consult