EMERGENCY DEPARTMENT TREATMENT NOTE
THE EVALUATION, MANAGEMENT, SERVICES AND PROCEDURES, AS WELL AS THE KEY COMPONENTS OF THE PATIENT’S CARE DESCRIBED HEREIN WERE PERFORMED IN THE PRESENCE OF: [ ]
CHIEF COMPLAINT(S): [ ]
HISTORY OF PRESENT ILLNESS: [ ]
REVIEW OF SYSTEMS:
Constitutional – [no] fever;
Eyes- [no] eye pain;
ENT – [no] change in hearing;
Respiratory – [no] shortness of breath;
Cardiac – [no] chest pain;
Abdominal – [no] vomiting;
Genitourinary – [no] dysuria;
Musculoskeletal – [no] joint paint;
Neurologic – [no] headache;
Integumentary – [no] rash;
PAST MEDICAL/SURGICAL HISTORY: [ ]
MEDICATIONS: [none]
ALLERGIES: [no known drug allergies]
SOCIAL HISTORY: [-]tobacco use [-]alcohol use
FAMILY HISTORY: [+] Diabetes and heart disease
EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
Blood pressure was [ ], pulse was [ ], respirations were [ ], temperature was [ ] pulse ox was [ ]% on [room air]
General: [appear comfortable on stretcher.];
HEENT: [mucous membranes moist];
Cardiovascular: [Regular rate and rhythm];
Respiratory: [Symmetric and clear breath sounds];
Gastrointestinal: [Soft, nontender, nondistended in all quadrants.];
Musculoskeletal: [There was no gross deformity];
Skin: [No rash];
Neurologic: [The patient is oriented to person, place and time. Strength and sensation are grossly intact. Face is symmetric.];
MEDICAL DECISION MAKING AND COURSE IN THE ED WITH INTERPRETATION/REVIEW OF DIAGNOSTIC STUDIES:
The patient presents with [ ].
I have considered serious and life-threatening causes of the patient’s presenting symptoms, which included [ ].
I have been able to exclude [ ] from consideration as it is inconsistent with my history and physical exam.
Due to my inability to exclude the diagnosis of a [ ] from my differential diagnosis with my history and physical exam alone. I decided to obtain [ ] which [ ].
My clinical impression is that the patient has a presentation most consistent with a self-limiting and non-life threatening process. I have explained to the patient in appropriate terminology their diagnosis and provided anticipatory guidance for further management as an outpatient. I told them that we cannot definitively rule out a life-threatening cause of their symptoms during an emergency department visit, therefore they are absolutely required to follow-up with a physician to further assess them for risks of life-threatening causes of their presentation. If the patient cannot follow-up as an outpatient within a reasonable time period, that is, a few days, they should return to the ED so that we could help facilitate follow-up. I also explained to the patient that they were correct to present to the emergency department for this symptoms as I would prefer for them to err on the side of safety with this complaint and to continue to do so in the future. The patient has verbalized their understanding and at this time I feel they are stable for discharge home.
I have asked the patient to return to the ED should [ ].
Because [ ], the patient require further evaluation and management in an inpatient setting.
FINAL IMPRESSION(S)/DIAGNOSES:
[ ]