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: [ ]
DISPOSITION: [ ]
FINAL IMPRESSION(S)/DIAGNOSES:
[ ]