AUC Macros: MDM - Assessments

MEDICATION REFILL ASSESSMENT: Jennifer was prescribed Vilazodone by her psychiatrist and has been on a stable dose for about one year. She tried several SSRIs before this one without much benefit, but finally found benefit with Vilazodone and it has significantly improved her depression and anxiety. She denies any SI or HI now or recently. Maks was prescribed Lexapro by his psychiatrist about three months ago. It has dramatically improved his life. He has been on a stable dose of 10mg since the beginning. He took his last dose three days ago. He states that due to a pharmacy error, he was not able to get a refill and desperately needs a refill as he has already notice worsening of his mood. He denies any SI or HI at this time, but has had SI in the past. PLAN: Prescription for 10mg Lexapro sent with one refill. Prescription for 40mg Vilazodone sent with three refills.

MDM Acute febrile illness

Acute febrile illness, unclear etiology. Most likely viral syndrome. The patient is completely nontoxic appearing, vigorous, NAD. The patient is tolerating P.O.'s and interacting extremely well with parent and myself.

There is no suspicion at this time for UTI, meningitis, peritonitis, otitis media, pneumonia,or septicemia.

I gave parent the weight based doses for Tylenol and ibuprofen. Parent will call PCP in the morning to schedule a follow up appointment for recheck. Encourage plenty of fluids. Return to the emergency department if symptoms worsen, or as needed.

MDM Allergic reaction rash 1

Acute allergic reaction with dermatomal involvement only. Unclear etiology.
I see no evidence to suggest airway compromise, anaphylaxis, cellulitis, SJS ,TENS (Toxic epidermal necrolysis, erythema multiforme, scarlet fever, sepsis, bacteremia at this time. And the patient had a widely patent airway throughout their time under my care. The patient was observed without worsening of symptoms.
The patient is very well-appearing and nontoxic. Patient will be treated on an outpatient basis based on relative stability/improvement of the patient's symptoms.

MDM Abdominal Pain Female 1

Pt presents with abdominal pain unclear etiology. Pt nontoxic in appearance w/i nml vitals. Pt tolerating PO and able to control pain with distraction and PO medication.

Not Ectopic – negative ICON
Unlikely torsion – No adnexal tenderness
Unlikely PID – monogamous, no discharge, no vaginal pain
Unlikely AAA- location inconsistent, no bruits, no h/o HTN
Unlikely cholecystitis – location inconsistent, no relation with meals, negative murphy’s
Unlikely SBO – pt having BMs and flatus. No N/V
Unlikely Mes Isch- HPI inconsistent, does not coincide with meals, other dx more likely
Unlikely Pancreatitis – no h/o alcohol abuse, unlikely gallstone obstructing, location inconsistent
Unlikely Diverticulitis – age and location not most common, no h/o diverticula, no fever, no WBC, no bloody stool

considering PUD vs duodenal ulcer vs GI bleed

The patient presents with abdominal pain of uncertain etiology.

Based on the patient's clinical picture at this time and the workup as performed above, I see no evidence for more malignant underlying processes. Patient is appropriate for workup as an outpatient.

MDM Abdominal pain male

No abdominal bruits, no relation to fatty meals, negative Murphy’s, no radiation to back, no CVA tenderness, no h/o alcohol abuse, no h/o diverticula or bloody stool. Pt having flatus. Passing BM, although intermittently watery. Pt nontoxic in appearance w nml vitals. Unlikely AAA, cholecystitis, pancreatitis, SBO, appendicitis, mesenteric ischemia, nephrolithiasis, pyelonephritis, or diverticulitis. Pt tolerating PO and able to control pain with distraction and PO medication. Plan DC home w/ return precautions. The patient appears stable for outpatient therapy and expresses the desire to go home.

Risk Factors for AAA
♦ Advanced age (generally > 50years)
♦ Male
♦ History of hypertension (although patients may present with hypotension)
♦ History of smoking
♦ Hyperlipidemia
♦ Diabetes
♦ Atherosclerotic vascular disease
♦ Family history of AAA
♦ Connective tissue disorder (Marfan’s or Ehrlos Danlos syndrome).

MDM Anxiety and Chest Pain

I feel the patient's symptoms are most consistent with anxiety. The patient does not have suicidal ideation or evidence for frank psychiatric decompensation.

Given the patient’s history and evaluation here today, I feel that more malignant processes are extremely unlikely.

I did consider the possibility of arrhythmia, pulmonary embolus or other more significant organic cause for the patient's anxiety. The patient's EKG shows no evidence of STEMI or ischemic changes.

The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an illness, an initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and the patient understands that worsening, changing or persistent symptoms should prompt an immediate call or follow up with this clinic for reevaluation. The importance of appropriate follow up for long term management of the patient's symptoms was also discussed with the patient.

MDM Back pain

Low suspicion for acute cord compression or cauda equina at this time, given presentation and symptoms, including epidural abscess or hematoma. Patient has no history of malignancy, active or distant history. Patient has no unexplained weight loss. No recent fevers, rigors, malaise, or recent infection. No history of IVDU or skin-popping. Patient does not have any history concerning for saddle anesthesia/perianal sensory loss or complaining of decreased rectal tone. Patient does not have urinary retention or inability to control urine from overflow. Patient has no tenderness overlying spinous process. Patient has no focal weakness on examination.

Given exam and history, low suspicion for cord compression, cauda equina, epidural abscess/hematoma. Distally neurovascuarly intact. Query likely musculoskeletal component versus sciatica.

MDM Bronchitis

DDx: Pneumonia, Allergic rhinitis, asthma, pertussis infection, CHF, Reflux esophagitis, URI.

MDM Chest pain 1

DDx: Myocardial infarction, Unstable angina,Tension pneumothorax,Pericarditis with tamponade,Pulmonary embolism,Thoracic Aortic dissection (TAD), myocarditis, costochondritis, pleurisy, gastritis.
Coronary artery disease risk factors include:
The patient's chest pain and pressure, left arm pain are/are not sufficiently worrisome for cardiac-associated symptoms to warrant EKGs as needed. The patient's EKG showed no diagnostic acute ischemic changes. Patient referred to ED for further testing to rule out myocardial infarction

**The patient's EKG does not show changes consistent with malignant underlying process.
Chest pain and shoulder pain were reproducible with palpation.
The patient was hemodynamically stable throughout course.

MDM Conjunctivitis 1

{{age}} YEAR OLD {{gender}} presents with apparent conjunctivitis. There is a distinct possibility that this represents viral or allergic conjunctivitis, however, after discussion with the patient we opted to treat with topical antibiotic drops*** to insure coverage for possible bacterial conjunctivitis.

Exam revealed no foreign body, corneal abrasion or other concerning findings.

No vision changes or physical exam findings to suggest glaucoma, globe rupture, entrapment, retrobulbar hematoma, orbital cellulitis, among others considered in differential as unlikely in differential. Pt given antibiotic drops and impressed upon the importance of f/u with ophtho, as well as instructions for return to ED and expressed understanding of this.

MDM Cellulitis

differential: superficial thrombophlebitis, gout, contact dermatitis, Insect bites and stings, localized drug reactions, inflammatory carcinoma, Calciphylaxis, cellulitis, drug reaction.

MDM Dizziness/BPV 1

Patient presents with likely peripheral vertigo. The patient's history and physical exam are consistent with peripheral vertigo given that the patient symptoms were abrupt in onset, they extinguish intermittently, they are worsened by movement, they are reproducible on exam, they are not associated with other neurological findings on exam, there is no associated headache. There is no evidence at this time for a more malignant/concerning central process.

Based on the above considerations, radiological evaluation was deferred at this time.

The patient desires an outpatient trial of symptomatic control/treatment. We will attempt outpatient treatment with meclizine and antiemetics.

I discussed the possibility of more malignant covert etiologies with patient. The patient understands this possibility and will return or call immediately with worsening symptom. Specifically we discussed the need to return if other neurologic symptoms develop (including problems walking, talking, vision problems, numbness or tingling), and other concerns.

No LOC and no acute neurologic deficits c/f syncope, seizure, stroke.
Unlikely vertigo: Pt has negative dix hallpike nystagmus or recreation of symptoms w head movement, not described as room spinning, episodes last longer than 30 minutes, well appearing
Unlikely AOM: no ear pain, not the most common age, no TM bulging
Unlikely labyrinthitis: no hearing loss or preceding URI
Unlikely tumor/mass: more acute in onset
Unlikely meningitis: Pt afebrile, nontoxic appearing, no meningismus
Unlikely GI bleed
Unlikely other infectious process.

MDM/Plan Eustachian tube dsfxn

Pt has signs and symptoms of ear effusion most likely due to Eustachian Tube Dysfunction. No evidence of perforation. Mastoid process in tact, mild hearing impairment due to conductive hearing loss. The condition was discussed with pt. Recommended to avoid altitude changes as well as forceful nasal blowing.
OTC medication claritin D or Sudafed
Gentle Valsalva maneuver after topical decongestant use
If signs of infection appears such as increased pain and pressure then consider antibiotics.

MDM Gastroenteritis/diarrhea 1

The patient is alert and vigorous in the clinic. The patient has a completely soft, nondistended, and nontender abdomen with no peritoneal findings. Given this completely normal exam, and is tolerating PO fluids. No IV was started at this time.

Differential Diarrhea
Irritable bowel disease (not chronic in this patient)
Pseudomembranous (Clostridium difficile) colitis (no antibiotic therapy)
Celiac disease (no history of wheat intolerance and condition today is acute)
Crohn disease (no abdominal pain)
Ulcerative colitis (no abdominal pain or bleeding)
Food poisoning (possible for onset of condition)

1. Patient presents with abdominal pain suggestive of acute gastroenteritis.No e/o acute abdomen, cholecystitis, pancreatitis, pyelonephritis, ischemic bowel, bowel obstruction, surgical abdomen or other DDx considered.

2. Patient presents with abdominal pain and diarrhea suggestive of Giardia/bacterial GE. Acute gastroenteritis and other parasitic infection considered in differential DDx. No e/o acute abdomen, cholecystitis, pancreatitis, pyelonephritis, ischemic bowel, bowel obstruction, surgical abdomen or other DDx considered.
PLAN: Discussed risks/benefits and alternatives to treatment. Patient made informed decision and was prescribed
metroNIDAZOLE 250 mg oral tablet one tablet TID x7 days
Advised to follow up in 3-5 days, or sooner if any worsening symptoms. ER precautions given if symptoms worsen. Patient agrees with plan and instructions.

MDM GERD

Symptoms described as a burning sensation in the retrosternal area and regurgitation, mostly experienced in the postprandial period.
Likely GERD. This is considered troublesome if mild symptoms occur two or more days a week, or moderate to severe symptoms occur more than one day a week. Will assess and treat with appropriate medication.
The DDx of GERD includes infectious esophagitis, pill esophagitis, eosinophilic esophagitis, esophageal rings/webs, and impaired peristalsis.

MDM Head Concussion/Trauma1

Pt is < 60 years old. There is no history of seizure, syncope, or loss of consciousness. Pt denies severe headache, vomiting, mood change/agitation, confusion, difficulty balancing, otorrhea, periorbital/postauricular bruising, rhinorrhea, bleeding diathesis/use of anticoagulant medication, seizures, and retrograde amnesia. The patient has a normal, non-focal neurologic exam and is ambulatory. GCS 15. No signs of basilar skull fracture or open/depressed skull fracture. There is no clinical suspicion at this time for acute intracranial, spinal, or neurologic injury. Pt suitable for outpatient monitoring with strict ER precautions.

The patient will be discharged home in stable condition. Head injury after care instructions were given to the patient. Patient told to take Tylenol as needed for pain control.

MDM Headache

who presents with Headache. Most likely 2/2 tension headache, migraine, or headache of non-emergent etiology. No focal neurological symptoms. Neuro exam is benign. Pt is nontoxic. VSS.

Unlikely SAH: headache is non thunderclap. Headache is gradual, non-maximal at onset and similar to headaches in the past.

Unlikely Subdural/epidural hematoma: no history of trauma, no anticoagulation.

Unlikely Meningitis: afebrile, no meningismus, mild photophobia.

Unlikely Temporal arteritis: pt < 60 years old. no tenderness in temporal area

Unlikely Acute angle glaucoma: PERRL, no eye pain.

Unlikely Carbon Monoxide Poisoning: no other house members with similar symptoms.

Plan: Will give pain medication and reexamine.

Headache Protocol

All patients with headache as chief/major c/o should have the following noted:

  1. h/o same in past noted? If noted as “worst H/A ever”, needs ER eval
  2. Full neuro exam, including cerebellar, gait, eyes

DDx considered – SAH, mass, meningitis

See guidelines for head CT indication

CBC, TSH, CMP, Urinalysis w/reflex to culture, HCG (TPO antibody, Free T4, Free T3, and vitamin B12)

Consider urine drug test

Head CT Scan Guidelines