AUC Macros: Plan

Plan: Kyla Telemed

Lab ordered: COVID-19
Pt scheduled for COVID swab

Recommendations:
Stay away from others: As much as possible, you should stay in a specific “sick room” and away from other people in your home. Use a separate bathroom, if available.
Recommended frequent hand washing, wash with soap and water for at least 20 seconds
Social distancing as possible (stay home, avoid public area, avoid public transportation)
Clean and disinfect "high-touch" surfaces
Over-the-counter fever reducer such as Tylenol and cough/cold remedies
Get plenty of rest and drink plenty of fluids
Monitor for any new or worsening symptoms
ED precautions given
Follow up in 3 days for result review
Contact the CDC with further questions or concerns.

If you develop emergency warning signs for COVID-19 get medical attention immediately. Emergency warning signs include*:
Difficulty breathing or shortness of breath
Persistent pain or pressure in the chest
New confusion or inability to arouse
Bluish lips or face
*This list is not all inclusive. Please consult your medical provider for any other symptoms that are severe or concerning.

PLAN abscess Yesim

TDAP is/is not given today
FBS
wound culture could not send since no d/c
Warm compress application Every 2 hours for 20 minutes
We will start patient to Bactrim DS for MRSA coverage,
Topical mupirocin ointment twice daily
Advised of potential S/Es of medication and advised to use OTC probiotic daily if needed for GI distress.
Advised to use OTC IBU/Tylenol as needed for pain relief.
Advised of routine management to include keeping area clean with soap and water, and keeping on covered to assist with healing and prevent secondary infection.
Strict extremity elevation.
No stressful activities or swimming or bathing to prevent worsening symptoms
Advised to maintain PO intake and hydration.

Patient is educated about possible complications like sepsis, OM, amputation even death due to uncontrolled infection.
FU in 2-3 days or earlier
Strict emergency and return precautions: persistent worsening symptoms, fever, chills, fatigue, weakness, lightheaded/dizziness, syncope/presyncope, chest pain, SOB, n/v, loss of sensation or motor function to affected area, bleeding of wound, discharge from wound, burning sensation, and numbness/tingling of extremities.

Plan discussed with patient. Patient verbalized understanding and agreed to plan.

See also Cellulitis

See also I&D

PLAN Abdominal Pain

The patient requires diagnostic workup with imaging and laboratory studies.

Laboratory Studies: *** CBC, CMP, Lipase, H.pylori and UA, add CRP for pediatric patients
Diagnostic Imaging: *** Ultrasound of the abdomen, CT of abdomen w/o contrast, KUB x-ray

Urinalysis is negative for signs of infection or dehydration.

***Urine HCG is negative

The possibility of more malignant occult pathology was discussed in depth with the patient. The patient
understands the need to return promptly with any worsening symptoms or changes, and that no initial workup, no matter how extensive, can definitely exclude some more serious intra-abdominal and pelvic processes early in the disease course.

The patient understands the need for follow up with this office as instructed in 3-5 days.

ED precautions given.

Plan Acne- Nav

Doxycycline prescribed
Use a mild facial cleanser morning and evening and whenever you become sweaty. Avoid scrubbing the face, as this can make the acne worse.
Avoid squeezing or picking pimples as this will make them worse and may cause scarring.
Use water-based moisturizers rather than oil-based products.
Aim to eat a healthy balanced diet. If you notice that a particular food makes your acne flare up, try to avoid it.
Drink plenty of water and exercise regularly.
Avoid exposing your skin to too much cold, heat and sunlight. Exposure to sun can improve acne in about 60% of people but the use of tanning beds or lamps is not advised due to the long-term risks of sun damage and skin cancer. Humid weather may worsen the acne due to excess sweating.
F/U in one week.

Plan Asthma/Reactive Airway Dz

Patient presents with appears to be a reactive airway disease exacerbation.

I see no evidence for pneumonia at this time. The patient did respond well to therapy and I feel it is reasonable to discharge the patient and undertake treatment on an outpatient basis.

Patient was instructed to continue albuterol MDI/nebulizers and I have also administered a short course of Prednisone. There is no evidence for more malignant etiology for the patient’s symptoms at this time. I discussed the possibility of more malignant covert etiologies with patient. Patient understands this
possibility and will follow up immediately with worsening symptoms. The patient understands the importance of proper follow with this clinic or Emergency for dyspnea or other concerns of airway obstruction.

Plan Asthma/bronchitis/cough

Asthma exacerbation r/t bronchitis:

In clinic: duoneb, toradol

RX: Tessalon Perles, ProAir RespiClick 90 mcg/inh inhalation powder,

Possible add ons: Medrol Dosepak 4 mg oral tablet, Flovent Diskus 100mcg x 2 weeks, Azithromycin x 5 days if no improvement or worsening of symptoms

OTC/Therapeutic:
Allergy medication of choice: i.e. loratadine (Claritin) or cetirizine (Zyrtec) during allergy season
For cough during day: Guaifenesin (mucinex without cough suppressant) 200-400 mg orally every 4 hours when required, maximum 2400 mg/day
Sinex (or other nasal decongestant) as needed
Ibuprofen as needed to help with pain, fever, and inflammation
Acetaminophen as needed for discomfort and fever
Adequate rest and hydration, steam inhalation.
Honey is a natural cough suppressant and anti-bacterial. Try to use some in hot herbal tea for cough relief.

Followup:
In 1 day for cxr if no improvement
In 3-5 days if improvement noted
ER precautions given.

Plan Allergic Reaction

Patient presents with an allergic reaction likely secondary to ***. I see no evidence for frank anaphylaxis at this time and the patient had a widely patent airway throughout their time under my care and at the time of discharge. The patient was observed without worsening of symptoms.

The patient will be treated on an outpatient basis based on relative stability/improvement of the patient's symptoms.

The patient will be treated with a short course of antihistamines, steroids and the patient was also prescribed an Epi-Pen as a precaution.

Extensive counseling was given to the patient in regard to worsening allergic symptoms and airway compromise. They understand they are to avoid ***(the suspected offending agent)*** and all medications or substances that are similar to it. The patient was instructed to follow up with this office within 72 hours for a recheck. They understand they may require referral to allergist in the near future. The patient agrees to return immediately if symptoms return or new symptoms arise or report immediately to the Emergency for evaluation and treatment. The patient was improved at discharge compared to initial presentation and with normal vital signs.

Plan Bite animal/human -MC

# ***bite
-bleeding controlled
-wound care provided. wound copiously irrigated with soap and water
-bacitracin and dry gauze applied
-rabies risk low, pt declined rabies vaccination
-pt educated on how to care for wound, and to keep from infection
-augmentin prescribed for prophylaxis
-TDAP UTD
-RTC 24-48 hours to reevaluate wound and change dressing, sooner if signs of infection develop

Pt understands and agrees with plan of care.

PLAN: BRAT diet

BRAT Diet advised:

First six hours: In the immediate six or so hours after vomiting has stopped, it is best to give your stomach a rest. Following a period of one to two hours, suck on hard candy or popsicle (no chewing). Then progress to ice chips or sips of water if nausea persists.

First 24 hours: (Day One) Gradually add clear liquids if the vomiting has ceased. Beginning with a sip or two every ten minutes is a good way to start. Suggestions include water, apple juice, flat soda, weak tea, jello (in liquid or gelatin form), broth or bouillon (clear base from a non-greasy soup). If symptoms of nausea or vomiting return, begin the process again, taking nothing by mouth for an hour or so.

Day Two: Begin to add bland foods like bananas, rice, applesauce, crackers, cooked cereals (Farina, Cream of Wheat), toast and jelly.

Day Three: Progress to a "regular" diet by adding such things as soft cooked eggs, sherbet, stewed fruits, cooked vegetables, white meat of chicken or turkey.

FOODS TO AVOID:
Avoid milk and dairy products for three days.
Avoid fried, fatty, greasy and spicy foods.
Avoid pork, veal, salmon, and sardines.
Avoid raw vegetables such as parsnips, beets, sauerkraut, corn on the cob, cabbage family, onions.
Avoid citrus fruits: pineapples, oranges, grapefruits, tomatoes.
Other fruits to avoid are cherries, grapes, figs, currants, raisins, rhubarb, seeded berries.
Avoid extremely hot or cold beverages.
Avoid alcohol.
Avoid coffee and caffeinated sodas.
ADDITIONAL HEALTH GUIDELINES
Drink plenty of water or liquids to avoid dehydration from fluid losses due to your illness.
Rest and avoid exertion to give your body a chance to recover.
Consult your health care provider about taking medication.
Nausea and vomiting may be caused by viruses, food poisoning, medications, alcohol, anxiety, and pregnancy. In addition, nausea may be a sign of an upper respiratory illness with a post-nasal drip.
Diarrhea may be "acute", beginning suddenly and resolving over a few days with dietary discretion, or of a "chronic" ongoing process. Causes of this symptom are similar to the ones listed for nausea and vomiting.

Plan Bronchitis Viral

TX: ***
ED: Educated pt that bronchitis is almost always self-limited not requiring antibiotics. Increase fluid intake. use humidity and mist therapy PRN. Avoid irritants, such as smoke, solvents and cleaners. Cover your nose and mouth when you sneeze or cough. Use good hand washing. Get plenty of rest and increase activity as tolerated. Eat a nutritious diet. Drink 8-10 glasses of water a day. Tylenol or Motrin for fever and malaise. Expectorants such as guaifenesin with dextromethorphan to treat minor cough from bronchial/throat irritation. Recommended yearly flu vaccination
RTC 2-3 days
Pt understands and agrees with plan of care.

Plan Bronchitis Bacterial

Patient presents with likely acute bronchitis based on the patient's changing pattern of cough productivity and cough duration with possible reactive airway disease symptoms.

I see no evidence for pneumonia at this time based on the patient's physical exam, afebrile status and normal oxygen saturation.

Chest x-ray deferred due to mildness of symptoms

The patient is a good candidate for outpatient therapy based on normal PO intake, reassuring exam and normal oxygen saturation/lack of respiratory distress upon discharge.

I feel it is reasonable to discharge the patient and undertake treatment on an outpatient basis including: Augment 875/125 one tablet PO BID x10 days

There is no overt evidence for more malignant etiology for the patient's symptoms at this time. I discussed the possibility of more malignant covert etiologies with patient. The patient understands this possibility and will follow up immediately with worsening symptoms.

Return to clinic in 72 hours for recheck
ED precautions given.

Plan Bursitis

Bursitis
Rx: Ibuprofen 800mg
MedrolPak
Cephalexin
Tramadol for severe pain
ICE, ELEVATION, REST, COMPRESSION ACE WRAP.

Plan C. Diff

Assessment: Persistent diarrhea x # weeks after antibiotic use , most likely antibiotic-associated colitis
Empiric treatment is reasonable in the setting of high clinical suspicion for CDI

Plan:
Empiric treatment for C. Diff will be initiated today
Ordered C.diff stool culture - results pending
Rx: Metronidazole 500mg PO q8h for 10 days
Continue oral hydration and BRAT diet

Educated pt on C.Diff prevention and management : early detection and isolation, contact precautions to avoid
spreading to others, good hand hygiene, effective environmental cleaning and avoid child-care settings
F/U 5-7 days for culture results.

Plan Cellulitis

Patient presents with appears to be a superficial infection/cellulitis. Patient does not have evidence for a more malignant process at this time.

The patient does not have evidence for abscess or underlying foreign body. Patient does not have signs of systemic illness/sepsis.

The patient appears to be a good candidate for outpatient therapy at this time based on generally favorable clinical appearance and ability to tolerate oral medications/liquids.

Patient will be treated on an outpatient basis with oral antibiotics.

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 infection, 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 their primary physician or return for reevaluation. The importance of appropriate follow up was also discussed with the patient. More extensive discharge instructions were given in the patient's discharge paperwork.

See also Abscess

PLAN Chest Pain

The patient's (specific symptoms, and character, i.e. chest pain SOB etc)*** are sufficiently worrisome for cardiac-associated symptoms to warrant admission for serial cardiac enzymes and EKGs as needed. The patient's initial ( enter cardiac enzyme testing)*** was negative, and the patient's EKG showed no diagnostic acute ischemic changes.

Wells criteria was considered in the evaluation of this patient. The patient did not have a Wells score indicating an emergent workup is necessary. The patient's EKG does not show changes consistent with pericarditis or other malignant underlying process. The patient's symptomatology and physical exam are not completely consistent with myocarditis, costochondritis, pleurisy, aortic pathology or pulmonary embolus. (if CXR or EKG is not normal, edit appropriate findings)***

The patient was administered aspirin upon arrival.(edit-- must account for where/when aspirin was given i.e. in ED, ambulance, home, or if not--why not)***

Coronary artery disease risk factors include: (HTN, high cholesterol, early fam fx, diabetes, smoking)***

The patient was hemodynamically stable throughout course (if patient had low or high blood pressue in course, this should be changed and treatment, if any explained/outlined).

Consultation: I discussed this case with Dr. ***, who agreed with assessment and plan.

Plan Cerumen Impaction

The patient presents with cerumen impaction. There is no evidence of infection and antibiotic therapy is not indicated at this time.

Manual removal of cerumen via lavage was undertaken as outlined above with good relief of symptoms. There was no evidence for significant trauma or complications.

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 a process, 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 office for reevaluation. The importance of appropriate follow up was also discussed with the patient.

PLAN child stable

The patient is a good candidate for outpatient symptomatic therapy based on general clinical appearance,
which is good/non-toxic.The patient and parent(s) understand that at this time there is no evidence for a more malignant underlying process, but the patient and parent(s) also understand that early in the process of an illness or infection, an initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and parent(s) and they understand that worsening, changing or persistent symptoms should prompt an immediate call or follow up with their primary physician or return for reevaluation. The importance of appropriate follow up was also discussed with the patient and parent(s). More extensive discharge instructions were given in the patient’s discharge paperwork.

PLAN Concussion

Patient presents with a concerning head injury mechanism and history.

After review of the patient's history, physical exam and pertinent laboratory data, it was clear that a CT scan was/was not indicated to further evaluate for significant intracranial/skull injury. The risks and benefits were discussed with the patient and parent(s) and it was agreed to order/defer the head CT.

Given the patient's reassuring neurological exam throughout their course, the patient is appropriate for outpatient symptomatic management.

The patient was counseled regarding concussion/closed head injury, and understands it is necessary to follow up with us or primary care physician and to monitor continuing progress of recovery from concussion. I also recommended that the patient be restricted from vigorous or contact activities until the patient is reevaluated. Patient is to follow standard protocol for concussion treatment which is a gradual return to full activity, both physical and psychological with adjustment periods between each progression of activity.

The patient and/or parent(s) were instructed to return or call with any questions concerning new or worsening symptoms. The patient/family expressed understanding of the plan, agreed to the above.

More extensive ED precautions and head injury instructions were given.

The patient was instructed to return for reevaluation in 5 days. The patient/family expressed understanding of the plan, and agreed to the above.

Plan Conjunctivitis -MC

#conjunctivitis
-cipro eye drops
-avoid touching eyes
-warm compresses PRN
-observe for s/s of worsening infection such as fever, eye lid swelling and redness

RTC 2-3 days

ED precautions discussed

Pt understands and agrees with plan of care.

Plan Conjunctivitis

{{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.

The patient understands that follow up as instructed with ophthalmology is very important if symptoms persist and that they should return or call immediately with any changes or worsening symptoms. They understand that sometimes very serious eye issues can appear relatively benign initially.

Conjunctivitis can be caused by infections, allergies or irritation. Patient advised to use cool or warm compresses for comfort. If using drops in one eye, clean receptacle before using in other eye. Wash hands frequently, and each time you touch eye to prevent spreading. Patient instructed not to wear contact lenses until treatment is completed and symptoms have completely resolved.

Return to this clinic or go to the emergency room if you have any trouble seeing or develop pain, visual changes, or fever.

PLAN Constipation in Children

The following is a comprehensive approach to resolving constipation in children from the age of two to adulthood. The appropriate methods were discussed with both patient and parents during visit today.

1. Osmotic laxative

Fecal impaction is the retention of feces, usually palpable per abdomen, to a degree where spontaneous evacuation is unlikely. These children may require an osmotic laxative to achieve regular bowel movements. Osmotic laxatives, such as polyethylene glycol (PEG) 3550 electrolyte solutions, have been shown to be effective.

2. Dietary modifications

Dietary changes remain a common initial recommendation, particularly increased intake of fluids and dietary fiber. However, a review found no evidence that increased water intake or hyperosmolar fluid supplementation had any effect on increasing stool frequency or decreasing difficulty in stool passage. There was some evidence that, compared with placebo, fiber is more effective in improving stool frequency and consistency, and reducing abdominal pain. Increase in physical activity may be suggested for older children.

3. Stimulant laxative

These children may require the short-term addition of a stimulant laxative (e.g., senna, particularly for children =12 years of age, or bisacodyl for children >12 years of age) to achieve regular bowel movements.


4. Phosphate Enema

Older children may require a phosphate enema to clear the impacted rectum. This should be used only as a rescue measure.

The invasiveness and trauma of enemas may exacerbate the child's fear and intensify the psychological disturbance.

The US Food and Drug Administration warns that using more than one dose in 24 hours or using higher than recommended doses of over-the-counter sodium phosphate preparations (solution or enema) to treat constipation may cause rare but serious harm to the kidneys and heart, and even death as a consequence of severe dehydration and changes in serum electrolyte levels. Young children, adults over 55 years of age, patients who are dehydrated or who have renal disease, bowel obstruction, or inflammation of the bowel, and patients who are using medications that affect renal function may be at higher risk. Use caution in children ages 5 years and younger. The rectal form should not be given to children younger than 2 years of age. Avoid exceeding the recommended dose and concomitant use with laxatives containing sodium phosphate.

5. Fecal Softener

In addition to maintaining dietary improvements, behavioral modification (unhurried time on the toilet after meals, a reward system linked with successful toilet usage, and a diary of stool frequency), and osmotic laxatives (e.g., lactulose, polyethylene glycol 3550 electrolyte solutions) following resolution of acute impaction, these children may require the addition of a fecal softener (e.g., docusate sodium or mineral oil [also known as liquid paraffin, and suitable for children =5 years old]) to establish normal bowel habits. Generally, it is necessary to maintain medication until the child has achieved regular bowel movements without difficulty.

ED precautions given.

Plan Corneal abrasion

Prophylactic topical antibiotic drops-Tobramycin. Wash hands before instilling eye drops. Do not touch applicator tip to eye.
Wear protective glasses when doing construction work.
RTC for eye drainage, vision disturbances or eye pain.
ER precautions advised for severe eye pain or sudden loss of vision.
Patient agrees with treatment plan.

PLAN Diarrhea

The patient presents with loose stools/diarrhea, without evidence for more malignant underlying process or invasive infection. There is no evidence clinically for significant dehydration.

***Labs collected: CBC, CMP, UA

The patient denies recent antibiotic use. No fever or reported blood in stool.

Based on the patient's current exam and history, including duration of symptoms, the patient appears to be a good candidate for outpatient symptomatic therapy and prompt follow up if symptoms continue or worsen.

There is no evidence for more malignant etiologies for the patient's symptoms at this time. I discussed the possibility of more malignant covert etiologies with patient. The patient understands this possibility and will follow up or call immediately with worsening symptoms.

Plan Dyspepsia

Dyspepsia is a symptom or a combination of symptoms that indicates an upper GI (UGI) problem. Typical symptoms include epigastric pain or burning, early satiety and postprandial fullness, belching, bloating, nausea, or discomfort in the upper abdomen. Symptoms alone are suggestive and not diagnostic. This was discussed with the patient.

The patient was informed that the assessment of UGI symptoms has a degree of diagnostic uncertainty inherent in this approach. These assessments can provide functional working diagnoses, but there is always a danger of misclassification. An important consequence of the inability to make a definitive diagnosis based on symptoms alone is an over-diagnosis of gastroesophageal reflux disease (GERD) and the under-recognition of H pylori-related disease.

Conservative treatment is a first-line approach but has the need for follow up to assess effectiveness and complete resolution of symptoms.

Pharmacotherapy must be couple with lifestyle management changes to achieve both effective and lasting results.

Patient is advised to decrease fatty foods, spicy foods and very acidic foods in diet. PPIs are an effective first-line treatment but further testing may be necessary if symptoms either fail to resolve or persist with only temporal improvement from medical management of symptoms. Specifically, H. pylori testing will be necessary if there is no quick resolution to symptoms. Furthermore, consideration of GI bleed must be considered and appropriate serological and clinical testing (such as hemoccult) will be necessary for prolonged symptoms.

Patient expresses understanding and agreement with treatment plan.

Plan Fracture possible -mc

Rest your ankle, do not put weight on it.
You can apply ice to the injured area for the first 1-2 days. Don't leave it on longer than 30 minutes as ice can burn you.
Keep the splint dry. If you need to shower you can either remove the splint or better yet, place a plastic bag around it.
Take children's motrin 400-600 mg (with food) three times a day for the next three days for pain management as needed.
Return if any numbness, weakness, color change, increasing pain or other concerns.
Pt (and mother) understands and agrees with treatment plan.

Plan Gastroenteritis - MC

OTC Geri-lanta for gastric discomfort
BRAT diet advised
PO re-hydration advised
ED precautions given
RTC 3-5 days, sooner if worse
The patient appears stable for outpatient therapy and expresses the desire to go home.

Plan GERD

#GERD
-prilosec daily
-consider refer to GI
-Lose weight. Extra stomach fat places pressure on your abdomen, pushing gastric juices up into your esophagus.
Avoid foods known to cause reflux such, Fatty foods,Spicy foods
Acidic foods, like tomatoes and citrus,Mint,Chocolate,Onions,Coffee or any caffeinated beverage,Carbonated beverages
Eat smaller meals. Large meals fill the stomach and put pressure on the LES, making reflux and GERD more likely.
Don't lie down after eating. Wait at least three hours before you lie down after a meal. Gravity normally helps keep acid reflux from developing. When you eat a meal and then stretch out for a nap, you're taking gravity out of the equation. As a result, acid more easily presses against the LES and flows into the esophagus.
Elevate your bed. Raising the head of your bed six to eight inches can help gravity keep gastric acid down in your stomach. You could also use a wedge-shaped support. Don't use extra pillows, as they only raise your head and will not help with GERD. You need your entire upper body elevated to get relief.
Review your medications. There are a number of medications that can increase your risk of GERD, either by relaxing the LES, interfering with the digestive process, or further irritating an already inflamed esophagus. These medications include:
Non-steroidal anti-inflammatory drugs, or NSAIDs
Calcium channel blockers (often used to treat high blood pressure)
Certain asthma medications, including beta-agonists like albuterol
Anticholinergics, medications used to treat conditions such as seasonal allergies and glaucoma
Bisphosphonates, used to boost bone density
Sedatives and painkillers
Some antibiotics
Potassium
Iron tablet
Quit smoking. Some studies have found that nicotine can relax the muscles of the LES and can also interfere with your saliva's ability to clear acid out of the esophagus.
Cut back on alcohol. As with smoking, alcohol can cause the LES to relax. Alcohol can also cause the esophageal muscles to spasm.
Wear loose-fitting clothes. Do not wear tight clothing or belts that can constrict your stomach.
Try a gluten-free diet. At least one study has found that gluten, a protein found in grains like barley, rye, and wheat, may cause or exacerbate GERD symptoms. Try eliminating gluten from your diet and see if it makes a difference.

PLAN Gout

Acute management with Colchicine and Indomethacin with warnings about possible adverse effects associated with NSAIDs use. The gastrointestinal, renal and cardiovascular adverse effects associated with NSAIDs have been discussed with the patient. The patient has been instructed to take the medication with food, and antacids if necessary, and drinks plenty of fluid. NSAID should be stopped and the patient should inform the provider if any of the above adverse events occurs. The patient understands and agrees. Patient has no history of renal failure.



Corticosteroids are a possible alternative but the choice was made to use anti-inflammatory medications.  Oral prednisone could be considered as a first-line treatment for acute gout, as it is effective and associated with few adverse events, especially when used for a short period of time.

Long-term management
- The long-term management for gout includes dietary modifications and weight loss (if indicated).
- Prophylactic drug therapy is indicated by presence of the following factors:
- Recurrent attacks (>2-3 per year)
- Tophaceous gout
- Radiographic changes and chronic destructive joint disease
- Urate nephrolithiasis
- Patient preference because of severe and debilitating polyarticular attacks.

Allopurinol reduces the production of uric acid. It should be started 2 weeks after the last exacerbation at a low dose of 100 mg/day. The dose should be increased over several weeks to months until the uric acid level is <6 mg/dL with a maximum dose of 800mg/day. ***Labs were collected today to rule out gout vs infectious process. These included Uric acid, CBC, ESR, CRP.

Febuxostat is a nonpurine selective xanthine oxidase inhibitor that reduces the production of uric acid, and was considered but is the last choice for recalcitrant gout.

***Remove if not applicable or modify as appropriate
Lesinurad, a uricosuric agent that inhibits uric acid transporters (URAT1 and OAT4) in the proximal tubule of the kidney, was considered as an adjunctive therapy to allopurinol or febuxostat in patients who have not achieved target serum uric acid levels with Allopurinol alone. It is approved by the Food and Drug Administration (FDA) for use in combination with allopurinol or febuxostat only.

***Remove if not applicable or modify as appropriate
Urate-lowering agents should not be started until at least 2 weeks after the resolution of acute gout, as such agents may increase the risk of recurrence or prolongation of the attacks by rapidly decreasing the serum urate level. NSAIDs or low-dose colchicine should be considered as prophylaxis during the initiation and titration of a urate-lowering agent. They should be continued for 3 to 12 months after reaching the target level of uric acid. Once patients with gout start on urate-lowering agents, they need to take them permanently unless there is a serious adverse reaction; provided that the diagnosis of gout is accurate.

PLAN Headache NO CT

After extensive review of the patient's history and thorough examination of the patient's head and neurological status, we opted to defer CT scan at this time. The patient had no loss of consciousness, notes no concerning signs or symptoms at time of evaluation, no neurological deficits and it is the opinion of writer that the risk of a CT scan of the patient's head outweighs the benefits. This was discussed extensively with the patient, who is in agreement with this plan. Given the patient's reassuring neurological exam throughout the course, the patient is appropriate for outpatient symptomatic treatment. I have discussed proper use of Imitrex the patient. Patient understands this medication may only be taken PRN and not on a regular basis.

Strong ED precautions given for worsening or intractable headache or development of neurological symptoms.

Plan Hemorrhoids

1) Proper bowel & eating habits best preventative measures
2) Cold packs 1st few hours, hot sitz bath BID for 20-30 minutes
3) Use of bulk laxatives or a high fiber diet, stool softeners & lubricants
4) Medications - anusol suppository and cream ordered, ibuprofen ordered for pain
5) Encourage the patient to take colace, senakot, miralax.
6) Gastroenterologist referral given appt made ***.

PLAN HIV PreP- PEP

Pre-exposure prophylaxis (or PrEP) is medicine taken to prevent getting HIV. PrEP is highly effective for preventing HIV when taken as prescribed.
PrEP reduces the risk of getting HIV from sex by about 99%.
PrEP reduces the risk of getting HIV from injection drug use by at least 74%.
PrEP is less effective when not taken as prescribed. Since PrEP only protects against HIV, condom use is still important for the protection against other STDs. Condom use is also important to help prevent HIV if PrEP is not taken as prescribed.
How long do I have to take PrEP before it is highly effective?

PrEP pill reaches maximum protection from HIV for receptive anal sex (bottoming) at about 7 days of daily use.
For receptive vaginal sex and injection drug use, PrEP reaches maximum protection at about 21 days of daily use.
No data are available for insertive anal sex (topping) or insertive vaginal sex.
For more information please visit:
https://www.cdc.gov/hiv/basics/prep.html.

Plan: hordeolum Yesim

Eyelids: + red swollen eye lid with small bean size nodule in left upper eye lid. no d/c FB/lesion on lid eversion. CN 3 and 7 intact

Patient has chalazion or hordeolum but most likely hordeolum since it is tender and has erythema around the nodule. Exam revealed no foreign body, corneal abrasion or other concerning findings.
No clinical evidence of any malignant process

advised to apply warm compress every 2 hours for 20 minutes
advised to wash hands frequently, and each time you touch eye to prevent secondary infection.
Patient instructed not to wear contact lenses until treatment is completed and symptoms have completely resolved.
apply the antibiotic eye ointment/drop as directed
Med side effects are explained to the patient.

We will fu in 2-3 days or earlier. The patient understands that follow up as instructed with ophthalmology is very important if symptoms persist and that they should return or call immediately with any changes or worsening symptoms. They understand that sometimes very serious eye issues can appear relatively benign initially.

Return to this clinic or go to the emergency room if have any vision change, trouble seeing or develop pain, visual changes, pain or restriction with eye movement, headache, numbness, tingling, fever, chills, nausea, vomiting, CP, SOB, or dizziness or for other concern.

Patient voiced understanding and agreed with the plan.

PLAN ADD-Insomnia Yesim

Patient has been using the medication more than 4 years. No side effects.
Denies any other subs controlled medication or drugs.
Denies extra med use.
Takes the medication early morning so it does not affect the sleep.
No appetite change or weight loss.
No CP or palpitations.
Reports once a week break to prevent tolerance or addiction.

Ambien has been controlling his insomnia which has been chronic since his teens.
CURES report was run today and we will f/u in 3 months but pt can get monthly refill until next visit.

Emergency precautions discussed.
Patient voiced understanding and agreed with the plan.

Plan I&D Template CB

PRE-OP DIAGNOSIS: subcutaneous abscess and cellulitis
POST-OP DIAGNOSIS: Same
PROCEDURE: incision and drainage of abscess
Performing Provider: Clark Bishop PA-C
Supervising Physician (if applicable): _

PROCEDURE:
A timeout protocol was performed prior to initiating the procedure. The area was prepared and draped in the usual, sterile manner. The site was anesthetized with _% lidocaine with epinephrine. A linear incision along the local skin lines was made and the purulent material expressed. The abcess was explored thoroughly and sequestered pockets were opened. Bleeding was minimal.
Packing: _

Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

See also Abscess

See also Cellulitis

Plan Influenza -MC

Tamiflu sent to pharmacy. Pt instructed how to use.
Encouraged supportive care including increased fluid intake and rest.
The patient is a good candidate for outpatient symptomatic therapy based on general clinical appearance,
which is good/non-toxic.

Plan Influenza Treatment

Medication management: Tamiflu 75 mg one capsule BID times five days

Return to action urgent care or go to the emergency room if…

You are dizzy, or you are urinating less or not at all.
You have a headache with a stiff neck, and you feel tired or confused.
You have new pain or pressure in your chest.
Your symptoms, such as shortness of breath, vomiting, or diarrhea, get worse.
Your symptoms, such as fever and coughing, seem to get better, but then get worse.

Use Ibuprofen/Acetaminophen for fever and body aches
Increase fluid intake to maintain hydration

Follow-up in three days or sooner if worsening symptoms.

Plan Insect bites

Rx: Topical Triamcinolone cream
Rx: Cetirizine (10 mg once a day)
- Patient Education: Reduction of local edema may be induced with cooling (ice or cold pack). Topical creams, gels and lotions, such as those containing calamine or pramoxine, decrease pruritus.
- Eradication of fleas in homes without an obvious animal vector involves insecticidal dusts or sprays, vacuuming, and cleaning
- Referral to an allergy specialist should be facilitated whenever possible. Allergy specialists are able to assess the patient's clinical history to assure that the correct trigger for the allergic reaction has been identified and in some cases, perform confirmatory testing. For patients who have suffered anaphylaxis, allergists are able to provide effective training in the self-injection of epinephrine.

- Close follow up and monitoring as required.

Plan Laceration No Repair

The patient presents with superficial laceration(s) as described above. Due to the superficial nature of the injuries, repair was not performed at this time. On exam there was no definitive evidence for associated complications such as tendon, nerve or arterial compromise.

I discussed the possibility of residual foreign body with patient and that no matter how thorough the search it is still a possibility. I explained to return with any thought of retained FB.

I also explained what to look for with regard to infection. The patient agreed to call/return with any increasing discharge, extending erythema, fever, nausea/vomiting or any other changes.

I also discussed the inevitability of scarring with the patient. They understand that all lacerations will leave a varying degree of scarring and optimal outcome/cosmetic appearance can never be guaranteed. They also understand the possibility of revision by plastic surgery in the future if deemed necessary.

The patient was also instructed to return/call with any perceived weakness or numbness/tingling that persists more than 1-2 days. The patient was instructed to return or call with any questions concerning new or worsening symptoms. More in depth discharge instructions regarding follow up were given also in the patient's discharge paperwork. The patient/family expressed understanding of the plan, agreed to the above.

PLAN License Reissue post DUI

Patient has been cleared for reissue of license with adamant warnings not use cannabis or alcohol while driving and that doing so is an illegal act for which he will be prosecuted if discovered. He is counseled it is a life-threatening act both to himself and those around him while operating a vehicle or machinery. His clearance to have a license reissued is contingent upon his compliance with these instructions and patient agrees to this and states he will comply. Patient has completed counseling in regards to this matter and there is no medically apparent reason why license should not be reissued at this time.

Plan: Lifestyle Modifications

Lifestyle – Recommendations
• At least 30 minutes of moderate-intensity physical activity on most, if not all, days of the week (daily total can be accumulated e.g. three 10-minute sessions).
• Smoking cessation. Refer patients to Quitline. Consider recommending nicotine replacement therapy and/or prescribing oral therapy (bupropion or varenicline) in patients who smoke more than 10 cigarettes per day and have no contraindications.
• Waist measurement < 94 cm for men and < 80 cm for women, body mass index (BMI) < 25.
When recommending weight loss, advise patients on reducing caloric intake as well as increasing physical activity.
• Dietary salt restriction: ≤ 4 g/day (65 mmol/day sodium). Recommend low-salt and reduced-salt foods as part of a healthy eating pattern.
• Limited alcohol intake: maximum of two standard drinks per day for men or one standard drink per day for women.

Plan Motor Vehicle Collision

The patient presents following a motor vehicle collision. There was no loss of consciousness***. The patient was restrained***. Airbags did not deploy***.

Imaging was performed and revealed no acute abnormality***.

Cervical spine was clinically cleared without difficulty***.

The patient felt better after symptomatic medications given here today***.

The patient will be discharged home with symptomatic medications and instructions for prompt return if symptoms worsen or new symptoms arise.

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 they understand that worsening, changing or persistent symptoms should prompt an immediate call or follow up with this office or the Emergency Room for reevaluation. The importance of appropriate follow up was also discussed with the patient.

Patient stable at time of discharge with normal vital signs and no neurological deficits.

PLAN precautions NSAIDs

The gastrointestinal, renal and cardiovascular adverse effects associated with NSAIDs have been discussed with the patient. The patient has been instructed to take the medication with food, and antacids if necessary, and drinks plenty of fluid. NSAID should be stopped and the patient should inform the provider if any of the above adverse events occurs. The patient understands and agrees.

PLAN precautions Narcotics

PRECAUTIONS WITH MEDICATIONS: I have advised the patient not to drive, operate any machinery or engage in any activities that require concentration or quick reflexes. The patient understands and agrees.

Plan Otitis externa

Assessment: There is no clinical evidence of FB, cerumen impaction
Tx:
Intact TM, Mild: Acetic acid/hydrocortisone drops for 7 days or up to 14 days if needed. However, the combo has significantly increased in price so that the cipro combo is less expensive now (I have heard - please check!)
Intact TM, Moderate:
ciprofloxacin-hydrocortisone drops
Drip 3 drops into affected ear twice daily for 7 days; may extend an additional 7 days if symptoms are improving but not yet resolved.
7 days or up to 14 days if needed.

ED: advised pt to clean only outer ear as needed. Do not use q-tips or any other device to clean deep in canal as it usually just pushes wax deeper in ear and the canal can be damaged. Consider using blow dryer to dry ears as needed. Use drying drops after swimming. Educated pt on how to instill drops by placing them down canal and then using earlobes back and forth. Avoid swimming until symptoms have completely resolved.
RTC 3 days
Pt understands and agrees with plan of care.

Plan Otitis media - Adult

- Amoxicillin
- Tylenol or Motrin for fever/pain
- To help prevent further infection, do not put anything in the ears, including cotton tipped applicators. They can push wax back into the ear canal, causing wax buildup. The wax blocks the ear canal, making it hard to see the ear drum, leading to decreased hearing and infections

RTC 48 hours

Pt understands and agrees with plan of care

Plan Otitis media -Pediatric

# otitis media
-Amoxicillin
-Tylenol or Motrin for fever/pain
-wash your child's hands often, always wash hands before eating and after playing, especially with other children
-do not smoke. Children exposed to secondhand smoke increases the risk of ear infections
-consider use a heating pad on a low setting
-Never give aspirin to a child under 18 years of age. It could possibly lead to Reyes Syndrome, which can be fatal.
-To help prevent further infection, do not put anything in the ears, including cotton tipped applicators. They can push wax back into the ear canal, causing wax buildup. The wax blocks the ear canal, making it hard to see the ear drum, leading to decreased hearing and infections
-childhood immunizations encouraged to be given at recommended ages

RTC 48 hours

Pts parent understands and agrees with plan of care.

Plan Pain/Injury Female

Ms. _______ is a ___ year-old female who presents to clinic to explore different treatment options for her illness/injury. In my opinion, Ms. _____'s condition should be addressed in an interdisciplinary fashion including medication optimization and physical rehabilitation.

PHYSICAL REHABILITATION INSTRUCTIONS: I have encouraged the patient to stay active and engage in a regimental home exercise program.

MEDICATION COUNSELING: Patient was educated on various medications, dosing, their side effects and potential interactions. The patient continues on stable doses of medications in a responsible and compliant fashion. I have refilled the medication today.

PRECAUTIONS WITH MEDICATIONS: I have advised the patient not to drive, operate any machinery or engage in any activities that require concentration or quick reflexes. The patient understands and agrees.

Plan Pain/Injury Male

Mr. _______ is a ___ year-old male who presents to clinic to explore different treatment options for his injury/illness. In my opinion, Mr. _____'s pain should be addressed in an interdisciplinary fashion including medication optimization and physical rehabilitation.

PHYSICAL REHABILITATION INSTRUCTIONS: I have encouraged the patient to stay active and engage in a regimental home exercise program.

MEDICATION COUNSELING: Patient was educated on various medications, dosing, their side effects and potential interactions. The patient continues on stable doses of medications in a responsible and compliant fashion. I have refilled the medication today.

PRECAUTIONS WITH MEDICATIONS: I have advised the patient not to drive, operate any machinery or engage in any activities that require concentration or quick reflexes. The patient understands and agrees.

Plan Plantar Fasciitis

f/u foot xray - soft tissue swelling suggestive of plantar fasciitis

- Recommend rest and icing for severe pain
- NSAIDs for pain and inflammation
- Performing of stretching exercises for the plantar fascia and calf muscles, which the patient can do at home. Home exercises include plantar and calf-plantar fascia stretches, foot-ankle circles, toe curls, toe towel curls, and unilateral heel raises with toe dorsiflexion
- Avoiding the use of flat shoes and barefoot walking. Wear Athletic shoes, arch-supporting shoes
- Using prefabricated, over-the-counter, silicone heel shoe inserts (arch supports and/or heel cups)
- Decreasing physical activities that may be causative or aggravating (eg, excessive running, dancing, or jumping)
- Patient education and hand outs given.

PLAN: poison ivy/oak/sumac

Contact dermatitis 2/2 plant exposure
1. Skin care discussed, encouraged neosporin/bacitracin/vaseline application over open sores to prevent infx
2. PO and TOP steroids ordered 2/2 mod severity of dermatitis, SE's reviewed
3. Anti-hist, analgesia, and cool packs enc for sxs prn
4. Hydration, rest enc
5. Discussed prevention of dermatitis 2/2 plant exposure
6. Enc f/u in 1 week for eval and further mgmt.
7. ED precautions reviewed.

Plan Psych meds

Continue current meds

Increase

Start

Add

D/C

Consider therapy in addition to medication / Refer for therapy / Recommend therapy

Discussed risks, benefits and common and rare side effects associated with the medication

Patient consents to new medication

Increase fluid intake

Monitor BP / weight / for side effects / for sedation / for mood changes / for emergence of manic symptoms or SI


Call 911 in case of a psychiatric emergency

RTO in * weeks for follow-up, sooner if symptoms persist or worsen or side effects appear

Patient understands and is comfortable with the current treatment plan.

Plan RICE therapy

***Patient was placed in a (type of) splint. Neurovascular checks were completed after placement and found to be normal.

Diagnostic imaging ordered. Return in 48 hours for radiologist’s report.

REST- stop change or take a break from any activity that causes pain
ICE-ice bags reduce pain and swelling apply to the affected area 15-20 minutes. intervals liberally as needed . if possible every other hour first 2 days.
COMPRESSION-apply a scrap or compression splint to minimize movement and prevent further swelling
ELEVATION-elevate affected body part above the level of the heart when sitting or lying down

NSAIDs will help pain and/or swelling.The gastrointestinal, renal and cardiovascular adverse effects associated with NSAIDs have been discussed with the patient. The patient has been instructed to take the medication with food, and antacids if necessary, and drinks plenty of fluid. NSAID should be stopped and the patient should inform the provider if any of the above adverse events occurs. The patient understands and agrees.

If you have numbness tingling increased pain changing color coolness or swelling go to the emergency room or return to the clinic immediately.

Plan SCABIES

Permethrin prescription sent
OTC BENADRYL AND CALAMINE LOTION FOR ITCHING
Scabies education handouts given
1) To apply, through and gently massage your prescription cream into all skin surfaces from your neck to the soles
of your feet. Be sure that infants and elderly patients are also treated for scabies on the scalp, temple and
forehead. The cream should be left on overnight for 8 to 14 hours and removed the next morning by bathing and
shampooing. Repeat again seven days later.
2) It is extremely important to put the cream on every square inch of your body: not just where the rash is.
That includes applying it under your fingernails and toenails, around the nail beds between your fingers and toes,
and in the cleft of your buttocks and genital area. If you wash your hands or any other area during the treatment
period, new cream must be applies immediately.
3) Other family members may be infected and may well need treatment. Everyone affected should be treated at the
same time. Consult your dermatologist.
4) Itching, mild burning and/or stinging may occur after application of the cream.
5)In addition to the above you may be given a shot or other medication to relieve the itching.
6)Be sure to change your clothes and bed linens, and have all the affected articles washed at the same time on a hot
cycle or professionally dry cleaned. Alternatively, since mites die on clothing after 2-3 days, set the contaminated
clothing aside for a few days. It is not usually necessary to clean sweaters, jackets, furniture, drapes or rugs.
7) You will not usually be contagious after one treatment if these instructions and your physician’s directions have
been followed carefully. The scabies mites will be gone in a matter of days; however, the rash and itching may
persist up to four weeks after treatment. This is rarely a sign of treatment failure and is not necessarily an
indication for re-treatment. If itching is excessive or if irritation persists, consult your physician.
8) Avoid contact with your eyes. If the cream accidentally gets in your eyes, flush with water immediately.

F/U 10 days if symptoms still present or f/u with pcp.

Plan Shingles

The patient presents with likely herpes zoster reactivation. There is no evidence of ocular involvement and no concern for meningitis.

1***There is no evidence for systemic illness and based on timing of presentation, the patient appears to be a candidate for outpatient oral antiviral therapy.1***

2***There is no evidence for systemic illness and due to delayed nature of the patient's presentation, there will be no benefit in outpatient antiviral therapy at this time.2***

The patient will be treated as an outpatient with analgesics, immunosuppressive therapy and anti-viral therapy as listed.

Famcyclovir
Prednisone
Topical Lidocaine

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 such as zoster, 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 office for reevaluation. The importance of appropriate follow up was also discussed with the patient.

Plan sleep Hygiene

Sleep hygiene, good sleeping habits includes:
1) Sleep only as much as necessary to feel rested and then get out of bed.
2) Maintain a regular sleep schedule (the same bedtime and wake time every day).
3) Do not force sleep. (See 'Stimulus control' below.)
4) Avoid caffeinated beverages after lunch.
5) Avoid alcohol near bedtime.
6) Do not smoke (particularly during the evening).
7) Do not go to bed hungry.
8) Adjust the bedroom environment (light, noise, temperature) so that you are comfortable before you lie down.
9) Deal with concerns or worries before bedtime. Make a list of things to work on for the next day so anxiety is reduced at night.
10) Exercise regularly, preferably four or more hours before bedtime.
11) Avoid prolonged use of phones or reading devices ("e-books") that give off light before bed. This can make it harder to fall asleep.
12) You should spend no more than 20 minutes lying in bed trying to fall asleep.
13) If you cannot fall asleep within 20 minutes, get up, go to another room and read or find another relaxing activity until you feel sleepy again. Activities such as eating, balancing your checkbook, doing housework, watching TV, or studying for a test, which "reward" you for staying awake, should be avoided.
14) When you start to feel sleepy, you can return to bed. If you cannot fall asleep in another 20 minutes, repeat the process.
15) Set an alarm clock and get up at the same time every day, including weekends.
16) Do not take a nap during the day.
17) You may not sleep much on the first night. However, sleep is more likely on succeeding nights because sleepiness is increased and naps are not allowed.

More recommendations to integrate


LINK: Counseling: Sleep Hygiene


Plan smoke inhalation

smoke inhalation
spirometry ___
chest xray
albuterol HFA inhaler for sob
promethazine for cough

close follow up - RTC in 1 day for xray results.

Plan Sports physical 1

ROS

Healthy athlete with no complaints and negative in all systems.

** yo male/female with no past medical history presents for sports physical.
No abnormalities noted on PE
No Hx of childhood congenital illnesses, heart defects, seizures, or asthma

** Snellen performed
** UTD with vaccinations
***TDaP Given today

Health Education with respect to sports reviewed:
Use of protective gear, sunblock, hydration, teammate bullying, appropriate relationships with adults & coaches, avoidance of use of inappropriate supplements & performance enhancements, proper warm-up stretching, use of protective gear, understand signs and symptoms of dehydration, heat stroke, muscle strain, weakness, cramping, and will advocate for self if not feeling well.
Counseled pt on STD prevention, stress management, diet, sleep regimen and drugs.

Cleared for participation in sports without restrictions.
School form signed and scanned.

LINK: Sports Physical: Assessment


Plan STI

Today you were tested for sexually transmitted infections.your results will be available in 7 to 10 days. Throat infections from oral sex and rectal infections from receptive anal sex cannot be detected in the urine and you should tell your provider if you are having a sore throat or any rectal discharge.
Follow-up to review labs and develop treatment plan if necessary. At times we treat for STIs prior to review results being available based on clinical presentation. If you received treatment today you should still follow up with labs.

To lower your risk of STI and transmission of such you can:
1. Abstain from sexual acts
2. Use condoms
3. Practice monogamy or reduce the number of sexual encounters and partners.

PLAN Strep Pharyngitis

TX:
PCN 500mg PO TID x 10 days - give 1 hr before or 2 hr after meals
Ibuprofen as needed to help with pain, fever, and inflammation
Tylenol as needed for pain & fever
Chloraseptic spray for comfort
Herbal tea with honey for comfort
Salt water gargles
Return with worsening or changing symptoms or inability to drink or take medications by mouth.

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 such as strep, 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 office for reevaluation. The importance of appropriate follow up was also discussed with the patient.

Follow up in 3-5 days

Pt understands and agrees with plan of care.

PLAN Pharyngitis

Plan Stye

Tx: erythromycin ointment
warm compresses
consider refer to ophthalmologist if no response to antibiotic therapy
ED: Reinforce good hand hygiene, instructed on proper eyelid hygiene, discard all eye make up, observe for s/s of worsening infection
RTC 2 days
Pt understands and agrees with plan of care.

Plan Discharge for URI/ FLU - GB

Encouraged supportive care including increased fluid intake and rest.
The patient is a good candidate for outpatient symptomatic therapy based on general clinical appearance,
which is good/non-toxic.
The patient and parent(s) understand that at this time there is no evidence for a more malignant underlying
process, but the patient and parent(s) also understand that early in the process of an illness or infection, an
initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and parent(s)
and they understand that worsening, changing or persistent symptoms should prompt an immediate call or
follow up with their primary physician or return for reevaluation. The importance of appropriate follow up was
also discussed with the patient and parent(s). More extensive discharge instructions were given in the patient's
discharge paperwork.
RTC as needed with worsening or persistence of symptoms.
ED precautions discussed.
Patient agrees with plans of care.

Plan URI

We discussed non-pharmacalogic interventions to improve their congestion and cough. I recommended hydration, good quality sleep, a humidifier next to the bed, salt-water gargles, hot tea with honey, cough drops, hot showers, etc. Warm fluids, like soups and teas can increase the rate of mucous flow and provide symptom relief.

Options for OTC pharmacalogic treatment include:
Nasal sprays, such as Afrin or Flonase, to reduce nasal congestion and runny nose. There are different categories:

Cough suppressants tend to only reduce cough mildly. Dextromethorphan is the only OTC cough medication and is the original Robitussin and found in many other medications that have DM after the name.

Oral decongestants, such as pseudoephedrine (Sudafed) are usually associated with sinus pain and pressure. You must ask the pharmacist for these, but they are not prescription.

Sudafed that is on the shelf without pharmacist assistance (phenylephrine) is not effective.

Use acetaminophen (Tylenol) or NSAIDs (ibuprofen/naproxen) for headache and/or fevers. These two categories may safely be combined or alternated. Do not mix NSAIDs with other NSAIDs in the same day, as they are dosed differently. Ibuprofen is available as Advil and Motrin. Naproxen is available as Aleve.

Educated pt that illness is self limited d/t virus. No antibiotics therapy is necessary. Encouraged increase fluid intake and nutritious diet. Practice good hand hygiene techniques with soap and water or hand sanitizer. Do not share food and drinks. Cover your mouth and nose when you cough or sneeze.

Recommended flu vaccination yearly.

RTC 3-5 days

Pt understands and agrees with plan of care.

PLAN Urticaria

There is no evidence for frank anaphylaxis at this time and the patient had a widely patent airway throughout course.

Extensive historical effort was undertaken to elucidate the cause of the patient's symptoms without success.

The patient is a good candidate for outpatient therapy given the stability/improvement of the patient's symptoms during their course here today.

Patient was instructed to follow up with this office in the near future for a recheck and to continue outpatient medications as prescribed in this visit. They understand a referral to an allergist may be necessary if symptoms persist or recur.

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 office for reevaluation or Emergency room if any concern for severe reaction or airway compromise.

Patient is stable at time of discharge.

Plan UTI

Macrobid prescription sent to pharmacy. Instructed on how to use.
Culture and Sensitivity submitted
Education given re how to prevent UTIs.
ER precautions given.
RTC in 5 days for f/u, sooner if not better.

Plan Worker's Comp

Female/Male who presents to explore different treatment options
for her/his industrial injury. In my opinion, {{patient}} condition should be addressed in an interdisciplinary
fashion including medication optimization and physical rehabilitation. There is no evidence of acute injury.

The patient is improved since her initial injury. She/He is not 100%. She/He has ___ continuing pain in the *** with ***

PHYSICAL REHABILITATION INSTRUCTIONS: I have encouraged the patient to stay active and engage in a regimental home exercise program. She/He appears to be functioning near full capacity at this point.

WORK STATUS: patient is to return to work as of today with/ without restrictions.

FOLLOW UP: follow-up in ___ weeks for an/final assessment. If she/he is not completely improved physical therapy will be a consideration.

Patient understands and agrees with plan.

Please provide authorization for continued medically necessary treatment to cure or relieve the effect of the industrial injury per CCR 9792.6. I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code 139.3.

Plan Wound Care CL'H

Pt Education:
Wound Care Instructions
- Wash laceration with H2O2 QD & apply prescribed antibiotic ointment BID. TID
- Use non-adherent gauze covering to maintain moisture from ointment ATC to promote skin proliferation & healing.
- Finish antibiotics, take with food if stomach becomes upset.
- Take probiotics, when taking antibiotics.
- Rx: Bacitracin Mupirocin

RTC in 3 day or sooner for fever, swelling, intense pain, distal discoloration, foul smell, discharge loss of sensation or numbness

Prophylactic antibiotics were not prescribed due to superficial nature of injury and immediate attention after the time of injury. Watchful for s/sx of infections will determine if antibiotics are necessary.

Plan: Injury care

Diagnosis
1. Supportive measures enc, including: rest, icing, elevation of limb, compression, and PO Motrin with food PRN pain/inflammation
2. Pt enc to avoid extended use of affected site until full resolution of symptoms
3. Imaging ordered to r/o internal injury, will f/u when results available
4. Ortho/PT/MRI referral will be made pending xray findings
5. Continue to monitor affected site for worsening or persisting sxs, f/u prn
6. RTC in 2 weeks for reassessment and care
7. ED prec reviewed.

PLAN Vaginitis

Start [insert medication here]
Wear loose fitting clothing.
Use condoms during sexual intercourse.
Limit number of sexual partners.
After using the bathroom, wipe from front to back.
Wear cotton underwear, and avoid tight fitting clothes.
Do not use soap inside your vagina. You can wash the external genitals lightly with a mild product such as Cetaphil.
Consider taking probiotics to promote healthy flora.