Resident Physician Medical Decision Making - Allergic Rxn:
PATIENT WAS TREATED FOR AN ACUTE ALLERGIC DURING HIS ED COURSE. IN MY MEDICAL OPINION, I CONSIDER PT TO BE AT LOW RISK FOR ANY AIRWAY COMPROMISE, ANAPHYLAXIS, ANGIONEUROTIC EDEMA, EPIGLOTTITIS OR OTHER SERIOUS/LIFE-THREATENING ENTITY. BASED ON THE INFORMATION AVAILABLE TO ME AT THIS TIME, PT APPEARS TO BE STABLE FOR DISCHARGE. WE RECOMMENDED THAT PT FOLLOW UP WITH A PCP FOR ANY ONGOING ISSUES.
AS WAS DISCUSSED, PT IS TO RETURN TO OUR ER IMMEDIATELY, IF THERE IS ANY WORSENING OF HIS CONDITION (ESPECIALLY IF INCREASING SHORTNESS OF BREATH, DIFFICULTY SWALLOWING, WORSENING PAIN, SWELLING, ETC.).CASE DISCUSSED W/ MY ATTENDING PHYSICIAN, WHO HAS SEEN AND INDEPENDENTLY EVALUATED PATIENT.
Resident Physician Medical Decision Making - Low back pain:
PATIENT DENIES ANY SADDLE ANESTHESIA, DISTAL RADICULAR SYMPTOMS, OR BOWEL/BLADDER INCONTINENCE. PT DENIES ANY FEVER. PT DENIES ANY SIGNIFICANT TRAUMA THAT WOULD MAKE ME CONCERNED FOR FRACTURE. PT STATES THAT PT PAIN IS WORSE WITH MOVEMENT.
ON EXAMINATION PT HAS SOME GENERALIZED LOWER BACK TENDERNESS TO PALPATION. THE LOWER EXTREMITY STRENGTH, SENSATION, & DTRS ARE NORMAL B/L.
THERE IS NO SIGNIFICANT BONY TENDERNESS THAT WOULD MAKE ME BE CONCERNED FOR OSTEOMYELITIS, EPIDURAL ABSCESS, DISCITIS, OR VERTEBRAL FRACTURE. I ALSO HAVE LOW SUSPICION FOR ANY VASCULAR ETIOLOGIES SUCH AS AAA, OTHER ARTERY ANEURYSM, OR RENAL INFARCTION. NOR DO I SUSPECT THAT HIS PAIN IS FROM ANY UROLOGICAL (i.e. STONE) OR GI (i.e. DIVERTICULITIS) SOURCE.
I SUSPECT THE ETIOLOGY FOR HIS PAIN IS MOST LIKELY DUE TO SOFT-TISSUE DYSFUNCTION (MUSCULAR, LIGAMENTOUS, ETC.) I RECOMMENDED SOME REST FOR NOW, & STRESSED THE IMPORTANCE OF PCP FOLLOW UP FOR PERSISTENT SYMPTOMS. FINALLY, PT WAS TOLD TO RETURN IMMEDIATELY IF ANY WORSENING SYMPTOMS (AS WAS DISCUSSED). CASE DISCUSSED W/ MY ATTENDING PHYSICIAN, WHO HAS SEEN AND INDEPENDENTLY EVALUATED PATIENT.
Resident Physician Medical Decision Making – Chest pain, ADMIT:
AFTER EVALUATION, SOME OF THE CLINICAL ENTITIES THAT I CONSIDERED INCLUDED AMI, ACS, PE, THORACIC DISSECTION, PNEUMOTHORAX, HEMOTHORAX, PERICARDITIS, MYOCARDITIS, PNEUMONIA, PLEURAL EFFUSION, COSTOCHONDRITIS & SHINGLES.
BASED ON MY HISTORY AND PHYSICAL, APPROPRIATE TESTING WAS OBTAINED. IN MY JUDGMENT, AT THIS TIME, I SUSPECT THAT PT IS POTENTIALLY AT RISK FOR SERIOUS PATHOLOGY, AND I AM RECOMMENDING HOSPITALIZATION FOR FURTHER EVALUATION. CASE DISCUSSED W/ MY ATTENDING PHYSICIAN, WHO HAS SEEN AND INDEPENDENTLY EVALUATED PATIENT.
Resident Physician Medical Decision Making- Chest pain, DISCHARGE:
AFTER EVALUATION, SOME OF THE CLINICAL ENTITIES I CONSIDERED FOR HIM, INCLUDED AMI, ACS, PE, THORACIC DISSECTION, PNEUMOTHORAX, HEMOTHORAX, PERICARDITIS, MYOCARDITIS, PNEUMONIA, PLEURAL EFFUSION, COSTOCHONDRITIS, & SHINGLES
BASED ON MY HISTORY AND PHYSICAL, APPROPRIATE TESTING WAS OBTAINED. IN MY JUDGMENT, AT THIS TIME, I SUSPECT PT IS STABLE FOR OUTPATIENT MANAGEMENT. I EXPLAINED TO HIM THAT PT IS TO RETURN IMMEDIATELY IF HIS CONDITION, OR IF PT DEVELOPS NEW OR DIFFERENT SYMPTOMS. I ALSO RECOMMENDED THAT PT FOLLOW UP WITH A PCP IN THE NEXT 1-2 DAYS. CASE DISCUSSED W/ MY ATTENDING PHYSICIAN, WHO HAS SEEN AND INDEPENDENTLY EVALUATED PATIENT.