RESIDENT PHYSICIAN MEDICAL DECISION MAKING – Eye Pain:

            A SLIT-LAMP EXAMINATION WAS PERFORMED ON HIM.    AFTER MY INDEPENDENT EVALUATION, SOME OF THE CLINICAL ENTITIES THAT I CONSIDERED INCLUDED: CORNEAL ABRASION, CORNEAL ULCER, SCLERAL ABRASION, CONJUNCTIVITIS, GLAUCOMA, IRITIS, EPISCLERITIS, HERPES KERATITIS, UV KERATITIS, GLOBE PENETRATION, AND HYPHEMA.

           IN MY MEDICAL OPINION, I CONSIDER HIM TO BE LOW RISK FOR ANY SERIOUS CAUSE OF VISION LOSS, & DEEM HIM STABLE FOR DISCHARGE.    I RECOMMEND THAT PT FOLLOW UP IN 1-2 DAYS EITHER WITH AN OPHTHALMOLOGIST OR HIS PCP.  IF PT IS UNABLE TO GET ARRANGE THIS FOLLOW UP, HE WAS INFORMED TO RETURN TO OUR ER FOR RE-EVALUATION (ESPECIALLY IF HIS CONDITION WORSENS, I.E.   INCREASED PAIN,  DECREASED VISION,  INCREASED HEADACHE,  FEVER,  ETC.). CASE DISCUSSED W/ MY ATTENDING PHYSICIAN, WHO HAS SEEN AND INDEPENDENTLY EVALUATED PATIENT.

RESIDENT PHYSICIAN MEDICAL DECISION MAKING- Headache:

     AFTER  EVALUATION, MY CLINICAL OPINION AT THIS TIME IS THAT PT IS STABLE FOR DISCHARGE.     SOME OF THE CLINICAL ENTITIES AND THAT I CONSIDERED FOR HIM INCLUDED TENSION HEADACHE,  MIGRAINE HEADACHE,  CVA [ISCHEMIC & HEMORRHAGE (SUCH AS SAH)],  MENINGITIS,  ENCEPHALITIS, IDIOPATHIC INTRACRANIAL HYPERTENSION,  TEMPORAL ARTERITIS,  VENOUS SINUS THROMBOSIS,  &  SEIZURES.

       WE WILL TREAT HIM SYMPTOMATICALLY, AND RECOMMEND OUTPATIENT MANAGEMENT WITH A PCP.    AT THIS TIME, I CONSIDER HIM LOW RISK FOR ANY SERIOUS OR LIFE-THREATENING ENTITY, AND DEEM HIM STABLE FOR DISCHARGE.    AS WE DISCUSSED,  PT IS TO RETURN TO OUR ER IF THERE IS ANY WORSENING OF HIS CONDITION.  CASE DISCUSSED W/ MY ATTENDING PHYSICIAN, WHO HAS SEEN AND INDEPENDENTLY EVALUATED PATIENT.

RESIDENT PHYSICIAN MEDICAL DECISION MAKING – Headache, LP DECLINED:

            AFTER EVALUATION, SOME OF THE CLINICAL ENTITIES THAT I CONSIDERED INCLUDED TENSION HEADACHE,  MIGRAINE HEADACHE,  CVA [ISCHEMIC AND HEMORRHAGE (SUCH AS SAH)],  MENINGITIS,  ENCEPHALITIS,  IHSS,  TEMPORAL ARTERITIS,  VENOUS SINUS THROMBOSIS,  & SEIZURES.

         BECAUSE OF MY CONCERN FOR SAH & MENINGITIS , WE RECOMMENDED THAT PT ALLOW US TO PERFORM A LUMBAR PUNCTURE (LP).    WE DISCUSSED THE PROCEDURE ITSELF, IN ADDITION TO THE RISKS & BENEFITS OF NOT PERFORMING AN LP.    ANY QUESTIONS WERE ANSWERED.    PT UNDERSTANDS THAT I CANNOT EXCLUDE THESE ENTITIES WITHOUT ANALYSIS OF PT CSF.     PT ALSO UNDERSTANDS THAT DELAY/FAILURE TO DIAGNOSE IN THESE ENTITIES COULD RESULT IN SERIOUS HARM & POSSIBLY EVEN DEATH.   PT APPEARS TO BE CLINICALLY COMPETENT TO MAKE THIS DECISION.   AT THIS TIME PT IS DECLINING TO HAVE THE LP PERFORMED.    PT WAS TOLD TO RETURN IMMEDIATELY, IF PT CHANGES PT MIND, OR IF PT CONDITION WORSENS IN ANY WAY WHATSOEVER (AS WE DISCUSSED).CASE DISCUSSED W/ MY ATTENDING PHYSICIAN, WHO HAS SEEN AND INDEPENDENTLY EVALUATED PATIENT.

RESIDENT PHYSICIAN MEDICAL DECISION MAKING – URI:

                  AFTER  EVALUATION, PT APPEARS TO HAVE A SELF-LIMITING ILLNESS LIKELY DUE TO A VIRAL URI.     AT THIS TIME THERE IS NO EVIDENCE OF PNEUMONIA,  HYPOXIA,  OM,  BACTERIAL SINUS  INFECTION,  BACTERIAL BRONCHITIS,  MYOCARDITIS,  BACTEREMIA,  OR  SEPSIS.

                  IN MY MEDICAL OPINION, I CONSIDER HIM LOW RISK FOR ANY SERIOUS/LIFE-THREATENING ENTITY, & DEEM HIM STABLE FOR DISCHARGE.      THIS IS BASED ON THE INFORMATION THAT WAS AVAILABLE TO ME AT TIME OF THIS ED VISIT.    AS WAS DISCUSSED, PT IS TO RETURN TO OUR ER IMMEDIATELY, IF THERE IS ANY WORSENING OF HIS CONDITION, SUCH AS INCREASED COUGH,   SHORTNESS OF BREATH,   PERSISTENT FEVERS,   REPEATED VOMITING,   DEHYDRATION,  OR  IF HIS CONDITION WORSENS.

RESIDENT PHYSICIAN MEDICAL DECISION MAKING – URI, child:

                  AFTER  EVALUATION, PT APPEARS TO HAVE A SELF-LIMITING ILLNESS LIKELY DUE TO A VIRAL URI.     AT THIS TIME THERE IS NO EVIDENCE OF PNEUMONIA,  HYPOXIA,  OM,  BACTERIAL SINUS  INFECTION,  BACTERIAL BRONCHITIS,  MYOCARDITIS,  BACTEREMIA,  OR  SEPSIS.

                  IN MY MEDICAL OPINION, I CONSIDER HIM LOW RISK FOR ANY SERIOUS/LIFE-THREATENING ENTITY, & DEEM HIM STABLE FOR DISCHARGE.    THIS IS BASED ON THE INFORMATION THAT WAS AVAILABLE TO ME AT TIME OF THIS ED VISIT.    I RECOMMENDED FOLLOW UP IN A COUPLE DAYS WITH HIS PEDIATRICIAN, OR PCP.     AS WAS DISCUSSED,  THE PARENT/GUARDIAN IS  TO BRING HIM BACK TO OUR ER IMMEDIATELY, IF THERE IS ANY WORSENING OF HIS CONDITION, SUCH AS INCREASED COUGH,   SHORTNESS OF BREATH,   PERSISTENT FEVERS,   REPEATED VOMITING,   DEHYDRATION,  OR  IF THE CHILD'S CONDITION WORSENS IN ANY OTHER WAY.CASE DISCUSSED W/ MY ATTENDING PHYSICIAN, WHO HAS SEEN AND INDEPENDENTLY EVALUATED PATIENT.