MDM - Cervical Muscle Strain (Whiplash Injury) - Motor Vehicle Collision

[##]-year-old [male/female] with neck pain following a motor vehicle collision (MVC) with history and exam consistent with likely cervical muscle strain (whiplash injury).

Initial consideration in this patient included cervical spine fracture or dislocation, soft tissue injury to the chest, neck or torso, and cervical muscle strain among others.

Patient arrived to the ED following a [low/moderate] risk MVC [in cervical spine immobilization/and was placed in a cervical collar in triage/without indication for cervical spine immobilization in the field].  Cervical spine [could not be] cleared by [NEXUS criteria/Canadian C-Spine Rule] upon arrival in the ED.  Patient was noted to have a normal neurologic exam in the ED.  [CT/Plain films were obtained in the ED with no evidence of significant injury as noted above.]  Patient noted to have [right-/left-sided/bilateral] paraspinal muscle tenderness [with/without] associated muscle spasm.  Patient noted to have [no] evidence of contusions to the chest consistent with seatbelt injury.  No other significant tenderness or injury noted on exam with no indications for further imaging at this time.

Patient reported significant improvement with [treatment] prior to discharge from the ED.  We discussed return precautions, treatment [with analgesics/NSAIDs], and follow up with primary care doctor within one week for further evaluation, and the patient demonstrated understanding and agreement with this plan.

https://www.mdcalc.com/canadian-c-spine-rule
https://www.mdcalc.com/nexus-criteria-c-spine-imaging

MDM - Nursemaid's Elbow

[##-month/year-old male/female] presents with [mother/father/parents] with history and exam consistent with radial head subluxation (nursemaid’s elbow).

Initial considerations in this patient included nursemaid’s elbow, supracondylar fracture, radial head fracture, and other fractures and dislocations of the upper extremity among others.

Patient presented with sudden onset of pain and unwillingness to move the [left/right] arm after longitudi0nal traction injury.  Patient noted to have a normal pulse and grossly intact sensation in the distal [left/right] extremity.  Plain films were [obtained and noted to have no evidence of fracture or other significant injury/not obtained in patient with classic story and findings on exam for radial head subluxation].  Successful reduction was achieved using [hyperpronation/supination] technique, and the patient was noted to be spontaneously moving the [left/right] arm within 30 minutes of procedure.

Prior to discharge, we discussed return precautions and counseled the patient’s [mother/father/parents] on avoiding traction on the affected arm as this injury is frequently recurrent, and they demonstrated understanding and agreement with this plan.

https://www.orthobullets.com/pediatrics/4012/nursemaids-elbow

MDM - Dysfunctional Uterine Bleeding (DUB)

[##]-year-old female with history and exam consistent with likely dysfunctional uterine bleeding.

Initial consideration in this patient included pregnancy, ectopic pregnancy, non-structural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic) and structural causes (polyp, adenomyosis, leiomyoma, malignancy or hyperplasia), urinary tract infection (UTI), vaginitis, [differentia diagnosis], and vaginal, perineal, and cervical trauma among others.

Patient presented with [menorrhagia (>7 days (prolonged) or >80 mL/day (excessive) uterine bleeding at regular intervals/metrorrhagia (irregular vaginal bleeding outside the normal cycle)/menometrorrhagia (excessive irregular vaginal bleeding)] suggestive of likely dysfunctional uterine bleeding.  Pelvic exam performed with [dark red blood in vaginal vault without evidence of brisk or active bleeding].  A pregnancy test was obtained and noted to be negative making pregnancy-related complications unlikely. 

Given evidence of [mild/moderate/severe] uterine bleeding on evaluation in the ED, we [discussed/initiated] treatment with [iron supplementation and Ibuprofen/initiation of oral contraceptive/Medroxyprogesterone intramuscular injection/tranexamic acid (TXA) and consulted Gynecology].

Patient noted to have no evidence of significant anemia on [exam/hemoglobin and hematocrit].  Patient noted to have no evidence of coagulopathy on [history/exam/labs].  Patient noted to have no evidence of endocrine disorder on history or exam.  No evidence of UTI on urinalysis in the ED.  Vaginitis considered unlikely based on history and exam.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening or persistent bleeding, treatment [with specify interventions], and follow up with [primary care doctor/Gynecology] within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

https://wikem.org/wiki/Vaginal_Bleeding_(Non-Pregnant)
http://www.emdocs.net/non-pregnant-vaginal-bleeding/

MDM - Allergic Reaction (Rash)

[##]-year-old [male/female] with [rash/throat swelling/etc.] with history and exam consistent with likely allergic reaction to [allergen/unknown precipitant].

Initial consideration in this patient included allergic reaction, anaphylaxis, angioedema, Stevens-Johnson, toxic epidermal necrolysis, and infectious etiologies among others.

Patient presented with [describe symptoms] concerning for allergic reaction.  Patient noted to have no evidence of anaphylaxis on presentation given absence of severe symptoms or involvement of 2 or more symptoms.  Patient noted to have rash consistent with urticaria [to the location/diffusely].  No evidence of mucosal involvement, desquamation, fever, or other findings suggestive of Stevens-Johnson, toxic epidermal necrolysis, or infectious rash.  Patient noted to have no swelling of the lips, tongue, or throat suggestive of angioedema at time of ED evaluation.  Patient noted to have no wheezing, cough, or other respiratory symptoms at time of ED evaluation.  Patient treated with Diphenhydramine (H1 antagonist), [Famotidine/Ranitidine] (H2 antagonist) [and corticosteroid] with noted improvement.

Patient [reported/denied] a history of similar episodes of allergic reaction in the past [to specify/an unknown allergen].  Patient was counseled on return precautions for evidence of more severe allergic reaction or evidence of anaphylaxis.

Prior to discharge, we discussed return precautions, specifically for evidence of recurrent allergic symptoms, treatment [with antihistamine/steroid], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement.

Patient was prescribed an intramuscular epinephrine auto-injector at time of discharge with instructions in the ED about appropriate use.  We specifically emphasized that this medication was for life-threatening emergencies, and any use required return to the ED, and the patient demonstrated understanding and agreement.

https://www.epipen.com/-/media/files/epipen/howtouseepipenautoinjector.pdf

MDM - Pneumonia (Admit)

[##]-year-old [male/female] with history and exam consistent with [viral/atypical/community-acquired] pneumonia.

Initial consideration in this patient included pneumonia, bronchitis, influenza, upper respiratory infections (URI), malignancy, atelectasis, tuberculosis, pulmonary embolism (PE), diffuse alveolar hemorrhage, and cardiac etiologies among others. 

Patient presented with [fever, productive cough, abnormal lung sounds] concerning for pneumonia.  A chest x-ray was obtained in the evaluation of this patient and was notable for [right/left/upper/middle/bilateral/multifocal consolidation(s) with/without associated effusion].  Labs were obtained and were notable for [leukocytosis with a leftward shift/etc.].  Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.] on presentation [with/without significant improvement] after treatment with [IV fluids/anti-pyretics/antibiotics].  Patient felt to [not] have evidence of [sepsis/septic shock] based on [relevant abnormalities].  Blood cultures were obtained due to planned admission for pneumonia. 

Patient felt to be low risk for PE based on history, exam, and absence of significant risk factors.  No significant risk factors to suggest cardiac etiology for symptoms.

Patient noted to have [no] recent antibiotic use.  Patient noted to have [no] recent admission to a hospital or residence in a nursing home.  Hospital-acquired pneumonia felt to be [likely/unlikely] in this patient.

Patient felt to not be appropriate for outpatient treatment of pneumonia based on [evidence of sepsis, absence of good social support and moderate/high risk CURB-65 score as noted above].  Antibiotics were selected based on [facility antibiogram/professional guidelines/to cover for community-acquired/healthcare-associated and atypical pathogens] and initiated in the ED.

We discussed planned admission with the patient who demonstrates understanding and agreement with this plan.  We discussed case with Dr. [NAME] who evaluated the patient and agrees with need for admission to [general floor/telemetry unit/step-down unit/ICU].

https://www.mdcalc.com/curb-65-score-pneumonia-severity
https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap

https://wikem.org/wiki/Pneumonia_(main)

MDM - Pneumonia (Discharge)

[##]-year-old [male/female] with history and exam consistent with [viral/atypical/community-acquired] pneumonia.

Initial consideration in this patient included pneumonia, bronchitis, influenza, upper respiratory infections (URI), malignancy, atelectasis, tuberculosis, pulmonary embolism (PE), diffuse alveolar hemorrhage, and cardiac etiologies among others. 

Patient presented with [fever, productive cough, abnormal lung sounds] concerning for pneumonia.  A chest x-ray was obtained in the evaluation of this patient and was notable for [right/left/upper/middle/bilateral/multifocal consolidation(s) with/without associated effusion].  Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.] on presentation with noted [improvement/resolution] after treatment with [IV fluids/anti-pyretics/antibiotics].  Doubt sepsis or significant systemic infection at this time.  Patient felt to be low risk for PE based on history, exam, and absence of significant risk factors.  No significant risk factors to suggest cardiac etiology for symptoms.

Patient noted to have [no] recent antibiotic use.  Patient noted to have [no] recent admission to a hospital or residence in a nursing home.  Hospital-acquired pneumonia felt to be [likely/unlikely] in this patient.  Patient reported good social support, and access to follow up medical care.  Patient felt to be appropriate for outpatient treatment based on [overall stable appearance, response to treatment, and low risk CURB-65 score as noted above].  Antibiotics were selected based on [facility antibiogram/professional guidelines/to cover for community-acquired/healthcare-associated and atypical pathogens].

Prior to discharge, we discussed return precautions, specifically for evidence of persistent or worsening infection, treatment with appropriate antibiotics [0bronchodilators/anti-pyretics], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

https://www.mdcalc.com/curb-65-score-pneumonia-severity
https://www.mdcalc.com/psi-port-score-pneumonia-severity-index-cap
https://wikem.org/wiki/Pneumonia_(main)

Decision Rule - CURB-65 Score

CURB-65 Score for Pneumonia:

-Confusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-BUN >19 mg/dL (>7 mmol/L) . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-Respiratory rate >30 bpm . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

-Systolic BP <90 mmHg or diastolic BP ≤60 mmHg  . .  [No (+0 points)/Yes (+1 point)]

-Age ≥65  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (+0 points)/Yes (+1 point)]

TOTAL = [## points]

Patient is determined to be low risk (0-1 points) with a 1.5% mortality, and recommendation for close outpatient care.

Patient is determined to be moderate risk (2 points) with a mortality of 9.2%, and recommendation for inpatient versus observation admission.

Patient is determined to be high risk (≥3 points) with a mortality of 22% and inpatient treatment and consideration of ICU admission is recommended for a score of 4-5.

https://www.mdcalc.com/curb-65-score-pneumonia-severity

MDM - COPD Exacerbation (Admit)

[##]-year-old [male/female] with history and exam consistent with acute exacerbation of COPD.

Initial consideration in this patient included exacerbation of COPD, acute decompensated heart failure, acute coronary syndrome (ACS), acute bronchitis, pneumonia, influenza, asthma exacerbation, allergic rhinitis, upper respiratory infections (URI), foreign body airway obstruction, pulmonary embolism (PE) among others. 

Patient presented for [cough/shortness of breath/wheezing] with a known history of COPD consistent with acute exacerbation.  Patient’s lung sounds were [notable for expiratory wheezing/noted to be normal].  Patient noted to [have/have no] evidence of fever [or other systemic infectious symptoms].  A chest x-ray was obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/specify findings].  An EKG was obtained and [noted to have no evidence of acute abnormalities/notable for atrial fibrillation without rapid ventricular rate/multifocal atrial tachycardia/notable for chronic findings consistent with COPD].

Treatment was initiated with nebulized bronchodilators (albuterol and ipratropium) and [oral/intravenous] corticosteroids.  Patient was noted to have [significant improvement with this treatment/persistent symptoms which prompted further treatment with intravenous magnesium sulfate.  The patient was ultimately noted to have significant respiratory distress requiring initiation of non-invasive positive pressure ventilation (NIPPV).]  [The patient was noted to have a measured peak expiratory flow rate (PEFR) of [##]% predicted after treatment in the ED consistent with mild/moderate/severe/very severe COPD.]  

Acute decompensated heart failure was felt to be a less likely cause of the patient’s symptoms given [absence of evidence of significant pulmonary congestion, peripheral edema, or other findings suggestive of volume overload and an unremarkable brain natriuretic peptide (BNP)].  Patient noted to be high risk for failure of outpatient management based on [Ottawa COPD Score as noted above/failure to significantly improve with treatment in the ED].  Antibiotics were felt to be indicated in the setting of [moderate/severe] exacerbation requiring admission.

The patient [reported/denied] current tobacco use [and we discussed smoking cessation prior to discharge with the patient noted to be pre-contemplative/contemplative/expressing desire to quit at this time].

We discussed planned admission with the patient who demonstrates understanding and agreement with this plan.  We discussed case with Dr. [NAME] who evaluated the patient and agrees with need for admission to [general floor/telemetry unit/step-down unit/ICU].

https://www.mdcalc.com/ottawa-copd-risk-scale#evidence
https://rebelem.com/rebel-core-cast-3-0-asthma-copd-pna/
https://www.mdcalc.com/global-initiative-obstructive-lung-disease-gold-criteria-copd
https://litfl.com/ecg-in-chronic-obstructive-pulmonary-disease/

MDM - Ectopic Pregnancy

[##]-year-old female G[#]P[####] at [##] weeks and [##] days gestational age with history and exam consistent with ectopic pregnancy.

Initial consideration in this patient included ectopic pregnancy, inevitable, incomplete, active or threatened spontaneous abortion, septic abortion, subchorionic hemorrhage, hematoma, endometritis, pelvic inflammatory disease (PID), and urinary tract infection (UTI) among others. 

Patient presented with [vaginal bleeding/pelvic pain] and [known/unknown] pregnancy.  Patient was deemed to be [hemodynamically stable/unstable] on arrival in the ED [and initial resuscitation initiated].  A bedside FAST exam was performed and [noted to be negative/noted to be positive increasing concern for ectopic pregnancy].  Initial labs were obtained to include a urine pregnancy test, a serum quantitative hCG, ]and type and screen/cross/etc.].  A [bedside/formal] ultrasound was obtained [with no clear evidence of intrauterine pregnancy (IUP)/free fluid in pelvis/etc.].

Cervix noted to be closed on exam making inevitable abortion unlikely.  No mass or focal tenderness on bimanual or ultrasound.  No evidence of brisk active bleeding on pelvic exam in the ED.  Patient noted to have [A/B/O +/-] blood type with [no indication for RhoGAM/RhoGAM given prior to discharge from ED].

Doubt septic abortion based on absence of fever, significant uterine tenderness on exam, or evidence of purulent vaginal discharge.  Doubt significant ovarian cyst or torsion at this time based on [history/exam/ultrasound].  No evidence of cervical motion tenderness to suggest PID at this time.

Ectopic pregnancy [confirmed/highly suspected] based on findings noted on ultrasound.  Quantitative hCG of [###] mIU/mL noted to be [above/below] the discriminatory zone.  Case discussed with Dr. [NAME] of Obstetrics with discussion of [plan to evaluate the patient for possible laparotomy given evidence of instability/plan to evaluate the patient for potential medical management with Methotrexate].

[After discussion with Dr. NAME of Obstetrics the patient was felt to be appropriate for outpatient medical management given absence of absolute contraindications (including current breastfeeding, underlying hepatic, renal, hematologic, cardiac or pulmonary disease, or known hypersensitivity) or relative contraindications (adnexal mass >3.5 cm in largest diameter, presence of fetal heart rate, free fluid in the pouch of Douglas, quantitative hCG >5000 mIU/mL).  We discussed strict return precautions for worsening pain, syncope, or other symptoms suggestive of ruptured ectopic pregnancy with the patient who demonstrated understanding.  We discussed the importance of follow up at 4 and 7 days for repeat hCG levels to ensure satisfactory decline in hCG level (at least 15% between days 4 and 7).  Close follow up was planned with Obstetrics prior to discharge.]

[After discussion with Dr. NAME of Obstetrics the patient was deemed to be appropriate for operative management.  The patient was counseled on the risks, benefits and alternatives to operative management, and demonstrated understanding with planned admission/Given emergent nature of illness and noted instability on presentation, emergency consent was felt to be implied.  Crossmatched/Emergency release blood transfusion was initiated in the ED prior to transfer.]

http://www.emdocs.net/obcast-ectopic-pregnancy/

https://www.mdcalc.com/pregnancy-due-dates-calculator

Procedure Note - Greater Occipital Nerve (GON) Block

Greater Occipital Nerve (GON) Block Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided [written/verbal] consent.  A timeout procedure was performed prior to initiating the procedure. 

The patient was placed in a seated and the approximate location of the greater occipital nerve (GON) was identified based on landmarks (the index finger was placed on the occipital protuberance with the thumb placed on the mastoid process (either side)-measured 1/3 the distance from the occipital protuberance as the likely location of the GON).  The area was cleaned appropriately using [alcohol/chlorhexadine/betadine].  Using a 23-gauge needle [3-5 mL of 1/2% lidocaine/2-4 mL of 0.25/0.5% bupivicaine] was infiltrated at the site of the GON using a 'fanning technique' (1 mL of anesthetic injected immediately adjacent to GON, 1 mL medial to the GON, and 1 mL lateral to the GON for maximal infiltration (may be repeated bilaterally)).

The patient was monitored following the procedures and reported [moderate/significant] relief in pain.  The patient tolerated the procedure well without complications.

http://www.emdocs.net/pain-profiles-ed-migraine-management-the-new-kid-on-the-block/

Procedure Note - Sphenopalantine Ganglion (SPG) Block

Sphenopalantine Ganglion (SPG) Block Note:

The patient was counseled on the risks, benefits, and alternatives to the procedure, and provided [written/verbal] consent.  We specifically discussed risk of a bitter taste from the anesthetic, nausea, trauma resulting in epistaxis, lightheadedness, and numbness in the posterior pharynx among others.  A timeout procedure was performed prior to initiating the procedure. 

The patient was placed in a supine position with the head tilted into a 'sniffing' position.  The patient was placed on a cardiac monitor (because of administration of anesthetic in a highly vascular area).  The nasal passage was anesthesized with 1 mL of 1% lidocaine per nostril aerosolized using an atomizer.  A cotton-tip applicator was soaked in [1/2]% lidocaine and advanced along the superior border of the middle turbinate of each nostril until the tip contacts the mucosa overlying the sphenopalantine galglion (SPG).

The applicators were left in place [for 10 minutes/until the patient felt relief], and were then gently removed.  The patient tolerated the procedure well without complications.

https://www.aliem.com/trick-sphenopalatine-ganglion-block-primary-headaches/

MDM - Migraine Headache

[##]-year-old [male/female] with headache with history and exam consistent with likely migraine.

Initial consideration in this patient included migraine, cluster headache, tension headache, meningitis, encephalitis, subarachnoid hemorrhage (SAH), venous sinus thrombosis, and intracranial hemorrhage or tumor among others.  

Patient presented with headache suggestive of likely migraine based on [headache lasting 4-72 hours with unilateral location, pulsating quality, moderate to severe pain intensity and avoidance of routine physical activity with associated nausea and/or vomiting, photophobia, and phonophobia].  Patient noted to have a normal neurologic exam without report of preceding trauma.  Patient [did/did not] describe associated aura suggestive of typical migraine.  Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time.  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.  

Neuroimaging was felt to [not be indicated at this time based on normal neurologic exam in patient with headache with features suggestive of migraine/obtained in this patient due to report of headache that differs in character from prior migraines/other concerning feature(s)].  After discussion of available options for treatment [the patient was given Metoclopramide (Reglan)/Prochlorperazine (Compazine)/Haloperidol (Haldol)/Dexamethasone (Decadron) with Diphenhydramine (Benadryl)/Ketorolac (Toradol)/Acetaminophen (Ofirmev)/a sphenopalantine ganglion (SPG) block/a greater occipital nerve (GON) block].  Patient reported significant improvement with treatment prior to discharge from ED.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation and consideration of possible imaging or referral to Neurology, and the patient demonstrated understanding and agreement.

https://www.aliem.com/trick-sphenopalatine-ganglion-block-primary-headaches/
http://www.emdocs.net/pain-profiles-ed-migraine-management-the-new-kid-on-the-block/

Decision Rule - Ottawa Subarachnoid Hemorrhage (SAH) Rule

Ottawa Subarachnoid Hemorrhage (SAH) Rule:

-Age ≥40 . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]
-Neck pain or stiffness   . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]
-Witnessed loss of consciousness . . . . . . .  [No (0 points)/Yes (+1 point)]
-Onset during exertion  . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]
-Thunderclap headache   . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]
  (Defined as headache peaking within 1 second)  
-Limited neck flexion on examination . . . .  [No (0 points)/Yes (+1 point)]

TOTAL SCORE = [## points]

A subarachnoid hemorrhage (SAH) cannot be ruled out if one or more criteria above are met.  
Provider may consider avoiding further subarachnoid hemorrhage (SAH)-specific workup in patients who meet all negative criteria.

https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation

MDM - COPD Exacerbation (Discharge)

[##]-year-old [male/female] with history and exam consistent with acute exacerbation of COPD.

Initial consideration in this patient included exacerbation of COPD, acute decompensated heart failure, acute coronary syndrome (ACS), acute bronchitis, pneumonia, influenza, asthma exacerbation, allergic rhinitis, upper respiratory infections (URI), foreign body airway obstruction, pulmonary embolism (PE) among others. 

Patient presented for [cough/shortness of breath/wheezing] with a known history of COPD consistent with acute exacerbation.  Patient’s lung sounds were [notable for expiratory wheezing/noted to be normal].  Patient noted to [have/have no] evidence of fever [or other systemic infectious symptoms].  A chest x-ray was obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/specify findings].  An EKG was obtained and [noted to have no evidence of acute abnormalities/notable for atrial fibrillation without rapid ventricular rate/multifocal atrial tachycardia/notable for chronic findings consistent with COPD].

Treatment was initiated with nebulized bronchodilators (albuterol and ipratropium) and [oral/intravenous] corticosteroids.  Patient was noted to have [significant improvement with this treatment/persistent symptoms which prompted further treatment with intravenous magnesium sulfate.  The patient was ultimately noted to have significant respiratory distress requiring initiation of non-invasive positive pressure ventilation (NIPPV).]  [The patient was noted to have a measured peak expiratory flow rate (PEFR) of [##]% predicted after treatment in the ED consistent with mild/moderate/severe/very severe COPD.]  Acute decompensated heart failure was felt to be a less likely cause of the patient’s symptoms given [absence of evidence of significant pulmonary congestion, peripheral edema, or other findings suggestive of volume overload and an unremarkable brain natriuretic peptide (BNP)].  Patient was felt to be appropriate for outpatient management based on [Ottawa COPD Score as noted above/significant improvement with treatment in the ED].  Antibiotics were [felt to be indicated given the presence of all three cardinal symptoms (increased dyspnea, increased sputum volume, and increased sputum purulence)/presence of two cardinal symptoms if increased sputum purulence is present/given severe exacerbation requiring non-invasive mechanical ventilation].

The patient [reported/denied] current tobacco use [and we discussed smoking cessation prior to discharge with the patient noted to be pre-contemplative/contemplative/expressing desire to quit at this time].

We discussed return precautions, specifically for evidence of worsening or persistent asthma symptoms or difficulty breathing, treatment with [bronchodilators/steroids/antibiotics], and close follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.  Prior to discharge we ensured that the patient had refills of all asthma control and rescue medications.

https://www.mdcalc.com/ottawa-copd-risk-scale#evidence
https://rebelem.com/rebel-core-cast-3-0-asthma-copd-pna/
https://www.mdcalc.com/global-initiative-obstructive-lung-disease-gold-criteria-copd
https://litfl.com/ecg-in-chronic-obstructive-pulmonary-disease/

Decision Rule - Ottawa COPD Score

Ottawa COPD Score

History

-Coronary bypass graft . . . . . . . . . . . . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]

-Intervention for peripheral vascular disease  . . . . . . .  [No (0 points)/Yes (+1 point)]

-Any history of intubation for respiratory distress  . . .  [No (0 points)/Yes (+2 points)]

Examination

-Heart rate ≥110 beats/minute on arrival  . . . . . . . . . . .  [No (0 points)/Yes (+2 points)]

-To ill to do walk test after treatment in ED   . . . . . . . .  [No (0 points)/Yes (+2 points)]

(Saturation <90% or HR ≥120/min after 3 minute walk test)

Investigations

-Acute ischemic changes on EKG . . . . . . . . . . . . . . . . . .   [No (0 points)/Yes (+2 points)]

-Pulmonary congestion on chest x-ray  . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]

-Hemoglobin <10 g/dL (100 g/L)  . . . . . . . . . . . . . . . . . .  [No (0 points)/Yes (+3 points)]

-BUN ≥34 mg/dL (Urea ≥12 mmol/L) . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]

-Serum ≥CO₂ 35 mEq/L (35 mmol/L)  . . . . . . . . . . . . . . .  [No (0 points)/Yes (+1 point)]

TOTAL Score = [## points]

[Score 0] Patient deemed to be low risk for adverse events in the next 30 days based on the Ottawa COPD Risk scale consistent with a 2.2% risk.

[Score 1-2] Patient deemed to be medium risk for adverse events in the next 30 days based on the Ottawa COPD Risk scale consistent with a 4.0-7.2% risk.  We discussed this risk with the patient after noting significant improvement in symptoms prior to discharge.  Admission was considered and discussed with the patient, who preferred discharge home with close follow up.  Patient noted to have access to close follow up care, and demonstrated understanding of risk, return precautions, and follow up care.

[Score 3-7] Patient deemed to be high risk for adverse events in the next 30 days based on the Ottawa COPD Risk scale consistent with a [12.5/20.9/32.9/47.5/62.6]% risk.  We discussed this risk with the patient and recommended admission for further treatment.

MDM - Asthma Exacerbation (Discharge)

[##]-year-old [male/female] with history and exam consistent with acute exacerbation of asthma.

Initial consideration in this patient included exacerbation of asthma, acute bronchitis, pneumonia, influenza, COPD exacerbation, allergic rhinitis, upper respiratory infections (URI), foreign body airway obstruction, pulmonary embolism (PE) among others. 

Patient presented for [cough/shortness of breath/wheezing] with a known history of asthma consistent with acute exacerbation.  Patient’s lung sounds were [notable for expiratory wheezing/noted to be normal].  Patient noted to [have/have no] evidence of fever or other systemic infectious symptoms.  A chest x-ray [was/was not] obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/due to absence of abnormal lung sounds or other evidence suggestive of pneumonia or other acute intrathoracic pathology]. 

[A peak expiratory flow rate (PEFR) was measured in this patient at presentation, and was noted to be [##]% of predicted.]  Treatment was initiated with nebulized bronchodilators (albuterol and ipratropium) and [oral/intravenous] corticostreroids.  Patient was noted to have [significant improvement with this treatment/persistent symptoms which prompted further treatment with intravenous magnesium sulfate/terbutaline/epinephrine/heliox.  The patient was ultimately noted to have significant respiratory distress requiring initiation of non-invasive positive pressure ventilation (NIPPV).]  The patient was noted to have a measured peak expiratory flow rate (PEFR) of [##]% predicted after treatment in the ED [consistent with high likelihood of successful outpatient management].

We discussed return precautions, specifically for evidence of worsening or persistent asthma symptoms or difficulty breathing, treatment with [bronchodilators/steroids], and close follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.  Prior to discharge we ensured that the patient had refills of all asthma control and rescue medications.

https://www.mdcalc.com/estimated-expected-peak-expiratory-flow-peak-flow#next-steps

https://emcrit.org/emcrit/severe-asthmatic/

https://emcrit.org/ibcc/asthma/

MDM - Acute Bronchitis

[##]-year-old [male/female] with history and exam consistent with acute bronchitis of likely [viral/bacterial] etiology.

Initial consideration in this patient included bronchitis, pneumonia, influenza, allergic rhinitis, upper respiratory infections (URI), pulmonary embolism (PE), and reactive airway diseases (asthma, chronic bronchitis) among others. 

Patient presented with cough [productive of sputum] and [reported/evidence of] wheezing consistent with bronchitis.  Patient’s lung sounds were [notable for expiratory wheezing/noted to be normal].  Patient noted to [have/have no] evidence of fever or other systemic infectious symptoms.  A chest x-ray [was/was not] obtained [and noted to have no evidence of consolidations suggestive of pneumonia or other acute abnormality/due to absence of abnormal lung sounds or other evidence suggestive of pneumonia or other acute intrathoracic pathology].  The patient [reported/denied] a history of obstructive lung disease (asthma or COPD).  Patient [reported/denied] a history of tobacco use [and we discussed smoking cessation prior to discharge with the patient noted to be pre-contemplative/contemplative/expressing desire to quit at this time].  Patient noted to have [mild/some/significant] improvement after treatment with [specify] in the ED prior to discharge.

We discussed return precautions, specifically for evidence of worsening difficulty breathing, treatment with [bronchodilators/steroids], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

Decision Rule - Well's Score for Deep Vein Thrombosis (DVT)

Well’s Criteria for Deep Vein Thrombosis (DVT):

Active malignancy (treatment or palliation within 6 months)
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Bedridden recently >3 days or major surgery within 4 weeks
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Calf swelling >3 cm compared to the other leg (measured 10 cm below the tibial tuberosity)
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Collateral (nonvaricose) superficial veins present
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Entire leg swollen
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Localized tenderness along the deep venous system
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Pitting edema confined to symptomatic leg
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Paralysis, paresis, or recent plaster immobilization of the lower extremity
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Previously documented DVT
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . +1 points
    -SCORE = [##] points

Alternative diagnosis to DVT as likely or more likely
    -No . . . . . . . . . . . . . . 0 points
    -Yes . . . . . . . . . . . . . . -2 points
    -SCORE = [##] points

TOTAL SCORE = [##] points
Patient is determined to be low risk (0 points or lower) with an incidence of DVT of 5%.
Patient is determined to be moderate risk (1-2 points) with an incidence of DVT of 17%.
Patient is determined to be high risk (≥3 points) with an incidence of DVT of 17-53%.

MDM - Deep Vein Thrombosis (DVT) Rule Out

[##]-year-old [male/female] with [right/left calf pain/swelling] with history and exam consistent with low risk for deep vein thrombosis and likely [muscle strain].

Initial consideration in this patient included deep vein thrombosis (DVT), muscle strain, edema, cellulitis, arterial occlusions, [differential diagnoses], and pulmonary embolism (PE) among others.

Patient presented with complaint of [leg swelling/calf pain] with [no] recent [flight/surgery/immobilization] within the past [days/weeks] prior to onset of symptoms.  Patient noted to have [low/moderate/high] risk Wells score for DVT at this time.  A D-dimer was obtained and noted to be [negative/positive].  [Bedside/Formal] ultrasound obtained of the [right/left/bilateral leg(s)] with no evidence of clot and completely compressible vessels at visulaized portions of the common femoral, greater saphenous, superficial femoral, deep femoral, or popliteal veins.  [We discussed limitations of bedside ultrasound evaluation, specifically limited ability to visualize the smaller vessels of the calf.]  Patient felt to be low risk at this time with no indication for initiation of anticoagulation.  Discussed need for follow up within 1-2 weeks for repeat evaluation with ultrasound for persistent symptoms, and the patient demonstrated understanding and agreement.  No report of chest pain, shortness of breath, or other symptoms or findings suggestive of PE at this time.  Patient noted to have [some/mild/significant] improvement after treatment with [specify] in the ED.

Prior to discharge, we discussed return precautions, specifically for evidence of chest pain or shortness of breath suggestive of PE, treatment [with specify interventions], and follow up with primary care doctor within [2-3 days/1 week] to arrange for repeat US for DVT, and the patient demonstrated understanding and agreement.

Discharge Instructions - Shingles

As discussed in the Emergency Department prior to discharge, you have been diagnosed with shingles.  If you have been diagnosed with shingles, you likely had chicken pox when you were a child.  The virus that caused chicken pox never actually leaves the body; it hides, or "sleeps" inside the spinal cord.  For most people, the virus stays quiet inside the spinal cord and never reactivates or "wakes up."  However, for 1 in 5 people (about 20 percent of people), the virus does reactivate.  It travels down one of the nerves from the spinal cord, causing the rash to appear along the path of that nerve.  This usually causes a burning pain to the area, then a skin rash appears a few days later.

To control your pain, start with Ibuprofen (also known as Advil or Motrin) or Naproxen (also known as Aleve).  An hour after you’ve taken one of them, if it still hurts too much to take a deep breath, you can add a stronger pain medication.  You may have been prescribed a stronger pain medication such as Hydrocodone (Norco) or Oxycodone (Percocet).  These stronger medications can make you drowsy, so DO NOT DRIVE OR OPERATE MACHINERY WITHIN 8 HOURS OF TAKING THEM.  These medications usually also cause constipation, so take an over-the-counter medicine for constipation, such as Metamucil or Docusate, at the same time as taking these medications.

For a small number of patients, the pain lasts more than a month (even after the rash is gone).  This is called “post-herpetic neuralgia.”  See your primary care provider if this is the case for you.

If you have been prescribed an anti-viral medication, start it as soon as possible and complete the entire course (do not stop taking it early).  If you have been prescribed a steroid medication, start it as soon as possible and complete the entire course (do not stop taking it early).

Remember that you are contagious while you have the skin rash.  The risk is that you can give another person chicken pox if they haven’t had chicken pox before; however, you can’t give them shingles.

Specifically avoid contact with the following people:

    -Pregnant women

    -People who are taking chemotherapy

    -Anyone who has not had chicken pox or has not been vaccinated against chicken pox

The skin rash is no longer contagious when the bubbles have popped and dried over.  You can put a bandage and/or lots of layers of clothing on top of the bubbles to try to prevent spreading the virus.

If the rash is itchy, you can apply chamomile lotion or try oatmeal baths.  Keep the skin rash clean and dry as best as you can.  It usually lasts 2-4 weeks.

Monitor your rash daily.  If the rash is getting redder in the surrounding skin, it may be becoming infected.  If so, you will need to get antibiotics from your primary care provider or the Emergency Department.

See your primary care provider within 1-2 weeks.  If the rash is on your forehead, you will need to follow-up with an Ophthalmologist (an eye doctor) as well, as the eye can be affected in this area, particularly if the rash is also on the end of the nose.

Return to the Emergency Department for rash spreading to the other side of the body, or to another area of the body, fever (≥38.0 °C or 100.4 °F), confusion, or any new or concerning symptoms.