MDM - Stye (Hordeolum)

[##]-year-old [male/female] presents with history and exam consistent with stye (hordeolum) to the [right/left upper/lower] eyelid.

Initial considerations in this patient included stye, orbital and periorbital cellulitis, allergic reaction, chalazion, blepharitis, dacrocystitis, and conjunctivitis from allergic, bacterial and viral etiologies among others.

Patient presented with erythema and swelling to the [right/left upper/lower] eyelid [with/without] significant surrounding erythema.  Patient noted to have pustule to the affected eyelid consistent with stye.  Patient noted to have no evidence of associated purulent drainage from the affected eye.  Patient noted to have no associated visual deficits.

Prior to discharge, we discussed return precautions, specifically for evidence of progression to periorbital or orbital cellulitis, treatment with warm compresses [and topical antibiotic ointment/systemic antibiotics due to associated erythema suggestive of early periorbital cellulitis], and follow up with [primary care provider/ophthalmology] within [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement with this plan.

https://www.aafp.org/afp/1998/0601/p2695.html

MDM - Elderly Mechanical Fall (Negative CT)

[##]-year-old [male/female] presents with history and exam consistent with likely mechanical fall [with soft tissue abrasions] without evidence of significant intracranial injury at this time.

Initial considerations in this patient included intracranial hemorrhages including subarachnoid, subdural epidural hemorrhages, brain contusions, delayed intracranial hemorrhages, cervical spine fractures and dislocations, spinal cord injuries, musculoskeletal injuries, syncope from cardiac etiologies including dysrhythmia and other neurologic etiologies including cerebrovascular accident (CVA) and transient ischemic attack (TIA), and fall syndromes (history of recurrent falls) among others.

Patient presented after [## hours] after a fall [at home/assisted living facility/public place] described by the [patient/bystanders] as “[tripping/stumbling/etc.]” consistent with likely mechanical fall (non-syncopal fall from standing).  A 12-lead EKG was obtained with [no evidence of dysrhythmia, ischemia or infarction/atrial fibrillation without evidence of rapid ventricular response/describe finding].  The patient [reported/denied] current use of anticoagulants [specifically Warfarin (Coumadin)/Rivaroxaban (Xarelto)/Apixaban (Eliquis)/Dabigatran (Pradaxa)/Enoxaparin (Lovenox)/but did report use of anti-platelet agent (aspirin/Plavix)].  Patient was noted to have a neurological exam with [no evidence of focal deficits/other].  CT scans of the head [and cervical spine] were obtained with no evidence of significant intracranial hemorrhage [and no evidence of acute spinal injuries].

The patient [and family] were questioned on fall history with [no report of frequent/prior falls/report of prior episodes and discussion of the importance of close follow up with primary care provider to discuss what can be done to decrease fall risk].  A gait assessment was performed in the ED [with mobility device/cane/walker] and [noted to be unremarkable/notable for slow, unsteady gait].  The patient lives [alone/with family] and was noted to have [a family member/friend who is able to check up on them over the next several days/no family or friends who are able to check up on them consistently on discharge].

Prior to discharge, we discussed return precautions, specifically emphasizing the signs of delayed intracranial hemorrhage, and close follow up with primary care provider in the next [2-3 days/week] to discuss ways to decrease fall risk [and consideration of whether the benefits of anticoagulation outweigh the risks, and the patient [and family] demonstrated understanding and agreement with this plan.

[Due to concern for delayed hemorrhage in a patient who remains a fall risk and has limited social support, we discussed admission for observation and consideration of repeat CT scans with the patient [and family].  We discussed admission with [Dr. Name/admitting hospitalist] who evaluated the patient in the ED, and agreed with planned admission.]

https://www.hippoed.com/em/ercast/episode/mechanicalfalls/mechanicalfalls

Timed Up & Go Test: https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf
https://gempodcast.com/2018/11/09/retiring-the-term-mechanical-fall-for-older-patients/

MDM - Electrical Injury

[##]-year-old [male/female] presents with history and exam consistent with [low/high voltage] electrical injury [with dysrhythmia/superficial cutaneous burns/etc.].

Initial considerations in this patient included complications from electrical injury including dysrhythmias including ventricular and atrial arrhythmias, cutaneous burns, cardiovascular and central nervous system injuries, orthopedic injuries including fractures, dislocations and compartment syndrome, and rhabdomyolysis among others.

Patient presented with report of electrical injury from [household/industrial] source consistent with [low voltage (<1000 Volts)/high voltage (>1000 Volts) DC/AC current] exposure.  A 12-lead EKG was obtained with [no evidence of dysrhythmia, ischemia or infarction/notable for evidence of atrial fibrillation/frequent premature atrial/ventricular contractions/other specific abnormality].  Patient was noted to have [no evidence of significant cutaneous burns/first degree burns at the point of contact with electrical source with appropriate burn care provided in the ED].  Patient felt to have [no other concerning features with electrical exposure/high risk features including prolonged exposure/wet skin/loss of consciousness (LOC)].  Labs were [not obtained in patient felt to have no high risk features or findings on exam to suggest significant injury/obtained to include electrolytes/creatinine kinase/troponin/etc. and noted to be normal/notable for abnormality].  Patient noted to have [no focal deficits/subjective complaints of numbness/tingling with no significant focal deficits/describe abnormality] on neurological exam in the ED.

Prior to discharge, we discussed return precautions, specifically for evidence of significant electrical injury, symptomatic treatment, and recommended follow up with primary care provider in [1-2 weeks/2-3 days], and the patient demonstrated understanding and agreement with this plan.

https://www.ebmedicine.net/topics/burns/electric-shock-burns
http://www.emdocs.net/electrical-injury/

MDM - Influenza (Admit)

[##]-year-old [male/female] presents with [fever/body aches/upper respiratory symptoms] with history and exam consistent with [seasonal] influenza.

Initial considerations in this patient included influenza, bacterial and viral etiologies of upper respiratory infection (URI), bronchitis, pneumonia, sinusitis, toxic exposure, sepsis, meningitis, encephalitis, and other pulmonary or cardiac etiologies among others.

Patient presented with symptoms suggestive of influenza during appropriate season.  Patient noted to [not] have significant risk factors for complications from influenza [specifically age less than 2 years/age greater than 65 years/pregnancy through to 2 weeks after delivery/chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus)/immunosuppression, including that caused by medications or HIV/persons younger than 19 years of age who are receiving long-term aspirin therapy/American Indians and Alaska Natives/extreme obesity (BMI ≥40 kg/m²)/patients in nursing homes or chronic care facilities].  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].  Blood cultures [were/were not] obtained due to planned admission.  Confirmatory testing for influenza obtained in patient felt to require admission and noted to be [negative/positive].

Influenza felt to be likely cause of symptoms with antiviral treatment initiated in the ED [with Oseltamavir (Tamiflu)/Zanamivir (Relenza)/Peramivir (Rapivab) and empiric antibiotic coverage due to evidence of sepsis].  Patient felt to not be appropriate for outpatient treatment based on [evidence of sepsis, absence of good social support].  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].

Note: This is based on the 2018 recommendations for treatment of seasonal influenza from the Infectious Disease Society of America (IDSA).

https://rebelem.com/idsa-guideline-on-seasonal-influenza-management-2018/

https://www.idsociety.org/practice-guideline/influenza/

MDM - Influenza (Discharge)

[##]-year-old [male/female] presents with [fever/body aches/upper respiratory symptoms] with history and exam consistent with [seasonal] influenza.

Initial considerations in this patient included influenza, bacterial and viral etiologies of upper respiratory infection (URI), bronchitis, pneumonia, sinusitis, toxic exposure, sepsis, meningitis, encephalitis, and other pulmonary or cardiac etiologies among others.

Patient presented with symptoms suggestive of influenza during appropriate season.  Patient noted to [not] have significant risk factors for complications from influenza [specifically age less than 2 years/age greater than 65 years/pregnancy through to 2 weeks after delivery/chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus)/immunosuppression, including that caused by medications or HIV/persons younger than 19 years of age who are receiving long-term aspirin therapy/American Indians and Alaska Natives/extreme obesity (BMI ≥40 kg/m²)/patients in nursing homes or chronic care facilities].  Confirmatory testing for influenza felt [not to be indicated as the results were unlikely to change management/obtained in patient felt to be high risk and noted to be negative/positive].  No evidence of pneumonia on history or exam [and no evidence of consolidations on chest x-ray]. 

Influenza felt to be likely cause of symptoms in patient presenting [within 48 hours of onset of symptoms/over 48 hours from onset of symptoms] with antiviral treatment felt to be [indicated after discussion of potential benefits and risks with the patient/indicated in patient with risk factors for complications/indicated in patient with household contacts who are high risk for complications/indicated in a healthcare worker caring for high risk individuals].  Prior to discharge, we discussed return precautions, specifically for symptoms suggestive of bacterial co-infection or worsening illness, and recommended follow up with primary care provider within [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement with this plan.

Note: This is based on the 2018 recommendations for treatment of seasonal influenza from the Infectious Disease Society of America (IDSA).

https://rebelem.com/idsa-guideline-on-seasonal-influenza-management-2018/
https://www.idsociety.org/practice-guideline/influenza/

Decision Rule - King's College Criteria for Acetaminophen Toxicity

King’s College Criteria for Acetaminophen Toxicity

-Arterial pH <7.30  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  [No/Yes]

-INR >6.5 (PT >100 seconds) . . . . . . . . . . . . . . . . . . . . . . . .  [No/Yes]

-Creatinine 3.4 mg/dL (300 µmol/L) . . . . . . . . . . . . . . . . . . . . [No/Yes]

-Grade III or IV hepatic encephalopathy  . . . . . . . . . . . . . . . .  [No/Yes]

The presence of any of the above should prompt referral and possible transfer to a center capable of liver transplantation.

Other predictors of a poor prognosis without transplant:

-Lactate >3.5 mmol/L after fluid resuscitation (<4 hours)  . . .  [No/Yes]

-Lactate >3 mmol/L after full fluid resuscitation (12 hours) . .  [No/Yes]

-Phosphate >3.75 mg/dL (1.2 mmol/L) at 48-96 hours . . . . .  [No/Yes]

https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity

https://www.mdcalc.com/hepatic-encephalopathy-grades-stages

MDM - Acetaminophen Overdose

[##]-year-old [male/female] presents with history and exam consistent with acetaminophen overdose [as a suicide attempt/additional].

Initial considerations in this patient included acetaminophen intentional and accidental overdose, other intentional ingestions and co-ingestions including salicylates, alcohol, toxic alcohols, opioids, benzodiazepines, anticholinergic medications, and antidepressant medications including tricyclic antidepressant (TCA) among others, other self-injury, and other infectious and toxicologic etiologies among others.

Patient presented with [suspected/reported] overdose of acetaminophen [## hours/days] prior to presentation.  Patient felt to have [no indication for intubation or more aggressive airway management on presentation/indication for intubation due to altered mental status].  Patient noted to be [unstable with appropriate resuscitation initiated/hemodynamically stable] on presentations.  Gastrointestinal decontamination with activated charcoal [felt to not be indicated given presentation over 3 hours from reported/suspected ingestion/administered in patient presenting within 3 hours from reported/suspected ingestion].  Initial labs were obtained including an ethyl alcohol level, salicylate level, [others] and liver function tests, which were [noted to be unremarkable/notable for elevated hepatic enzymes/specify].  A 12-lead EKG was obtained [with no evidence of acute ischemia, infarction or other QRS, ST, or T wave changes associated with tricyclic antidepressant overdose/notable for specify abnormality].

An [initial/4-hour] acetaminophen level was obtained and [noted to be elevated based on Rumack-Matthew nomogram/noted to be elevated in the setting of unknown time of ingestion].  Treatment with N-acetylcysteine (NAC) initiated via [oral/intravenous] route along with supportive care as noted above.  Patient felt to have [no] indication for transfer to transplant center by King's Criteria at this time.

Case discussed with [ICU team/admitting hospitalist and Poison Control] with plan for admission to the [ICU/telemetry unit/etc.].  Planned admission and treatment [was/was not] discussed with the patient [who demonstrated understanding and agreement with plan/who is involuntary for admission at this time/due to altered mental status].

https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity
https://edsmartchart.blogspot.com/2020/06/decision-rule-kings-college-criteria.html
http://www.emdocs.net/toxcard-acetaminophen-toxicity-and-management/

Procedure Note - Restraint Note(s)

Initial Restraint Note:

Patient felt to meet indications for [chemical/physical/chemical and physical restraint] due to concern that the patient presents an imminent threat to themselves and staff.  Attempts at de-escalation [were unsuccessful/could not be attempted due to agitation and violent behavior].  We considered risks of the use of [chemical/physical] restraints, and felt that the benefits of harm reduction outweighed these risks at this time.

Chemical restraint was initiated with [antipsychotic-Haloperidol (Haldol) ## mg IM/IV/Olanzapine (Zyprexa) ## mg PO/IM/IV/Ziprasidone (Geodon) ## mg IM and benzodiazepine-Lorazepam (Ativan) ## mg IM/IV/Midazolam (Versed) ## mg IM/IV].

Physical restraints were felt to be necessary due to [continued agitation despite use of chemical restraints for rapid tranquilization/due to continued agitation while awaiting maximal effects of chemical restraint/inability to safely administer chemical restraints due to agitation and aggressive behavior].

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.  We discussed plan for nursing to reassess the patient every [10-15] minutes, and will plan to repeat our exam within 1 hour with the goal of potentially discontinuing some or all of the applied physical restraints.

Continued Restraint Note

Patient felt to still meet indications for physical restraint at this time due to concern that the patient still presents an imminent threat to themselves and staff.  We again made unsuccessful attempts at de-escalation which [were unsuccessful/still could not be attempted due to agitation and violent behavior].  We considered risks of the continued use of physical restraints, and felt that the benefits of harm reduction outweighed these risks at this time.

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.  We discussed plan for nursing to reassess the patient every [10-15] minutes, and will plan to repeat our exam within 1 hour with the goal of potentially discontinuing some or all of the applied physical restraints.

Discontinuing Restraint Note

Patient felt to no longer meet indications for physical restraint at this time with plan [to discontinue all restraints at this time/to transition from 4-point to 2-point and ultimately discontinue all restraints if patient remains calm and cooperative].  Patient noted to have no evidence of complications from restraint use, such as significant soft tissue injuries or rhabdomyolysis among others.

I personally evaluated the patient before and after restraint placement [along with my attending/resident Dr. NAME] as documented in the history and physical exam section.

Note: Laws regarding the use of restraints vary by state and hospital, so you should be aware of the specific requirements at your institution.  These should all be time-stamped and signed for legal purposes.  It is absolutely essential that you re-evaluate any patient you place into physical restraints frequently with the goal of always using the least restrictive method to control the agitated patient.

https://ercast.libsyn.com/art-of-the-chemical-takedown
http://www.emdocs.net/agitation/

MDM - Suicidal Ideations (Discharge)

[##]-year-old [male/female] with [depression/suicidal ideations] with history and exam consistent with likely [presumptive diagnosis].

Initial consideration in this patient included major depressive disorder, adjustment disorder, suicide attempt (intentional overdose and self-injury amongst others), alcohol or other substance related mood disorders, and organic causes of altered mental status among others.

Patient presented to the ED [due to concerns over suicidal thoughts/after police were called due to suicidal comments/after his coworkers/supervisor noted suicidal comments].  On initial exam the patient was noted to be hemodynamically stable [with/without] evidence of intoxication.  Patient noted to have [no] evidence of [likely] self-injury [specify].  Labs [were/were not] ordered [and unremarkable as noted above/notable for elevated ethanol level without other evidence of overdose, illicit drugs or significant toxins].  The patient expressed [passive suicidal ideations/no suicidal ideations] in the ED [without/and no specific] plan [specify].

The patient was considered to be [low/moderate] risk for suicide based on consideration of risk factors, including [absence of suicidal plan/report of good social support].  Prior to discharge the patient [and family/bystanders] were questioned on access to firearms, which was [denied/planned for removal/secured].

The patient demonstrated a willingness to form a safety contract prior to discharge, as detailed in the discharge instructions below.  Return precautions for any concerns for safety were discussed, as well as follow up with [Mental Health] on [date] with the patient demonstrating understanding and agreement prior to discharge.

http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/
https://edsmartchart.blogspot.com/2020/06/physical-exam-psychiatric-mental-status.html
https://edsmartchart.blogspot.com/2020/06/discharge-instructions-contract-for.html

Discharge Instructions - Contract for Safety

Based on our clinical examination and testing, we feel that you are safe for discharge home today with the following precautions:

As discussed in the emergency department prior to discharge, you should be aware that worsening depression, thoughts of suicide with thoughts or images of specific plans, and behavior such as writing notes or giving away possessions are warning signs for risk of suicide.  If you experience these symptoms or have any concerns for your safety, you must return to the emergency department immediately, preferably by ambulance or with a friend or family member.

As discussed in the emergency department, you can attempt to distract yourself from depressive thoughts by engaging in healthy coping strategies, such as exercising, watching television or a movie, or contacting a friend, family member, or a chaplain or religious leader to talk.  You can obtain free and confidential support if you feel in distress or are having thoughts of suicide 24 hours a day 7 days a week by calling the National Suicide Prevention Hotline at 1-800-273-8255 or visit their website at https://suicidepreventionlifeline.org.  You can also communicate with someone via text message if you are in distress or have thoughts of suicide by texting “HOME” to 741741 (https://www.crisistextline.org) and you will be connected to a crisis counselor.

[Military-specific resources-You can also talk, text or online chat confidentially with a qualified responder, many of whom have military experience, by calling the Military Crisis Line at (<https://www.veteranscrisisline.net/ActiveDuty.aspx>).  You can also obtain additional information about available resources for coping with the stresses of military life at Military One Source (<http://www.militaryonesource.mil/>).]  

[The Trevor Project offers crisis intervention and suicide prevention to LGBTQ youth through its hotline, chat feature, and online support center.  You can call the Trevor Project to speak to a counsellor 24 hours a day 7 days a week at 1-866-488-7386.  You can also talk to a counsellor from The Trevor Project 24 hours a day 7 days a week by texting START to 678678.  You can chat with a counsellor from The Trevor Project by going to https://www.thetrevorproject.org/get-help-now/ and selecting the CHAT option in the upper right hand corner of the page.]

Please note that if your condition worsens or changes significantly, we would like to see you again.  You may return at any time if you have further concerns.  Following up with your primary care provider and/or specialist as indicated is important for your overall health and wellness.  As discussed in the emergency department prior to discharge, by signing these discharge instructions you are agreeing with this safety plan and agree to return if you have worsening thoughts of suicide or any other safety concerns.

Note: There are differing opinions on the utility of a safety contract in suicidal patients.  ACEP provides some templates for developing a safety contract and safety plan at this website: https://www.acep.org/patient-care/iCar2e/.

It will come down to provider preference whether you use this document as a safety contract, but there are resources where patients can obtain emergency counseling nationwide that are helpful to provide on discharge.

https://www.healthline.com/health/mental-health/suicide-resource-guide#4

Decision Rule - SAD PERSONS Score

SAD PERSONS Score:

-Sex = male [0 points/1 point]
-Age <19 or >45 years [0 points/1 point]
-Depressed symptoms [0 points/2 points]

-Past psychiatric history or suicide attempts [0 points/1 point]
-ETOH/drug use history [0 points/1 point]
-Rational thought loss [0 points/2 points]
-Separated, divorced or widowed or sickness with 3 or more prescription medications [0 points/1 point]
-Organized plan or serious attempt [0 points/2 points]
-No social support [0 points/1 point]
-Stated intent (or ambivalence) [0 points/2 points]

Note: This score was originally developed by Hockberger and Rothstein at the Harbor-UCLA Medical Center in 1988, as a scoring tool to predict the need for hospitalization in individuals at risk for suicide. After analysis of 119 patients, Hockberger and Rothsetin identified a score ≥ 6 as having a sensitivity of 94% and a specificity of 71% for predicting the need for psychiatry directed hospitalization (P<0.001).

This should not be used as your sole justification in determining someone does or doesn't need to be admitted.  This is most useful as a way of remembering suicidal risk factors, and for making a case in documentation for admission.  It is especially helpful for newer students and residents to remember and organize the questions they will ask as part of medical clearance of a suicidal patient.  It is included as a "Decision Rule" for ease of organizing it as a template on this site, even though it does not perfectly fit that description.

http://www.emdocs.net/emergency-department-tips-tricks-managing-suicidal-patient/

-

MDM - Suicidal Ideations (Admit)

[##]-year-old [male/female] with [depression/suicidal ideations] with history and exam consistent with likely [presumptive diagnosis].

Initial consideration in this patient included major depressive disorder, adjustment disorder, suicide attempt (intentional overdose and self-injury amongst others), alcohol or other substance related mood disorders, and organic causes of altered mental status among others.

Patient presented to the ED [due to concerns over suicidal thoughts/after police were called due to suicidal comments/after his coworkers/supervisor noted suicidal comments].  On initial exam the patient was noted to be hemodynamically stable [with/without] evidence of intoxication.  Patient noted to have [no] evidence of [likely] self-injury [specify].  Labs [were/were not] ordered [and unremarkable as noted above/notable for elevated ethanol level without other evidence of overdose, illicit drugs or significant toxins].  The patient expressed [passive suicidal ideations/no suicidal ideations] in the ED [with/without] plan [specify].

Patient medically cleared based on history, exam, and workup as noted above with no evidence of significant medical instability or medical condition causing or contributing to psychiatric condition at this time.  The patient was considered to be [moderate/high] risk for suicide based on consideration of risk factors, including [access to a firearm/suicidal plan involving lethal means/poor access to outpatient care or social support/unwillingness to safety contract in the ED/a SAD PERSONS score of ## points consistent with high risk]. 

Patient was evaluated by [mental health provider name] who agreed with need for admission.  Concerns for safety and plan for admission were discussed with the patient, who is [voluntary/involuntary] with plan for admission at this time.

http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/
https://edsmartchart.blogspot.com/2020/06/physical-exam-psychiatric-mental-status.html
https://edsmartchart.blogspot.com/2020/06/decision-rule-sad-persons-score.html

Physical Exam - Psychiatric Mental Status Exam

The patient’s mood [how the patient tells you they’re feeling-is described as anxious/depressed/crawling out of their skin/etc.].  The patient’s affect [what you observe-appears anxious/depressed/flattened/blunted/restricted/exaggerated] which is [congruent/incongruent] with their reported mood.  Patient noted to be [making good/poor eye contact/frequently looking down/away].  Patient [was/was not] noted to be attending to internal stimuli [specify/with patient noted to be conversing in an empty room/etc.].  The patient’s thought process is noted to be [organized/disorganized with/without delusions/obsessions].  The patient’s speech [is noted to be unremarkable/notable for pressured speech/inappropriately loud/soft given size of the room and distance apart/tangential speech/etc.].  The patient was noted to be [well kempt and groomed/disheveled/encrusted with urine and feces].  

The patient was noted to be expressing [suicidal thoughts with/without reported plan/no suicidal or homicidal thoughts or plan at this time].  The patient [reported/denied] hallucinations [described as auditory/visual].

https://www.hippoed.com/em/ercast/episode/march2017/examiningmental

MDM - Bell's Palsy

[##]-year-old [male/female] presents with complaint of [right-sided/left-sided] facial asymmetry with history and exam consistent with Bell's palsy.

Initial considerations in this patient included Bell's palsy, cerebrovascular accident CVA), transient ischemic attack (TIA), trigeminal neuralgia, intracranial mass or hemorrhage, tick paralysis and the Lyme disease, and other infectious and toxicologic etiologies among others.

Patient presented with [## hours/days] of facial asymmetry without other associated neurologic deficits.  Patient noted to have complete [right-sided/left-sided] facial droop and weakness in the distribution of the facial nerve (cranial nerve VII), specifically including inability to raise the eyebrow or wrinkle her forehead on the affected side.  Patient reported associated [alteration in taste/hyperacusis/subjective facial numbness with no objective findings on exam/retroauricular pain].  Patient noted to have otherwise unremarkable neurologic exam.  Patient [reported/denied] prior similar episodes in the past.  Patient denied any preceding trauma.  Doubt significant intracranial process at this time with no indication for acute imaging.

Given onset of symptoms [within the past 72 hours/greater than 72 from time of presentation] we discussed plan for discharge [with/without] Prednisone.  We also discussed plan for discharge with [Valacyclovir/Acyclovir] despite limited evidence of benefit with no significant associated harm.  We also discussed covering the eye overnight and provided patient with lubricating eye-drops on discharge.  We discussed return precautions and recommended follow up with primary care provider in [time frame], and the patient demonstrated understanding and agreement.

http://www.emdocs.net/bells-palsy-pearls-and-pitfalls-in-evaluation-and-management/