Differential diagnosis documentation

Abdominal pain

Abdominal pain in adult female

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Abdominal pain adult male

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; GI bleeding, or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with testicular torsion, prostatitis, hernia, STI, or other testicular issue.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Abdominal pain peds female

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with intussception; bowel perforation/obstruction; volvulus; appendicitis; peritonitis; cholecystitis, ascending cholangitis or other gallbladder disease; significant GI bleeding, splenic rupture/infarction; hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with incarcerated hernia; pancreatitis, DKA; kidney stone; ischemic colitis; psoas or other abscess; methanol poisoning; heavy metal toxicity; porphyria; or abuse.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, otitis media, or other focal bacterial infection.

@NAME@ is not currently dehydrated and is tolerating POs.

Strict return and follow-up precautions have been given by me personally to the family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Abdominal pain peds male

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with intussception; bowel perforation/obstruction; volvulus; appendicitis; peritonitis; cholecystitis, ascending cholangitis or other gallbladder disease; significant GI bleeding, splenic rupture/infarction; hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with incarcerated hernia; pancreatitis, DKA; kidney stone; ischemic colitis; psoas or other abscess; methanol poisoning; heavy metal toxicity; porphyria; or abuse.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, otitis media, or other focal bacterial infection.

@NAME@ is not currently dehydrated and is tolerating POs.

Strict return and follow-up precautions have been given by me personally to the family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Abscess

There is no area of retained pus after procedure. The presentation of @NAME@ is NOT consistent with necrotizing fascitis or osteomyolitis. There is no evidence of retained foreign body (besides packing), or neurovascular or tendon injury. The presentation of @NAME@ is NOT consistent with sepsis and/or bacturemia. @NAME@ meets outpatient criteria for treatment and is sent home on empiric antibiotics covering the relevant bacteria.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

AGE

@NAME@ likely has viral acute gastro-enteritis. Able to take down POs. No indication for antibiotics or further studies at this time.

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Asthma

The presentation of @NAME@ is not consistent with cardiac wheeze, congestive heart failure, pneumothorax, pulmonary emboli, or other emergent process.

Additionally, @NAME@ has no evidence of of pneumonia, sepsis, or other indication for antibiotics.

Upon discharge, @NAME@ has no evidence of respiratory failure or signs of tiring, and is comfortable without respiratory distress. @NAME@ meets outpatient treatment criteria.

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Cellulitis

There is no area of currently drain-able abscess. The presentation of @NAME@ is NOT consistent with necrotizing fascitis or osteomyolitis. There is no evidence of retained foreign body, or neurovascular or tendon injury. The presentation of @NAME@ is NOT consistent with sepsis and/or bacturemia. @NAME@ meets outpatient criteria for treatment and is sent home on empiric antibiotics covering the relevant bacteria, including MRSA if applicable.

Strict return and follow-up precautions have been given personally by me.

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Chest Pain Discharge

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with Acute Coronary Syndrome (ACS) and/or myocardial ischemia, pulmonary embolism, aortic dissection; Borhaave's, significant arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Further, the presentation of @NAME@ is NOT consistent with pericarditis, myocarditis, cholecystitis, pancreatitis, mediastinitis, endocarditis, new valvular disease.

Additionally, the presentation of @NAME@ is NOT consistent with flail chest, cardiac contusion, ARDS, or significant intra-thoracic or intra-abdominal bleeding.

Similarly, this presentation is NOT consistent with pneumonia, sepsis, or pyelonephritis.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Crying infant

@NAME@ has no evidence of occult UTI, corneal abrasion, hair tourniquets, insect bites, burns in mouth, otitis, physical abuse, anal fissures, intussusception, incarcerated hernias, testicular torsion, drug exposure or withdrawal, meningitis, SVT, PNA, rib fractures, ASA OD, surgical abdomen, infection, fracture or other trauma, or other emergent cause of symptoms.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Fever adult

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with meningitis, sepsis and/or bactermia. @NAME@ is not severely dehydrated and can tolerate POs at home.

Further, the presentation of @NAME@ is NOT consistent with surgical abdomen and/or peritonitis, for example appendicitis; bowel prerforation or obstruction; volvulus; intussception; pyloric stenosis; gallbladder disease; splenic rupture/infarction; Hepatic abscess; psoas or other abscess.

Further, the presentation of @NAME@ is NOT consistent pyelonephritis, urinary infection, pneumonia, or otitis media, or other focal bacterial infection.

@NAME@ is not at risk for Ebola, MERS, or other specific travel-related infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Fever Peds

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with meningitis, sepsis and/or bactermia. @NAME@ is not severely dehydrated and can tolerate POs at home.

Further, the presentation of @NAME@ is NOT consistent with surgical abdomen and/or peritonitis, for example appendicitis; bowel prerforation or obstruction; volvulus; intussception; pyloric stenosis; gallbladder disease; splenic rupture/infarction; Hepatic abscess; psoas or other abscess.

Similarly, this presentation is NOT consistent with Kawasaki's or other emergency cause of fever.

Further, the presentation of @NAME@ is NOT consistent pyelonephritis, urinary infection, pneumonia, or otitis media, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to parent(s)/guardian(s).

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Fracture

@NAME@ has no evidence of an open fracture; dislocation; retained foreign body; nerve, tendon, or vascular injury; compartment syndrome; septic joint or other infection.

Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Headache

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with fracture, meningitis/encephalitis, SAH/sentinel bleed, Intracranial Hemorrhage (ICH) (subdura/epidural), acute obstructive hydrocephalus, space occupying lesions, CVA, CO Poisoning, Basilar artery dissection, preeclampsia, cerebral venous thrombosis, hypertensive emergency, suicidal ideation, temporal Arteritis, Idiopathic Intracranial Hypertension (pseudotumor cerebri).

Strict return and follow-up precautions have been given by me personally.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Head laceration

@NAME@ has no evidence of retained foreign body; nerve, tendon, or vascular injury; fracture; compartment syndrome; or infection.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with with emergent intracranial pathology, including hemorrhage, epidural, subdural, or other intra-cranial bleeding.

Similarly, the presentation of @NAME@ is not consistent with fracture, other head or neck injury, septal hematoma, or other emergent injury. @NAME@ meets low risk criteria for head trauma and risk/benifits of additional studies and outpatient observation were discussed.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Head Trauma

@NAME@ has no evidence of retained foreign body; nerve, tendon, or vascular injury; fracture; compartment syndrome; or infection.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with with emergent intracranial pathology, including hemorrhage, epidural, subdural, or other intra-cranial bleeding.

Similarly, the presentation of @NAME@ is not consistent with fracture, other head or neck injury, septal hematoma, or other emergent injury. @NAME@ meets low risk criteria for head trauma and risk/benifits of additional studies and outpatient observation were discussed.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Asymptomatic hypertension

No e/o hypertensive emergency. Started on additional agent with goal of gradual cautious reduction of BP to normal level.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Kidney stone

Female

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with an infected stone, nephric abscess, sepsis, or renal failure.

Similarly, this presentation is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Male

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with an infected stone, nephric abscess, sepsis, or renal failure.

Similarly, this presentation is not consistent with a AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; GI bleeding, or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with testicular torsion, prostatitis, hernia, STI, or other testicular issue.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Knee Trauma

@NAME@ has no evidence of an open wound; fracture; dislocation; retained foreign body; nerve or vascular injury; compartment syndrome; septic joint or other infection.

Given her equivocal knee exam due to acute trauma, she has been splinted with a knee immobilizer with crutches and told to follow up with her PMD and/or orthopedics in the next several days for further evaluation after the swelling has resolved and the knee exam is more reliable. She may require an MRI or other studies at that time.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Laceration

@NAME@ has no evidence of retained foreign body; nerve, tendon, or vascular injury; fracture; compartment syndrome; or infection.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Low back pain

Not consistent with fracture, AAA, kidney stone, surgical abdomen, kidney infection, renal failure, pneumonia, paraspinal or epidural infection, cord compression or cauda equina, pyelonephritis or UTI, or other emergent cause.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

General ortho

@NAME@ has no evidence of a fracture; dislocation; retained foreign body; nerve, tendon, or vascular injury; compartment syndrome; DVT; septic joint, cellulitis, osteomyelitis, abscess, or other infection.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Otitis media peds

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with meningitis, sepsis and/or bactermia. @NAME@ is not severely dehydrated and can tolerate POs at home.

Further, the presentation of @NAME@ is NOT consistent with surgical abdomen and/or peritonitis, for example appendicitis; bowel prerforation or obstruction; volvulus; intussception; pyloric stenosis; gallbladder disease; splenic rupture/infarction; Hepatic abscess; psoas or other abscess.

Similarly, this presentation is NOT consistent with Kawasaki's or other emergency cause of fever.

Further, the presentation of @NAME@ is NOT consistent pyelonephritis, urinary infection, or pneumonia.

Further, there is no evidence of malignant otitis externa, perforated tympanic membrane, or mastoiditis.

Strict return and follow-up precautions have been given by me personally to parent(s)/guardian(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Paronychia

There is no area of retained pus after procedure. The presentation of @NAME@ is NOT consistent with necrotizing fascitis, osteomyolitis, flexor tenosynovitis, felon or other infection.. There is no evidence of retained foreign body (besides packing), or neurovascular or tendon injury. The presentation of @NAME@ is NOT consistent with sepsis and/or bacturemia. @NAME@ meets outpatient criteria for treatment and is sent home on appropriate antibiotic coverage.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Psych discharge

@NAME@ has no suicidal ideations or plan, no homicidal ideation or plan, and does have a plan for self care; @NAME@ does not meet any hold-able criteria. @NAME@ has no evidence of delirium or an organic cause of psychiatric illness. @NAME@ is aware that we have social services available at any time, if needing any additional help. @NAME@ is advised not to use illegal drugs or substances, and not to drive or operate heavy machinery if using alcohol or other mind-altering substances.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Pyelo female

@NAME@ has pyelonephritis, without evidence of complication. There is no evidence of sepsis ongoing after antibiotic treatment initiated and @NAME@ meets widely accepted outpatient treatment criteria.

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, pneumonia, or other emergent cardiopulmonary condition.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Salter Harris Type 1

Given tenderness to palpation over possible growth plate, patient will be splinted in case of Salter Harris type 1 fracture, with plan to follow up for a recheck by pediatrics/orthopedics in 5-6 days.

Adan Leiva has no evidence of an open fracture; dislocation; retained foreign body; nerve, tendon, or vascular injury; compartment syndrome; septic joint or other infection.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Sickle cell crisis

@NAME@'s presentation is not consistent with new bony infarction, avascular necrosis, acute chest syndrome, pneumonia, asthma exacerbation, new pulmonary hypertension, surgical abdomen, infection, worsening anemia, CVA, TIA, ICH, priapism.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Symptomatic cholelithiasis

Patient with symptomatic cholilithiasis, however no current evidence of cholecystitis, ascending cholangitis, or other complication. Given precautions personally by me to return if concerning symptoms for latter.

Given the large differential diagnosis for @NAME@, the decision making in this case was of high complexity.

After evaluating all of the data points in this case, the presentation of Alexandria Meyer is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

General Trauma

@NAME@'s presentation and findings are not consistent with intracranial pathology including hemorrhage, epidural, subdural, etc. No evidence of fracture, other head or neck injury, septal hematoma, or other injury. Meets low risk criteria for head trauma and risk/benifits of additional studies and outpatient observation discussed.

It is not consistent with a spine injury; vertebral fracture or dislocation; tracheo-broncheal injury; esophageal injury; major vascular injury; or other spine injury.

Additionally, it is not consistent with pneumo- or hemo-thorax; pulmonary contusion; ARDS; cardiac tamponade; cardiac contusion; mediastinal disruption; aortic injury; or other major chest trauma.

Additionally, @NAME@'s presentation is not consistent with intra-abdominal or retro-peritoneal bleeding; liver, spleen, kidney, or other solid organ injury; stomach, large or small bowel perforation; ureter, kidney, bladder or urethral injury; pelvic fracture; or other major abdominal trauma.

Additionally, @NAME@ has no evidence of an open fracture; fracture, dislocation; retained foreign body; nerve, tendon, or vascular injury; compartment syndrome; septic joint or other infection.

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

UTI female

The presentation is NOT consistent with pyelonephritis, sepsis, or sterile pyuria..

Given the large differential diagnosis, the decision making in this case is of high complexity.

After evaluating all of the data points in this case, the presentation of Monirath Say is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.

Similarly, this presentation is NOT consistent with pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

Vaginal bleeding in pregnancy

Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.

There is no evidence of an ectopic pregnancy, life-threatening vaginal bleeding/serious anemia, or infection. I have additionally performed an evaluation of the need for RhoGam and notified the patient of her blood type.

Further, after evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; hepatic abscess; or other surgical/acute abdomen.

Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; pulmonary embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.

Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome,Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.

Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.

Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).

Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.

See Also

• Documentation for emergency physicians

Authors

Ross Donaldson, Garvin Chan