{"_note":"© 2026 Kim Trinh, MD. All rights reserved. Original, synthetic documentation language for education only — not medical or legal advice and not a template for any specific patient. Each *** is a fill-in (an Epic wildcard): in Epic, press F2 to jump to the next *** and type or delete it. Edit to fit the actual encounter and your local policy. Runs entirely in the browser; nothing entered or added is stored on a server.","categories":[{"id":"mdm","label":"MDM & rule-out"},{"id":"cantmiss","label":"Can't-miss by complaint"},{"id":"return","label":"Return / bounceback visit"},{"id":"sdm","label":"Shared decision-making & consent"},{"id":"refusal","label":"Refusal · AMA · capacity"},{"id":"uncertainty","label":"Uncertainty & safety-net"},{"id":"reassess","label":"Reassessment"},{"id":"discharge","label":"Discharge & return"},{"id":"data","label":"Data & results"},{"id":"coding","label":"E/M & MDM coding (2023)"},{"id":"comms","label":"Communication & handoff"},{"id":"timecrit","label":"Time-critical pathways"},{"id":"psych","label":"Psych & safety"},{"id":"special","label":"Special populations"},{"id":"proc","label":"Procedures & sedation"}],"phrases":[{"id":"mdm-cantmiss","trigger":".mdmcantmiss","title":"Can't-miss differential considered & excluded","cat":"mdm","tags":"differential life-threatening rule out considered excluded emergent reasoning","body":"The emergent and life-threatening causes of *** were actively considered. ***, ***, and *** were each evaluated against the history, examination, and data documented above and judged unlikely at this time. No high-risk features were identified to suggest an emergent process. Residual risk is felt to be low but non-zero, and this was discussed with the patient along with a specific plan for reassessment and return.","aliases":"worst first cannot miss can't miss dangerous deadly emergent life threatening ruled out red flag differential"},{"id":"mdm-workup","trigger":".mdmworkup","title":"Workup selected by pretest probability","cat":"mdm","tags":"workup testing pretest probability rationale deliberate risk benefit","body":"Diagnostic studies were selected deliberately based on the pretest probability of the dangerous diagnoses under consideration, rather than reflexively. Results were personally reviewed and interpreted in the clinical context above. The decision to {{decision|defer|pursue|forgo}} further testing reflects a considered risk-benefit judgment and was discussed with the patient.","aliases":"why i ordered these tests rationale ordering labs imaging chose judicious workup pretest"},{"id":"mdm-lowrisk-tool","trigger":".mdmlowrisk","title":"Risk stratified with a validated tool","cat":"mdm","tags":"risk score heart wells perc nexus canadian validated stratification low","body":"Risk was stratified using the {{tool|HEART score|Wells score (PE)|PERC rule|Wells DVT score|Canadian Syncope Risk Score|Glasgow-Blatchford score|Ottawa SAH rule|Centor / McIsaac score|Alvarado score|qSOFA}} (score ***; {{risk|low|moderate|high}} risk). This validated instrument was used to inform — not replace — clinical judgment, and is consistent with the overall low-risk impression. The score, its inputs, and its role in the disposition are documented above.","aliases":"score scores decision rule heart wells perc nexus canadian ottawa pecarn risk calculator low risk stratify"},{"id":"mdm-discordant-vital","trigger":".mdmvital","title":"Abnormal vital sign addressed before disposition","cat":"mdm","tags":"abnormal vital sign tachycardia hypertension fever rechecked discordant addressed discharge","body":"The *** noted during the visit was specifically addressed and rechecked prior to disposition: ***. It was interpreted in the context of *** and was not felt to represent an unstable or untreated process. The patient met disposition criteria with {{vitals|normal|stable|improved}} vital signs; the abnormal value was not overlooked.","aliases":"abnormal vitals tachycardia tachycardic hypotension hypertension hypoxia fever heart rate blood pressure before discharge persistent"},{"id":"mdm-negative-workup","trigger":".mdmnegwork","title":"Workup reassuring — treating symptoms, no dangerous cause found","cat":"mdm","tags":"negative reassuring workup symptomatic benign diagnosis of exclusion follow up","body":"The evaluation to date is reassuring and does not identify an emergent cause for ***. A symptomatic / benign diagnosis of *** is favored, made in part by exclusion of the dangerous alternatives above. The patient understands this is a working diagnosis, that further evaluation may be warranted if the course is atypical, and the plan for follow-up and return was reviewed.","aliases":"negative workup normal labs nothing found reassuring symptomatic treatment no dangerous cause"},{"id":"cm-chestpain","trigger":".cmchestpain","title":"Chest pain — can't-miss line","cat":"cantmiss","tags":"chest pain acs mi pe dissection pneumothorax esophageal can't miss","body":"For this chest pain I actively considered acute coronary syndrome, pulmonary embolism, aortic dissection, tension/spontaneous pneumothorax, and esophageal rupture. ACS — pain not exertional, pressure-like, or radiating, no diaphoresis or nausea, no prior CAD, ECG without ischemic change, troponin {{troponin|negative|serial negative|mildly elevated}}, HEART score {{HEART|low risk|moderate risk|high risk}}. PE — no hemoptysis, no estrogen or oral-contraceptive use, no prior DVT/PE, no recent surgery or immobilization, no unilateral leg swelling, HR {{HR|<100|100–110|>110}}, SpO2 {{SpO2|≥95% on room air|92–94%|<92% or on O₂}}; Wells {{Wells|low|moderate|high}}; PE {{PE conclusion|excluded by PERC — no testing indicated|excluded by negative d-dimer with low pretest probability|excluded by negative CT angiogram|not yet excluded — testing in progress}}. Aortic dissection — no tearing or migratory pain, symmetric pulses without deficit, no diastolic murmur, no uncontrolled hypertension or connective-tissue disorder. These emergent causes were {{conclusion|judged unlikely; residual risk low but non-zero|incompletely excluded — observation for serial testing arranged|of sufficient concern that admission was arranged}}.","specs":["cards","pulm","vasc"],"aliases":"chest pain heart attack mi acs angina pe pulmonary embolism aortic dissection chest pressure tightness noncardiac"},{"id":"cm-headache","trigger":".cmheadache","title":"Headache — can't-miss line","cat":"cantmiss","tags":"headache sah subarachnoid meningitis mass stroke gca can't miss thunderclap","body":"For this headache I considered subarachnoid hemorrhage, meningitis/encephalitis, mass lesion with raised ICP, stroke/ICH, cerebral venous sinus thrombosis, and (when age-appropriate) giant cell arteritis. Not thunderclap or maximal at onset, not the worst of life, no exertional onset; no fever, neck stiffness, or photophobia; no focal deficit and no papilledema; no immunosuppression, no anticoagulation; no estrogen/OCP or hypercoagulable risk for CVST; no jaw claudication, scalp tenderness, or visual loss. ESR/CRP {{ESR/CRP|normal|elevated|pending}}, CT/LP {{CT/LP|not indicated — Ottawa negative and low-risk features|CT negative within 6 h of onset — SAH effectively excluded|CT negative and LP negative — SAH and meningitis excluded|CT negative, LP deferred after shared decision with documented return plan|pending}}. The dangerous causes were judged unlikely on the basis above.","specs":["neuro","nsgy"],"aliases":"headache migraine worst headache of life thunderclap sah subarachnoid meningitis bleed head pain temporal arteritis"},{"id":"cm-abdominal","trigger":".cmabd","title":"Abdominal pain — can't-miss line","cat":"cantmiss","tags":"abdominal pain aaa appendicitis perforation mesenteric ischemia ectopic obstruction can't miss","body":"For this abdominal pain I considered abdominal aortic aneurysm, mesenteric ischemia, perforated viscus, appendicitis, bowel obstruction, and (in patients of reproductive potential) ectopic pregnancy. No pulsatile mass, tearing, or back pain and equal femoral pulses; pain proportionate to exam with no atrial fibrillation or vascular disease to suggest mesenteric ischemia; no rigidity, rebound, or free air; no migration to the RLQ; no obstipation, prior surgery, or distension; pregnancy {{pregnancy|negative|positive — IUP confirmed on ultrasound, ectopic effectively excluded|positive — no IUP yet, ectopic workup in progress|N/A}}. Lactate {{lactate|normal|elevated|pending}}, imaging {{imaging|negative|positive|pending}}. The surgical and vascular emergencies were judged unlikely, with reassessment planned for any change.","specs":["gi","surg","vasc","obgyn"],"aliases":"abdominal pain belly pain stomach ache tummy appendicitis aaa bowel obstruction perforation mesenteric gastroenteritis"},{"id":"cm-backpain","trigger":".cmback","title":"Back pain — can't-miss line","cat":"cantmiss","tags":"back pain cauda equina epidural abscess aaa cord compression can't miss red flags","body":"For this back pain I screened for cauda equina syndrome, spinal epidural abscess, malignant cord compression, and abdominal aortic aneurysm. No saddle anesthesia, urinary retention (post-void residual {{PVR|not indicated|< 100 mL — reassuring|> 200 mL — concerning, MRI pursued}}), or new bowel/bladder dysfunction; no bilateral or progressive deficit; no fever, IVDU, immunosuppression, recent bacteremia, or spinal instrumentation; no history of cancer, unexplained weight loss, or night/rest pain; no pulsatile mass; neurologic exam intact. Red-flag features were absent and specifically documented.","specs":["nsgy","vasc"],"aliases":"back pain cauda equina epidural abscess aortic spinal cord lower back lumbar sciatica"},{"id":"cm-syncope","trigger":".cmsyncope","title":"Syncope — can't-miss line","cat":"cantmiss","tags":"syncope arrhythmia pe aaa sah occult hemorrhage cardiac can't miss","body":"For this syncope I considered arrhythmia/structural cardiac syncope, pulmonary embolism, occult hemorrhage (including AAA, GI, and ectopic), and subarachnoid hemorrhage. Reassuring prodrome/trigger, not exertional or supine, no palpitations, no family history of sudden death, no structural heart disease; ECG without ischemia, block, pre-excitation, or prolonged QT; no PE risk features; hemodynamically stable without orthostasis or anemia; non-focal neurologic exam; pregnancy {{pregnancy|negative|positive|N/A}}. The dangerous causes were judged unlikely; disposition reflects the assessed risk ({{disposition|discharge|observation|admission|transfer}}).","specs":["cards","neuro"],"aliases":"syncope passed out fainting faint loss of consciousness blackout collapse near syncope presyncope"},{"id":"cm-dizziness","trigger":".cmdizziness","title":"Dizziness / vertigo — can't-miss line","cat":"cantmiss","tags":"dizziness vertigo posterior stroke vertebral dissection arrhythmia hints central peripheral co","body":"For this dizziness/vertigo I distinguished a peripheral cause from posterior-circulation stroke, vertebral or carotid dissection, and cardiac arrhythmia (and considered carbon monoxide and hypoglycemia). HINTS {{HINTS|peripheral pattern — positive head-impulse, unidirectional nystagmus, no skew|central pattern — urgent imaging and neurology|not applicable — episodic/positional symptoms, Dix-Hallpike performed}}, able to walk unaided with no truncal ataxia or dysmetria; no new headache or neck pain, no focal deficit; no cardiac symptoms, ECG {{ECG|non-ischemic|no acute changes|ischemic changes}}; glucose {{glucose|normal|low|elevated}}. An emergent central cause was judged unlikely on the basis above.","specs":["neuro","ent","cards"],"aliases":"dizziness vertigo lightheaded room spinning stroke posterior circulation imbalance"},{"id":"cm-dyspnea","trigger":".cmdyspnea","title":"Dyspnea — can't-miss line","cat":"cantmiss","tags":"dyspnea shortness of breath pe acs chf tension pneumothorax anaphylaxis airway dka acidosis","body":"For this dyspnea I considered pulmonary embolism, ACS and heart failure, tension pneumothorax, upper-airway compromise/anaphylaxis, severe pneumonia or bronchospasm, and metabolic acidosis (including DKA). PE — no hemoptysis, no estrogen or oral-contraceptive use, no prior VTE, no recent surgery or immobilization, no unilateral leg swelling; Wells {{Wells|low|moderate|high}} / PERC negative. No ischemic chest pain or ECG change; breath sounds equal with trachea midline; no stridor or angioedema; SpO2 {{SpO2|≥95% on room air|92–94%|<92% or on O₂}}, work of breathing {{work of breathing|unlabored|mild distress|moderate distress|severe distress}}; glucose/anion gap ***. The dangerous causes were judged unlikely; disposition reflects the assessed risk.","specs":["pulm","cards"],"aliases":"shortness of breath dyspnea sob breathing trouble cant breathe winded copd chf pe pneumonia hypoxia"},{"id":"cm-fever","trigger":".cmfever","title":"Fever / sepsis (adult) — can't-miss line","cat":"cantmiss","tags":"fever sepsis septic shock meningitis necrotizing endocarditis neutropenic source immunocompromised","body":"For this fever I screened for sepsis and its dangerous sources — meningitis/encephalitis, necrotizing soft-tissue infection, endocarditis, an intra-abdominal or urinary source, and (in the immunocompromised or neutropenic patient) opportunistic infection. No hypotension or end-organ hypoperfusion, mental status at baseline, no meningismus, no pain out of proportion or crepitus, no new murmur or embolic stigmata, indwelling line or recent procedure {{device|none|present — considered and addressed as a source}}; lactate {{lactate|normal|elevated|pending}}, source workup {{source|unrevealing — urinalysis and chest imaging negative|focal source identified and treated|cultures pending — empiric therapy started}}. Septic shock and an occult deep infection were judged unlikely or addressed.","specs":["id"],"aliases":"fever sepsis infection febrile adult high temperature septic"},{"id":"cm-ams","trigger":".cmams","title":"Altered mental status — can't-miss line","cat":"cantmiss","tags":"altered mental status ams hypoglycemia stroke ich cns infection intoxication withdrawal sepsis electrolyte ncse","body":"For this altered mental status I addressed the reversible and dangerous causes — hypoglycemia, hypoxia/hypercapnia, stroke/ICH, CNS infection, intoxication and withdrawal, sepsis, metabolic and electrolyte derangement, and nonconvulsive seizure. Glucose {{glucose|normal|low|elevated}}, SpO2 {{SpO2|≥95% on room air|92–94%|<92% or on O₂}}, focused neurologic exam non-focal, no meningismus, no toxidrome; sodium/calcium/ammonia {{labs|unremarkable|abnormal — addressed|pending}}, toxicology {{tox|not indicated|negative|positive — managed accordingly|pending}}; CT head {{CT head|negative|positive|pending}}. Structural, infectious, and metabolic emergencies were considered and addressed as documented.","specs":["neuro","tox","id"],"aliases":"altered mental status confusion ams delirium unresponsive not acting right encephalopathy lethargic"},{"id":"cm-gibleed","trigger":".cmgibleed","title":"GI bleeding — can't-miss line","cat":"cantmiss","tags":"gi bleed hemorrhage variceal aortoenteric fistula peptic ulcer aaa shock orthostatic","body":"For this GI bleeding I assessed for hemodynamically significant hemorrhage and its high-risk sources — variceal bleeding, aortoenteric fistula (prior aortic graft {{graft|none|present — CTA to exclude aortoenteric fistula}}), and peptic ulcer disease — and considered a ruptured AAA and ACS-with-anemia. Hemodynamically stable without orthostasis, no stigmata of cirrhosis or portal hypertension, no prior aortic surgery; hemoglobin {{Hgb|at baseline|mildly decreased|significantly decreased — transfusion considered}}, type and screen sent, Glasgow-Blatchford {{Glasgow-Blatchford|low risk|high risk}}. Exsanguinating and occult vascular sources were judged unlikely or addressed.","specs":["gi","surg"],"aliases":"gi bleed bleeding blood in stool melena hematochezia hematemesis vomiting blood black stool rectal bleeding"},{"id":"cm-earlypreg","trigger":".cmearlypreg","title":"Early-pregnancy bleeding / ectopic — can't-miss line","cat":"cantmiss","tags":"ectopic pregnancy first trimester bleeding heterotopic molar hcg ultrasound ruptured hemoperitoneum reproductive","body":"For this first-trimester bleeding/pain I treated ectopic pregnancy as the can't-miss diagnosis until excluded, and considered heterotopic and molar pregnancy and hemorrhagic shock from a ruptured ectopic. Risk factors reviewed (prior ectopic, tubal surgery, PID, IUD, assisted reproduction); hemodynamically stable with no peritoneal signs; quantitative hCG {{hCG|obtained and interpreted with the ultrasound|below the discriminatory zone|above the discriminatory zone|pending}}, Rh {{Rh|positive|negative — Rho(D) given}}; pelvic ultrasound: {{ultrasound|intrauterine pregnancy confirmed — ectopic effectively excluded (heterotopic considered if assisted reproduction)|no IUP, hCG below discriminatory zone — ectopic not excluded; ectopic precautions and serial hCG in 48 h|no IUP, hCG above discriminatory zone — high concern for ectopic; OB consulted|free fluid or adnexal mass — emergent OB consultation|pending}}. The patient was counseled on ectopic precautions and strict return, with follow-up arranged: {{follow-up|serial hCG in 48 hours|repeat ultrasound|OB/GYN within 48 hours|already admitted to OB}}.","specs":["obgyn"],"aliases":"early pregnancy bleeding ectopic miscarriage first trimester positive pregnancy spotting threatened abortion"},{"id":"cm-pelvic","trigger":".cmpelvic","title":"Pelvic pain (female) — can't-miss line","cat":"cantmiss","tags":"pelvic pain ectopic ovarian torsion tubo-ovarian abscess pid ruptured cyst appendicitis doppler","body":"For this pelvic pain I considered ectopic pregnancy, ovarian torsion, tubo-ovarian abscess/PID, a ruptured ovarian cyst with hemoperitoneum, and appendicitis. Pregnancy {{pregnancy|negative|positive — IUP confirmed on ultrasound, ectopic effectively excluded|positive — no IUP yet, ectopic workup in progress|N/A}}; pain not sudden and severe with vomiting to suggest torsion, no adnexal mass; ovarian Doppler {{Doppler|normal arterial and venous flow — torsion less likely (normal flow does not fully exclude it)|diminished or absent flow — urgent gynecology consulted|not indicated}}; no cervical-motion or adnexal tenderness, no fever; pelvic ultrasound {{ultrasound|negative|positive|pending}}. The time-sensitive surgical and obstetric emergencies were judged unlikely or addressed, with reassessment planned for any change.","specs":["obgyn","surg"],"aliases":"pelvic pain female lower abdominal ovarian torsion pid ectopic tubo ovarian"},{"id":"cm-sorethroat","trigger":".cmsorethroat","title":"Sore throat — can't-miss line","cat":"cantmiss","tags":"sore throat epiglottitis supraglottitis peritonsillar retropharyngeal deep neck abscess ludwig lemierre airway","body":"For this sore throat I screened for the airway and deep-space emergencies — epiglottitis/supraglottitis, peritonsillar, retropharyngeal, and other deep-neck abscesses, Ludwig angina, and Lemierre syndrome. Airway patent with no stridor, drooling, or tripod positioning; voice normal with no trismus, uvular deviation, or floor-of-mouth swelling; no neck swelling, torticollis, or pain out of proportion; no rigors or unilateral neck pain to suggest Lemierre. An airway-threatening infection was judged unlikely on the basis above.","specs":["ent","id"],"aliases":"sore throat pharyngitis epiglottitis peritonsillar abscess throat pain trouble swallowing odynophagia"},{"id":"cm-brue","trigger":".cmbrue","title":"Pediatric BRUE — can't-miss line","cat":"cantmiss","tags":"brue brief resolved unexplained event infant apnea nonaccidental abuse sepsis arrhythmia seizure pertussis risk","body":"For this brief resolved unexplained event I considered nonaccidental trauma, sepsis/meningitis, a cardiac arrhythmia or congenital heart disease, seizure, an inborn error of metabolism, and pertussis/RSV with apnea. Well-appearing at baseline with a normal exam and no bruising or bleeding, no fever or ill contacts, no recurrent events; lower- versus higher-risk BRUE criteria applied (age >60 days ***, term/≥32 weeks, first event, <1 minute, no CPR by a trained provider). ECG {{ECG|non-ischemic|no acute changes|ischemic changes}}. Caregiver instructions and risk-appropriate follow-up were provided.","specs":["peds","cards"],"aliases":"brue alte baby stopped breathing infant event apnea turned blue limp choking spell"},{"id":"cm-pedfever","trigger":".cmpedfever","title":"Febrile infant / young child — can't-miss line","cat":"cantmiss","tags":"pediatric febrile infant neonate sepsis sbi uti bacteremia meningitis hsv myocarditis age appearance","body":"For this febrile young infant I evaluated for serious bacterial infection and the can't-miss neonatal causes — bacteremia, urinary tract infection, bacterial meningitis, and (in the neonate) herpes simplex and myocarditis. Age *** days, appearance {{appearance|well-appearing|ill-appearing}}; age-appropriate workup (urinalysis and urine culture, blood culture, CBC/inflammatory markers, LP {{LP|performed|not indicated by risk stratification|deferred — shared decision with strict return precautions}}, HSV PCR/acyclovir {{HSV|not indicated|sent — acyclovir started empirically}}). Disposition and empiric therapy ({{empiric|none — low-risk pathway|ceftriaxone|ampicillin + cefotaxime|ampicillin + gentamicin}}) reflect the age- and appearance-based risk.","specs":["peds","id"],"aliases":"febrile infant baby fever young child pediatric fever newborn fever well appearing child"},{"id":"cm-pedresp","trigger":".cmpedresp","title":"Pediatric respiratory distress / bronchiolitis — can't-miss line","cat":"cantmiss","tags":"pediatric respiratory distress bronchiolitis apnea foreign body anaphylaxis myocarditis pneumonia pertussis wheeze","body":"For this pediatric respiratory distress I considered apnea or impending respiratory failure, foreign-body aspiration, anaphylaxis, myocarditis/heart failure, pneumonia, and pertussis beyond bronchiolitis. Work of breathing {{work of breathing|unlabored|mild distress|moderate distress|severe distress}}, SpO2 {{SpO2|≥95% on room air|92–94%|<92% or on O₂}}, feeding and hydration {{hydration|adequate|borderline|poor}}; no apnea, no choking or witnessed aspiration, no focal findings or hepatomegaly/gallop; apnea risk factors (age <*** weeks, prematurity) considered. Impending respiratory failure and the non-bronchiolitis emergencies were judged unlikely or addressed.","specs":["peds","pulm"],"aliases":"pediatric respiratory distress bronchiolitis rsv croup child breathing wheezing kid retractions"},{"id":"cm-pedvomit","trigger":".cmpedvomit","title":"Pediatric vomiting — can't-miss line","cat":"cantmiss","tags":"pediatric vomiting bilious malrotation volvulus intussusception pyloric stenosis hernia icp dka torsion","body":"For this pediatric vomiting I screened for malrotation with midgut volvulus (bilious emesis in a young infant ***), intussusception, pyloric stenosis, an incarcerated hernia, raised intracranial pressure, DKA, and testicular torsion. Emesis non-bilious and non-bloody, abdomen soft and non-distended with no mass, hernia orifices clear, GU exam normal, hydration ***; glucose {{glucose|normal|low|elevated}}. The time-critical causes were judged unlikely or evaluated as documented.","specs":["peds","surg"],"aliases":"pediatric vomiting child throwing up pyloric stenosis intussusception malrotation kid vomit bilious"},{"id":"cm-flank","trigger":".cmflank","title":"Flank pain — can't-miss line","cat":"cantmiss","tags":"flank pain aaa ruptured aneurysm dissection pyelonephritis renal infarct stone first stone older","body":"For this flank pain I did not anchor on renal colic: I considered a ruptured or symptomatic abdominal aortic aneurysm (older patient or first presentation ***), aortic dissection, pyelonephritis, and renal infarction. No pulsatile mass, equal pulses, hemodynamically stable; no atrial fibrillation or vascular disease to suggest embolic infarction; fever/CVA tenderness {{fever/CVA|absent|present}}; urinalysis {{urinalysis|negative|positive|pending}}, imaging {{imaging|negative|positive|pending}}. AAA and dissection were judged unlikely or excluded as documented.","specs":["uro","vasc"],"aliases":"flank pain kidney stone renal colic nephrolithiasis ureteral stone side pain pyelonephritis aaa hematuria"},{"id":"cm-scrotal","trigger":".cmscrotal","title":"Testicular / scrotal pain — can't-miss line","cat":"cantmiss","tags":"testicular torsion scrotal pain fournier gangrene incarcerated hernia appendix testis doppler urology","body":"For this acute scrotal pain I treated testicular torsion as the time-critical diagnosis and considered Fournier gangrene, an incarcerated or strangulated hernia, and torsion of the appendix testis. Onset {{onset|gradual|acute|sudden}}, cremasteric reflex present, normal testicular lie with no high-riding testis; no crepitus or perineal necrosis; no irreducible hernia; Doppler {{Doppler|showed normal symmetric flow — torsion unlikely|showed decreased or absent flow — emergent urology|was bypassed in favor of emergent urology given a convincing presentation}}. Urology was {{urology|not required|consulted|consulted emergently}} and not delayed for imaging when torsion was suspected. A surgical emergency was judged unlikely or acted upon as documented.","specs":["uro","surg"],"aliases":"testicular pain scrotal pain testicle torsion groin epididymitis swollen"},{"id":"cm-vision","trigger":".cmvision","title":"Acute vision loss / red eye — can't-miss line","cat":"cantmiss","tags":"vision loss red eye crao angle closure glaucoma giant cell arteritis retinal detachment endophthalmitis stroke","body":"For this acute vision change/red eye I screened for central retinal artery occlusion, acute angle-closure glaucoma, giant cell arteritis, retinal detachment, endophthalmitis, and posterior-circulation stroke. Visual acuity {{acuity|normal|reduced|counting fingers / hand motion}}, intraocular pressure {{IOP|normal|elevated}}, afferent pupillary defect {{APD|absent|present}}, fundus {{fundus|normal|abnormal}}; no headache, jaw claudication, or scalp tenderness (ESR/CRP {{ESR/CRP|normal|elevated|pending}} if GCA considered); no flashes, floaters, or curtain; no recent intraocular procedure. An emergent ophthalmologic or neurologic cause was judged unlikely or referred.","specs":["ophtho","neuro"],"aliases":"vision loss red eye pink eye eye pain blind acute glaucoma retinal detachment blurry vision flashes floaters"},{"id":"cm-weakness","trigger":".cmweakness","title":"Weakness / focal symptoms — can't-miss line","cat":"cantmiss","tags":"weakness stroke tia cord compression guillain barre hypoglycemia hyperkalemia hyponatremia botulism myasthenia","body":"For this weakness I distinguished stroke/TIA, spinal cord compression, Guillain-Barré syndrome, and metabolic causes (hypoglycemia, hyperkalemia, hyponatremia), and considered botulism and myasthenic crisis. Pattern {{pattern|focal|symmetric/ascending}}, reflexes {{reflexes|normal|brisk|reduced or absent}}, no sensory level or bowel/bladder change, no bulbar or respiratory involvement (NIF/FVC {{NIF/FVC|not indicated|reassuring|reduced — monitored closely with airway planning}}); glucose and electrolytes {{labs|normal|abnormal — corrected|pending}}; last-known-well {{LKW|clearly established|unknown — last seen normal time used}} and CT/CTA {{imaging|negative|showed acute findings — stroke pathway activated|not indicated|pending}} if stroke considered. A time-critical cause was judged unlikely or addressed.","specs":["neuro","nsgy"],"aliases":"weakness focal numbness stroke tia hemiparesis cant move arm leg facial droop tingling paralysis"},{"id":"cm-seizure","trigger":".cmseizure","title":"Seizure — can't-miss line","cat":"cantmiss","tags":"seizure first seizure hypoglycemia hyponatremia eclampsia cns infection mass hemorrhage toxic withdrawal ncse","body":"For this seizure I looked for dangerous provocations — hypoglycemia, hyponatremia, eclampsia ({{pregnancy status|not pregnant or postpartum|pregnant/postpartum — BP assessed, obstetrics involved}}), CNS infection, an intracranial mass or hemorrhage, toxic ingestion or withdrawal, and nonconvulsive status if mental status fails to recover. Glucose {{glucose|normal|low|elevated}}, sodium {{sodium|normal|low — corrected|pending}}, returned to baseline, no fever or meningismus, no focal deficit, no anticoagulation or trauma; toxicology/medication review {{tox|unremarkable|identified a provoking agent — addressed|pending}}; CT head {{CT head|negative|positive|pending}}. A dangerous secondary cause was judged unlikely or evaluated.","specs":["neuro"],"aliases":"seizure convulsion fit first seizure status epilepticus shaking"},{"id":"cm-palpitations","trigger":".cmpalpitations","title":"Palpitations — can't-miss line","cat":"cantmiss","tags":"palpitations ventricular tachycardia wpw pre-excitation long qt heart block acs pe thyroid storm ecg","body":"For these palpitations I considered ventricular tachycardia, pre-excitation (WPW), long-QT, and high-grade block, along with ACS, pulmonary embolism, electrolyte derangement, and thyroid storm. ECG reviewed — rate/rhythm {{rhythm|sinus|sinus tachycardia|irregularly irregular}}, QTc {{QTc|normal|borderline|prolonged}}, no delta wave or ischemic change; no exertional syncope or family history of sudden death; electrolytes and magnesium ***, TSH *** if indicated. A malignant arrhythmia or dangerous trigger was judged unlikely on the basis above.","specs":["cards"],"aliases":"palpitations heart racing fluttering arrhythmia afib svt skipped beats pounding"},{"id":"cm-leg","trigger":".cmleg","title":"Unilateral leg pain / swelling — can't-miss line","cat":"cantmiss","tags":"leg pain swelling dvt acute limb ischemia arterial occlusion compartment syndrome necrotizing fasciitis pulses","body":"For this unilateral leg pain/swelling I considered deep vein thrombosis, acute limb ischemia, compartment syndrome, and necrotizing soft-tissue infection. Pulses {{pulses|symmetric|intact|diminished|absent}}, perfusion intact, no pain out of proportion or pain with passive stretch, compartments soft; no crepitus, bullae, or rapidly advancing erythema; Wells DVT {{Wells DVT|unlikely|likely}} / ultrasound {{ultrasound|negative|positive|pending}}. A limb- or life-threatening cause was judged unlikely or evaluated as documented.","specs":["vasc","ortho","surg"],"aliases":"leg pain leg swelling dvt clot blood clot calf unilateral swelling deep vein thrombosis"},{"id":"cm-rash","trigger":".cmrash","title":"Dangerous rash — can't-miss line","cat":"cantmiss","tags":"rash anaphylaxis stevens johnson sjs ten meningococcemia purpura necrotizing fasciitis toxic shock dress nikolsky","body":"For this rash I screened for the dermatologic emergencies — anaphylaxis, Stevens-Johnson syndrome/TEN, meningococcemia and other purpuric eruptions, necrotizing fasciitis, toxic shock syndrome, and DRESS. No airway, respiratory, or hemodynamic compromise; no mucosal involvement, skin tenderness, or sloughing (Nikolsky negative); no petechiae or purpura, no pain out of proportion or crepitus; no fever with hypotension or facial edema/eosinophilia. A life-threatening eruption was judged unlikely on the basis above.","specs":["derm","id"],"aliases":"rash dangerous rash petechiae purpura sjs ten necrotizing fasciitis skin meningococcal hives blistering"},{"id":"cm-joint","trigger":".cmjoint","title":"Acute hot joint — can't-miss line","cat":"cantmiss","tags":"monoarthritis hot joint septic arthritis gout crystal gonococcal arthrocentesis synovial necrotizing","body":"For this acutely swollen, painful joint I treated septic arthritis as the can't-miss diagnosis — crystal disease does not exclude infection — and considered disseminated gonococcal infection and overlying necrotizing infection. Fever {{fever|absent|low-grade|present}}, joint warmth and effusion with pain on micro-motion; risk factors reviewed (prosthetic joint, immunosuppression, IVDU); arthrocentesis with cell count, Gram stain, and crystals {{arthrocentesis|performed — results pending|performed — crystals present, Gram stain negative; concurrent infection still considered|performed — findings concerning for septic arthritis, orthopedics consulted|deferred after shared decision with documented return plan}} before attributing the presentation to gout. A joint-destroying infection was judged unlikely or evaluated.","specs":["ortho","id"],"aliases":"hot joint septic arthritis swollen joint gout red joint knee monoarthritis"},{"id":"cm-neck","trigger":".cmneck","title":"Neck pain — can't-miss line","cat":"cantmiss","tags":"neck pain meningitis cervical artery dissection carotid vertebral epidural abscess subarachnoid cord compression","body":"For this neck pain I screened beyond musculoskeletal strain for meningitis, cervical artery (carotid or vertebral) dissection, spinal epidural abscess, subarachnoid hemorrhage, and cord compression. No meningismus or fever, no IVDU, immunosuppression, or recent bacteremia; no headache, Horner syndrome, or focal/posterior-circulation symptoms to suggest dissection; neurologic exam intact; CTA/MRI *** if dissection considered. A vascular, infectious, or compressive emergency was judged unlikely.","specs":["neuro","nsgy","vasc"],"aliases":"neck pain stiff neck meningitis carotid dissection cervical spine torticollis"},{"id":"cm-hemoptysis","trigger":".cmhemoptysis","title":"Hemoptysis — can't-miss line","cat":"cantmiss","tags":"hemoptysis massive airway pulmonary embolism malignancy tuberculosis diffuse alveolar hemorrhage vasculitis","body":"For this hemoptysis I considered massive or airway-threatening hemorrhage, pulmonary embolism, malignancy, tuberculosis and other infection, and diffuse alveolar hemorrhage/vasculitis. Volume {{volume|scant|small|moderate|massive}} with airway protected, hemodynamically stable, SpO2 {{SpO2|≥95% on room air|92–94%|<92% or on O₂}}; no PE risk features (Wells {{Wells|low|moderate|high}} / PERC negative); no weight loss or smoking history; TB exposure {{TB|none|present — isolation and testing initiated}}; imaging {{imaging|negative|positive|pending}}. A life-threatening cause was judged unlikely or evaluated as documented.","specs":["pulm"],"aliases":"hemoptysis coughing blood blood in sputum bloody cough"},{"id":"cm-obpain","trigger":".cmobpain","title":"Late-pregnancy pain / bleeding — can't-miss line","cat":"cantmiss","tags":"third trimester abdominal pain bleeding placental abruption preeclampsia hellp uterine rupture preterm labor previa","body":"For this third-trimester abdominal pain/bleeding I considered the obstetric emergencies — placental abruption, preeclampsia/HELLP, uterine rupture, and preterm labor — alongside appendicitis and other surgical causes. Blood pressure {{BP|normal|mildly elevated|severe-range}}, no severe-range BP or preeclampsia symptoms (headache, visual change, RUQ pain), no painful vaginal bleeding or rigid uterus, no prior uterine surgery; fetal status and monitoring ***; digital/speculum exam deferred until placenta previa is excluded by ultrasound {{ultrasound|negative|positive|pending}}. An obstetric catastrophe was judged unlikely or escalated to obstetrics.","specs":["obgyn"],"aliases":"late pregnancy pain bleeding third trimester abruption preeclampsia preterm labor contractions pregnant"},{"id":"sdm-general","trigger":".sdm","title":"Shared decision-making discussion","cat":"sdm","tags":"shared decision making risks benefits alternatives agreed understanding options","body":"I discussed the working diagnosis, the diagnostic uncertainty that remains, and the reasonable options — including *** and *** — with the patient. The risks, benefits, and alternatives of each were explained in plain language. The patient asked questions, demonstrated understanding, and we reached a shared decision to ***. The patient voiced agreement with this plan.","aliases":"shared decision making sdm discussed options risks benefits joint decision patient choice agreed"},{"id":"sdm-consent","trigger":".consent","title":"Informed consent for a procedure","cat":"sdm","tags":"informed consent procedure risks benefits alternatives voluntary","body":"Informed consent was obtained for ***. I explained the indication, what the procedure involves, the material risks (including bleeding, infection, injury to adjacent structures, failure or incomplete success, and the possible need for repeat intervention), the expected benefits, and the alternatives including no intervention. The patient's questions were answered and consent was given voluntarily by ***.","aliases":"informed consent procedure consented risks benefits alternatives understood"},{"id":"sdm-imaging","trigger":".sdmimaging","title":"Imaging / radiation shared decision","cat":"sdm","tags":"ct radiation imaging shared decision contrast risk benefit defer","body":"The role of *** was discussed, including the low but real risks of *** weighed against the diagnostic yield given this patient's pretest probability. After this discussion the patient elected to *** imaging. The decision and its rationale were shared and documented; a clear plan for return or follow-up was provided if symptoms change.","aliases":"imaging radiation ct scan shared decision radiation risk avoid ct contrast"},{"id":"ref-ama","trigger":".ama","title":"Against medical advice","cat":"refusal","tags":"ama against medical advice leaving capacity risks death return harm reduction","body":"The patient elected to leave against medical advice. The patient demonstrates intact decision-making capacity: alert, oriented, not intoxicated or otherwise impaired, and able to articulate an understanding of the situation. I explained the suspected/possible diagnoses, the specific risks of leaving — including serious deterioration, permanent harm, and death — and that I strongly recommended ***. The patient verbalized understanding of these risks and chose to leave. The patient was told they may return at any time without prejudice, was given return precautions, and was offered *** as a harm-reduction measure.","aliases":"ama against medical advice leaving signing out left refused admission discharge"},{"id":"ref-test","trigger":".refusetest","title":"Refusal of a recommended test or treatment","cat":"refusal","tags":"refuse decline test treatment capacity risks consequences respected","body":"I recommended *** and explained why it matters given the differential, including the specific risks of declining: ***. The patient, who has capacity, declined after this discussion and verbalized understanding of the potential consequences. The decision was respected; the door was left open to reconsider, and a clear plan to return for reassessment was provided.","aliases":"refused test refused treatment declined recommended testing patient refusal declines"},{"id":"ref-capacity","trigger":".capacity","title":"Decision-making capacity assessment","cat":"refusal","tags":"capacity competence understand appreciate reason communicate choice intact","body":"Capacity for this specific decision was assessed and is felt to be intact: the patient can communicate a choice, understands the relevant information about ***, appreciates how it applies to their own situation, and can reason through the options. At the time of this discussion the patient was not impaired by intoxication, acute psychiatric illness, or a cognitive deficit that would undermine these abilities.","aliases":"capacity competent decision making competence understands risks capacitated decisional"},{"id":"ref-lwbs","trigger":".lwbs","title":"Left without being seen / before completion","cat":"refusal","tags":"lwbs eloped left before completion absent attempts to contact","body":"The patient was sought for *** and found to have left the department of their own accord. When last observed the patient appeared ***. Attempts to locate/contact the patient: ***. The department remained available to provide care had the patient stayed; this is documented for the record.","aliases":"lwbs left without being seen eloped left before evaluation walked out elopement"},{"id":"unc-uncertainty","trigger":".uncertainty","title":"Diagnostic uncertainty acknowledged","cat":"uncertainty","tags":"diagnostic uncertainty residual risk non-zero undifferentiated acknowledged","body":"A definitive diagnosis was not established during this encounter. The emergent and dangerous causes of *** were considered and felt unlikely on the basis above; however, some diagnostic uncertainty remains and the residual risk is judged to be low but not zero. This uncertainty was explained to the patient in plain language, along with a specific plan for reassessment, follow-up, and return.","aliases":"uncertain unclear undifferentiated diagnostic uncertainty dont know unsure working diagnosis"},{"id":"unc-safetynet","trigger":".safetynet","title":"Safety-net established","cat":"uncertainty","tags":"safety net return precautions means follow up understanding plan","body":"A safety-net was established and documented: the patient was given specific, complaint-relevant return precautions, understands which symptoms warrant immediate return, has the means and intent to return, and has timely follow-up arranged. The patient verbalized understanding of when and why to seek further care.","aliases":"safety net return precautions worsening come back contingency strict"},{"id":"re-reassess","trigger":".reassess","title":"Serial reassessment","cat":"reassess","tags":"reassessment serial repeat exam stable improved trajectory time","body":"The patient was reassessed at ***. *** is {{status|improved|stable|worse}}, vital signs are {{vitals|stable|improved|abnormal}}, and the repeat examination shows ***. There are no new concerning findings. The trajectory supports the working assessment and the planned disposition.","aliases":"reassess serial exam re exam recheck rechecked monitored trend repeat exam"},{"id":"re-pain","trigger":".painreassess","title":"Pain reassessed after treatment","cat":"reassess","tags":"pain reassessed analgesia improved tolerating po ambulating","body":"Pain was reassessed after ***: now ***, down from *** on arrival. The patient is {{status|more comfortable|comfortable|improved}}, able to ***, and the response is consistent with a benign course. Ongoing analgesia and reassessment were addressed.","aliases":"pain reassessed pain reassessment after pain meds analgesia improved pain score controlled"},{"id":"re-observation","trigger":".obs","title":"Observation / extended monitoring","cat":"reassess","tags":"observation monitoring extended serial trend ed course","body":"Given ***, the patient was observed in the department with serial clinical and *** reassessments over ***. The course was {{course|stable|improving|worsening}} without evolution of concerning findings. This monitored interval was used to refine the assessment before disposition.","aliases":"observation obs extended monitoring observed monitored prolonged ed stay"},{"id":"dc-ready","trigger":".dcready","title":"Discharge readiness","cat":"discharge","tags":"discharge readiness criteria stable vitals tolerating ambulating capacity","body":"At the time of discharge the patient is hemodynamically stable with {{vitals|normal|stable|rechecked and acceptable}} vital signs, tolerating oral intake, ambulating at baseline, with pain adequately controlled and a clear understanding of the plan. The patient has capacity, reliable follow-up, and the means to return. Discharge criteria are met.","aliases":"discharge ready safe for discharge dispo home stable for discharge criteria met"},{"id":"dc-return","trigger":".returnprecautions","title":"Return precautions given","cat":"discharge","tags":"return precautions red flags written instructions understanding worsening","body":"Return precautions were reviewed in plain language. The patient was specifically instructed to return immediately for ***. Written instructions were provided and the patient verbalized understanding.","aliases":"return precautions come back worsening warning signs when to return strict"},{"id":"dc-followup","trigger":".followup","title":"Follow-up arranged","cat":"discharge","tags":"follow up referral pcp specialty timeframe appointment","body":"Follow-up was arranged with *** within {{timeframe|24–48 hours|3–5 days|1 week|1–2 weeks}}. The patient understands the importance of keeping this appointment and was advised to return to the ED sooner if symptoms worsen or new symptoms develop. ***","aliases":"follow up referral pcp appointment arranged specialist"},{"id":"data-review","trigger":".datareview","title":"Studies personally reviewed","cat":"data","tags":"personally reviewed ecg imaging films images interpretation preliminary","body":"I personally reviewed the {{study|ECG|imaging|laboratory}} studies — including the actual *** rather than relying solely on a preliminary report. My interpretation is documented above and was incorporated into the clinical decision-making.","aliases":"results reviewed personally reviewed labs imaging studies interpreted ekg"},{"id":"data-critical","trigger":".criticalresult","title":"Critical / abnormal result addressed","cat":"data","tags":"critical abnormal result acknowledged addressed action communicated plan","body":"The *** result of *** was noted, acknowledged, and addressed: ***. The finding was communicated to *** and a specific plan for *** was established and documented. No abnormal result was left unaddressed at disposition.","aliases":"critical result panic value abnormal result acted on addressed flagged"},{"id":"data-incidental","trigger":".incidental","title":"Incidental finding communicated","cat":"data","tags":"incidental finding communicated outpatient follow up documented nodule","body":"An incidental finding of *** was identified on ***. This was explained to the patient, documented for the record, and communicated to *** for appropriate outpatient follow-up. The patient was advised of the importance of following up on this finding and given written notice.","aliases":"incidental finding incidentaloma nodule communicated unrelated finding documented"},{"id":"data-pending","trigger":".pending","title":"Pending results at disposition","cat":"data","tags":"pending results culture follow up callback responsibility disposition","body":"At disposition, the following studies remained pending: ***. The patient was informed that results are pending, the mechanism and responsibility for follow-up/callback were established ({{mechanism|ED callback of the patient|PCP receives and acts on results|patient portal with written instructions|on-call physician callback}}), and the patient was given instructions for how results will be communicated and when to return.","aliases":"pending results labs pending cultures pending at discharge results not back culture"},{"id":"comm-consult","trigger":".consult","title":"Consultant discussion","cat":"comms","tags":"consult specialist discussed recommendation agree time service","body":"I discussed this patient with *** at ***. I summarized the presentation, the relevant findings, and my specific question/concern. The recommendation was ***, with which I {{agreement|agree|agree, with modifications}}. The discussion, the consultant's involvement, and the agreed plan are documented.","aliases":"consult consultant specialist called discussed admitting service recommendation"},{"id":"comm-handoff","trigger":".handoff","title":"Care transition / sign-out","cat":"comms","tags":"handoff sign out transition shift pending contingency responsibility","body":"Care was transitioned to *** at change of shift. The working assessment, the outstanding studies, the pending tasks, and the contingency plan were explicitly communicated, and follow-up responsibilities were assigned. The patient was made aware of the change in treating physician.","aliases":"handoff sign out signout care transition shift change transition of care pending tasks"},{"id":"comm-callback","trigger":".callback","title":"Result callback / patient notification","cat":"comms","tags":"callback notify patient result phone attempts understanding return","body":"The patient was contacted at *** regarding ***. I explained the finding and the recommended action: ***. The patient verbalized understanding and agreement and was advised to ***. ***","aliases":"callback called patient result notification phoned reached patient voicemail"},{"id":"comm-interpreter","trigger":".interpreter","title":"Interpreter used","cat":"comms","tags":"interpreter language translation certified communication understanding","body":"This encounter was conducted with the assistance of a {{interpreter|certified medical interpreter|telephone interpreter|video interpreter}} for ***. The history, assessment, plan, and discharge instructions were communicated through the interpreter, and the patient demonstrated understanding.","aliases":"interpreter translator language line non english spanish interpretation limited english"},{"id":"tc-stroke","trigger":".stroke","title":"Acute stroke documentation","cat":"timecrit","tags":"stroke code last known well nihss thrombolysis tpa thrombectomy ct glucose","body":"Last known well: ***. Code stroke activated at ***. NIHSS ***. Finger-stick glucose {{glucose|normal|low|elevated}}. Non-contrast head CT obtained at *** to exclude hemorrhage. The risks and benefits of *** — including the risk of symptomatic intracranial hemorrhage — versus no reperfusion were discussed with the ***, and a shared decision was reached to ***.","specs":["neuro"],"aliases":"stroke cva tpa tnk thrombolytic code stroke last known well alteplase tenecteplase nihss lvo"},{"id":"tc-stemi","trigger":".stemi","title":"STEMI / ACS activation","cat":"timecrit","tags":"stemi acs cath lab ecg aspirin reperfusion door to balloon onset","body":"ECG obtained at *** (within *** minutes of arrival) showed ***. Cardiology / cath lab activated at ***. Aspirin *** administered. Time of symptom onset ***. The reperfusion plan and its risks/benefits were discussed; serial ECGs and troponins were initiated and the patient was monitored continuously.","specs":["cards"],"aliases":"stemi heart attack mi acs cath lab activation cardiac cardiology ekg door to balloon"},{"id":"tc-sepsis","trigger":".sepsis","title":"Sepsis bundle","cat":"timecrit","tags":"sepsis lactate cultures antibiotics fluids source resuscitation time","body":"Sepsis was identified based on ***. Lactate and blood cultures were drawn prior to antibiotics; broad-spectrum antibiotics (***) were given at ***. Fluid resuscitation with *** was initiated and the hemodynamic response reassessed. Source control was {{source control|addressed|planned|not required}}; the patient was monitored for response to therapy.","specs":["id"],"aliases":"sepsis septic shock bundle lactate antibiotics fluids source infection resuscitation"},{"id":"psy-safety","trigger":".psychsafety","title":"Suicidal ideation / safety assessment","cat":"psych","tags":"suicidal ideation safety assessment plan intent means risk protective psychiatry","body":"A safety assessment was performed. The patient {{ideation|denies|endorses}} active suicidal ideation, {{plan|without|with}} plan, intent, or access to means. Risk and protective factors were weighed: ***. The environment was made safe (***, ***). Psychiatry / crisis was {{psych|consulted|not consulted}}; the disposition reflects the assessed level of risk.","specs":["psych"],"aliases":"suicidal suicide self harm safety assessment si homicidal hi psychiatric risk overdose intentional ideation"},{"id":"psy-restraint","trigger":".restraints","title":"Restraint use","cat":"psych","tags":"restraint physical chemical danger least restrictive monitoring reassessment","body":"Restraint ({{restraint|physical|chemical|physical and chemical}}) was applied at *** because the patient posed an imminent danger to {{danger|self|others|self and others}} and less-restrictive measures were attempted and insufficient. The patient was monitored per protocol with {{frequency|continuous|15-minute}} reassessment of circulation, airway, breathing, and the continued need for restraint. Restraints were discontinued as soon as the patient was safe.","specs":["psych"],"aliases":"restraints restrained physical restraint chemical restraint violent agitated combative seclusion"},{"id":"psy-intox","trigger":".intoxicated","title":"Intoxicated / altered — serial exams","cat":"psych","tags":"intoxicated altered capacity impaired serial sober reassess disposition","body":"The patient presented {{state|intoxicated|altered}} and currently lacks capacity for disposition decisions. The patient was observed with serial neurologic and clinical reassessments, monitored for evolving findings and for alternative causes of altered mental status (including trauma, infection, metabolic, and toxicologic causes), and will be reassessed for capacity and discharge readiness once clinically improved.","specs":["psych","tox"],"aliases":"intoxicated drunk altered serial exams alcohol drugs sober up clinically sober metabolize"},{"id":"sp-geriatricfall","trigger":".gerifall","title":"Geriatric fall workup","cat":"special","tags":"geriatric elderly fall syncope head ct anticoagulation home safety recurrent","body":"In this older adult presenting after a fall, I evaluated for both injury and the cause of the fall. Syncope, arrhythmia, medication effects, infection, and other medical precipitants were considered. *** Anticoagulation status: ***. Functional status, home safety, and the risk of recurrent falls were addressed in the disposition.","specs":["geri"],"aliases":"geriatric fall elderly fall mechanical fall ground level fall syncope workup older head strike"},{"id":"sp-anticoag","trigger":".anticoag","title":"Anticoagulated patient — bleeding risk","cat":"special","tags":"anticoagulation warfarin doac bleeding intracranial gi threshold imaging","body":"The patient is taking ***. This was specifically considered in the evaluation of *** given the elevated risk of {{site|intracranial|GI|other}} hemorrhage. The threshold for imaging and observation was lowered accordingly: ***. ***","specs":["heme"],"aliases":"anticoagulated blood thinner warfarin coumadin eliquis apixaban xarelto rivaroxaban pradaxa doac noac bleeding risk head injury"},{"id":"sp-pregtest","trigger":".pregtest","title":"Pregnancy status before imaging / meds","cat":"special","tags":"pregnancy hcg testing radiation teratogenic imaging reproductive","body":"Pregnancy status was *** prior to ***. Result: ***. This was incorporated into the risk-benefit discussion and the choice of ***.","specs":["obgyn"],"aliases":"pregnancy test hcg before imaging before meds rule out pregnancy childbearing teratogen"},{"id":"sp-peds","trigger":".peds","title":"Pediatric — reassurance & return","cat":"special","tags":"pediatric child weight based dosing well appearing hydrated caregiver return","body":"Weight-based dosing was used and verified. The child is {{appearance|well-appearing|ill-appearing}} with ***. The caregiver was given clear, specific return precautions, verbalized understanding, and has the means and intent to return or follow up. ***","specs":["peds"],"aliases":"pediatric child reassurance return kid well appearing parents discharge"},{"id":"proc-timeout","trigger":".timeout","title":"Pre-procedure time-out","cat":"proc","tags":"time out timeout correct patient site side consent equipment","body":"A pre-procedure time-out was performed confirming the correct patient, the correct procedure, the correct site/side, and that consent, necessary equipment, and monitoring were in place.","aliases":"time out pre procedure timeout site verification universal protocol before procedure"},{"id":"proc-sedation","trigger":".sedation","title":"Procedural sedation","cat":"proc","tags":"procedural sedation asa airway npo monitoring capnography recovery consent","body":"Pre-sedation assessment completed: ***, airway ***, NPO status ***, and risks/benefits discussed and consented. Continuous monitoring (cardiac, pulse oximetry, ***) was maintained with a dedicated provider. Agent(s)/doses and times: ***. The patient tolerated the procedure, recovered to baseline with stable vital signs, and met discharge criteria.","aliases":"procedural sedation conscious sedation ketamine propofol etomidate moderate sedation npo"},{"id":"proc-lac","trigger":".lacrepair","title":"Laceration repair","cat":"proc","tags":"laceration repair wound explored foreign body neurovascular tendon irrigation tetanus","body":"*** laceration. The wound was explored under ***; no foreign body and no involvement of ***; neurovascular and motor function intact distally before and after. Irrigated copiously and closed with ***. Tetanus {{Tetanus|up to date|updated today|deferred}}. Wound care, suture removal timing, and infection return precautions were reviewed.","aliases":"laceration repair sutures stitches wound closure laceration glue staples"},{"id":"proc-neurovasc","trigger":".neurovasc","title":"Neurovascular check before & after","cat":"proc","tags":"neurovascular check distal pulses sensation motor before after reduction splint","body":"Distal neurovascular status was documented before and after ***: pulses ***, capillary refill ***, sensation ***, and motor function *** in the affected ***. There was no change attributable to the intervention.","specs":["ortho"],"aliases":"neurovascular check pulses cap refill sensation motor before after splint reduction"},{"id":"ret-bounceback","trigger":".bounceback","title":"Return visit — independent re-evaluation","cat":"return","tags":"bounceback return repeat visit re-evaluation anchoring prior diagnosis reset reason for return","body":"This is an unscheduled return visit for *** following an encounter on ***. I reviewed the prior assessment, diagnosis, and results, and approached this visit as an independent re-evaluation rather than assuming the earlier diagnosis was correct. I specifically reconsidered the can't-miss causes, rechecked the previously *** findings and vital signs, and addressed why the patient returned. A return visit raises my level of concern and lowers my threshold for further testing, observation, or consultation.","aliases":"bounceback return visit second visit came back repeat re evaluation independent fresh look"},{"id":"ret-dispo","trigger":".bouncebackdispo","title":"Repeat visit — lowered threshold","cat":"return","tags":"bounceback repeat second visit threshold admit observe escalate red flag persistence","body":"Because this is a *** visit for the same or worsening complaint, I treated it as a higher-acuity presentation. Persistence or progression of symptoms despite the prior plan was itself weighed as a red flag. My threshold for *** was lowered accordingly, and the rationale for the current disposition — including why outpatient management does or no longer does remain appropriate — is documented above.","aliases":"repeat visit bounceback lowered threshold admit second visit third visit failed outpatient"},{"id":"mdm-benign","trigger":".benigndx","title":"Benign diagnosis — dangerous mimics excluded","cat":"mdm","tags":"benign diagnosis anchoring premature closure mimics excluded concurrent serious considered","body":"Although the presentation is most consistent with ***, I did not anchor on it. The dangerous conditions that can mimic this complaint — *** and *** — were specifically considered and judged unlikely on the basis of ***, not excluded by assumption. A plausible benign explanation was not allowed to stop the screen for a concurrent serious process.","aliases":"benign minor not serious dangerous mimics excluded reassuring diagnosis nos nonspecific"},{"id":"mdm-notest","trigger":".notest","title":"No test ordered — clinical reasoning documented","cat":"mdm","tags":"test deferred not ordered reasoning pretest probability low yield restraint defer imaging","body":"I considered *** and elected not to pursue it at this time. Given ***, the result was not expected to change management, and the limited benefit was outweighed by ***. This was a deliberate clinical decision; the patient was counseled and given a plan to return if *** so the question can be revisited.","aliases":"no test not ordering deferred testing why no labs no imaging clinical reasoning low yield"},{"id":"mdm-negtest","trigger":".negtest","title":"Negative test — its limitations acknowledged","cat":"mdm","tags":"negative normal test sensitivity limit not excluded residual risk ct lp window pretest","body":"The *** was ***, but I did not treat this as definitive exclusion of ***: its sensitivity is limited ***. I weighed the negative result against the pretest probability and the clinical picture, and the plan reflects this residual risk — ***.","aliases":"negative result normal test false negative sensitivity limitation does not exclude"},{"id":"mdm-relief","trigger":".reliefnotruleout","title":"Feeling better after treatment does not rule out disease","cat":"mdm","tags":"response to therapy relief improvement not reassuring rule out recurrent pain analgesia","body":"Improvement of *** after *** was noted but was not used as a rule-out: response to therapy does not reliably distinguish benign from dangerous causes. Recurrent, escalating, or difficult-to-control symptoms were treated as raising — not lowering — my concern, and the disposition rests on the overall assessment rather than transient relief.","aliases":"feels better after treatment gi cocktail nitro response relief does not rule out"},{"id":"mdm-reconcile","trigger":".reconcile","title":"Records reconciled — all complaints addressed","cat":"mdm","tags":"triage nursing ems notes reconciled discrepancy every complaint addressed unexplained chart review","body":"I reviewed the triage, nursing, and *** documentation and reconciled it with my own history and examination. Every complaint and abnormal finding recorded by any provider — including *** — was specifically addressed, and discrepancies between notes were clarified with the patient and resolved. No documented symptom was left unexplained at disposition.","aliases":"old records prior chart reviewed all complaints addressed reconciled outside records"},{"id":"mdm-gestalt","trigger":".gestalt","title":"Overall clinical impression — well-appearing","cat":"mdm","tags":"gestalt well appearing no distress concrete observed ambulating tolerating po serial appearance","body":"The patient's well appearance is supported by concrete, observed findings rather than a bare conclusion: ***. Serial observations over the ED course were consistent, and there was no change toward an ill or toxic appearance prior to disposition.","aliases":"gut feeling well appearing looks well overall impression clinical judgment nontoxic"},{"id":"mdm-highrisk","trigger":".highrisk","title":"High-risk feature — expanded differential","cat":"mdm","tags":"high risk feature elderly postpartum immunocompromised anticoagulated diabetic expanded differential","body":"Because of ***, I broadened the can't-miss differential beyond the typical causes of ***. Each serious entity considered — *** and *** — was either excluded, treated presumptively, or made the basis for ***, rather than left unaddressed because the presentation seemed benign.","aliases":"red flag high risk feature concerning broadened expanded differential escalate worrisome"},{"id":"mdm-functional","trigger":".functionallabel","title":"Functional / psychiatric cause — organic disease excluded first","cat":"mdm","tags":"anxiety functional psychiatric label organic excluded not dismissive basis prior history","body":"I did not attribute these symptoms to *** by default. Organic and dangerous explanations were evaluated and addressed first, and a *** attribution is supported by *** rather than by assumption. The assessment is objective and free of dismissive characterization of the patient.","aliases":"functional psychogenic conversion nonorganic somatic anxiety rule out organic before psychiatric"},{"id":"mdm-neuroexam","trigger":".neuroexam","title":"Full neurologic exam documented","cat":"mdm","tags":"neuro neurologic exam cranial nerves motor sensory reflexes cerebellar gait tandem complete","body":"A complete neurologic examination was performed and documented: mental status and level of alertness, cranial nerves II–XII, motor strength by group, sensation, deep-tendon reflexes, coordination and cerebellar testing, and gait (including tandem gait when able). Findings are detailed above — a focused, complete examination rather than a global 'neuro intact.'","specs":["neuro"],"aliases":"neuro exam cranial nerves strength sensation reflexes gait coordination neurologic documented"},{"id":"data-radreadback","trigger":".radreadback","title":"Radiology read confirmed","cat":"data","tags":"radiology radiologist preliminary final read discrepancy callback images visualized concern communicated","body":"I *** and communicated my specific clinical concern for ***. The *** interpretation and its limitations (adequacy of ***, whether the *** was visualized) were considered, and a mechanism is in place for notification if the final read differs from the preliminary one.","aliases":"radiology read wet read preliminary final read discrepancy x ray ct read confirmed imaging radiologist"},{"id":"dc-fucontingency","trigger":".followupcontingency","title":"Follow-up with contingency","cat":"discharge","tags":"follow up time specific contingency cannot reach doctor return window disease tempo stakes","body":"Follow-up was arranged with *** within {{timeframe|24–48 hours|3–5 days|1 week|1–2 weeks}}. I gave time- and action-specific instructions — return or seek care sooner if *** worsens or fails to improve by *** — and addressed what to do if the patient cannot obtain the appointment (***). The patient verbalized understanding of the importance and the stakes of timely follow-up.","aliases":"follow up contingency if not better backup plan cant get appointment fails"},{"id":"dc-admitrec","trigger":".admitrec","title":"Admission recommended — patient response","cat":"discharge","tags":"admission recommended observation physician recommendation patient preference declined response","body":"I recommended {{recommendation|admission|observation|further inpatient evaluation}} and explained the reasons, including the diagnoses I was concerned about. *** This disposition reflects my medical recommendation, not merely the patient's preference.","aliases":"recommended admission patient declined admit refused admission against advice"},{"id":"dc-transfer","trigger":".transfer","title":"Stable for discharge / transfer (EMTALA)","cat":"discharge","tags":"emtala transfer stable discharge accepting facility risk benefit mode monitoring condition","body":"At *** the patient is stable, with ***. For transfer: the medical benefits of transfer to *** for *** outweigh the risks; an accepting physician and bed were secured; and transport with {{monitoring|ALS|BLS|critical-care}} of monitoring was arranged. The patient or surrogate was informed of the risks and benefits and agreed.","aliases":"transfer emtala stable for transfer higher level of care accepting facility"},{"id":"unc-snapshot","trigger":".snapshot","title":"Single-visit snapshot — the picture may still evolve","cat":"uncertainty","tags":"snapshot impression point in time evolve declare itself serial re-evaluation not guarantee","body":"This assessment represents my clinical impression at this point in time. I explained to the patient that some conditions cannot be diagnosed at a single visit and may declare themselves over hours to days, that this is a snapshot rather than a guarantee, and that re-evaluation is expected if the course changes. This framing and the plan for serial evaluation were discussed and understood.","aliases":"single visit snapshot may evolve point in time impression early presentation illness script"},{"id":"comm-attending","trigger":".attending","title":"Attending attestation / APP supervision","cat":"comms","tags":"attending attestation supervision app resident pa np reviewed discussed agree involvement","body":"I personally *** and discussed the case with ***. I agree with the assessment and plan ***. Supervision included independent bedside evaluation where indicated; this attestation reflects active involvement in the patient's care, not a signature alone.","aliases":"attending attestation supervision app pa np resident staffed seen and evaluated"},{"id":"sp-nat","trigger":".nat","title":"Nonaccidental trauma concern","cat":"special","tags":"nonaccidental trauma child abuse mandated reporter cps inflicted bruise pattern non-ambulatory","body":"In this ***, the finding of *** is not explained by the history provided and raises concern for nonaccidental trauma. The injuries were described precisely (***), history was obtained ***, and as a mandated reporter I notified *** at ***. The evaluation and report are documented objectively, without accusation.","specs":["peds"],"aliases":"nonaccidental trauma child abuse nat suspicious injury inflicted mandatory report sentinel"},{"id":"asthma-mdm","trigger":".asthmamdm","title":"Asthma exacerbation — severity & MDM","cat":"mdm","tags":"asthma exacerbation reactive airway severity peak flow fatal risk mdm dyspnea wheeze","body":"For this asthma exacerbation I assessed severity and considered the dangerous mimics and complications — anaphylaxis, pneumothorax, pneumonia, pulmonary embolism, foreign-body aspiration, and a cardiac cause of dyspnea — judged unlikely on the history and examination. Initial severity {{severity|mild|moderate|severe|life-threatening}}: speaking in {{speech|full sentences|phrases|single words|unable to speak}}, {{wob|no increased work of breathing|mild accessory-muscle use|marked accessory-muscle use/retractions}}, SpO₂ {{SpO2|≥95% on room air|92–94%|<92% or on O₂}}, {{auscultation|good air movement with scattered wheeze|diffuse wheeze|poor air movement / silent chest}}, peak flow {{PEF|>70% of predicted/personal best|40–69%|<40% or unable}}. High-risk features for fatal asthma were specifically reviewed: {{fatal-risk|none identified|prior intubation or ICU admission|hospitalization or ED visit in the past year|frequent rescue-inhaler use|poor adherence or no controller therapy}}. Treatment and serial reassessment are documented below; residual risk and the plan for reassessment and return were discussed.","specs":["pulm"],"aliases":"asthma wheezing reactive airway bronchospasm exacerbation severity copd"},{"id":"asthma-reassess","trigger":".asthmarx","title":"Asthma — treatment & response reassessment","cat":"reassess","tags":"asthma treatment albuterol steroids magnesium reassessment response peak flow quality","body":"The patient was treated and reassessed serially. Therapy: inhaled short-acting bronchodilator (albuterol ± ipratropium) ×***, systemic corticosteroids given at *** (within *** of arrival), and {{adjuncts|no adjuncts required|IV magnesium|continuous nebulization|IM epinephrine}}. Response to treatment is {{response|good — at or near baseline|partial|poor / minimal}}: now speaking in {{speech|full sentences|phrases|single words}}, SpO₂ {{SpO2|≥95% on room air|92–94%|<92% or on O₂}}, work of breathing {{wob|unlabored|mildly increased|markedly increased}}, peak flow {{PEF|>70% of predicted/personal best|40–69%|<40% or unable}}. The trajectory and the repeat examination support the working assessment and the planned disposition.","specs":["pulm"],"aliases":"asthma treatment response albuterol nebulizer duoneb reassessment wheezing breathing better"},{"id":"asthma-dc","trigger":".asthmadc","title":"Asthma — discharge (steroids, technique, action plan, return)","cat":"discharge","tags":"asthma discharge steroids inhaler technique action plan follow-up return precautions quality","body":"At discharge the patient has a sustained good response with {{status|SpO₂ ≥95% on room air|peak flow >70% of personal best|comfortable breathing at rest}}, is tolerating oral intake, and is ambulating at baseline. Plan: a systemic corticosteroid course (***), continued or stepped-up controller therapy plus a rescue inhaler, and inhaler/spacer technique was {{technique|reviewed with teach-back confirmed|demonstrated to the patient}}. A written asthma action plan was provided, and follow-up was arranged with {{followup|primary care|pulmonology|the patient's asthma provider}} within {{timeframe|24–48 hours|3–5 days|1 week}}. Specific return precautions were reviewed — return immediately for worsening shortness of breath, a rescue inhaler that is not lasting or not helping, difficulty speaking in full sentences, or lack of improvement — and the patient verbalized understanding.","specs":["pulm"],"aliases":"asthma discharge steroids inhaler technique action plan return albuterol prednisone"},{"id":"asthma-severe","trigger":".asthmasevere","title":"Severe asthma / impending respiratory failure","cat":"timecrit","tags":"asthma severe status asthmaticus respiratory failure magnesium BiPAP intubation time-critical","body":"This is a severe asthma exacerbation with concern for impending respiratory failure. Continuous bronchodilators, systemic corticosteroids, and IV magnesium were given, with {{escalation|no further escalation required|IM epinephrine|noninvasive ventilation (BiPAP)|preparation for intubation}}. Concerning findings were reviewed and addressed: {{findings|none of the following|fatigue or altered mentation|silent chest / poor air movement|a normalizing or rising CO₂ despite distress|falling oxygen saturation}}. The risks and benefits of *** were discussed with the patient or surrogate as the situation allowed, and the airway plan, continuous monitoring, and disposition (***) were established. The patient was reassessed continuously for response to therapy and the need to escalate.","specs":["pulm"],"aliases":"severe asthma status asthmaticus respiratory failure impending intubation magnesium bipap"},{"id":"sz-mdm","trigger":".szmdm","title":"Seizure — workup & reasoning","cat":"mdm","tags":"seizure convulsion epilepsy mdm rule-out provoked","body":"For this seizure I screened for the dangerous provocations and mimics. Point-of-care glucose {{glucose|normal|low|elevated}} (hypoglycemia excluded immediately). The patient is {{baseline|back to neurologic baseline|improving postictally|persistently altered}} with {{exam|a non-focal exam|a resolving Todd paralysis|a persistent focal deficit}}; no fever or meningismus, no head trauma or anticoagulation, no toxic ingestion or withdrawal. Pregnancy {{pregnancy|negative|positive|N/A}} (eclampsia considered in patients of reproductive potential). Sodium and targeted labs {{labs|normal|pending|abnormal}}; neuroimaging {{CT head|not indicated|negative|pending}} where indicated. The event was {{type|a single self-terminated seizure|a breakthrough seizure on known epilepsy|a first unprovoked seizure|a provoked seizure}}; status epilepticus was excluded. Residual risk was discussed with a specific plan for reassessment, follow-up, and return.","specs":["neuro"],"aliases":"seizure convulsion fit epilepsy workup reasoning"},{"id":"sz-known","trigger":".szbreakthrough","title":"Breakthrough seizure (known epilepsy)","cat":"mdm","tags":"seizure epilepsy breakthrough medication level adherence","body":"This patient has known epilepsy and presents with a seizure {{stereotyped|consistent with their typical events|different from their usual events}}. I assessed for a breakthrough trigger — medication {{adherence|adherent|missed doses|recently changed}}, sleep deprivation, intercurrent illness or infection, alcohol, and new interacting drugs. Antiseizure drug level {{level|therapeutic|sub-therapeutic|pending|not available}}; point-of-care glucose {{glucose|normal|low|elevated}}; returned to baseline with a non-focal exam. Dangerous secondary causes were considered and judged unlikely after this assessment; medication and follow-up were addressed with neurology input as needed.","specs":["neuro"],"aliases":"breakthrough seizure known epilepsy missed meds subtherapeutic level noncompliant"},{"id":"sz-first","trigger":".szfirst","title":"First seizure — counseling, driving, follow-up","cat":"discharge","tags":"seizure first unprovoked counseling driving neurology EEG MRI return","body":"This was a first unprovoked seizure and the dangerous acute symptomatic causes were screened for and addressed as documented. The patient and family were counseled in plain language about the diagnosis and the risk of recurrence, and given seizure-precaution instructions: {{driving|advised not to drive and informed of the local restriction/reporting requirement|cleared to drive per local rule}}, and to avoid swimming, heights, and operating heavy machinery until cleared. Outpatient follow-up was arranged — {{followup|neurology referral|outpatient EEG|outpatient MRI brain|EEG and MRI}} within ***. Specific return precautions (a recurrent or prolonged seizure, failure to return to normal, injury, or new neurologic symptoms) were reviewed and the patient verbalized understanding.","specs":["neuro"],"aliases":"first seizure counseling driving dmv follow up new onset seizure restrictions"},{"id":"sz-status","trigger":".szstatus","title":"Status epilepticus — management","cat":"timecrit","tags":"status epilepticus seizure benzodiazepine levetiracetam time-critical","body":"Status epilepticus was identified (a seizure ≥ 5 minutes or recurrent seizures without recovery of consciousness). Time of seizure onset ***. Airway, breathing, and circulation were supported and a point-of-care glucose was checked. First-line benzodiazepine ({{benzo|lorazepam IV|midazolam IM|diazepam IV}}) was given at *** and repeated for ongoing seizure. A second-line antiseizure agent ({{secondline|levetiracetam|valproate|fosphenytoin}}) was {{secondline-given|administered|prepared}}. Reversible causes were addressed — glucose, sodium, eclampsia, toxic ingestion (including isoniazid → pyridoxine), and CNS infection: ***. The patient was monitored continuously, with a plan to escalate to a continuous infusion and definitive airway management if seizures persisted.","specs":["neuro"],"aliases":"status epilepticus prolonged seizure benzos continuous seizing not stopping refractory"},{"id":"sz-reassess","trigger":".szreassess","title":"Post-ictal reassessment / return to baseline","cat":"reassess","tags":"seizure postictal reassessment baseline neuro exam","body":"The patient was reassessed after the event at ***. Mental status is {{status|back to baseline|improving|still postictal|persistently altered}}, vital signs are {{vitals|stable|improved|abnormal}}, and the neurologic examination shows {{exam|no focal deficit|a resolving deficit|a persistent deficit}}. There has been no recurrent seizure activity. The trajectory supports the working assessment and the planned disposition; failure to return to baseline would prompt evaluation for nonconvulsive status epilepticus or a structural or infectious cause.","specs":["neuro"],"aliases":"postictal post ictal back to baseline seizure recovery returned to baseline neuro intact"},{"id":"etoh-mdm","trigger":".etohmdm","title":"Alcohol intoxication — mimics excluded (MDM)","cat":"mdm","tags":"alcohol intoxication etoh found down head injury hypoglycemia co-ingestion mdm","body":"Alcohol intoxication was treated as a diagnosis of exclusion, not an explanation. Point-of-care glucose {{glucose|normal|low — corrected|elevated}}. A trauma survey found {{trauma|no signs of head injury|signs of head injury — imaged}}; the patient is {{anticoag|not anticoagulated|anticoagulated — threshold for CT lowered}}. Co-ingestion was considered: {{coingestion|no suggestion of co-ingestion|acetaminophen/salicylate levels and an osmolal gap obtained}}. The neurologic exam was {{exam|non-focal|focal — imaged}} and the presentation is {{baseline|typical of the patient's prior episodes|different from baseline — workup broadened}}. Mental status {{course|improved steadily toward baseline|failed to improve — imaging and labs obtained}} over serial examinations. Thiamine {{thiamine|given|not indicated}}.","specs":["tox"],"aliases":"drunk intoxicated alcohol ethanol etoh inebriated mimics head injury alcohol level"},{"id":"etoh-sobriety","trigger":".etohdc","title":"Clinical sobriety — discharge of the intoxicated patient","cat":"discharge","tags":"alcohol sobriety discharge intoxicated capacity safe disposition counseling","body":"At discharge the patient has reached clinical sobriety: alert and oriented at baseline, conversing appropriately, {{gait|ambulating steadily without assistance|ambulating at their baseline}}, tolerating oral intake, and demonstrating decision-making capacity. Vital signs are {{vitals|normal|stable}} and a repeat assessment shows no new findings. The patient was counseled not to drive; disposition is {{dispo|with a sober adult|by arranged transport|to a monitored setting}}. Brief counseling about alcohol use was provided and {{resources|referral resources were given and accepted|resources were offered and declined}}; the patient was advised to return for confusion, headache, vomiting, withdrawal symptoms, or any concern.","specs":["tox"],"aliases":"clinical sobriety discharge intoxicated sober alcohol drunk safe to leave reassessed"},{"id":"etoh-withdrawal","trigger":".ciwa","title":"Alcohol withdrawal — CIWA-based management","cat":"timecrit","tags":"alcohol withdrawal ciwa dts delirium tremens benzodiazepine thiamine seizure","body":"Alcohol withdrawal was identified — last drink ***, prior withdrawal {{history|none|seizures|delirium tremens|seizures and DTs}}. Severity was scored and trended (CIWA-Ar {{ciwa|< 10 — mild|10–18 — moderate|> 18 — severe}}), with symptom-triggered {{benzo|diazepam|lorazepam|chlordiazepoxide}} and reassessment after each dose. Thiamine was given {{thiamine|before|with}} glucose, with magnesium and electrolyte repletion as indicated. The patient was monitored for seizures, hallucinosis, and autonomic instability; escalation to {{escalation|no escalation required|phenobarbital|ICU-level care}} was {{escalated|not required|arranged}}. Disposition reflects the trajectory and the risk of progression to delirium tremens.","specs":["tox"],"aliases":"alcohol withdrawal ciwa dts delirium tremens shakes benzodiazepine withdrawal seizure"},{"id":"consent-procedure","trigger":".consentproc","title":"Informed consent — procedure (detailed)","cat":"sdm","tags":"consent procedure informed risks benefits alternatives capacity witness","body":"Informed consent was obtained for {{procedure|the procedure|laceration repair|incision and drainage|central venous catheter|tube thoracostomy (chest tube)|lumbar puncture|joint or fracture reduction|procedural sedation|paracentesis|arthrocentesis}}. In plain language I explained the indication, what the procedure involves, the material risks ({{risks|bleeding, infection, injury to adjacent structures, and failure or need to repeat|bleeding, infection, pneumothorax, and arterial puncture|bleeding, infection, nerve injury, and post-procedure headache|bleeding, infection, neurovascular injury, and re-displacement|sedation risks: respiratory depression, aspiration, and the need for airway support}}), the expected benefits, and the alternatives including no intervention. Questions were answered and consent was given voluntarily {{consenter|by the patient, who has capacity|by the patient's surrogate decision-maker|verbally with a witness given the urgency}}. The discussion was conducted {{language|in the patient's primary language|through a certified interpreter}}.","aliases":"informed consent procedure detailed risks benefits alternatives complications questions answered"},{"id":"consent-transfusion","trigger":".consenttransfusion","title":"Blood transfusion — informed consent","cat":"sdm","tags":"consent transfusion blood prbc ffp platelets reaction TRALI TACO","body":"Informed consent for transfusion of {{product|packed red blood cells|fresh frozen plasma|platelets|cryoprecipitate}} was obtained. The indication ({{indication|symptomatic anemia|acute hemorrhage with hemodynamic compromise|active bleeding on anticoagulation|critical coagulopathy}}) was explained, along with the benefits, the risks — acute hemolytic and febrile/allergic reactions, transfusion-related acute lung injury (TRALI), circulatory overload (TACO), and the very low risk of transmitted infection — and the alternatives ({{alternatives|none appropriate given the urgency|IV iron if non-urgent|observation with serial hemoglobin}}). Consent was given {{consenter|by the patient, who has capacity|by the surrogate decision-maker|under the emergency exception, given life-threatening hemorrhage and inability to consent}}. The patient was typed and crossmatched and will be monitored for a reaction during and after transfusion.","specs":["heme"],"aliases":"blood transfusion consent informed consent blood products prbc"},{"id":"consent-transfusion-refusal","trigger":".refusetransfusion","title":"Blood transfusion — refusal (capacity documented)","cat":"refusal","tags":"refusal transfusion blood jehovah witness capacity bloodless alternatives","body":"The patient declined blood products. Capacity for this decision is intact: the patient is alert and unimpaired and can understand, appreciate, and reason through the situation and its consequences. I explained the specific risks of refusing transfusion in this context — {{consequence|worsening anemia and end-organ injury|hemodynamic deterioration|and, with ongoing hemorrhage, a risk of death}} — and why transfusion was recommended. The basis for refusal was {{basis|a religious objection (e.g., Jehovah's Witness)|a personal preference|explored and respected}}. Acceptable alternatives were offered where applicable ({{alternatives|none acceptable to the patient|cell salvage / bloodless-medicine measures|IV iron and erythropoiesis-stimulating agents|tranexamic acid and hemostatic measures}}). The patient verbalized understanding; the decision was respected and documented (with any advance directive on file), and the patient may reconsider at any time.","specs":["heme"],"aliases":"refused transfusion jehovah witness blood refusal declined blood capacity documented"},{"id":"consent-emergency","trigger":".emergencyconsent","title":"Consent — surrogate / emergency exception","cat":"sdm","tags":"consent surrogate emergency implied minor capacity two physician","body":"The patient {{capacity|lacks capacity for this decision (altered, intoxicated, or critically ill)|is a minor}}, and {{path|consent was obtained from the legal surrogate or parent|no surrogate was immediately available}}. {{emergency|Given an immediate threat to life or limb, the emergency exception (implied consent) was applied and necessary care was not delayed|After discussion of the diagnosis, proposed treatment, risks, benefits, and alternatives, the surrogate agreed to proceed}}. The clinical urgency, attempts to reach a decision-maker (***), and the rationale are documented.","aliases":"emergency consent surrogate implied consent unable to consent next of kin incapacitated two physician"},{"id":"mdm-dispo-rationale","trigger":".dispo","title":"Disposition decision — risk/benefit","cat":"mdm","tags":"disposition decision risk benefit discharge admit observation rationale","body":"The disposition decision weighed the likelihood and consequence of a dangerous diagnosis against the burden and risks of further inpatient evaluation. Given {{basis|reassuring serial exams and a low-risk workup|a low validated risk score and reliable follow-up|resolution of the presenting concern}}, the decision was to {{dispo|discharge with a specific return and follow-up plan|place in observation for serial evaluation|admit for further workup and monitoring|transfer for a higher level of care}}. The residual risk was judged {{residual|low but non-zero and discussed with the patient|acceptable given the monitoring plan}}, and the patient (and family where appropriate) agreed with the plan.","aliases":"disposition admit discharge decision risk benefit plan dispo"},{"id":"mdm-course","trigger":".course","title":"ED course & response to treatment","cat":"mdm","tags":"ED course response treatment trajectory trend improved disposition","body":"Over the ED course the patient was monitored and treated, and the clinical trajectory was {{course|reassuring — symptoms improved and vital signs normalized|stable without evolution of concerning findings|dynamic — re-evaluated and the plan adjusted accordingly}}. Response to {{treatment|the interventions above|analgesia|fluids|bronchodilators|antiemetics}} was {{response|good|partial|minimal}}, and this was incorporated into the assessment. The disposition rests on the overall course rather than any single data point.","aliases":"ed course progress response to treatment hospital course improvement reevaluation"},{"id":"mdm-collateral","trigger":".collateral","title":"Collateral history & source reliability","cat":"mdm","tags":"collateral history source reliability historian family EMS records","body":"Additional history was obtained from {{source|the patient|family at the bedside|family by telephone|EMS|the nursing facility or its staff|prior records}}, given {{reason|the patient is a limited historian|altered mental status|the need to corroborate the history|the severity of the presentation}}. The history is felt to be {{reliability|reliable|partially reliable|limited}}, and this was factored into the assessment and the threshold for testing. Key collateral details: ***.","aliases":"collateral history family ems witness bystander source reliability corroborate"},{"id":"mdm-mse","trigger":".mse","title":"Medical screening exam (EMTALA)","cat":"mdm","tags":"EMTALA medical screening exam emergency medical condition stabilized payer","body":"A medical screening examination within the capability of this emergency department was performed to determine whether an emergency medical condition exists. Based on the history, examination, and indicated testing, an emergency medical condition {{emc|was not identified|was identified and stabilized within our capability|was identified and requires a higher level of care}}. The screening was applied consistently, without regard to payer or ability to pay.","aliases":"medical screening exam emtala screening triage stabilize"},{"id":"data-chronicfinding","trigger":".chronicfinding","title":"Abnormal result — chronic / expected, not a new problem","cat":"data","tags":"abnormal result chronic expected baseline prior comparison incidental acknowledged","body":"The {{finding|laboratory|imaging|ECG}} result showing *** was reviewed and judged to be {{nature|chronic and unchanged from prior|an expected finding in this clinical context|a known, previously documented finding}} rather than an acute process, after comparison with prior studies where available. It was acknowledged — not overlooked — and {{action|requires no acute intervention|was addressed with outpatient follow-up|was discussed with the patient}}.","aliases":"chronic finding old expected baseline unchanged stable longstanding not new comparison"},{"id":"data-medrec","trigger":".medrec","title":"Medication reconciliation & allergies","cat":"data","tags":"medication reconciliation allergies anticoagulant interaction high-risk verified","body":"Medications and allergies were reconciled with {{source|the patient|family|the pharmacy record|the medication list on file}}. Allergies: {{allergies|no known drug allergies|as listed and verified}} (***). Particular attention was paid to {{highrisk|anticoagulants and antiplatelets|insulin and oral hypoglycemics|interacting or QT-prolonging agents|recent antibiotic or steroid courses}}, and prescribing decisions accounted for them.","aliases":"medication reconciliation med rec allergies home meds medication list current meds"},{"id":"comm-badnews","trigger":".badnews","title":"Serious diagnosis disclosed to patient/family","cat":"comms","tags":"bad news serious diagnosis disclosure family prognosis communication","body":"The {{kind|new diagnosis|serious finding|critical result}} of *** was disclosed to {{recipient|the patient|the patient and family|the family, as the patient was unable to participate}} in plain language. Questions were answered, the immediate plan ({{plan|admission|urgent consultation|transfer|initiation of treatment}}) and the prognosis as currently known were discussed, and support was offered. Understanding was confirmed and the conversation is documented.","aliases":"bad news serious diagnosis breaking bad news cancer disclosed told patient family difficult conversation"},{"id":"sp-ipv","trigger":".ipv","title":"IPV / elder or vulnerable-adult screen","cat":"special","tags":"intimate partner violence elder abuse vulnerable adult screening mandatory reporting safety","body":"Given the presentation, screening for {{concern|intimate-partner violence|elder abuse or neglect|vulnerable-adult abuse}} was performed in a private setting. The screen was {{result|negative and the patient denied abuse|positive or concerning}}. {{action|Resources and a safety plan were offered and confidentiality was maintained|A report was made to the appropriate agency per mandatory-reporting requirements, and safety and disposition were addressed}}. Findings were documented objectively, in the patient's own words where relevant.","aliases":"ipv domestic violence intimate partner elder abuse vulnerable adult screen safety"},{"id":"sp-custody","trigger":".custody","title":"Law-enforcement request / forensic","cat":"special","tags":"law enforcement police custody forensic blood draw medical clearance warrant consent chain of custody","body":"A request from law enforcement was addressed. {{type|A medical clearance / fitness-for-incarceration evaluation was performed|A forensic (legal) blood draw was requested|Information was requested}}. {{consent|The patient, who has capacity, consented to the requested testing or release|The patient declined, which was respected absent a valid warrant or legal mandate|A valid warrant or legal authority was confirmed}}. Care of the patient was not compromised by the law-enforcement presence; the interaction, the authority relied upon, and the chain of custody where applicable are documented.","aliases":"law enforcement police custody forensic blood draw warrant prisoner legal chain of custody"},{"id":"proc-chaperone","trigger":".chaperone","title":"Chaperone present for sensitive exam","cat":"proc","tags":"chaperone sensitive exam genitourinary pelvic breast rectal consent privacy","body":"A chaperone ({{chaperone|a nurse|a trained staff member}}) was present for the {{exam|genitourinary|pelvic|breast|rectal|sensitive}} examination. The indication and what the examination would involve were explained, the patient consented, and the chaperone's name is recorded. The patient was draped and privacy was maintained throughout.","aliases":"chaperone sensitive exam pelvic genital breast witness present"},{"id":"cm-uri","trigger":".cmuri","title":"URI / sinusitis — can't-miss line","cat":"cantmiss","tags":"uri sinusitis cold congestion orbital cellulitis intracranial complication periorbital flu influenza","specs":["ent","id"],"body":"For this upper respiratory presentation I screened for the complications that hide behind 'sinusitis' — orbital extension (periorbital swelling, pain with eye movement, vision change) and intracranial extension (severe or worsening headache, vomiting, altered mentation, meningism). Periorbital tissues normal, extraocular movements full and painless, vision at baseline, and no neurologic symptoms. A complicated course was judged unlikely on the basis above.","aliases":"cold sinus infection congestion facial pressure runny nose orbital cellulitis flu"},{"id":"cm-ear","trigger":".cmear","title":"Ear pain — can't-miss line","cat":"cantmiss","tags":"ear otitis mastoiditis malignant necrotizing otitis externa facial nerve ramsay hunt","specs":["ent"],"body":"For this ear pain I screened for mastoiditis (no postauricular swelling, erythema, or auricular protrusion), necrotizing otitis externa (no diabetes/immunocompromise with pain out of proportion; no canal granulation tissue), and facial nerve involvement (facial movements symmetric, no vesicles). The tympanic membrane was directly visualized: {{TM|normal|bulging and erythematous|perforated with otorrhea}}.","aliases":"earache ear infection otitis swimmers ear mastoid"},{"id":"cm-dental","trigger":".cmdental","title":"Dental / facial pain — can't-miss line","cat":"cantmiss","tags":"dental tooth ludwig angina deep space infection trismus cardiac jaw cavernous sinus","specs":["ent","surg"],"body":"For this dental/facial pain I screened for airway-threatening spread and the non-dental mimics: floor of mouth soft with the tongue freely mobile, no trismus, drooling, voice change, or dysphagia; no midface infection with headache or eye findings; and no exertional pattern or cardiac risk profile to suggest an anginal equivalent. The presentation was judged consistent with a dental source, with dental follow-up arranged.","aliases":"toothache tooth abscess jaw pain facial swelling ludwig"},{"id":"cm-cellulitis","trigger":".cmcellulitis","title":"Cellulitis — can't-miss line","cat":"cantmiss","tags":"cellulitis necrotizing fasciitis abscess dvt stasis dermatitis skin infection crepitus bullae","specs":["derm","id"],"body":"For this soft-tissue infection I specifically assessed necrotizing features — no pain out of proportion, rapid progression, crepitus, bullae, dusky discoloration, woody induration, cutaneous anesthesia, or systemic toxicity. {{Distribution|Unilateral involvement|Bilateral involvement — stasis dermatitis considered as the likelier process}}; a drainable collection was {{collection|not identified|identified and drained}}. DVT was considered for the swollen red limb.","aliases":"skin infection red leg spider bite boil abscess nec fasc"},{"id":"cm-wrist","trigger":".cmwrist","title":"Wrist / hand injury — can't-miss line","cat":"cantmiss","tags":"wrist hand scaphoid snuffbox perilunate lunate gilula foosh kanavel flexor tenosynovitis","specs":["ortho"],"body":"For this wrist/hand injury I examined the scaphoid specifically (snuffbox, scaphoid tubercle, axial thumb load: {{scaphoid|non-tender|tender — treated as scaphoid fracture despite imaging}}), reviewed the films for carpal alignment including the Gilula arcs and the lunate on the lateral view, and confirmed neurovascular and tendon function with no rotational deformity of the digits.","aliases":"fell on hand foosh broken wrist scaphoid snuffbox hand injury"},{"id":"uc-abx","trigger":".noabx","title":"Antibiotics not indicated — stewardship discussion","cat":"sdm","tags":"antibiotics stewardship viral not indicated shared decision uri bronchitis expectations","specs":["id"],"body":"The likely viral nature of this illness was discussed, including why antibiotics are not expected to help and can cause harm (adverse effects, resistance, C. difficile). The patient's expectations were addressed directly, supportive care was reviewed, and a specific plan was given to return or fill a contingency prescription if symptoms persist beyond *** or follow a worsening-after-improving course. The patient {{response|verbalized understanding and agreed|preferred antibiotics; shared decision documented}}.","aliases":"no antibiotics viral stewardship patient wants antibiotics z pack"},{"id":"uc-scaphoid","trigger":".scaphoid","title":"Scaphoid precautions despite negative X-ray","cat":"uncertainty","tags":"scaphoid negative xray thumb spica repeat imaging occult fracture snuffbox","specs":["ortho"],"body":"Snuffbox/scaphoid tenderness with negative initial radiographs: the patient was treated as having a presumed occult scaphoid fracture. A thumb-spica splint was applied, and repeat examination and imaging in 10–14 days were arranged. The patient understands that a normal X-ray today does not exclude a scaphoid fracture, and that untreated scaphoid fractures can fail to heal and lose blood supply.","aliases":"scaphoid negative xray thumb spica wrist sprain repeat film"},{"id":"uc-necfasc","trigger":".necfasc","title":"Necrotizing infection considered","cat":"mdm","tags":"necrotizing fasciitis considered cellulitis crepitus bullae pain out of proportion","specs":["derm","id","surg"],"body":"Necrotizing soft-tissue infection was specifically considered. On directed examination there was no pain out of proportion to findings, no crepitus, bullae, dusky or gray discoloration, woody induration, or cutaneous anesthesia, no progression over hours, and no systemic toxicity. The pretest probability was judged low; the patient was instructed to return immediately for rapidly spreading redness, severe escalating pain, fever, or confusion.","aliases":"nec fasc necrotizing fasciitis ruled out flesh eating"},{"id":"uc-margin","trigger":".margin","title":"Cellulitis margin marked","cat":"discharge","tags":"cellulitis margin marked demarcation progression return instructions","specs":["derm"],"body":"The border of erythema was marked in the ED and the patient was instructed to photograph it daily, to return if the redness extends past the line, fails to improve within 48 hours of antibiotics, or if fever, streaking, or worsening pain develops. First dose administered ***.","aliases":"marked the redness draw line cellulitis worse return"},{"id":"uc-ind","trigger":".ind","title":"Incision & drainage — procedure note","cat":"proc","tags":"abscess incision drainage i&d procedure packing loop culture","specs":["derm","surg"],"body":"Incision and drainage of *** abscess. Consent obtained; risks including bleeding, infection, scarring, and recurrence discussed. Local anesthesia with ***. Incision over the point of maximal fluctuance; *** purulent material expressed; loculations broken gently; wound {{wound|packed|fitted with loop drain|left open to drain}}. Cultures {{cultures|not sent (uncomplicated)|sent}}. Hemostasis achieved; tolerated well. Wound care, packing follow-up, and infection return precautions reviewed.","aliases":"drained abscess i and d incision drainage packing boil"},{"id":"uc-otitis","trigger":".otitisobs","title":"AOM — observation option (shared decision)","cat":"sdm","tags":"otitis media observation watchful waiting delayed antibiotics peds shared decision safety net","specs":["peds","ent"],"body":"For this acute otitis media, the options of immediate antibiotics versus a 48–72 hour observation period were discussed in line with guideline criteria (age, laterality, severity, otorrhea). The {{plan|observation option was chosen, with a safety-net prescription to start if symptoms persist or worsen at 48–72 hours|immediate antibiotic option was chosen}}. Analgesia was addressed, and return precautions (worsening pain, fever, postauricular swelling, lethargy) were reviewed.","aliases":"ear infection watchful waiting delayed antibiotics safety net prescription"},{"id":"uc-flu","trigger":".fluhighrisk","title":"Influenza in a high-risk patient","cat":"mdm","tags":"influenza flu antiviral oseltamivir high risk pregnancy immunocompromised elderly","specs":["id","pulm"],"body":"Influenza-like illness in a patient with high-risk features (***). Antiviral treatment was {{antiviral|started, given symptom onset within the treatment window and host risk|discussed and not started, with rationale documented}}; hypoxia was excluded ({{sat|SpO₂ ≥ 94% at rest|see vitals}}), lower respiratory involvement was assessed, and a specific worsening plan (dyspnea, inability to maintain hydration, confusion, symptoms that improve then return with fever) was reviewed.","aliases":"flu tamiflu pregnant flu elderly influenza antiviral"},{"id":"uc-tetanus","trigger":".tetanus","title":"Tetanus status addressed","cat":"data","tags":"tetanus immunization booster wound prophylaxis tdap","specs":[],"body":"Tetanus status reviewed for this {{wound class|clean minor wound|tetanus-prone wound (contaminated, puncture, devitalized tissue)}}: {{status|up to date — no booster required|booster administered today|declined — documented after discussion}}.","aliases":"tetanus shot booster tdap wound"},{"id":"uc-worknote","trigger":".worknote","title":"Work / school note documented","cat":"comms","tags":"work note school excuse activity restriction duty return clearance","specs":[],"body":"A work/school note was provided: excused {{scope|today|through ***}} with {{restrictions|no restrictions on return|the following restrictions: ***}}. The note reflects the clinical assessment only; fitness-for-duty determinations beyond this visit's scope were not made and were deferred to the patient's regular clinician or occupational health.","aliases":"work excuse school note off work letter doctor note"},{"id":"cm-pedcough","trigger":".cmpedcough","title":"Pediatric cough — can't-miss line","cat":"cantmiss","tags":"pediatric cough child foreign body aspiration pertussis whooping cough pneumonia croup respiratory distress hypoxia apnea","specs":["peds","pulm","id"],"body":"For this child's cough I screened the dangerous causes that hide behind a viral picture: foreign-body aspiration (no witnessed choking or sudden onset; breath sounds symmetric without focal or unilateral findings), pertussis (no paroxysms, whoop, post-tussive emesis, or infant apnea; immunization status reviewed), pneumonia (no focal crackles, decreased breath sounds, or hypoxia), and respiratory compromise (work of breathing comfortable, SpO₂ {{SpO2|≥ 95% on room air|see vitals}}, feeding and hydration adequate, no stridor at rest). The dangerous causes were judged unlikely on the basis above.","aliases":"child cough kid cough peds cough foreign body pertussis whooping croup pneumonia"},{"id":"peds-croup","trigger":".croup","title":"Croup — severity & management","cat":"mdm","tags":"croup laryngotracheitis stridor dexamethasone racemic epinephrine barky cough westley severity","specs":["peds","ent"],"body":"Croup (viral laryngotracheitis): severity graded as {{severity|mild — no stridor at rest|moderate — stridor at rest with mild retractions|severe — stridor at rest with marked work of breathing}}. Dexamethasone {{dex|given|given, and racemic epinephrine administered with a post-treatment observation period}}. No drooling, toxic appearance, or tripoding to suggest epiglottitis or a retropharyngeal process. After treatment and observation the child was {{dispo|comfortable at rest and dischargeable with return precautions|admitted/observed for persistent stridor at rest}}.","aliases":"croup barky cough stridor dexamethasone racemic epi laryngotracheitis"},{"id":"peds-pertussis","trigger":".pertussis","title":"Pertussis considered — testing & public health","cat":"timecrit","tags":"pertussis whooping cough bordetella paroxysm whoop post tussive emesis apnea infant public health azithromycin exposure","specs":["peds","id"],"body":"Pertussis was considered given ***. Testing ({{test|PCR sent|nasopharyngeal swab obtained}}) was performed, and immunization status and household/childcare exposures were reviewed. {{treat|Macrolide treatment and exposure prophylaxis were addressed per local guidance|Treatment was deferred pending testing}}; public-health reporting requirements were noted. Apnea is the lethal complication in young infants, so a low admission threshold and explicit apnea/color-change return precautions were given to the caregiver.","aliases":"pertussis whooping cough bordetella azithromycin exposure public health apnea infant"},{"id":"coding-indhistorian","trigger":".indhistorian","title":"Independent historian","cat":"coding","tags":"independent historian collateral data complexity ems family unable history 2023 mdm","body":"Because the patient was unable to give a complete or reliable history (***), history was obtained from an independent historian, *** (e.g., EMS, family, prior records). Their account -- *** -- materially informed the assessment and plan and is documented as part of the data reviewed.","aliases":"independent historian collateral ems family unreliable history obtained from data element"},{"id":"coding-indinterp","trigger":".indinterp","title":"Independent interpretation of a test","cat":"coding","tags":"independent interpretation ecg radiograph pocus imaging data complexity 2023 mdm own read","body":"I personally performed an independent interpretation of the *** (e.g., ECG / chest radiograph / point-of-care ultrasound), separate from any formal interpretation by ***. My interpretation: ***. This was incorporated into the medical decision-making and is documented as a distinct data element.","aliases":"independent interpretation own read ecg xray ultrasound pocus interpreted myself data"},{"id":"coding-extconsult","trigger":".extconsult","title":"Discussion of management with external clinician","cat":"coding","tags":"discussion external physician consultant qualified health professional data complexity 2023 mdm","body":"I discussed the management of this patient directly with ***, a physician/qualified health professional outside my own group/specialty (***). The substance of the discussion -- *** -- and the agreed plan -- *** -- are documented as part of the data reviewed and analyzed.","aliases":"discussion external physician consultant qhp called spoke with specialist coordination data"},{"id":"coding-extrecords","trigger":".extrecords","title":"Review of external notes / records","cat":"coding","tags":"external records notes unique source review reconciliation data complexity 2023 mdm","body":"I reviewed external notes/records from *** (a unique source: ***) and reconciled them against the current presentation. Pertinent findings: ***. This review informed the assessment and is documented as a data element.","aliases":"external records notes outside hospital prior chart reviewed unique source reconciled data"},{"id":"coding-datacomplexity","trigger":".datacomplexity","title":"Data reviewed & analyzed (summary)","cat":"coding","tags":"amount complexity data reviewed analyzed unique tests summary 2023 mdm element","body":"Data reviewed and analyzed at this encounter included: unique test(s) ordered and/or reviewed (***); independent interpretation of *** ; an independent historian (***); and discussion with an external clinician (***), each as documented above. These were synthesized into the assessment that follows.","aliases":"data reviewed analyzed amount complexity unique tests summary moderate extensive element"},{"id":"coding-problemsaddressed","trigger":".problemsaddressed","title":"Problem(s) addressed & complexity","cat":"coding","tags":"problems addressed number complexity acute chronic systemic threat 2023 mdm element","body":"Problem(s) addressed at this visit: ***. Based on ***, this is best characterized as *** (e.g., acute uncomplicated illness; acute illness with systemic symptoms; acute complicated injury; chronic illness with exacerbation; or an acute illness or injury that poses a threat to life or bodily function).","aliases":"problems addressed number complexity acute illness systemic symptoms threat to life chronic element"},{"id":"coding-riskmdm","trigger":".riskmdm","title":"Risk of complications / morbidity of management","cat":"coding","tags":"risk complications morbidity management hospitalization prescription drug 2023 mdm element","body":"The risk of complications and/or morbidity of patient management was *** (low / moderate / high), reflected by ***: e.g., prescription drug management; the decision regarding hospitalization or observation; diagnostic testing/treatment carrying its own risk; or the degree of diagnostic uncertainty requiring *** to exclude an emergent condition.","aliases":"risk of complications morbidity mortality management prescription hospitalization element column"},{"id":"coding-hospdecision","trigger":".hospdecision","title":"Decision regarding hospitalization","cat":"coding","tags":"decision hospitalization admission observation discharge risk benefit 2023 mdm high risk","body":"The decision regarding hospitalization versus discharge was actively weighed: factors favoring admission/observation (***) against those supporting discharge (***). The disposition of *** reflects this documented risk/benefit analysis.","aliases":"decision regarding hospitalization admit observe discharge risk benefit disposition high risk"},{"id":"coding-rxmgmt","trigger":".rxmgmt","title":"Prescription drug management","cat":"coding","tags":"prescription drug management moderate risk medication started adjusted 2023 mdm","body":"Management included prescription drug management: *** was started/continued/adjusted for ***, with attention to interactions, contraindications, and monitoring (***). This is documented as an element of management risk.","aliases":"prescription drug management medication started prescribed adjusted moderate risk element"},{"id":"coding-critcare","trigger":".critcare","title":"Critical care time (if applicable)","cat":"coding","tags":"critical care time 99291 imminent deterioration high probability resuscitation","body":"Critical care was provided to a patient with a high probability of imminent or life-threatening deterioration (***). I personally delivered *** minutes of critical care, exclusive of any separately billable procedure, including ***. Time and medical necessity reflect care actually delivered.","aliases":"critical care time minutes 99291 imminent life threatening deterioration resuscitation unstable"},{"id":"coding-emlevel","trigger":".emlevel","title":"Level of service supported (summary)","cat":"coding","tags":"level of service medical decision making complexity supported summary 2023 mdm honest","body":"Taken together -- the problem(s) addressed (***), the amount and complexity of data reviewed and analyzed (***), and the risk of complications/morbidity of management (***) -- the documentation supports a medical decision-making complexity of ***. This reflects the cognitive work actually performed for this patient, not a target level.","aliases":"level of service supported mdm complexity summary moderate high honest reflects work performed"},{"id":"proc-intubation","trigger":".intubation","title":"Endotracheal intubation — procedure note","cat":"proc","tags":"intubation rsi airway endotracheal laryngoscopy capnography ventilator","body":"Endotracheal intubation for ***. {{Consent|Emergent — implied consent|Risks/benefits discussed with patient/family}}. Preoxygenated; hemodynamics optimized. Induction with *** and paralysis with ***. {{Device|Video laryngoscopy|Direct laryngoscopy}}, grade *** view; ***-mm cuffed tube passed through the cords under direct visualization to *** cm at the teeth. Placement confirmed by continuous waveform capnography and bilateral breath sounds; chest x-ray confirms position above the carina. No hypoxia or hemodynamic collapse during the attempt{{Attempts|; first-pass success|; *** attempts, oxygenation maintained between attempts}}. Post-intubation analgesia and sedation initiated; initial ventilator settings: ***.","aliases":"intubation rsi rapid sequence airway ett tube vent endotracheal procedure note first pass"},{"id":"proc-codenote","trigger":".codenote","title":"Cardiac arrest — resuscitation narrative","cat":"proc","tags":"cardiac arrest code cpr acls resuscitation rhythm defibrillation rosc","body":"Cardiac arrest resuscitation. Arrest {{Location|prior to arrival (downtime ***)|witnessed in the ED}}; initial rhythm ***. High-quality CPR with rhythm checks every 2 minutes; airway managed with ***; IV/IO access established. Interventions: epinephrine ***; {{Defib|defibrillation ×*** for shockable rhythms|no shockable rhythm}}; ***. Reversible causes were actively addressed — hypoxia, hypovolemia, hyperkalemia/metabolic, hypothermia, tension pneumothorax, tamponade, toxins, and thrombosis (coronary and pulmonary) — with *** identified and treated. {{Outcome|ROSC achieved at *** — see post-ROSC care|Resuscitation terminated at *** (see pronouncement note)}}. I led the resuscitation and was present throughout.","aliases":"code blue arrest narrative acls cpr resus note pulseless vf vt asystole pea hs ts"},{"id":"proc-rosc","trigger":".rosc","title":"Post-ROSC care","cat":"proc","tags":"rosc post arrest targeted temperature ecg stemi neuro icu","body":"Post-ROSC care: 12-lead ECG obtained immediately — {{ECG|no STEMI; cardiology aware|STEMI — cath lab activated}}. Targeting normoxia (SpO2 92–98%), normocapnia, and MAP ≥ 65 with ***. {{Neuro|Following commands|Not following commands — targeted temperature management addressed with ICU}}. Head CT ***; labs including lactate, potassium, and troponin sent; the precipitating cause is being pursued (***). Admitted to intensive care; discussed directly with the accepting intensivist.","aliases":"rosc return of spontaneous circulation post arrest ttm cooling cath stemi icu handoff"},{"id":"proc-pronounce","trigger":".pronounce","title":"Termination of resuscitation / pronouncement","cat":"proc","tags":"death pronouncement termination resuscitation family notification me coroner","body":"Resuscitation was terminated after *** minutes of ACLS-guided efforts with no ROSC, persistent {{Rhythm|asystole|PEA}} despite treatment of reversible causes, and end-tidal CO2 persistently ***. Time of death: ***. The family was {{Family|present during resuscitation, supported by staff|notified in person|notified by phone}} and their questions were answered. {{Referral|Medical examiner/coroner notified|Death does not meet ME criteria; attending physician to certify}}; organ procurement organization notified per protocol.","aliases":"death pronounce termination tod expired family notification coroner medical examiner opo"},{"id":"proc-cardioversion","trigger":".cardioversion","title":"Synchronized cardioversion — procedure note","cat":"proc","tags":"cardioversion synchronized afib flutter svt vt sedation joules","body":"Synchronized electrical cardioversion for ***. {{Consent|Risks/benefits discussed and consented|Emergent — unstable, implied consent}}. Procedural sedation with *** (see sedation note). Synchronization confirmed on the monitor; *** J biphasic delivered ×{{Shocks|1|***}}. Post-cardioversion rhythm: ***. The patient recovered to baseline with stable vital signs; post-procedure ECG obtained. Anticoagulation status and stroke risk addressed: ***.","aliases":"cardioversion shock synchronized dccv afib rvr flutter svt unstable joules"},{"id":"proc-centralline","trigger":".centralline","title":"Central venous catheter — procedure note","cat":"proc","tags":"central line cvc ultrasound sterile seldinger internal jugular femoral subclavian","body":"Central venous catheter placement, {{Site|right internal jugular|left internal jugular|right femoral|left femoral|subclavian}} vein, for ***. {{Consent|Consent obtained|Emergent — implied consent}}. Full sterile barrier precautions; site prepped with chlorhexidine. Real-time ultrasound guidance; vein entered on pass ***; wire advanced without ectopy and never released; dilated; ***-Fr catheter advanced and each port aspirated and flushed. Secured at *** cm; sterile dressing applied. {{Confirmation|Chest x-ray confirms tip position without pneumothorax|Femoral — no confirmation film required}}. No arterial puncture, hematoma, or immediate complication; tolerated well.","aliases":"central line cvc ij femoral subclavian triple lumen cordis ultrasound seldinger sterile"},{"id":"proc-chesttube","trigger":".chesttube","title":"Tube / finger thoracostomy — procedure note","cat":"proc","tags":"chest tube thoracostomy pneumothorax hemothorax pigtail triangle safety","body":"{{Type|Tube thoracostomy|Finger thoracostomy|Pigtail catheter}} on the {{Side|right|left}} for ***. {{Consent|Consent obtained|Emergent — implied consent}}. Site within the triangle of safety (4th–5th intercostal space, anterior to the mid-axillary line); sterile prep; local anesthesia ***. Blunt dissection over the rib; pleura entered with an immediate {{Return|rush of air|return of *** mL blood|both air and blood}}; finger sweep confirmed intrathoracic placement. ***-Fr tube directed {{Direction|apically|posteriorly}}, secured, and connected to a water-seal drainage system. Chest x-ray confirms position and re-expansion. Breathing and hemodynamics improved; no immediate complication.","aliases":"chest tube thoracostomy finger pigtail pneumo hemothorax tension decompression water seal"},{"id":"mdm-general","trigger":".generalmdm","title":"General MDM — any complaint","cat":"mdm","tags":"general template differential any complaint fallback mdm skeleton","body":"Medical decision-making: I evaluated this patient for ***. The differential included the life-threatening causes — *** — as well as ***. I considered ***: *** — unlikely. The findings argue against *** — ***. Data reviewed: ***. {{Risk tool|Risk stratification: *** score *** (***)|No validated risk tool applies to this presentation}}. Taken together, the presentation is most consistent with ***. The dangerous causes above have been addressed and are unlikely; I treated and dispositioned the patient accordingly, with specific return precautions.","aliases":"general mdm template any complaint blank skeleton fallback medical decision making differential"}],"specialties":[{"id":"peds","label":"Peds"},{"id":"cards","label":"Cardiology"},{"id":"pulm","label":"Pulm / Resp"},{"id":"gi","label":"GI"},{"id":"neuro","label":"Neurology"},{"id":"nsgy","label":"Neurosurgery / Spine"},{"id":"obgyn","label":"OB/Gyn"},{"id":"uro","label":"Urology"},{"id":"vasc","label":"Vascular"},{"id":"ortho","label":"Ortho / MSK"},{"id":"ophtho","label":"Ophtho"},{"id":"ent","label":"ENT"},{"id":"derm","label":"Derm"},{"id":"id","label":"Infectious Dz"},{"id":"tox","label":"Tox / Addiction"},{"id":"psych","label":"Psych"},{"id":"heme","label":"Heme / Transfusion"},{"id":"surg","label":"Surgery"},{"id":"geri","label":"Geriatrics"}]}