Differential diagnosis documentation: Difference between revisions

(Created page with "==Abdominal pain in adult female== :Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity. :After evaluating all of the...")
 
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==Abdominal pain in adult female==
==Abdominal pain in adult female==
:Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.   
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.   


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


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


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


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


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


:Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
 
Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.   
 
==Abdominal pain adult male==
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity. 
 
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; GI bleeding, or other surgical/acute abdomen. 
 
Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.
 
Similarly, this case is NOT consistent with testicular torsion, prostatitis, hernia, STI, or other testicular issue.
 
Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.
 
Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.
 
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
 
Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.   
 
==Abdominal pain peds female==
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity. 
 
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with intussception; bowel perforation/obstruction; volvulus; appendicitis; peritonitis; cholecystitis, ascending cholangitis or other gallbladder disease; significant GI bleeding, splenic rupture/infarction; hepatic abscess; or other surgical/acute abdomen. 
 
Similarly, this presentation is NOT consistent with incarcerated hernia; pancreatitis, DKA; kidney stone; ischemic colitis; psoas or other abscess; methanol poisoning; heavy metal toxicity; porphyria; or abuse.
 
Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.
 
Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, otitis media, or other focal bacterial infection.
 
@NAME@ is not currently dehydrated and is tolerating POs. 
 
Strict return and follow-up precautions have been given by me personally to the family/caregiver(s).
 
Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.   
 
==Abdominal pain peds male==
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity. 
 
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with intussception; bowel perforation/obstruction; volvulus; appendicitis; peritonitis; cholecystitis, ascending cholangitis or other gallbladder disease; significant GI bleeding, splenic rupture/infarction; hepatic abscess; or other surgical/acute abdomen. 
 
Similarly, this presentation is NOT consistent with incarcerated hernia; pancreatitis, DKA; kidney stone; ischemic colitis; psoas or other abscess; methanol poisoning; heavy metal toxicity; porphyria; or abuse.
 
Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, otitis media, or other focal bacterial infection.
 
@NAME@ is not currently dehydrated and is tolerating POs. 
 
Strict return and follow-up precautions have been given by me personally to the family/caregiver(s).
 
Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.   


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




[[Category:Documentation]]
[[Category:Documentation]]

Revision as of 18:50, 2 January 2017

Abdominal pain in adult female

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

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

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

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

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

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

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

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

Abdominal pain adult male

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

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

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

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

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

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

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

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

Abdominal pain peds female

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

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

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

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

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

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

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

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

Abdominal pain peds male

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

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

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

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

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

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

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