Differential diagnosis documentation
Abdominal pain
Abdominal pain in adult female
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.
Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.
Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.
Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.
Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Abdominal pain adult male
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; GI bleeding, or other surgical/acute abdomen.
Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.
Similarly, this case is NOT consistent with testicular torsion, prostatitis, hernia, STI, or other testicular issue.
Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.
Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Abdominal pain peds female
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with intussception; bowel perforation/obstruction; volvulus; appendicitis; peritonitis; cholecystitis, ascending cholangitis or other gallbladder disease; significant GI bleeding, splenic rupture/infarction; hepatic abscess; or other surgical/acute abdomen.
Similarly, this presentation is NOT consistent with incarcerated hernia; pancreatitis, DKA; kidney stone; ischemic colitis; psoas or other abscess; methanol poisoning; heavy metal toxicity; porphyria; or abuse.
Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.
Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, otitis media, or other focal bacterial infection.
@NAME@ is not currently dehydrated and is tolerating POs.
Strict return and follow-up precautions have been given by me personally to the family/caregiver(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Abdominal pain peds male
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with intussception; bowel perforation/obstruction; volvulus; appendicitis; peritonitis; cholecystitis, ascending cholangitis or other gallbladder disease; significant GI bleeding, splenic rupture/infarction; hepatic abscess; or other surgical/acute abdomen.
Similarly, this presentation is NOT consistent with incarcerated hernia; pancreatitis, DKA; kidney stone; ischemic colitis; psoas or other abscess; methanol poisoning; heavy metal toxicity; porphyria; or abuse.
Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, otitis media, or other focal bacterial infection.
@NAME@ is not currently dehydrated and is tolerating POs.
Strict return and follow-up precautions have been given by me personally to the family/caregiver(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Abscess
There is no area of retained pus after procedure. The presentation of @NAME@ is NOT consistent with necrotizing fascitis or osteomyolitis. There is no evidence of retained foreign body (besides packing), or neurovascular or tendon injury. The presentation of @NAME@ is NOT consistent with sepsis and/or bacturemia. @NAME@ meets outpatient criteria for treatment and is sent home on empiric antibiotics covering the relevant bacteria.
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
AGE
@NAME@ likely has viral acute gastro-enteritis. Able to take down POs. No indication for antibiotics or further studies at this time.
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with AAA; Mesenteric Ischemia; Bowel Perforation; Bowel Obstruction; Sigmoid Volvulus; Diverticulitis; Appendicitis; Peritonitis; Cholecystitis, ascending cholangitis or other gallbladder disease; perforated ulcer; significant GI bleeding, splenic rupture/infarction; Hepatic abscess; or other surgical/acute abdomen.
Similarly, this presentation is NOT consistent with ACS or Myocardial Ischemia or cardiac etiology; Pulmonary Embolism; fistula; incarcerated hernia; Pancreatitis, Aortic Dissection; Diabetic Ketoacidosis; Kidney Stone; Ischemic colitis; Psoas or other abscess; Methanol poisoning; Heavy metal toxicity; or porphyria.
Similarly, this case is NOT consistent with Fitz-Hugh-Curtis Syndrome, Ectopic Pregnancy, Placental Abruption, PID, Tubo-ovarian abscess, Ovarian Torsion, or STI.
Similarly, this presentation is NOT consistent with acute coronary syndrome, pulmonary embolism, dissection, borhaave's, arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.
Similarly, this presentation is NOT consistent with sepsis, pyelonephritis, urinary infection, pneumonia, or other focal bacterial infection.
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Asthma
The presentation of @NAME@ is not consistent with cardiac wheeze, congestive heart failure, pneumothorax, pulmonary emboli, or other emergent process.
Additionally, @NAME@ has no evidence of of pneumonia, sepsis, or other indication for antibiotics.
Upon discharge, @NAME@ has no evidence of respiratory failure or signs of tiring, and is comfortable without respiratory distress. @NAME@ meets outpatient treatment criteria.
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Cellulitis
There is no area of currently drain-able abscess. The presentation of @NAME@ is NOT consistent with necrotizing fascitis or osteomyolitis. There is no evidence of retained foreign body, or neurovascular or tendon injury. The presentation of @NAME@ is NOT consistent with sepsis and/or bacturemia. @NAME@ meets outpatient criteria for treatment and is sent home on empiric antibiotics covering the relevant bacteria, including MRSA if applicable.
Strict return and follow-up precautions have been given personally by me.
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Chest Pain Discharge
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with Acute Coronary Syndrome (ACS) and/or myocardial ischemia, pulmonary embolism, aortic dissection; Borhaave's, significant arrythmia, pneumothorax, cardiac tamponade, or other emergent cardiopulmonary condition.
Further, the presentation of @NAME@ is NOT consistent with pericarditis, myocarditis, cholecystitis, pancreatitis, mediastinitis, endocarditis, new valvular disease.
Additionally, the presentation of @NAME@ is NOT consistent with flail chest, cardiac contusion, ARDS, or significant intra-thoracic or intra-abdominal bleeding.
Similarly, this presentation is NOT consistent with pneumonia, sepsis, or pyelonephritis.
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Crying infant
@NAME@ has no evidence of occult UTI, corneal abrasion, hair tourniquets, insect bites, burns in mouth, otitis, physical abuse, anal fissures, intussusception, incarcerated hernias, testicular torsion, drug exposure or withdrawal, meningitis, SVT, PNA, rib fractures, ASA OD, surgical abdomen, infection, fracture or other trauma, or other emergent cause of symptoms.
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Fever adult
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with meningitis, sepsis and/or bactermia. @NAME@ is not severely dehydrated and can tolerate POs at home.
Further, the presentation of @NAME@ is NOT consistent with surgical abdomen and/or peritonitis, for example appendicitis; bowel prerforation or obstruction; volvulus; intussception; pyloric stenosis; gallbladder disease; splenic rupture/infarction; Hepatic abscess; psoas or other abscess.
Further, the presentation of @NAME@ is NOT consistent pyelonephritis, urinary infection, pneumonia, or otitis media, or other focal bacterial infection.
@NAME@ is not at risk for Ebola, MERS, or other specific travel-related infection.
Strict return and follow-up precautions have been given by me personally to the patient/family/caregiver(s).
Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Fever Peds
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with meningitis, sepsis and/or bactermia. @NAME@ is not severely dehydrated and can tolerate POs at home.
Further, the presentation of @NAME@ is NOT consistent with surgical abdomen and/or peritonitis, for example appendicitis; bowel prerforation or obstruction; volvulus; intussception; pyloric stenosis; gallbladder disease; splenic rupture/infarction; Hepatic abscess; psoas or other abscess.
Similarly, this presentation is NOT consistent with Kawasaki's or other emergency cause of fever.
Further, the presentation of @NAME@ is NOT consistent pyelonephritis, urinary infection, pneumonia, or otitis media, or other focal bacterial infection.
Strict return and follow-up precautions have been given by me personally to parent(s)/guardian(s).
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Fracture
@NAME@ has no evidence of an open fracture; dislocation; retained foreign body; nerve, tendon, or vascular injury; compartment syndrome; septic joint or other infection.
Data Reviewed/Counseling: I have reviewed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.
Headache
Given the large differential diagnosis for @NAME@, the decision making in this case is of high complexity.
After evaluating all of the data points in this case, the presentation of @NAME@ is NOT consistent with fracture, meningitis/encephalitis, SAH/sentinel bleed, Intracranial Hemorrhage (ICH) (subdura/epidural), acute obstructive hydrocephalus, space occupying lesions, CVA, CO Poisoning, Basilar artery dissection, preeclampsia, cerebral venous thrombosis, hypertensive emergency, suicidal ideation, temporal Arteritis, Idiopathic Intracranial Hypertension (pseudotumor cerebri).
Strict return and follow-up precautions have been given by me personally.
Data Reviewed/Counseling: I have reviwed the patient's vital signs, nursing notes, and other relevant tests/information. I had a detailed discussion regarding the historical points, exam findings, and any diagnostic results supporting the discharge diagnosis. I also discussed the need for outpatient follow-up and the need to return to the ED if symptoms worsen or if there are any questions or concerns that arise at home.