MDM for different chief complaints - Revision history

Rossdonaldson1: /* See Also */

2026-03-25T17:31:58Z

Danbot: Expanded See Also with documentation/billing/discharge links, added documentation pages template

2026-03-24T11:08:38Z

Expanded See Also with documentation/billing/discharge links, added documentation pages template

← Older revision		Revision as of 11:08, 24 March 2026
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	==See Also==		==See Also==
			*[[Documentation for emergency physicians]]
			*[[MDM for different chief complaints (peds)]]
			*[[Differential diagnosis documentation]]
			*[[Billing]]
			*[[Discharge documentation]]

			{{Documentation pages}}

			==References==
			<references/>

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

Ostermayer at 18:16, 16 January 2026

2026-01-16T18:16:05Z

← Older revision		Revision as of 18:16, 16 January 2026
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	{{~~Adult top}} [[~~MDM for different chief complaints (peds)~~]]."~~		{{AdultPage\|MDM for different chief complaints (peds)}}

	==Chest Pain==		==Chest Pain==

Jean.Kalima: /* Lower Abdominal pain F non preg MDM */

2024-04-10T14:22:57Z

Lower Abdominal pain F non preg MDM

← Older revision		Revision as of 14:22, 10 April 2024
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	===Lower Abdominal pain F non preg MDM===		===Lower Abdominal pain F non preg MDM===
	Patient presents with lower abdominal pain/pelvic pain. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. Considered ~~and doubt~~ ovarian torsion given history and presentation. Given work up low suspicion for acute hepatobiliary disease (including acute cholecystitis), acute pancreatitis (neg lipase), PUD and gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, diverticulitis. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.		Patient presents with lower abdominal pain/pelvic pain. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. Considered ovarian torsion but doubt given history and presentation. Given work up low suspicion for acute hepatobiliary disease (including acute cholecystitis), acute pancreatitis (neg lipase), PUD and gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, diverticulitis. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.

	===Abdominal pain M MDM===		===Abdominal pain M MDM===

MacheteBetty: /* Lower GI bleed */

2023-06-21T22:57:01Z

Lower GI bleed

← Older revision		Revision as of 22:57, 21 June 2023
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	===Lower GI bleed===		===Lower GI bleed===
	This patient presents with symptoms concerning for a lower GI bleed. Differential diagnoses include ~~diverticulitis~~ (most common cause) versus hemorrhoids. Less likely etiologies include angiodysplasia, cancer, IBD. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena.		This patient presents with symptoms concerning for a lower GI bleed. Differential diagnoses include diverticulosis (most common cause) versus hemorrhoids. Less likely etiologies include angiodysplasia, cancer, IBD. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena.

	===UGIB===		===UGIB===

Thomaslterman: /* Eye */

2022-10-09T20:26:35Z

Eye

← Older revision		Revision as of 20:26, 9 October 2022
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	Presentation consistent with subconjunctival hemorrhage.		Presentation consistent with subconjunctival hemorrhage.
	Given history and exam I have low suspicion for corneal abrasion or ulcer, globe rupture, uveitis, HSV keratitis, Endopthalmitis, Retinal Detachment, Angle Closure Glaucoma, Foreign Body, hyphema.		Given history and exam I have low suspicion for corneal abrasion or ulcer, globe rupture, uveitis, HSV keratitis, Endopthalmitis, Retinal Detachment, Angle Closure Glaucoma, Foreign Body, hyphema.

			===Swollen Eye MDM===
			[]-year-old patient presenting with swollen eye. Otherwise well-appearing.No history of trauma. No urticarial rash to suggest allergic reaction. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. Ddx includes allergic reaction vs. preseptal cellulitis. Will treat empirically with antibiotics and antihistamines. Discussed need for outpatient follow-up and return precautions for signs/symptoms of orbital cellulitis or anaphylaxis.

	===Vision loss painless MDM===		===Vision loss painless MDM===

Thomaslterman: /* Alcohol intoxication MDM */

2022-10-06T23:20:40Z

Alcohol intoxication MDM

← Older revision		Revision as of 23:20, 6 October 2022
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	===Alcohol intoxication MDM===		===Alcohol intoxication MDM===
	Patient presents with altered mental status likely secondary to EtOH intoxication. Patient maintained his airway, and metabolized to sobriety and no longer altered. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. No infectious symptoms and afebrile so doubt sepsis. Patient with no signs of any medical emergencies at this time. Patient observed for until clinically sober. No signs or symptoms of alcohol withdrawal while in the emergency department. Safe ride home was arranged with __. Patient offered transferred to rehab facility but declined.		Patient presents with altered mental status likely secondary to EtOH intoxication. Patient maintained his airway, and metabolized to sobriety and no longer altered. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. No infectious symptoms and afebrile so doubt sepsis. Exam prior to discharge shows no evidence of Wernicke's encephalopathy. Patient with no signs of any medical emergencies at this time. Patient observed for until clinically sober. No signs or symptoms of alcohol withdrawal while in the emergency department. Safe ride home was arranged with __. Patient offered transferred to rehab facility but declined.

	===Alcohol withdrawal MDM===		===Alcohol withdrawal MDM===

Thomaslterman: /* headache and Neuro complaints */

2022-10-06T23:17:57Z

headache and Neuro complaints

← Older revision		Revision as of 23:17, 6 October 2022
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	===Seizure MDM===		===Seizure MDM===
	This patient presents with symptoms consistent with acute seizure, most likely due to _. I considered, but think less likely, secondary etiologies of epileptic seizures to include drug / toxin etiologies (ETOH, stimulants, medication side effects), metabolic disturbances (glucose, Na), acute CNS infections (meningitis, encephalitis, abscess), ICH / tumor / CVA. Presentation not consistent with impact seizure related to head trauma. Patient with no signs of trauma from the seizure. DMV was notified to remove patient's licence_, patient was given strict seizure precautions. Patient to follow up with PMD.		This patient presents with symptoms consistent with acute seizure, most likely due to _. I considered, but think less likely, secondary etiologies of epileptic seizures to include drug / toxin etiologies (ETOH, stimulants, medication side effects), metabolic disturbances (glucose, Na), acute CNS infections (meningitis, encephalitis, abscess), ICH / tumor / CVA. Presentation not consistent with impact seizure related to head trauma. Patient with no signs of trauma from the seizure. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. DMV was notified to remove patient's licence_, patient was given strict seizure precautions. Patient to follow up with PMD.

	===Stroke MDM===		===Stroke MDM===

Thomaslterman: /* Alcohol intoxication MDM */

2022-09-24T14:54:57Z

Alcohol intoxication MDM

← Older revision		Revision as of 14:54, 24 September 2022
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	===Alcohol intoxication MDM===		===Alcohol intoxication MDM===
	Patient presents with altered mental status likely secondary to EtOH intoxication. Patient maintained his airway, and metabolized to sobriety and no longer altered. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. No infectious symptoms and afebrile so doubt sepsis. Patient with no signs of any medical emergencies at this time.		Patient presents with altered mental status likely secondary to EtOH intoxication. Patient maintained his airway, and metabolized to sobriety and no longer altered. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. No infectious symptoms and afebrile so doubt sepsis. Patient with no signs of any medical emergencies at this time. Patient observed for until clinically sober. No signs or symptoms of alcohol withdrawal while in the emergency department. Safe ride home was arranged with __. Patient offered transferred to rehab facility but declined.

	===Alcohol withdrawal MDM===		===Alcohol withdrawal MDM===

Thomaslterman: /* Drug intoxication MDM */

2022-09-24T14:51:02Z

Drug intoxication MDM

← Older revision		Revision as of 14:51, 24 September 2022
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	===Drug intoxication MDM===		===Drug intoxication MDM===
	Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. Patient maintained their airway. Given clinical picture have low suspicion for thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism.		Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. Patient maintained their airway. Given clinical picture have low suspicion for thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism. Symptoms treated with ativan. Patient denies suicidal intention or coingestion. Patient offered transferred to rehab facility but declined. Patient observed until clinically sober.

	Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke.		Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. Patient denies suicidal intention or coingestion. Patient offered transferred to rehab facility but declined. Patient observed for __ and was clinically sober at time of discharge. Safe ride home was arranged with __. Patient discharged with prescription for narcan.

	===Alcohol intoxication MDM===		===Alcohol intoxication MDM===

← Older revision		Revision as of 17:31, 25 March 2026
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	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]
	*[[MDM for different chief complaints (peds)]]
	*[[Differential diagnosis documentation]]
	*[[Billing]]
	*[[Discharge documentation]]

	{{Documentation pages}}		{{Documentation pages}}