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Procedure: Abscess Incision and Drainage

Diagnosis: Subcutaneous Abscess

Procedure performed by: ***

Informed Consent: Informed consent was obtained.

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment. The site was marked.

Anesthesia/Sedation: 1% Lidocaine with Epinephrine

Procedure Note: Universal precautions were observed. The patient was prepped and draped in a sterile fashion. The patient was anesthetized. Excellent anesthesia was obtained.   An appropriate incision was made in the center of the abscess and gross pus was obtained. The loculations were broken up and the wound was explored. There were no obvious foreign bodies. The wound was irrigated. The wound was packed with gauze. There were no complications. The patient tolerated the procedure well. A sterile dressing was applied.

The patient’s emergency department course was discussed with the admitting team. They have agreed to evaluate and admit the patient to their service for continued medical care.

This was discussed with the patient and they are in agreement with this plan. Further orders and medical decision making per admitting team.

Despite the best efforts of this physician, the patient insisted on leaving prior to completing diagnostic workup and treatment.

Risks of not completing treatment up to and including death were explained and the patient states that they understand. The patient was able to repeat these risks back to me in their own words.

The patient is alert, oriented, and appears to possess the capacity to make this decision at this time. They are not slurring their speech, and do not appear intoxicated. They are appropriately conversant, their oxygenation saturation’s are within normal limits, and I feel their illness is unlikely to have any effect of their decision making capacity at this time.

The patient was welcomed and encouraged to return to the ED or seek treatment in the event that they desire treatment. The patient was asked to sign our hospital AMA form prior to leaving.

Procedure: Anoscopy

Diagnosis: Rectal bleeding

Procedure performed by: ***

Informed Consent: Informed consent was obtained.

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment.

Anesthesia/Sedation: None

Procedure Note: Universal precautions were observed. An anoscope was easily passed. Under direct visualization there was no obvious evidence of fissure, hemorrhoid or other abnormality. There was no evidence of foreign body. The patient tolerated the procedure well. There was no blood loss. There were no complications.

At this time there are no concerning symptoms including bowel or bladder incontinence, saddle anesthesia, fever, IV drug use, cancer, weakness, numbness or recent trauma. There are no abnormal neurologic findings. I do not feel emergent imaging is indicated at this time.

I will advise the patient to follow up with his primary care team for continued pain management. We will provide a short course of analgesics

I do not believe that the patient has an acute emergency medical condition requiring additional emergency management at this time. The patient is currently stable for outpatient treatment and continuation of care. Important signs and symptoms that would warrant return to the emergency department were reviewed. The patient was provided the opportunity to ask questions. All questions were addressed and the patient was discharged from the ED. The patient demonstrated understanding and agreed to plan

Musculoskeletal: The patient has mild tenderness to palpation over the ***.  No abrasions or ecchymosis over the back. Seated straight leg raise is negative bilaterally.

Neurologic: Alert and oriented x3. Normal mental status. The patient has symmetric 5/5 muscle strength with flexion and extension at the wrists, elbows and shoulders. The patient has symmetric 5/5 muscle strength with flexion and extension at the hips, ankles, knees and great toes bilaterally. The patient has symmetric sensation to touch in the distal upper and lower extremities. There are 2+ patellar reflexes bilaterally and normal ankle jerk. Full ROM at knees, hips and toes without pain. The patient is ambulatory with normal gait.

Procedure: Ultrasound Guided Central Catheter Placement

Diagnosis: Need for Central Venous Access

Procedure performed by: Dr. ***

Informed Consent: Informed consent was obtained.

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment. The site was marked

Anesthesia/Sedation: Anesthesia with 1% Lidocaine with Epinephrine. Sedation with ***

Procedure Note: Universal precautions were observed. The patient was prepped in a sterile manner. The patient was placed in Trendelenburg position. The patients *** internal jugular vein was accessed under direct ultrasound guidance. A Triple Lumen Central venous catheter was placed using Seldinger technique. It was secured in place at 15cm using 2 interrupted sutures. The site was again cleaned, and a Biopatch placed. A sterile dressing was placed over the access site. A chest X-ray was ordered to confirm placement

The patient tolerated the procedure well. There were no complications

Pt presents with chest pain. An EKG was immediately obtained which shows no ST segment elevation. The patient was placed on a cardiopulmonary monitor, oxygen and an IV established. We will obtain comprehensive laboratory studies including cardiac enzymes in addition to a chest x-ray. We will treat the patients pain, and give Aspirin.

Procedure: Conscious sedation

Diagnosis: ***

Procedure performed by:  Dr. ***

Informed Consent: Informed consent was obtained.

Procedural Pause was observed at: ***

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment. The site was marked.

Procedure Start Time: ***

Procedure Stop Time: ***

Procedure Note: Universal precautions were observed. The patient was placed in the supine position. Continuous oxygen, cardiopulmonary and CO2 monitoring was initiated. A bag valve mask, suction and “airway box” was immediately available. The patient was given ***. Good sedation was achieved. The patient maintained his airway and normal breathing throughout the procedure. Oxygen saturation remained above 94% throughout the procedure. The patient awoke spontaneously.

Patient tolerated the procedure well. There were no complications.

The patient has an absence of posterior midline cervical tenderness, a normal level of alertness, no evidence of intoxication, no abnormal neurologic findings and no painful distracting injuries.

I do not believe that the patient has an acute emergency medical condition requiring additional emergency management at this time. The patient is currently stable for outpatient treatment and continuation of care. Important signs and symptoms that would warrant return to the emergency department were reviewed. The patient was provided the opportunity to ask questions. All questions were addressed and the patient was discharged from the ED. The patient demonstrated understanding and agreed to plan

ENT: Dental cavities and poor oral dentition noted, pain along tooth #*** , midline uvula, no trismus, oropharynx moist and clear, no abscess noted, no oropharyngeal erythema or edema, neck supple and no tenderness. No facial edema

Procedure: Dermabond wound closure

Diagnosis: Laceration

Site: Laceration of ***

Length: Laceration *** cm noted.

Procedure performed by: Dr.

Informed Consent: Verbal informed consent was obtained.

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment. The site was marked.

Anesthesia/Sedation: None

Procedure Note: Universal precautions were observed. The wound was explored under a clean, dry, and bloodless field. There were no obvious foreign bodies. There is no evidence of infection. The wound was irrigated and cleaned. The wound was closed with several strips of dermabond. There was excellent wound opposition. There were no complications.

This patient’s prescription history has been investigated using the Arizona Board of Pharmacy controlled substance prescription monitoring program computer website. There is clear evidence of excessive prescriptions and multiple prescribers. I have discussed this with the patient. I have emphasized the fact that as physician my job is to help people, and that I can offer no help by simply prescribing more of the medications that are the problem. The only way I can help is by offering ways to get off of these medications, and that the appropriate phone number(s) will be included in the discharge instructions. However, no narcotic pain medications will be prescribed, and it will be noted in the medical record that narcotic prescriptions should not be offered except in the most obvious circumstances of acute need. All this was discussed at length with the patient. This conversation was carried forth in a helpful, non-confrontational manner, and the patient understands that any pain medications other than over-the-counter medications must at all times be prescribed by the patient’s primary care physician or a pain management physician. The patient is strongly encouraged to take advantage of the phone number(s) provided and obtain professional help for this problem.

The patient was noted to be hypertensive today in the emergency department. I have spoken with the patient regarding hypertension and the need for improved management. I instructed the patient to followup with the Primary care doctor within 4 days to improve the management of the patient’s hypertension. I also counseled the patient regarding the signs and symptoms which would require an emergent visit to an emergency department for hypertensive urgency and/or hypertensive emergency. The patient understood the need for improved hypertensive management.

Procedure: Endotracheal Intubation

Diagnosis: Acute Respiratory Failure

Procedure performed by: Dr. ***

Informed Consent: Emergent

Verification: I have verified the correct patient, correct procedure, correct position, correct site, and available equipment.

Induction Agent: ***

Paralytic: ***: Succinylcholine

Procedure Note: Universal precautions were observed. The patient was fully pre-oxygenated prior to medication administration. BURP pressure was utilized. Suction was immediately available at the bedside. The patient was intubated with a Macintosh 4 blade and a *** endotracheal tube under direct visualization of the vocal cords. The tube was secured at ***cm at the teeth. After the procedure, there was good fogging in the tube. There were good bilateral breath sounds. There was good end tidal CO2 color change. There were no sounds over the epigastric area. A post-intubation chest x-ray was ordered. There were no complications.

Post Procedure Medications: ***

Ventilator Settings: Per ICU Team, See Respiratory Records

Procedure: Laceration Repair: Sutures

Diagnosis: Laceration

Laceration Length: ***

Laceration Site: ***

Laceration Complexity:  ***

Procedure performed by: Dr. ***

Informed Consent: Verbal informed consent was obtained.

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment. The site was marked.

Anesthesia/Sedation: 1% Lidocaine with Epinephrine

Procedure Note: Universal precautions were observed. The patient was prepped and draped in a sterile fashion. The wound was anesthetized. Excellent anesthesia was obtained. The wound was explored under a clean, dry, and bloodless field through full range of motion. There were no obvious tendon lacerations or foreign bodies in the wound. The wound was irrigated and cleaned. The wound was closed with *** interrupted ***-O sutures. There were no complications. A dressing was applied. Pt remained neurovascularly intact following procedure.

Blood Loss: Minimal

Procedure: Laceration Repair: Staples

Diagnosis: Laceration

Laceration Length: ***

Laceration Site: ***

Procedure performed by: Dr. ***

Informed Consent: Verbal informed consent was obtained.

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment. The site was marked.

Anesthesia/Sedation: None

Procedure Note: Universal precautions were observed. The patient was prepped and draped in a clean fashion. The wound was explored under a clean, dry, and bloodless field. There were no obvious foreign bodies in the wound. The wound was irrigated and cleaned. The wound was closed with *** staples. There was excellent wound opposition. There were no complications. A dressing was applied.

Blood Loss: Minimal

Procedure: Lumbar Puncture

Diagnosis: Severe Headache

Procedure performed by: Dr. ***

Informed Consent: Informed consent was obtained.

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment. The site was marked.

Anesthesia/Sedation: Anesthesia with 1% Lidocaine

Procedure Note: Informed consent was obtained. Risks, benefits, and alternatives were discussed. Universal precautions were observed. Pt was prepped and draped in a sterile manner. Using anatomical landmarks the L4-L5 interspace was identified and marked. Using a spinal needle the subarachnoid space was accessed. Opening pressure was not obtained. Clear spinal fluid was collected and sent for analysis. The stylet was replaced and the needle removed. Pressure was held, and the patient placed in the supine position. Pt tolerated procedure well. There were no complications

GU: No signs of any lesion on the penis or testicles. The penis and testicles are nontender. No testicular masses appreciated. No signs of any inguinal hernias. No signs of any discharge from the penis.

Knee: No gross deformity noted. Patient has full active and passive range of motion without pain. There is no joint effusion noted. No erythema, or warmth overlaying the joint.  There is tenderness to palpation over the ***. There is no abnormal laxity to medial or lateral stress. Negative anterior and posterior drawer sign. 2+ DP pulse’s bilaterally. All compartments are soft.  Sensation intact distal to injury.

Shoulder: No gross deformity noted. Patient has full active and passive range of motion without pain. There is no joint effusion noted. No erythema, or warmth overlaying the joint. There is no effusion. There is tenderness to palpation over the ***.2+ Radial pulses bilaterally. Pt has intact symmetric sensation and motor function in the ulnar, radial, axially and medial nerve distributions. All compartments are soft

Foot/Ankle: No gross deformity noted. Patient has full active and passive range of motion without pain. There is no joint effusion noted. No erythema, or warmth overlaying the joint. There is tenderness to palpation over the ***. no pain to fifth metatarsal area, no pain to navicular region. 2+ DP pulses, sensation intact to medial, lateral, dorsal and plantar aspects.

Neurologic: Alert and oriented x3. Cranial nerves II through XII are grossly intact. Bilateral fundi visualized. Optic discs are flat. Visual fields intact.  The patient has symmetric 5/5 muscle strength with flexion and extension at the wrists, elbows and shoulders. The patient has symmetric 5/5 muscle strength with flexion and extension at the hips, ankles and knees. The patient has symmetric sensation in the distal upper and lower extremities. There are 2+ patellar reflexes bilaterally. No pronator drift. Normal finger to nose. The patient is ambulatory with normal gait.

Alert and oriented x3. Cranial nerves II through XII are grossly intact. The patient has symmetric 5/5 muscle strength with flexion and extension at the wrists, elbows and shoulders. The patient has symmetric 5/5 muscle strength with flexion and extension at the hips, ankles and knees. The patient has symmetric sensation in the distal upper and lower extremities.

A non-contrasted CT scan of the head is not clinically indicated at this time. The patient did not lose consciousness or have post-traumatic amnesia. There are no focal neurologic deficits, no vomiting, the patient does not have a severe headache, the patient is not greater than or equal to 65 years old, there are not signs of basilar skull fracture, the GCS is not <15, the patient does not have a known coagulopathy and there is no history of a significantly dangerous mechanism of injury. [/av_toggle] [av_toggle title='Female Pelvic Exam' tags='Physical Exam'] Pelvic exam: RN in room as chaperone, external female genitalia normal with no signs of lesions or injuries. Speculum exam shows normal cervix with no obvious discharge. Bimanual exam with no adnexal tenderness, no cervical motion tenderness, uterus normal size and nontender, no masses appreciated. The external cervical os is closed.

Pelvic exam: RN in room as chaperone, external female genitalia normal with no signs of lesions or injuries. Speculum exam shows blood in the vault and at the external cervical os. No obvious discharge. Bimanual exam with no adnexal tenderness, no cervical motion tenderness, uterus normal size and nontender, no masses appreciated. The external cervical os is closed

Pulmonary embolism can be essentially ruled out by PERC criteria. The patient is less than 50 years of age, has a heart rate of less than 100 beats per minute, has an oxyhemoglobin saturation of greater than 95%, has no hemoptysis, does not take any form of estrogen, has no history of DVT or PE, has no unilateral leg swelling, and has no surgery or trauma which required hospitalization within the previous 4 weeks.

Rectal: No fissures or external hemorrhoids observed. Normal Tone. No melena. Pt is hemoccult ***

Slit lamp Exam: Normal eye lids and lashes. No swelling of the lacrimal duct. Conjunctive is non-injected. Sclera white. No corneal abrasions seen on fluorescent stain bilaterally. No Seidel sign. No foreign bodies visualized. Pupils are round and reactive. Lens normal. Anterior chamber is deep with no cell’s or flair. Opthalmic exam reveals normal fundi bilateral. Tonopen pressures are *** in the left eye and *** in the right eye. Visual acuity is 20/*** in left eye and 20/*** in right eye.

Procedure: Toenail Removal

Diagnosis: Ingrown Toenail

Procedure performed by: Dr.***

Informed Consent: Informed consent was obtained

Verification: I have verified the correct patient, correct procedure, correct position, correct site/side, and available equipment. The site was marked.

Anesthesia/Sedation: Digital Block with 1% Lidocaine without Epinephrine.

Procedure Note: Universal precautions were observed. The patients great toe was anesthetized with 1% lidocaine without epinephrine using a digital block. Excellent anesthesia was achieved. The toe and toenail bed were cleaned. Surgical scissors were passed under the toenail to the cuticle. A roughly 0.5cm strip of toenail was excised and removed using a hemostat. Pressure was held on the exposed nailbed to control bleeding. A vasoline dressing was applied to the wound following resolution of the bleeding.

There were no complications. The patient tolerated the procedure well. Given Podiatry follow up and strict return precautions. Signs of infection discussed with patient.

Blood Loss: Minimal

Constitutional: This patient is laying flat in bed in no acute distress. C-Collar is in Place

Head: Atraumatic. No abrasions or ecchymosis noted. Pupils are equal, round, and reactive to light. Extraocular eye movements are intact.There is no blood in the oropharynx. No dental fractures noted. Midface is stable. There is no midline c-spine tenderness.

ENT: Oropharynx is non-erythematous with no signs of infections or lesions. Nose is non-tender without deformity or bleeding. There is no septal hematoma. No auricular hematoma. No malocclusion. Mucous membranes moist.

Respiratory: No chest wall tenderness. Respirations are clear to auscultation bilaterally with normal effort. There are no wheezes, crackles, or rales

Cardiovascular: The patient has a regular rate and rhythm. Non-muffled heart tones. There are no obvious murmurs. Radial pulses are 2+ bilaterally.

Gastrointestinal: No bruising or abrasions noted. Soft, nontender, nondistended. There are normal bowel sounds. No guarding, no rebound.

Musculoskeletal: No gross deformity of the extremities. The patient has no bony tenderness to palpation over their shoulders, elbows, wrist, knees or ankles. There is no clubbing,or cyanosis of the extremities. 2+ Radial and Dorsalis pedis pulses bilaterally. No lower extremity edema.

The patients back was examined using “Log Roll” technique for spinal stabilization. There is no abrasions or ecchymosis noted. No midline tenderness to palpation. No step offs.

Skin: Warm and dry without rashes.

Neurological: Alert and oriented x3. The patient has a GCS of 15. The patient has symmetric 5/5 muscle strength with flexion and extension at the shoulder, elbows, wrists, hips, knees and ankles. Symmetric grip strength. Sensation intact in distal upper and lower extremities. Patellar DTR 2+.

No gross deformity noted. Patient has full active and passive range of motion without pain. There is no joint effusion noted. No erythema, or warmth overlaying the joint. There is tenderness to palpation over the ***. The patient has normal sensation and motor function in the median, ulnar, and radial nerve distributions. There is no anatomic snuff box tenderness. The patient has normal active and passive range of motion of their digits. 2+ Radial pulse.

The patient does not appear acutely ill at this time. The symptoms and exam are consistent with a viral syndrome. Will recommend continued anti-pyretics, fluids, and symptomatic treatment. I have counseled the patient to see the PCP in 24-48 hours if still feeling ill, or return to the ED sooner if any complications arise before that time.

Bedside ultrasound was used to localize a vein for cannulation. The target vein was mapped out in both a longitudinal and transverse fashion. It was compressible on ultrasound. Color Doppler was utilized as needed. Adjacent arteries were visualized and mapped out. The target vein was cannulated using ultrasound guidance in a standard format without any complications. The IV flushed without problems. The patient tolerated the procedure well and is DNVI after the procedure.

I was personally available for consultation in the emergency department. I have reviewed the chart and agree with the documentation as recorded by the MLP, including the assessment, treatment plan and disposition.

I personally evaluated and examined the patient in conjunction with the MLP and agree with the assessment, treatment plan and disposition of the patient as recorded by the MLP.

I personally saw and examined the patient. I have reviewed and agree with the resident’s findings including all diagnostic interpretations and treatment plans as documented. I was present for key portions of separately performed procedures and the inclusive time noted in any critical care situation.

I personally performed the services described in this documentation and have reviewed and edited the documentation which was dictated to the scribe in my presence, and it accurately reflects my words and actions.

Vital Signs:  Triage vitals were reviewed, as noted by RN.

Constitutional: This patient is well appearing, sitting in bed in no acute distress.

Respiratory: Respirations are clear to auscultation bilaterally with normal effort.  There are no wheezes, crackles, or rales.

HEENT:  Pupils are equal, round, and reactive to light. Extraocular eye movements are intact. Oropharynx is non-erythematous with no signs of infections or lesions. Mucous membranes moist.

Cardiovascular: Normal S1 and S2. Regular rhythm.  There are no obvious murmurs. Radial pulses are 2+ bilaterally.

Gastrointestinal:  Soft, nontender, nondistended.  There are normal bowel sounds.  No guarding, no rebound.

Musculoskeletal:  There is no clubbing,or cyanosis of the extremities. No lower extremity edema.

Skin:  Warm and dry without rashes.

Neurological: Alert and oriented x3.  Normal Mental status. No focal deficits

Psychiatric Exam: Patient has normal affect, is pleasant and cooperative.

Pt presents c/o dental pain. There is no evidence of abscess, no trismus, and the uvula is midline.

The patient will be given prescriptions for antibiotics and analgesics.  The patient was counseled to follow up with a dentist for further treatment.

The patient was informed to return to the ED if there is interval development of hoarseness, trismus, erythema, difficulty breathing, swelling of the neck or worsening pain. The patient verbalized understanding of the plan and agrees.  The patient was provided the opportunity to ask questions.  All questions were answered.

At this time I feel the patient is clinically sober. They are appropriately conversant, they are not slurring their speech.  They are eating, drinking, and ambulatory with a steady gait.

Pulmonary embolism can be essentially ruled out by PERC criteria. I have a very low clinical suspicion for PE.  The patient is less than 50 years of age, has a heart rate of less than 100 beats per minute, has an oxyhemoglobin saturation of greater than 95%, has no hemoptysis, does not take any form of estrogen, has no history of DVT or PE, has no unilateral leg swelling, and has no surgery or trauma which required hospitalization within the previous 4 weeks.

I feel this patient has very low risk for ACS or Unstable Angina. Their TIMI score is *** and their Heart Score is ***. They have had 2 negative sets of cardiac enzymes as well as 2 EKG that show no ischemic changes.  I have had a detailed discussion about the risks and benefits of hospitalization vs outpatient stress test with the patient. Risk of adverse cardiac event in the next 30 days is less than 2% per risk stratification via Heart Score. Will discharge patient with close outpatient follow up for stress test within the next 72 hours per AHA guidelines. Patient counseled to return to the ED for any re-occurrence or worsening of their chest pain, as their risk for CAD is not zero. They are instructed to call or return to the ED if they are unable to schedule their outpatient stress test. The patient was provided an opportunity to ask questions. All questions were address prior to discharge.

The patients headache was initially concerning for possible SAH. A non-contrast head CT is negative. After a detailed discussion of the risks and benefits the patient has refused a Lumbar Puncture. Patient is aware SAH cannot be excluded with a negative head CT and risk of SAH can be as high as 7-10%. Lumbar Puncture is a common procedure and local anesthesia was offered. Patient aware that SAH can lead to death and permanent disability, and even though their headache is currently improved, this does not exclude the diagnosis. I feel the patient has the capacity to make this decision at this time, they have normal mental status, normal oxygenation, and are not intoxicated.