setfit-all-mpnet-189b_189g_v3

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• ed_course section: 11/24/23 1442 Fri Nov 24, 2023 1050 X rays of the right hand independently reviewed and are negative for acute fracture Clinical Impressions as of 11/24/23 1442 Crushing injury of finger, initial encounter Subungual hematoma of digit of hand, initial encounter Disposition: Discharge 10 year old male presented with a crush injury between the door hinge in the garage. Sustained injuries to the tips of the 3rd and 4th fingers on the right hand. Patient was soft tissue swelling noted on exam with small subungual hematoma on the 3rd nail. No obvious bony abnormalities noted. Neurovascularly intact without any open wounds. Has an obvious bruise adjacent to the lateral nail fold of the 3rd finger. X rays of the right hand independently reviewed and are negative. Radiation interpretation is in agreement. A cage splint was applied over the 3rd finger given that this is the most prominent pain source. Will continue rest, ice, immobilization, splint for protection and NSAIDs at home. No evidence of acute fracture, dislocation, laceration, or intra articular injury. Possible underlying osseous contusion. Supportive care discussed with his parents. After my initial evaluation, the patient requires testing, treatment and/or serial reevaluations to rule in or out the need for admission or emergency surgery. I reviewed Outside records: none I independently interpreted the following studies: diagnostic imaging I spoke with a family member, healthcare worker, or other source to obtain history: no I spoke with these other providers/staff about patient management: None This patient has these chronic conditions that will impact their recovery and risk of serious illness: none The following social determinants of health directly affected my ability to evaluate or manage this patient: none Drug Therapies: I instructed the patient to obtain over the counter drugs. Amount and/or Complexity of Data Reviewed Independent Historian: parent Radiology: ordered and independent interpretation performed. Decision making details documented in EMERGENCY DEPARTMENT Course. Risk OTC drugs. No data recorded ed_diagnosis section: None physical examination section: EMERGENCY DEPARTMENT Triage Vitals [11/24/23 1021] Temperature Heart Rate Resp BLOOD PRESSURE 36.4 °C (97.5 °F) 100 24 (!) 126/69 SpO2 Temp Source Heart Rate/Pulse Source Patient Position 91 % Oral BLOOD PRESSURE Location FiO2 (%) Vitals and nursing note reviewed. Constitutional: General: He is active. Appearance: Normal appearance. He is well developed. HENT: Head: Normocephalic and atraumatic. Eyes: Extraocular Movements: Extraocular movements intact. Pupils: Pupils are equal, round, and reactive to light. Cardiovascular: Pulses: Normal pulses. Pulmonary: Effort: Pulmonary effort is normal. Musculoskeletal: General: Swelling and tenderness present. No deformity. Normal range of motion. Cervical back: Normal range of motion. Comments: Soft tissue swelling noted to the tips of the right 3rd and 4th fingers along the distal phalanx. There is a less than 5% subungual hematoma to the 3rd fingernail. No open wounds noted. No active bleeding. Mild bruising noted to the medial nail fold of the right 3rd finger. Tenderness across the distal phalanx of the 3rd and 4th finger more prominently in the 3rd finger. Range of motion is intact with normal flexion and extension. Normal sensory exam. No foreign bodies noted. No obvious bony deformity. Skin: General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds. Neurological: Mental Status: He is alert and oriented for age. EMERGENCY DEPARTMENT Course  MDM History of present illness section: History reviewed. No pertinent past medical history. Past Surgical History: Procedure Laterality Date • TONSILLECTOMY No family history on file. Tobacco Use • Smoking status: Never • Smokeless tobacco: Never Procedure: None Review of System: Musculoskeletal: Positive for myalgias. Skin: Positive for color change. Negative for wound. Neurological: Negative for weakness and numbness. . Lab Results: None Medications: ibuprofen (ADVIL,MOTRIN) 100 mg/5 mL suspension 400 mg (400 mg oral Given 11/24/23 1033) Results: Labs Reviewed No data to display X ray hand 3+ views right EMERGENCY DEPARTMENT Interpretation Neg BMU Final Result No acute osseous findings. No orders to display Follow Up: Lisa Samuelson, MD 400 McCaslin Louisville CO 80027 303 666 7337 EMERGENCY DEPARTMENT Discharge Orders (From admission, onward) None Electronically signed by Brandon Uttley, PA C 11/24/23 1445 bmkCopy
• ed_course section: 38 year old female with uncontrolled pain to her right ankle status post ORIF. Patient had extensive workup as an outpatient recently with ultrasound performed. On exam there is no evidence of wound infection, DVT, compartment syndrome, arterial occlusion, abscess or any other acute findings. Suspect this is pain related to her recent surgical repair by Dr. Leland. Small course of pain medication was given along with muscle relaxers as she has excellent follow up on Tuesday with Orthopedics. Cast padding and Ace wrap was reapplied along with her 3 way splint. Neurovascularly intact pre and post splint application. No indication clinically for any imaging or other diagnostics at this time. After my initial evaluation, the patient requires testing, treatment and/or serial reevaluations to rule in or out the need for admission or emergency surgery. I reviewed Outside records: PDMP and last admission I independently interpreted the following studies: none I spoke with a family member, healthcare worker, or other source to obtain history: no I spoke with these other providers/staff about patient management: None This patient has these chronic conditions that will impact their recovery and risk of serious illness: psychiatric disease The following social determinants of health directly affected my ability to evaluate or manage this patient: none Drug Therapies: I instructed the patient to obtain over the counter drugs. and I initiated or managed prescription drugs. Amount and/or Complexity of Data Reviewed External Data Reviewed: radiology and notes. Risk OTC drugs. Prescription drug management. No data recorded ed_diagnosis section: None physical examination section: EMERGENCY DEPARTMENT Triage Vitals [06/09/23 0919] Temperature Heart Rate Resp BLOOD PRESSURE 36.8 °C (98.3 °F) 91 16 103/76 SpO2 Temp Source Heart Rate/Pulse Source Patient Position 92 % Oral Sitting BLOOD PRESSURE Location FiO2 (%) Right arm Vitals and nursing note reviewed. Constitutional: General: She is not in acute distress. Appearance: Normal appearance. She is well developed. She is not ill appearing. HENT: Head: Normocephalic and atraumatic. Eyes: Conjunctiva/sclera: Conjunctivae normal. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Pulses: Normal pulses. Heart sounds: No murmur heard. Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: Normal breath sounds. Musculoskeletal: General: Swelling and tenderness present. No deformity. Cervical back: Normal range of motion and neck supple. Comments: Incision to the medial right ankle noted without wound dehiscence. Sutures are clean dry and intact without discharge. There is no erythema, induration or fluctuance. Bruising around the ankle noted with swelling into the foot. There is bruising to the lateral lower calf. No palpable venous cords. Sensory exam diminished to the entirety of the foot however intact to the lower leg. No edema to the calf. No adductor canal tenderness. 2+ DP and POSTERIOR TIBIAL pulses are intact. Good capillary refill less than 2 seconds. Able to wiggle toes. Full range motion of the knee intact. Limited range of motion of the ankle. No obvious joint effusion or increased warmth across the right ankle joint Skin: General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds. Neurological: General: No focal deficit present. Mental Status: She is alert and oriented to person, place, and time. Mental status is at baseline. Psychiatric: Mood and Affect: Mood normal. EMERGENCY DEPARTMENT Course  MDM Clinical Impressions as of 06/09/23 1651 Postoperative pain Acute right ankle pain Disposition: Discharge History of present illness section: Chief Complaint Patient presents with • Ankle Pain Posterior Tibial BIBA with c/o 9/10 pain in her right ankle. Posterior Tibial fractured ankle 3 weeks ago, requiring surgical fixation, and was sent home with a splinted leg and crutches. She reports running out of oxy 1 week ago. Has been taking tylenol, ibuprofen, and RICE without relief. States she has been putting more weight on the leg than she is supposed to and thinks that is making the pain worse. 38 year old female postoperative day 4 from ORIF right ankle trimalleolar fracture with repair by Dr. Leland presents to the emergency department with continuation of pain. Patient states that her pain has not been well managed at home. She is been nonweightbearing with crutches however states that the pain is intense and not well controlled with OTC meds. She ran out of her oxycodone that was prescribed to her on her surgical day on Monday. Patient had an ultrasound performed 4 days ago which was negative. She denies any fevers, chills but does endorse increasing swelling to the foot and ankle causing numbness. This has been present since she had a fall and tripped over her dog on 05/19. No prior history of DVT. Denies any chest pain, shortness of breath, fevers, chills or notable discharge from the wound. Has a follow up next Tuesday with Dr. Leland. States that her foot has been swollen and numb since the injury occurred in May. Pain is sharp and constant with radiation up the leg. Past Medical History: Diagnosis Date • Anxiety • Anxiety attack Past Surgical History: Procedure Laterality Date • ABDOMINAL SURGERY • CESAREAN SECTION, LOW TRANSVERSE • FRACTURE SURGERY • HERNIA REPAIR Family History Family history unknown: Yes Tobacco Use • Smoking status: Every Day Packs/day: 0.50 Years: 19.00 Pack years: 9.50 Types: Cigarettes • Smokeless tobacco: Never Vaping Use • Vaping Use: Never used Substance Use Topics • Alcohol use: Yes Alcohol/week: 28.0 standard drinks Types: 28 Cans of beer per week Comment: 3 4 tall boys/day • Drug use: Not Currently Procedure: None Review of System: Constitutional: Negative for fever. Respiratory: Negative for shortness of breath. Cardiovascular: Negative for chest pain. Musculoskeletal: Positive for arthralgias and joint swelling . Skin: Positive for wound. Neurological: Positive for numbness. Negative for weakness. Hematological: Does not bruise/bleed easily. . Lab Results: None Medications: No data to display Results: Labs Reviewed No data to display No orders to display No orders to display Follow Up: No follow up provider specified. EMERGENCY DEPARTMENT Discharge Orders (From admission, onward) Start Ordered Status Ordering User 06/09/23 0000 06/09/23 0954 methocarbamoL (ROBAXIN) 500 mg tablet 4 times daily PRN Ordered UTTLEY, BRANDON 06/09/23 0000 06/09/23 0954 oxyCODONE acetaminophen (PERCOCET) 5 325 mg per tablet Every 6 hours PRN Ordered UTTLEY, BRANDON Electronically signed by Brandon Uttley, PA C 06/09/23 1652 bmkCopy
• ed_course section: Amount and/or Complexity of Data Reviewed Radiology: ordered and independent interpretation performed. Decision making details documented in EMERGENCY DEPARTMENT Course. Risk Prescription drug management. Vital signs reviewed and stable upon arrival Left foot x ray ordered No signs of neurovascular compromise/tenting of skin/compartment syndrome/extremities and joints examined above and below area of concern and are neurovascularly intact. Left foot x ray my read via PAC shows no fracture, no dislocation Placed in Sampson boot, podiatry follow up Clinical Impressions as of 09/18/23 1612 Foot injury, left, initial encounter ed_diagnosis section: 1. Foot injury, left, initial encounter physical examination section: Vitals: 09/15/23 2244 BLOOD PRESSURE: 147/87 Pulse: 108 Resp: 18 Temp: 36.8 °C (98.2 °F) TempSrc: Tympanic SpO2: 95% Weight: 113 kg (250 lb) Height: 1.829 m (6) Vital signs reviewed and triage nurse notes reviewed General Appearance/VS: awake, alert, non toxic, no distress, polite and cooperative teenage female Eyes: EOMI, no icterus ENT: moist mucous membranes, nares patent Lungs: Symmetric with no chest wall rise, no respiratory distress, no tachypnea CARDIOVASCULAR: no pedal edema, good capillary refill, tachycardia GASTROINTESTINAL: no abdominal distention, no wincing upon palpation Musculoskeletal: 2/2 pedal pulses, strength 5/5, left foot tenderness at the base of the 5th metatarsal with bruising. DIP/MTP flexion/extension intact with good light touch sensation. no deformities, no clubbing, no cyanosis, no edema. Compartments are soft. Left Ankle: Plantar flexion to 50°, dorsiflexion to 20°. Foot inversion to 35 degree. No tenderness/swelling Anterior talofibular ligament. No tenderness/swelling Calcaneofibular ligament, no tenderness/swelling posterior talofibular ligament, no tenderness/swelling posterior inferior tibiofibular ligament. Achilles tendon intact. Plantar flexion and dorsiflexion intact. Neuro: normal speech, 5/5 strength throughout, ambulatory without deficits Psych: normal mood/affect Skin: pink, no rash on exposed skin, good capillary refill History of present illness section: Patient is a 19 year old female who presents via walk in with left lateral aspect of left foot at the base of her left little toe pain and bruising. She is requesting x ray. Patient states that she "banged" her foot into a metal shoe rack. Was not wearing shoes. Worked all day serving food and had increased pain. Acuity: Acute Severity: 4/10 Modifying Factors: Supportive measures with transient relief Signs and Symptoms: No bleeding, no radiation, no numbness, no weakness, no tingling, no incontinence, no decreased range of motion, no swelling, + pain, no fever Past Medical History: Diagnosis Date • Bipolar disorder (CMS/HCC) Past Surgical History: Procedure Laterality Date • TONSILLECTOMY • WISDOM TOOTH EXTRACTION Socioeconomic History • Marital status: Single Spouse name: None • Number of children: None • Years of education: None • Highest education level: None Occupational History • None Tobacco Use • Smoking status: Never • Smokeless tobacco: Never Substance and Sexual Activity • Alcohol use: None Comment: occasional • Drug use: Yes Types: Marijuana • Sexual activity: None Other Topics Concern • None Social History Narrative • None Social Determinants of Health Financial Resource Strain: Not on file Food Insecurity: Not on file Transportation Needs: Not on file Physical Activity: Not on file Stress: Not on file Social Connections: Not on file Intimate Partner Violence: Not on file Housing Stability: Not on file Family History:No family history on file. Allergies:Patient has no known allergies. Procedure: Review of System: None Lab Results: Labs Reviewed No data to display Medications: XR foot left 3+ views Final Result Negative. No acute fracture. No data to display This Chart was Electronically Signed by Stephen MacDade, MD EMERGENCY DEPARTMENT Prescriptions None This patient was seen under the supervision of my secondary supervising physician. I evaluated and cared for this patient independently. Terra Rudd, PA C 09/15/23 2349 Stephen MacDade, MD 09/18/23 1612 bmkCopy
• ed_course section: 01/13/23 1651 Fri Jan 13, 2023 1648 X ray: Reviewed by myself. No fracture. Clinical Impressions as of 01/13/23 1651 Sprain of right ankle, initial encounter Disposition: Data Unavailable MDM ed_diagnosis section: None physical examination section: EMERGENCY DEPARTMENT Triage Vitals [01/13/23 1556] Temperature Heart Rate Resp BLOOD PRESSURE 36.7 °C (98.1 °F) 75 20 (!) 153/97 SpO2 Temp src Heart Rate/Pulse Source Patient Position 99 % Sitting BLOOD PRESSURE Location FiO2 (%) Right arm Vitals and nursing note reviewed. Constitutional: General: She is not in acute distress. Appearance: Normal appearance. Comments: Alert, oriented x3, able to describe the events. HENT : Head: Normocephalic and atraumatic. Musculoskeletal: General: Swelling and tenderness present. Normal range of motion. Comments: Significant swelling over the right lateral malleoli as well as slightly anterior. No discomfort at the fibular head. No discomfort or tenderness at the head of the 5th metatarsal. Dorsalis pedis and posterior tibial pulses are intact. Neurological: Mental Status: She is alert. EMERGENCY DEPARTMENT Course  MDM History of present illness section: Past Medical History: Diagnosis Date • Depression • Dermatitis • Developmental delay • Hyperlipidemia • Obesity • Seizures (CMS/HCC) Past Surgical History: Procedure Laterality Date • BREAST BIOPSY Right 2019 No family history on file. Tobacco Use • Smoking status: Never • Smokeless tobacco: Never Vaping Use • Vaping Use: Never used Substance Use Topics • Alcohol use: Never • Drug use: Never Procedure: None Review of System: Unable to perform ROS: Other (History of developmental delay.) Constitutional: Negative for chills and fever. HENT: Negative for congestion, rhinorrhea and sore throat. Eyes: Negative for pain and visual disturbance. Respiratory: Negative for cough and shortness of breath. Cardiovascular: Negative for chest pain and palpitations. Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting. Genitourinary: Negative for dysuria, hematuria and vaginal discharge. Skin: Negative for color change and rash. Neurological: Negative for dizziness, seizures, syncope, light headedness and headaches. All other systems reviewed and are negative. . Lab Results: None Medications: No data to display Results: Labs Reviewed No data to display XR ankle right 3+ views Final Result 1. Negative. No acute fracture or ankle arthropathy. 2. Chronic Achilles tendinopathy with dystrophic calcification and enthesophyte formation. No orders to display Follow Up: No follow up provider specified. EMERGENCY DEPARTMENT Discharge Orders (From admission, onward) None Electronically signed by Kim Feldhaus, MD 01/13/23 1651 bmkCopy