Differential diagnosis documentation - Revision history

Rossdonaldson1: /* See Also */

2026-03-25T17:30:31Z

Danbot: Expanded See Also with MDM and billing links, added documentation pages template

2026-03-24T11:07:55Z

Expanded See Also with MDM and billing links, added documentation pages template

← Revisión anterior		Revisión del 11:07 24 mar 2026
Línea 525:		Línea 525:
	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]		*[[Documentation for emergency physicians]]
			*[[MDM for different chief complaints]]
			*[[MDM for different chief complaints (peds)]]
			*[[Billing]]
			*[[Discharge documentation]]

			{{Documentation pages}}

			==References==
			<references/>

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

Rossdonaldson1: /* Fever Peds (1) */

2021-10-06T20:32:04Z

Fever Peds (1)

← Revisión anterior		Revisión del 20:32 6 oct 2021
Línea 176:		Línea 176:

	==Fever Peds (1)==		==Fever Peds (1)==
	~~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 is NOT consistent with meningitis, sepsis and/or bactermia. The patient is not severely dehydrated and can tolerate POs at home.

	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 is NOT consistent with surgical abdomen and/or peritonitis, for example appendicitis; bowel perforation 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 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.		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.		Further, the presentation 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).		Strict return and follow-up precautions have been given by me personally to parent(s)/guardian(s).

TannerLeeFrey: /* UTI female */

2020-12-24T21:36:11Z

UTI female

← Revisión anterior		Revisión del 21:36 24 dic 2020
Línea 420:		Línea 420:
	Given the large differential diagnosis, the decision making in this case is of high complexity.		Given the large differential diagnosis, the decision making in this case is of high complexity.

	After evaluating all of the data points in this case, the presentation of ~~Monirath Say~~ 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.
Línea 432:		Línea 432:
	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.		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.

	==Vaginal bleeding in pregnancy==		==Vaginal bleeding in pregnancy==

Rossdonaldson1: /* Fever (2) */

2020-07-01T17:31:45Z

Fever (2)

← Revisión anterior		Revisión del 17:31 1 jul 2020
Línea 190:		Línea 190:
	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.		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 (2)==		==Peds Fever (2)==
	~~oubt~~ meningitis, pyelonephritis, bacterial PNA, AOM, pharyngitis, rheumatologic disease, ingestion,malignancy		Doubt meningitis, pyelonephritis, bacterial PNA, AOM, pharyngitis, rheumatologic disease, ingestion,malignancy

Rossdonaldson1: /* Fever Peds */

2020-07-01T17:16:00Z

Fever Peds

← Revisión anterior		Revisión del 17:16 1 jul 2020
Línea 175:		Línea 175:
	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.

	==Fever Peds==		==Fever Peds (1)==
	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.

Línea 188:		Línea 188:
	Strict return and follow-up precautions have been given by me personally to parent(s)/guardian(s).		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.		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 (2)==
			oubt meningitis, pyelonephritis, bacterial PNA, AOM, pharyngitis, rheumatologic disease, ingestion,malignancy


			Upon re-evaluation, patient is well hydrated non-toxic appearing and tolerating PO intake. There is no suspicion of immunocompromised state, their vaccines are up to date, there is no prior sserious bacterial infections with good home/social environment including a care taker who is reliable and the child has a PMD who can see them promptly for followup.

			Vital signs stable and patient well appearing. Pain controlled in ED, discharged with _, care giver and patient instructed on strict return precautions and outpatient pain control methods. They agree with assessment and plan which was explained and repeated back with questions answered . They agree to follow up with primary doctor for further workup and management.

	==Fracture==		==Fracture==

Rossdonaldson1: /* Sickle cell crisis */

2020-07-01T17:14:55Z

Sickle cell crisis

← Revisión anterior		Revisión del 17:14 1 jul 2020
Línea 365:		Línea 365:
	@NAME@'s presentation is not consistent with new bony infarction, avascular necrosis, acute chest syndrome, pneumonia, asthma exacerbation, new pulmonary hypertension, surgical abdomen, infection, worsening anemia, CVA, TIA, ICH, priapism.		@NAME@'s presentation is not consistent with new bony infarction, avascular necrosis, acute chest syndrome, pneumonia, asthma exacerbation, new pulmonary hypertension, surgical abdomen, infection, worsening anemia, CVA, TIA, ICH, priapism.

	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.

			==Seizure (peds)==
			Suspect unprovoked seizure
			Highly doubt isoniazid ingestion or other toxic ingestions, meningitis, encephalopathy, ICH, ICM, encepalitis, hydrocephalus, pseudoseizure, hypoglycemia. Doubt accidental or non-accidental trauma. Doubt seizure mimics such as cardiac arrythmia, GERD, syncope, breath holding spells.
			As patient without recent infection or fever, doubt simple or complex febrile seizure

			Vital signs stable and patient well appearing. Pain controlled in ED, discharged with _, care giver and patient instructed on strict return precautions and outpatient pain control methods. They agree with assessment and plan which was explained and repeated back with questions answered . They agree to follow up with primary doctor for further workup and management.
			Caregivers counseled that 4-6% of children <16yo have seizures, 6-12% of them have no known inciting event

	==Symptomatic cholelithiasis==		==Symptomatic cholelithiasis==

Rossdonaldson1: /* Otitis media peds */

2020-07-01T17:13:56Z

Otitis media peds

← Revisión anterior		Revisión del 17:13 1 jul 2020
Línea 288:		Línea 288:
	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.

	==Otitis media peds==		==Otitis media peds (1)==
	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.		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.

Línea 301:		Línea 301:
	Strict return and follow-up precautions have been given by me personally to parent(s)/guardian(s).		Strict return and follow-up precautions have been given by me personally to parent(s)/guardian(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.

			==Otitis media peds (2)==

			uspect AOM due to the presence of <48hr symptoms, middle ear effusion and inflammation with otalgia. Severe features include (>48hr symptoms, severe otalgia,T>39C).
			(Treat all patients <6mo, severe symptoms, 6-23mo with b/l symptoms)
			-This patient did NOT fail prior therapy and so will be treated with amoxicillin
			-This patient did fail prior therapy and so will be treated with amoxicillin-clav
			-This patient is a candidate for outpatient wait-and-wwatch therapy

			Doubt chronic otitis media, simple middle ear effusion, mastoiditis, cholesteatoma, otitis externa, TM perforation

			Upon re-evaluation, the patient is well hydrated non-toxic appearing and tolerating PO intake. There is no suspicion of immunocompromised state, their vaccines are up to date, there is no prior serious bacterial infections with good home/social environment including a care taker who is reliable and the child has a PMD who can see them promptly for followup. The caretaker was instructed on avoiding second hand smoke and staying UTD on their vaccines.

			Vital signs stable and patient well appearing. Pain controlled in ED, discharged with _, care giver instructed on strict return precautions and outpatient pain control methods. They agree with assessment and plan which was explained and repeated back with questions answered . They agree to follow up with primary doctor for further workup and management.

	==Paronychia==		==Paronychia==

Rossdonaldson1: /* Crying infant */

2020-07-01T17:11:58Z

Crying infant

@@ Línea 128: / Línea 128: @@
 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==

Rossdonaldson1: /* Pyelo female */

2020-07-01T17:10:33Z

Pyelo female

← Revisión anterior		Revisión del 17:10 1 jul 2020
Línea 284:		Línea 284:

	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.

			==Pediatric Rash==
			Suspect viral exanthum
			Doubt Measles, SJS, SSSS, TEN, Kawasaki or Anaphylaxis
			Doubt Drug rash, Henoch-Schonlein Purpura (HSP), Herpangina, Herpes simplex virus, Infectious Mononucleosis, Meningitis, Measles, Molluscum contagiosum, Roseola infantum, Rubella, Scarlet fever, Smallpox, Varicella (Chickenpox)

			Upon re-evaluation, patient is well hydrated non-toxic appearing and tolerating PO intake. There is no suspicion of immunocompromised state, their vaccines are up to date, there is no prior sserious bacterial infections with good home/social environment including a care taker who is reliable and the child has a PMD who can see them promptly for followup.

			Vital signs stable and patient well appearing. Pain controlled in ED, discharged with _, care giver and patient instructed on strict return precautions and outpatient pain control methods. They agree with assessment and plan which was explained and repeated back with questions answered . They agree to follow up with primary doctor for further workup and management.

	==Pyelo female==		==Pyelo female==
Línea 300:		Línea 309:
	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.		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.

	==Salter Harris Type 1==		==Salter Harris Type 1==

← Revisión anterior		Revisión del 17:30 25 mar 2026
Línea 524:		Línea 524:

	==See Also==		==See Also==
	*[[Documentation for emergency physicians]]
	*[[MDM for different chief complaints]]
	*[[MDM for different chief complaints (peds)]]
	*[[Billing]]
	*[[Discharge documentation]]

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