GI Bleed MDM

GI Bleed MDMLast reviewed: March 2026 Contents MDM Templates Upper GI Bleed Lower GI Bleed Variceal Hemorrhage Clinical Education Resuscitation Priorities Upper vs Lower GI Bleed Risk Stratification Variceal Hemorrhage Pearls Anticoagulant Reversal PPI in GI Bleeding Disposition References MDM Templates Upper GI Bleed Patient presents with hematemesis / melena / coffee-ground emesis consistent with … More GI Bleed MDM

2023 Documentation and Billing

Level 5 Template Medical Decision Making Complexity (and number) of Problems Addressed: High.– Complaint that could pose threat to life or bodily function addressed: Chest PainEmergent differential diagnoses considered but not limited to:ACS, Pneumothorax, Pulmonary Embolus, Tamponade, Aortic Dissection.Given history, exam, workup presentation not overtly consistent with above diagnoses.Last Stress Test:  neverLast Heart Catheterization:  neverHEART … More 2023 Documentation and Billing

Pneumothorax and Pneumomediastinum

Pneumothorax & Pneumomediastinum Last reviewed: March 2026 Quick Links: MDM Templates Clinical Education References MDM Templates Pneumomediastinum Patient presents with chest pain, dyspnea, and neck fullness. Examination reveals subcutaneous emphysema in the neck and chest wall, with a palpable air crackle on palpation. Chest imaging confirms pneumomediastinum without evidence of tension physiology or hemodynamic compromise. … More Pneumothorax and Pneumomediastinum

Bariatric Surgery Problems

Bariatric Surgery Problems MDMLast reviewed: March 2026 Contents MDM Templates Post-Bariatric Abdominal Pain Dumping Syndrome Marginal Ulcer Clinical Education Deadly Complications Imaging Approach Dumping Syndrome Pearls Marginal Ulcer Pearls Nutritional Deficiencies Adjustable Gastric Band Complications Disposition References MDM Templates Post-Bariatric Abdominal Pain Patient with history of *** (Roux-en-Y gastric bypass / sleeve gastrectomy) performed *** … More Bariatric Surgery Problems

AV Fistula Problems

AV Fistula Problems MDMLast reviewed: March 2026 Contents MDM Templates Fistula Pain / Dysfunction Fistula Bleeding Fistula Infection Clinical Education Fistula Physical Exam Stenosis and Thrombosis Steal Syndrome Bleeding Management Infection Approach References MDM Templates Fistula Pain / Dysfunction Patient with ESRD on hemodialysis presents with pain and concern for dysfunction of their AV fistula. … More AV Fistula Problems

Foot and Ankle Problems MDM

Foot and Ankle Problems MDMLast reviewed: March 2026 Contents MDM Templates Foot Fracture Ankle Sprain Ankle Fracture Foot Puncture Wound Achilles Tendon Rupture Clinical Education Ottawa Ankle & Foot Rules Hindfoot Fractures Midfoot — Lisfranc Injuries Forefoot — Jones vs Pseudo-Jones Ankle Fracture Classification (Weber) Achilles Rupture Pearls Foot Puncture Pearls References MDM Templates Foot … More Foot and Ankle Problems MDM

Tuberculosis MDM

+ cough + night sweats + fatigue +travel/exposure history Presentation concerning for possible Pulmonary Tuberculosis. AFB Culture [other non-sterile, PHL sputum induced], M. tuberculosis PCR with Rifampin Resistance (sputum or expectorated or induced), HIV antigen/antibody screen (blood) Presentation Symptoms Weight loss (>1 month), Cough (>2 weeks), Fever (>2 weeks), Night sweats (>1 month), Malaise (>1 month), … More Tuberculosis MDM

Hyper/Hypothermia Problems MDM

Hyper/Hypothermia Problems MDMLast reviewed: March 2026 Contents MDM Templates Heat Stroke Heat Exhaustion / Minor Heat Illness Environmental Hypothermia Hypothermic Cardiac Arrest Clinical Education Heat Illness Spectrum Cooling Methods Toxicologic Hyperthermia Hypothermia Pearls Rewarming Methods Disposition References MDM Templates Heat Stroke Patient presents with elevated core temperature and CNS dysfunction (altered mental status, confusion, seizure, … More Hyper/Hypothermia Problems MDM

General MDM Template

ED Workup: CBC, BMP ED Findings: ECG: No overt evidence of STEMI. No evidence of Brugada’s sign, Delta wave, Epsilon wave, significantly prolonged QTc, or malignant arrhythmia Given History, Exam, and Workup I have low suspicion for *** or other emergent problem as a cause for this presentation. ED interventions: analgesia Reassessment: Prior to discharge patient’s pain … More General MDM Template

Ascites Problems MDM

Ascites Problems MDMLast reviewed: March 2026 Contents MDM Templates Tense Ascites / Volume Burden Spontaneous Bacterial Peritonitis New-Onset Ascites Procedure Notes Paracentesis Clinical Education SBP Pearls SAAG and Ascitic Fluid Analysis Paracentesis Pearls Albumin Replacement Hepatorenal Syndrome Disposition References MDM Templates Tense Ascites / Volume Burden Patient with known cirrhosis presents with abdominal distension, discomfort, … More Ascites Problems MDM