Denies dysuria or recent UTI. Denies blunt trauma to abdomen or genitals. No urethral instrumentation. No colicky flank pain and no history of kidney stones. No other bleeding sources or bruising. No NSAID use or sickle cell disease. No receptive rectal sex or rectal instrumentation. Nonsmoker. No cancer history.

Critical Care Time This patient required critical care. Due to the fact that the patient required a significant amount of one on one physician – patient contact time, ordering and review of studies, arranging urgent treatment with development of a management plan, evaluation of patient’s response to treatment with frequent reassessments, and discussions with other … More Critical Care Time

Performed by: Self Indication: ___ Universal Protocol: Time out was performed. Patient, side, site and procedure was verified. Consent: Consent was obtained prior to the procedure. Indications, risks, and benefits were explained at length. Patient was placed on continuous cardiac monitoring and continuous pulse oximetry. Supplemental oxygen was administered via nasal cannula. Electrodes were placed … More Cardioversion Procedure

CVC ACCESS PROCEDURE NOTE INDICATION: Emergency vascular access for fluid and drug administration. INFORMED CONSENT: The risks of the procedure including bleeding, pneumothorax, and infection were explained to the patient. The patient verbalized their understanding of the procedure, the risks, benefits and alternatives and wished to proceed. PROCEDURE: The patient was placed in Trendelenburg and … More CVC Procedure

Knee Problem MDMLast reviewed: March 2026 Contents MDM Templates Knee Sprain Patellar Dislocation Knee / Tibial Plateau Fracture Procedure Notes Knee Arthrocentesis Clinical Education Ottawa Knee Rules X-Ray Pearls — Ligamentous Injury on Plain Film Traumatic Knee Effusion Patellar Dislocation Pearls Tibial Plateau Fracture Pearls Septic Joint Considerations References MDM Templates Knee Sprain Patient presents … More Knee Problem MDM

Ear (Katz extractor) The patient’s ___ ear was addressed. A time out was undertaken to determine that this was the correct patient and the correct procedure for this patient. Using [Katz extractor] the foreign body was easily mobilized and removed from the external auditory canal. Post procedure reevaluation of the external auditory canal demonstrates an … More Foreign Body Removal Procedure

Wrist and Forearm Problems MDMLast reviewed: March 2026 Contents MDM Templates Distal Radius Fracture Ulnar Shaft Fracture Scaphoid Fracture Procedure Notes Hematoma Block Wrist Fracture Reduction Forearm Nerve Block Clinical Education Distal Radius Fracture Pearls Both-Bone Forearm Fractures Scaphoid Fracture Pearls Galeazzi and Monteggia Splinting Guide Forearm Nerve Block Anatomy References MDM Templates Distal Radius … More Wrist and Forearm Problems MDM

Patient has a neck strain and will be discharged home.  Patient has currently been stabilized in the emergency department. [Patient was negative by NEXUS criteria and therefore no imaging was performed]. Patient’s symptoms not typical for other emergent conditions such as arterial dissection, osteomyelitis, epidural abscess, c-spine fracture, other spinal emergencies. Patient will be discharged … More Neck Strain MDM

presents with palpitations. EKG: No STEMI and no evidence of Brugada’s sign, delta wave, epsilon wave, significantly prolonged QTc, or malignant arrhythmia. Based on H&P and testing, this patient appears to be low risk for emergent causes of palpitations such as, but not limited to, a malignant cardiac arrhythmia, ACS, pulmonary embolism, thyrotoxicosis, PNA, PTX. … More Palpitations NOS MDM

Sickle Cell Pain MDMLast reviewed: March 2026 Contents MDM Templates Vaso-Occlusive Crisis — Discharge Vaso-Occlusive Crisis — Admit Acute Chest Syndrome Aplastic Crisis Clinical Education Pain Management Acute Chest Syndrome Pearls Transfusion Indications Other SCD Complications References MDM Templates Vaso-Occlusive Crisis — Discharge Patient with sickle cell disease presents with pain to *** that is … More Sickle Cell Pain MDM