Sepsis Guideline Compliance It is my opinion that the patient DOES in fact have a likely infectious etiology for meeting Sepsis Criteria. Upon meeting sepsis criteria resuscitation according to Best Practice Statements and in accordance with this patient’s safety was initiated Fluids: 30 mL/kg of IV crystalloid fluid ordered to be given within the first 1 … More Sepsis Criteria and Interventions

Meningitis MDMLast reviewed: March 2026 Contents MDM Templates Bacterial Meningitis (Suspected) Viral / Aseptic Meningitis Clinical Education Approach to Suspected Meningitis CT Before LP CSF Interpretation Empiric Antibiotic Regimens HSV Encephalitis Chemoprophylaxis for Contacts Disposition References MDM Templates Bacterial Meningitis (Suspected) Patient presents with headache, fever, and neck stiffness. Exam notable for meningismus. No focal … More Meningitis MDM

_ year old G0P0 patient presents with _days vaginal bleeding. Denies changes in hair distribution, no weight change, no change in acne, no visual changes, no sensation of inappropriate warmth or cold. No oral or other mucosal bleeding identified. Denies history of vaginal/uterine instrumentation, hard sex, or sexual abuse. Patient is monogamous with sexual partner also … More Vaginal Bleeding HPI

I was notified by nursing at *** that the patient was ***. Family members were notified that the patient may pass away soon. I came to bedside at ***. I examined the patient and there was no pupillary response to light. I did not observe spontaneous breathing or appreciate heart sounds on auscultation. There was … More Death Note

Contents MDM Templates Clinical Education References Last reviewed: March 2026 MDM Templates Threatened Abortion — Discharge Patient at *** weeks EGA presents with vaginal bleeding. Ultrasound confirms intrauterine pregnancy with fetal cardiac activity. Cervical os closed. Hemodynamically stable. Rh status checked — RhoGAM administered if Rh-negative. History and exam lower suspicion for ectopic pregnancy, molar … More Vaginal Bleeding (1st Trimester) MDM

Cystitis (uncomplicated) Patient with no significant medical history who presents with ___ days of dysuria and frequency. Also complains of mild suprapubic discomfort. Patient has otherwise been in their normal state of health. No history of UTI previous to this visit within one month or one year. Patient not taking any immunosuppressive medications and does … More UTI/Cystitis/Pyelo HPI

Contents MDM Templates Procedure Notes Clinical Education References Last reviewed: March 2026 MDM Templates Uncomplicated Cystitis — Female Discharge Patient presents with dysuria and urinary frequency. UA supports UTI. Well appearing without systemic infectious signs. Not pregnant. History and exam lower suspicion for pyelonephritis, complicated UTI, STI, ovarian torsion, appendicitis, or other acute abdomen. Plan: … More UTI MDM

Low Back Pain MDMLast reviewed: March 2026 Contents MDM Templates Benign / MSK / Disc Herniation Sciatica Cauda Equina / Cord Compression Clinical Education Red Flags Cauda Equina Pearls When to Image ED Treatment Spinal Epidural Abscess Disposition References MDM Templates Benign / MSK / Disc Herniation Patient presents with low back pain without red-flag … More Low Back Pain MDM

Location: Lower back Duration: Weeks, worsening over past few days Quality: Aching Severity: Moderate Timing: Constant; worsens with movement Modifying factors: Relieved with rest Associated signs and symptoms: Context: Other: Denies sudden onset or other unexplained changes in bladder or bowel control (retention or incontinence). Denies sudden onset or otherwise unexplained lower extremity weakness. Denies saddle … More Low Back Pain HPI

___ yo with PMH ___ presents with acute onset ___ flank pain that radiates to groin. Pain began acutely ___ hours ago. Pt was in his normal state of health until this episode. Pt has history of similar pain that was previously diagnosed as kidney stone. Pt has no recent gross hematuria though does have … More Flank Pain/Nephro/Urolithiasis HPI