General Benign Primary Headache ___ year old patient with PMH ___ presents with headache for ___ hours that was non-thunderclap in origin. This gradual headache that was non-maximal at onset is similar to headaches the patient has had in the past. The patient has no recent history of head trauma and is not taking any anticoagulation. … More Headache HPI

Normal Adult (8 systems) General: Alert and oriented x3, No apparent distress. Skin: Intact, Warm, no rashes. HEENT: Normocephalic, Atraumatic. Normal neck range of motion, Supple. Trachea midline. Respiratory: Lungs are clear to auscultation, Breath sounds are equal bilaterally with equal chest expansion. Cardiovascular: RRR, normal S1, S2, No murmurs. Distal pulses 2+ Musculoskeletal: No … More Physical Exam

Heart Failure: ED Management Heart Failure MDM Last reviewed: March 2026 Contents MDM Templates Acute Decompensated Heart Failure — Wet and Warm Acute Decompensated Heart Failure — Wet and Cold HFpEF Exacerbation Flash Pulmonary Edema Clinical Education Hemodynamic Profiles and Classification Nitroglycerin: The Workhorse NIPPV and Preload Reduction IV Diuretics Flash Pulmonary Edema Pearl Cardiogenic … More Heart Failure MDM

Eye exam: The patient was examined with the slit lamp. Extraocular movements are intact Pupils are equally round and reactive to light Visual acuity: Eyelids/under eyelids: normal Conjunctivae and sclera: normal Corneas: normal without fluorescein uptake, and negative Seidel sign Anterior chambers: normal without cell, flare, or hyphema Eye pressures (tonometer): left eye  , right … More EYE Exam

Hyperglycemia Patient has not been adherent with diabetes medication regimen. Endorses polyuria and polydipsia. Patient feels otherwise at their baseline with no other acute complaints. Denies abdominal pain. Denies chest pain. Denies shortness of breath. Denies FNVD. DKA Endorses Abdominal pain. Pain described as gradual and continuous. Report no specific relationship with fatty meals. No … More Hyperglycemia Problems HPI

Uncomplicated Pt presents with abdominal pain ML 2/2 cholecystitis. No abdominal bruits, no radiation to back, no CVA tenderness, no h/o alcohol abuse, no h/o diverticula or bloody stool. Pt having flatus and nml BMs. Pt nontoxic in appearance w nml vitals. Unlikely AAA, pancreatitis, SBO, appendicitis, mesenteric ischemia, nephrolithiasis, pyelonephritis, or diverticulitis. Workup: CBC, … More Cholecystitis MDM

Traumatic Iritis Pt presents with painful, unilateral vision loss after trauma ___ days ago. Eye exam w ciliary flush and consensual photophobia; slit lamp with cells and flare ___ with hypopyon. Midface stable, not concerning for Le Fort fracture, and no dental trauma. EOMI reassuring against entrapment. (-) foreign body. No abrasion or ulcer noted on … More EYE Iritis MDM

Suicidal Patient complains of suicidal ideation. They have been having thoughts of taking their own life for *** days. Suicide Plan: None Prior Suicide Attempts: None Denies AH, VH, HI. Denies any ingestions and denies any other medical complaints. They have felt otherwise in their normal state of health They deny fever, nausea, vomiting. Denies … More Psych HPI

Patient was the ___ in an automobile which was involved in an accident. The patient denies rollover or other severe mechanism, or steering wheel damage. The patient was ___ wearing a seatbelt, did not ___ require extrication, and was not ___ ejected. The patient did not ___ experience loss of consciousness, and denies numbness, paralysis, … More MVC HPI

Pt p/w crampy, intermittent abdominal pain. Pt with risk factor history of ___ (i.e. abdominal surgery, hernia, abdominal radiation. anticholinergic or TCA use). No h/o abdominal trauma. Pt without recent BM or flatus. (+) N/V. (+) Distention and Abdominal TTP. Unlikely other acute abdomen. Plan NPO, pain and nausea control, CBC, BMP, Lipase, BUS, CT w/ IV contrast. —————— … More SBO MDM