Admitted Patient Consultation Respiratory Distress Mid Level Chart Attestation Medical Student Chart Attestation Admitted Patient Consultation Respiratory Distress Consulted for emergent aid for this patient in respiratory distress. Upon arrival to patient room it was clear that the patient was in fact in respiratory distress necessitating airway intervention. Shared decision among teams was made to … More Consultation Note/Chart Attestation

presenting with an injury to the ___ shoulder that occurred just prior to arrival. Patient states that the injury occurred at ___ when they fell. Pain is described as moderate in nature. Patient ___ has had a previous shoulder dislocation. Associated symptoms: Denies loss of feeling to arm. Denies for syncope. ROS: [Negative ] for … More Shoulder Problem Note

The patient required a lumbar puncture and this was done in the standard fashion. Both written and verbal consent were obtained and the patient is well aware of all risks, benefits and alternatives. A time out was undertaken to assure that this was the correct patient and the correct procedure for this patient. The patient … More Lumbar Puncture Procedure

(With punches to head) presenting after an assault that occurred [just prior to arrival]. Patient complains of pain in the ___ Patient states that the injury occurred at ___ Pain is described as moderate in nature and worse with movement. Patient states that they ___ know the assailant. Physical Violence Context: Patient was punched. Patient … More Assault HPI

The patient had a significant amount of ascites in the abdominal cavity necessitating paracentesis. The patient was placed in a semi-Fowlers position. A time out was undertaken to ensure that this is the correct patient and the correct procedure for this patient. Ultrasound was used to identify a safe area where bowel was limited and … More Paracentesis Procedure

presenting with moderate GI bleeding characterized as hematemesis that began today. There is associated abdominal pain. The patient endorses feeling weak or lightheaded. There is a history of similar bleeding. Positive for melena. The patient endorses a history of alcohol abuse and liver disease.   Associated symptoms include: No recent illness or fever + nausea … More GI Bleed HPI

HPI presenting with moderate GI bleeding characterized as hematemesis that began today. There is associated abdominal pain. The patient endorses feeling weak or lightheaded. There is a history of similar bleeding. Positive for melena. The patient endorses a history of alcohol abuse and liver disease.   Associated symptoms include: No recent illness or fever + … More GI Bleed Note

presenting with an injury to the ___ hand that occurred ___ hours prior to arrival. Patient states that the injury occurred at ___ when they ____. Pain is described as moderate in nature and worse with movement. Associated symptoms: Negative  for loss of feeling to hand and fingers in affected extremity.

Tachydysrhythmias Last reviewed: March 2026 Quick Links: MDM Templates Clinical Education References MDM Templates Undifferentiated Tachycardia Patient presents with palpitations and heart rate of *** bpm. Clinical exam reassuring with no evidence of hemodynamic compromise — blood pressure stable, no signs of acute heart failure, mental status intact. Deny chest pain, dyspnea, or syncope. History … More Tachydysrhythmias MDM

The patient is suffering from shortness of breath, but the immediate cause is not apparent. Potential causes considered include, but are not limited to, asthma or COPD, congestive heart failure, pulmonary embolism, pneumothorax, coronary syndrome, pneumonia, and pleural effusion. Despite the evaluation including history, exam, and testing, the cause of the shortness of breath remains … More SOB NOS MDM