PWF3a – AP MSK and Acute Conditions – Physician Workflow Part 3a

A/P:
#UPPER RESPIRATORY INFECTION:
with components of rhinitis sinusitis eustachian tube dysfunction otitis media pharyngitis post-nasal drip laryngitis other-
-No concerning focal bacterial infection identified.
-Advised pt that sx duration usually 7-10 days (3 days longer in smokers).
-Reassured patient that abx not currently indicated and have side effects.
-Advised pt of the risks/benefits of sx mgmt.
-Pt declined symptomatic treatment.
-The patient requests the following symptomatic tx which were ordered: acetaminophen (Discussed appropriate dosing, alcohol avoidance, and hepatotoxicity risk) NSAIDs (Discussed appropriate dosing, limiting use to 1-2 weeks, and potential risks including: GI bleed, renal failure, CV events) oral antihistamine (discussed prn use, side effects risk of drowsiness, constipation, mental confusion, falls if elderly) Nasal saline Decongestants (Discussed limiting use to less than 72 hours; discussed risks of tachycardia/arrhythmias, anxiety, insomnia, hypertension, and rebound rhinitis Brown Honey (OTC only, not for use in chilren under 1 year old) Vapor Rub (OTC only) Benzonatate capsules (cough suppressant, swallow whole) Menthol lozenges Zinc lozenges (may shorten duration of illness, OTC only) Guaifenesin (Discussed possible drowsiness, headache, rash, nausea, and limited trials of efficacy) Nasal steroids (Discussed possible nasal dryness, thrush, epistaxis).
-Gave return precautions to include: fever over 101F not relieved by tylenol/NSAIDS purulent discharge severe facial pain shortness of breath difficulty swallowing sx >10 days sx worsen after previously improving.
-Followup: with PCM with unit providerother specialties
-Explained the above assessment and plan to patient who:

#THROAT/SINUS PAIN:
-Dx- acute steptococcal pharyngitis acute pharyngitis (viral more likely than streptococcal) likely streptococcal pharyngitis acute mild sinusitis acute moderate/severe sinusitis chronic rhinitis post-nasal drip
-Reasoning- rapid strep test performed and positive CENTOR score rapid strep test performed and negative (throat culture obtained/results pending) physical exam findings as above severe features of sinusitis present (fever and/or face pain) duration of sinusitis sx beyond 2wks progressively worsening sinusitis sx
-Discussed/recommended- ordered rapid strep/culture adequate rest/hydration frequent handwashing cough etiquette use of nasal rinse
-Medications ordered/recommended OTC- none mucinex mucinex-D cepacol tylenol motrin nasal steroid spray nasal antihistamine oral antihistamine antibiotics oral steroids albuterol inhaler
-Gave return precautions to include: fever over 101F not relieved by tylenol/NSAIDS worsening face pain shortness of breath difficulty swallowing no improvement after one week sx worsen after previously improving.
-Patient disposition- return to work return to school not return to school until afebrile for 48 hours not return to work until afebrile for 48 hours light duty profile quarters x24hrs referred to ED for further workup return to normal activities
-Followup: with PCM with unit providerother specialties
-Explained the above assessment and plan to patient who:

#GI CONDITION:
-Leading Dx- viral gastroenteritis suspected bacterial gastroenteritis suspected food poisoning gastroesophageal reflux disorder suspected gastric ulcer/PUD melena hematochezia constipation suspected appendicitis suspected gallbladder disease
-Diagnostic labs ordered- none (not indicated) CBC BMP CMP GI viral/bacterial pathogen panel fecal occult blood fecal leukocytes stool culture stool ova and parasites H pylori stool Ag H pylori Ab (blood) Tissue Transglutamase
-Imaging ordered- none (not indicated) KUB Acute Abdominal Series CT Abd/Pelv
-Interventions/Treatment- no intervention currently indicated discussed progressive oral rehydration efforts with electrolyte solution and/or diluted apple juice provided IV rehydration with normal saline provide IV rehydration with lactated ringers discussed avoidance of foods shown to worsen patient’s condition rx’d empiric trial of PPI rx’d empiric antibiotic rx’d loperamide discussed adequate daily fluid intake discussed daily recommended fiber intake discussed soft, healthy, regular bowel movements rx'd/rec'd Miralax bolus protocol of 1 capful q1-2h until first BM then daily mtn dose rx'd/rec'd Miralax 1-3 capfuls daily rx'd/rec'd Dulcolax rx'd/rec'd Mg Citrate prn discussed goal of constipation treatment of daily/near daily effortless BMs
-Referral- none (not indicated) routine GI referral ASAP GI referral with warm handoff ASAP General Surgery referral with warm handoff
-Followup: with PCM with unit providerother specialties
-Patient Disposition- stable and discharged home with return precautions sent to emergency department for further evaluation and treatment patient acknowledged understanding and intent to comply

#MSK Condition(1):
-Diagnosis- Acuity Likely/Unlikely Factors Prognosis Workup Mgmt Self Care Mgmt Work/Duty Limits Mgmt Stretches/Exercises Mgmt Medications Mgmt Phys Therapy Mgmt Other Modalities Mgmt Other Specialities/Subspecialties
-Acuity- new/acute injury chronic condition 1st assessment chronic condition followup
-Likely factor(s): repetitive use poor mechanics/ergonomics/form inadequate conditioning muscle strain muscle spasm joint/ligament sprain muscle weakness tendinopathy somatic dysfunction(osteopathic);bone/joint/disc neuropathy referred pain osteoarthritis joint degeneration joint/ligament instability disc degeneration spinal stenosis disc herniation occult fracture;other anxiety depression opioid-induced hyperalgesia
-Unlikely factor(s): repetitive use poor mechanics/ergonomics/form inadequate conditioning muscle strain muscle spasm joint/ligament sprain muscle weakness tendinopathy somatic dysfunction(osteopathic);bone/joint/disc neuropathy referred pain osteoarthritis joint degeneration joint/ligament instability disc degeneration spinal stenosis disc herniation occult fracture;other anxiety depression opioid-induced hyperalgesia
-Prognosis: freetext mild severity moderate severity acute injury likely self-limited anticipate full recovery anticipate at least partial recovery additional improvement unlikely likely progressive degenerative process prognosis unclear workup will help further assess prognosis encouraging improving with current treatments not improving with current treatments concern for worsening has not yet met MRDP has met MRDP and will referral for MEB
-Workup - freetext No imaging or dx studies currently indicated Xray CT MRI U/S EMG
-Management:
-Conservative/Self-care measures- freetext rest ice/heat soft splinting rigid splinting early mobilization
-Work/school/duty limitations issued- none

specific limitations
-Home stretches/exercises- demonstrated provided handout reiterated home exercises continue previously rx'd home exercises
-Medications- none NSAIDS tylenol muscle relaxer transdermal lidocaine patches topical capsaicin
-Physical therapy- freetext referred for formal physical therapy continue formal physical therapy discontinue current physical therapy
-Other modalities- freetext OMT Dry Needling Triggerpoint Injections Auricular Acupuncture Acupuncture
-Other specialties managing: freetext sports medicine (new referral) sports medicine (continue/ongoing) orthopedics (new referral) orthopedics (continue/ongoing) PM&R (new referral) PM&R (continue/ongoing) spine surgeon (new referral) spine surgeon (continue/ongoing) neurosurgeon (new referral) neurosurgeon (continue/ongoing) chiropractic (new referral) chiropractic (continue/ongoing) pain management (new referral) pain management (continue/ongoing) OMT (new referral) OMT (continue/ongoing
-Followup: with PCM with unit provider with sports medicine with orthopedics with PM&R with neurosurgeon with spine surgeon with pain mgmt other-
-Gave the following return precautions: freetext n/a fever severe progressive pain progressive/severe swelling inability to bear weight new onset/worsening numbness new onset/worsening weakness
-Explained the above assessment and plan to patient who: freetext

#MSK Condition(2):
-Diagnosis- Acuity Likely/Unlikely Factors Prognosis Workup Mgmt Self Care Mgmt Work/Duty Limits Mgmt Stretches/Exercises Mgmt Medications Mgmt Phys Therapy Mgmt Other Modalities Mgmt Other Specialities/Subspecialties
-Acuity- new/acute injury chronic condition 1st assessment chronic condition followup
-Likely factor(s): repetitive use poor mechanics/ergonomics/form inadequate conditioning muscle strain muscle spasm joint/ligament sprain muscle weakness tendinopathy somatic dysfunction(osteopathic);bone/joint/disc neuropathy referred pain osteoarthritis joint degeneration joint/ligament instability disc degeneration spinal stenosis disc herniation occult fracture;other anxiety depression opioid-induced hyperalgesia
-Unlikely factor(s): repetitive use poor mechanics/ergonomics/form inadequate conditioning muscle strain muscle spasm joint/ligament sprain muscle weakness tendinopathy somatic dysfunction(osteopathic);bone/joint/disc neuropathy referred pain osteoarthritis joint degeneration joint/ligament instability disc degeneration spinal stenosis disc herniation occult fracture;other anxiety depression opioid-induced hyperalgesia
-Prognosis: freetext mild severity moderate severity acute injury likely self-limited anticipate full recovery anticipate at least partial recovery additional improvement unlikely likely progressive degenerative process prognosis unclear workup will help further assess prognosis encouraging improving with current treatments not improving with current treatments concern for worsening has not yet met MRDP has met MRDP and will referral for MEB
-Workup - freetext No imaging or dx studies currently indicated Xray CT MRI U/S EMG
-Management:
-Conservative/Self-care measures- freetext rest ice/heat soft splinting rigid splinting early mobilization
-Work/school/duty limitations issued- none

specific limitations
-Home stretches/exercises- demonstrated provided handout reiterated home exercises continue previously rx'd home exercises
-Medications- none NSAIDS tylenol muscle relaxer transdermal lidocaine patches topical capsaicin
-Physical therapy- freetext referred for formal physical therapy continue formal physical therapy discontinue current physical therapy
-Other modalities- freetext OMT Dry Needling Triggerpoint Injections Auricular Acupuncture Acupuncture
-Other specialties managing: freetext sports medicine (new referral) sports medicine (continue/ongoing) orthopedics (new referral) orthopedics (continue/ongoing) PM&R (new referral) PM&R (continue/ongoing) spine surgeon (new referral) spine surgeon (continue/ongoing) neurosurgeon (new referral) neurosurgeon (continue/ongoing) chiropractic (new referral) chiropractic (continue/ongoing) pain management (new referral) pain management (continue/ongoing) OMT (new referral) OMT (continue/ongoing
-Followup: with PCM with unit provider with sports medicine with orthopedics with PM&R with neurosurgeon with spine surgeon with pain mgmt other-
-Gave the following return precautions: freetext n/a fever severe progressive pain progressive/severe swelling inability to bear weight new onset/worsening numbness new onset/worsening weakness
-Explained the above assessment and plan to patient who: freetext

#MSK Condition(3):
-Diagnosis- Acuity Likely/Unlikely Factors Prognosis Workup Mgmt Self Care Mgmt Work/Duty Limits Mgmt Stretches/Exercises Mgmt Medications Mgmt Phys Therapy Mgmt Other Modalities Mgmt Other Specialities/Subspecialties
-Acuity- new/acute injury chronic condition 1st assessment chronic condition followup
-Likely factor(s): repetitive use poor mechanics/ergonomics/form inadequate conditioning muscle strain muscle spasm joint/ligament sprain muscle weakness tendinopathy somatic dysfunction(osteopathic);bone/joint/disc neuropathy referred pain osteoarthritis joint degeneration joint/ligament instability disc degeneration spinal stenosis disc herniation occult fracture;other anxiety depression opioid-induced hyperalgesia
-Unlikely factor(s): repetitive use poor mechanics/ergonomics/form inadequate conditioning muscle strain muscle spasm joint/ligament sprain muscle weakness tendinopathy somatic dysfunction(osteopathic);bone/joint/disc neuropathy referred pain osteoarthritis joint degeneration joint/ligament instability disc degeneration spinal stenosis disc herniation occult fracture;other anxiety depression opioid-induced hyperalgesia
-Prognosis: freetext mild severity moderate severity acute injury likely self-limited anticipate full recovery anticipate at least partial recovery additional improvement unlikely likely progressive degenerative process prognosis unclear workup will help further assess prognosis encouraging improving with current treatments not improving with current treatments concern for worsening has not yet met MRDP has met MRDP and will referral for MEB
-Workup - freetext No imaging or dx studies currently indicated Xray CT MRI U/S EMG
-Management:
-Conservative/Self-care measures- freetext rest ice/heat soft splinting rigid splinting early mobilization
-Work/school/duty limitations issued- none

-Explained the above assessment and plan to patient who:

#URINARY TRACT INFECTION:
- based on clinical suspicion and history/findings confirmatory labwork
- with ”pyridium antibiotics nitrofurantoin trimethoprim/sulfamethox b-lactam flouroquinolone”.
-Followup: with PCM with unit providerother specialties
-Gave the following return precautions: fever severe progressive pain increasing lightheadness increasing nausea/vomiting other-

-Explained the above assessment and plan to patient who:

#CONTRACEPTIVE MANAGEMENT:
-Discussed these methods to include contraindications, indications, and possible side effects: oral combination estrogen/progesterone pills oral progesterone only pills hormone-releasing IUD Copper IUD progesterone IM injections Nuvaring Transdermal patches Nexplanon periodic abstinence barrier methods (condom and diaphragm in combination with spermicidal lubrication) withdrawal methods permanent sterilization methods (tubal ligation, vasectomy, and essure) abstinence birth control while breastfeeding and lactation amenorrhea.
-Patient appears a reasonable candidate for any of these for: prevention of pregnancy regulating irregular menstrual cycles dysmenorrhea menorrhagia acne other-
-Discussed relative risks/benefits of each, and relative/absolute contraindications of each.
-Patient opted for: .
-HCG testing MDM: CDC criteria checklistCriteria for not requiring HCG test
Is less than or equal to 7 days after the start of normal menses Has not had sexual intercourse since the start of last normal menses Has been correctly and consistently using a reliable method of contraception Is less than or equal to 7 days after spontaneous or induced abortion Is within 4 weeks postpartum Is fully or nearly fully breastfeeding (exclusively breastfeeding or the vast majority - more than 85 percent - of feeds are breastfeeds), amenorrheic, and less than 6 months postpartum--Score --> numberscore=(variable_1) out of 6 items
--Interpretation --> resultscore2=(variable_1);score2>0?'Testing optional - Can be reasonably certain that patient is not pregnant without a pregnancy test':'Testing recommended - Cannot be reasonably certain that patient is not pregnant without a pregnancy test'
-HCG testing decision:
-Next action(s): Pills prescribed and patient to pickup in pharmacy. Applicable procedure performed same visit - see procedure note. Patient will be scheduled for applicable procedure. Patient referred to procedures clinic for scheduling of applicable procedure. Gave Medroxyprogesterone 150mg IM injection.
-Patient verbally consented
-
-Lot# , Exp Date
-Date/time given:
-Next window: calc valuescore1=(DepoDate).dateAdd(77) THRU calc valuescore1=(DepoDate).dateAdd(105) 11-15wk range backed by high quality evidence of efficacy
-Observed for 5 minutes following injection
-No immediate complications noted
-Left in stable condition
-Followup: with PCM with unit providerother specialties
-Explained the above assessment and plan to patient who:

#PSEUDOFOLLICULITIS BARBAE: first/initial visit followup
-Severity: mild moderate severe
-Current Mgmt- no substantial pre/during/post-shave techniques or pharm tx attempted shaving at night shaving 2-3x/wk adequate 15min shave prep time dislodging hairs rough cloth exfoliation preshave moisturizing lotion using single/double bladed razor using clippers aftershave moisturizing lotion benzoyl peroxide tretinoin topical low-potency topical steroid temporary shaving profile permanent shaving profile
-Effect of current mgmt- condition improved condition well-controlled condition WORSENED condition NOT well-controlled undesirable/intolerable side effects of treatment(s)
-Plan- continue current/above regimen add benzoyl peroxide add tretinoin topical add low-potency topical steroid add temporary shaving profile add permanent shaving profile referred to dermatology counseled on TB MED 287 and/or derm guidelines regarding - shaving at night shaving 2-3x/wk (not daily) planning for adequate 15min shave prep dislodging hairs rough cloth exfoliation use of preshave moisturizing lotion use single/double bladed razor (not 3+ blades) use of clippers use of aftershave moisturizing lotion
-Followup: with PCM with unit providerother specialties
-Explained the above assessment and plan to patient who:

#BEHAVIORAL HEALTH:
-Acuity-
-Dx: adjustment d/o with depressed mood adjustment d/o with anxiety adjustment d/o with mixed depression/anxiety sx depression anxiety PTSD ADHD bipolar
-Current Mgmt- IBHC psychologist CBT psychiatrist management of medications SSRI SNRI benzodiazepine mood stabilizer(s) atypical antipsychotic no prior treatment stimulant non-stimulant
-Effect of current mgmt- sx improved sx well-controlled sx not well-controlled sx NOT improved sx WORSENED undesirable/intolerable side effects of pharm tx
-Serious/concerning sx check- no manic symptoms no SI no HI SI without plan SI WITH plan no psychotic symptoms psychotic symptoms
-Plan- continue current/above regimen refer for psychologist counseling refer to IBHC refer to psychiatrist for mgmt of medication start SSRI adjust SSRI discontinue SSRI start SNRI adjust SNRI discontinue SNRI start benzodiazepine adjust benzodiazepine discontinue benzodiazepine start mood stabilizer adjust mood stabilizer discontinue mood stabilizer start atypical antipsychotic adjust atypical antipsychotic discontinue atypical antipsychotic
-Labs
-Patient disposition-
-Followup: with PCM with unit providerother specialties

#NICOTINE DEPENDENCE:
-Conducted Tobacco Cessation Counseling (3-10 Minutes)
-Discussed with patient impact of tobacco use on health, benefits of tobacco cessation, support resources to include: phone hotline 1-800-QUIT-NOW Web based resources MTF Tobacco Cessation Program medication options quit strategies
-Patient’s readiness to quit:
-Plan: continue to address at each visit start nicotine replacement therapy start bupropion therapy start varenicline therapy consult with clinical pharmacist patient self-refer to MTF tobacco cessation program Add CPT code: 4000F or 4004F or these E&M codes for other therapies : 99406 or 99407

#Other Dx
-Condition - Established diagnosis New diagnosis Chronic condition controlled uncontrolled stable unstable improving worsening concern for worsening
-Treatment goal -

-Evaluation/Surveillance -

-Management -

-Referrals -

-Additional comments:

#Other Dx
-Condition - Established diagnosis New diagnosis Chronic condition controlled uncontrolled stable unstable improving worsening concern for worsening
-Treatment goal -

-Evaluation/Surveillance -

-Management -

-Referrals -

-Additional comments:

#Other Dx
-Condition - Established diagnosis New diagnosis Chronic condition controlled uncontrolled stable unstable improving worsening concern for worsening
-Treatment goal -

-Evaluation/Surveillance -

-Management -

-Referrals -

-Additional comments:

#Other Dxdx
- Established diagnosis New diagnosis Chronic condition controlled uncontrolled stable unstable improving worsening concern for worsening
-Treatment goal -

-Evaluation/Surveillance -

-Management -

-Referrals -

-Additional comments:

-Gave return precautions to include: worsening symptoms despite recommended treatment progressive intractable fever progressive pain despite recommended treatment new neuro symptoms severe intolerable side effects of medications prescribed worsening shortness of breath difficulty swallowing inability to perform ADLs other-

-Followup: with PCM with unit providerother

-Explained the above assessment and plan to patient who:

-The above SocHx/Allergies/Meds/PMHx/PSHx/FMHx were reviewed & updated at today's visit.
-The scribe/medic/nurse/student assisted in collecting and documenting the patient's history.
-I have personally reviewed it and verified its accuracy.
-The scribe/medic/nurse/student assisted in documenting the physical exam performed by me.
-I have personally reviewed it and verified its accuracy.
-Laboratory results as displayed were reviewed and interpreted
-Radiologic study results as displayed were reviewed and interpreted
-Radiologic study images which results are displayed in note were reviewed and interpreted
-Pap smear was performed and sample collected at today's visit, sample to be sent to lab for analysis

Virtual Encounter Verbage*
- Spent minutes via involving obtaining/reviewing history, conducting visual exam discussing test results discussing workup discussing above plan patient education
Links to Procedure TemplatesLaceration Repair / Toenail Removal / Minor Skin Procedures / Female Procedures / OMT/Auricular Acupuncture

PWF3a – AP MSK and Acute Conditions – Physician Workflow Part 3a

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