Evidence Based Medical Decision Making Notes and Templates

by miamidoc13 (Posted Wed Dec 04, 2013 11:47 pm)Examples:Pediatric Head Trauma@AGE@ @SEX@ presenting with head trauma. Patient's neurological exam was non-focal and unremarkable. Canadian Head CT Rule was applied and patient did not have any of the following; GCS score < 15 at 2 hours after injury, suspected open or depressed skull fracture, any sign of basilar skull fracture, 2 or more episodes of vomiting, age ≥ 65 years old, amnesia for ≥ 30 minutes of events before impact, dangerous mechanism. 100% sensitivity (95% CI 92-100%) for predicting neurological intervention (Lancet 2001 May 5;357(9266):1391). I discussed in length with the patient that based on history and physical exam findings, I did not believe that a head CT was warranted. At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. I also considered SAH, SDH, Epidural Hematoma, IPH, skull fracture, migraine but this appears less likely considering the data gathered thus far. Patient provided ***. Patient remained stable and neurologically intact while in the emergency department. Discussed warning signs that would prompt return to ED. Head trauma handout was provided. Discussed in detail concussion management. No sports or strenuous activity until symptoms free. Return to emergency department urgently if new or worsening symptoms develop. Impression: Head TraumaConcussion***Plan • Discharge from ED• Tylenol for pain control. Avoid aspirin, NSAI...
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