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Clerking Patients: A few tips

Mind The Bleep

Have a proforma so you don’t miss things Save a proforma (if electronic documentation ) or print one out. If they are dehydrated: give fluids; if they are in pain: give analgesia ; if theres an infection of unknown source: do a thorough examination & take cultures and samples from everywhere you can.

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Medical Malpractice Insights: Brain Abscess

EMDocs

He has been ill for 3 days with abdominal pain, fever, diarrhea, and vomiting, and his father thinks his son is dehydrated. Exam documents that he is alert and oriented but “tired appearing” and “not appearing post-ictal.” Defense : The EP did address the seizure when he documented “not post-ictal.” EM is a “team sport.”

Seizures 101
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Cerebral Edema and Diabetic Ketoacidosis: Rebaked

Pediatric EM Morsels

Kids < 5 years of age New onset of diabetes at presentation Longer duration of symptoms Severity of acidosis Elevated BUN Greater degree of dehydration and hyperventilation Cerebral Edema and DKA: Diagnostic Considerations Early detection and treatment is the best means to prevent brain injury and death.

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Medical Malpractice Insights: A Rare Presentation – Groin pain? Nec fasc? Diabetes? Appendicitis?

EMDocs

Exam is normal except for tenderness as documented in the diagram. She never had a documented abdominal exam. She had no persistent vomiting, was not dehydrated and had no fever. I just failed to document it. The EP documented seeing the patient and agreed with the ARNP’s plan. Temp is 98.7 and pulse 121.

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Failure to thrive

Don't Forget the Bubbles

Failure to thrive’ has many definitions We use standardized charts to document infant growth. Are there signs of significant dehydration or malnutrition? If severely dehydrated or malnourished, then they require admission for close monitoring with rehydration and refeeding. First and foremost, do they look well or unwell?

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EQUAL: a Straightforward Approach To Caring for Disabled Patients

ACEP Now

This makes documentation and communication of the utmost importance for these patients for their health and safety. Oftentimes, it can be an indication of pain, infection, distress, anxiety, dehydration, or the first sign of sepsis. This leads into the next part of the model—Assessment. One commonly used example is tachycardia.

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Behavioural and Psychological Symptoms of Dementia (BPSD)

Mind The Bleep

ICD-10 codes: F00-03 are the ICD codes for dementia and its subtypes F02. environmental factors, pain, infection, dehydration, electrolyte disturbance, head injury, medication etc) Does the individual have capacity? This article outlines the main factors related to the presentation, aetiology, and treatment of BPSD.