Notes

Follow Up on AMA patients this weekend at Noblesville South- quick summary 2 refused test in the ER and signed out AMA- physicians did treat suspected infection and arranged follow up. Two patients refused admission to the hospital and signed out AMA- more details on each one below. I included MD’s decision making from each patients chart.


1.MRN 1014331 Dr. Steck was attending- 10 year old boy with sore throat and painful lymph node on side of neck was seen at Urgent care and had negative strep test- patient also had recent travel to Central America-


· Medical Decision Making




I discussed with mother my suspicion for reactive lymphadenopathy to left otitis media. Discussed that I cannot fully exclude a more deep seeded infection or possible mass without performing CT scan. Discussed I would recommend checking labs to evaluate for abnormalities in blood counts. Mother and patient decline to have this recommended testing performed. I discussed the risks of foregoing recommended testing. These risks included death, missed diagnosis, or permanent disability. Mother and patient understood this and chose to forego recommended testing. Patient mother choosing to leave AGAINST MEDICAL ADVICE. Discussed that we will treat otitis media with amoxicillin and patient is to follow-up with primary care provider. All questions and concerns addressed with patient and mother in emergency department. They are given detailed return to ER instructions.


2.MRN 1014356 Dr. Steck was attending- 53year old female presents with bilateral ankle swelling and pain- has know RA and on Humeria for this and has oxycodone at home for this pt refused other test to r/o blood clot or any other causes of above stated issues and signed out AMA


· Medical Decision Making




Discussed with patient my suspicion that this is a component of her rheumatoid arthritis. However, I discussed that I would recommend performing additional testing to evaluate for other ongoing processes. Recommended ultrasounds of bilateral lower extremities, labs, x-ray, and possible treatment for symptoms. However patient declines to have these things performed. I discussed the risks of foregoing recommended testing. These risks included missed diagnosis, death, or permanent disability. Patient verbalized understanding of these risks and chose to forego recommended testing. I gave patient detailed return to ER instructions. Struck the patient regarding the importance of follow-up with her rheumatologist and primary care clinic. Patient reports having ample oxycodone pain medications at home for pain.





This patient is choosing to leave against medical advice. The EP has personally explained to the patient that choosing to do so may result in permanent bodily harm or death. The EP discussed at great length that without further evaluation and monitoring there may be unforeseen circumstances and/or deterioration causing permanent bodily harm or death as a result of the patient's choice. The patient verbalized these risks back to the physician in layman’s terms. The patient is alert, oriented, and shows the mental capacity to make clear decisions regarding the patient's health care at this time. The patient continues to wish to leave against medical advice.



In light of the patient's decision to leave AMA, follow-up has been arranged and the patient is aware of the importance of following up as instructed. The patient has been advised that she should return to the ED immediately if she changes her mind at any time, or if her condition begins to change or worsen in any way.
3.MRN 1014372 Dr. Torres was the attending- this is a 50 year old mane presents with alcohol withdrawal and Abdominal pain- CT revealed mild ileus and despite Ativan was concerned of alcohol withdrawals


· Decision to Admit Based On




Multiple re-evaluations: Patient's blood pressure did come down with the Ativan and other medication given here in the emergency room. His amylase and lipase were within the normal limits as well as his bilirubin but his liver function tests were mildly elevated which could be consistent with the alcoholism. Patient CT scan did show a mild small bowel ileus which was concerning and due to the fact that he still has some persistent pain I have recommended that we admit him to the hospital for the small bowel ileus bowel rest and for further treatment of his mild withdrawal symptoms. His CIWA score that I calculated came back at 11 that did not improve with the Ativan. At this point time patient states he still had some abdominal pain has still felt shaky. Again I did offer to admit him multiple times but he declined. I did give him time for him to talk it over with his wife and after that time. He is still declining admission to the hospital. I did explain to him that alcohol withdrawal can kill but is very concerning and that if he continues to quit drinking that he needs to be done under medical supervision and I strongly urged him to follow-up with his primary care physician tomorrow. As for the small bowel ileus I have recommended that he stick to a liquid diet and have given a prescription for Zofran as well. I am concerned that his condition could get worse and this could lead into an obstruction. He was aware of this and still signing out AGAINST MEDICAL ADVICE. He understands that he can return to the emergency room at any point in time or any worsening of symptoms. Patient is being discharged AGAINST MEDICAL ADVICE and guarded/serious condition.


4.MRN 1005682 Dr. Bradenburg was attending- 41year old male presents to ER with chest pain had negative work up but had been seen a month prior with same complaint. Case was discussed with Dr. Price cardiology that suggested admission with cardiac r/o. and close follow up with cardiology. PA Bridgette called and accepted admission and patient refused admission and choose to leave AMA.




· MD Notes / Patient Care Notes: 1418: NAD. Pt wants to leave AMA. Myself and the RN spent quite a bit of time trying to convince him to stay. So did his girlfriend. He understands the risks of leaving AMA and why I think he should not. He is going to consider it for a few more minutes. I will re-check him shortly.

1426: He's still wants to leave AMA and understands the risks. He agrees with getting repeat markers now just to be a little more certain that this is not an ACS. He still understands all the risks of leaving AMA and is willing to accept them. I will give him PCP f/u and have asked him to see them ASAP and to return here for more symptoms or if he changes his mind.

1456 : NAD. Repeat Troponin is negative. He still refuses admission. He says he will take a daily ASA & stop smoking.He will sign AMA paperwork. I went over all instructions with the patient & the need for follow-up. I also went over the reasons to immeditaly return to the ED or see a doctor for. The patient understands. The patient understands all this.



This patient is choosing to leave against medical advice. The EP has personally explained to the patient that choosing to do so may result in permanent bodily harm or death. I discussed at great length that without further evaluation and monitoring there may be unforeseen circumstances and/or deterioration causing permanent bodily harm or death as a result of the patient's choice. The patient verbalized these risks back to the physician in layman’s terms. The patient is alert, oriented, and shows the mental capacity to make clear decisions regarding the patient's health care at this time. The patient continues to wish to leave against medical advice.



In light of the patient's decision to leave AMA, follow-up has been arranged and the patient is aware of the importance of following up as instructed. The patient has been advised that he should return to the ED immediately if he changes his mind at any time or if his condition begins to change or worsen in any way.