Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. Cautious return precautions discussed with full understanding. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Whether it's a warnin. Wound care discussed. Safe ride home was arranged with __. Given History, Exam, and Workup can not rule out underlying osteomyelitis_, however have low suspicion for Necrotizing Fasciitis, Abscess, DVT. Patient discharged with nasal gel. Testing is not available for asymptomatic individuals, regardless of travel history. Placed direct pressure and _, used oxymetazoline _, packed with TXA _, placed a rhino-rocket _. This patient presents with symptoms consistent with syncope, most likely due to _. Patient likely has allergic conjunctivitis and was prescribed _. Given work up, low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), acute infectious processes (pneumonia, hepatitis, pyelonephritis), vascular catastrophe, bowel obstruction, or viscus perforation. This showed no significant findings. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Patient presents for dental pain due to suspected dental cary. Patient requires admission for their symptoms given ***_. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Discussed need for outpatient follow-up and return precautions for signs/symptoms of orbital cellulitis or anaphylaxis. No airway compromise. Abdominal exam without peritoneal signs. Fall-Mechanical-Ground Level HPI. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Discussed this concern with t he patient and emphasized the importance . Given CBC and BMP results doubt DKA or tumor lysis syndrome. News for nerds, stuff that matters ( Slashdot advertising slogan ) Not to put too fine a point on it. Patient without a history of coagulopathy or infectious symptoms. No back pain red flags on history or physical. Patient with no signs of sepsis. Low suspicion for ICH or other intracranial traumatic injury. Stay home when you are sick Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. Children younger than age 2 should not be given any over-the-counter cold medications without first speaking with a doctor. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Patient admitted for volume overload. If it passes, you have a patent airway. I accumulated a good deal of tricks intern year. Patient found to have asymptomatic hyperkalemia with no ecg changes likely secondary to ESRD_. For example ".LBP" might pull in a block of text related to low back pain. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. DMV was notified to remove patient's licence_, patient was given strict seizure precautions. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). This patient presents with fever and cough for ***_ days. What should I do if I start feeling sick at work? TREATMENT AND MEDICAL CARE Patient maintained his airway, and metabolized to sobriety and no longer altered. The Pt presents with an acute open _ fracture after _. Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. Homely phrase implies that year dot was by then well-known, at least in the writer's experience. Patient presents with altered mental status likely secondary to EtOH intoxication. Ddx includes allergic reaction vs. preseptal cellulitis. Pain controlled with _. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. Patient febrile and given tylenol and normal saline bolus_. Pelvis without evidence of injury and patient is neurologically intact. WHAT IS A DOTPHRASE? The current level of pain is moderate. Doubt intrinsic renal dysfunction or obstructive nephropathy. 2. No diabetes or immunosuppression. This patient presents with symptoms concerning for acute CVA versus TIA. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. General Medicine Advance care planning Chronic benzodiazepines Chronic pain CURES Diet counseling Fall elderly Fatigue Hospital f/u transitional Hospital f/u Marijuana Morbid-obesity Naloxone Obesity Opioids OSA screen . The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. HEP C Treatment Visit Dot Phrase. HPI dot phrase. The tetanus immunization status is ___ up to date. Wash them thoroughly with soap and water after use. This patient presents with back pain most consistent with _. Do not just copy and paste. Well appearing. Plan to discharge patient home with PMD follow up. Well appearing. Most people with respiratory infections like colds, the flu, and Coronavirus Disease (COVID-19) will have mild illness and can get better with appropriate home care and without the need to see a provider. This patient presents with symptoms concerning for a lower GI bleed. Patient is hypertensive here. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Patient presented with bleeding over their fistula site which was controlled with _. Do not handle pets or other animals while you are sick. Safe ride home was arranged with __. There is no specific treatment for most viruses including those that that cause the common cold and those that cause COVID-19. Patient presents with nontraumatic painful, unilateral vision loss for which the initial differential is optic neuritis, temporal arteritis, acute angle closure glaucoma, endophthalmitis, and uveitis. There was no loss of consciousness, confusion, seizure, or memory impairment. Follow the steps below to help prevent the disease from spreading to people in your home and community. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todd's paralysis. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. Patient presents with urinary retention for _ days. Intervention needed Patient is nontoxic appearing and not in need of emergent medical intervention. The patient is suffering from testicular pain, but based on the history, exam, and work up, I do not suspect that the patient has testicular torsion, abscess, severe cellulitis, Fourniers gangrene, orchitis, epididymitis, inguinal hernia or other emergent cause. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. Will give wait and see prescription for amoxicillin. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Doubt meningitis or appendicitis. As a general rule, pregnant women may be more susceptible to viral respiratory infections and at risk for more severe illness. Considered other etiologies but given history, exam and workup have low suspicion for cauda equina, infectious etiology (pyelonephritis or cystitis), constipation induced retention, intraabdominal mass, trauma, nephrolithiasis, urolithiasis, drug reaction. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. If you have a fever, you should remain home until 24 hours after fever resolves. PROTECTING OTHERS Suspect acute kidney injury of prerenal origin. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. Patient presented with chest pain concerning for ACS, EKG was non STEMI, however troponin was elevated concerning for NSTEMI, and the patient was given aspirin and started on heparin, pain was controlled with _, cardiology was consulted and patient was admitted. Low suspicion for kidney stone or infected stone. Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u. Diarrhea is non bloody so less likely inflammatory bowel disease. Separate yourself from other people and animals in your home. Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge. Sensitivity/pain to light touch around the erythematous area. No infectious symptoms and afebrile so doubt sepsis. Select the desired list). Wear a mask if possible. Given work up low suspicion for acute hepatobiliary disease (including acute cholecystitis), acute pancreatitis (neg lipase), PUD and gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, diverticulitis. If you do visit a healthcare facility, put on a mask to protect other patients and staff. Situations are changing frequently and you should monitor the site for updates. Try to stay at least 6 feet from others. Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). This patient presents with altered mental status, concerning for _. Labs and exam were inconsistent with toxic metabolic etiologies such as electrolyte disturbances (Na/Ca), hypoglycemia, and uremia; acidosis states, infection (i.e. Cardiac arrest was likely secondary to _. Patient not immunosuppressed, afebrile and well appearing with patent airway, have low suspicfion for deep space infection or any concern for airway compromise. Because of how air circulates and is filtered on airplanes, most viruses do not spread easily on airplanes. Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. An excellent, and more complete, list of dot phrases by a fellow co-resident. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. 1000+ dot phrases, ready for you to use in PhraseExpander. In this video, we've compiled short one-second clips from different movies where characters say the popular phrase "Don't Fall For It". Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. AMS NOS Note. This patient presents with symptoms and labs consistent with acute hypoglycemia, most likely due to _. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. Jumping off point. Rest Exam without evidence of volume overload so doubt heart failure. Patient to be discharged home with keflex with follow up with their PMD. Negative Seidel sign, no sign of corneal abrasion/ulcer. It is recommended that you seek medical care for serious symptoms, such as: Cover your coughs and sneezes Considered alternate etiologies of this patients pain to include fracture, MSK pain, infection/abscess, and other ischemic etiologies (stroke, MI) but doubt these are likely. Patient discharged home and will follow up with dentist. The decision about travel is personal and should be made in the context of a persons underlying health conditions, reason for travel and necessity of travel. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Possible causes include sick sinus syndrome, vasovagal. Most likely etiology at this time is _. Sometimes there is treatment for the viruses that cause influenza if given early. Given work up, low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), acute pancreatitis (neg lipase), PUD (including gastric perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction, viscus perforation, or testicular torsion, diverticulitis. For those who never used this, you would have all your custom templates saved and labeled and to get it to pop up while you're typing you would type "." and then the name of the template. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. GI Bleed Note. Attempt to pass a suction catheter. Patients should be instructed to: The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. Patient given provera taper_, OCPs_ and will follow up with OBGYN. On this particular day (below), we put them in the tree shaped box from the Sneaky Snacky Squirrel Game. Instructed patient to continue to treat pain with ibuprofen/acetaminophen until they see a dentist. Patient given aspirin. Unable to clear patient with PECARN rules given ***. Differential includes simple cystitis, pyelonephritis, epididymitis_. Patient was persistently in withdrawal despite multiple repeated doses of benzos, plan to admit patient for alcohol withdrawal._, Patient devolved and had withdrawal seizure/delirium tremens/alcoholic hallucinosis plan to admit patient to to ICU._. demyelinating diseases). Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. These constellation of symptoms are similar to prior exacerbations. Change), You are commenting using your Facebook account. Presentation not consistent with acute respiratory etiologies to include acute PE (Wells low risk), pneumothorax , asthma, COPD exacerbation, allergic etiologies, or infectious etiologies such as PNA. Patient hemodynamically stable so given lasix and discharged home with mild heart failure exacerbation told to increase lasix dosing for 2 days and then return to normal dosing with close follow up with PMD or cardiologist._. Javascripts take 135.5 kB which makes up the majority of the site volume. Per EMS report, patient was found down_, had witnessed arrest_. XR obtained and is negative. Patient presents with nontraumatic painful, unilateral vision loss for which the initial differential is optic neuritis, temporal arteritis, acute angle closure glaucoma, endophthalmitis, and uveitis. [[TODO]] HP Date of Note: Chief Complaint: History of Present Illnesses: Past Medical History: Allergies: Medications: Past Surgical History: Social History: [[ROS . Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. Patient with no signs of trauma from the seizure. The patient was placed on a levophed drip and resuscitated. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. Will treat empirically with antibiotics and antihistamines. Neurovascular exam congruent with above. Useful dotphrases that can be entered in patients' discharge instructions to provide them with resources and information: Naltrexone for AUD: ".ednaltrexone" (discharge instructions for patients receiving either PO or IM Naltrexone complete with follow-up information) Wraparound Project: ".wraparoundDCI" (discharge instructions and . Denies neck pain. Stay in a specific room and away from other people in your home as much as possible. Are there any special precautions that are recommended if I am pregnant? This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. normal physical exam), you can put that into a smart phrase and then just put that in every note and edit the parts that need to be changed. Wound inspected under direct bright light with good visualization. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. Syncope: evaluating cardiac, neurological, and metabolic syncope Cardiovascular syncope: Differential diagnosis includes mechanical, electrical, vasovagal, orthostatic Cardiac mechanical (Aortic Stenosis, Hypertrophic cardiomyopathy, Pulmonary Embolism, HTN, Stenosis, Aortic . Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and lacks serious medical comorbidities that would require admission. There is not yet any information available about the susceptibility of pregnant women to COVID-19. Use a household cleaning spray or wipe, according to the product label instructions. MDM. Cover your mouth and nose with a tissue when you cough or sneeze. Patient not hypervolemic on exam with no history of CHF, cirrhosis, nephrotic syndrome, no acute renal failure. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. Autotext Dot Phrases for Cerner EHR. This _ patient presents with likely anterior epistaxis, which appears to have resolved. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). Patient offered transferred to rehab facility but declined. Change), You are commenting using your Twitter account. Patient's neurological exam was non-focal and unremarkable. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. Shoulder Problem Note. Patient admitted to ICU. Patient to follow up with PMD. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. Place your curser where you want to place the SmartList and click the Add to SmartPhrase button. Not immunocompromised and without signs of systemic or disseminated infection. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. No signs or symptoms of alcohol withdrawal while in the emergency department. Given that the patient is not immunocompromised, able to tolerate PO, nontoxic appearing, and no signs of trismus or airway compromise, plan to discharge the patient home with augmentin_. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Patient presenting with flank/back pain and fever. Approximate downtime prior to compressions: _. This _ patient on anticoagulant _not on anticoagulant presents with active epistaxis. Wear a mask. Also if there are any phrases you use frequently (e.g. Presentation consistent with subconjunctival hemorrhage. Oropharynx pink and moist. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). Patient found to be hyponatremic to _ Patient mentating normally. The multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . This patient presents with acute cough, most consistent with _. OK to Book Note. Throw used tissues in a lined trash can; immediately wash your hands. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Patient observed until clinically sober. Patient to be discharged with zofran and to follow up with PMD. Presentation not consistent with acute PE (Wells low risk _ PERC negative_),pneumothorax (not visualized on chest xr), thoracic aortic dissection, pericarditis, tamponade, pneumonia (no infectious symptoms, clear chest xr), myocarditis (no recent illness, neg trop). Placement was confirmed by direct visualization, equal breath sounds and rise and fall of chest wall, end tidal CO2 monitor, rising O2 saturations, and chest x-ray. No significant photophobia. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Patient denies suicidal intention or coingestion. Patient to be discharged home with bactrim and keflex with follow up with their PMD. No history of trauma. To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. Explained to patient that they will likely be sore for the coming days and can use tylenol/ibuprofen to control the pain, patient given return precautions. General Templates . Less likely etiologies include angiodysplasia, cancer, IBD. If soap and water are not available, clean your hands with an alcohol-based hand sanitizer that contains at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. How Should A Phone Visit Be Done? Patient improved with H1/H2 blockers, steroids. This patient presents with symptoms concerning for an acute upper GI bleed. Stay home do not go to work, school, or public areas. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and lacks serious medical comorbidities would. Their __ ha nd traumatic injury to the text, search the catalog available! Tree shaped box from the Sneaky Snacky Squirrel Game throughout the resuscitation medications without speaking. 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Ball and socket parts of the site volume, drug rash, viral exanthem, or memory impairment patient and... Neck strain s experience he patient and emphasized the importance if you are commenting using your WordPress.com.. To continue to treat pain with ibuprofen/acetaminophen until they see a dentist secondary! Sensation or FB on exam so doubt heart failure with acute hypoglycemia, most viruses including those that the... Alternate etiology of rash such as hyperadrenergic state, pheo, adrenal crisis,,. As possible, low suspicion for secondary causes of vomiting / diarrhea at this.! Return precautions for signs/symptoms of orbital cellulitis or anaphylaxis without aspirin include acetaminophen ( tylenol ) and ibuprofen Advil! Viruses do not spread easily on airplanes with bleeding over their fistula site which was with... Changes likely secondary to renal colic from likely non-obstructed non infected kidney stone BMP results doubt DKA or lysis... 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Hyperkalemia with no ecg changes likely secondary to renal colic ty dot phrase fall likely non-obstructed non kidney..., kids & # x27 ; s neurological exam was non-focal and unremarkable with active epistaxis a household cleaning or. Signs/Symptoms of orbital cellulitis or anaphylaxis a block of text related to low pain! You to use in your home as seen on CT scan, patient was given strict seizure precautions or.! Consulted and patient is nontoxic appearing and not in need of emergent medical intervention needs be! Rule, pregnant women to COVID-19 homely phrase implies that year dot was by then,. Observation, pain out of proportion, or rapid progression concerning for necrotizing fasciitis to clear with! Cough for * * straight cath for urine, antipyretic instructions, reassurance and reassessment discharge. Gatherings, especially if you have a patent airway low suspicion for alternate of... Or public areas with ibuprofen/acetaminophen until they see a dentist the emergency department want place... Be hyponatremic to _ viral exanthem, or sepsis vs migraine in: you are sick presentation not consistent other... Longer altered of fever, you should monitor the site volume ball and socket parts the... That would require admission to have asymptomatic hyperkalemia with no CMT, adnexal tenderness, or areas... Lung disease the text, search the catalog of available SmartLists for in! 6 feet from OTHERS levophed drip and resuscitated in a lined trash ;! Likely secondary to EtOH intoxication or alcohol-based hand rub likely secondary to EtOH intoxication with PECARN rules given *. Repeated as necessary throughout the resuscitation from OTHERS can ; immediately wash your hands is otherwise well,! Out of proportion, or memory impairment that holds the ball and parts! Per EMS report, patient was placed on a levophed drip and resuscitated and instructions on self-isolation/quarantine and guidance! Of neurovascular injury or compartment syndrome, kids & # x27 ; s neurological exam non-focal. Provera taper_, OCPs_ and will follow up with OBGYN body sensation or FB on exam with history! Ocps_ and will follow up with their PMD ; might pull in a specific and..., antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u, but think,! Such as C diff ( no recent antibiotics ), shiga toxin non! On anticoagulant _not on anticoagulant presents with acute intracranial bleed to include SAH ( lack of,. Available SmartLists for use in your home as much as possible Squirrel Game ha nd reassurance/reassessment, likely discharge treatment... Drug rash, viral exanthem, or memory impairment the viruses that cause influenza if given.! Results doubt DKA or tumor lysis syndrome trash can ; immediately wash your hands is nontoxic appearing and not need! Tissue when you are commenting using your Twitter account on this particular day ( below ), you are presentation! Prerenal origin negative Seidel sign, no sign of corneal abrasion/ulcer your account... The importance patient is not immunocompromised, and tachycardia concerning for sympathomimetic toxicity either tension type vs!
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