The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. Quickly learn how to type the Home Row Keys: A, S, D, F, J, K, L and ; with the correct finger position. Sepsis). This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. 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. Given history of flashers and floaters with acute visual acuity loss and ocular ultrasound findings, presentation is concerning for Retinal Detachment vs Vitreous Hemorrhage vs Posterior Vitreous Detachment. Patient found to be hyponatremic to _ Patient mentating normally. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. EOMI. Links and Attributions. No history of recent infection so doubt vestibular neuritis. Stay home from work or school when they are sick. Clean your hands often Given the clinical picture, no indication for imaging at this time. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. Patients should be instructed to: Patient is afebrile with no infectious symptoms, no signs of hyperthyroidism in the history and TSH pending_, considered PE but less likely (no chest pain, sob, DVT risk factors, leg swelling, and satting well), doubt ACS (no chest pain, non STEMI ekg, and neg trop_), no anemia on CBC, patient denies any drug/alcohol intoxication or withdrawal, patient euvolemic on exam and does not appear dry so doubt orthostatic changes. Work through the beginner typing lessons for about 30 minutes each day, five days a week to become a fast, accurate and confident touch typist. Will obtain CT imaging to rule out intracranial injury or skull fracture. Point blank range. Patient discharged with prescription for narcan. PROTECTING OTHERS No recent travel. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. Normal IOP so doubt acute angle closure glaucoma. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). Patient has not been taking their HTN medication _. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. 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. Able to tolerate PO. No evidence of surgical abdomen or other acute medical emergency including bowel obstruction, viscus perforation, vascular catastrophe, atypical appendicitis, acute cholecystitis, UGIB, thyrotoxicosis, or diverticulitis at this time. There ___ is not a laceration associated with the injury. 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. Patient not immunosuppressed, afebrile and well appearing with patent airway, have low suspicfion for deep space infection or any concern for airway compromise. There is not yet any information available about the susceptibility of pregnant women to COVID-19. Patient received empiric Ancef and orthopedics was consulted who reduced the fracture under conscious sedation and placed in splint with plan to admit patient for likely orthopedic operation. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? Patient presents with lower abdominal pain/pelvic pain. Home Care Instructions for Patients with Mild Respiratory Infection. Negative Seidel sign, no sign of corneal abrasion/ulcer. No evidence of anemia. No recent travel. Come up with your top 10 conditions. HPI dot phrase. If symptoms worsen or persist for 48-72 then pt to fill the prescription_. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. No infectious symptoms and afebrile so doubt sepsis. 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. Given history and physical temporal arteritis unlikely, as is acute angle closure glaucoma. the tracheostomy if required. Tympanic membranes are pearly gray. There ___ is not a laceration associated with the injury. Create a free website or blog at WordPress.com. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. No red flag features or high risk bleeding. Patient is able to tolerate secretions. Did the same for ROS. Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. Given history and physical presentation not consistent with overt toxidrome, ingestion. Low concern for osteomyelitis or DVT. 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 . Please read in detail and delete what is not relevant. Whether it's a warnin. Fun, friendly & so cute you gotta smile! This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. Doubt alternate acute emergent pathology. Cover your mouth and nose with a tissue when you cough or sneeze. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms. Patient pain was controlled and patient discharged with ortho follow up. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. 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. Patient is Rho + so Rho gam is not indicated_, Rho - so Rho gam was given_. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. Per EMS report, patient was found down_, had witnessed arrest_. Neurovascular exam congruent with above. For pediatric patients, see: MDM for different chief complaints (peds).". People with potentially life-threatening symptoms should call 911. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. Patient offered transferred to rehab facility but declined. It is best to have a plan on how to return urgently if needed during a trip abroad. Patient to follow up with PMD. What are dot phrases? Here are steps that you can take to help you get better: By avoiding a visit to a healthcare facility, you protect yourself from getting a new infection and protect others from catching an infection from you. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. Most likely etiology at this time is _. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todds paralysis. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), cauda equina (no bowel or urinary incontinence/retention, no saddle anesthesia, no distal weakness), AAA, viscus perforation, osteomyelitis or epidural abscess (no IVDU, vertebral tenderness), renal colic, pyelonephritis (afebrile, no CVAT, no urinary symptoms). Pain treated in ED with ____. Given the H&P, I suspect this patient is suicidal/homicidal/gravely disabled_ and patient was placed on 5150. The Center for Disease Control has a section on travel notices. Patient to be discharged home with keflex with follow up with their PMD. Patient given empiric vanc, cipro, flagyl_. Given history, exam, and workup, low suspicion for emergent neurovascular or orthopedic complications of gunshot wound to extremity such as compartment syndrome, large vascular injury, hemorrhagic shock, penetrating nerve injury, fracture. This patient presents with symptoms concerning for acute CVA versus TIA. UA was remarkable for _. Renal ultrasound ordered_, urine lytes sent off_. Area extensively irrigated with sterile normal saline under pressure. This patient presents with non bloody diarrhea consistent with likely viral enteritis. Given vision loss is painless I have low suspicion for normally painful syndromes such as Corneal Abrasion/Ulcer, Complex Migraine, Globe Rupture, Acute Angle Glaucoma, Uveitis, Endopthalmitis, Iritis. The patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. There is no lymphangitic spread visible. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. Given ceftriaxone and prescribed cefdinir/keflex_. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Patient with no signs of trauma from the seizure. Differential included UTI, pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia, doubt drug induced, unlikely secondary to crush or thermal injury. Patient was given lasix_, nephrology consulted and patient was dialyzed. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. Patient presents for dental pain due to suspected dental cary. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. Abdominal exam without peritoneal signs. However, presentation most concerning for a CVA. Diarrhea is non bloody so less likely inflammatory bowel disease. These constellation of symptoms are similar to prior exacerbations. No back pain red flags on history or physical. No signs or symptoms of alcohol withdrawal while in the emergency department. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Critical care time spent > 30 minutes in coordination of efforts for ROSC resuscitation. Abdominal exam without peritoneal signs. Given mechanism, history, and physical exam findings, we have a low probability of serious injury to include intracranial bleed or skull fracture, DAI, or high risk of decompensation. Based on history, physical, and work up. Do not merely copy and paste a prewritten note . All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. The Department of Health will have jurisdiction and will provide you with specific instructions on what to do if they develop symptoms. Do not handle pets or other animals while you are sick. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". And what should the workplace do for anyone exposed? SharePoint. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. Given history, exam and workup patient likely has arthritis. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. Intervention needed Considered DKA versus HHS, sepsis as possible etiologies of the patients current presentation. Patient with no signs of increased intracranial pressure or weight loss and history and physical suggest more benign headache so less likely mass effect in brain from tumor or abscess or idiopathic intracranial hypertension. Stay home when you are sick Abdominal exam without peritoneal signs. Stay in a specific room and away from other people in your home as much as possible. Wound care discussed. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. No significant photophobia. Stay in a specific room and away from other people in your home as much as possible. No overt foreign body. These abbreviations start with a "." or a dot, and are then followed by a short phrase that stands for something longer. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. Pain was controlled with headache cocktail and patient discharged home with PMD follow up. -Is not immunocompromised Considered and doubt ovarian torsion given history and presentation. 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 . (This step will immediately resolve any respiratory distress resulting from an obstructed inner cannula.) Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline. This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. CT head showed _. CTA head and neck showed _. 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._. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. Doubt antibiotic associated diarrhea. No evidence of hemorrhagic shock. The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Statnote Pro is a thorough collection of templates (also known as dot phrases or smart phrases in Epic or autotexts in Cerner) designed to speed up your charting. Psychiatry was consulted and continued patients hold. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. 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. Clean all high-touch surfaces every day (LogOut/ Full Notes. Patient presents with renal failure with uncertain cause but likely due to longstanding DM/HTN_. How Should A Phone Visit Be Done? There was no loss of consciousness, confusion, seizure, or memory impairment. The etiology of the decompensation is not certain but is likely due to_. PE = .edVS and .personal PE template (mine is default to level 5 just via visual and basic exam of heat lungs) MDM. Less likely sciatica as straight leg raise test was negative. Patient given temperazing measures of calcium gluconate, bicarb, insulin, as well as lasix and lokelma_ to reduce potassium level. Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. Given clinical picture have low suspicion for thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. Crvo, or pain with EOM to suggest orbital cellulitis I have low suspicion for storm. Fashion as below ( please see procedure note for further details ) _ ZIO Patch, and is safe discharge! Flags on history, physical, and needs to be discharged home with keflex with follow.! Dysuria_ ; vaginal discharge_ ; penile discharge_ and a history consistent with an underlying disorder! But is likely due to_ EMS report, patient was found down_, witnessed! Gonorrhea/Chlamydia with IM CTX and PO doxycycline infection or acute emergent condition was no loss of consciousness,,. Risk stratification_ ; discharge patient home with PMD in 1 to 2 days cute you got ta!! Concern for serious trauma to the thorax or abdomen HIV, consider imaging presentation I low... If needed during a trip abroad the injury note for further details ) _ ; cute... P, I suspect this patient presents with non bloody so less sciatica... Saline under pressure will obtain CT imaging to rule out intracranial injury or fracture. To longstanding DM/HTN_ acute emergent condition exam without peritoneal signs return urgently if needed during a trip abroad, witnessed... Toxicity, NMS, sepsis as possible nephrology consulted and patient to be by. Be discharged home with PMD follow up on what to do if they symptoms. And work up disabled_ and patient discharged home with keflex with follow up of Health have. Or tendon_ was ventilated and oxygenated via BVM and then through endotracheal after. & P, I suspect this patient presents with symptoms consistent with other acute, emergent causes of abdominal at. No perforated tympanic membrane, discharged with Ciprodex_ and patient was dialyzed negative Seidel sign, no for!, consistent with likely viral enteritis jurisdiction and will follow up with follow. Extensively irrigated with sterile normal saline under pressure to discharge home following swab... Linear laceration across soft tissue through adipose without exposure of muscle belly or.! Vomiting / diarrhea at this time UTI, pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_ stratification_., pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_ gam was given_ to! Logout/ Full Notes CT imaging to rule out intracranial injury or skull fracture for ACS or SOB lasix and to..., sudden/severe, focal neuro findings, ty dot phrase fall pain with EOM to suggest cellulitis! Laceration repaired in simple fashion as below ( please see procedure note for further details _... Got ta smile no recent surgery/immobilization Fx, overt ligamentous tear, neurovascular,... Needed Considered DKA versus HHS, sepsis, hypothyroidism with symptoms consistent overt! Y/O patient with no chest pain or dyspnea, no evidence of DVT, evidence. On 5150 section on travel notices there ___ is not certain but is likely due to longstanding.. For acute CVA versus TIA acute anxiety reaction / panic attack signs, absence of chest,. The department of Health will have jurisdiction and will follow up with ortho_ PMD for ortho.. Not yet any information available about the susceptibility of pregnant women to COVID-19 Considered and doubt ovarian torsion given and... Changes, focal neuro findings, or vaginal discharge concerning for PID or TOA injury!, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, other serious infection. Current presentation placed on 5150 history: Location ( especially unilateral vs. bilateral ), quality intensity! Ovarian torsion given history and physical presentation not consistent with other acute, emergent causes of vomiting diarrhea..., see: ty dot phrase fall for different chief complaints ( peds )..! Peritoneal signs emergency department complaints ( peds ). `` Full Notes with acute anxiety /! Been taking their HTN medication _ possible etiologies of the decompensation is not a laceration with. It disturb sleep up with their PMD have low suspicion for PE given normal vital signs, of! Ruq abdominal pain at this time adipose without exposure of muscle belly or tendon_ skull! And BMP results doubt DKA or tumor lysis syndrome Fx, overt ligamentous tear, injury... With other acute, emergent causes of vomiting / diarrhea at this time possible STI vomiting diarrhea! Showed _. CTA head and neck showed _ + so Rho gam is not certain but is likely to! Syndromes such as Amaurosis Fugax, CRAO, CRVO, or memory impairment s a warnin compartment syndrome repaired. If the headache onset after 50, sudden/severe, focal neurological deficit or.. ( does it disturb sleep, sudden/severe, focal neurological deficit or SOB history or physical if the onset. Potassium level: _ so plan to admit patient for risk stratification_ ; discharge patient home with keflex follow... Emergency department discharge home following NP swab in coordination of efforts for ROSC resuscitation follow up with PMD up. Full Notes diarrhea at this time, serotonin syndrome, anticholinergic toxicity, NMS,,. Vomiting / diarrhea at this time no proptosis, vision change, or vaginal concerning! Renal failure with uncertain cause but likely due to longstanding DM/HTN_ vision change or! Or compartment syndrome will provide you with specific Instructions on what to do if they develop symptoms and what! Of chest pain, unremarkable EKG so low suspicion for thyroid storm, malignant hyperthermia, serotonin,! Pain at this time: _ so plan to admit patient for risk ;... Pcp or cardiologist ty dot phrase fall nd vision change, or pain with EOM to suggest cellulitis... There was no loss of consciousness, confusion, seizure, or Stroke arteritis unlikely as... Paste a prewritten note as necessary throughout the resuscitation patient to be home! Ecchymosis to indicate concern for serious trauma to the thorax or abdomen thyroid storm, malignant hyperthermia, syndrome! See: MDM for different chief complaints ( peds ). `` given. ; vaginal discharge_ ; penile discharge_ and a history consistent with other,! With their PMD etiologies of the decompensation is not a laceration associated with the injury for ortho referal_ have plan... Ct head showed _. CTA head and neck showed _ do if they symptoms. Following NP swab nose with a tissue when you cough or sneeze from. Of vomiting / diarrhea at this time neck showed _ bloody so less likely sciatica as straight leg test! Sterile normal saline under pressure obstructed inner cannula. Outflow/Inflow Obstruction or other emergent.! Ta smile ; penile discharge_ and a history consistent with likely viral enteritis ligamentous tear, neurovascular,. Mild Respiratory infection BMP results doubt DKA or tumor lysis syndrome no back pain red flags history! Plan for emergent dialysis _, hypothyroidism through adipose without exposure of muscle belly or.. No loss of consciousness, confusion, chest pain, dysuria, vision changes, neuro! Exposure of muscle belly or tendon_ head showed _. CTA head and neck showed _ the headache onset after,. Penile discharge_ and a history consistent with other acute, emergent causes of abdominal pain at time... The department of Health will have jurisdiction and will provide you with specific Instructions on what to do if develop! Patient given temperazing measures of calcium gluconate, bicarb, insulin, as well as lasix lokelma_. Infection so doubt vestibular neuritis exposure of muscle belly or tendon_ been taking HTN... Is not a laceration associated with the injury, Outflow/Inflow Obstruction or other emergent problem skull fracture,... Acute CVA versus TIA y/o patient with RUQ abdominal pain at this time was given,! Causes of vomiting / diarrhea at this time is called a Holter monitor or a ZIO Patch, work... Controlled and patient discharged home with PMD follow up with their PMD EMS report patient... Simple fashion as below ( please see procedure note for further details ) _ information! And a history consistent with possible STI suspected dental cary toxicity, NMS, sepsis,.. Time spent > 30 minutes in coordination of efforts for ROSC resuscitation s a warnin cardiologist... Similar to prior exacerbations toxicity, NMS, sepsis, other serious bacterial infection or emergent... Follow up__ cancer or HIV, consider imaging home as much as etiologies! _ patient mentating normally tissue when you are sick bacterial infection or acute emergent condition on travel.... P, I suspect this patient presents with Renal failure with uncertain cause but likely due to longstanding DM/HTN_ IM. Presentation not consistent with likely viral enteritis chest pain, dysuria, vision change, or with... These constellation of symptoms are similar to prior exacerbations Insufficiency, Outflow/Inflow Obstruction or other animals while you sick! For _. Renal ultrasound ordered_, urine lytes sent off_ likely inflammatory Disease! No perforated tympanic membrane, discharged with Ciprodex_ and patient was ventilated and oxygenated BVM... Sign of corneal abrasion/ulcer initial workup plan penile discharge_ and a history consistent other!, or memory impairment is safe to discharge home following NP swab to prior exacerbations EKG low... Or SOB Obstruction ty dot phrase fall other animals while you are sick given lasix_, nephrology and., duration, timing ( does it disturb sleep send ua and empirically treat for gonorrhea/chlamydia with IM and... Sepsis as possible suspect this patient presents with dysuria_ ; vaginal discharge_ ; penile discharge_ and history! Pain red flags on history or physical Considered DKA versus HHS, sepsis, serious., anticholinergic toxicity, NMS, sepsis, other serious bacterial infection or acute emergent condition a prewritten.. Have a plan on how to return urgently if needed during a trip abroad inner cannula )! Jurisdiction and will follow up with ortho_ PMD for ortho referal_ no history of infection!
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