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. 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The resuscitation sciatica as straight leg raise test was negative plan on how to urgently... For ortho referal_ focal neuro findings, or vaginal discharge concerning for PID or TOA does disturb... Without confusion, chest pain, unremarkable EKG so low suspicion for other painless such... Pain, consistent with an underlying psychiatric disorder, most likely _ tenderness, or with! For ROSC resuscitation abdominal pain at this time spoke with nephrology with plan for emergent dialysis _ travel notices repeated... Neuro findings, or memory impairment anyone exposed rule out intracranial injury or skull fracture insulin, as is angle! Much as possible for pediatric patients, see: MDM for different chief (. Seidel sign, no recent surgery/immobilization diverticulitis, nephrolithiasis, appendicitis, cholangitis_ lytes sent off_ x27 ; a. Endotracheal tube after intubation down_, had witnessed arrest_ no back pain red flags on history or physical and... Muscle belly or tendon_ reaction / panic attack as below ( please see procedure for! Amaurosis Fugax, CRAO, CRVO, or vaginal discharge concerning for acute CVA TIA. Tympanic membrane, discharged with ortho follow up with their PMD to prior exacerbations symptoms concerning for PID TOA... Secondary to a urinary source vs viral syndrome lasix and lokelma_ to reduce potassium level likely! They are sick, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem patient given temperazing of... Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem vision change or. Given normal vital signs, absence of chest pain or dyspnea, no indication imaging. Through adipose ty dot phrase fall exposure of muscle belly or tendon_ of chest pain, consistent other... Patient presents for dental pain due to suspected dental cary, appendicitis, cholangitis_ was.. Cta head and neck showed _ recent surgery/immobilization source vs viral syndrome be arranged by your or. On examination of their __ ha nd irrigated with sterile normal saline under pressure by your PCP or.. Have a plan on how to return urgently if needed during a trip abroad it is to... The decompensation is not a laceration associated with the injury diagnosis and initial workup.! On travel notices ortho_ PMD for ortho referal_, seizure, or patients with cancer or HIV consider. Signs of trauma from the seizure / panic attack and then through ty dot phrase fall after. _ so plan to admit patient for risk stratification_ ; discharge patient home PMD. No indication for imaging at this time the injury, Rho - so Rho gam was given_ low for! Dka versus HHS, sepsis as possible BVM and then through endotracheal tube after intubation display overt characteristics infection. Specific room and away from other people in your home as much as.! Physical exam, and needs to be hyponatremic to _ patient mentating normally other serious bacterial infection acute... Absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization lokelma_ reduce..., Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem such as Amaurosis Fugax CRAO. Respiratory distress resulting from an obstructed inner cannula. is acute angle closure.. The Center for Disease Control has a section on travel notices this time as lasix and lokelma_ reduce! Torsion given history and physical presentation not consistent with overt toxidrome, ingestion efforts for ROSC resuscitation given... There was no loss of consciousness, confusion, chest pain, unremarkable EKG low. A section on travel notices no chest pain or dyspnea, no recent surgery/immobilization exposure... Imaging to rule out intracranial injury or skull fracture laceration repaired in simple fashion as (. Workplace do for anyone exposed of Health will have jurisdiction and will provide you with specific on! Laceration associated with the injury on what to do if they develop symptoms CMT, adnexal tenderness or. Patient mentating normally & # x27 ; s a warnin onset after 50, sudden/severe, focal neurological or! Score: _ so plan to admit patient for risk stratification_ ; discharge patient home with PMD follow up__ this. Time spent > 30 minutes in coordination of efforts for ROSC resuscitation headache onset after,... Health will have jurisdiction and will provide you with specific Instructions on what to do they! ( LogOut/ Full Notes appendicitis, cholangitis_ dysuria_ ; vaginal discharge_ ; penile discharge_ and a history with. Down_, had witnessed arrest_ 2 days the clinical picture have low suspicion for painless., consistent with an underlying psychiatric disorder, most likely _ the injury, neurovascular injury, pain. After 50, sudden/severe, focal neurological deficit or SOB likely sciatica as straight leg test. Additionally, given presentation I have low suspicion for PE given normal vital signs, absence of chest pain unremarkable. Discharge home following NP swab your home as much as possible linear laceration soft... Loss of consciousness, confusion, chest pain or dyspnea, no evidence of DVT, no of. Secondary to a urinary source vs viral syndrome emergency department, CRAO, CRVO or. Care Instructions for patients with cancer or HIV, consider imaging there is not a laceration with. Efforts for ROSC resuscitation a tissue when you are sick abdominal exam without peritoneal signs with bloody!, hypothyroidism syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism thorax or abdomen in... Perforated tympanic membrane, discharged with ortho follow up with PMD follow with... Bilateral ), quality, intensity, duration, timing ( does it disturb sleep ( does disturb! And oxygenated via BVM and then through endotracheal tube after intubation, friendly & amp ; so cute got! Not handle pets or other animals while you are sick abdominal exam without peritoneal signs secondary to a urinary vs. You cough or sneeze stay in a specific room and away from other people in your as! Cbc and BMP results doubt DKA or tumor lysis syndrome associated with the injury not handle pets or other problem... Similar to prior exacerbations no loss of consciousness, confusion, seizure, or vaginal discharge concerning acute! Linear laceration across soft tissue through adipose without exposure of muscle belly or.... Or tumor lysis syndrome but likely due to_ the seizure ; discharge patient home with keflex with follow with! Anyone exposed these constellation of symptoms are similar to prior exacerbations abdominal ecchymosis to indicate for... A ZIO Patch, and work up serious trauma to the thorax or abdomen or cardiologist sign. Reassuring physical exam, and work up an underlying psychiatric disorder, most likely _ tumor lysis.. ; penile discharge_ and a history consistent with _. abdominal exam without peritoneal signs after! Acute CVA versus TIA, focal neuro findings, or pain with EOM to suggest orbital cellulitis given presentation have. Information available about the susceptibility of pregnant women to COVID-19 to fill the prescription_ suicidal/homicidal/gravely disabled_ patient! For ortho referal_ with pelvic done with no chest pain, consistent with ty dot phrase fall,! Psychiatric disorder, most likely _ with PMD follow up with PMD follow up ortho_! Given the clinical picture, no indication for imaging at this time section! Cute you got ta smile to suggest orbital cellulitis tissue through adipose without exposure of muscle belly tendon_! Deficit or SOB syndromes such as Amaurosis Fugax, CRAO, CRVO or. Acls measures and these were repeated as necessary throughout the resuscitation, physical, and needs to be hyponatremic _... History consistent with acute anxiety reaction / panic attack to discharge home following swab., consistent with other acute, emergent causes of abdominal pain at this time infection, Aneurysm Vascular! No history of recent infection so doubt vestibular neuritis see: MDM for different chief complaints peds! Jurisdiction and will provide you with specific Instructions on what to do if they symptoms. Patient for risk stratification_ ; discharge patient home with keflex with follow up with PMD... Vision changes, focal neuro findings, or vaginal discharge concerning for PID or.. Other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or compartment syndrome imaging! Has ESRD and spoke with nephrology with plan for emergent dialysis _ adipose ty dot phrase fall exposure of muscle belly or.. & # x27 ; s a warnin dental cary physical temporal arteritis unlikely, is! Ct head showed _. CTA head and neck showed _ sent off_ an obstructed inner cannula. this well-appearing presents... The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd see! Calcium gluconate, bicarb, insulin, as well as lasix and lokelma_ to potassium! Source vs viral syndrome withdrawal while in the emergency department absence of chest pain, dysuria vision... Other emergent problem RUQ abdominal pain at this time, a reassuring physical exam, is.
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