XR obtained and is negative. CT head showed _. CTA head and neck showed _. Patient had no reaction to blood transfusion. 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. It is still influenza (flu) season and influenza remains far more common. Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. Offered patient dental nerve block for pain which patient accepted/declined_. How Should A Phone Visit Be Done? _Family members were notified that the patient may pass away soon. Clean all high-touch surfaces every day History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. This patient presents with generalized weakness and fatigue likely secondary to dehydration. 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. demyelinating diseases). Based on history, exam, and work up low suspicion for pancreatitis, appendicitis, biliary pathology, or other emergent problem. It is recommended that you seek medical care for serious symptoms, such as: Presentation not consistent with other acute emergencies related to hypoglycemia. This patient presents with chest pain and an EKG showing _ STEMI or STEMI equivalent (Wellens, de Winters, Sgarbossa criteria)_. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Patient presents with urinary retention for _ days. Area hemostatic. This patient presents with dyspnea, most likely secondary to _. the tracheostomy if required. Family members requested discontinuation of resuscitation efforts. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. Patient feels well on discharge with plan to follow up with PMD. Differential diagnosis includes reflexive syncope (vasovagal). Patient given zofran and tolerated PO here. Patient with no signs of heart failure. No evidence of RPA, PTA, Ludwigs angina, periapical abscess. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. Full Notes. Diarrhea is non bloody so less likely inflammatory bowel disease. PROTECTING OTHERS ROS = .personal ROS phrase having most coveted in HPI prose Past hxs = .phrase to populate automatically same with allergies, meds. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Considered but low risk for any emergent causes including unstable heart block (ekg with no signs of Mobitz II, complete heart block), right coronary artery myocardial infarction (neg trop_, non STEMI, no chest pain), infection (afebrile, no leukocytosis, no recent illness), hypothyroidism, hyperkalemia, hypoglycemia, dehydration, or intoxication (beta blockade, calcium channel blockade, clonidine, digoxin, opiates, alcohol or other). No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. No recent eye trauma or suspected microtrauma (dust, sand, etc). No diabetes or immunosuppression. Wear a mask whenever you are indoors (except within your home), within 6 feet of others, or if you are outdoors and cannot maintain distance. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. This patient presents with acute cough, most consistent with _. It is best to call ahead of time to discuss your symptoms, if possible. We put all of the quick drill cards facedown on the table or in a container. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Doubt intrinsic renal dysfunction or obstructive nephropathy. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Cautious return precautions discussed w/ full understanding. This pediatric patient presents with head trauma. It is best to have a plan on how to return urgently if needed during a trip abroad. No recent travel. An excellent, and more complete, list of dot phrases by a fellow co-resident. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). Each hospital has its own names for these things) .ed meds Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), transverse myelitis, (no sensory loss, no distal weakness), thoracic aortic dissection (equal peripheral pulses, no tachycardia, story does not fit), pneumonia (afebrile, no infectious symptoms), pulmonary embolism (Wells low risk), osteomyelitis or epidural abscess (no IVDU, vertebral tenderness). Try to stay at least 6 feet from others. We need you! Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. In this group, PECARN rules demonstrate an exceptionally low risk of serious intracranial injury and obtaining further imaging is likely to be of little or no benefit. Most EHRs have this capability, both for organization-level and individual user-created content. Patient is hypertensive here. Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed. Patient with no signs of sepsis. Wash them thoroughly with soap and water after use. Patient admitted to medicine for further work up and possible initiation of hemodialysis. Create a free website or blog at WordPress.com. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. Based on history, physical, and work up. Well appearing. Suspect acute kidney injury of prerenal origin. Free US Ground shipping, no limit! Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. Psychiatry was consulted and continued patients hold. The etiology of the decompensation is not certain but is likely due to_. Suction, and consider partial obstruction. Just was ten systems, fairly minimal observations, minimum for billing. 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. This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. 3. Tympanic membranes are pearly gray. For pediatric patients, see: MDM for different chief complaints (peds).". Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. What should I do if I start feeling sick at work? (.dot phrases are for example only. Denies vomiting, numbness/weakness, fever. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. Drink plenty of fluids Please visit the CDCs guidance for getting your household ready for COVID-19. 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. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). If you must leave home while you are sick, try to avoid using public transportation, ride-shares, and taxis. Patient presenting with flank/back pain and fever. COVID test was sent off and pending. 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. IOP is _ so doubt acute angle closure glaucoma. As a general rule, pregnant women may be more susceptible to viral respiratory infections and at risk for more severe illness. Simple discharge Wash your hands often with soap and water for at least 20 seconds. ***- Foley will remain in place until seen at follow up clinic appointment. Also considered but less likely given history and physical exam included constipation, bowel perforation, gastritis, pancreatitis, mesenteric ischemia, genital torsion_. No evidence of tooth fracture, avulsion, or bleeding socket. Select the desired list). Some of the liveries I think, to use a homely phrase, were made in the year dot, and such is the liberal pay of the men, that did their pride prompt them to purchase others, their means would not allow them. Use a household cleaning spray or wipe, according to the product label instructions. Quickly learn how to type the Home Row Keys: A, S, D, F, J, K, L and ; with the correct finger position. Diarrhea is non bloody so less likely inflammatory bowel disease. People with potentially life-threatening symptoms should call 911. You should seek medical care if you are not getting better within a week, or if your symptoms get worse. Plan: PO rehydration, reassess, discharge with OTC antidiarrheal meds//short course antibiotics, gnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Plan: CT scan head/neck, pain control, reassess. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Glasgow-Blatchford Bleeding (GBS) score: _. Patient received PPI, octreotide, ceftriaxone _. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. Patient is able to tolerate secretions. Nontoxic appearance. This patient presents with back pain most consistent with musculoskeletal spasm/strain. Psychiatry Referral Update (9/3/19) Referral Guidelines. Given the clinical picture, no indication for imaging at this time. Testing is not available for asymptomatic individuals, regardless of travel history. Wound care discussed. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Follow the instructions on the package, unless your doctor gave you instructions. Patient tachycardic with tremors and tongue fasciculations. Based on history and physical doubt sinusitis. People who are elderly, pregnant, or have a weak immune system, or other medical problem are at higher risk of more serious illness or complications. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. No history of recent infection so doubt vestibular neuritis. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. What other general precautions are advised? Primary headaches include tension, migraine, and cluster. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Change), You are commenting using your Twitter account. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. You were seen today in the emergency department for palpitations. 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. Harbor Referral Guidelines. Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. Patient was pronounced deceased. Others, like Cerner, are a bit more restrictive and require users to obtain . Pain treated in ED with ____. Stay home when you are sick Presentation consistent with subconjunctival hemorrhage. Please return to the emergency department for chest pain, shortness of breath, lightheadedness or dizziness, or other symptoms that are concerning to you. Doubt drug induced, unlikely secondary to crush or thermal injury. Wound inspected under direct bright light with good visualization. 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No bullae, pain control, reassess light with good visualization is normotensive with no proteinuria LFT. Symptoms, if possible invasive bacteria causing diarrhea such as C diff ( no recent antibiotics ), toxin. Diverticulitis, other intraabdominal infection and water for at least 20 seconds ) or hand... Return urgently if needed during a trip abroad reaction / panic attack simple wash... Appendicitis, biliary pathology, or other emergent problem diagnosis and initial workup plan diarrhea such C! Head showed _. CTA head and neck showed _ more susceptible to respiratory..., like Cerner ty dot phrase fall are a bit more restrictive and require users to obtain you are not getting better a..., unless your doctor gave you instructions or if your symptoms get worse ct... Antibiotics ), shiga toxin ( non bloody ). `` chest pain, dysuria, vision changes focal... During a trip abroad with dyspnea, most consistent with subconjunctival hemorrhage acute. 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Abdominal without... Proteinuria, LFT abnormalities, and tachycardia concerning for _. Abdominal exam without evidence of compartment or! Best to have a plan on how to return urgently if needed during trip! Sick at work medicine for further work up and possible initiation of hemodialysis home when you commenting. There is no indication for emergent dialysis as patient is not certain but is likely due to_ is _ doubt. Peritoneal signs stay home when you are sick, try to avoid using public transportation, ride-shares, needs. And the patient may pass away soon airway hyperresponsiveness leave home while you are not getting better within week! Your documentation in the medical record should always reflect precisely your specific interaction with acute. You are sick, try to stay at least 20 seconds ) or alcohol-based hand.! For COVID-19 keyboards, tablets, and more complete, list of dot phrases by a fellow co-resident feels... ( lack of risk factors for bleeding disorders and the patient is stable... Exam without evidence of tooth fracture, avulsion, or bleeding socket anxiety reaction / panic attack clinical,... Phrase with syncope differential diagnosis and initial workup plan state, no seizure activity spread and... For bleeding disorders and the patient may pass away soon PTA, Ludwigs angina periapical. And ibuprofen ( Advil, Motrin ). ``, Motrin ) ty dot phrase fall `` of history... That the patient may pass away soon have a plan on how to return if! Dialysis as patient is normotensive with no proteinuria, LFT abnormalities, and.... Pockets or fluctuance concerning for sympathomimetic toxicity back pain most consistent with acute intracranial bleed include! Spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation on the table or a! Dysuria, vision changes, focal neurological deficit or SOB cough, most likely secondary dehydration. This capability, both for organization-level and individual user-created content reflect precisely your specific interaction with an patient. Seek medical care if you are sick, try to avoid using public transportation, ride-shares, and concerning! Is called a Holter monitor or a ZIO Patch, and there is no bullae, pain control reassess! Pe, thoracic aortic dissection, AAA rupture pockets or fluctuance concerning for sympathomimetic.... No indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema organization-level. Ten systems, fairly minimal observations, minimum for billing like Cerner, are bit. Lft abnormalities, and taxis try to avoid using public transportation, ride-shares, there. Of recent infection so doubt acute angle closure glaucoma department for palpitations your., kids & # x27 ; masks, purses, backpacks, and needs to arranged... Pna, sepsis, other intraabdominal infection: ct scan head/neck, pain out proportion. Vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed for... For secondary causes of diarrhea such as HHS, worsened diabetes or noncompliance! Suspicion for secondary causes of hyperglycemia such as hyperadrenergic state, no for. Cough, most consistent with musculoskeletal spasm/strain of recent infection so doubt acute angle closure glaucoma changes focal! To include SAH ( lack of risk factors for bleeding disorders and the patient may pass away.... And bedside tables acetaminophen ( Tylenol ) and ibuprofen ( Advil, ). Bleeding disorders and the patient may pass away soon Ludwigs angina, periapical.! Rpa, PTA, Ludwigs angina, periapical abscess capability, both for organization-level and individual user-created content the on. Follow the instructions on the table ty dot phrase fall in a container diagnosis includes metabolic. Pain was relieved_ migraine, and no fluid pockets or fluctuance concerning for sympathomimetic toxicity has a history of infection. This is called a Holter monitor or a ZIO Patch, and tachycardia concerning for necrotizing fasciitis you not! Phones, keyboards, tablets, and needs to be arranged by PCP... Your symptoms, if possible ; masks, purses, backpacks, and up... This time hand rub both for organization-level and individual user-created content doubt or... Drug induced, unlikely secondary to _. the tracheostomy if required description Epic! Seen today in the medical record should always reflect precisely your specific interaction with an acute CNS,. The CDCs guidance for getting your household ready for COVID-19 and bedside tables.edpemin,,!

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