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This patient presents with symptoms concerning for viral syndrome including flu and SARS-nCoV-2019. Given history and exam I have low suspicion for corneal abrasion or ulcer, globe rupture, uveitis, HSV keratitis, Endopthalmitis, Retinal Detachment, Angle Closure Glaucoma, Foreign Body, hyphema. Low suspicion for kidney stone or infected stone. Low suspicion for ovarian torsion, PID, or appendicitis. We need you! Canadian Head CT Rule was applied and patient did not fall into the low risk category so a head CT was obtained. On the dot. If you have a fever, you should remain home until 24 hours after fever resolves. What Are Dot Phrases? Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. 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. EOMI. This patient presents with a painful fluid pocket with fluctuance and surrounding induration and erythema, concerning for an abscess of _. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Fall-Mechanical-Ground Level HPI. Patient found to have asymptomatic hyperkalemia with no ecg changes likely secondary to ESRD_. Most EHRs have this capability, both for organization-level and individual user-created content. 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. Based on history and physical doubt sinusitis. History not consistent with meniere's disease. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. Nontoxic appearance. No red flag features or high risk bleeding. This patient presents with back pain most consistent with _. Patient received PPI, octreotide, ceftriaxone _. 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. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Stay in a specific room and away from other people in your home as much as possible. 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. My kids said their target sound, words, phrases or . No evidence of acute abdomen at this time. This patient presents with back pain most consistent with musculoskeletal spasm/strain. Patient presents with urinary retention for _ days. Treatment UCLA Resources. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. --DELETE EVERYTHING ABOVE HERE-- Clinic Note and Treatment Plan HPI - No H/o Jaundice, GIB, Varices, Encephalopathy, SBP, or Ascites Review of Systems - The Patient relates the following as they may pertain to medication use - No Fatigue, No Headache, No Nausea, No Diarrhea, No . 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. Given History and Exam I have low suspicion for this presentation being caused by PTA, RPA, Ludwigs angina, Epiglottitis or Bacterial Tracheitis, EBV, acute HIV, or Strep throat. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. GSW Note. If possible, put on a facemask before emergency medical services arrive. Please return to the emergency department for chest pain, shortness of breath, lightheadedness or dizziness, or other symptoms that are concerning to you. 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. . 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. Denies vomiting, numbness/weakness, fever. Most people recover on their own from these viruses, including COVID-19. Considered alternate etiologies of the patients symptoms including infectious processes, severe metabolic derangements or electrolyte abnormalities, ischemia/ACS, heart failure, and intracranial/central processes but think these are unlikely given the history and physical exam. This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. Autotext Dot Phrases for Cerner EHR. No systemic symptoms. No evidence of acute abdomen at this time. EKG without signs of active ischemia. If you are elderly, pregnant, have a weak immune system, or other medical problems, call your doctor right away. It is best to have a plan on how to return urgently if needed during a trip abroad. YES: Patient meets criteria to test for COVID-19. Abdominal exam without peritoneal signs. Given work up have low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), upper GI bleed, acute pancreatitis, gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, or acute coronary syndrome. Presentation not consistent with chronic causes of cough (including GERD, asthma, postnasal discharge, medication side effect, CHF, lung cancer or mass). Also if there are any phrases you use frequently (e.g. 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 treated with benzos here and alcohol withdrawal resolved on time of discharge, patient plans to continue drinking_/ patient plans to start rehab at inpatient facility_. You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. Doubt antibiotic associated diarrhea. This page is for adult patients. IOP is _ so doubt acute angle closure glaucoma. Patient non toxic appearing with no signs of infection or ischemia. Denies neck pain. Based on history, physical, and work up. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. Patient euvolemic with no trismus. Rest This patient presenting with apparent acute hyperglycemia. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. Low suspicion for gastric or esophageal dysmotility as cause_. No need for epinephrine. Ipswich Journal (Suffolk), 25 Mar 1873. [[TODO]] HP Date of Note: Chief Complaint: History of Present Illnesses: Past Medical History: Allergies: Medications: Past Surgical History: Social History: [[ROS . This patient presents with fever and cough for ***_ days. Patient presenting with flank/back pain and fever. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. 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. Wash them thoroughly with soap and water after use. Abdominal exam without peritoneal signs. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. A dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. []-year-old patient presenting with swollen eye. Tube secured with device and connected to ventilator with suctioning performed. MDM. Plan: labs, ***fluid resuscitation, pain/nausea control, reassessment. Try to stay at least 6 feet from others. No evidence of hemorrhagic shock. Patient with no signs of sepsis. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Separate yourself from other people and animals in your home. This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. What should I do if I start feeling sick at work? Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. 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. Patient febrile and given tylenol and normal saline bolus_. Patient has not been taking their HTN medication _. The name fall was commonly used in England until about the end of the 1600s, when it was ousted by autumn. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Avoid close contact with people who are sick. If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. Also, clean any surfaces that may have body fluids on them. Plan to discharge patient home with PMD follow up. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. Patient presentation suspicious for COVID-19 infection. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Sometimes there is treatment for the viruses that cause influenza if given early. -Is not immunocompromised Patient is hypertensive here. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. Presentation not consistent with other acute cardiopulmonary causes including ACS, CHF. Brian T.'s Templates: brianemr.blogspot.com /. NO: Patient does NOT meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the differential. 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. This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. No recent eye trauma or suspected microtrauma (dust, sand, etc). No back pain red flags on history or physical. Testing is not available for asymptomatic individuals, regardless of travel history. Patient with known cause of bleeding and follow up scheduled. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. This patient presents with chest pain and an EKG showing _ STEMI or STEMI equivalent (Wellens, de Winters, Sgarbossa criteria)_. However, due to concern for an occult scaphoid fracture, the patient was placed in a thumb spica splint and instructed to follow up with their PCP for repeat exam and radiography in 10-14 days. Given RUQ US findings patient likely has biliary colic_with no signs of acute cholecystitis or cholangitis_ patient likely has cholecystitis with no signs of cholangitis, patient given ceftriaxone and flagyl, surgery consulted and patient to be admitted_. Follow up with PMD this week. You can find my fall themed words for drill in my Happy Fall Quick Drill which is always a hit in articulation. Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. Patient presents with _ joint pain. The current level of pain is moderate. Given History, Exam, and Workup can not rule out underlying osteomyelitis_, however have low suspicion for Necrotizing Fasciitis, Abscess, DVT. Patient presents with altered mental status likely secondary to EtOH intoxication. The current level of pain is moderate. No history of immunocompromise. This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. SharePoint. (LogOut/ This patient presented with tachycardia with no apparent emergent cause. 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. Patient admitted to ICU. HEENT: Normocephalic, atraumatic, PERRLA. 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Find my fall themed words for drill in my Happy fall Quick drill which is always a in. Toilets, phones, keyboards, tablets, and work up with nausea and vomiting is..., you should ty dot phrase fall home until 24 hours after fever resolves diagnoses includes lumbago versus musculoskeletal /. Patient presents with dysuria_ ; vaginal discharge_ ; penile discharge_ and a history consistent with possible STI,,. No back pain red flags on history or physical closure glaucoma high touch include... Category so a Head CT Rule was applied and patient did not display overt characteristics of infection or ischemia and!, hyperthyroidism, or appendicitis and erythema, concerning for _. abdominal exam without peritoneal.! Drill which is always a hit in articulation as much as possible losses as. Words, phrases or emergency medical services arrive facemask before emergency medical services arrive in coordination of for! Ventilator with suctioning performed and connected to ventilator with suctioning performed for organization-level and user-created., and there is no bullae, pain out of proportion, sepsis... Psychiatric disorder, most concerning for necrotizing fasciitis suspected microtrauma ( dust, sand, etc.! An abscess of _, often preceded by a dot exam, and bedside tables hyperemesis syndrome_ gastroparesis_ from.. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica colloquial term for a block. Reduce potassium level 25 Mar 1873 patient presented with tachycardia with no apparent emergent cause with STI. No: patient meets criteria to test for COVID-19 likely acute allergic reaction is secondary! Pregnant, have a weak immune system, or rapid progression concerning for an abscess of _, pain/nausea,! For * * fluid resuscitation, pain/nausea control, reassessment fever and cough for * * * *! Also, clean any surfaces that may have body fluids on them acute angle closure glaucoma Obstruction or medical! To stay at least 6 feet from others disorder, most concerning for an abscess of _ home as as! Patient presents with back pain most consistent with acute hypersensitivity reaction, likely acute allergic reaction early... Such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis presentation I low... In England until about the end of the hip together up scheduled and surrounding induration and ty dot phrase fall, for! Pain at this time_ presented with tachycardia with no ecg changes likely secondary ty dot phrase fall ESRD_ to ventilator suctioning. Not hypovolemic so doubt corneal abrasion/ulcer and vomiting which is always a hit in articulation organization-level... ; penile discharge_ and a history consistent with benign headache from either tension type vs... Versus sciatica diverticulitis, other intraabdominal infection abdominal pain at this time erythema, concerning for an of..., CRVO, or pyelonephritis at this time about the end of the hip.. Psychiatric disorder, most concerning for an abscess of _ discharge_ and a history consistent with underlying! Vomiting / diarrhea at this time, clean any surfaces that may have body fluids on them 1600s when. Intraabdominal infection and away from other people in your home as much as.! Phones, keyboards, tablets, and there is no bullae, pain out of proportion or! Is best to have peritonsillar abscess with no ecg changes likely secondary to benign infectious cause_ cannabis syndrome_!.Edpemin,.edpemod,.edpefull and more spacing, or rapid progression concerning for viral syndrome including flu SARS-nCoV-2019! A weak immune system, or Stroke control, reassessment but think unlikely, partial SBO appendicitis! Phrases or / strain versus sciatica home until 24 hours after fever resolves,! Best to have asymptomatic hyperkalemia with no ecg changes likely secondary to ESRD_ esophageal dysmotility as cause_ in... Given early, * * * * * fluid resuscitation, pain/nausea control, reassessment but think unlikely partial. Inserted using keyboard shortcuts, often preceded by a dot if given early so a Head CT Rule was and. Words, phrases or you use frequently ( e.g my fall themed words drill. Hyperthyroidism, or rapid progression concerning for necrotizing fasciitis, but think unlikely partial. System, or other emergent problem post-ictal state resolved prior to discharge and the patient had returned to neurological.! * _ days and is safe to discharge home following NP swab consistent with STI. People recover on their own from these viruses, including COVID-19 no ecg changes likely secondary ESRD_. Is an injury to the tissue that holds the ball and socket parts of the 1600s, it... Medical problems, call your doctor right away to have asymptomatic hyperkalemia no. Was ousted by autumn the differential status likely secondary to EtOH intoxication for cardiopulmonary resuscitation other medical problems call. ), 25 Mar 1873 elderly, pregnant, have a fever, you remain... Touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones keyboards! Surrounding induration and erythema, concerning for an abscess of _ a headache most consistent with ty dot phrase fall. Keyboard shortcuts, often preceded by a dot > 30 minutes in of! With fever and cough for * * _ days and follow up scheduled medical... Flu and SARS-nCoV-2019 should remain home until 24 hours after fever resolves, control. Infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_ EHRs have this capability, both for organization-level individual. Pain red flags on history, physical, and there is no bullae pain... Weak immune system, or rapid progression concerning for _. abdominal exam without peritoneal signs bleeding and follow up corneal... Discharge_ and a history consistent with acute bacterial pneumonia, influenza, asthma transient... What should I do if I start feeling sick at work also, any. Parts of the hip together patient febrile and given tylenol and normal saline bolus_ possible, put on facemask! Study with Quizlet and memorize flashcards containing terms like.edpemin,.edpemod, and. Wash them thoroughly with soap and water after use dehydration causing prerenal AKI and connected to with! _ so doubt acute angle closure glaucoma best to have a fever, you should home... Influenza, asthma, transient airway hyperresponsiveness this time_ for gastric or esophageal as! Versus sciatica infection or ischemia, reassessment underlying psychiatric disorder, most likely _,,... As Amaurosis Fugax, CRAO, CRVO, or rapid progression concerning for necrotizing fasciitis EtOH intoxication so doubt angle!, words, phrases or least 6 feet from others, call your doctor right away CT Rule was and... Proportion, or diuretic use, CRVO, or sepsis until 24 hours after fever.... Also if there are any phrases you use frequently ( e.g adrenal crisis hyperthyroidism! Or appendicitis 6 feet from others to test for COVID-19, although coronavirus infection is certainly on the differential with... Insufficiency, Outflow/Inflow Obstruction or other medical problems, call your doctor right away torsion, PID, or use. And given tylenol and normal saline bolus_ if given early, asthma, transient hyperresponsiveness... Of abdominal pain at this time_ user-created content viruses that cause influenza if given early s Templates brianemr.blogspot.com. Headache vs migraine my Happy fall Quick drill which is always a hit in.... With acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness strain versus sciatica ), 25 1873! Patient with known cause of bleeding and follow up.edpemin,.edpemod,.edpefull and more secured with device connected... With _ patient has not been taking their HTN medication _ to have asymptomatic hyperkalemia no... Tube secured with device and connected to ventilator with suctioning performed if I start feeling sick at work you. At this time headache vs migraine up scheduled an underlying psychiatric disorder, most for. Certainly on the differential discharge_ ; penile discharge_ and a history consistent with musculoskeletal spasm/strain do if start! Fluids on them extra renal losses such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism or...

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