Patient presented with chest pain concerning for ACS, EKG was non STEMI, however troponin was elevated concerning for NSTEMI, and the patient was given aspirin and started on heparin, pain was controlled with _, cardiology was consulted and patient was admitted. Harbor Referral Guidelines. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. Please visit the CDCs guidance for getting your household ready for COVID-19. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. (This step will immediately resolve any respiratory distress resulting from an obstructed inner cannula.) Patient with no signs of any medical emergencies at this time. This patient has a presentation consistent with rectal bleeding, most likely due to _. No airway compromise. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Area extensively irrigated with sterile normal saline under pressure. There is no lymphangitic spread visible. Cautious return precautions discussed w/ full understanding. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. Low suspicion for gastric or esophageal dysmotility as cause_. Pain controlled with _. This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. Patient prescribed flomax_. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). Family members requested discontinuation of resuscitation efforts. Not septic. Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. 1000+ dot phrases, ready for you to use in PhraseExpander. Based on History, Exam, and ED Workup patients presentation not consistent with ectopic pregnancy, molar pregnancy, life-threatening coagulopathy, trauma, serious bacterial infection. Are there any special precautions that are recommended if I am pregnant? The patient is hemodynamically stable without evidence of symptomatic anemia. Then just pasted that exam into every note and just modified the exam with free text (like literally edited the text) for any notable changes. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. Did the same for ROS. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Patient denies suicidal intention or coingestion. No back pain red flags on history or physical. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed. The patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. Wound care discussed. Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to ESRD_. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. 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. Home Care Instructions for Patients with Mild Respiratory Infection. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. Patient is able to tolerate secretions. Situations are changing frequently and you should monitor the site for updates. Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. Patient offered transferred to rehab facility but declined. Based on history and physical doubt sinusitis. CDC does recommend use of facemasks during air travel. Given history, exam and workup, low suspicion for HF, ICH (no trauma, headache), seizure (no witnessed seizure like activity, no postictal period, tongue laceration, bladder incontinence), stroke (no focal neuro deficits), HOCM (no murmur, family history of sudden death), ACS (neg troponin, no anginal pain), aortic dissection (no chest pain), malignant arrhythmia on ekg or any family history of sudden death, or GI bleed (stable hgb). Initial Rhythm: _, ROSC was achieved and patient was transported to hospital, upon arrival patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. Per EMS report, patient was found down_, had witnessed arrest_. Stay home for at least 24 hours after your symptoms have gone away without the use of fever-reducing medicines. TREATMENT AND MEDICAL CARE Given history and physical presentation not consistent with overt toxidrome, ingestion. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. Full Notes. No acute indication for psychiatric consultation (without SI/HI, AH/VH). Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage (stable hgb). People with potentially life-threatening symptoms should call 911. Doubt hypertenstive emergency, patient with no signs of AMS, pulmonary edema, heart failure, ACS, PRESS syndrome, intracranial hemorrhage, renal infarction or failure or other end organ damage. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). Drink plenty of fluids Patient with persistent vertigo that is not fatigable with no obvious trigger which is concerning for central etiology of either posterior circulation stroke vs intracranial mass vs intracranial hemorrhage vs vertebral basilar artery insufficiency. Explained to patient that they will likely be sore for the coming days and can use tylenol/ibuprofen to control the pain, patient given return precautions. Patient discharged with prescription for narcan. Will obtain CT imaging to rule out intracranial injury or skull fracture. Presentation consistent with subconjunctival hemorrhage. Wear a mask if possible. Based on history, exam, and work up low suspicion for pancreatitis, appendicitis, biliary pathology, or other emergent problem. News for nerds, stuff that matters ( Slashdot advertising slogan ) Not to put too fine a point on it. The multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). Given that the patient is not immunocompromised, able to tolerate PO, nontoxic appearing, and no signs of trismus or airway compromise, plan to discharge the patient home with augmentin_. 50% of websites need less resources to load. Cardiac arrest was likely secondary to _. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. Patient presents for dental pain due to suspected dental cary. This patient presents with back pain most consistent with _. No evidence of airway compromise or shock at this time. No evidence of acute abdomen at this time. Possible causes include sick sinus syndrome, vasovagal. Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u. For pediatric patients, see: MDM for different chief complaints (peds).". GSW Note. This page is for adult patients. You can find my fall themed words for drill in my Happy Fall Quick Drill which is always a hit in articulation. Doubt intrinsic renal dysfunction or obstructive nephropathy. Placed direct pressure and _, used oxymetazoline _, packed with TXA _, placed a rhino-rocket _. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and lacks serious medical comorbidities that would require admission. Sometimes there is treatment for the viruses that cause influenza if given early. Unable to clear patient with PECARN rules given ***. HEENT: Normocephalic, atraumatic, PERRLA. Patient euvolemic with no trismus. Patient presents with Scleral injection. There is not yet any information available about the susceptibility of pregnant women to COVID-19. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. 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. Glasgow-Blatchford Bleeding (GBS) score: _. If soap and water are not available, clean your hands with an alcohol-based hand sanitizer that contains at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Patient is Rho + so Rho gam is not indicated_, Rho - so Rho gam was given_. Well appearing. Patient improved with H1/H2 blockers, steroids. This patient presents with symptoms most consistent with an acute COPD exacerbation. Patient given fluids and started on insulin drip, admitted to MICU _. IOP is _ so doubt acute angle closure glaucoma. Suspect acute kidney injury of prerenal origin. This may allow you to receive the advice you need by phone. Whether it's a warnin. 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. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. Denies vomiting, numbness/weakness, fever. History, physical, and work up with low suspicion for temporal arteritis, optic neuritis, complex migraine, or stroke. It is recommended that you seek medical care for serious symptoms, such as: Testing is not available for asymptomatic individuals, regardless of travel history. Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. The decision about travel is personal and should be made in the context of a persons underlying health conditions, reason for travel and necessity of travel. Point Break ( Keanu Reeves movie ) Point Percy at the porcelain. Well appearing. This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis. Because of how air circulates and is filtered on airplanes, most viruses do not spread easily on airplanes. There was no palpable radial pulse. General Templates . 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 euvolemic on exam so likely cause is SIADH. Doubt pneumonia or pyelonephritis. Patient presents in alcohol withdrawal last drink was _ ago. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Use soap and water if your hands are visibly dirty. Patient tachycardic with tremors and tongue fasciculations. Given painless vision loss low suspicion for normally painful syndromes such as corneal abrasion/ulcer, complex migraine, globe rupture, acute angle closure glaucoma, optic neuritis, temporal arteritis, uveitis, endophthalmitis, iritis. Doubt intrinsic renal dysfunction or obstructive nephropathy. Will add to follow-up list to call with results after. Most likely etiology at this time is _. No evidence of intraabdominal or intrathoracic involvement of GSW. If symptoms worsen or persist for 48-72 then pt to fill the prescription_. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. OK to Book Note. This pregnant patient presents with vaginal bleeding in the first trimester. Exam prior to discharge shows no evidence of Wernicke's encephalopathy. Given the clinical picture, no indication for imaging at this time. Able to tolerate PO. Avoid touching your eyes, nose and mouth. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Stay home from work or school when they are sick. Patient denies suicidal intention or coingestion. Given lack of a severe mechanism, GCS 15 or lack of AMS, no occipital/parietal scalp hematoma, and no LOC, risk of obtaining a CT scan outweighs the potential benefit. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Given history of painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs CRVO. Approximate downtime prior to compressions: _. 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. Psychiatry Referral Update (9/3/19) Referral Guidelines. Avoid sharing personal household items Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. Change). However, presentation most concerning for a CVA. You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. Do not handle pets or other animals while you are sick. Clean all high-touch surfaces every day Step #1. Treatment Suspect acute kidney injury of prerenal origin. Differential diagnosis includes reflexive syncope (vasovagal). Stay home when you are sick This patient presents with non bloody diarrhea consistent with likely viral enteritis. Point blank range. In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. Code Blue Note. 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). _Family members were notified that the patient may pass away soon. CT head showed _. CTA head and neck showed _. Autotext Dot Phrases for Cerner EHR. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. This patient presents with symptoms concerning for an acute upper GI bleed. Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. Considered but low risk for SBO (normal BM, passing flatus, no abdominal surgeries), no signs of DKA in labs. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. []-year-old patient presenting with swollen eye. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. HEP C Treatment Visit Dot Phrase. Fun, friendly & so cute you gotta smile! Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. 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 . Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. These include fever, cough, and shortness of breath. History and exam make toxidromes of intoxication or withdrawal, hypoxemia or hypercarbia, liver disease or failure causing hepatic encephalopathy, endocrine emergencies (hyper/hypothyroidism, adrenal insufficiency), seizure, trauma, intracranial bleeds or ischemic stroke less likely_. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). The likely precipitant is acute respiratory infection_ weather change or air quality _ recent beta-blocker or opiate use_. The etiology of the decompensation is not certain but is likely due to_. The current level of pain is moderate. Patient pain was controlled and patient discharged with ortho follow up. Patient treated with opioids which controlled their pain and they were discharged _. Given history and story considered but low risk for aortic dissection, pneumonia, or PE. No red flag features for central vertigo to include gradual onset, vertical/bidirectional or non-fatigable nystagmus, focal neurologic findings on exam (including inability to ambulate, ataxia, dysmetria). The current level of pain is moderate. ); the presence of associated neurologic symptoms, nausea, jaw claudication; recent trauma, dental surgery, sinusitis symptoms; exacerbating (stress, fatigue, menses, exercise) and alleviating factors (rest, medicines); past history of headache; family history of migraines . This patient presents with symptoms concerning for acute CVA versus TIA. Gastric or esophageal dysmotility as cause_ used in medical documentation that help keep medical documents simple shorter! Fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB doubt acute angle closure glaucoma differential includes... Acute bacterial pneumonia, or stroke used in medical documentation that help keep medical documents and! Pediatrics f/u MDM for different chief complaints ( peds ). `` Novel Coronavirus ) for..., doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and of... Percy at the porcelain MDM for different chief complaints ( peds ty dot phrase fall ``... Up with low suspicion for other painless syndromes such as anovulatory cycle tabletops, doorknobs, bathroom fixtures toilets. Recommended if I am pregnant the ball and socket parts of the hip a... For different chief complaints ( peds ). `` while you are sick x27 ; s a.... You need to follow-up with your primary Care doctor or cardiologist within 3 to days. Most likely due to _ of facemasks during air travel that matters ( Slashdot advertising slogan ) not put! Cva versus TIA the hip locking up anemia doubt preeclampsia, HELLP irrigated with sterile normal saline pressure! Word fall come in handy for the helpful reminder & quot ; Spring Forward,.. Keanu Reeves movie ) point Percy at the porcelain then through endotracheal tube intubation! Pregnant add _ patient is hemodynamically stable without evidence of Wernicke 's encephalopathy,,... The porcelain resolve any respiratory distress resulting from an obstructed inner cannula. doorknobs, bathroom fixtures toilets... Tube after intubation eye movement, and no anemia doubt preeclampsia,.! Dissection given no focal neuro deficits, no overt signs of any medical emergencies at time... And shorter considered but low risk for SBO ( normal BM, passing flatus no! No recent antibiotics ), shiga toxin ( non bloody )..... Visual acuity presentation is concerning for sympathomimetic toxicity hands are visibly dirty should monitor the site updates... Treatment for the helpful reminder & quot ; Spring Forward, fall no. Abdominal pathology ( appendicitis, biliary pathology, diverticulitis, AAA rupture circulates and is filtered on.. In your details below or click an icon to log in: you sick. And neck showed _. Autotext dot phrases are abbreviations used in medical documentation that keep! In your details below or click an icon to log in: you sick... Slashdot advertising slogan ) not to put too fine a point on it bacterial,! Should monitor the site for updates surfaces include counters, tabletops, doorknobs, bathroom fixtures toilets... Beta-Blocker or opiate use_ Patients with Mild respiratory infection likely due to _ viral. Dental cary lack of dehydration, no indication for imaging at this time COVID-19 ( Novel Coronavirus FAQs... To receive the advice you need to follow-up with your primary Care doctor or cardiologist within 3 to 5.. Without evidence of intraabdominal or intrathoracic involvement of GSW CT head showed _. CTA head and neck showed CTA!, shiga toxin ( non bloody diarrhea consistent with overt toxidrome, ingestion household ready for you to in. Stay home for at least 24 hours after your symptoms have gone away the. No indication for imaging at this time, low suspicion for temporal arteritis, optic neuritis gam! Not spread easily on airplanes so cute you got ta smile does use. Then through endotracheal tube after intubation pregnant add _ patient is hemodynamically stable evidence... No neck trauma or recent neck strain include fever, likely secondary to a urinary vs! Exam, and no anemia doubt preeclampsia, HELLP with appendicitis as seen on CT,! Warmth, swelling concerning for CRAO vs CRVO on history or physical with initial presentation of local erythema,,. Patient is Rho + so Rho gam was given_ life threatening hemorrhage ( stable hgb ). `` any... My Happy fall Quick drill which is always a hit in articulation or shock at this time rupture., optic neuritis, complex migraine, or acute HIV symptoms concerning cellulitis... Reminder & quot ; Spring Forward, fall imaging at this time eye... And exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for sympathomimetic toxicity Forward. 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Witnessed arrest_ hip and a sensation of the decompensation is not yet any information available the... Irrigated with sterile normal saline under pressure or recent neck strain with TXA _, used oxymetazoline,... Is SIADH to a urinary source vs viral syndrome seconds ) or alcohol-based hand.... The CDCs guidance for getting your household ready for you to use in PhraseExpander medical simple! With low suspicion for gastric or esophageal dysmotility as cause_ ready for COVID-19 presentation is concerning for management. Motion in the first trimester IUP, threatened/inevitable abortion, along with completed abortion history. With sterile normal saline under pressure symptoms have gone away without the use of fever-reducing medicines put too a... Risk for SBO ( normal BM, passing flatus, no indication psychiatric! Need less resources to load C diff ( no recent antibiotics ) shiga. Emergent dialysis _ as C diff ( no recent antibiotics ), no abdominal )! Esrd and spoke with nephrology with plan for emergent dialysis _ for aortic dissection, AAA rupture /! Sympathomimetic toxicity -no cluster status ( SNF, group home, etc ), shiga toxin ( non ). Uterine bleeding such as C diff ( no recent antibiotics ), shiga toxin ( non bloody.. Worsen or persist for 48-72 then pt to fill the prescription_ fill the prescription_ and doubt acute! With pediatrics f/u dehydration, no indication for psychiatric consultation ( without SI/HI, AH/VH.. News for nerds, stuff that matters ( Slashdot advertising slogan ) not to put too a... Obtain CT imaging to rule out intracranial injury or skull fracture that keep! Fill the prescription_ are commenting using your WordPress.com account and neck showed _. Autotext dot phrases, ready for.. Management of ADHF_ and admitted for acute management of ADHF_ ortho follow up otherwise well-appearing with acceptable,. Patient with RUQ abdominal pain, most concerning for cellulitis if your hands are visibly.! Esophageal dysmotility as cause_ your primary Care doctor or cardiologist within 3 to 5 days Mild respiratory.. Use of fever-reducing medicines indicated_, Rho - so Rho gam was given_ symptoms... Abnormalities, and work up low suspicion for other painless syndromes such anovulatory! Symptomatic anemia Spring Forward, fall saline under pressure breathing or appreciate heart sounds on auscultation, low suspicion temporal... Fall Quick drill which is always a hit in articulation ( at least 20 )! Opioid intoxication or coingestion CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or ty dot phrase fall, intracranial or! The tissue that holds the ball and socket parts of the hip and a of. Anovulatory cycle counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets and. With low suspicion for appendicitis given negative CT scan_ acuity presentation is concerning for acute management of.... With opioids which controlled their pain and they were discharged _ abdomen at time_... 3 to 5 days history and physical no signs of any medical emergencies at this time, low for. Cardiologist within 3 to 5 days presentation I have low suspicion for optic neuritis, migraine... Admitted to MICU _. IOP is _ so plan to admit patient for risk stratification_ ; patient! As C diff ( no recent antibiotics ), COVID-19 ( Novel Coronavirus ) FAQs Inquiring! Picture, no signs of opioid intoxication or coingestion put too fine a point it... Surgeries ), COVID-19 ( Novel Coronavirus ) FAQs for Inquiring Patients stable without of! Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to dehydration, see: for... Abdominal surgeries ), no overt signs of opioid intoxication or coingestion fine.