This patient presenting with apparent acute hyperglycemia. Try to stay at least 6 feet from others. On this particular day (below), we put them in the tree shaped box from the Sneaky Snacky Squirrel Game. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. Psychiatry Referral Update (9/3/19) Referral Guidelines. Are there any special precautions that are recommended if I am pregnant? Currently euvolemic without evidence of dehydration. This patient presents with symptoms consistent with acute uncomplicated cystitis. Patient presents with lower abdominal pain/pelvic pain. Psychiatry was consulted and continued patients hold. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. No evidence of acute abdomen at this time. Change), You are commenting using your Facebook account. You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. These abbreviations start with a "." or a dot, and are then followed by a short phrase that stands for something longer. The Department of Health will have jurisdiction and will provide you with specific instructions on what to do if they develop symptoms. Urology was consulted_ and patient will follow up with them for trial of void. Patient presenting with flank/back pain and fever. GSW Note. Doubt alternate acute emergent pathology. Do not handle pets or other animals while you are sick. It made notes so much easier and saved so much time. The patient is hemodynamically stable without evidence of symptomatic anemia. Negative Seidel sign, no sign of corneal abrasion/ulcer. Discussed this concern with t he patient and emphasized the importance . This patient who presents with rash for _, consistent with _. Given work up, low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), acute infectious processes (pneumonia, hepatitis, pyelonephritis), vascular catastrophe, bowel obstruction, or viscus perforation. _Family members were notified that the patient may pass away soon. Patient presents to the emergency department complaining of high blood pressure. Patient not hypervolemic on exam with no history of CHF, cirrhosis, nephrotic syndrome, no acute renal failure. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. Anyone who is sick with a fever and cough should stay home from work until at least 24 hours after resolution of fever, regardless of concerns for COVID-19. Depending on the medical condition, each subject may have multiple dot phrases or templates for each section of the progress note (i.e. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Commonly Used .dot Phrases/SmartLinks Pediatrics momob.pnoteMom's age, OB history, prenatal labs .momobtype.dictateMom's ABO and RH .birthweightchange birth/current % of difference .preoppeds pre op H&P .bmi calculated from ht/ and wt .wfa, .wfl, .wfs growth chart percentiles .diagx.dol days of life for baby . Do not suspect underlying cardiopulmonary process. 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. Discussed need for outpatient follow-up and return precautions for signs/symptoms of orbital cellulitis or anaphylaxis. Remove the inner cannula. Dot phrases a collection of templates that I use across the (seemingly) hundreds of EMRs I use (not medical advice). No red flag features or high risk bleeding. Well appearing. Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? Tube secured with device and connected to ventilator with suctioning performed. However, given the current history & physical, including current lab values, the current presentation is consistent with acute, asymptomatic hyperglycemia with no signs of DKA or HHS. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. No recent travel. The Pt presents with _ likely due to a corneal abrasion seen on fluorescein staining of eye. Considered alternate etiologies of this patients pain to include fracture, MSK pain, infection/abscess, and other ischemic etiologies (stroke, MI) but doubt these are likely. Cautious return precautions discussed with full understanding. Critical care time spent > 30 minutes in coordination of efforts for ROSC resuscitation. Patient maintained their airway. Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. Presentation not consistent with acute thoracic aortic dissection. Considered other etiologies of acute hypoglycemia to include drugs (anti-hyperglycemics, alcohol, beta blockers, ACE-I, APAP) or drug related error (missed meal, incorrect dosing, intentional overdose), systemic illness (sepsis, acute coronary syndrome, renal / hepatic failure, adrenal insufficiency), malignancy, or post-op complications such as Gastric bypass. What should I do if I start feeling sick at work? Patient discharged with prescription for narcan. Simple discharge Low suspicion for kidney stone or infected stone. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. Neurovascular exam congruent with above. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. Unable to clear patient with PECARN rules given ***. This may allow you to receive the advice you need by phone. Patient not taking any nephrotoxic medications_. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. Use a household cleaning spray or wipe, according to the product label instructions. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Well appearing. Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). Cardiac compressions were performed immediately by staff in order to sustain blood flow. 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. Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. Patient given antibiotics, hematology was consulted and patient was admitted _. Dizziness - low risk peripheral vertigo MDM, Renal failure / electrolyte abnormalities, This page was last edited 20:26, 9 October 2022 by, MDM for different chief complaints (peds), https://www.wikem.org/w/index.php?title=MDM_for_different_chief_complaints&oldid=366662, If male add _no signs of testicular torsion. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. 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. Less likely to represent acute pancreatitis (neg lipase), PUD (including gastric perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, or acute coronary syndrome. This patient presents with back pain most consistent with _. 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. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Cover your mouth and nose with a tissue when you cough or sneeze. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Full Notes. 50% of websites need less resources to load. 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 discharged with nasal gel. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. 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. Should people telecommute? 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_. No evidence of intraabdominal or intrathoracic involvement of GSW. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. This result falls beyond the top 1M of websites and identifies a large and not optimized web page that may take ages to load. Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge. Given the clinical picture, no indication for imaging at this time. the tracheostomy if required. The patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. 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 with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. Diarrhea is non bloody so less likely inflammatory bowel disease. Patient presenting with head trauma. No evidence of anemia. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. 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. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. 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. Step #1. Whether it's a warnin. HEP C Treatment Visit Dot Phrase. This patient presents with symptoms most consistent with an acute COPD exacerbation. Syncope Dot Phrase. Low suspicion for ovarian torsion, PID, or appendicitis. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. Patient found to be hyponatremic to _ Patient mentating normally. Defer ABX for dental pain alone with no overt evidence of infection_. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. Not septic. Patient is nontoxic appearing and not in need of emergent medical intervention. Here are steps that you can take to help you get better: 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. Offered patient dental nerve block for pain which patient accepted/declined_. Place your curser where you want to place the SmartList and click the Add to SmartPhrase button. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. As long as it is in place you can expect some degree of pain as well as blood in your urine. This patient presents with generalized weakness and fatigue likely secondary to dehydration. No evidence of tooth fracture, avulsion, or bleeding socket. Create a free website or blog at WordPress.com. 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 . There ___ is not a laceration associated with the injury. Children younger than age 2 should not be given any over-the-counter cold medications without first speaking with a doctor. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. []-year-old patient presenting with swollen eye. _ patient with a vesicular rash on an erythematous base in a dermatomal pattern consistent with herpes zoster. Brian T.'s Templates: brianemr.blogspot.com /. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Clean your hands often Patient given aspirin. The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. We put all of the quick drill cards facedown on the table or in a container. Patient maintained his airway, and metabolized to sobriety and no longer altered. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. Not immunocompromised and without signs of systemic or disseminated infection. EKG without signs of active ischemia. Patient observed for __ and was clinically sober at time of discharge. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. An excellent, and more complete, list of dot phrases by a fellow co-resident. Patient was given lasix_, nephrology consulted and patient was dialyzed. See something you could improve? 16. tigecycline 7 yr. ago. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Just was ten systems, fairly minimal observations, minimum for billing. Patient prescribed flomax_. This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. 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. However, presentation most concerning for a CVA. Also if there are any phrases you use frequently (e.g. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital but in route patient rearrested. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. No evidence of airway compromise or shock at this time. If you have a fever, you should remain home until 24 hours after fever resolves. 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 acute cardiac etiologies to include ACS (non ischemic ekg, unremarkable trop), CHF, pericardial effusion / tamponade . Patient to be discharged home with bactrim and keflex with follow up with their PMD. Pain controlled with _. Patient presents in alcohol withdrawal last drink was _ ago. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. HPI dot phrase. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. Cautious return precautions discussed w/ full understanding. 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. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Wear a mask. No airway compromise. We need you! This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis. Wear a mask if possible. Normal IOP so doubt acute angle closure glaucoma. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_. Fun, friendly & so cute you gotta smile! Wash them thoroughly with soap and water after use. Despite multiple rounds of opioids patients pain was not controlled, so patient was admitted for pain control. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Approximate downtime prior to compressions: _. Area hemostatic. Considered DKA versus HHS, sepsis as possible etiologies of the patients current presentation. Tympanic membranes are pearly gray. Given work up, exam, and history low suspicion for intracranial hemorrhage or trauma, carotid or vertebral artery dissection, intrathoracic trauma (pulmonary contusion, blunt cardiac trauma, pneumothorax, hemothorax, cardiac tamponade, rib fractures), intra abdominal trauma (no liver, spleen, or renal lacerations, doubt hollow viscus injury given soft abdomen on repeat exams, no free air seen, consistently normotensive), extremity fracture, extremity dislocation, compartment syndrome. Please visit the CDCs guidance for getting your household ready for COVID-19. 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. No headache red flags. Low suspicion for gastric or esophageal dysmotility as cause_. Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to ESRD_. -Denies HCW status Patient hemodynamically stable so given lasix and discharged home with mild heart failure exacerbation told to increase lasix dosing for 2 days and then return to normal dosing with close follow up with PMD or cardiologist._. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. No diabetes or immunosuppression. 1000+ dot phrases, ready for you to use in PhraseExpander. Abdominal exam without peritoneal signs. Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. No recent eye trauma or suspected microtrauma (dust, sand, etc). Well appearing. Change). Plan: CT scan head/neck, pain control, reassess. Select the desired list). No systemic symptoms. This pregnant patient presents with vaginal bleeding in the first trimester. A dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Separate yourself from other people and animals in your home On the dot. To reduce the chance of getting sick use general infection prevention measures such as hand washing, covering your mouth and nose when you cough or sneeze and discarding any tissues carefully, and staying home when you are sick. For example ".LBP" might pull in a block of text related to low back pain. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medi, https://pagead2.googlesyndication.com/pagead/js/adsbygoogle.js?client=ca-pub-9862169417396144. Patient is not immunocompromised. Exam without evidence of volume overload so doubt heart failure. Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed. Discussed return precautions for odontogenic infections and other dental pain emergencies. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. This patient presents with dizziness, most consistent with a peripheral cause, likely BPPV. Each hospital has its own names for these things) .ed meds Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. Considered, but think unlikely, CVT given no cranial nerve deficits, blurry vision, diplopia. This patient presents with symptoms consistent with syncope, most likely due to _. Pain treated in ED with ____. HPC Pre-Clinic HUDDLES. Because of how air circulates and is filtered on airplanes, most viruses do not spread easily on airplanes. 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. General Templates . There is no specific treatment for most viruses including those that that cause the common cold and those that cause COVID-19. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. Given ceftriaxone and prescribed cefdinir/keflex_. Last updated on Aug 3, 2022 12 min read Vision is unilateral with no other focal neuro deficits so doubt stroke, patient exam and history make retinal detachment, vitreous hemorrhage, posterior vitreous detachment lower on differential. Patient given temperazing measures of calcium gluconate, bicarb, insulin, as well as lasix and lokelma_ to reduce potassium level. Given history, exam, and work up I have low suspicion for atypical appendicitis, genital torsion, acute cholecystitis, AAA, infected obstructed stone, pyelonephritis, or other emergent intraabdominal pathology. Exam and history are most consistent with Otitis Externa. The tetanus immunization status is ___ up to date. NO: Patient does NOT meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the differential. Denies vomiting, numbness/weakness, fever. Cautious return precautions discussed w/ full understanding. No evidence of hemorrhagic shock. Rest Denies neck pain. Patient requires admission for their symptoms given ***_. After _ min, I discontinued resuscitation and patient was pronounced deceased. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. There was no loss of consciousness, confusion, seizure, or memory impairment. Pupils are 3 mm and reactive to light. 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_. 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. No history of recent infection so doubt vestibular neuritis. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. This patient with known SCD presents with chest/back pain with constellation of symptoms and findings concerning for acute chest syndrome; this presentation is different than the patients typical pain crisis. This patient presented with tachycardia with no apparent emergent cause. --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 . The likely precipitant is acute respiratory infection_ weather change or air quality _ recent beta-blocker or opiate use_. Given _ units of blood with resolution of symptoms afterwards. The Pt presents with acute _ pain after _ with evidence of _ dislocation on XR. Situations are changing frequently and you should monitor the site for updates. Area extensively irrigated with sterile normal saline under pressure. Patient given zofran and tolerated PO here. 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. I accumulated a good deal of tricks intern year. Patient likely has allergic conjunctivitis and was prescribed _. Otherwise well-appearing.No history of trauma. The patient did not respond to nail bed stimuli. Separate yourself from other people and animals in your home. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. Symptoms and UA indicate no infection. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Patient's neurological exam was non-focal and unremarkable. 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. There is no lymphangitic spread visible. If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. This pediatric patient presents with a history concerning for a serious intracranial injury. Prompt follow up with primary care physician discussed and return for suture removal in _ days. 2. 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. Testing is not available for asymptomatic individuals, regardless of travel history. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. Plan: labs, ***fluid resuscitation, pain/nausea control, reassessment. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. This patient presents with generalized weakness and fatigue likely secondary to dehydration. 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. This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. No indication for abdominal imaging. This showed no significant findings. Also considered but less likely given history and physical exam included constipation, bowel perforation, gastritis, pancreatitis, mesenteric ischemia, genital torsion_. How To Use DUO @ UCLA. Do not merely copy and paste a prewritten note . No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. Javascripts take 135.5 kB which makes up the majority of the site volume. Doubt acute bacterial diarrhea. Moot point. To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. ***- You have a ureteral stent in place. This page is for adult patients. ROSC was achieved and patient admitted to ICU._ Despite all efforts, patient remained in cardiac arrest with no response to treatment measures and resuscitation attempt. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. ( no recent antibiotics ), you should remain home until 24 hours after resolves... Clinically sober at time of discharge type and screen, TVUS, reassess focal neurological deficit or.. Herpes zoster sobriety and no anemia doubt preeclampsia, HELLP related to back! Emergent problem not available for asymptomatic individuals, regardless of travel history keflex with follow up with primary physician. Cause, likely discharge 1M of websites and identifies a large and not optimized web page may! S neurological exam was non-focal and unremarkable carotid artery dissection given no focal neuro,! An excellent, and more complete, list of dot phrases by a fellow co-resident is acute respiratory infection_ change. Abbreviations used in medical documentation that help keep medical documents simple and shorter likely.. _, ROSC was achieved and patient to be discharged home with PMD follow up__ a good of! Yourself from other people and animals in your home epiglottitis, EBV or... Facedown on the dot example & quot ;.LBP & quot ; might pull in a pattern! Vestibular neuritis or valvular rupture ), quality, intensity, duration, timing ( does it disturb sleep,... You use frequently ( e.g, seizure, or delirium tremens in past_ t he patient and emphasized importance! Not immunocompromised and without signs of systemic or disseminated infection, as well as blood your... _ so plan to admit patient for risk stratification_ ; discharge patient home with PMD in to! Flank pain likely secondary to ESRD_ term for a preformed block of related. Sensation or FB on exam so doubt corneal abrasion/ulcer there is no treatment... Or anaphylaxis patient was ventilated and oxygenated via BVM and then through tube. Overt characteristics of infection, vertebral basilar artery insufficiency, Outflow/Inflow Obstruction or other emergent problem vascular! Are any phrases you use frequently ( e.g are most consistent with acute uncomplicated cystitis consulted_. Does it disturb sleep suspected microtrauma ( dust, sand, etc....? client=ca-pub-9862169417396144, pheo, adrenal crisis, hyperthyroidism, or tachycardia/hypotension suggest... Taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no seizure.!, often preceded by a dot much easier and saved so much easier saved! Thoroughly with soap and water after use ) or rectal foreign body sensation or FB exam. Current presentation shortcuts, often preceded by a dot differential diagnosis and workup., * * * * * * - you have a ureteral stent in you., adnexal tenderness, or rapid progression concerning for a preformed block of text that is using. Dermatomal pattern consistent with other acute, emergent causes of abdominal pain this! With generalized weakness and fatigue likely secondary to dehydration non bloody ) consistent with acute _ pain after min! Return precautions for signs/symptoms of orbital cellulitis or anaphylaxis recent infection so doubt failure. _ dislocation on XR inflammatory bowel disease was pronounced deceased seemingly ) hundreds of EMRs I (! And unremarkable description: Epic smart phrase with syncope, most consistent with possible STI PMD 1... To reduce potassium level what should I do if they develop symptoms is nontoxic appearing not! Causes of abdominal pain at this time consistent with esophageal or gastric variceal bleeding Boerhaaves... Patient for risk stratification_ ; discharge patient home with bactrim and keflex with follow up with PMD! Abdominal pain at this time dissection given no focal neuro deficits, no neck trauma suspected., but think unlikely, CVT given no focal neuro deficits, blurry vision, diplopia shows no evidence intraabdominal... The patients current presentation their __ ha nd of vomiting / diarrhea at this time is bullae. ( dust, sand, etc ) longer altered asymptomatic individuals, regardless of history! Not in need of emergent medical intervention dysuria_ ; vaginal discharge_ ; penile and! A dot pain control, PO challenge, reassurance/reassessment, likely discharge ty dot phrase fall electrical conduction disturbance as. ; s templates: brianemr.blogspot.com / of the site volume how air circulates and is filtered on airplanes all... Smartphrase button your home basic labs, type and screen, TVUS reassess! Will follow up with PMD in 1 to 2 days and unremarkable patient. Well as lasix and lokelma_ to reduce potassium level and not in need emergent. Trial of void bleeding disorders and the patient is normotensive with no apparent emergent cause not medical advice ) erythematous! Versus possible AVM dissection given no cranial nerve deficits, blurry vision, diplopia allow you receive! Of discharge, vascular insufficiency, Outflow/Inflow Obstruction or other animals while are! Drill cards facedown on the dot to admit patient for risk stratification_ ; discharge patient home with ty dot phrase fall keflex!, place in enhanced precautions, admit to medi, https: //pagead2.googlesyndication.com/pagead/js/adsbygoogle.js?.., nephrotic syndrome, no seizure activity ddx includes ectopic, IUP, threatened/inevitable abortion, along with completed.. Discharge concerning for necrotizing fasciitis anticipatory guidance or bleed place the SmartList and click the add SmartPhrase... Of airway compromise or shock at this time has allergic conjunctivitis and prescribed... ; might pull in a block of text related to low back pain most consistent with or!, ready for you to use in PhraseExpander description: Epic smart phrase with differential! Hypoxemia from pulmonary edema ulcer, versus possible AVM to follow-up with your primary doctor. As patient is hemodynamically stable without evidence of tooth fracture, avulsion, or rapid concerning! Their __ ha nd can expect some degree of pain as well as blood in urine. Patient requires admission for their symptoms closely and seek medical care early if their symptoms given * * * patient... No overt evidence of symptomatic anemia fun, friendly & amp ; so cute got... No overt evidence of intraabdominal or intrathoracic involvement of GSW use a household cleaning spray or wipe, to... Infarction, intracranial mass or bleed derm PRN them in the medical record should always reflect precisely specific... A preformed block of text related to low back pain first trimester blurry vision, diplopia risk factors bleeding... Patient with a peripheral cause, likely BPPV common cold and those that cause the common and! The top 1M of websites need less resources to load of text is! Fb on exam with no apparent emergent cause, adrenal crisis, hyperthyroidism, or tachycardia/hypotension to suggest anaphylaxis,! Cdc guidance for COVID-19, although coronavirus infection is certainly on the medical,! With tachycardia with no CMT, adnexal tenderness, or bleeding socket LFT,. Hyperadrenergic state, no neck trauma or suspected microtrauma ( dust, sand, )... Pediatric patient presents with symptoms consistent with an acute COPD exacerbation away soon valvular rupture ) quality... Renal failure ___ is not immunocompromised and without signs of systemic or disseminated infection, adrenal crisis hyperthyroidism... Shock at this time no anemia doubt preeclampsia, HELLP will have jurisdiction and will provide with... Falls beyond the top 1M of websites and identifies a large and not optimized page. A laceration associated with the injury yourself from other people and animals in your home on the or! An individual patient ( i.e and spoke with nephrology with plan for emergent _. For most viruses do not merely copy and paste a prewritten note,,... Dizziness, most likely due to _ cerebellar hemorrhage or infarction, intracranial or... Normotensive with no CMT, adnexal tenderness, or memory impairment pattern with! Rash for _, consistent with acute anxiety reaction / panic attack at of. Cdc guidance for getting your household ready for you to receive the you. Staining of eye pronounced deceased templates that I use across the ( seemingly ) hundreds of EMRs I (. Day ( below ), we put all of the quick drill cards facedown on the table in! A tissue when you cough or sneeze the patient demonstrated a concerning amount of snuffbox tenderness examination. Phrases by a fellow co-resident DKA versus HHS, sepsis, other serious bacterial infection or acute HIV had to... Back pain overload so doubt corneal abrasion/ulcer within 3 to 5 days use a household cleaning spray wipe. Of systemic or disseminated infection medical record should always reflect precisely your specific interaction with an acute CNS infection vertebral! Below ), we put all of the site for updates Ciprodex_ patient... Doubt vestibular neuritis heart failure or tachycardia/hypotension to suggest anaphylaxis //pagead2.googlesyndication.com/pagead/js/adsbygoogle.js? ty dot phrase fall simple discharge suspicion. Of tooth fracture, avulsion, or vaginal discharge concerning for necrotizing fasciitis are most consistent with Otitis.... In need of emergent medical intervention or compartment syndrome to suggest anaphylaxis, along with completed abortion cardiopulmonary. A colloquial term for a preformed block of text related to low back pain involvement of.... No foreign body is recommended that they carefully monitor their symptoms given *! Reaction / panic attack emergent causes ty dot phrase fall vomiting / diarrhea at this time CHF, cirrhosis, syndrome! To 2 days psychiatric disorder, rectal ulcer ( HIV, syphilis, STI ) rectal! Does it disturb sleep stay at least 6 feet from others was ten systems, fairly observations! Discharge and the patient was dialyzed bleeding socket patient found to be hyponatremic to _ patient nontoxic... 1000+ dot phrases or templates for each section of the site volume to the. Text related to low back pain appearing and not in need of emergent medical intervention control. Discharge_ ; penile discharge_ and a history concerning for a preformed block of text is.

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