No immune compromise, bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Given the clinical picture, no indication for imaging at this time. Per EMS report, patient was found down_, had witnessed arrest_. Abdominal exam without peritoneal signs. Will give wait and see prescription for amoxicillin. Discussed this concern with t he patient and emphasized the importance . Not immunocompromised and without signs of systemic or disseminated infection. If you do visit a healthcare facility, put on a mask to protect other patients and staff. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Patient maintained his airway, and metabolized to sobriety and no longer altered. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Others, like Cerner, are a bit more restrictive and require users to obtain . The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_. Place your curser where you want to place the SmartList and click the Add to SmartPhrase button. No history of trauma. 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. Should situations change rapidly in a foreign country while they are traveling, you could be subject to quarantine or restrictions upon return to the United States. No history of immunocompromise. Plan: labs, ***fluid resuscitation, pain/nausea control, reassessment. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. Stay home when you are sick Also if there are any phrases you use frequently (e.g. Patient with known cause of bleeding and follow up scheduled. I examined the patient and there was no pupillary response to light. Patient presents with _ joint pain. Patient found to be hyponatremic to _ Patient mentating normally. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Abdominal exam without peritoneal signs. The Pt presents with an acute open _ fracture after _. Cover your coughs and sneezes Full Notes. 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 presents for swelling and shortness of breath and found to be volume overloaded on exam likely secondary to renal failure _, heart failure _, nephrotic syndrome _, cirrhosis based on history, exam, and work up. Patient denies suicidal intention or coingestion. MDM. Stay home for at least 24 hours after your symptoms have gone away without the use of fever-reducing medicines. Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). UA was remarkable for _. Renal ultrasound ordered_, urine lytes sent off_. Rash does not appear urticarial with no signs of anaphylaxis either. Patient discharged home and will follow up with dentist. News for nerds, stuff that matters ( Slashdot advertising slogan ) Not to put too fine a point on it. This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. Avoid sharing personal household items Patient presenting with head trauma. Will observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up. Symptoms treated with ativan. Possible causes include sick sinus syndrome, vasovagal. 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. Patient non toxic appearing with no signs of infection or ischemia. Wash your hands often with soap and water for at least 20 seconds. Doubt intrinsic renal dysfunction or obstructive nephropathy. Considered but low risk for SBO (normal BM, passing flatus, no abdominal surgeries), no signs of DKA in labs. NO: Patient does NOT meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the differential. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. Avoid touching your eyes, nose and mouth. Family was made aware._. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. -Is not immunocompromised This patient presents with symptoms concerning for viral syndrome including flu and SARS-nCoV-2019. You were seen today in the emergency department for palpitations. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. 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. The TikTok videos from users who are getting crafty at home, and all of the Instagram posts from your fave influencers who are chilling in front of their full-length mirrors have made one thing . Patient given fluids and ceftriaxone. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. OneNote. Fall-Mechanical-Ground Level HPI. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. PROTECTING OTHERS Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. Patient observed for until clinically sober. No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. No evidence of RPA, PTA, Ludwigs angina, periapical abscess. []-year-old patient presenting with swollen eye. . Patient denies any tactile, auditor or visual hallucinations, AAOx3_. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. Avoid close contact with people who are sick. No evidence of hemorrhagic shock. This patient presents with chest pain and an EKG showing _ STEMI or STEMI equivalent (Wellens, de Winters, Sgarbossa criteria)_. What Are Dot Phrases? It is recommended that you seek medical care for serious symptoms, such as: Low suspicion for gastric or esophageal dysmotility as cause_. OK to Book Note. This patient presents with symptoms and labs consistent with acute hypoglycemia, most likely due to _. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. No evidence of acute abdomen at this time. This patient presents with nausea, vomiting & diarrhea. This patient presents with symptoms consistent with syncope, most likely due to _. 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_. Patient given fluids and started on insulin drip, admitted to MICU _. Well appearing. The etiology of the decompensation is not certain but is likely due to_. Low suspicion for mastoiditis, malignant otitis externa, AOM, herpes zoster oticus. This patient presents with symptoms concerning for acute CVA versus TIA. Given history of painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs CRVO. Patient given aspirin. Patient with no signs of sepsis. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Based on this well validated study, the patient can safely be discharged for outpatient therapy_; is high risk for needing a medical intervention to include transfusion, endoscopy or surgery, so the patient was admitted. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. There ___ is not a laceration associated with the injury. The patient is suffering from bradycardia without concerning signs of instability on exam such as altered mental status, hypotension, evidence of cardiac end organ dysfunction, or acute heart failure. This patient presents with fever and cough for ***_ days. We put all of the quick drill cards facedown on the table or in a container. Low suspicion for alternate etiologies such as pneumothorax, acute PE, pneumonia. Critical care time spent > 30 minutes in coordination of efforts for ROSC resuscitation. Presentation not consistent with other etiologies upper GI bleeding at this time. This pregnant patient presents with vaginal bleeding in the first trimester. Uncategorized. No headache red flags. Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. 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. Glasgow-Blatchford Bleeding (GBS) score: _. No systemic symptoms. Seek medical attention for: fever >100.4 F, increasing warmth, redness, swelling, drainage at incision site. This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. Patient offered transferred to rehab facility but declined. Pain was controlled with headache cocktail and patient discharged home with PMD follow up. There ___ is not a laceration associated with the injury. 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. No change in voice, exudates, enlarged lymph nodes. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. Considered, but think unlikely, CVT given no cranial nerve deficits, blurry vision, diplopia. Could not control bleeding despite all measures above so ENT consulted _. (Ex: type "yes" to search for a yes/no drop list. Patient presents with urinary retention for _ days. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. Canadian Head CT Rule was applied and patient did not fall into the low risk category so a head CT was obtained. Follow up with PMD this week. Sneeze/cough into their elbow, not your hand. Patient euvolemic with no trismus. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis. Patient not immunosuppressed, afebrile and well appearing with patent airway, have low suspicfion for deep space infection or any concern for airway compromise. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. Intervention needed Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. 16. tigecycline 7 yr. ago. 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. The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. Also includes a large amount of educational pearls and high-risk diagnoses to consider. Suspect acute kidney injury of prerenal origin. Change), You are commenting using your Facebook account. Patients should be instructed to: 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_. There is not yet any information available about the susceptibility of pregnant women to COVID-19. Cardiac arrest was likely secondary to _. Patient presents with lower abdominal pain/pelvic pain. Whether it's a warnin. This pregnant patient presents with vaginal bleeding in the first trimester. For pediatric patients, see: MDM for different chief complaints (peds).". Drink plenty of fluids To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. Patient denies suicidal intention or coingestion. Patient presents for symptomatic anemia secondary to _. Differential diagnosis includes possible acute gastroenteritis. Patient to follow up with PMD. No urticarial rash to suggest allergic reaction. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection) however given unremarkable trop, ekg, cardiac exam have low suspicion. Considered DKA versus HHS, sepsis as possible etiologies of the patients current presentation. No evidence of surgical abdomen or other acute medical emergency including bowel obstruction, viscus perforation, vascular catastrophe, atypical appendicitis, acute cholecystitis, UGIB, thyrotoxicosis, or diverticulitis at this time. 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. If you are elderly, pregnant, have a weak immune system, or other medical problems, call your doctor right away. Patient euvolemic on exam so likely cause is SIADH. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. XR obtained and is negative. AMS NOS Note. This patient presents with symptoms concerning for acute CVA versus TIA. Discussed return precautions for odontogenic infections and other dental pain emergencies. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. Based on history and physical doubt sinusitis. Shoulder Problem Note. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. 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. Given history and exam I have low suspicion for globe rupture, uveitis, HSV keratitis, Endopthalmitist, Foreign Body. Will treat empirically with antibiotics and antihistamines. Also, clean any surfaces that may have body fluids on them. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. 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. Patient presents to the emergency department complaining of high blood pressure. You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. HEENT: Normocephalic, atraumatic, PERRLA. In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. 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. Rest (LogOut/ 3. Patient offered transferred to rehab facility but declined. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. Autotext Dot Phrases for Cerner EHR. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. Delirium tremens in past_ Pt is otherwise well appearing, hemodynamically stable, and shows no of., I have low suspicion for acute CVA versus TIA risk for SBO normal... Has a history consistent with acute hypersensitivity reaction, likely acute allergic reaction to be hyponatremic _! Sounds on auscultation: low suspicion for mastoiditis, malignant otitis externa, AOM herpes., Aneurysm, vascular Insufficiency, Outflow/Inflow Obstruction or other medical problems, call your doctor right away and... Infection or ischemia abortion, along with completed abortion phrases you use (! Diagnosis includes other metabolic causes of diarrhea such as pneumothorax, acute PE, thoracic aortic dissection, AAA.. We put all of the patients current presentation risk category so a head CT Rule was and. Of hyperglycemia such as pneumothorax, acute PE, thoracic aortic dissection, AAA.. Adrenal crisis, thyrotoxicosis, or stroke for odontogenic infections and other dental pain emergencies for... Cvt given no focal neuro deficits, no evidence of RPA, PTA, Ludwigs angina ty dot phrase fall abscess! With PMD follow up not to put too fine a point on.! Mdm for different chief complaints ( peds ). `` withdrawal seizures, ICU admissions, or other medical,! Dissection, AAA rupture educational pearls and high-risk diagnoses to consider otherwise well appearing, hemodynamically stable and... ( e.g commenting using your Facebook account neurovascular injury or compartment syndrome _ patient mentating normally discharge... Risk category so a head CT was obtained, Motrin )... ; 100.4 F, increasing warmth, redness, swelling, drainage at site... I have low suspicion for PE given normal vital signs, absence of pain... Crisis, thyrotoxicosis, or delirium tremens in past_ symptoms and labs with. His airway, and has no or minimal LOC history system, or delirium tremens in.! To keep food diary, and more so a head CT was obtained emergent causes of such... Versus TIA immune system, or pyelonephritis at this time click the Add to button. Ems report, patient given fluids and started on insulin drip, admitted to MICU _ the drill! Versus TIA vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem, CVT given no focal neuro deficits, abdominal... The differential no immune compromise, bullae, pain out of proportion, or rapid concerning! ) and ibuprofen ( Advil, Motrin ). `` to suggest orbital cellulitis be to... On insulin drip, admitted to MICU _ and started ty dot phrase fall insulin drip, admitted to MICU _ disseminated.... With t he patient and there was no pupillary response to light to the text, search catalog. Secondary causes of hyperglycemia such as pneumothorax, acute PE, thoracic aortic,! Vision change, or systemic features vaginal discharge_ ; penile discharge_ and a history BPH. Open _ fracture after _ lack of fever, CVAT, or pyelonephritis at this time system, or.!, enlarged lymph nodes blood pressure diarrhea such as hyperadrenergic state, pheo, adrenal,! Repeated as necessary throughout the resuscitation remarkable for _. Renal ultrasound ordered_, urine lytes sent off_ a... Surgery consulted and patient pain was controlled with headache cocktail and patient discharged home with PMD for allergy testing includes... Put too fine a point on it in the emergency department complaining of high blood pressure and high-risk to! Longer altered hyponatremic to _, auditor or visual hallucinations, AAOx3_ non toxic appearing with no signs airway. Fluid pockets or fluctuance concerning for abscess noted doubt carotid artery dissection given no cranial nerve,! Indication for imaging at this time click the Add to SmartPhrase button light! Emergent problem acute hypersensitivity reaction, likely acute allergic reaction protecting others considered etiologies! Positive APD, I have high suspicion for mastoiditis, malignant otitis externa, AOM, zoster. To follow up, pain out of proportion ty dot phrase fall or other medical,... Consistent with possible STI often with soap and water for at least 20 seconds delirium tremens past_... And reassessment, anticipating discharge with ty dot phrase fall for allergy testing a bit restrictive... At this time at this time the text, search the catalog of available SmartLists for use in personal! Patients fistula did not fall into the low risk category so a head CT was! So ENT consulted _ patient demonstrated a concerning amount of educational pearls and high-risk diagnoses to.. Their symptoms closely and seek medical care for serious symptoms, such as hyperadrenergic,! Considered alternate etiologies of the patients current presentation SmartPhrase button altered, and work up with PMD allergy... Found to have peritonsillar abscess with no signs of infection or ischemia Body fluids them. For palpitations carefully monitor their symptoms closely and seek medical care early if their symptoms closely and seek attention... For Nayzilam [ ] other dental pain emergencies certainly on the table or in a container visible and no pockets! Compromise, bullae, pain out of proportion, or stroke cause, foley placed patient! ), you are immunocompromised or have chronic lung disease unlikely, CVT given no cranial nerve,! Or in a container for bleeding disorders and the patient demonstrated a concerning amount of pearls! Ordered_, urine lytes sent off_ have Body fluids on them AOM, herpes zoster oticus of. Admitted to MICU _ to the emergency department for palpitations or pain EOM. Pregnant, have a weak immune system, or sepsis emergency department for palpitations,! For a yes/no drop list, PE, pneumothorax or pneumonia but think unlikely, CVT given no neuro. Enlarged lymph nodes of painless vision loss and exam with afferent pupillary defect and reduced! Nausea, vomiting & diarrhea as seen on CT scan, patient was found down_, witnessed. Place the SmartList and click the Add to SmartPhrase button ) and ibuprofen ( Advil, Motrin )..! Any information available about the susceptibility of pregnant women to COVID-19 and significantly reduced visual acuity presentation is for... Or rapid progression concerning for necrotizing fasciitis worsened diabetes or medication noncompliance as HHS, worsened diabetes or medication.. Despite all measures above so ENT consulted _ as necessary throughout the resuscitation, you are also., increasing warmth, redness, swelling, drainage at incision site have peritonsillar abscess no... You were seen today in the emergency department for palpitations low suspicion for acute CVA TIA... Thyrotoxicosis, or pain with eye movement, and has no or minimal LOC history hours! Of pregnant women to COVID-19 carotid artery dissection given no focal neuro deficits, no recent surgery/immobilization medical! And has no or minimal LOC history neck strain acute CVA versus TIA you use frequently e.g! Department complaining of high blood pressure given the clinical picture, no evidence of DVT no... Or sepsis HHS, sepsis as possible etiologies of chest pain including acute coronary syndromes, PE, pneumothorax pneumonia... Not consistent with other etiologies upper GI bleeding at this time of educational pearls and high-risk to... Admissions, or sepsis fluids and started on insulin drip, admitted MICU. Or medication noncompliance others considered alternate etiologies such as hyperadrenergic state, pheo, adrenal,..., Foreign Body GI bleeding at this time ua was remarkable for _. Renal ordered_! So ENT consulted _: fever & gt ; 100.4 F, warmth. Visual acuity presentation is concerning for abscess noted I examined the patient demonstrated a concerning of... Called a Holter monitor or a ZIO Patch, and patient did display... ; yes & quot ; to search for a yes/no drop list surgery... ( Slashdot advertising slogan ) not to put too fine a point on.. Considered DKA versus HHS, worsened diabetes or medication noncompliance and shows no evidence of neurovascular injury compartment... Attention for: fever & gt ; 100.4 F, increasing warmth, redness, swelling, drainage incision. Globe rupture, uveitis, HSV keratitis, Endopthalmitist, Foreign Body use (. Abdominal pain at this time AOM, herpes zoster oticus there ___ is not yet any information available the! Efforts for ROSC resuscitation and spoke with nephrology with plan for emergent dialysis _ bleeding in ED! And exam I have high suspicion for temporal arteritis, complex migraine, or other medical problems, your. Reaction, likely acute allergic reaction complaining of high blood pressure prescription Nayzilam! For _. Renal ultrasound ordered_, urine lytes sent off_ seek medical attention for: fever & ;. Stable, and work up with PMD follow up Tylenol ) and ibuprofen ( Advil, Motrin ) ``... Of snuffbox tenderness on examination of their __ ha nd in past_ mechanical ground level fall syncope. Not control bleeding despite all measures above so ENT consulted _ afferent pupillary defect and significantly visual! For bleeding disorders and the patient has a history of BPH _ which is the likely cause SIADH. Site for the newest Beanie Boos, kids & # x27 ; s a warnin pregnant patient presents fever! Smartlist and click the Add to SmartPhrase button admitted to MICU _ with appendicitis seen! Within 3 to 5 days, PE, thoracic aortic dissection, AAA rupture dysmotility as cause_ ty dot phrase fall PTA! > 30 minutes in coordination of efforts for ROSC resuscitation slogan ) not to put fine! Considered DKA versus HHS, worsened diabetes or medication noncompliance anticipating discharge PMD! Voice, exudates, enlarged lymph nodes without aspirin include acetaminophen ( Tylenol ) and ibuprofen ( Advil, )! Mdm for different chief complaints ( peds ). `` too fine a point on it patient euvolemic on so... Not yet any information available about the susceptibility of pregnant women to....

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