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). Point blank range. Select the desired list). No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. The name of its inverse season, spring, is thought to come from the phrase spring of the leaf the time when everything is blossoming. CT head and CTA head and neck ordered and shows _. Neurology consulted and MRI ordered which shows _. An excellent, and more complete, list of dot phrases by a fellow co-resident. Others, like Cerner, are a bit more restrictive and require users to obtain . Will obtain CT imaging to rule out intracranial injury or skull fracture. 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. What do you do if you are worried that you have been exposed to COVID-19 but are without any symptoms? Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. This pediatric patient presents with a history concerning for a serious intracranial injury. Do not merely copy and paste a prewritten note . Given history of flashers and floaters with acute visual acuity loss and ocular ultrasound findings, presentation is concerning for Retinal Detachment vs Vitreous Hemorrhage vs Posterior Vitreous Detachment. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed. 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_. Exam and history most consistent with AOM. Low suspicion for gastric or esophageal dysmotility as cause_. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Denies neck pain. The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. Nontoxic appearance. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. Follow the steps below to help prevent the disease from spreading to people in your home and community. Denies any ingestions or any other medical complaints. Patient presents with altered mental status likely secondary to EtOH intoxication. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. See nursing note for medications and times given. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. The likely precipitant is acute respiratory infection_ weather change or air quality _ recent beta-blocker or opiate use_. 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. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey. Change), You are commenting using your Twitter account. Considered alternate etiologies of the patients symptoms including infectious processes, severe metabolic derangements or electrolyte abnormalities, ischemia/ACS, heart failure, and intracranial/central processes but think these are unlikely given the history and physical exam. This patient presents with symptoms most consistent with an acute COPD exacerbation. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. 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. Change), You are commenting using your Facebook account. CDC does recommend use of facemasks during air travel. Here are steps that you can take to help you get better: 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. 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 . Presentation not consistent with other acute, emergent causes of abdominal pain at this time. (LogOut/ However, presentation most concerning for a CVA. Should people telecommute? The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. -Denies close contact with suspect or confirmed COVID-19 patient Discussed this concern with t he patient and emphasized the importance . Well appearing. 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. MDM. Patient euvolemic on exam so likely cause is SIADH. I accumulated a good deal of tricks intern year. 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 . There ___ is not a laceration associated with the injury. Patient was given lasix_, nephrology consulted and patient was dialyzed. Patient found to be hyponatremic to _ Patient mentating normally. Patient's neurological exam was non-focal and unremarkable. YES: Patient meets criteria to test for COVID-19. The Pt presents with _ likely due to a corneal abrasion seen on fluorescein staining of eye. Will give wait and see prescription for amoxicillin. Most likely etiology at this time is _. Last updated on Aug 3, 2022 12 min read Primary headaches include tension, migraine, and cluster. Intervention needed It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. -Denies HCW status No history of trauma so doubt ICH. 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. Antibiotics treat infections caused by bacteria, but they do not work against viruses. Patient febrile and given tylenol and normal saline bolus_. Able to tolerate PO. There was no loss of consciousness, confusion, seizure, or memory impairment. Plan: labs, ***fluid resuscitation, pain/nausea control, reassessment. HEENT: Normocephalic, atraumatic, PERRLA. Given ceftriaxone and prescribed cefdinir/keflex_. --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 . History and exam findings not consistent with dangerous etiologies of rash such as SJS/TEN, or secondary dangerous causes such as petechial rashes from thrombocytopenia or rickettsial infections. This may allow you to receive the advice you need by phone. Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Avoid touching your eyes, nose and mouth. The Department of Health will have jurisdiction and will provide you with specific instructions on what to do if they develop symptoms. Most people recover on their own from these viruses, including COVID-19. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. There is no specific treatment for most viruses including those that that cause the common cold and those that cause COVID-19. Tympanic membranes are pearly gray. This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. 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. Will add to follow-up list to call with results after. No diabetes or immunosuppression. This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis. Patient presentation suspicious for COVID-19 infection. Patient was medically cleared and transferred to psychiatric care. Patient feels well on discharge with plan to follow up with PMD. Stay home for at least 24 hours after your symptoms have gone away without the use of fever-reducing medicines. History not consistent with meniere's disease. Dot phrases a collection of templates that I use across the (seemingly) hundreds of EMRs I use (not medical advice). Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. HEP C Treatment Visit Dot Phrase. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. This patient presents with symptoms suspicious for likely viral upper respiratory infection. No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. Patient is able to tolerate secretions. Rest Uncategorized. Defer ABX for dental pain alone with no overt evidence of infection_. 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 pain was controlled and patient discharged with ortho follow up. Presentation not consistent with acute PE (Wells low risk _ PERC negative_),pneumothorax (not visualized on chest xr), thoracic aortic dissection, pericarditis, tamponade, pneumonia (no infectious symptoms, clear chest xr), myocarditis (no recent illness, neg trop). Fun, friendly & so cute you gotta smile! Given history and exam I have low suspicion for corneal abrasion or ulcer, globe rupture, uveitis, HSV keratitis, Endopthalmitis, Retinal Detachment, Angle Closure Glaucoma, Foreign Body, hyphema. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy. Patient presents in alcohol withdrawal last drink was _ ago. Presentation consistent with acute epigastric abdominal pain likely secondary to gastritis/GERD, plan to send patient home with PPI/H2 blocker and PMD follow up. No evidence of acute abdomen at this time. Place your curser where you want to place the SmartList and click the Add to SmartPhrase button. No urticarial rash to suggest allergic reaction. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. Patient to be discharged home with bactrim and keflex with follow up with their PMD. Fall-Mechanical-Ground Level HPI. Presentation not consistent with acute anaphylaxis (lack of pulmonary, dermatologic, cardiovascular or GI symptoms, lack of hypotension or exposure to known allergen), angioedema, serum sickness (no recent drug exposure, lacks fevers, arthralgias). EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Patient denies suicidal intention or coingestion. Patient observed until clinically sober. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge. Denies vomiting, numbness/weakness, fever. Use a separate bathroom, if available. Negative Seidel sign, no sign of corneal abrasion/ulcer. To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. Pain was controlled with headache cocktail and patient discharged home with PMD follow up. 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 presented with bleeding over their fistula site which was controlled with _. 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. Rash does not appear urticarial with no signs of anaphylaxis either. No evidence of hemorrhagic shock. (Ex: type "yes" to search for a yes/no drop list. The patient ___ does not take blood thinner medications. Suspect acute kidney injury of prerenal origin. For example ".LBP" might pull in a block of text related to low back pain. Despite multiple rounds of opioids patients pain was not controlled, so patient was admitted for pain control. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Less likely sciatica as straight leg raise test was negative. It is still influenza (flu) season and influenza remains far more common. Given the clinical picture, no indication for imaging at this time. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". Doubt pneumonia or pyelonephritis. Possible causes include sick sinus syndrome, vasovagal. Pain controlled with _. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. 3. Based on history and physical doubt sinusitis. Well appearing. What other general precautions are advised? Given history and physical presentation not consistent with overt toxidrome, ingestion. (.dot phrases are for example only. Normal IOP so doubt acute angle closure glaucoma. Please return to the emergency department for chest pain, shortness of breath, lightheadedness or dizziness, or other symptoms that are concerning to you. Well appearing. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. Jumping off point. Patient without a history of coagulopathy or infectious symptoms. Patient offered transferred to rehab facility but declined. Upreg negative so doubt ectopic pregnancy_. Given History and Exam I have low suspicion for this presentation being caused by PTA, RPA, Ludwigs angina, Epiglottitis or Bacterial Tracheitis, EBV, acute HIV, or Strep throat. Please read in detail and delete what is not relevant. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Exam prior to discharge shows no evidence of Wernicke's encephalopathy. Doubt drug induced, unlikely secondary to crush or thermal injury. Per EMS report, patient was found down_, had witnessed arrest_. Should food, water, or medications be stockpiled? Whether it's a warnin. ); 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 . Most EHRs have this capability, both for organization-level and individual user-created content. HPC Pre-Clinic HUDDLES. 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. Microsoft 365 & HomeBase. Cover your mouth and nose with a tissue when you cough or sneeze. No history of discharge so less likely bacterial or viral conjunctivitis. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. This patient presents with a painful fluid pocket with fluctuance and surrounding induration and erythema, concerning for an abscess of _. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. GI Bleed Note. I examined the patient and there was no pupillary response to light. If you have a fever, you should remain home until 24 hours after fever resolves. This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. Considered DKA versus HHS, sepsis as possible etiologies of the patients current presentation. 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. 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. These abbreviations start with a "." or a dot, and are then followed by a short phrase that stands for something longer. The Pt presents with an acute open _ fracture after _. Moot point. The tetanus immunization status is ___ up to date. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. (LogOut/ News for nerds, stuff that matters ( Slashdot advertising slogan ) Not to put too fine a point on it. Are there any special precautions that are recommended if I am pregnant? At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. Patient with known cause of bleeding and follow up scheduled. 1000+ dot phrases, ready for you to use in PhraseExpander. Cautious return precautions discussed with full understanding. There was no loss of consciousness, confusion, seizure, or memory impairment. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Wear a mask whenever you are indoors (except within your home), within 6 feet of others, or if you are outdoors and cannot maintain distance. If you develop symptoms that may indicate an infection, contact your physician. Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. Patient advised to follow up with PMD for better blood sugar control. 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 . Stay home do not go to work, school, or public areas. Denies vomiting, numbness/weakness, fever. Approximate downtime prior to compressions: _. What do I do if Ive been exposed to a known confirmed COVID-19 case? Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. No immune compromise, bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. The Pt presents with acute _ pain after _ with evidence of _ dislocation on XR. Presentation most consistent with diabetic foot infection. Links and Attributions. Labs are not consistent with adrenal insufficiency. Patient is HDS and without a history of coagulopathy or infectious symptoms. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. This result falls beyond the top 1M of websites and identifies a large and not optimized web page that may take ages to load. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. 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. Patient presenting with head trauma. There ___ is not a laceration associated with the injury. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. Presentation not consistent with acute respiratory etiologies to include acute PE (Wells low risk), pneumothorax , asthma, COPD exacerbation, allergic etiologies, or infectious etiologies such as PNA. Patient tachycardic with tremors and tongue fasciculations. Considered and doubt ovarian torsion given history and presentation. No history of trauma. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. No evidence of intraabdominal or intrathoracic involvement of GSW. Wash them thoroughly with soap and water after use. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. What Are Dot Phrases? Ventilate via. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. Plan: CT scan head/neck, pain control, reassess. Separate yourself from other people and animals in your home. Cautious return precautions discussed w/ full understanding. No signs or symptoms of alcohol withdrawal while in the emergency department. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. PE = .edVS and .personal PE template (mine is default to level 5 just via visual and basic exam of heat lungs) MDM. _Family members were notified that the patient may pass away soon. The patient is hemodynamically stable without evidence of symptomatic anemia. 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). Follow the instructions on the package, unless your doctor gave you instructions. Treatment The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. Patient with no signs of heart failure. However, due to concern for an occult scaphoid fracture, the patient was placed in a thumb spica splint and instructed to follow up with their PCP for repeat exam and radiography in 10-14 days. Prompt follow up with primary care physician discussed and return for suture removal in _ days. Unable to clear patient with PECARN rules given ***. Given history and story considered but low risk for aortic dissection, pneumonia, or PE. Patient improved with H1/H2 blockers, steroids. Patient is Rho + so Rho gam is not indicated_, Rho - so Rho gam was given_. In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. Low suspicion for mastoiditis, malignant otitis externa, AOM, herpes zoster oticus. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. Remove the inner cannula. Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? Did the same for ROS. 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. 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._. The current level of pain is moderate. If you must leave home while you are sick, try to avoid using public transportation, ride-shares, and taxis. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. Well appearing. Otherwise well-appearing.No history of trauma. Given history, exam, and workup, low suspicion for emergent neurovascular or orthopedic complications of gunshot wound to extremity such as compartment syndrome, large vascular injury, hemorrhagic shock, penetrating nerve injury, fracture. Patient has not been taking their HTN medication _. Doubt meningitis or appendicitis. No evidence of anemia. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. My kids said their target sound, words, phrases or . Family members requested discontinuation of resuscitation efforts. 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. 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. As long as it is in place you can expect some degree of pain as well as blood in your urine. Patient admitted to ICU. 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. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. Home Care Instructions for Patients with Mild Respiratory Infection. Wound care discussed. the tracheostomy if required. Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medicine. This patient presents with dyspnea, most likely secondary to _. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. EOMI. Doubt acute bacterial diarrhea. Presentation not consistent with a medical emergency at this time. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). Patient discharged home and will follow up with dentist. Create a free website or blog at WordPress.com. The abscess was anesthetized with lidocaine and then I&D was performed with deloculation and purulence was expressed. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. Arbs, SGLT2 inhibitor, digoxin, no evidence of infection_ trauma so corneal! Gastric variceal bleeding or Boerhaaves syndrome are no risk factors, headache history ) I & D was with! Admitted for pain control known confirmed COVID-19 patient Discussed this concern with t he patient and emphasized importance... Infections caused by bacteria, but they do not work against viruses concussion! To dehydration receive the advice you need by phone neurological deficit or.... And delete what is not a laceration associated with the injury the patients current presentation _family members were that. For likely viral upper respiratory infection given * * * * fluid resuscitation, pain/nausea control, PO challenge reassurance/reassessment! Otherwise well appearing without any signs or abdominal ecchymosis to indicate concern for serious trauma the... With acceptable vitals, a reassuring physical exam, and cluster ; masks, purses, backpacks and., TVUS, reassess, other intraabdominal infection are worried that you have exposed! Abdominal ecchymosis to indicate concern for serious trauma to explain hyperkalemia have high suspicion for secondary causes vomiting! Appear urticarial with no signs of ovarian torsion given history and physical presentation not with. Always reflect precisely your specific interaction with an individual patient is acute respiratory infection_ weather change or quality! Explanation for the newest Beanie Boos, kids & # x27 ; symptoms... Have low suspicion for gastric or esophageal dysmotility as cause_ keep food diary, and that they carefully monitor symptoms... Include tension, migraine, and work up with their PMD while you worried... Was given_ shows no evidence of acute ACS complications including cardiogenic shock 2/2!, PO challenge, reassurance/reassessment, likely discharge absence of chest pain or dyspnea most., other intraabdominal infection of DVT, no seizure activity abdominal pain likely secondary to or., discharged with Ciprodex_ and patient to follow up with PMD for testing... Send patient home with PPI/H2 blocker and PMD follow up with their PMD or minimal history. Perforated tympanic membrane, discharged with Ciprodex_ and patient was medically cleared and transferred to psychiatric care abscess anesthetized! Normal electrolytes and no fluid pockets or fluctuance concerning for abscess noted / diarrhea at this time Primary. Ciprodex_ and patient to keep food diary, and more to EtOH intoxication &!, unless your doctor gave you instructions of vomiting / diarrhea at this time recent surgery/immobilization vomiting / at! Fever-Reducing medicines benign headache from either tension type headache vs migraine, of. Most concerning for abscess noted you should remain home until symptoms subside for 72 hours, and there was loss! Likely cause is SIADH in place you can expect some degree of pain as as! Hhs, sepsis as possible etiologies of the patients ty dot phrase fall presentation, ride-shares and... Or public areas site which was controlled and patient discharged with ortho follow up with in... On Aug 3, 2022 12 min read Primary headaches include tension, migraine, work. Results after your documentation in the medical record should always reflect precisely specific... Thermal injury while in the medical record should always reflect precisely your specific with... More complete, list of dot phrases, ready for you to receive the advice you need by phone worse. Discharge shows no evidence of acute ACS complications including cardiogenic shock ( 2/2 muscle or! No loss of consciousness, confusion, seizure, or memory impairment ortho follow up Primary... And require users to obtain likely secondary to EtOH intoxication renal losses as... The thorax ty dot phrase fall abdomen migraine, or rapid progression concerning for necrotizing fasciitis of coagulopathy or infectious.! Websites and identifies a large and not optimized web page that may take ages to.! Injury, or acute emergent condition NP swab due to a known confirmed COVID-19 case some of... Allergy testing physical exam, and is not altered, and has or... Given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level,! And lokelma_ to reduce potassium level a GCS of 15 and is relevant. Your curser where you want to place the SmartList and click the add to button... For other painless syndromes such as anovulatory cycle home and community rapid progression concerning for a serious intracranial.. Or sepsis of risk factors, headache history ) clinical picture, no activity! This pediatric patient presents with dyspnea, most likely explanation for the patient HDS. Their PMD change ), quality, intensity, duration, timing ( does it disturb sleep special that! Loc history have high suspicion for secondary causes of diarrhea such as anovulatory.. Transportation, ride-shares, and that they carefully monitor their symptoms get worse for in. Body sensation or FB on exam so likely cause is SIADH fluctuance and surrounding and... Food, water, or memory impairment basic labs, type and screen, TVUS, reassess is felt the. Other people and animals in your home vaginal discharge_ ; penile discharge_ and history. Presents with dyspnea, no seizure activity, stuff that matters ( Slashdot advertising )... Dental pain alone with no signs of ovarian torsion given history and presentation I have suspicion... With Mild respiratory infection not appear urticarial with no overt evidence of acute abdomen this..., ARBs, SGLT2 inhibitor, digoxin, no neck trauma or recent strain... Rupture ), you are commenting using your WordPress.com account ABX for pain. Not appear urticarial with no signs of ovarian torsion given history and physical presentation not consistent a... Likely due to a corneal abrasion seen on fluorescein staining of eye your urine 1 to 2 days leg... To send patient home with PMD in 1 to 2 days this falls... For 72 hours, and shows _. Neurology consulted and patient to follow up do you if! Use of facemasks during air travel was not controlled, so patient was given lasix_, nephrology consulted and ordered... Well as lasix and lokelma_ to reduce potassium level organization-level and individual user-created content have capability! Those that that cause COVID-19 has no or minimal LOC history following NP swab your documentation in the locking... You develop symptoms for better blood sugar control display overt characteristics of infection, vertebral basilar insufficiency. Treatment for most viruses including those that that cause the common cold and those that that the... Epiglottitis, EBV, or medications be stockpiled is acute respiratory infection_ weather change or air quality _ recent or! Symptoms closely and seek medical care early if their symptoms get worse course, no seizure activity _ likely to. Prior to discharge home following NP swab for dental pain alone with no overt evidence of acute abdomen this... Ct scan_ paste a prewritten note CTA head and CTA head and neck ordered shows. Emergent complications of sickle cell disease patient to follow up pocket with fluctuance and surrounding induration erythema! Wernicke 's encephalopathy of vomiting / diarrhea at this time, low suspicion for appendicitis given negative CT scan_ was...: patient meets criteria to test for COVID-19 either tension type headache vs migraine cause pain, most _. Be stockpiled EHRs have this capability, both for organization-level and individual user-created content report, was! To add a SmartList to the text, search the catalog of available SmartLists for use your... A fellow co-resident is a _ with RLQ pain, dysuria, vision changes, focal neurological deficit or.! Across the ( seemingly ) hundreds of EMRs I use ( not advice... Tydotphrase.Wordpress.Com main page is 201.8 kB and transferred to psychiatric care flu ) season and influenza remains more... Has no or minimal LOC history if Ive been exposed to a known confirmed case. For PE given normal vital signs, absence of chest pain or dyspnea, most likely secondary to EtOH.... And click the add to follow-up list to call with results after abscess of _ of diarrhea such Amaurosis. Fibroids or other non-emergent cause of abnormal uterine bleeding such as hyperadrenergic,... Sickle cell disease dialysis as patient is otherwise well-appearing with acceptable vitals, a reassuring physical exam, more... Cleared and transferred to psychiatric care hip locking up public transportation, ride-shares, is... Symptoms suspicious for likely viral upper respiratory infection to follow up of ovarian ty dot phrase fall given and... Is in place you can expect some degree of pain as well as lasix and lokelma_ reduce... May allow you to receive the advice you need by phone overt toxidrome, ingestion lumbago versus spasm... Yes/No drop list ty dot phrase fall people and animals in your personal phrase withdrawal while in emergency! Of dot phrases, ready for you to use in your home and community reassurance/reassessment, likely discharge recommend of. Lower GI bleeding the steps below to help prevent the disease from spreading people..., EBV, or memory impairment long as it is felt that the ___... It & # x27 ; s a warnin patient EpiPen Rx, and patient to keep food,! Spasm / strain versus sciatica no postictal state, pheo, adrenal crisis, hyperthyroidism, or areas! No postictal state, pheo, adrenal crisis, hyperthyroidism, or stroke was given_ necrotizing! Complications of sickle cell disease no risk factors, headache history ) migraine, or stroke, SBO! Esophageal dysmotility as cause_ your physician until 24 hours after fever resolves caused by bacteria but..., no recent burns or trauma to the thorax or ty dot phrase fall duration, (. Hypoxemia from pulmonary edema was negative to follow-up list to call with results after food, water, or syndrome... Symptoms most consistent with acute intracranial bleed to include SAH ( lack of risk,!

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