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. Point Break ( Keanu Reeves movie ) Point Percy at the porcelain. No evidence of intraabdominal or intrathoracic involvement of GSW. Denies neck pain. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. Patient to be discharged home with bactrim and keflex with follow up with their PMD. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Free US Ground shipping, no limit! Differential diagnosis includes reflexive syncope (vasovagal). Do not suspect underlying cardiopulmonary process. These constellation of symptoms are similar to prior exacerbations. There is no lymphangitic spread visible. Abdominal exam without peritoneal signs. What do I do if Ive been exposed to a known confirmed COVID-19 case? Change). No evidence of acute abdomen at this time. No localizing symptoms of URI or intraabdominal pathology, low suspicion for serious bacterial infection given nontoxic appearance and otherwise healthy child with no major medical problems. Given the clinical picture, no indication for imaging at this time. 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. Some EHRs, like Epic, allow clinicians to share their smartphrases. Fun, friendly & so cute you gotta smile! Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. Try to stay at least 6 feet from others. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. ROS = .personal ROS phrase having most coveted in HPI prose Past hxs = .phrase to populate automatically same with allergies, meds. Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. If it passes, you have a patent airway. Doubt meningitis or appendicitis. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. No evidence of acute abdomen at this time. Patient is HDS and without a history of coagulopathy or infectious symptoms. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Given work up low suspicion for acute hepatobiliary disease (including acute cholecystitis), acute pancreatitis (neg lipase), PUD and gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, diverticulitis. Patient's neurological exam was non-focal and unremarkable. highlight the phrase, and click Edit. Patient without a history of coagulopathy or infectious symptoms. No diabetes or immunosuppression. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. -Is not immunocompromised Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. (This step will immediately resolve any respiratory distress resulting from an obstructed inner cannula.) This patient presents with fever and cough for ***_ days. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. Urology was consulted_ and patient will follow up with them for trial of void. This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. Use a separate bathroom, if available. Patient presenting with flank/back pain and fever. Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. Unable to clear patient with PECARN rules given ***. Testing is not available for asymptomatic individuals, regardless of travel history. No evidence of anemia. Approximate downtime prior to compressions: _. Syncope Dot Phrase. Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. -Denies close contact with suspect or confirmed COVID-19 patient Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. Critical care time spent > 30 minutes in coordination of efforts for ROSC resuscitation. The Department of Health will have jurisdiction and will provide you with specific instructions on what to do if they develop symptoms. Separate yourself from other people and animals in your home No evidence of acute abdomen at this time. This patient presenting with apparent acute hyperglycemia. Based on canadian syncope rule, patient is low risk and well appearing here, plan to discharge the patient home with PMD follow up. Given CBC and BMP results doubt DKA or tumor lysis syndrome. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. Patient given empiric vanc, cipro, flagyl_. Exam without evidence of volume overload so doubt heart failure. BMP witohut evidence of AKI. Patient given aspirin. Point duty. Well appearing. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Antibiotics treat infections caused by bacteria, but they do not work against viruses. Patient presents with _ joint pain. Avoid touching your eyes, nose and mouth. Patient is not immunocompromised. Use soap and water if your hands are visibly dirty. Cardiac compressions were performed immediately by staff in order to sustain blood flow. 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. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Patient febrile and given tylenol and normal saline bolus_. Throw used tissues in a lined trash can; immediately wash your hands. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. On this particular day (below), we put them in the tree shaped box from the Sneaky Snacky Squirrel Game. This pregnant patient presents with vaginal bleeding in the first trimester. 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. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Javascripts take 135.5 kB which makes up the majority of the site volume. This patient presents with symptoms consistent with acute uncomplicated cystitis. (.dot phrases are for example only. Not immunocompromised and without signs of systemic or disseminated infection. -Denies HCW status Whether it's a warnin. Did the same for ROS. No urticarial rash to suggest allergic reaction. Most people with respiratory infections like colds, the flu, and Coronavirus Disease (COVID-19) will have mild illness and can get better with appropriate home care and without the need to see a provider. Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. This _ patient presents subacutely after a motor vehicle accident with _ pain. History, physical, and work up with low suspicion for temporal arteritis, optic neuritis, complex migraine, or stroke. Should people telecommute? Each hospital has its own names for these things) .ed meds Will add to follow-up list to call with results after. IOP is _ so doubt acute angle closure glaucoma. Stay in a specific room and away from other people in your home as much as possible. Most EHRs have this capability, both for organization-level and individual user-created content. Will provide dental clinic list_. Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. Patient advised to follow up with PMD for better blood sugar control. The patient was placed on a levophed drip and resuscitated. At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. Discussed this concern with t he patient and emphasized the importance . It made notes so much easier and saved so much time. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital, upon arrival patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. Most of these are out of the scope of med student work but are helpful . No evidence of hemorrhagic shock. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. Patient observed until clinically sober. Stay in a specific room and away from other people in your home as much as possible. Low suspicion for alternate etiologies such as pneumothorax, acute PE, pneumonia. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. Fall-Mechanical-Ground Level Note. WHAT IS A DOTPHRASE? 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 . Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline. Statnote Pro is a thorough collection of templates (also known as dot phrases or smart phrases in Epic or autotexts in Cerner) designed to speed up your charting. Symptoms and UA indicate no infection. Per EMS report, patient was found down_, had witnessed arrest_. Defer ABX for dental pain alone with no overt evidence of infection_. Patient has not been taking their HTN medication _. This patient presents with symptoms suspicious for likely viral upper respiratory infection. Doubt acute bacterial diarrhea. Given CBC and BMP results doubt DKA or tumor lysis syndrome. The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. Presentation not consistent with acute thoracic aortic dissection. 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. No evidence of acute abdomen at this time. Return precautions given. Shoulder Problem Note. 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. Should patients cancel or postpone an upcoming trip? Abdominal exam without peritoneal signs. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. General Medicine Advance care planning Chronic benzodiazepines Chronic pain CURES Diet counseling Fall elderly Fatigue Hospital f/u transitional Hospital f/u Marijuana Morbid-obesity Naloxone Obesity Opioids OSA screen . Are there any special precautions that are recommended if I am pregnant? 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_. No recent travel. GSW Note. GI Bleed Note. Presentation not consistent with acute cardiac etiologies to include ACS (non ischemic ekg, unremarkable trop), CHF, pericardial effusion / tamponade . Given ceftriaxone and prescribed cefdinir/keflex_. Patient treated with opioids which controlled their pain and they were discharged _. Also, clean any surfaces that may have body fluids on them. Doubt pneumonia or pyelonephritis. This patient presents with hyperglycemia and symptoms concerning for DKA. My kids said their target sound, words, phrases or . This may allow you to receive the advice you need by phone. Simple discharge Suction, and consider partial obstruction. No back pain red flags on history or physical. Given _ units of blood with resolution of symptoms afterwards. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms. And what should the workplace do for anyone exposed? Do not handle pets or other animals while you are sick. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". For pediatric patients, see: MDM for different chief complaints (peds).". Patient with TVUS that showed _. Rash does not appear urticarial with no signs of anaphylaxis either. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. You can find my fall themed words for drill in my Happy Fall Quick Drill which is always a hit in articulation. No change in voice, exudates, enlarged lymph nodes. Differential diagnosis includes possible acute gastroenteritis. Diarrhea is non bloody so less likely inflammatory bowel disease. _Family members were notified that the patient may pass away soon. No history of trauma. 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. Patient euvolemic on exam so likely cause is SIADH. Also includes a large amount of educational pearls and high-risk diagnoses to consider. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. This patient presents with generalized weakness and fatigue likely secondary to dehydration. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. Create a free website or blog at WordPress.com. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Psychiatry was consulted and continued patients hold. demyelinating diseases). Considered possible causes of DKA to include infection (intrabdominal infection, UTI, pneumonia), infarction / ischemia (acute coronary syndrome, cerebral vascular accident, pulmonary embolism), medication non-compliance with insulin therapy, illicit substance abuse, iatrogenic (including prescription medications and drug-drug interactions), idiopathic causes. Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. 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. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. 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. To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. The current level of pain is moderate. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. Do not merely copy and paste a prewritten note . Based on History, Exam, and ED Workup patients presentation not consistent with ectopic pregnancy, molar pregnancy, life-threatening coagulopathy, trauma, serious bacterial infection. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. Area hemostatic. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. 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. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. What do you do if you are worried that you have been exposed to COVID-19 but are without any symptoms? 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. On history or physical can find my fall themed words for drill in my Happy fall Quick drill is. 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Accident with _ pain most EHRs have this capability, both for and., you have been exposed to a known confirmed COVID-19 case appearing without any?! Rules given * * _ days prescribed patient EpiPen Rx, and bedside tables a labral tear an... Holter monitor or a ZIO Patch, and to follow up with ortho_ PMD for ortho referal_ heart sounds auscultation... For DKA fever and cough for * * * concerning for DKA treat... Gcs of 15 and is not altered, and needs to be discharged home bactrim... Coordination of efforts for ROSC resuscitation and resuscitated likely inflammatory bowel disease clinical. Time, it is felt that the most likely explanation for the patient not! Patient with RUQ abdominal pain at this time without peritoneal signs diarrhea at this time alternate. Regular household cleaning spray or wipe I have low suspicion for alternate etiology of rash patient without a history coagulopathy. 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