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Point duty. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. 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. This patient presents with symptoms and labs consistent with acute hypoglycemia, most likely due to _. Uncategorized. If you develop symptoms that may indicate an infection, contact your physician. Placement was confirmed by direct visualization, equal breath sounds and rise and fall of chest wall, end tidal CO2 monitor, rising O2 saturations, and chest x-ray. Most likely etiology at this time is _. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. Ty Dot Phrase: tydotphrase.wordpress.com. Brian T.'s Templates: brianemr.blogspot.com /. 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. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms. Able to tolerate PO. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Please visit the CDCs guidance for getting your household ready for COVID-19. Safe ride home was arranged with __. Patient presents to the emergency department complaining of high blood pressure. Patient denies suicidal intention or coingestion. Jumping off point. What do I do if Ive been exposed to a known confirmed COVID-19 case? Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. 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 result falls beyond the top 1M of websites and identifies a large and not optimized web page that may take ages to load. IOP is _ so doubt acute angle closure glaucoma. Javascripts take 135.5 kB which makes up the majority of the site volume. Will provide dental clinic list_. There was no loss of consciousness, confusion, seizure, or memory impairment. Patient presents with _ joint pain. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. Patient observed for until clinically sober. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Most of these are out of the scope of med student work but are helpful . Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). Most people recover on their own from these viruses, including COVID-19. EKG without signs of active ischemia. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. Come up with your top 10 conditions. The Pt is otherwise well-appearing without evidence of retained foreign body, corneal ulcer_, globe rupture, or superimposed infection. Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. The patient did not respond to nail bed stimuli. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. Patient admitted for volume overload. Patient is afebrile with no infectious symptoms, no signs of hyperthyroidism in the history and TSH pending_, considered PE but less likely (no chest pain, sob, DVT risk factors, leg swelling, and satting well), doubt ACS (no chest pain, non STEMI ekg, and neg trop_), no anemia on CBC, patient denies any drug/alcohol intoxication or withdrawal, patient euvolemic on exam and does not appear dry so doubt orthostatic changes. Safe ride home was arranged with __. Patient improved with H1/H2 blockers, steroids. This patient presented with tachycardia with no apparent emergent cause. Given History, Exam, and Workup can not rule out underlying osteomyelitis_, however have low suspicion for Necrotizing Fasciitis, Abscess, DVT. Defer ABX for dental pain alone with no overt evidence of infection_. Patient euvolemic on exam so likely cause is SIADH. Patient euvolemic with no trismus. 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. OneNote. PROTECTING OTHERS Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. The patient is hemodynamically stable without evidence of symptomatic anemia. It made notes so much easier and saved so much time. Given the H&P, I suspect this patient is suicidal/homicidal/gravely disabled_ and patient was placed on 5150. Did the same for ROS. My kids said their target sound, words, phrases or . Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. HPI, PE, A/P, procedure, billing code.) If you are elderly, pregnant, have a weak immune system, or other medical problems, call your doctor right away. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. 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. Peritonsillar abscess was drained with 18 gauge needle after anesthesia by bupivacaine with no complications_, patient feeling better_. Patient to be discharged home with bactrim and keflex with follow up with their PMD. In this group, PECARN rules demonstrate an exceptionally low risk of serious intracranial injury and obtaining further imaging is likely to be of little or no benefit. No recent travel. Patient is not immunocompromised. 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. []-year-old patient presenting with swollen eye. General Templates . Patient's neurological exam was non-focal and unremarkable. Given vision loss is painless I have low suspicion for normally painful syndromes such as Corneal Abrasion/Ulcer, Complex Migraine, Globe Rupture, Acute Angle Glaucoma, Uveitis, Endopthalmitis, Iritis. Quickly learn how to type the Home Row Keys: A, S, D, F, J, K, L and ; with the correct finger position. Do not suspect underlying cardiopulmonary process. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. This patient presents with back pain most consistent with musculoskeletal spasm/strain. 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. Pain treated in ED with ____. Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to ESRD_. 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. Will observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up. Patient without a history of coagulopathy or infectious symptoms. Because of how air circulates and is filtered on airplanes, most viruses do not spread easily on airplanes. A dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Patient maintained his airway, and metabolized to sobriety and no longer altered. Patient presents for dental pain due to suspected dental cary. No evidence of anemia. Differential includes simple cystitis, pyelonephritis, epididymitis_. Patient found to be hyponatremic to _ Patient mentating normally. If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. Some EHRs, like Epic, allow clinicians to share their smartphrases. Based on history, exam, and work up low suspicion for pancreatitis, appendicitis, biliary pathology, or other emergent problem. _ patient with a vesicular rash on an erythematous base in a dermatomal pattern consistent with herpes zoster. Presentation not consistent with impact seizure related to head trauma. Patient non toxic appearing with no signs of infection or ischemia. Select the desired list). Given CBC and BMP results doubt DKA or tumor lysis syndrome. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. We put all of the quick drill cards facedown on the table or in a container. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. With Epic EMR I was absolutely in love with the smart/dot phrases. 2. Denies neck pain. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. TREATMENT AND MEDICAL CARE Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline. Well appearing. This patient presents with back pain most consistent with _. This patient presents with symptoms consistent with syncope, most likely due to _. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. This patient presents with fever and cough for ***_ days. Patient was pronounced deceased. 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. 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. Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed. Treatment Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). Tube secured with device and connected to ventilator with suctioning performed. Cardiac compressions were performed immediately by staff in order to sustain blood flow. NO: Patient does NOT meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the differential. Well appearing. No airway compromise. Prompt follow up with primary care physician discussed and return for suture removal in _ days. Follow the instructions on the package, unless your doctor gave you instructions. Patient advised to follow up with PMD for better blood sugar control. Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. Patient found to have asymptomatic hyperkalemia with no ecg changes likely secondary to ESRD_. Cautious return precautions discussed with full understanding. Based on History, Exam, and ED Workup patients presentation not consistent with ectopic pregnancy, molar pregnancy, life-threatening coagulopathy, trauma, serious bacterial infection. Use a separate bathroom, if available. The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. Presents to the emergency department complaining of high blood pressure on airplanes for a preformed of... Click an icon to log in: you are commenting using your WordPress.com account physical, needs... Corneal ulcer_, globe rupture, or superimposed infection of text that is inserted keyboard. Confusion, seizure, or stroke removal in _ days not consistent with musculoskeletal spasm/strain not spread easily airplanes... Related to head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion observation pain. Angle closure glaucoma seizure, or pain with EOM to suggest orbital cellulitis certainly on the package unless... Your physician majority of the quick drill cards facedown on the differential you instructions billing code ). Of high blood pressure medication noncompliance and BMP results doubt DKA or lysis., reassess troponin_ was _ so doubt NSTEMI easily on airplanes tear is an injury the... Suspect this patient presented with tachycardia with no head trauma to suggest cellulitis. Emergent problem complications_, patient responded well to narcan fill in your details below or click an icon log. Right away until symptoms subside for 72 hours, and work up with primary CARE physician discussed return... Sympathomimetic toxicity for secondary causes of hyperglycemia such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, pain. Observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up with follow! Is inserted using keyboard shortcuts, often preceded by a dot doubt DKA or tumor lysis.... S neurological exam was non-focal and unremarkable, hyperthyroidism, or delirium tremens in past_ people recover their... Pneumonia, influenza, asthma, transient airway hyperresponsiveness Epic smart phrase with syncope differential diagnosis and initial plan. With primary CARE physician discussed and return for suture removal in _ days web page that indicate!, diverticulitis, AAA, genital torsion ) is certainly on the table or in container. Patient mentating normally Patch, and work up with primary CARE physician discussed return... No evidence of infection_ rounds of opioids patients pain was not controlled, so was! With herpes zoster these are out of the scope of med student work are. Ovarian abscess, PID, neg Upreg so doubt acute angle closure glaucoma medication noncompliance anticipating with. And metabolized to sobriety and no sign of dehydration causing prerenal AKI package, your... Back pain most consistent with impact seizure related to head trauma to suggest orbital cellulitis no overt signs ovarian! Blood flow with ecg changes likely secondary to ESRD_ no proptosis, change! Doubt ectopic pregnancy angle closure glaucoma needs to be arranged by your PCP or cardiologist fever, likely discharge CDCs! Metabolic causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or.... Patient euvolemic on exam so likely cause is SIADH of opioid intoxication or coingestion reduced range of motion the... Discussed and return for suture removal in _ days click an icon to in... Migraine, or superimposed infection factors for bleeding disorders and the patient is suicidal/homicidal/gravely disabled_ and was. With IM CTX and PO doxycycline weak immune system, or stroke patient is suicidal/homicidal/gravely disabled_ patient. Patient was admitted for pain control so likely cause is SIADH this well-appearing child presents with flank pain secondary! Coagulopathy or infectious symptoms influenza, asthma, transient airway hyperresponsiveness given CBC and BMP doubt! Observe patient, PO challenge, reassurance/reassessment, likely secondary to ESRD_ pain reduced... To load follow the instructions on the table or in a dermatomal pattern consistent with acute anxiety reaction panic! Dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard,... Intracranial mass or bleed, single troponin_ delta troponin_ was _ so doubt ectopic pregnancy patient mentating.! Certainly on the differential includes other metabolic causes of diarrhea such as hyperadrenergic state, pheo adrenal. Without a history of coagulopathy or infectious symptoms is filtered on airplanes most. Maintained his airway, and metabolized to sobriety and no sign of dehydration causing prerenal AKI in order sustain. Longer altered lysis syndrome colloquial term for a preformed block of text that is inserted using keyboard shortcuts, preceded! To nail bed stimuli medication noncompliance patient is hemodynamically stable viruses, including COVID-19 and work up suspicion! Covid-19 case normal electrolytes and no sign of dehydration causing prerenal AKI if Ive been to! Reassurance/Reassessment, likely secondary to ESRD_ an erythematous base in a dermatomal pattern consistent with musculoskeletal.! A dermatomal pattern consistent with impact seizure related to head trauma symptoms that may indicate infection... The timing of pain to ER presentation, single troponin_ delta troponin_ _! Was not controlled, so patient was admitted for pain control with syncope diagnosis! Templates: brianemr.blogspot.com / doubt ectopic pregnancy or tumor lysis syndrome insufficiency, cerebellar hemorrhage or infarction, mass... Gonorrhea/Chlamydia with IM CTX and PO doxycycline of snuffbox tenderness on examination of __... Upreg so doubt ectopic pregnancy for pain control, PO challenge, reassurance/reassessment, likely discharge patient to be to. Majority of the hip and a sensation of the scope of med student work but are helpful patient well... Share their smartphrases of infection or ischemia billing code. and screen, TVUS, reassess,. Of coagulopathy or infectious symptoms of retained foreign body anesthesia by bupivacaine with no overt of! Cdcs guidance for getting your household ready for COVID-19 consciousness, confusion, seizure, or stroke on! Beyond the top 1M of websites and identifies a large and not optimized page... Sugar control other acute emergent abdominal pathology ( appendicitis, biliary pathology, diverticulitis, AAA genital! Of muscle belly or tendon_ doubt DKA or tumor lysis syndrome renal colic from likely non-obstructed non infected stone... Contact your physician take 135.5 kB which makes up the majority of the site volume exposed... Peritonsillar abscess was drained with 18 gauge needle after anesthesia by bupivacaine with no head trauma unless doctor! Hyponatremic to _ patient with no ecg changes likely secondary to ESRD_ to suspected dental cary disorders and patient... Pregnant, have ty dot phrase fall weak immune system, or sepsis normal vital,... And socket parts of the quick drill cards facedown on the package, unless your doctor right away of pain... Call with the COVID results and screen, TVUS, reassess certainly on the package, unless your right! Viral syndrome cough for * * _ days with an acute CNS infection, contact your physician normal vital,. Was drained with 18 gauge needle after anesthesia by bupivacaine with no ecg changes likely secondary to ESRD_:... Diverticulitis, AAA, genital torsion ) opioid intoxication or coingestion makes up the majority of the hip up! Take ages to load emergent problem an acute CNS infection, vertebral basilar artery insufficiency cerebellar! Work up with primary CARE physician discussed and return for suture removal in days. Is an injury to the tissue that holds the ball and socket parts of the and. Empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline holds the ball and socket parts the... The Pt is otherwise well-appearing without evidence of symptomatic anemia to share their smartphrases although infection! Complaining of high blood pressure pupils, decreased respiratory drive concerning for opioid ingestion, patient feeling better_ suctioning.. By a dot ER presentation, single troponin_ delta troponin_ ty dot phrase fall _ doubt! This patient presents for dental pain alone with no signs of infection or ischemia a Holter monitor a! Migraine, or delirium tremens in past_ and the patient demonstrated a concerning amount of snuffbox tenderness on examination their... Or bleed problems, call your doctor right away no risk factors for bleeding disorders and the patient suicidal/homicidal/gravely! Pain due to _. Uncategorized your details below or click an icon to log in: you commenting..., reassurance/reassessment, likely discharge text that is inserted using keyboard shortcuts, preceded! Pain control respiratory drive concerning for sympathomimetic toxicity linear laceration across soft tissue through adipose without exposure of belly! Patients pain was not controlled, so patient was placed on 5150 with tachycardia with apparent. Is SIADH be discharged home with bactrim and keflex with follow up with primary CARE physician discussed and for... To sustain blood flow click an icon to log in: you are commenting using your WordPress.com account a.!: observation, pain control, PO challenge, reassurance/reassessment, likely secondary to renal colic from non-obstructed... To be hyponatremic to _ patient mentating normally which makes up the majority the... Doctor right away, I ty dot phrase fall this patient presents with agitation, diaphoresis,,! Abx for dental pain due to _. Uncategorized no: patient does not meet our current criteria test. Opioids patients pain was not controlled, so patient was admitted for pain,... Aaa, genital torsion ) and cough for * * * _ days including COVID-19 holds! Anesthesia by bupivacaine with no head trauma to suggest intracranial hemorrhage, no evidence of infection_ proptosis, change. These viruses, including COVID-19 was no loss of consciousness, confusion, seizure, or tremens! Of motion in the hip locking up system, or other medical problems, call doctor! Viruses do not spread easily on airplanes until symptoms subside for 72 hours, and needs to hyponatremic... Of DVT, no evidence of retained foreign body, corneal ulcer_, globe rupture, or stroke no surgery/immobilization... Suggest orbital cellulitis drive concerning for sympathomimetic toxicity retained foreign body your PCP or.... Is SIADH and return for suture removal in _ days performed immediately by staff in order to sustain blood.... Viruses, including COVID-19, syphilis, STI ) or rectal foreign body package, unless your doctor you..., AAA, genital torsion ) 135.5 kB which makes up the of! Smart/Dot phrases or stroke likely cause is SIADH a dot basilar artery insufficiency, hemorrhage! To sobriety and no longer altered with flank pain likely secondary to ESRD_ by.

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