(Ex: type "yes" to search for a yes/no drop list. No signs or symptoms of alcohol withdrawal while in the emergency department. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. These constellation of symptoms are similar to prior exacerbations. No evidence of hemorrhagic shock. The current level of pain is moderate. 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. Use soap and water if your hands are visibly dirty. SharePoint. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), transverse myelitis, (no sensory loss, no distal weakness), thoracic aortic dissection (equal peripheral pulses, no tachycardia, story does not fit), pneumonia (afebrile, no infectious symptoms), pulmonary embolism (Wells low risk), osteomyelitis or epidural abscess (no IVDU, vertebral tenderness). No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Place your curser where you want to place the SmartList and click the Add to SmartPhrase button. Well appearing. Instructed patient to continue to treat pain with ibuprofen/acetaminophen until they see a dentist. Doubt alternate acute emergent pathology. Will give wait and see prescription for amoxicillin. Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. It made notes so much easier and saved so much time. Just was ten systems, fairly minimal observations, minimum for billing. Low suspicion for gastric or esophageal dysmotility as cause_. Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. Given history, I have low suspicion for giardia or other parasites. Are there any special precautions that are recommended if I am pregnant? Change). This patient presents with symptoms concerning for an acute upper GI bleed. No evidence of acute abdomen at this time. This showed no significant findings. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. Most likely etiology at this time is _. Considered alternate etiologies of this patients pain to include fracture, MSK pain, infection/abscess, and other ischemic etiologies (stroke, MI) but doubt these are likely. OK to Book Note. Cardiac compressions were performed immediately by staff in order to sustain blood flow. This patient presents with acute cough, most consistent with _. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. Offered patient dental nerve block for pain which patient accepted/declined_. Cover your coughs and sneezes If you do visit a healthcare facility, put on a mask to protect other patients and staff. If it passes, you have a patent airway. This _ patient on anticoagulant _not on anticoagulant presents with active epistaxis. Doubt drug induced, unlikely secondary to crush or thermal injury. This patient presents with nausea, vomiting & diarrhea. This patient has a presentation consistent with rectal bleeding, most likely due to _. PE = .edVS and .personal PE template (mine is default to level 5 just via visual and basic exam of heat lungs) MDM. Patient given zofran and tolerated PO here. Doubt meningitis or appendicitis. Patient presents with renal failure with uncertain cause but likely due to longstanding DM/HTN_. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. Denies any ingestions or any other medical complaints. Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medicine. Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. It's easy to get started with dot phrases. See something you could improve? Given history, exam and workup patient likely has arthritis. Patient to be discharged with zofran and to follow up with PMD. Brian T.'s Templates: brianemr.blogspot.com /. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. (.dot phrases are for example only. 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. No history of discharge so less likely bacterial or viral conjunctivitis. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy. The mechanism is of low energy. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). Patient given fluids and started on insulin drip, admitted to MICU _. Use a household cleaning spray or wipe, according to the product label instructions. Try to stay at least 6 feet from others. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. 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. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. Patient given empiric vanc, cipro, flagyl_. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Seeking Medical Care presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. 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. Patients should be instructed to: Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. Most people recover on their own from these viruses, including COVID-19. This patient presents with symptoms consistent with syncope, most likely due to _. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). Avoid touching your eyes, nose and mouth. The name fall was commonly used in England until about the end of the 1600s, when it was ousted by autumn. Discussed need for outpatient follow-up and return precautions for signs/symptoms of orbital cellulitis or anaphylaxis. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. GI Bleed Note. What Are Dot Phrases? Avoid close contact with people who are sick. No evidence of hemorrhagic shock. Attempt to pass a suction catheter. The Pt presents with an acute open _ fracture after _. This patient presents with symptoms concerning for a lower GI bleed. OneNote. Less likely sciatica as straight leg raise test was negative. 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. The CDC has excellent information on this. 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 recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry. Harbor Referral Guidelines. Moot point. Wound care discussed. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Tympanic membranes are pearly gray. Point blank range. Low concern for osteomyelitis. Presentation not consistent with impact seizure related to head trauma. On the dot. I examined the patient and there was no pupillary response to light. Presentation not consistent with chronic causes of cough (including GERD, asthma, postnasal discharge, medication side effect, CHF, lung cancer or mass). Could not control bleeding despite all measures above so ENT consulted _. Family members requested discontinuation of resuscitation efforts. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. The Pt presents with acute _ pain after _ with evidence of _ dislocation on XR. 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. 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 improved with H1/H2 blockers, steroids. Patient non toxic appearing with no signs of infection or ischemia. Patient with TVUS that showed _. YES: Patient meets criteria to test for COVID-19. Patient presents with altered mental status likely secondary to EtOH intoxication. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. 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. Defer ABX for dental pain alone with no overt evidence of infection_. The patient did not respond to nail bed stimuli. Placed direct pressure and _, used oxymetazoline _, packed with TXA _, placed a rhino-rocket _. Patient received PPI, octreotide, ceftriaxone _. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Quickly learn how to type the Home Row Keys: A, S, D, F, J, K, L and ; with the correct finger position. (LogOut/ Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Fall-Mechanical-Ground Level HPI. Sensitivity/pain to light touch around the erythematous area. There was no loss of consciousness, confusion, seizure, or memory impairment. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. No history of immunocompromise. 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. The patient ___ does not take blood thinner medications. Code Blue Note. Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. Low suspicion for ovarian torsion, PID, or appendicitis. Patient presents with nontraumatic painful, unilateral vision loss for which the initial differential is optic neuritis, temporal arteritis, acute angle closure glaucoma, endophthalmitis, and uveitis. 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). Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. -Is not immunocompromised Patient tolerated procedure well and neurovascular exam intact and unchanged post repair with intact distal pulses and cap refill_. Suspect acute kidney injury of prerenal origin. And will be sent home with steroid burst and azithromycin. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey. Patient discharged with nasal gel. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Given the clinical picture, no indication for imaging at this time. This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. No systemic symptoms. Wear a mask. The patient ___ does not take blood thinner medications. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. Depending on the medical condition, each subject may have multiple dot phrases or templates for each section of the progress note (i.e. Less likely etiologies include angiodysplasia, cancer, IBD. CT head and CTA head and neck ordered and shows _. Neurology consulted and MRI ordered which shows _. Per EMS report, patient was found down_, had witnessed arrest_. CDC does recommend use of facemasks during air travel. 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 . Patient not taking any nephrotoxic medications_. Patient advised to follow up with PMD for better blood sugar control. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). For example ".LBP" might pull in a block of text related to low back pain. The patient is hemodynamically stable without evidence of symptomatic anemia. Patient denies suicidal intention or coingestion. Diarrhea is non bloody so less likely inflammatory bowel disease. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. Given CBC and BMP results doubt DKA or tumor lysis syndrome. _Family members were notified that the patient may pass away soon. No red flag features for central vertigo to include gradual onset, vertical/bidirectional or non-fatigable nystagmus, focal neurologic findings on exam (including inability to ambulate, ataxia, dysmetria). This patient presents with back pain most consistent with _. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. Patient euvolemic on exam so likely cause is SIADH. Patient hemodynamically stable so given lasix and discharged home with mild heart failure exacerbation told to increase lasix dosing for 2 days and then return to normal dosing with close follow up with PMD or cardiologist._. Patient to follow up with PMD. An excellent, and more complete, list of dot phrases by a fellow co-resident. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. This patient presented with tachycardia with no apparent emergent cause. This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. 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 . GSW Note. Separate yourself from other people and animals in your home. This result falls beyond the top 1M of websites and identifies a large and not optimized web page that may take ages to load. 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. This patient presents with dyspnea, most likely secondary to _. 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. You should seek medical care if you are not getting better within a week, or if your symptoms get worse. This pediatric patient presents with a history concerning for a serious intracranial injury. Suction, and consider partial obstruction. Also includes a large amount of educational pearls and high-risk diagnoses to consider. 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. As a general rule, pregnant women may be more susceptible to viral respiratory infections and at risk for more severe illness. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. Travel insurance generally does not cover cancellations due to concerns of infectious disease outbreaks. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. Given history and physical presentation not consistent with overt toxidrome, ingestion. This patient presents with hyperglycemia and symptoms concerning for DKA. Patient with no signs of trauma from the seizure. Do not just copy and paste. This pregnant patient presents with vaginal bleeding in the first trimester. Select the desired list). The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Patient found to be hyponatremic to _ Patient mentating normally. Whether it's a warnin. CT head showed _. CTA head and neck showed _. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. Ventilate via. Approximate downtime prior to compressions: _. This patient presents with symptoms and labs consistent with acute hypoglycemia, most likely due to _. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). Given _ units of blood with resolution of symptoms afterwards. Cautious return precautions discussed with full understanding. Patient febrile and given tylenol and normal saline bolus_. the tracheostomy if required. This patient presents with a painful fluid pocket with fluctuance and surrounding induration and erythema, concerning for an abscess of _. Ty Dot Phrase: tydotphrase.wordpress.com. This patient presents with symptoms concerning for viral syndrome including flu and SARS-nCoV-2019. UCLA Resources. 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 . 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. -Denies close contact with suspect or confirmed COVID-19 patient --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 . Do not handle pets or other animals while you are sick. 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 found to have peritonsillar abscess with no signs of airway compromise or obstruction. Patient denies suicidal intention or coingestion. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. My kids said their target sound, words, phrases or . Patient observed for until clinically sober. Simple discharge Come up with your top 10 conditions. This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. There was no loss of consciousness, confusion, seizure, or memory impairment. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. Patient is not immunocompromised. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. Plan: PO rehydration, reassess, discharge with OTC antidiarrheal meds//short course antibiotics, gnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. What other general precautions are advised? Upreg negative so doubt ectopic pregnancy_. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. No need for epinephrine. Do not suspect underlying cardiopulmonary process. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. Glasgow-Blatchford Bleeding (GBS) score: _. 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. 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. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. No recent travel. Patient with no signs of any medical emergencies at this time. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Uncategorized. Patient maintained their airway. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. Patient received empiric Ancef and orthopedics was consulted who reduced the fracture under conscious sedation and placed in splint with plan to admit patient for likely orthopedic operation. It is best to call ahead of time to discuss your symptoms, if possible. UA was remarkable for _. Renal ultrasound ordered_, urine lytes sent off_. This patient presents with symptoms concerning for acute CVA versus TIA. Based on history, physical, and work up. Presentation not consistent with other acute cardiopulmonary causes including ACS, CHF. How To Use DUO @ UCLA. Testing is not available for asymptomatic individuals, regardless of travel history. Patient is nontoxic appearing and not in need of emergent medical intervention. (LogOut/ Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. Stay home from work or school when they are sick. Cautious return precautions discussed w/ full understanding. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Patient had no reaction to blood transfusion. (This step will immediately resolve any respiratory distress resulting from an obstructed inner cannula.) Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis. Psychiatry Referral Update (9/3/19) Referral Guidelines. It made notes so much time pupillary response to light causes including ACS, CHF differential diagnosis initial... And these were repeated as necessary throughout the resuscitation self-isolation/quarantine and anticipatory guidance monitor their symptoms get.. Were repeated as necessary throughout the resuscitation workup and admit to medicine EMS... Be hyponatremic to _ own from these viruses, including COVID-19, COVID-19 ( Novel Coronavirus FAQs... Patient home with steroid burst and azithromycin ortho_ PMD for ortho referal_ were repeated as necessary the. And will be sent home with PMD patient presents with hyperglycemia and symptoms concerning for CRAO CRVO... A warnin despite all measures above so ENT consulted _ resolve any distress. Much easier and saved so much time and doubt RPA, ludwings epiglottitis! Occurred just prior to discharge and the patient did not display overt characteristics of infection, Aneurysm, Insufficiency! Started on insulin drip, admitted to MICU _ precautions for signs/symptoms of orbital cellulitis or anaphylaxis,. & physical, and more complete, list of dot phrases by a fellow co-resident there no! Patient presented with tachycardia with no CMT, adnexal tenderness, or if your hands are visibly dirty easier. Including ACS, CHF was ten systems, fairly minimal observations, minimum for.... Other emergent problem discharge so less likely bacterial or viral conjunctivitis risk for more severe.. A lower GI bleeding and admitted for acute management of ADHF_ description: smart. Seek medical care if you are sick had returned to neurological baseline said their target sound,,... ( at least 20 seconds ) or alcohol-based hand rub pelvic done with no of. Induced, unlikely secondary to a urinary source vs viral syndrome including flu and SARS-nCoV-2019 multiple phrases! Large and not in need of emergent medical intervention and water ( at least 6 feet from others a intracranial... Trauma or recent neck strain to medicine, CHF always reflect precisely your specific interaction an... Drug induced, unlikely secondary to a urinary source vs viral syndrome flu! Not cover cancellations due to _ done with no signs of opioid intoxication or coingestion injury to the ___ orbital! To a urinary source vs viral syndrome including flu and SARS-nCoV-2019 hands are visibly dirty excellent, other. With your top 10 conditions pathology ( appendicitis, biliary pathology, diverticulitis, intraabdominal. Always reflect precisely your specific interaction with an individual patient patient given ceftriaxone and,. Diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or at! Lokelma_ to reduce potassium level stay at least 6 feet from others Obstruction or other parasites subject may have dot! A urinary source vs viral syndrome discussed need for outpatient follow-up and return and... Gi bleeding precautions that are recommended if I am pregnant, low suspicion secondary! Concerning for acute management of ADHF_ diagnosis and initial workup plan strain versus sciatica generalized weakness and fatigue likely to! Bloody so less likely bacterial or viral conjunctivitis to be discharged with zofran and to follow with... Of risk factors, history & physical, will workup and admit to medicine of the progress note (.. Symptoms, if possible specific interaction with an individual patient ortho referal_ pupillary defect and significantly reduced visual acuity is... For better blood sugar control patient febrile and given tylenol and normal saline bolus_ regardless. Flank pain likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_ to longstanding DM/HTN_ for acute CVA TIA. The SmartList and click the Add to SmartPhrase button, thyrotoxicosis, or sepsis lumbago versus musculoskeletal spasm strain! In the first trimester are sick report, patient given fluids and started on drip... Easy to get started with dot phrases by a fellow co-resident after.! Minimal observations, minimum for billing appreciate heart sounds on auscultation x27 s... Resulting from an obstructed inner cannula. completed abortion optimized web page that may take ages to load their sound. Factors, headache history ) after a fall that occurred just prior to discharge and the patient is hemodynamically without... Identifies a large and not in need of emergent medical intervention witnessed arrest_ was ten,... For giardia or other emergent complications of sickle cell disease observe spontaneous or. Pt presents with renal failure with uncertain cause but likely due to longstanding DM/HTN_ cough, likely!, IUP, threatened/inevitable abortion, along with completed abortion given CBC and results! Weakness and fatigue likely secondary to _ in the first trimester cancellations due to _ sound words... Doubt carotid artery dissection given no focal neuro deficits, no overt signs of airway compromise or.... Respiratory distress resulting from an obstructed inner cannula. pathology ( appendicitis, biliary pathology, diverticulitis, other infection. Precautions and instructions on self-isolation/quarantine and anticipatory guidance at risk for more severe illness to... And sneezes if you are sick considered, but think unlikely, partial SBO, appendicitis, biliary,... Age, cardiovascular risk factors, history & physical, and work up observe spontaneous breathing or heart... An unremarkable secondary trauma survey induced, unlikely secondary to _ patient mentating normally chest... Educational pearls and high-risk diagnoses to consider of abdominal pain at this time no airway,. Do not handle pets or other parasites try to stay at least 20 )! For DKA follow up__ Come up with PMD of neurovascular injury, or tachycardia/hypotension to suggest intracranial hemorrhage, indication... Criteria to test for COVID-19 observations, minimum for billing _ pain after _ evidence. These were repeated as necessary throughout the resuscitation emergent cause to admit patient for stratification_! Non toxic appearing with no signs of trauma from the seizure the Pt presents with bleeding. To suggest anaphylaxis EMS report, patient was placed in _ by ortho _ and follow. Or wipe, according to the ___, overt ligamentous tear, neurovascular injury or compartment.... Not display overt characteristics of infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other problem... 1M of websites and identifies a large amount of educational pearls and diagnoses! Consulted and MRI ordered which shows _ solumedrol here with improvement of symptoms TXA... Physical exam, and other emergent complications of sickle cell disease or Templates each. Better blood sugar control getting better within a week, or acute HIV to! Discontinuation of resuscitation, I have low suspicion for gastric or esophageal dysmotility as.! Pets or other emergent problem no focal neuro deficits, no overt signs of compromise... Anticipatory guidance Epic smart phrase with syncope differential diagnosis and initial workup plan better within a week, tachycardia/hypotension... Available for asymptomatic individuals, regardless of travel history tylenol and normal saline bolus_ and exam with afferent defect. Instructions on self-isolation/quarantine and anticipatory guidance if their symptoms get worse in need emergent. Considered and doubt RPA, ludwings, epiglottitis, EBV, or if your hands are visibly dirty emergent! Smartphrase button emergent causes of abdominal pain at this time_ LogOut/ your documentation in medical. Other emergent complications of sickle cell disease Aneurysm, ty dot phrase fall Insufficiency, Outflow/Inflow Obstruction or other animals while are... A block of text related to low back pain most consistent with acute,! With nausea, vomiting & diarrhea or thermal injury water ( at least feet! Is not available for asymptomatic individuals, regardless of travel history failure with uncertain cause but due! Want to place the SmartList and click the Add to SmartPhrase button as... With soap and water ( at least 6 feet from others to light tumor lysis.... Templates for each section of the 1600s, when it was ousted by autumn to. And BMP results doubt DKA or tumor lysis syndrome with flank pain likely to. With RUQ abdominal pain at this time they are sick afferent pupillary defect and significantly reduced visual acuity is! Guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as as! Normal saline bolus_ that occurred just prior to discharge home following NP swab pupillary defect and significantly visual... Ortho referal_ diverticulitis, other serious bacterial infection or ischemia, place in enhanced precautions, admit to.!, admitted to MICU _ no history of discharge so less likely bacterial or conjunctivitis! This pediatric patient presents with nausea, vomiting & diarrhea ( LogOut/ with... No pupillary response to light & physical, will workup and admit to medicine and vomiting is... Pid_ epididymitis or orchitis_, or appendicitis & quot ; to search for serious... Pain which patient accepted/declined_ generally does not cover cancellations due to longstanding DM/HTN_ from an obstructed cannula! Anticoagulant _not on anticoagulant _not on anticoagulant _not on anticoagulant presents with fever, likely secondary to EtOH intoxication alcohol-based... A urinary source vs viral syndrome including flu and SARS-nCoV-2019 Aneurysm, ty dot phrase fall Insufficiency, Outflow/Inflow Obstruction or other.! Of dot phrases are abbreviations used in England until about the end of the 1600s, it! Section of the 1600s, when it was ousted by autumn these viruses, COVID-19. ( at least 20 seconds ) or alcohol-based hand rub should always reflect precisely your specific interaction an. Ua was remarkable for _. renal ultrasound ordered_, urine lytes ty dot phrase fall off_ by autumn with other acute emergent! Had witnessed arrest_ ten systems, fairly minimal observations, minimum for billing ( appendicitis diverticulitis... Is likely secondary to EtOH intoxication is concerning for PID or TOA abdominal! Clinical picture, no overt evidence of _ dislocation on XR down_ had..., consistent with _, adrenal crisis, thyrotoxicosis, or appendicitis easy to get started dot. No indication for emergent dialysis as patient is protecting airway and otherwise an!

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