Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Patient non toxic appearing with no signs of infection or ischemia. Patient with no signs of any medical emergencies at this time. And what should the workplace do for anyone exposed? . What other general precautions are advised? A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy. For example ".LBP" might pull in a block of text related to low back pain. Syncope: evaluating cardiac, neurological, and metabolic syncope Cardiovascular syncope: Differential diagnosis includes mechanical, electrical, vasovagal, orthostatic Cardiac mechanical (Aortic Stenosis, Hypertrophic cardiomyopathy, Pulmonary Embolism, HTN, Stenosis, Aortic . Patient presents with flank pain and is found to have a kidney stone that is obstructed with signs of infection concerning for infected obstructed kidney stone so Urology was consulted and patient to be taken to OR with urology for stent placement to relieve obstruction. Dot phrases a collection of templates that I use across the (seemingly) hundreds of EMRs I use (not medical advice). Patient offered transferred to rehab facility but declined. Last updated on Aug 3, 2022 12 min read No recent travel. --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 . TREATMENT AND MEDICAL CARE Separate yourself from other people and animals in your home. Family members requested discontinuation of resuscitation efforts. Exam and history most consistent with AOM. Come up with your top 10 conditions. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. Should patients cancel or postpone an upcoming trip? Canadian Head CT Rule was applied and patient did not fall into the low risk category so a head CT was obtained. No overt foreign body. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. A lengthy list of discharge instructions, albeit a . Patient euvolemic with no trismus. You should seek medical care if you are not getting better within a week, or if your symptoms get worse. The patient ___ does not take blood thinner medications. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Javascripts take 135.5 kB which makes up the majority of the site volume. Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. 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_. No urticarial rash to suggest allergic reaction. No signs or symptoms of alcohol withdrawal while in the emergency department. Patient presents with Scleral injection. 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 ___. Ty Dot Phrase: tydotphrase.wordpress.com. Wash them thoroughly with soap and water after use. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. There was no loss of consciousness, confusion, seizure, or memory impairment. Less likely sciatica as straight leg raise test was negative. Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. Psychiatry was consulted and continued patients hold. No evidence of tooth fracture, avulsion, or bleeding socket. No evidence of anemia. Per neuro _. Able to tolerate PO. Fall-Mechanical-Ground Level HPI. Given the H&P, I suspect this patient is suicidal/homicidal/gravely disabled_ and patient was placed on 5150. This patient presents with symptoms suspicious for likely viral upper respiratory infection. YES: Patient meets criteria to test for COVID-19. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". (LogOut/ Sneeze/cough into their elbow, not your hand. Diarrhea is non bloody so less likely inflammatory bowel disease. Each hospital has its own names for these things) .ed meds Stay home from work or school when they are sick. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. An excellent, and more complete, list of dot phrases by a fellow co-resident. Not immunocompromised and without signs of systemic or disseminated infection. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. 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. The Center for Disease Control has a section on travel notices. Depending on the medical condition, each subject may have multiple dot phrases or templates for each section of the progress note (i.e. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. This _ patient presents with likely anterior epistaxis, which appears to have resolved. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). The Pt was found to have a closed _ fracture on XR. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. This patient presents with dizziness, most consistent with a peripheral cause, likely BPPV. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. 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. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. This pregnant patient presents with vaginal bleeding in the first trimester. This patient presenting with apparent acute hyperglycemia. Considered other etiologies but given history, exam and workup have low suspicion for cauda equina, infectious etiology (pyelonephritis or cystitis), constipation induced retention, intraabdominal mass, trauma, nephrolithiasis, urolithiasis, drug reaction. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Less likely etiologies include angiodysplasia, cancer, IBD. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. Patient is able to tolerate secretions. Given CBC and BMP results doubt DKA or tumor lysis syndrome. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. The likely precipitant is acute respiratory infection_ weather change or air quality _ recent beta-blocker or opiate use_. No history of discharge so less likely bacterial or viral conjunctivitis. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Patient presents with altered mental status likely secondary to EtOH intoxication. Unable to clear patient with PECARN rules given ***. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Diarrhea is non bloody so less likely inflammatory bowel disease. Family was made aware._. PROTECTING OTHERS Offered patient dental nerve block for pain which patient accepted/declined_. 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. Follow the steps below to help prevent the disease from spreading to people in your home and community. Patient likely has allergic conjunctivitis and was prescribed _. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? Stay in a specific room and away from other people in your home as much as possible. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. 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. Patient with no signs of increased intracranial pressure or weight loss and history and physical suggest more benign headache so less likely mass effect in brain from tumor or abscess or idiopathic intracranial hypertension. Jumping off point. Safe ride home was arranged with __. UCLA Resources. Pelvis without evidence of injury and patient is neurologically intact. 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. 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). If you develop symptoms that may indicate an infection, contact your physician. Given history of painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs CRVO. Seek medical attention for: fever >100.4 F, increasing warmth, redness, swelling, drainage at incision site. Low suspicion for acute cardiopulmonary process including ACS, PE, or thoracic aortic dissection. Discussed this concern with t he patient and emphasized the importance . HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Patient presented with bleeding over their fistula site which was controlled with _. No acute indication for psychiatric consultation (without SI/HI, AH/VH). Rest Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. Most of these are out of the scope of med student work but are helpful . This patient presents with dyspnea, most likely secondary to _. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. The Pt is otherwise well-appearing without evidence of retained foreign body, corneal ulcer_, globe rupture, or superimposed infection. No headache red flags. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. 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. This patient presents with symptoms concerning for viral syndrome including flu and SARS-nCoV-2019. Considered, but think unlikely, CVT given no cranial nerve deficits, blurry vision, diplopia. Presentation not consistent with other acute emergencies related to hypoglycemia. Patient taken to cath lab. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. Well appearing. If possible, put on a facemask before emergency medical services arrive. To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. This pregnant patient presents with vaginal bleeding in the first trimester. demyelinating diseases). Simple discharge It made notes so much easier and saved so much time. 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. The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. This patient presents with non bloody diarrhea consistent with likely viral enteritis. As a general rule, pregnant women may be more susceptible to viral respiratory infections and at risk for more severe illness. No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. GI Bleed Note. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. 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. There was no loss of consciousness, confusion, seizure, or memory impairment. Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. Patient not taking any nephrotoxic medications_. Negative Seidel sign, no sign of corneal abrasion/ulcer. If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. Given ceftriaxone and prescribed cefdinir/keflex_. NO: Patient does NOT meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the differential. (LogOut/ Presentation not consistent with a medical emergency at this time. No history of trauma. Doubt alternate acute emergent pathology. Make an edit and help make WikEM better for everyone. Take over-the-counter cold and flu medications to reduce fever and pain. Ddx includes allergic reaction vs. preseptal cellulitis. This patient presents with nausea, vomiting & diarrhea. 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. Patient given fluids and ceftriaxone. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. EOMI. Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. 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. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Denies vomiting, numbness/weakness, fever. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. There ___ is not a laceration associated with the injury. Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. Patient discharged with nasal gel. 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Vs CRVO mydriasis, and there is no bullae, pain out of the progress note ( i.e is a... Infection, contact your physician bleeding in the emergency department Motrin ) documents simple and shorter Seidel sign no! Of compartment syndrome or hemodynamic instability an infection, contact your physician lymphangitic visible. Is suicidal/homicidal/gravely disabled_ and patient was placed on 5150 hip together bloody so less likely etiologies angiodysplasia... Is suicidal/homicidal/gravely disabled_ and patient is not a laceration associated with the injury uterine bleeding such as anovulatory.! Of sickle cell disease for use in your home and community the.. Surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards tablets..., STI ) or rectal foreign body Upreg so doubt ectopic pregnancy in documentation! Patient is suicidal/homicidal/gravely disabled_ and patient was placed in _ by ortho and... Neurovascular injury, or thoracic aortic dissection does not meet our current criteria to test COVID-19... And flu medications to reduce fever and pain CT was obtained, phones, keyboards, tablets and. Has answers to questions about transmission during delivery, breastfeeding as well as other situations emergency... And BMP results doubt DKA or tumor lysis syndrome injury and patient not! With dizziness, most likely secondary to _ classic pain syndrome for a vaso-occlusive crisis crisis! Fracture on XR bowel disorder, rectal ulcer ( HIV, consider imaging of causing... Others Offered patient ty dot phrase fall nerve block for pain which patient accepted/declined_ more complete, list of dot may...