Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. Also considered but less likely given history and physical exam included constipation, bowel perforation, gastritis, pancreatitis, mesenteric ischemia, genital torsion_. 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. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. Patient presented with chest pain concerning for ACS, EKG was non STEMI, however troponin was elevated concerning for NSTEMI, and the patient was given aspirin and started on heparin, pain was controlled with _, cardiology was consulted and patient was admitted. Patient requires admission for their symptoms given ***_. The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. The CDC has excellent information on this. Patient admitted to medicine for further work up and possible initiation of hemodialysis. Patient not hypervolemic on exam with no history of CHF, cirrhosis, nephrotic syndrome, no acute renal failure. It's easy to get started with dot phrases. Follow up with PMD this week. Low suspicion for acute cardiopulmonary process including ACS, PE, or thoracic aortic dissection. Patient with known cause of bleeding and follow up scheduled. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Given CBC and BMP results doubt DKA or tumor lysis syndrome. You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. Low suspicion for ICH or other intracranial traumatic injury. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). Patient euvolemic with no trismus. Patient febrile and given tylenol and normal saline bolus_. Cautious return precautions discussed w/ full understanding. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. The current level of pain is moderate. There was no loss of consciousness, confusion, seizure, or memory impairment. Low suspicion for alternate etiologies such as pneumothorax, acute PE, pneumonia. This patient presents with dyspnea, most likely secondary to _. Presentation not consistent with acute respiratory etiologies to include acute PE (Wells low risk), pneumothorax , asthma, COPD exacerbation, allergic etiologies, or infectious etiologies such as PNA. Rash does not appear urticarial with no signs of anaphylaxis either. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. And will be sent home with steroid burst and azithromycin. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. 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. Patient with no signs of sepsis. This page is for adult patients. 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. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. Patient pain was controlled and patient discharged with ortho follow up. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Area extensively irrigated with sterile normal saline under pressure. 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_. Low suspicion for kidney stone or infected stone. The patient ___ does not take blood thinner medications. Well appearing. If you are elderly, pregnant, have a weak immune system, or other medical problems, call your doctor right away. WHAT IS A DOTPHRASE? Wash your hands often with soap and water for at least 20 seconds. Patient not immunosuppressed, afebrile and well appearing with patent airway, have low suspicfion for deep space infection or any concern for airway compromise. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). See something you could improve? Doubt alternate acute emergent pathology. 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. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. Avoid close contact with people who are sick. Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN. No indication for abdominal imaging. No evidence of tooth fracture, avulsion, or bleeding socket. Note that these medicines do not cure the illness and therefore do not stop you from spreading germs. We put all of the quick drill cards facedown on the table or in a container. Suction, and consider partial obstruction. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Patient has not been taking their HTN medication _. You can find my fall themed words for drill in my Happy Fall Quick Drill which is always a hit in articulation. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Symptoms and UA indicate no infection. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Based on history, physical, and work up. Patients should be instructed to: . 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. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. No acute indication for psychiatric consultation (without SI/HI, AH/VH). In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. Jumping off point. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. There ___ is not a laceration associated with the injury. Low concern for osteomyelitis. 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. Patient feels well on discharge with plan to follow up with PMD. 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 . 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. Patient presents with altered mental status likely secondary to EtOH intoxication. I examined the patient and there was no pupillary response to light. Not septic. COVID test was sent off and pending. Did the same for ROS. It is best to call ahead of time to discuss your symptoms, if possible. The patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. Clean all high-touch surfaces every day Considered DKA versus HHS, sepsis as possible etiologies of the patients current presentation. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. This patient presenting with apparent acute hyperglycemia. This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. ); the presence of associated neurologic symptoms, nausea, jaw claudication; recent trauma, dental surgery, sinusitis symptoms; exacerbating (stress, fatigue, menses, exercise) and alleviating factors (rest, medicines); past history of headache; family history of migraines . UA was remarkable for _. Renal ultrasound ordered_, urine lytes sent off_. Simple discharge Cautious return precautions discussed w/ full understanding. Use a household cleaning spray or wipe, according to the product label instructions. 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. Exam without evidence of volume overload so doubt heart failure. Patient without a history of coagulopathy or infectious symptoms. Given history and story considered but low risk for aortic dissection, pneumonia, or PE. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. This patient presents with symptoms concerning for an acute upper GI bleed. Patient maintained his airway, and metabolized to sobriety and no longer altered. demyelinating diseases). Patient given fluids and ceftriaxone. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. Patient maintained their airway. Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage (stable hgb). The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. The Pt presents with acute _ pain after _ with evidence of _ dislocation on XR. Patient presents in alcohol withdrawal last drink was _ ago. Intervention needed (LogOut/ Patient appropriate for discharge with outpatient follow-up and ___ for pain. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. No diabetes or immunosuppression. Differential includes simple cystitis, pyelonephritis, epididymitis_. OK to Book Note. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. If you must leave home while you are sick, try to avoid using public transportation, ride-shares, and taxis. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. If you have a fever, you should remain home until 24 hours after fever resolves. Prescribed antibiotics and instructed the Pt to follow up closely with ophthalmology and avoid wearing contacts_. 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. Low suspicion for mastoiditis, malignant otitis externa, AOM, herpes zoster oticus. Treatment Cardiac compressions were performed immediately by staff in order to sustain blood flow. No back pain red flags on history or physical. Nontoxic appearance. Patient to follow up with PMD. Patient to be discharged home with bactrim and keflex with follow up with their PMD. Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. 2. The multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . Should patients cancel or postpone an upcoming trip? Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? This patient presents with generalized weakness and fatigue likely secondary to dehydration. The patient was placed on a levophed drip and resuscitated. The Center for Disease Control has a section on travel notices. PROTECTING OTHERS Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. 3. Pain was controlled with headache cocktail and patient discharged home with PMD follow up. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Given the clinical picture, no indication for imaging at this time. Presentation consistent with subconjunctival hemorrhage. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. Wear a mask. This patient presents with symptoms concerning for a lower GI bleed. Most likely etiology at this time is _. Differential diagnosis includes possible acute gastroenteritis. Glasgow-Blatchford Bleeding (GBS) score: _. Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. 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._. 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 urticarial rash to suggest allergic reaction. Patient was given lasix_, nephrology consulted and patient was dialyzed. Here are steps that you can take to help you get better: My kids said their target sound, words, phrases or . Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. This patient presents with symptoms suspicious for likely viral upper respiratory infection. Doubt alternate acute emergent pathology. HPI, PE, A/P, procedure, billing code.) Try to stay at least 6 feet from others. There was no palpable radial pulse. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. If you do visit a healthcare facility, put on a mask to protect other patients and staff. Ventilate via. 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. This patient presents with back pain most consistent with musculoskeletal spasm/strain. Patient was medically cleared and transferred to psychiatric care. YES: Patient meets criteria to test for COVID-19. HEP C Treatment Visit Dot Phrase. This pediatric patient presents with head trauma. Well appearing. 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. Patient admitted for volume overload. Given _ units of blood with resolution of symptoms afterwards. Denies neck pain. Suspect acute kidney injury of prerenal origin. The Pt was found to have a closed _ fracture on XR. No evidence of hemorrhagic shock. -Is not immunocompromised Also considered but low risk for respiratory cause (COPD, asthma, PE, or PNA), medication noncompliance or dietary indiscretion, alcohol or drug abuse, endocrine (thyrotoxicosis), and anemia_. Patient had no reaction to blood transfusion. Patient given fluids and started on insulin drip, admitted to MICU _. Exam prior to discharge shows no evidence of Wernicke's encephalopathy. 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. No headache red flags. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Harbor Referral Guidelines. Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medicine. 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. Doubt pneumonia or pyelonephritis. 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. It is recommended that you seek medical care for serious symptoms, such as: Patient given zofran and tolerated PO here. Patient presents for dental pain due to suspected dental cary. Situations are changing frequently and you should monitor the site for updates. People who are elderly, pregnant, or have a weak immune system, or other medical problem are at higher risk of more serious illness or complications. No history of recent infection so doubt vestibular neuritis. Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Syncope Dot Phrase. 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. Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to ESRD_. Cover your mouth and nose with a tissue when you cough or sneeze. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. There is no lymphangitic spread visible. People with potentially life-threatening symptoms should call 911. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. Doubt drug induced, unlikely secondary to crush or thermal injury. This patient presents with symptoms consistent with acute seizure, most likely due to _. I considered, but think less likely, secondary etiologies of epileptic seizures to include drug / toxin etiologies (ETOH, stimulants, medication side effects), metabolic disturbances (glucose, Na), acute CNS infections (meningitis, encephalitis, abscess), ICH / tumor / CVA. There was no loss of consciousness, confusion, seizure, or memory impairment. Fun, friendly & so cute you gotta smile! Denies any ingestions or any other medical complaints. Labs are not consistent with adrenal insufficiency. 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. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. The patient is suffering from bradycardia without concerning signs of instability on exam such as altered mental status, hypotension, evidence of cardiac end organ dysfunction, or acute heart failure. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection) however given unremarkable trop, ekg, cardiac exam have low suspicion. Given history and physical temporal arteritis unlikely, as is acute angle closure glaucoma. Patient's neurological exam was non-focal and unremarkable. Given RUQ US findings patient likely has biliary colic_with no signs of acute cholecystitis or cholangitis_ patient likely has cholecystitis with no signs of cholangitis, patient given ceftriaxone and flagyl, surgery consulted and patient to be admitted_. Point duty. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. Stay home from work or school when they are sick. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. Patient presenting with flank/back pain and fever. Presentation most consistent with diabetic foot infection. Patient is hypertensive here. Family was made aware._. 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 . No red flag features or high risk bleeding. 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 ___. Moot point. Abdominal exam without peritoneal signs. Critical care time spent > 30 minutes in coordination of efforts for ROSC resuscitation. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. Use a separate bathroom, if available. Also includes a large amount of educational pearls and high-risk diagnoses to consider. Cover your coughs and sneezes TREATMENT AND MEDICAL CARE Abdominal exam without peritoneal signs. History, physical, and work up with low suspicion for temporal arteritis, optic neuritis, complex migraine, or stroke. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. 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. Doubt meningitis or appendicitis. No recent eye trauma or suspected microtrauma (dust, sand, etc). 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). Wound inspected under direct bright light with good visualization. This pregnant patient presents with vaginal bleeding in the first trimester. ROS = .personal ROS phrase having most coveted in HPI prose Past hxs = .phrase to populate automatically same with allergies, meds. Autotext Dot Phrases for Cerner EHR. 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. Ty Dot Phrase: tydotphrase.wordpress.com. 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_. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Children younger than age 2 should not be given any over-the-counter cold medications without first speaking with a doctor. 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. 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. Attempt to pass a suction catheter. This patient presents with symptoms concerning for acute CVA versus TIA. 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. [[TODO]] HP Date of Note: Chief Complaint: History of Present Illnesses: Past Medical History: Allergies: Medications: Past Surgical History: Social History: [[ROS . If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. In this video, we've compiled short one-second clips from different movies where characters say the popular phrase "Don't Fall For It". claude beanie baby value,