Well appearing. _ was reduced at bedside with conscious sedation_ and post reduction Xray shows successful reduction. Fall-Mechanical-Ground Level HPI. Presentation not consistent with acute thoracic aortic dissection. Please return to the emergency department for chest pain, shortness of breath, lightheadedness or dizziness, or other symptoms that are concerning to you. 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. Wear a mask if possible. Patient given fluids and started on insulin drip, admitted to MICU _. Shoulder Problem Note. At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. 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. If you have a fever, you should remain home until 24 hours after fever resolves. No infectious symptoms and afebrile so doubt sepsis. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. And will be sent home with steroid burst and azithromycin. Cover your mouth and nose with a tissue when you cough or sneeze. Presentation consistent with acute epigastric abdominal pain likely secondary to gastritis/GERD, plan to send patient home with PPI/H2 blocker and PMD follow up. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital but in route patient rearrested. Avoid close contact with people who are sick. 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._. Negative Seidel sign, no sign of corneal abrasion/ulcer. Patient non toxic appearing with no signs of infection or ischemia. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. TREATMENT AND MEDICAL CARE Use a separate bathroom, if available. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Given history, exam and workup patient likely has arthritis. The Pt presents with _ likely due to a corneal abrasion seen on fluorescein staining of eye. Will obtain CT imaging to rule out intracranial injury or skull fracture. Last updated on Aug 3, 2022 12 min read Just was ten systems, fairly minimal observations, minimum for billing. There was no loss of consciousness, confusion, seizure, or memory impairment. Well appearing. 50% of websites need less resources to load. Labs are not consistent with adrenal insufficiency. Based on this well validated study, the patient can safely be discharged for outpatient therapy_; is high risk for needing a medical intervention to include transfusion, endoscopy or surgery, so the patient was admitted. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. Wash your hands often with soap and water for at least 20 seconds. No evidence of acute abdomen at this time. Given history and exam I have low suspicion for globe rupture, uveitis, HSV keratitis, Endopthalmitist, Foreign Body. demyelinating diseases). Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. CDC does recommend use of facemasks during air travel. Upreg negative so doubt ectopic pregnancy_. ***- You have a ureteral stent in place. Patient was pronounced deceased. Patient is able to tolerate secretions. Cardiac arrest was likely secondary to _. Pain controlled with _. Patient pain was controlled and patient discharged with ortho follow up. Symptoms and UA indicate no infection. Use soap and water if your hands are visibly dirty. Patient given aspirin. What other general precautions are advised? This patient presents with diarrhea consistent with likely viral enteritis. No change in voice, exudates, enlarged lymph nodes. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. Point duty. No history of immunocompromise. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. Microsoft 365 & HomeBase. This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. Denies vomiting, numbness/weakness, fever. Glasgow-Blatchford Bleeding (GBS) score: _. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis. Given CBC and BMP results doubt DKA or tumor lysis syndrome. If it passes, you have a patent airway. Full Notes. This pregnant patient presents with vaginal bleeding in the first trimester. You can find my fall themed words for drill in my Happy Fall Quick Drill which is always a hit in articulation. Given history and story considered but low risk for aortic dissection, pneumonia, or PE. Less likely etiologies include angiodysplasia, cancer, IBD. Symptoms treated with ativan. If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. EOMI. Presentation consistent with subconjunctival hemorrhage. Stay home when you are sick A dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Links and Attributions. Area extensively irrigated with sterile normal saline under pressure. Patient without a history of coagulopathy or infectious symptoms. On the dot. Patient received PPI, octreotide, ceftriaxone _. The mechanism is of low energy. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. Patient is hypertensive here. XR obtained and is negative. EKG without signs of active ischemia. Less likely to represent acute pancreatitis (neg lipase), PUD (including gastric perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, or acute coronary syndrome. Work through the beginner typing lessons for about 30 minutes each day, five days a week to become a fast, accurate and confident touch typist. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. Patient with no signs of heart failure. Doubt intrinsic renal dysfunction or obstructive nephropathy. Patient tolerated procedure well and neurovascular exam intact and unchanged post repair with intact distal pulses and cap refill_. Will give wait and see prescription for amoxicillin. Able to tolerate PO. Patient presents for swelling and shortness of breath and found to be volume overloaded on exam likely secondary to renal failure _, heart failure _, nephrotic syndrome _, cirrhosis based on history, exam, and work up. 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 pneumonia or pyelonephritis. No airway compromise. No evidence of tooth fracture, avulsion, or bleeding socket. Cautious return precautions discussed with full understanding. (LogOut/ Select the desired list). Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia, doubt drug induced, unlikely secondary to crush or thermal injury. The Pt is otherwise well-appearing without evidence of retained foreign body, corneal ulcer_, globe rupture, or superimposed infection. Low suspicion for acute cardiopulmonary process including ACS, PE, or thoracic aortic dissection. After _ min, I discontinued resuscitation and patient was pronounced deceased. Well appearing. SharePoint. No need for epinephrine. Patient discharged home and will follow up with dentist. Placed direct pressure and _, used oxymetazoline _, packed with TXA _, placed a rhino-rocket _. Try to stay at least 6 feet from others. The patient is hemodynamically stable without evidence of symptomatic anemia. Also, clean any surfaces that may have body fluids on them. How To Trade A Shift on HomeBase. Autotext Dot Phrases for Cerner EHR. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Pelvis without evidence of injury and patient is neurologically intact. This pediatric patient presents with head trauma. Presentation not consistent with chronic causes of cough (including GERD, asthma, postnasal discharge, medication side effect, CHF, lung cancer or mass). Free US Ground shipping, no limit! Javascripts take 135.5 kB which makes up the majority of the site volume. I accumulated a good deal of tricks intern year. Stay home from work or school when they are sick. 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. ***- Foley will remain in place until seen at follow up clinic appointment. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). Normal IOP so doubt acute angle closure glaucoma. (LogOut/ Patient presented with bleeding over their fistula site which was controlled with _. Patient given antibiotics, hematology was consulted and patient was admitted _. Dizziness - low risk peripheral vertigo MDM, Renal failure / electrolyte abnormalities, This page was last edited 20:26, 9 October 2022 by, MDM for different chief complaints (peds), https://www.wikem.org/w/index.php?title=MDM_for_different_chief_complaints&oldid=366662, If male add _no signs of testicular torsion. Low suspicion for ICH or other intracranial traumatic injury. This patient presents with symptoms and labs consistent with acute hypoglycemia, most likely due to _. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. This patient presents with symptoms concerning for a lower GI bleed. Separate yourself from other people and animals in your home. No recent travel. The patient was placed on a levophed drip and resuscitated. This patient presents with non bloody diarrhea consistent with likely viral enteritis. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. Wound inspected under direct bright light with good visualization. Seek medical attention for: fever >100.4 F, increasing warmth, redness, swelling, drainage at incision site. 1000+ dot phrases, ready for you to use in PhraseExpander. Clean your hands often Use a household cleaning spray or wipe, according to the product label instructions. The decision about travel is personal and should be made in the context of a persons underlying health conditions, reason for travel and necessity of travel. These constellation of symptoms are similar to prior exacerbations. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. OK to Book Note. The current level of pain is moderate. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Well appearing. (Ex: type "yes" to search for a yes/no drop list. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. 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. Statnote Pro is a thorough collection of templates (also known as dot phrases or smart phrases in Epic or autotexts in Cerner) designed to speed up your charting. With Epic EMR I was absolutely in love with the smart/dot phrases. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Less likely sciatica as straight leg raise test was negative. -Denies HCW status Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. Stay in a specific room and away from other people in your home as much as possible. Patient presenting with head trauma. Patient offered transferred to rehab facility but declined. The name of its inverse season, spring, is thought to come from the phrase spring of the leaf the time when everything is blossoming. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Patient had no reaction to blood transfusion. Patient offered transferred to rehab facility but declined. Do not suspect underlying cardiopulmonary process. These abbreviations start with a "." or a dot, and are then followed by a short phrase that stands for something longer. 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_. This patient presents with acute cough, most consistent with _. Patient requires admission for their symptoms given ***_. Homely phrase implies that year dot was by then well-known, at least in the writer's experience. Low suspicion for kidney stone or infected stone. Step #1. Defer ABX for dental pain alone with no overt evidence of infection_. Patient admitted to ICU. No evidence of acute abdomen at this time. Patient denies suicidal intention or coingestion. Sensitivity/pain to light touch around the erythematous area. -Denies close contact with suspect or confirmed COVID-19 patient Suspect acute kidney injury of prerenal origin. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms. Patient is not immunocompromised. No evidence of airway compromise or shock at this time. Patient was persistently in withdrawal despite multiple repeated doses of benzos, plan to admit patient for alcohol withdrawal._, Patient devolved and had withdrawal seizure/delirium tremens/alcoholic hallucinosis plan to admit patient to to ICU._. Patient presents with _ joint pain. 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. 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. There is no lymphangitic spread visible. Considered alternate etiologies of the patients symptoms including infectious processes, severe metabolic derangements or electrolyte abnormalities, ischemia/ACS, heart failure, and intracranial/central processes but think these are unlikely given the history and physical exam. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Differential diagnosis includes reflexive syncope (vasovagal). We put all of the quick drill cards facedown on the table or in a container. For example ".LBP" might pull in a block of text related to low back pain. Offered patient dental nerve block for pain which patient accepted/declined_. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. As long as it is in place you can expect some degree of pain as well as blood in your urine. Doubt alternate acute emergent pathology. Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. Ventilate via. Clean all high-touch surfaces every day [[TODO]] HP Date of Note: Chief Complaint: History of Present Illnesses: Past Medical History: Allergies: Medications: Past Surgical History: Social History: [[ROS . The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. No headache red flags. Patient taken to cath lab. This patient presents with symptoms concerning for an acute upper GI bleed. This showed no significant findings. Given work up, exam, and history low suspicion for intracranial hemorrhage or trauma, carotid or vertebral artery dissection, intrathoracic trauma (pulmonary contusion, blunt cardiac trauma, pneumothorax, hemothorax, cardiac tamponade, rib fractures), intra abdominal trauma (no liver, spleen, or renal lacerations, doubt hollow viscus injury given soft abdomen on repeat exams, no free air seen, consistently normotensive), extremity fracture, extremity dislocation, compartment syndrome. We need you! Tympanic membranes are pearly gray. 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). Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. Could not control bleeding despite all measures above so ENT consulted _. This patient presents with symptoms concerning for acute CVA versus TIA. This _ patient presents with likely anterior epistaxis, which appears to have resolved. No back pain red flags on history or physical. 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. Differential diagnosis includes possible acute gastroenteritis. Do not handle pets or other animals while you are sick. Begin typing real words and phrases before the end of lesson one. Presentation not consistent with a medical emergency at this time. I had a "normal physical exam" dot phrase when I was an intern doing a TY year. Currently euvolemic without evidence of dehydration. Doubt meningitis or appendicitis. This patient presents with symptoms consistent with acute uncomplicated cystitis. --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 . []-year-old patient presenting with swollen eye. However, presentation most concerning for a CVA. Ddx includes allergic reaction vs. preseptal cellulitis. The multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. Unable to clear patient with PECARN rules given ***. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. Sometimes there is treatment for the viruses that cause influenza if given early. The patient ___ does not take blood thinner medications. Throw used tissues in a lined trash can; immediately wash your hands. This patient presenting with apparent acute hyperglycemia. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. No overt foreign body. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. It is recommended that you seek medical care for serious symptoms, such as: No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. The current level of pain is moderate. You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. How Should A Phone Visit Be Done? Patient feels well on discharge with plan to follow up with PMD. Seeking Medical Care Should people telecommute? Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. Exam and history most consistent with AOM. Cautious return precautions discussed w/ full understanding. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. Given work up have low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), upper GI bleed, acute pancreatitis, gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, or acute coronary syndrome. Given history and physical temporal arteritis unlikely, as is acute angle closure glaucoma. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Instructed patient to continue to treat pain with ibuprofen/acetaminophen until they see a dentist. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. Patient with TVUS that showed _. Patient presents in alcohol withdrawal last drink was _ ago. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. Considered, but think unlikely, CVT given no cranial nerve deficits, blurry vision, diplopia. However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. 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 . Considered but low risk for any emergent causes including unstable heart block (ekg with no signs of Mobitz II, complete heart block), right coronary artery myocardial infarction (neg trop_, non STEMI, no chest pain), infection (afebrile, no leukocytosis, no recent illness), hypothyroidism, hyperkalemia, hypoglycemia, dehydration, or intoxication (beta blockade, calcium channel blockade, clonidine, digoxin, opiates, alcohol or other). Please read in detail and delete what is not relevant. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Despite multiple rounds of opioids patients pain was not controlled, so patient was admitted for pain control. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. 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. Nontoxic appearance. Approximate downtime prior to compressions: _. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey. 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 pancreatitis (neg lipase), PUD (including gastric perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction, viscus perforation, or testicular torsion, diverticulitis. Discussed return precautions for odontogenic infections and other dental pain emergencies. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. This patient presents with symptoms most consistent with an acute COPD exacerbation. Our beginner typing lessons make it easy to learn typing. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). This patient has a presentation consistent with rectal bleeding, most likely due to _. Attempt to pass a suction catheter. Given the clinical picture, no indication for imaging at this time. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. Pain was controlled with headache cocktail and patient discharged home with PMD follow up. The CDC has excellent information on this. 3. Patient with persistent vertigo that is not fatigable with no obvious trigger which is concerning for central etiology of either posterior circulation stroke vs intracranial mass vs intracranial hemorrhage vs vertebral basilar artery insufficiency. 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. Doubt alternate acute emergent pathology. 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 .