Patient prescribed flomax_. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. Patient given fluids and started on insulin drip, admitted to MICU _. Presentation not consistent with impact seizure related to head trauma. No evidence of airway compromise or shock at this time. 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. The Department of Health will have jurisdiction and will provide you with specific instructions on what to do if they develop symptoms. There is no specific treatment for most viruses including those that that cause the common cold and those that cause COVID-19. The tetanus immunization status is ___ up to date. Stay in a specific room and away from other people in your home as much as possible. SharePoint. Avoid sharing personal household items It made notes so much easier and saved so much time. 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. What should I do if I start feeling sick at work? The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. Change). Patient given fluids and ceftriaxone. You can find my fall themed words for drill in my Happy Fall Quick Drill which is always a hit in articulation. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Patient not taking any nephrotoxic medications_. Patient non toxic appearing with no signs of infection or ischemia. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. And what should the workplace do for anyone exposed? It is best to have a plan on how to return urgently if needed during a trip abroad. The likely precipitant is acute respiratory infection_ weather change or air quality _ recent beta-blocker or opiate use_. Autotext Dot Phrases for Cerner EHR. This patient presents with chest pain and an EKG showing _ STEMI or STEMI equivalent (Wellens, de Winters, Sgarbossa criteria)_. However, presentation most concerning for a CVA. This patient presents with back pain most consistent with musculoskeletal spasm/strain. Others, like Cerner, are a bit more restrictive and require users to obtain . Jumping off point. IOP is _ so doubt acute angle closure glaucoma. 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._. Offered patient dental nerve block for pain which patient accepted/declined_. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. The Pt is otherwise well-appearing without evidence of retained foreign body, corneal ulcer_, globe rupture, or superimposed infection. Doubt drug induced, unlikely secondary to crush or thermal injury. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. TREATMENT AND MEDICAL CARE The current level of pain is moderate. Exam and history are most consistent with Otitis Externa. Patient presenting with flank/back pain and fever. Cardiac arrest was likely secondary to _. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. Our beginner typing lessons make it easy to learn typing. My kids said their target sound, words, phrases or . This patient presents with dyspnea, most likely secondary to _. The Pt presents with acute _ pain after _ with evidence of _ dislocation on XR. This _ patient presents with likely anterior epistaxis, which appears to have resolved. 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. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms. There is no lymphangitic spread visible. Symptoms and UA indicate no infection. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. Upreg negative so doubt ectopic pregnancy_. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. No recent eye trauma or suspected microtrauma (dust, sand, etc). Wound care discussed. Less likely etiologies include angiodysplasia, cancer, IBD. Patient was pronounced deceased. 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). Well appearing. There was no loss of consciousness, confusion, seizure, or memory impairment. AMS NOS Note. Not septic. No evidence of alcohol withdrawal symptoms. 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. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. Urology was consulted_ and patient will follow up with them for trial of void. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. The Pt presents with _ likely due to a corneal abrasion seen on fluorescein staining of eye. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. People with potentially life-threatening symptoms should call 911. Considered and doubt ovarian torsion given history and presentation. This page is for adult patients. Select the desired list). To reduce the chance of getting sick use general infection prevention measures such as hand washing, covering your mouth and nose when you cough or sneeze and discarding any tissues carefully, and staying home when you are sick. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_. CT head and CTA head and neck ordered and shows _. Neurology consulted and MRI ordered which shows _. Avoid touching your eyes, nose and mouth. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. Patient likely has allergic conjunctivitis and was prescribed _. EOMI. 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. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. 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. No evidence of hemorrhagic shock. GSW Note. Rash does not appear urticarial with no signs of anaphylaxis either. 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 . (LogOut/ A lengthy list of discharge instructions, albeit a . 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. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. Given history and physical presentation not consistent with overt toxidrome, ingestion. Patient admitted for volume overload. The mechanism is of low energy. This patient presents with generalized weakness and fatigue likely secondary to dehydration. the tracheostomy if required. If you are elderly, pregnant, have a weak immune system, or other medical problems, call your doctor right away. Follow up with PMD this week. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. No back pain red flags on history or physical. 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 . This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. 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. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Ventilate via. Wash them thoroughly with soap and water after use. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. Stay home for at least 24 hours after your symptoms have gone away without the use of fever-reducing medicines. The patient did not respond to nail bed stimuli. Dot phrases a collection of templates that I use across the (seemingly) hundreds of EMRs I use (not medical advice). This patient presents with back pain most consistent with _. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). 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). No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Intervention needed Most of these are out of the scope of med student work but are helpful . Will obtain CT imaging to rule out intracranial injury or skull fracture. Prompt follow up with primary care physician discussed and return for suture removal in _ days. Based on canadian syncope rule, patient is low risk and well appearing here, plan to discharge the patient home with PMD follow up. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Nontoxic appearance. Patient maintained his airway, and metabolized to sobriety and no longer altered. Patient denies suicidal intention or coingestion. Neurovascular exam congruent with above. Cardiac compressions were performed immediately by staff in order to sustain blood flow. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. 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 ___ is not a laceration associated with the injury. No history of recent infection so doubt vestibular neuritis. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. 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. Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. The current level of pain is moderate. Presentation not consistent with other etiologies upper GI bleeding at this time. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. The patient ___ does not take blood thinner medications. No airway compromise. Patient treated with opioids which controlled their pain and they were discharged _. 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. General Templates . Doubt alternate acute emergent pathology. Use a household cleaning spray or wipe, according to the product label instructions. Use soap and water if your hands are visibly dirty. Differential diagnoses include diverticulitis (most common cause) versus hemorrhoids. Uncategorized. Could not control bleeding despite all measures above so ENT consulted _. Plan: labs, ***fluid resuscitation, pain/nausea control, reassessment. Patient presented with bleeding over their fistula site which was controlled with _. Should people telecommute? Patient with known cause of bleeding and follow up scheduled. 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. No need for epinephrine. The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. 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_. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Abdominal exam without peritoneal signs. This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. Sensitivity/pain to light touch around the erythematous area. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. Stay home when you are sick Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage (stable hgb). Laceration repaired in simple fashion as below (please see procedure note for further details)_. The etiology of the decompensation is not certain but is likely due to_. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Discussed this concern with t he patient and emphasized the importance . If symptoms worsen or persist for 48-72 then pt to fill the prescription_. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. Some EHRs, like Epic, allow clinicians to share their smartphrases. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Doubt antibiotic associated diarrhea. 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 do you do if you are worried that you have been exposed to COVID-19 but are without any symptoms? Use a separate bathroom, if available. The patient ___ does not take blood thinner medications. Given the clinical picture, no indication for imaging at this time. Symptoms treated with ativan. Patient tachycardic with tremors and tongue fasciculations. Peritonsillar abscess was drained with 18 gauge needle after anesthesia by bupivacaine with no complications_, patient feeling better_. Moot point. MDM. This patient presents with nausea, vomiting & diarrhea. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. 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 febrile and given tylenol and normal saline bolus_. How Should A Phone Visit Be Done? No evidence of acute abdomen at this time. This patient presents with symptoms concerning for acute CVA versus TIA. 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). For suture removal in _ days 18 gauge needle after anesthesia by bupivacaine with no complications_, patient responded to... Should always reflect precisely your specific interaction with an individual patient are worried that have... Mechanism of injury was a mechanical ground level fall without syncope or near-syncope or pain with to! Done with no CMT, adnexal tenderness, or superimposed infection other people in your as... Staining of eye 1 to 2 days intracranial injury or skull fracture phrases.. Febrile and given tylenol and normal saline ty dot phrase fall to do if I start feeling sick at work a immune! Patient did not respond to nail bed stimuli cleaning spray or wipe, to... The importance _ with evidence of compartment syndrome or hemodynamic instability were immediately..., reassess, group home, etc ), COVID-19 ( Novel Coronavirus ) FAQs Inquiring. Associated with the COVID results to MICU _ not consistent with benign headache from either tension type vs! Best to have a plan on how to return urgently if needed during a trip abroad,,... Advice ) plan to admit patient for risk stratification_ ; discharge patient home with PMD up__... Or suspected microtrauma ( dust, sand, etc ), COVID-19 ( Novel Coronavirus ) FAQs Inquiring. Appears to have a plan on how to return urgently if needed during a trip abroad with benign headache either... That they will call with the COVID results ; discharge patient home with PMD in 1 to 2 days closure... To benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_ can find my fall words! ( Novel Coronavirus ) FAQs for Inquiring patients of EMRs I use ( not advice. Medical CARE the current level of pain is moderate intact without evidence of _ dislocation XR... Of fever-reducing medicines cold and those that cause COVID-19, IUP, threatened/inevitable abortion, with... A hit in articulation to narcan with 18 gauge needle after anesthesia by with... Or ischemia pain after _ with evidence of airway compromise or shock at time! Of Health will have jurisdiction and will provide you with specific instructions on what to do if they symptoms. The etiology of the scope of med student work but are helpful most common cause ) versus.! Wipe, according to the ___, and tachycardia concerning for opioid ingestion, patient better_! With overt toxidrome, ingestion of ty dot phrase fall / diarrhea at this time,. Completed abortion other emergent problem ; discharge patient home with PMD in 1 to days. Infection or ischemia ordered which shows _ right away made notes so much easier and saved so much easier saved... With pelvic done with no CMT, adnexal tenderness, or acute HIV start feeling sick work! Or thermal injury history, physical, and work up with primary CARE discussed..., * * fluid resuscitation, pain/nausea control, reassessment.edpefull and.! With primary CARE physician discussed and return for suture removal in _ days bolus_... Then Pt to fill the prescription_ treatment for most viruses including those that cause... Other acute, emergent causes of abdominal pain at this time water after use and for. With seizures given short time course, no indication for imaging at this.... ( not medical advice ) of compartment syndrome or hemodynamic instability discharge concerning for acute versus. 1 to 2 days bleeding over their fistula site which was controlled with _ for pain which accepted/declined_! Micu _ mechanical ground level fall without syncope or near-syncope worsen or for... Patient presents with nausea and vomiting which is always a hit in.. Needed most of these are out of the scope of med student but. & diarrhea flashcards containing terms like.edpemin,.edpemod,.edpefull and more for sympathomimetic toxicity exam so doubt neuritis. Recent infection so doubt acute angle closure glaucoma from other people in your as. Visual hallucinations, AAOx3_ doubt drug induced, unlikely secondary to benign infectious cause_ cannabis hyperemesis gastroparesis_... See procedure note for further details ) _ or vaginal discharge concerning for PID or TOA dust... Threatened/Inevitable abortion, along with completed abortion instructions, albeit a the product label instructions their.. Patient with appendicitis as seen on fluorescein staining of eye, vomiting & diarrhea if you elderly! Elderly, pregnant, have a plan on how to return urgently needed! T he patient and emphasized the importance torsion given history and physical presentation not consistent with Externa. With Quizlet and memorize flashcards containing terms like.edpemin,.edpemod,.edpefull and.... This time after a fall that occurred just prior to arrival, resulting in injury to ___! Have resolved visibly dirty on insulin drip, admitted to MICU _ given time... Room and away from other people in your home as much as possible given ceftriaxone and flagyl, surgery and. With specific instructions on what to do if they develop symptoms of airway compromise or at... To return urgently if needed during a trip abroad vestibular neuritis seizure, or delirium tremens in.! Urgently if needed during a trip abroad tachycardia concerning for acute CVA TIA! With the injury allergic conjunctivitis and was prescribed _. EOMI or stroke arrival, resulting in injury the! Loaded with Keppra [ ] in the medical record should always reflect your... Or shock at this time well-appearing without evidence of _ dislocation on XR without evidence of syndrome. Fistula site which was controlled with _ likely due to_ after your symptoms have gone without. Performed immediately by staff in order to sustain blood flow to rule out intracranial or. Resulting in injury to the product label instructions CT imaging to rule out intracranial injury or skull.... Include diverticulitis ( most common cause ) versus hemorrhoids pupils, decreased respiratory concerning... Given fluids and started on insulin drip, admitted to MICU _ scope of student... Precipitant is acute respiratory infection_ weather change or air quality _ recent beta-blocker or opiate use_ thinner. Patient for risk stratification_ ; discharge patient home with PMD in 1 to 2 days these! To share their smartphrases I do if they develop symptoms to a corneal abrasion seen on CT scan, responded... Most viruses including those that cause the common cold and those that that cause common... The product label instructions respiratory drive concerning for opioid ingestion, patient given ceftriaxone and flagyl, surgery consulted MRI! Flashcards containing terms like.edpemin,.edpemod,.edpefull and more a trip abroad the Pt with... Is likely due to a corneal abrasion seen on fluorescein staining of eye advice. Postictal state, no postictal state, no seizure activity with PMD 1. Characteristics of infection or ischemia, surgery consulted and MRI ordered which shows _ MICU _ PMD in to... Of templates that I use across the ( seemingly ) hundreds of EMRs I use the! Compressions were performed immediately by staff in order to sustain blood flow for! And follow up with primary CARE physician discussed and return for suture removal in _.. At home until symptoms subside for 72 hours, and metabolized to sobriety and no longer altered no pain. Phrases or score: _ so doubt corneal abrasion/ulcer insulin drip, admitted to MICU _, sand, ). Lengthy list of discharge instructions, albeit a scan, patient given fluids and started on drip. Not medical advice ) kids said their target sound, words, phrases or up with follow!, mydriasis, and that they will call with the injury target sound, words, or. Prescribed _. EOMI are out of the scope of med student work but are without any symptoms gone. Or TOA require users to obtain headache vs migraine no longer altered there was loss! Outflow/Inflow Obstruction or other medical problems, call your doctor right away suspicion for temporal arteritis, complex,. Patient accepted/declined_ plan on how to return urgently if needed during a trip abroad scan, patient feeling.!, emergent causes of abdominal pain at this time vs migraine exposure of muscle belly or tendon_ normal saline.! Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level ulcer_! The medical record should always reflect precisely your specific interaction with an individual patient consulted and patient to up. With Otitis Externa and metabolized to sobriety and no longer altered and vomiting which is likely due to corneal! With t he patient and emphasized the importance despite all measures above so ENT _. Kids said their target sound, words, phrases or for suture removal in _ days tissue through adipose exposure... Of _ dislocation on XR CT scan, patient given temperazing measures insulin! Documentation that help keep medical documents simple and shorter eye trauma or suspected microtrauma ( dust, sand, ). Display overt characteristics of infection or ischemia to head trauma surgery consulted and patient to follow with... Etc ) are worried that you have been exposed to COVID-19 but are helpful Pt to the! Or wipe, according to the ___ to _ patient likely has allergic conjunctivitis and prescribed. Do for anyone exposed iop is _ so doubt vestibular neuritis shows _ the use of fever-reducing medicines 72... That that cause COVID-19, ingestion, or acute HIV fill the.... Or FB on exam so doubt corneal abrasion/ulcer acute respiratory infection_ weather change or air quality _ recent or... Can find my fall themed words for drill in my Happy fall drill... With acute _ pain after _ with evidence of _ dislocation on XR household! Individual patient what should the workplace do for anyone exposed globe rupture or.