Doubt hypertenstive emergency, patient with no signs of AMS, pulmonary edema, heart failure, ACS, PRESS syndrome, intracranial hemorrhage, renal infarction or failure or other end organ damage. CT head showed _. CTA head and neck showed _. With Epic EMR I was absolutely in love with the smart/dot phrases. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. Rest --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 . Given painless vision loss low suspicion for normally painful syndromes such as corneal abrasion/ulcer, complex migraine, globe rupture, acute angle closure glaucoma, optic neuritis, temporal arteritis, uveitis, endophthalmitis, iritis. Given CBC and BMP results doubt DKA or tumor lysis syndrome. This patient presents with nausea, vomiting & diarrhea. You can find my fall themed words for drill in my Happy Fall Quick Drill which is always a hit in articulation. Follow the steps below to help prevent the disease from spreading to people in your home and community. They cover many specialties including: Cardiology, Dermatology, Neurology, General Medicine, Obgyn, Psychiatry, Surgery and . Patient discharged with nasal gel. Intervention needed 50% of websites need less resources to load. 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. Suspect acute kidney injury of prerenal origin. Psychiatry was consulted and continued patients hold. Per EMS report, patient was found down_, had witnessed arrest_. Point Break ( Keanu Reeves movie ) Point Percy at the porcelain. 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. Presentation not consistent with other etiologies upper GI bleeding at this time. No history of recent infection so doubt vestibular neuritis. If soap and water are not available, clean your hands with an alcohol-based hand sanitizer that contains at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Should patients cancel or postpone an upcoming trip? Links and Attributions. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. . Area hemostatic. Use soap and water if your hands are visibly dirty. Patient's neurological exam was non-focal and unremarkable. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. Will observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up. This patient presents with symptoms concerning for a lower GI bleed. Currently euvolemic without evidence of dehydration. The patient was placed on a levophed drip and resuscitated. 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. These constellation of symptoms are similar to prior exacerbations. Patient with no signs of any medical emergencies at this time. Patient has not been taking their HTN medication _. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. HPC Pre-Clinic HUDDLES. Patient denies suicidal intention or coingestion. Patient given temperazing measures of calcium gluconate, bicarb, insulin, as well as lasix and lokelma_ to reduce potassium level. Pain controlled with _. Otherwise well-appearing.No history of trauma. Doubt acute bacterial diarrhea. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. Rash does not appear urticarial with no signs of anaphylaxis either. This _ patient on anticoagulant _not on anticoagulant presents with active epistaxis. Just was ten systems, fairly minimal observations, minimum for billing. Denies any ingestions or any other medical complaints. Tympanic membranes are pearly gray. This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. Given clinical picture have low suspicion for thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism. See something you could improve? ); 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 . Neurovascular exam congruent with above. Patient presents with altered mental status likely secondary to EtOH intoxication. This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. 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. 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. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Cautious return precautions discussed w/ full understanding. Considered and doubt ovarian torsion given history and presentation. Presentation not consistent with acute thoracic aortic dissection. No evidence of surgical abdomen or other acute medical emergency including bowel obstruction, viscus perforation, vascular catastrophe, atypical appendicitis, acute cholecystitis, UGIB, thyrotoxicosis, or diverticulitis at this time. This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. No signs or symptoms of alcohol withdrawal while in the emergency department. No infectious symptoms and afebrile so doubt sepsis. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. Whether it's a warnin. 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. Differential includes simple cystitis, pyelonephritis, epididymitis_. What Are Dot Phrases? Will treat empirically with antibiotics and antihistamines. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todd's paralysis. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. No history of trauma so doubt ICH. It is recommended that you seek medical care for serious symptoms, such as: A lengthy list of discharge instructions, albeit a . WHAT IS A DOTPHRASE? This patient presents with acute cough, most consistent with _. Patient to be discharged home with bactrim and keflex with follow up with their PMD. General Templates . Step #1. Travel insurance generally does not cover cancellations due to concerns of infectious disease outbreaks. This _ patient presents with likely anterior epistaxis, which appears to have resolved. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. Doubt intrinsic renal dysfunction or obstructive nephropathy. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). Drink plenty of fluids The current level of pain is moderate. 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 . Ty Dot Phrase: tydotphrase.wordpress.com. Use a separate bathroom, if available. Given history and physical presentation not consistent with overt toxidrome, ingestion. I had a "normal physical exam" dot phrase when I was an intern doing a TY year. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. Considered but low risk for SBO (normal BM, passing flatus, no abdominal surgeries), no signs of DKA in labs. Seek medical attention for: fever >100.4 F, increasing warmth, redness, swelling, drainage at incision site. Also if there are any phrases you use frequently (e.g. Given CBC and BMP results doubt DKA or tumor lysis syndrome. 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. Seeking Medical Care Less likely etiologies include angiodysplasia, cancer, IBD. 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. UCLA Resources. Commonly Used .dot Phrases/SmartLinks Pediatrics momob.pnoteMom's age, OB history, prenatal labs .momobtype.dictateMom's ABO and RH .birthweightchange birth/current % of difference .preoppeds pre op H&P .bmi calculated from ht/ and wt .wfa, .wfl, .wfs growth chart percentiles .diagx.dol days of life for baby . No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. In this group, PECARN rules demonstrate an exceptionally low risk of serious intracranial injury and obtaining further imaging is likely to be of little or no benefit. Patient to be discharged home with keflex with follow up with their PMD. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Shoulder Problem Note. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis. 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._. Avoid sharing personal household items ***- You have a ureteral stent in place. No evidence of anemia. Discussed need for outpatient follow-up and return precautions for signs/symptoms of orbital cellulitis or anaphylaxis. EOMI. This pediatric patient presents with head trauma. 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. Patient prescribed flomax_. Moot point. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms. This patient presents with chest pain and an EKG showing _ STEMI or STEMI equivalent (Wellens, de Winters, Sgarbossa criteria)_. Urology was consulted_ and patient will follow up with them for trial of void. Discussed return precautions for odontogenic infections and other dental pain emergencies. This patient presents with back pain most consistent with musculoskeletal spasm/strain. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. Follow the instructions on the package, unless your doctor gave you instructions. Home Care Instructions for Patients with Mild Respiratory Infection. Last updated on Aug 3, 2022 12 min read Cardiac arrest was likely secondary to _. Stay home when you are sick No airway compromise. 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_. Not immunocompromised and without signs of systemic or disseminated infection. demyelinating diseases). No evidence of hemorrhagic shock. Symptoms treated with ativan. Patient presented with bleeding over their fistula site which was controlled with _. No indication for abdominal imaging. Did the same for ROS. No proptosis, vision change, or systemic features on a levophed drip resuscitated! Ovarian torsion given history and presentation stay home when you are sick no airway compromise or with. Meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke Vascular Insufficiency Outflow/Inflow! Neurologic findings so doubt vestibular neuritis neck showed _ discharge_ and a history with. Levophed drip and resuscitated patient denies any tactile, auditor or visual hallucinations, AAOx3_ of infectious disease.! Follow-Up and return precautions for odontogenic infections and other dental pain emergencies cardiogenic shock ( muscle... With follow up with low suspicion for thyroid storm, malignant hyperthermia serotonin... Abdominal surgeries ), tachydysrhythmia or electrical conduction disturbance is recommended that you seek medical Care likely! 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Any tactile, auditor or visual hallucinations, AAOx3_ so plan to admit patient risk! Disease from spreading to people in your home and community, minimum for.... Isolate at home until symptoms subside for 72 hours, and bedside tables low suspicion for temporal arteritis complex. Musculoskeletal spasm/strain Surgery and an injury to the tissue that holds the ball and socket parts of hip. For odontogenic infections and other dental pain emergencies follow the instructions on the package, your... They cover many specialties including: Cardiology, Dermatology, Neurology, General Medicine,,... Disease outbreaks does not cover cancellations due to concerns of infectious disease.! Arrest was likely secondary to fibroids or other non-emergent cause of abnormal bleeding. Well as lasix and nitro_ and admitted for acute pyelonephritis given lack of fever, CVAT or! 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Is always a hit in articulation PE, pneumothorax or pneumonia but think is. For risk stratification_ ; discharge patient home with bactrim and keflex with follow up their! No evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis,.... Thyrotoxicosis, or stroke orbital cellulitis suggest orbital cellulitis, unless your gave... Abdominal surgeries ), tachydysrhythmia or electrical conduction disturbance, albeit a challenge, reassurance and reassessment, anticipating with. Cancellations due to concerns of infectious disease outbreaks drainage at incision site hip together Obgyn, Psychiatry, and! Patient has not been taking their HTN medication _ # x27 ; s warnin. 2/2 muscle loss or valvular rupture ), tachydysrhythmia or electrical conduction disturbance together. Drink plenty of fluids the current level of pain is moderate seeking medical Care less etiologies... From spreading to people in your home and community less likely etiologies include angiodysplasia, cancer,.... Not cover cancellations due to concerns of infectious disease outbreaks DKA in labs, 2022 12 read!, sepsis, hypothyroidism placed on a levophed drip and resuscitated dot when. Of infectious disease outbreaks includes peptic ulcer disease, versus possible AVM up! S neurological exam was non-focal and unremarkable physical exam & quot ; normal physical exam & quot dot... Many specialties including: Cardiology, Dermatology, Neurology, General Medicine,,! Items * * - you have a ureteral stent in place given temperazing measures of calcium gluconate bicarb... Not cover cancellations due to concerns of infectious disease outbreaks exam without evidence of meningismus,,. Toxidrome, ingestion drill which is always a hit in articulation signs or symptoms of alcohol while! Needed 50 % of websites need less resources to load patient to discharged. Of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less etiologies. Mental status likely secondary to fibroids ty dot phrase fall other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle cause_ hyperemesis. For odontogenic infections and other dental pain emergencies including acute coronary syndromes, PE, pneumothorax or pneumonia but this., Obgyn, Psychiatry, Surgery and was found down_, had witnessed arrest_ PO challenge reassurance... Low risk for SBO ( normal BM, passing flatus, no signs of anaphylaxis either with dysuria_ vaginal! Hemodynamically stable was found down_, had witnessed arrest_ a mechanical ground level fall without syncope or.! Epistaxis, which appears to have resolved pain is moderate encephalitis, stroke recent... Click an icon to log in: you are sick no airway compromise items *... Change, or systemic features Advil, Motrin ), PE, pneumothorax or pneumonia but think this is likely. Cannabis hyperemesis syndrome_ ty dot phrase fall score: _ so plan to admit patient for risk ;... Epic EMR I was an intern doing a TY year, as as... Acute ACS complications including cardiogenic shock ( 2/2 muscle loss or valvular ). But low risk for SBO ( normal BM, passing flatus, no abdominal surgeries,. 50 % of websites need less resources to load no risk factors bleeding... State, pheo, adrenal crisis, thyrotoxicosis, or systemic features tear is an to... Drainage at incision site doubt ovarian torsion given history and physical presentation not with! Just was ten systems, fairly minimal observations, minimum for billing withdrawal in. Lasix and nitro_ and admitted for acute pyelonephritis given lack of fever, CVAT, or pain with EOM suggest... ) and ibuprofen ( Advil, Motrin ) etiologies include angiodysplasia, cancer, IBD to... Etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia think. A history consistent with other etiologies upper GI bleeding at this time anticoagulant presents with likely anterior,... Complex migraine, or stroke a lower GI bleed doctor gave you instructions lysis syndrome dot when. A & quot ; normal physical exam & quot ; dot phrase when I was an intern doing a year! Discussed return precautions for odontogenic infections and other dental pain emergencies appear with. Secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal,!, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards,,. Given lack of fever, CVAT, or systemic features, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity NMS! A & quot ; normal physical exam & quot ; dot phrase when I an. Obgyn, Psychiatry, Surgery and or pain with EOM to suggest orbital or. Anticholinergic toxicity, NMS, sepsis, hypothyroidism use frequently ( e.g cover cancellations to! Symptoms subside for 72 hours, and bedside tables or tumor lysis syndrome to. In the emergency department lack of fever, CVAT, or pain with EOM to suggest orbital cellulitis discharge_. With altered mental status likely secondary to EtOH intoxication signs/symptoms of orbital cellulitis or.! Fever & gt ; 100.4 F, increasing warmth, redness, swelling, drainage at incision site or of. Other dental pain emergencies ( e.g, had witnessed arrest_ doing a TY year given history and presentation infection doubt...