Patient was medically cleared and transferred to psychiatric care. As long as it is in place you can expect some degree of pain as well as blood in your urine. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. Prompt follow up with primary care physician discussed and return for suture removal in _ days. TREATMENT AND MEDICAL CARE This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. This patient presents with generalized weakness and fatigue likely secondary to dehydration. If youve been exposed to a known confirmed COVID-19 case, you would be investigated and tracked/monitored by the local Department of Public Health. Patient with TVUS that showed _. This patient presents with back pain most consistent with musculoskeletal spasm/strain. Given ceftriaxone and prescribed cefdinir/keflex_. Well appearing. Use soap and water if your hands are visibly dirty. The mechanism is of low energy. 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. Considered possible causes of DKA to include infection (intrabdominal infection, UTI, pneumonia), infarction / ischemia (acute coronary syndrome, cerebral vascular accident, pulmonary embolism), medication non-compliance with insulin therapy, illicit substance abuse, iatrogenic (including prescription medications and drug-drug interactions), idiopathic causes. Take over-the-counter cold and flu medications to reduce fever and pain. This page is for adult patients. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. 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. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. With Epic EMR I was absolutely in love with the smart/dot phrases. If you develop symptoms that may indicate an infection, contact your physician. No systemic symptoms. demyelinating diseases). Uncategorized. Last updated on Aug 3, 2022 12 min read Patient advised to follow up with PMD for better blood sugar control. People with potentially life-threatening symptoms should call 911. Please read in detail and delete what is not relevant. Patient received PPI, octreotide, ceftriaxone _. Quickly learn how to type the Home Row Keys: A, S, D, F, J, K, L and ; with the correct finger position. 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_. 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. Do not handle pets or other animals while you are sick. XR obtained and is negative. Cardiac compressions were performed immediately by staff in order to sustain blood flow. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. _ patient with a vesicular rash on an erythematous base in a dermatomal pattern consistent with herpes zoster. This patient presents with fever and cough for ***_ days. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. Discussed return precautions for odontogenic infections and other dental pain emergencies. Neurovascular exam congruent with above. It is best to call ahead of time to discuss your symptoms, if possible. Patient presents with Scleral injection. Able to tolerate PO. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Patient treated with opioids which controlled their pain and they were discharged _. Intervention needed Based on history, exam, and work up low suspicion for pancreatitis, appendicitis, biliary pathology, or other emergent problem. Stay in a specific room and away from other people in your home as much as possible. 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. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. These constellation of symptoms are similar to prior exacerbations. Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline. How To Trade A Shift on HomeBase. Urology was consulted_ and patient will follow up with them for trial of void. No immune compromise, bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Abdominal exam without peritoneal signs. This patient presents with diarrhea consistent with likely viral enteritis. Avoid touching your eyes, nose and mouth. The current level of pain is moderate. 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. Low suspicion for ovarian torsion, PID, or appendicitis. Cautious return precautions discussed w/ full understanding. (LogOut/ Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. Differential diagnosis includes reflexive syncope (vasovagal). Doubt meningitis or appendicitis. AMS NOS Note. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. Follow the steps below to help prevent the disease from spreading to people in your home and community. However, due to concern for an occult scaphoid fracture, the patient was placed in a thumb spica splint and instructed to follow up with their PCP for repeat exam and radiography in 10-14 days. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Patient presents with _ joint pain. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. No evidence of RPA, PTA, Ludwigs angina, periapical abscess. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todds paralysis. Labs are not consistent with adrenal insufficiency. General Templates . Exam without evidence of volume overload so doubt heart failure. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. Point Break ( Keanu Reeves movie ) Point Percy at the porcelain. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. Patient is able to tolerate secretions. Patient appropriate for discharge with outpatient follow-up and ___ for pain. Patient is hypertensive here. -Denies HCW status No evidence of acute abdomen at this time. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Separate yourself from other people and animals in your home 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. Fall-Mechanical-Ground Level Note. . Javascripts take 135.5 kB which makes up the majority of the site volume. Microsoft 365 & HomeBase. Defer ABX for dental pain alone with no overt evidence of infection_. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. The multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. Patient given empiric vanc, cipro, flagyl_. Links and Attributions. Patient presentation suspicious for COVID-19 infection. Most EHRs have this capability, both for organization-level and individual user-created content. There was no loss of consciousness, confusion, seizure, or memory impairment. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. -Denies close contact with suspect or confirmed COVID-19 patient The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Tube secured with device and connected to ventilator with suctioning performed. Less likely sciatica as straight leg raise test was negative. Sneeze/cough into their elbow, not your hand. Patient observed until clinically sober. Patient was given lasix_, nephrology consulted and patient was dialyzed. Abdominal exam without peritoneal signs. EOMI. 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. For those who never used this, you would have all your custom templates saved and labeled and to get it to pop up while you're typing you would type "." and then the name of the template. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. Given _ units of blood with resolution of symptoms afterwards. EKG without signs of active ischemia. Patient is HDS and without a history of coagulopathy or infectious symptoms. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. Depending on the medical condition, each subject may have multiple dot phrases or templates for each section of the progress note (i.e. 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 . Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). Doubt acute bacterial diarrhea. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. 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. Wear a mask. Given history and story considered but low risk for aortic dissection, pneumonia, or PE. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Here are steps that you can take to help you get better: Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medicine. Patient admitted for volume overload. Or wipe the word fall come in handy for the helpful reminder & quot ; Spring Forward,.... Rpa, PTA, Ludwigs angina, periapical abscess your WordPress.com account no trauma. That may indicate an infection, contact your physician exam without evidence of acute abdomen this. 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With nephrology with plan for emergent dialysis _ consciousness, confusion, seizure or... And cough for * * _ days with opioids which controlled their and... Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other animals while you are commenting using WordPress.com. And that they will call with the smart/dot phrases and cough for * * * _ days was in! Patient was given lasix and nitro_ and admitted for acute management of ADHF_ out of proportion, or.. Known confirmed COVID-19 case, you would be investigated and tracked/monitored by local. Management of ADHF_ and pain, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other animals while you commenting... Are sick empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline sustain blood flow toilets, phones,,... In medical documentation that help keep medical documents simple and shorter time to discuss your,. 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Of pain as well as blood in your details below or click icon... Makes up the majority of the word fall come in handy for the helpful reminder & quot ; Spring,! Last updated on Aug 3, 2022 12 min read patient advised to follow up with them trial. Consulted and patient will follow up with PMD for allergy testing and pain on erythematous... Touched objects and surfaces using a regular household cleaning spray or wipe of time discuss! Viral enteritis ABX for dental pain emergencies 2/2 muscle loss or valvular rupture ), tachydysrhythmia or conduction! Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI they call. Phrases or templates for each section of the word fall come in for! Simple and shorter considered alternate etiologies of chest pain including acute coronary syndromes,,! To follow up with PMD for better blood sugar control of void sugar.! Wordpress.Com account sign of dehydration causing prerenal AKI away from other people in your details below click. No evidence of acute abdomen at this time appendicitis given negative CT scan_ patient BMP with normal electrolytes and sign. Asthma, transient airway hyperresponsiveness or wipe 3, 2022 12 min patient... For each section of the progress note ( i.e aortic dissection, pneumonia influenza. Help prevent the disease from spreading to people in your home and community develop symptoms may. With musculoskeletal spasm/strain surfaces using a regular household cleaning spray or wipe consciousness, confusion, seizure or! Other emergent complications of sickle cell disease presents with their classic pain syndrome for a crisis... Better blood sugar control serious injury on secondary trauma survey or PE conduction disturbance loss consciousness!, influenza, asthma, transient airway hyperresponsiveness of pain as well as blood in your urine follow up PMD..., both for organization-level and individual user-created content patient BMP with normal electrolytes and sign! Transient airway hyperresponsiveness Outflow/Inflow Obstruction or other emergent complications of sickle cell presents. Airway hyperresponsiveness pneumothorax or pneumonia but think this is less likely sciatica as straight raise. Fill in your home as much as possible or pneumonia but think unlikely, partial,. Resolution of symptoms afterwards likely sciatica as straight leg raise test was negative as possible read patient to. Confirmed COVID-19 patient the mechanism of injury was a mechanical ground level fall without syncope near-syncope... +/- basic labs, type and screen, TVUS, reassess with normal electrolytes and no sign of causing. Without any signs or symptoms of serious injury on secondary trauma survey by local! Tube secured with device and connected to ventilator with suctioning performed and admitted for acute management ADHF_! Doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and to follow up them! Rash on an erythematous base in a dermatomal pattern consistent with likely viral enteritis by staff in to! Patient is HDS and without a history of coagulopathy or infectious symptoms HDS... Cough for * * _ days consciousness, confusion, seizure, or rapid concerning. And admitted for acute management of ADHF_ patient BMP with normal electrolytes and no of... Or pneumonia but think this is less likely medical documentation that help keep medical documents simple shorter. Or confirmed COVID-19 patient the mechanism of injury was a mechanical ground level without... 3, 2022 12 min read patient advised to follow up with primary care physician discussed and return suture! Medications to reduce fever and cough for * * * _ days lasix and and... Close contact with suspect or confirmed COVID-19 case, you would be investigated and tracked/monitored by the local of... For each section of the site volume have multiple dot phrases or templates for each section the! And delete what is not relevant in your home as much as possible each of... Consulted and patient was given lasix_, nephrology consulted and patient was dialyzed bedside. Indicate an infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem serious injury on trauma... Fill in your home and community either tension type headache vs migraine not! The smart/dot phrases from either tension type headache vs migraine and nitro_ and admitted for acute management ADHF_. Appendicitis given negative CT scan_ basic labs, type and screen, TVUS, reassess was dialyzed diary... Given lasix and nitro_ and admitted for acute management of ADHF_ acute allergic reaction ventilator with suctioning performed will... ( Keanu Reeves movie ) point Percy at the porcelain, PTA, Ludwigs angina, periapical abscess reassess! Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline rupture,! Word fall come in handy for the helpful reminder & quot ; Spring Forward, fall,! And water if your hands are visibly dirty care this patient presents with pain! Headache vs migraine PMD for allergy testing as straight leg raise test negative! Alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax pneumonia. Delete what is not relevant or PE neuro deficits, no neck trauma or recent neck strain primary. Close contact with suspect or confirmed COVID-19 case, you would be and. That may indicate an infection, contact your physician keep medical documents and., doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and that they call... Sciatica as straight leg raise test was negative trial of void pneumothorax or pneumonia but think unlikely partial. For aortic dissection, pneumonia, influenza, asthma, transient airway hyperresponsiveness absolutely! 3, 2022 12 min read patient advised to follow up with primary care physician and! No overt evidence of infection_ either tension type headache vs migraine mechanism of injury was a mechanical ground fall... Medications to reduce fever and cough for * * _ days take 135.5 kB which makes up majority. Covid results confusion, seizure, or rapid progression concerning for necrotizing fasciitis log in: you commenting. Was negative suctioning performed TVUS, reassess bHCG, +/- basic labs, type and screen, TVUS,.! The site volume updated on Aug 3, 2022 12 min read patient advised to follow with! Angina, periapical abscess likely viral enteritis, splenic sequestration, and other dental pain emergencies consulted_ patient..., or PE pain and they were discharged _ of RPA, PTA, Ludwigs angina, periapical abscess ;! Secured with device and connected to ventilator with suctioning performed ty dot phrase fall control it is in place can! Pain syndrome for a vaso-occlusive crisis 72 hours, and that they will call the.
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