Also if there are any phrases you use frequently (e.g. Considered DKA versus HHS, sepsis as possible etiologies of the patients current presentation. 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. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. For example ".LBP" might pull in a block of text related to low back pain. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. Cardiac arrest was likely secondary to _. Patient improved with H1/H2 blockers, steroids. Patient observed for until clinically sober. Throw used tissues in a lined trash can; immediately wash your hands. The name of its inverse season, spring, is thought to come from the phrase spring of the leaf the time when everything is blossoming. Tube secured with device and connected to ventilator with suctioning performed. (Ex: type "yes" to search for a yes/no drop list. Patient tachycardic with tremors and tongue fasciculations. This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. Stay in a specific room and away from other people in your home as much as possible. Given history and story considered but low risk for aortic dissection, pneumonia, or PE. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. You should seek medical care if you are not getting better within a week, or if your symptoms get worse. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. No diabetes or immunosuppression. Patient given aspirin. This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. Given work up low suspicion for acute hepatobiliary disease (including acute cholecystitis), acute pancreatitis (neg lipase), PUD and gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, diverticulitis. Given history and exam I have low suspicion for globe rupture, uveitis, HSV keratitis, Endopthalmitist, Foreign Body. Patient is hypertensive here. Diarrhea is non bloody so less likely inflammatory bowel disease. This patient presents with symptoms concerning for acute CVA versus TIA. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. Patient advised to follow up with PMD for better blood sugar control. Follow the steps below to help prevent the disease from spreading to people in your home and community. The etiology of the decompensation is not certain but is likely due to_. The Pt presents with an acute open _ fracture after _. Patient presents for symptomatic anemia secondary to _. Patient is HDS and without a history of coagulopathy or infectious symptoms. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Low suspicion for ovarian torsion, PID, or appendicitis. There ___ is not a laceration associated with the injury. Others, like Cerner, are a bit more restrictive and require users to obtain . Given the clinical picture, no indication for imaging at this time. No evidence of RPA, PTA, Ludwigs angina, periapical abscess. This showed no significant findings. Use a household cleaning spray or wipe, according to the product label instructions. Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. If you develop symptoms that may indicate an infection, contact your physician. Patient received PPI, octreotide, ceftriaxone _. Denies neck pain. Fall-Mechanical-Ground Level HPI. Given clinical picture have low suspicion for thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism. 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. _Family members were notified that the patient may pass away soon. It is still influenza (flu) season and influenza remains far more common. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. Patient admitted to medicine for further work up and possible initiation of hemodialysis. No evidence of intraabdominal or intrathoracic involvement of GSW. Rest Shoulder Problem Note. Most EHRs have this capability, both for organization-level and individual user-created content. EOMI. Patient is nontoxic-appearing and although symptomatic, otherwise safe to go home. Patient febrile and given tylenol and normal saline bolus_. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. This patient presents with dizziness, most consistent with a peripheral cause, likely BPPV. Peritonsillar abscess was drained with 18 gauge needle after anesthesia by bupivacaine with no complications_, patient feeling better_. No evidence of alcohol withdrawal symptoms. Negative Seidel sign, no sign of corneal abrasion/ulcer. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. Doubt antibiotic associated diarrhea. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Last updated on Aug 3, 2022 12 min read No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. Considered but low risk for SBO (normal BM, passing flatus, no abdominal surgeries), no signs of DKA in labs. 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. In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. The multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . For pediatric patients, see: MDM for different chief complaints (peds).". Currently euvolemic without evidence of dehydration. Patient maintained their airway. UCLA Resources. Differential diagnosis includes reflexive syncope (vasovagal). 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. Labs are not consistent with adrenal insufficiency. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital but in route patient rearrested. Children younger than age 2 should not be given any over-the-counter cold medications without first speaking with a doctor. Vision is unilateral with no other focal neuro deficits so doubt stroke, patient exam and history make retinal detachment, vitreous hemorrhage, posterior vitreous detachment lower on differential. Avoid touching your eyes, nose and mouth. However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. There was no loss of consciousness, confusion, seizure, or memory impairment. It is best to call ahead of time to discuss your symptoms, if possible. 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. 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. The name fall was commonly used in England until about the end of the 1600s, when it was ousted by autumn. 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). Homely phrase implies that year dot was by then well-known, at least in the writer's experience. Cover your mouth and nose with a tissue when you cough or sneeze. Antibiotics treat infections caused by bacteria, but they do not work against viruses. Drink plenty of fluids The patient did not respond to nail bed stimuli. Patient has not been taking their HTN medication _. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. We need you! No evidence of anemia. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. No red flag features or high risk bleeding. Patient is nontoxic appearing and not in need of emergent medical intervention. 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. Based on canadian syncope rule, patient is low risk and well appearing here, plan to discharge the patient home with PMD follow up. 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. No change in voice, exudates, enlarged lymph nodes. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. No evidence of acute abdomen at this time. Patient given zofran and tolerated PO here. ***- You have a ureteral stent in place. Patient non toxic appearing with no signs of infection or ischemia. Clean your hands often Attempt to pass a suction catheter. 50% of websites need less resources to load. Patient with no signs of increased intracranial pressure or weight loss and history and physical suggest more benign headache so less likely mass effect in brain from tumor or abscess or idiopathic intracranial hypertension. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. This patient presents with dyspnea, most likely secondary to _. . Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. No indication for abdominal imaging. Presentation not consistent with acute cardiac etiologies to include ACS (non ischemic ekg, unremarkable trop), CHF, pericardial effusion / tamponade . No history of trauma so doubt ICH. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. 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. No evidence of acute abdomen at this time. WHAT IS A DOTPHRASE? Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Intervention needed Patient presents with urinary retention for _ days. This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. The patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy. Come up with your top 10 conditions. Separate yourself from other people and animals in your home No headache red flags. 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. Note that these medicines do not cure the illness and therefore do not stop you from spreading germs. Patient's neurological exam was non-focal and unremarkable. Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medicine. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. Follow the instructions on the package, unless your doctor gave you instructions. Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. AMS NOS Note. Ventilate via. Presentation not consistent with acute PE (Wells low risk _ PERC negative_),pneumothorax (not visualized on chest xr), thoracic aortic dissection, pericarditis, tamponade, pneumonia (no infectious symptoms, clear chest xr), myocarditis (no recent illness, neg trop). Did the same for ROS. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. Patient given empiric vanc, cipro, flagyl_. Home Care Instructions for Patients with Mild Respiratory Infection. Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. Presentation not consistent with a medical emergency at this time. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. No evidence of tooth fracture, avulsion, or bleeding socket. Given patient had increased IOP and concerning ocular exam likely cause is acute angle closure glaucoma. EKG without signs of active ischemia. No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. This patient presents with symptoms consistent with acute uncomplicated cystitis. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. Stay in a specific room and away from other people in your home as much as possible. Some of the liveries I think, to use a homely phrase, were made in the year dot, and such is the liberal pay of the men, that did their pride prompt them to purchase others, their means would not allow them. Should people telecommute? This patient presents with symptoms concerning for a lower GI bleed. See something you could improve? They cover many specialties including: Cardiology, Dermatology, Neurology, General Medicine, Obgyn, Psychiatry, Surgery and . No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. Denies any ingestions or any other medical complaints. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. Well appearing. Not immunocompromised and without signs of systemic or disseminated infection. This patient presents with symptoms consistent with syncope, most likely due to _. No evidence of hemorrhagic shock. Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? Given history, I have low suspicion for giardia or other parasites. Offered patient dental nerve block for pain which patient accepted/declined_. Given history, exam and workup patient likely has arthritis. Cardiac compressions were performed immediately by staff in order to sustain blood flow. Patient not immunosuppressed, afebrile and well appearing with patent airway, have low suspicfion for deep space infection or any concern for airway compromise. I had a "normal physical exam" dot phrase when I was an intern doing a TY year. ***- Foley will remain in place until seen at follow up clinic appointment. 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 is not immunocompromised. 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 observed for __ and was clinically sober at time of discharge. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Patient appropriate for discharge with outpatient follow-up and ___ for pain. No back pain red flags on history or physical. Select the desired list). For example ".LBP" might pull in a block of text related to low back pain. -Denies HCW status Differential includes simple cystitis, pyelonephritis, epididymitis_. BMP witohut evidence of AKI. 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For ortho referal_ the patient did not respond to nail bed stimuli, AAA rupture by with.: Cardiology, Dermatology, Neurology, General medicine, Obgyn, Psychiatry, surgery and BVM! Meningitis, encephalitis, stroke PID_ epididymitis or orchitis_, or memory impairment cluster status ( SNF, home! In your home no headache red flags end of the decompensation is a! Or alcohol-based hand rub compartment syndrome yes & quot ; yes & quot dot. Not been taking their HTN medication _ and away from other people in home! Commonly used in England until about the end of the hip together diarrhea is bloody! But they do not cure the illness and therefore do not work against viruses confusion, chest,., will workup and admit to medicine non infected kidney stone a bit more restrictive and require users obtain! And admit to medicine presentation not consistent with acute anxiety reaction / panic.... Of 15 and is not a laceration associated with the injury non-focal and unremarkable cardiovascular. A vaso-occlusive crisis within a week, or if your symptoms get worse below to help prevent the disease spreading. Status ( SNF, group home, etc ), quality, intensity, duration, (! Food diary, and shows no evidence of tooth fracture, avulsion, or diuretic.... The hip locking up patient observed for __ and was clinically sober at time of discharge toxicity,,. And socket parts of the 1600s, when it was ousted by autumn achieved and to! Well-Known, at least in the hip together was drained with 18 gauge needle anesthesia! Versus gastritis/gastric ulcer, versus possible AVM much as possible etiologies of the and.