ty dot phrase fall

Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and lacks serious medical comorbidities that would require admission. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. SharePoint. Patient improved with H1/H2 blockers, steroids. []-year-old patient presenting with swollen eye. 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. CT head showed _. CTA head and neck showed _. Given the clinical picture, no indication for imaging at this time. Patient presents with flank pain and is found to have a kidney stone that is obstructed with signs of infection concerning for infected obstructed kidney stone so Urology was consulted and patient to be taken to OR with urology for stent placement to relieve obstruction. 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. This pediatric patient presents with a history concerning for a serious intracranial injury. 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 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. Safe ride home was arranged with __. Low suspicion for alternate etiologies such as pneumothorax, acute PE, pneumonia. The Center for Disease Control has a section on travel notices. WHAT IS A DOTPHRASE? Wear a mask. No recent travel. Normal IOP so doubt acute angle closure glaucoma. Avoid sharing personal household items The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Most EHRs have this capability, both for organization-level and individual user-created content. Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. Treatment Whether it's a warnin. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". There is no specific treatment for most viruses including those that that cause the common cold and those that cause COVID-19. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). Diarrhea is non bloody so less likely inflammatory bowel disease. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. There was no loss of consciousness, confusion, seizure, or memory impairment. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. 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. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). This patient presents with symptoms and labs consistent with acute hypoglycemia, most likely due to _. Patient was pronounced deceased. Patient given fluids and ceftriaxone. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. Will give wait and see prescription for amoxicillin. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. If symptoms worsen or persist for 48-72 then pt to fill the prescription_. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. News for nerds, stuff that matters ( Slashdot advertising slogan ) Not to put too fine a point on it. With Epic EMR I was absolutely in love with the smart/dot phrases. ); 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 . Patient is hypertensive here. Patient not taking any nephrotoxic medications_. 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. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Doubt pneumonia or pyelonephritis. Just was ten systems, fairly minimal observations, minimum for billing. Based on history and physical doubt sinusitis. Cardiac arrest was likely secondary to _. Try to stay at least 6 feet from others. 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. Will add to follow-up list to call with results after. 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. No evidence of tooth fracture, avulsion, or bleeding socket. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Full Notes. Primary headaches include tension, migraine, and cluster. No urticarial rash to suggest allergic reaction. HPC Pre-Clinic HUDDLES. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. Stay in a specific room and away from other people in your home as much as possible. Patient presents with lower abdominal pain/pelvic pain. In this video, we've compiled short one-second clips from different movies where characters say the popular phrase "Don't Fall For It". Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. Most EHRs have this capability, both for organization-level and individual user-created content. (LogOut/ A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. Patient observed for until clinically sober. Symptoms treated with ativan. Patient euvolemic on exam so likely cause is SIADH. Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage (stable hgb). Plan: CT scan head/neck, pain control, reassess. It is best to call ahead of time to discuss your symptoms, if possible. Stay home for at least 24 hours after your symptoms have gone away without the use of fever-reducing medicines. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u. Oropharynx pink and moist. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. Given history and exam I have low suspicion for globe rupture, uveitis, HSV keratitis, Endopthalmitist, Foreign Body. Code Blue Note. This patient presents with symptoms consistent with syncope, most likely due to _. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. No evidence of hemorrhagic shock. Home Care Instructions for Patients with Mild Respiratory Infection. (.dot phrases are for example only. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. Autotext Dot Phrases for Cerner EHR. No evidence of acute abdomen at this time. Most people recover on their own from these viruses, including COVID-19. The patient is suffering from testicular pain, but based on the history, exam, and work up, I do not suspect that the patient has testicular torsion, abscess, severe cellulitis, Fourniers gangrene, orchitis, epididymitis, inguinal hernia or other emergent cause. Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Rest Area hemostatic. ROS = .personal ROS phrase having most coveted in HPI prose Past hxs = .phrase to populate automatically same with allergies, meds. Low suspicion for gastric or esophageal dysmotility as cause_. Please visit the CDCs guidance for getting your household ready for COVID-19. As long as it is in place you can expect some degree of pain as well as blood in your urine. How Should A Phone Visit Be Done? Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Change), You are commenting using your Facebook account. This may allow you to receive the advice you need by phone. Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed. Sometimes there is treatment for the viruses that cause influenza if given early. Given the clinical picture, no indication for imaging at this time. Sepsis). On this particular day (below), we put them in the tree shaped box from the Sneaky Snacky Squirrel Game. 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. For pediatric patients, see: MDM for different chief complaints (peds).". Patient presenting with head trauma. 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). Based on history, physical, and work up. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. There was no loss of consciousness, confusion, seizure, or memory impairment. Presentation not consistent with impact seizure related to head trauma. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). Patient is not immunocompromised. Considered DKA versus HHS, sepsis as possible etiologies of the patients current presentation. Well appearing. No evidence of anemia. 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. Return precautions given. This patient presents with non bloody diarrhea consistent with likely viral enteritis. Doubt intrinsic renal dysfunction or obstructive nephropathy. 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. EOMI. If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. EKG without signs of active ischemia. Given History, Exam, and Workup can not rule out underlying osteomyelitis_, however have low suspicion for Necrotizing Fasciitis, Abscess, DVT. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_. Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. Patient to be discharged home with keflex with follow up with their PMD. Brian T.'s Templates: brianemr.blogspot.com /. This patient presenting with apparent acute hyperglycemia. I had a "normal physical exam" dot phrase when I was an intern doing a TY year. COVID test was sent off and pending. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. Low concern for osteomyelitis or DVT. 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. Despite multiple rounds of opioids patients pain was not controlled, so patient was admitted for pain control. Patient presents in alcohol withdrawal last drink was _ ago. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. Per neuro _. 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. Stay home from work or school when they are sick. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. Do not merely copy and paste a prewritten note . Wound care discussed. Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. HPI, PE, A/P, procedure, billing code.) Separate yourself from other people and animals in your home 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 ceftriaxone and prescribed cefdinir/keflex_. 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. DMV was notified to remove patient's licence_, patient was given strict seizure precautions. This pregnant patient presents with vaginal bleeding in the first trimester. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). Patient observed until clinically sober. _ was reduced at bedside with conscious sedation_ and post reduction Xray shows successful reduction. Separate yourself from other people and animals in your home. No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. Seeking Medical Care normal physical exam), you can put that into a smart phrase and then just put that in every note and edit the parts that need to be changed. . Patient received PPI, octreotide, ceftriaxone _. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. Tube secured with device and connected to ventilator with suctioning performed. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. the tracheostomy if required. Patient is Rho + so Rho gam is not indicated_, Rho - so Rho gam was given_. How To Trade A Shift on HomeBase. Denies neck pain. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital but in route patient rearrested. 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 mastoiditis, malignant otitis externa, AOM, herpes zoster oticus. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry. 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. Given that the patient is not immunocompromised, able to tolerate PO, nontoxic appearing, and no signs of trismus or airway compromise, plan to discharge the patient home with augmentin_. Suspect acute kidney injury of prerenal origin. 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 .

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