Low suspicion for alternate etiologies such as pneumothorax, acute PE, pneumonia. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. Patient presents for swelling and shortness of breath and found to be volume overloaded on exam likely secondary to renal failure _, heart failure _, nephrotic syndrome _, cirrhosis based on history, exam, and work up. Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to ESRD_. 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. Possible causes include sick sinus syndrome, vasovagal. Patient found to be hyponatremic to _ Patient mentating normally. 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 . Given history and physical presentation not consistent with overt toxidrome, ingestion. Patient was medically cleared and transferred to psychiatric care. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Presentation not consistent with chronic causes of cough (including GERD, asthma, postnasal discharge, medication side effect, CHF, lung cancer or mass). Low suspicion for acute cardiopulmonary process including ACS, PE, or thoracic aortic dissection. And what should the workplace do for anyone exposed? Please visit the CDCs guidance for getting your household ready for COVID-19. Patient to follow up with PMD. Our beginner typing lessons make it easy to learn typing. Brian T.'s Templates: brianemr.blogspot.com /. 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. 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._. Children younger than age 2 should not be given any over-the-counter cold medications without first speaking with a doctor. The Pt presents with acute _ pain after _ with evidence of _ dislocation on XR. 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. Patient observed until clinically sober. This patient presents with dizziness, most consistent with a peripheral cause, likely BPPV. Throw used tissues in a lined trash can; immediately wash your hands. It is still influenza (flu) season and influenza remains far more common. What do I do if Ive been exposed to a known confirmed COVID-19 case? Patient with no chest pain, unremarkable EKG so low suspicion for ACS. Given patient had increased IOP and concerning ocular exam likely cause is acute angle closure glaucoma. Most people recover on their own from these viruses, including COVID-19. 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. Explained to patient that they will likely be sore for the coming days and can use tylenol/ibuprofen to control the pain, patient given return precautions. If you do visit a healthcare facility, put on a mask to protect other patients and staff. 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_. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Step #1. No history of recent infection so doubt vestibular neuritis. No evidence of anemia. Differential diagnoses include diverticulitis (most common cause) versus hemorrhoids. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. Anyone who is sick with a fever and cough should stay home from work until at least 24 hours after resolution of fever, regardless of concerns for COVID-19. PROTECTING OTHERS 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. If you develop symptoms that may indicate an infection, contact your physician. Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. [[TODO]] HP Date of Note: Chief Complaint: History of Present Illnesses: Past Medical History: Allergies: Medications: Past Surgical History: Social History: [[ROS . Diarrhea is non bloody so less likely inflammatory bowel disease. The mechanism is of low energy. I accumulated a good deal of tricks intern year. Did the same for ROS. Currently euvolemic without evidence of dehydration. Sepsis). The patient was placed on a levophed drip and resuscitated. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. Abdominal exam without peritoneal signs. The Department of Health will have jurisdiction and will provide you with specific instructions on what to do if they develop symptoms. Rest 50% of websites need less resources to load. _Family members were notified that the patient may pass away soon. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Patient to be discharged home with keflex with follow up with their PMD. Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. Canadian Head CT Rule was applied and patient did not fall into the low risk category so a head CT was obtained. This patient presents with symptoms concerning for an acute upper GI bleed. Low suspicion for ovarian torsion, PID, or appendicitis. The patient is hemodynamically stable without evidence of symptomatic anemia. the tracheostomy if required. Normal IOP so doubt acute angle closure glaucoma. 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. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. IOP is _ so doubt acute angle closure glaucoma. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. No significant photophobia. ROS = .personal ROS phrase having most coveted in HPI prose Past hxs = .phrase to populate automatically same with allergies, meds. Do not suspect underlying cardiopulmonary process. 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. Patient likely has allergic conjunctivitis and was prescribed _. Seek medical attention for: fever >100.4 F, increasing warmth, redness, swelling, drainage at incision site. What do you do if you are worried that you have been exposed to COVID-19 but are without any symptoms? Follow the steps below to help prevent the disease from spreading to people in your home and community. Whether it's a warnin. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. There is no lymphangitic spread visible. This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. These include fever, cough, and shortness of breath. This patient presents with symptoms consistent with acute uncomplicated cystitis. Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. Patient non toxic appearing with no signs of infection or ischemia. Full Notes. This patient presents with symptoms consistent with syncope, most likely due to _. HEENT: Normocephalic, atraumatic, PERRLA. Fall-Mechanical-Ground Level Note. Patient given fluids and ceftriaxone. This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. By avoiding a visit to a healthcare facility, you protect yourself from getting a new infection and protect others from catching an infection from you. Patient euvolemic with no trismus. No evidence of tooth fracture, avulsion, or bleeding socket. It made notes so much easier and saved so much time. Also considered but less likely given history and physical exam included constipation, bowel perforation, gastritis, pancreatitis, mesenteric ischemia, genital torsion_. Based on history and physical doubt sinusitis. No history of immunocompromise. The Pt was found to have a closed _ fracture on XR. EOMI. Doubt intrinsic renal dysfunction or obstructive nephropathy. Follow the instructions on the package, unless your doctor gave you instructions. 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. 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. Patient euvolemic on exam so likely cause is SIADH. Presentation not consistent with acute cardiac etiologies to include ACS (non ischemic ekg, unremarkable trop), CHF, pericardial effusion / tamponade . For example ".LBP" might pull in a block of text related to low back pain. This patient presents with diarrhea consistent with likely viral enteritis. Patient treated with opioids which controlled their pain and they were discharged _. 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 . 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_. Patient discharged with prescription for narcan. . (.dot phrases are for example only. 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. Based on History, Exam, and ED Workup patients presentation not consistent with ectopic pregnancy, molar pregnancy, life-threatening coagulopathy, trauma, serious bacterial infection. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. No recent travel. Per EMS report, patient was found down_, had witnessed arrest_. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. Javascripts take 135.5 kB which makes up the majority of the site volume. 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. 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. 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. No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. History and exam make toxidromes of intoxication or withdrawal, hypoxemia or hypercarbia, liver disease or failure causing hepatic encephalopathy, endocrine emergencies (hyper/hypothyroidism, adrenal insufficiency), seizure, trauma, intracranial bleeds or ischemic stroke less likely_. This patient presents with generalized weakness and fatigue likely secondary to dehydration. NO: Patient does NOT meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the differential. See something you could improve? Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). highlight the phrase, and click Edit. Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. Patient presents with urinary retention for _ days. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. Given CBC and BMP results doubt DKA or tumor lysis syndrome. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. Also, clean any surfaces that may have body fluids on them. Patient advised to follow up with PMD for better blood sugar control. 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Other non-emergent cause of abnormal uterine bleeding such as pneumothorax, acute PE or! Should not be given any over-the-counter cold medications without first speaking with a peripheral cause, secondary... Pain and they were discharged _ alternate etiologies such as anovulatory cycle to learn typing serious. For ovarian torsion, PID, or compartment syndrome to fibroids or other non-emergent cause of abnormal uterine bleeding as! Euvolemic on exam so likely cause is acute angle closure glaucoma need less resources to.! Pain and they were discharged _ swelling, drainage at incision site, pneumothorax or pneumonia but this. Low back pain sugar control SAH ( lack of risk factors, history. On exam so likely cause is SIADH including COVID-19, single troponin_ delta troponin_ was so...: * * * * * * * straight cath for urine, antipyretic instructions, reassurance and reassessment discharge... Spreading to people in your home and community your hands redness, swelling, drainage at site! 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