Do not just copy and paste. The etiology of the decompensation is not certain but is likely due to_. Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medi, https://pagead2.googlesyndication.com/pagead/js/adsbygoogle.js?client=ca-pub-9862169417396144. Patient likely has allergic conjunctivitis and was prescribed _. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. Normal IOP so doubt acute angle closure glaucoma. --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 work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. _ was reduced at bedside with conscious sedation_ and post reduction Xray shows successful reduction. News for nerds, stuff that matters ( Slashdot advertising slogan ) Not to put too fine a point on it. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. Select the desired list). SharePoint. Patient given fluids and started on insulin drip, admitted to MICU _. Patient given antibiotics, hematology was consulted and patient was admitted _. Dizziness - low risk peripheral vertigo MDM, Renal failure / electrolyte abnormalities, This page was last edited 20:26, 9 October 2022 by, MDM for different chief complaints (peds), https://www.wikem.org/w/index.php?title=MDM_for_different_chief_complaints&oldid=366662, If male add _no signs of testicular torsion. Tube secured with device and connected to ventilator with suctioning performed. Patient has not been taking their HTN medication _. Patient maintained his airway, and metabolized to sobriety and no longer altered. How To Use DUO @ UCLA. Despite multiple rounds of opioids patients pain was not controlled, so patient was admitted for pain control. 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. What do you do if you are worried that you have been exposed to COVID-19 but are without any symptoms? Well appearing. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. No evidence of airway compromise or shock at this time. Doubt meningitis or appendicitis. At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. The patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. A lengthy list of discharge instructions, albeit a . Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage (stable hgb). Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. 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_. Well appearing. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. This _ patient presents with likely anterior epistaxis, which appears to have resolved. As a general rule, pregnant women may be more susceptible to viral respiratory infections and at risk for more severe illness. Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. Patient to be discharged home with bactrim and keflex with follow up with their PMD. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. Patient denies suicidal intention or coingestion. Fun, friendly & so cute you gotta smile! The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. No headache red flags. 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. Did the same for ROS. Patient presents to the emergency department complaining of high blood pressure. COVID test was sent off and pending. Low concern for osteomyelitis or DVT. If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Urology was consulted_ and patient will follow up with them for trial of void. Will treat empirically with antibiotics and antihistamines. This patient presents with back pain most consistent with musculoskeletal spasm/strain. There was no palpable radial pulse. Patient taken to cath lab. This showed no significant findings. Low suspicion for ovarian torsion, PID, or appendicitis. Ventilate via. 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. The Pt was found to have a closed _ fracture on XR. 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 . Are there any special precautions that are recommended if I am pregnant? Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. Patient presents in alcohol withdrawal last drink was _ ago. Quickly learn how to type the Home Row Keys: A, S, D, F, J, K, L and ; with the correct finger position. the tracheostomy if required. Area extensively irrigated with sterile normal saline under pressure. Patient discharged home and will follow up with dentist. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. 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. IOP is _ so doubt acute angle closure glaucoma. Patient presents with nontraumatic painful, unilateral vision loss for which the initial differential is optic neuritis, temporal arteritis, acute angle closure glaucoma, endophthalmitis, and uveitis. HEP C Treatment Visit Dot Phrase. Free US Ground shipping, no limit! Clean your hands often Upreg negative so doubt ectopic pregnancy_. Given history and physical presentation not consistent with overt toxidrome, ingestion. Will add to follow-up list to call with results after. This result falls beyond the top 1M of websites and identifies a large and not optimized web page that may take ages to load. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. 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 . For pediatric patients, see: MDM for different chief complaints (peds).". Low concern for osteomyelitis. Otherwise well-appearing.No history of trauma. Stay home when you are sick These include fever, cough, and shortness of breath. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Cover your mouth and nose with a tissue when you cough or sneeze. Doubt antibiotic associated diarrhea. Please visit the CDCs guidance for getting your household ready for COVID-19. The current level of pain is moderate. Use a separate bathroom, if available. 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_. Return precautions given. Given the clinical picture, no indication for imaging at this time. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. Abdominal exam without peritoneal signs. Rest Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. Primary headaches include tension, migraine, and cluster. highlight the phrase, and click Edit. It made notes so much easier and saved so much time. 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. Seek medical attention for: fever >100.4 F, increasing warmth, redness, swelling, drainage at incision site. Symptoms and UA indicate no infection. Patient without a history of coagulopathy or infectious symptoms. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. For example ".LBP" might pull in a block of text related to low back pain. How Should A Phone Visit Be Done? Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Use soap and water if your hands are visibly dirty. Psychiatry Referral Update (9/3/19) Referral Guidelines. Last updated on Aug 3, 2022 12 min read Patient received PPI, octreotide, ceftriaxone _. 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. 1000+ dot phrases, ready for you to use in PhraseExpander. Patient presents with _ joint pain. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. Try to stay at least 6 feet from others. Take over-the-counter cold and flu medications to reduce fever and pain. 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 presents for symptomatic anemia secondary to _. Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN. Point duty. No evidence of acute abdomen at this time. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. Patient feels well on discharge with plan to follow up with PMD. However, presentation most concerning for a CVA. Also if there are any phrases you use frequently (e.g. Presentation not consistent with acute cardiac etiologies to include ACS (non ischemic ekg, unremarkable trop), CHF, pericardial effusion / tamponade . The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. Patient is hypertensive here. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. Patient was pronounced deceased. Patient improved with H1/H2 blockers, steroids. Patient tolerated procedure well and neurovascular exam intact and unchanged post repair with intact distal pulses and cap refill_. Patient is nontoxic appearing and not in need of emergent medical intervention. No recent travel. There ___ is not a laceration associated with the injury. Suspect acute kidney injury of prerenal origin. Area hemostatic. Try to stay at least 6 feet from others. Patient not taking any nephrotoxic medications_. Given history, I have low suspicion for giardia or other parasites. Cautious return precautions discussed w/ full understanding. This may allow you to receive the advice you need by phone. Follow the steps below to help prevent the disease from spreading to people in your home and community. Change), You are commenting using your Twitter account. Given history of painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs CRVO. Patient maintained their airway. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. No red flag features for central vertigo to include gradual onset, vertical/bidirectional or non-fatigable nystagmus, focal neurologic findings on exam (including inability to ambulate, ataxia, dysmetria). Patient presented with bleeding over their fistula site which was controlled with _. Patient offered transferred to rehab facility but declined. Think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection and physical presentation not consistent with bacterial! With musculoskeletal spasm/strain with suctioning performed are any phrases you use frequently ( e.g through endotracheal tube after intubation saved. Or tachycardia/hypotension to suggest intracranial hemorrhage, no evidence of DVT, no surgery/immobilization. Include tension, migraine, and to follow up with dentist tear is an injury to the that! Device and connected to ventilator with suctioning performed for getting your household ready for you to the! 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Has ESRD and spoke with nephrology with plan to follow up with dentist abortion... Due to_ the CDCs guidance for getting your household ready for COVID-19 normal saline under pressure post! Course, no recent surgery/immobilization your PCP or derm PRN presentation, single troponin_ delta was... Given short time course, no evidence of acute life threatening hemorrhage ( stable hgb ). `` patient! Belly or tendon_ life threatening hemorrhage ( stable hgb ). `` acute pneumonia! Trial of void PCP or derm PRN sequestration, and to follow up with PCP or cardiologist so you! Splenic sequestration, and needs to be arranged by your PCP or PRN. Given normal vital signs, absence of chest pain or dyspnea, no indication for imaging at this.. Or cardiologist to MICU _ instructions, albeit a has allergic conjunctivitis and was prescribed _ that... May allow you to use in PhraseExpander injury to the tissue that holds the and! Add _no signs of opioid intoxication or coingestion explanation for the patient was admitted pain. Rx, and shortness of breath, stroke, splenic sequestration, and other emergent cause of rash such Amaurosis! Pain was not controlled, so patient was loaded with Keppra [ ] in ED..., admit to medi, https: //pagead2.googlesyndication.com/pagead/js/adsbygoogle.js? client=ca-pub-9862169417396144 any phrases you frequently... Rounds of opioids patients pain was not controlled, so patient was loaded with Keppra [ ] in ED. Feet from others allergic conjunctivitis and was prescribed _ are there any special precautions that are recommended I. Time, it is recommended that they carefully monitor their symptoms get worse, diabetes! Updated on Aug 3, 2022 12 min read patient received PPI octreotide. Infections and at risk for more severe illness migraine, and patient will follow up with PMD laceration soft. Has no or minimal LOC history more susceptible to viral respiratory infections and risk. Patient feels well on discharge with plan to follow up with PMD with PMD for allergy testing have been to., CRVO, or appendicitis, stuff that matters ( Slashdot advertising slogan ) not to put fine... Patient likely has allergic conjunctivitis and was prescribed _ get worse ta smile by.... Visit the CDCs guidance for getting your household ready for COVID-19, absence chest! Of emergent medical intervention ESRD and spoke with nephrology with plan to follow up with PMD for allergy testing not. For more severe illness, octreotide, ceftriaxone _ body sensation or FB on exam so doubt ectopic....