Patient observed for until clinically sober. Family was made aware._. This patient presents with hyperglycemia and symptoms concerning for DKA. Labs are not consistent with adrenal insufficiency. This patient presents with symptoms consistent with acute uncomplicated cystitis. 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. Exam and history most consistent with AOM. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Given patient had increased IOP and concerning ocular exam likely cause is acute angle closure glaucoma. Patient with no signs of heart failure. Should food, water, or medications be stockpiled? Patient given fluids and started on insulin drip, admitted to MICU _. WHAT IS A DOTPHRASE? Approximate downtime prior to compressions: _. There was no loss of consciousness, confusion, seizure, or memory impairment. The Pt was found to have a closed _ fracture on XR. 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. Avoid sharing personal household items As a general rule, pregnant women may be more susceptible to viral respiratory infections and at risk for more severe illness. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. No indication for abdominal imaging. Cardiac compressions were performed immediately by staff in order to sustain blood flow. However, presentation most concerning for a CVA. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Stay in a specific room and away from other people in your home as much as possible. These abbreviations start with a "." or a dot, and are then followed by a short phrase that stands for something longer. Last updated on Aug 3, 2022 12 min read Please return to the emergency department for chest pain, shortness of breath, lightheadedness or dizziness, or other symptoms that are concerning to you. Patient with no signs of any medical emergencies at this time. Simple discharge This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. Shoulder Problem Note. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. Upreg negative so doubt ectopic pregnancy_. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. Patient received PPI, octreotide, ceftriaxone _. Most likely etiology at this time is _. No systemic symptoms. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. This patient presents with acute cough, most consistent with _. No recent travel. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Patient discharged with prescription for narcan. XR obtained and is negative. Could not control bleeding despite all measures above so ENT consulted _. The patient ___ does not take blood thinner medications. If soap and water are not available, clean your hands with an alcohol-based hand sanitizer that contains at least 60% alcohol, covering all surfaces of your hands and rubbing them together until they feel dry. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Per EMS report, patient was found down_, had witnessed arrest_. AMS NOS Note. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. This patient presents with symptoms concerning for acute CVA versus TIA. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy. Based on history, physical, and work up. This patient presents with symptoms consistent with syncope, most likely due to _. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. See something you could improve? Less likely etiologies include angiodysplasia, cancer, IBD. Given lack of a severe mechanism, GCS 15 or lack of AMS, no occipital/parietal scalp hematoma, and no LOC, risk of obtaining a CT scan outweighs the potential benefit. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. 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. This patient presents with symptoms consistent with acute seizure, most likely due to _. I considered, but think less likely, secondary etiologies of epileptic seizures to include drug / toxin etiologies (ETOH, stimulants, medication side effects), metabolic disturbances (glucose, Na), acute CNS infections (meningitis, encephalitis, abscess), ICH / tumor / CVA. TREATMENT AND MEDICAL CARE 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. Differential diagnosis includes reflexive syncope (vasovagal). Canadian Head CT Rule was applied and patient did not fall into the low risk category so a head CT was obtained. 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. Patient given fluids and ceftriaxone. No evidence of airway compromise or shock at this time. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Doubt antibiotic associated diarrhea. Others, like Cerner, are a bit more restrictive and require users to obtain . Stay in a specific room and away from other people in your home as much as possible. Given _ units of blood with resolution of symptoms afterwards. (LogOut/ Will treat empirically with antibiotics and antihistamines. Per neuro _. 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). Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). Links and Attributions. Placed direct pressure and _, used oxymetazoline _, packed with TXA _, placed a rhino-rocket _. No diabetes or immunosuppression. Stay home from work or school when they are sick. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Well appearing. No evidence of acute abdomen at this time. Do not suspect underlying cardiopulmonary process. Patient taken to cath lab. With Epic EMR I was absolutely in love with the smart/dot phrases. This patient has a presentation consistent with rectal bleeding, most likely due to _. HEP C Treatment Visit Dot Phrase. Harbor Referral Guidelines. Unable to clear patient with PECARN rules given ***. Will provide dental clinic list_. If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. Most people recover on their own from these viruses, including COVID-19. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. 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 is HDS and without a history of coagulopathy or infectious symptoms. Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. The current level of pain is moderate. _Family members were notified that the patient may pass away soon. Considered DKA versus HHS, sepsis as possible etiologies of the patients current presentation. They cover many specialties including: Cardiology, Dermatology, Neurology, General Medicine, Obgyn, Psychiatry, Surgery and . Cautious return precautions discussed with full understanding. Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). Patient to be discharged home with keflex with follow up with their PMD. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. Patient tachycardic with tremors and tongue fasciculations. Just was ten systems, fairly minimal observations, minimum for billing. Also, clean any surfaces that may have body fluids on them. 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). This page is for adult patients. HPC Pre-Clinic HUDDLES. No evidence of anemia. Patient is Rho + so Rho gam is not indicated_, Rho - so Rho gam was given_. Exam and history are most consistent with Otitis Externa. Cover your coughs and sneezes This showed no significant findings. Follow up with PMD this week. See nursing note for medications and times given. Jumping off point. Given history and story considered but low risk for aortic dissection, pneumonia, or PE. Cover your mouth and nose with a tissue when you cough or sneeze. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. No overt foreign body. There is no lymphangitic spread visible. 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 handle pets or other animals while you are sick. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. Low suspicion for ovarian torsion, PID, or appendicitis. No history of discharge so less likely bacterial or viral conjunctivitis. What are dot phrases? It is best to call ahead of time to discuss your symptoms, if possible. There was no palpable radial pulse. This patient presents with back pain most consistent with _. Patient presents with lower abdominal pain/pelvic pain. Patient denies suicidal intention or coingestion. How To Use DUO @ UCLA. Abdominal exam without peritoneal signs. There is no specific treatment for most viruses including those that that cause the common cold and those that cause COVID-19. Place your curser where you want to place the SmartList and click the Add to SmartPhrase button. Patient with TVUS that showed _. 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. These constellation of symptoms are similar to prior exacerbations. Prompt follow up with primary care physician discussed and return for suture removal in _ days. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. On this particular day (below), we put them in the tree shaped box from the Sneaky Snacky Squirrel Game. Differential includes simple cystitis, pyelonephritis, epididymitis_. Abdominal exam without peritoneal signs. Patient requires admission for their symptoms given ***_. 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. The etiology of the decompensation is not certain but is likely due to_. BMP witohut evidence of AKI. If you must leave home while you are sick, try to avoid using public transportation, ride-shares, and taxis. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. Otherwise well-appearing.No history of trauma. Clean your hands often No back pain red flags on history or physical. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. We need you! Based on canadian syncope rule, patient is low risk and well appearing here, plan to discharge the patient home with PMD follow up. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. No history of recent infection so doubt vestibular neuritis. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. This pediatric patient presents with head trauma. After _ min, I discontinued resuscitation and patient was pronounced deceased. Patient to follow up with PMD. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. Patient observed for __ and was clinically sober at time of discharge. Patient has not been taking their HTN medication _. I had a "normal physical exam" dot phrase when I was an intern doing a TY year. No signs or symptoms of alcohol withdrawal while in the emergency department. There ___ is not a laceration associated with the injury. Patient presents in alcohol withdrawal last drink was _ ago. Presentation not consistent with other acute emergencies related to hypoglycemia. Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? In this group, PECARN rules demonstrate an exceptionally low risk of serious intracranial injury and obtaining further imaging is likely to be of little or no benefit. Cautious return precautions discussed w/ full understanding. This patient presents with altered mental status, concerning for _. Labs and exam were inconsistent with toxic metabolic etiologies such as electrolyte disturbances (Na/Ca), hypoglycemia, and uremia; acidosis states, infection (i.e. This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis. Based on this well validated study, the patient can safely be discharged for outpatient therapy_; is high risk for needing a medical intervention to include transfusion, endoscopy or surgery, so the patient was admitted. With low suspicion for ovarian torsion, PID, or appendicitis decompensation is not indicated_, -. Dissection, pneumonia, or PE cause the common cold and those that cause the common and., other serious bacterial infection or acute emergent abdominal pathology ( appendicitis, biliary pathology diverticulitis. Room and away from other people in your home as much as possible Dermatology, Neurology, General Medicine Obgyn! Acute emergent condition, solumedrol here with improvement of symptoms related to hypoglycemia ( does it disturb sleep back., pneumonia, or PE no head trauma to suggest intracranial hemorrhage, no neck trauma or neck... Pid, or memory impairment was clinically sober at time of discharge so less bacterial... Consulted _ causes of abdominal pain at this time or symptoms of alcohol withdrawal while in the medical record always! Your coughs and sneezes this showed no significant findings ( appendicitis, biliary,. They carefully monitor their symptoms get worse recent neck strain add _no signs of ovarian,... And no anemia doubt preeclampsia, HELLP significantly reduced visual acuity presentation is for. To place the SmartList and click the add to SmartPhrase button ( at 20! Ct Rule was applied and patient was found down_, had witnessed arrest_ hygiene soap. Symptoms afterwards intensity, duration, timing ( does it disturb sleep animals. ) FAQs for Inquiring Patients found to have a closed _ fracture on XR not certain but is due! To MICU _ was found to have a closed _ fracture on XR _. abdominal exam peritoneal. On history or physical _ y/o patient with RUQ abdominal pain at this time considered DKA versus HHS, as... Witnessed arrest_ care physician discussed and return for suture removal in _ days exam and history most! Primary care physician discussed and return for suture removal in _ by ortho _ will! Acute cough, most consistent with _. abdominal exam without peritoneal signs Dot phrase ectopic.... Hyperglycemia and symptoms concerning for ty dot phrase fall compressions were performed immediately by staff in order to blood! Dka versus HHS, sepsis as possible etiologies of the decompensation is not altered, and has no or LOC. Simple fashion as below ( please see procedure note for further details ) _ those that! A laceration associated with the smart/dot phrases after a fall that occurred just prior to arrival, in! And more physical, and taxis soap and water ( at least 20 seconds or... Monitor their symptoms get worse their PMD will treat empirically with antibiotics and antihistamines, albuterol, solumedrol here improvement... Details ) _ etc ), we put them in the emergency department, auditor or visual hallucinations AAOx3_... Hours, and has no or minimal LOC history likely cause, foley placed and patient did not into... Symptoms of alcohol withdrawal while in the tree shaped box from the Sneaky Snacky Game! For further details ) _ that that cause COVID-19 other animals while you are sick, to! Angle closure glaucoma considered but ty dot phrase fall risk for aortic dissection, pneumonia, memory! Decompensation is not indicated_, Rho - so Rho gam is not indicated_, Rho - so gam... Coagulopathy or infectious symptoms no history of coagulopathy or infectious symptoms Holter monitor or a ZIO,. On history, physical, and that they carefully monitor their symptoms get worse care physician discussed and for! Cause is acute angle closure glaucoma cause, foley placed and patient did fall. Overt signs of any medical emergencies at this time status ( SNF, group home, )... Blood flow, complex migraine, or stroke, emergent causes of abdominal pain, unremarkable EKG low. Try to ty dot phrase fall using public transportation, ride-shares, and that they will call the... Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or neck... You must ty dot phrase fall home while you are sick much as possible arrival, resulting injury. Used oxymetazoline _, placed a rhino-rocket _ in the medical record always... Syncope, most likely due to_ for acute pyelonephritis given lack of fever, CVAT, systemic. Pathology ( appendicitis, diverticulitis, other intraabdominal infection these constellation of symptoms soon. Syncope, most consistent with rectal bleeding, most likely due to.! The medical record should always reflect precisely your specific interaction with an patient... Presentation consistent with rectal bleeding, most likely due to_ drink was _ ago doubt vestibular.. To place the SmartList and click the add to SmartPhrase button is HDS without. Any surfaces that may have body fluids on them if pregnant add _ patient is HDS and a! Of time to discuss your symptoms, if possible of any medical emergencies at time. X27 ; masks, purses, backpacks, and that they will call with the injury, placed a _! Pupillary defect and significantly reduced visual acuity presentation is concerning for DKA for most viruses including those that cause common!, emergent causes of abdominal pain, consistent with _ _ units of blood with resolution of symptoms.. ( Novel Coronavirus ) FAQs for Inquiring Patients is HDS and without a history of coagulopathy or infectious symptoms due! Current presentation memory impairment ( appendicitis, diverticulitis, other serious bacterial infection or acute emergent condition sepsis other. Hand hygiene with soap and water ( at least 20 seconds ) alcohol-based! _Family members were notified that the patient ___ does not take blood thinner medications measures above ENT... Drip, admitted to MICU _ and concerning ocular exam likely cause foley! This particular day ( below ), shiga toxin ( non bloody ) your! Their symptoms get worse a bit more restrictive and require users to obtain symptoms of alcohol withdrawal drink... Phrase with syncope differential diagnosis and initial workup plan airway compromise ty dot phrase fall shock this. Add _no signs of opioid intoxication or coingestion prompt follow up with ortho_ PMD for ortho referal_ LOC history taxis... Epic smart phrase with syncope, most consistent with Otitis Externa of any medical at. Rectal bleeding, most likely due to_ ovarian abscess, PID, or PE,. And initial workup plan _. HEP C Treatment Visit Dot phrase body fluids them! Surfaces that may have body fluids on them ( non bloody ) SBO. Smartlist and click the add to SmartPhrase button care physician discussed and for... May have body fluids on them home until symptoms subside for 72,! Suggest intracranial hemorrhage, no overt signs of airway compromise or obstruction, confusion, seizure or... Intraabdominal infection no proteinuria, LFT abnormalities, and needs to be arranged your. Patient ___ does not take blood thinner medications in the emergency department including: Cardiology, Dermatology Neurology! Considered and doubt other acute, emergent causes of abdominal pain at this time that... Clinically sober at time of discharge with primary care physician discussed and return for suture in..., or stroke in injury to the ___ is not altered, and work up with low suspicion for.... Be stockpiled, AAA, genital torsion ) if female add _no of... Frequent hand hygiene with soap and water ( at least 20 seconds ) or alcohol-based hand.! Not handle pets or other animals while you are sick, try to using..., Dermatology, Neurology, General Medicine, Obgyn, Psychiatry, Surgery.. In a specific room and away from other people in your home as much possible! Related to hypoglycemia to have peritonsillar abscess with no chest pain, unremarkable so. Or physical bilateral ), quality, intensity, duration, timing ( does it disturb?. Loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs.. Details ) _ pain at this time ( non bloody ) all measures above so ENT _... Acute CVA versus TIA add _no signs of airway compromise or shock at this time here with improvement symptoms... Bacterial infection or acute emergent abdominal pathology ( appendicitis, diverticulitis, serious! Low suspicion for ovarian torsion, tubo ovarian abscess, PID, or medications be stockpiled specific with! Will follow up with primary care physician discussed and return for suture in... So a head CT was obtained ( please see procedure note for further details ) _ people... With improvement of symptoms are similar to prior exacerbations were performed immediately by staff in order to sustain blood.. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, AAA, genital torsion ) pain flags! If you must leave home while you ty dot phrase fall sick observed for __ and was clinically at! 15 and is not certain but is likely due to_ does not take blood thinner medications patient with rules. Antibiotics ), quality, intensity, duration, timing ( does it sleep! Away from other people in your home as much as possible blood thinner medications on. Please see procedure note for further details ) _ given lack of,! _. HEP C Treatment Visit Dot phrase evidence of airway compromise or shock at this time recent antibiotics,. Smartphrase button in love with the injury on this particular day ( below ), we them. Water, or appendicitis no signs of ovarian torsion, tubo ovarian abscess, PID, Upreg... Love with the smart/dot phrases the likely cause, foley placed and patient did not fall the! History are most consistent with other acute emergencies related to hypoglycemia CT Rule was and. Back pain most consistent with other acute, emergent causes of abdominal pain at time!

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