UCLA Resources. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. 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). With Epic EMR I was absolutely in love with the smart/dot phrases. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. There was no palpable radial pulse. Patient not hypervolemic on exam with no history of CHF, cirrhosis, nephrotic syndrome, no acute renal failure. Microsoft 365 & HomeBase. If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Avoid sharing personal household items Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. You need to follow-up with your primary care doctor or cardiologist within 3 to 5 days. Should people telecommute? And will be sent home with steroid burst and azithromycin. AMS NOS Note. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. Given history and exam I have low suspicion for corneal abrasion or ulcer, globe rupture, uveitis, HSV keratitis, Endopthalmitis, Retinal Detachment, Angle Closure Glaucoma, Foreign Body, hyphema. Each hospital has its own names for these things) .ed meds 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. Patient admitted to ICU. 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. 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. If possible, put on a facemask before emergency medical services arrive. PROTECTING OTHERS 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 . Cover your mouth and nose with a tissue when you cough or sneeze. Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. Last updated on Aug 3, 2022 12 min read Patients should be instructed to: Doubt pneumonia or pyelonephritis. No signs or symptoms of alcohol withdrawal while in the emergency department. Patient given aspirin. Suspect acute kidney injury of prerenal origin. Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. This patient presenting with apparent acute hyperglycemia. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. 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. 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_. No evidence of RPA, PTA, Ludwigs angina, periapical abscess. The current level of pain is moderate. Labs are not consistent with adrenal insufficiency. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. This patient presents with diarrhea consistent with likely viral enteritis. This patient presents with symptoms concerning for an acute upper GI bleed. 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. CT head and CTA head and neck ordered and shows _. Neurology consulted and MRI ordered which shows _. Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. Patient found to have asymptomatic hyperkalemia with no ecg changes likely secondary to ESRD_. No significant photophobia. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. If you develop symptoms that may indicate an infection, contact your physician. Denies neck pain. A dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. No back pain red flags on history or physical. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. 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. (LogOut/ This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Low concern for osteomyelitis. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Given work up, low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), acute pancreatitis (neg lipase), PUD (including gastric perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction, viscus perforation, or testicular torsion, diverticulitis. Try to stay at least 6 feet from others. Low suspicion for ICH or other intracranial traumatic injury. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. Patient observed for __ and was clinically sober at time of discharge. No evidence of acute abdomen at this time. Patient found to be hyponatremic to _ Patient mentating normally. This patient presents with acute cough, most consistent with _. This showed no significant findings. Uncategorized. Wear a mask whenever you are indoors (except within your home), within 6 feet of others, or if you are outdoors and cannot maintain distance. Most people recover on their own from these viruses, including COVID-19. Do not handle pets or other animals while you are sick. Presentation not consistent with chronic causes of cough (including GERD, asthma, postnasal discharge, medication side effect, CHF, lung cancer or mass). Stay in a specific room and away from other people in your home as much as possible. 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. -Denies HCW status Prescribed antibiotics and instructed the Pt to follow up closely with ophthalmology and avoid wearing contacts_. Cautious return precautions discussed w/ full understanding. No overt foreign body. 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. 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. Will observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up. Placed direct pressure and _, used oxymetazoline _, packed with TXA _, placed a rhino-rocket _. Urology was consulted_ and patient will follow up with them for trial of void. Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? Also, clean any surfaces that may have body fluids on them. Patient was given lasix_, nephrology consulted and patient was dialyzed. Diarrhea is non bloody so less likely inflammatory bowel disease. Follow up with PMD this week. There ___ is not a laceration associated with the injury. Safe ride home was arranged with __. These abbreviations start with a "." or a dot, and are then followed by a short phrase that stands for something longer. Drink plenty of fluids Presentation consistent with subconjunctival hemorrhage. Free US Ground shipping, no limit! This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. Presentation not consistent with impact seizure related to head trauma. Patient is hypertensive here. The etiology of the decompensation is not certain but is likely due to_. Patient presents with renal failure with uncertain cause but likely due to longstanding DM/HTN_. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. Patient advised to follow up with PMD for better blood sugar control. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. Patient presents with _ joint pain. The Pt was found to have a closed _ fracture on XR. CT head showed _. CTA head and neck showed _. (LogOut/ Just was ten systems, fairly minimal observations, minimum for billing. Patient presenting with head trauma. Patient is nontoxic appearing and not in need of emergent medical intervention. 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