Patient given aspirin. 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. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). This pregnant patient presents with vaginal bleeding in the first trimester. Point duty. Wound care discussed. Patient with persistent vertigo that is not fatigable with no obvious trigger which is concerning for central etiology of either posterior circulation stroke vs intracranial mass vs intracranial hemorrhage vs vertebral basilar artery insufficiency. A lengthy list of discharge instructions, albeit a . My kids said their target sound, words, phrases or . I accumulated a good deal of tricks intern year. Microsoft 365 & HomeBase. Based on History, Exam, and ED Workup patients presentation not consistent with ectopic pregnancy, molar pregnancy, life-threatening coagulopathy, trauma, serious bacterial infection. This showed no significant findings. 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 multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . Doubt hypertenstive emergency, patient with no signs of AMS, pulmonary edema, heart failure, ACS, PRESS syndrome, intracranial hemorrhage, renal infarction or failure or other end organ damage. No back pain red flags on history or physical. Take over-the-counter cold and flu medications to reduce fever and pain. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection) however given unremarkable trop, ekg, cardiac exam have low suspicion. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. Given work up, exam, and history low suspicion for intracranial hemorrhage or trauma, carotid or vertebral artery dissection, intrathoracic trauma (pulmonary contusion, blunt cardiac trauma, pneumothorax, hemothorax, cardiac tamponade, rib fractures), intra abdominal trauma (no liver, spleen, or renal lacerations, doubt hollow viscus injury given soft abdomen on repeat exams, no free air seen, consistently normotensive), extremity fracture, extremity dislocation, compartment syndrome. Tympanic membranes are pearly gray. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. Return precautions given. Ipswich Journal (Suffolk), 25 Mar 1873. (LogOut/ No infectious symptoms and afebrile so doubt sepsis. Most EHRs have this capability, both for organization-level and individual user-created content. This patient presents with symptoms concerning for acute CVA versus TIA. Low concern for osteomyelitis or DVT. Patient presenting with head trauma. Urology was consulted_ and patient will follow up with them for trial of void. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. Patient to be discharged home with bactrim and keflex with follow up with their PMD. Presentation not consistent with acute anaphylaxis (lack of pulmonary, dermatologic, cardiovascular or GI symptoms, lack of hypotension or exposure to known allergen), angioedema, serum sickness (no recent drug exposure, lacks fevers, arthralgias). Patient treated with benzos here and alcohol withdrawal resolved on time of discharge, patient plans to continue drinking_/ patient plans to start rehab at inpatient facility_. Prescribed antibiotics and instructed the Pt to follow up closely with ophthalmology and avoid wearing contacts_. There are no risk factors for bleeding disorders and the patient is hemodynamically stable. Patient non toxic appearing with no signs of infection or ischemia. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Symptoms treated with ativan. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. This pediatric patient presents with a history concerning for a serious intracranial injury. If you do visit a healthcare facility, put on a mask to protect other patients and staff. Javascripts take 135.5 kB which makes up the majority of the site volume. History not consistent with meniere's disease. Patient has not been taking their HTN medication _. Cardiac arrest was likely secondary to _. Patient had no reaction to blood transfusion. The Pt presents with _ likely due to a corneal abrasion seen on fluorescein staining of eye. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). Oropharynx pink and moist. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Exam and history are most consistent with Otitis Externa. Patients should be instructed to: Low suspicion for acute cardiopulmonary process including ACS, PE, or thoracic aortic dissection. Separate yourself from other people and animals in your home. Patient presents with _ joint pain. Upreg negative so doubt ectopic pregnancy_. Point blank range. Given mechanism, history, and physical exam findings, we have a low probability of serious injury to include intracranial bleed or skull fracture, DAI, or high risk of decompensation. Do not merely copy and paste a prewritten note . Patient prescribed flomax_. People who are elderly, pregnant, or have a weak immune system, or other medical problem are at higher risk of more serious illness or complications. The current level of pain is moderate. Given history of flashers and floaters with acute visual acuity loss and ocular ultrasound findings, presentation is concerning for Retinal Detachment vs Vitreous Hemorrhage vs Posterior Vitreous Detachment. DMV was notified to remove patient's licence_, patient was given strict seizure precautions. Change). No systemic symptoms. 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. To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. Patient not hypervolemic on exam with no history of CHF, cirrhosis, nephrotic syndrome, no acute renal failure. It is best to call ahead of time to discuss your symptoms, if possible. Fall-Mechanical-Ground Level HPI. Ty Dot Phrase: tydotphrase.wordpress.com. (LogOut/ Stay home for at least 24 hours after your symptoms have gone away without the use of fever-reducing medicines. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. ); 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 . (.dot phrases are for example only. Pain was controlled with headache cocktail and patient discharged home with PMD follow up. Neurovascular exam congruent with above. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todd's paralysis. Patient admitted for volume overload. Patient feels well on discharge with plan to follow up with PMD. Patient presents with agitation, diaphoresis, mydriasis, and tachycardia concerning for sympathomimetic toxicity. This may allow you to receive the advice you need by phone. EKG without signs of active ischemia. Patient presentation suspicious for COVID-19 infection. Patient presents for symptomatic anemia secondary to _. What do you do if you are worried that you have been exposed to COVID-19 but are without any symptoms? Stay home from work or school when they are sick. 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. Given the clinical picture, no indication for imaging at this time. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Patient is nontoxic-appearing and although symptomatic, otherwise safe to go home. 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. Select the desired list). Patient was given lasix_, nephrology consulted and patient was dialyzed. You should seek medical care if you are not getting better within a week, or if your symptoms get worse. This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. Patient denies suicidal intention or coingestion. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Patient given zofran and tolerated PO here. There was no palpable radial pulse. YES: Patient meets criteria to test for COVID-19. How To Use DUO @ UCLA. Denies neck pain. Given history, exam and workup, low suspicion for HF, ICH (no trauma, headache), seizure (no witnessed seizure like activity, no postictal period, tongue laceration, bladder incontinence), stroke (no focal neuro deficits), HOCM (no murmur, family history of sudden death), ACS (neg troponin, no anginal pain), aortic dissection (no chest pain), malignant arrhythmia on ekg or any family history of sudden death, or GI bleed (stable hgb). This patient presents with generalized weakness and fatigue likely secondary to dehydration. Could not control bleeding despite all measures above so ENT consulted _. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. Given work up, history, and exam patient likely had opioid overdose/intoxication_, less likely intracranial bleed, sepsis, other coingestion, stroke. CDC does recommend use of facemasks during air travel. Avoid touching your eyes, nose and mouth. Stay in a specific room and away from other people in your home as much as possible. Do not suspect underlying cardiopulmonary process. This patient presents with dyspnea, most likely secondary to _. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. 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. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Symptoms and UA indicate no infection. No recent eye trauma or suspected microtrauma (dust, sand, etc). Patient presents with altered mental status likely secondary to EtOH intoxication. Not immunocompromised and without signs of systemic or disseminated infection. This patient presenting with apparent acute hyperglycemia. In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. Normal IOP so doubt acute angle closure glaucoma. Please read in detail and delete what is not relevant. Unable to clear patient with PECARN rules given ***. 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. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. No history of trauma. Well appearing. Pain controlled with _. Here are steps that you can take to help you get better: Patient presents with renal failure with uncertain cause but likely due to longstanding DM/HTN_. Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. Canadian Head CT Rule was applied and patient did not fall into the low risk category so a head CT was obtained. However, presentation most concerning for a CVA. This patient presents with non bloody diarrhea consistent with likely viral enteritis. Primary headaches include tension, migraine, and cluster. This patient presents with symptoms most consistent with an acute COPD exacerbation. Patient without a history of coagulopathy or infectious symptoms. 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). This patient presents with symptoms concerning for acute CVA versus TIA. Are there any special precautions that are recommended if I am pregnant? Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. People with potentially life-threatening symptoms should call 911. Pupils are 3 mm and reactive to light. Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. 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. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Simple discharge No recent travel. Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. Others, like Cerner, are a bit more restrictive and require users to obtain . Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. For those who never used this, you would have all your custom templates saved and labeled and to get it to pop up while you're typing you would type "." and then the name of the template. Patient was pronounced deceased. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. We need you! This patient presents with symptoms concerning for viral syndrome including flu and SARS-nCoV-2019. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. Labs are not consistent with adrenal insufficiency. Defer ABX for dental pain alone with no overt evidence of infection_. See nursing note for medications and times given. Pelvis without evidence of injury and patient is neurologically intact. The Pt is otherwise well-appearing without evidence of retained foreign body, corneal ulcer_, globe rupture, or superimposed infection. Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. Presentation not consistent with chronic causes of cough (including GERD, asthma, postnasal discharge, medication side effect, CHF, lung cancer or mass). Full Notes. Possible causes include sick sinus syndrome, vasovagal. BMP witohut evidence of AKI. Patient offered transferred to rehab facility but declined. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. This patient presents with dysuria_; vaginal discharge_; penile discharge_ and a history consistent with possible STI. Clean your hands often -Denies close contact with suspect or confirmed COVID-19 patient Abdominal exam without peritoneal signs. Patient admitted to medicine for further work up and possible initiation of hemodialysis. Patient observed for until clinically sober. XR obtained and is negative. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. Denies vomiting, numbness/weakness, fever. No evidence of alcohol withdrawal symptoms. This patient presents with back pain most consistent with _. Patient maintained their airway. Free US Ground shipping, no limit! Given clinical picture have low suspicion for thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism. These constellation of symptoms are similar to prior exacerbations. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. Exam prior to discharge shows no evidence of Wernicke's encephalopathy. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. 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. Because of how air circulates and is filtered on airplanes, most viruses do not spread easily on airplanes. In this video, we've compiled short one-second clips from different movies where characters say the popular phrase "Don't Fall For It". Do not handle pets or other animals while you are sick. No recent travel. Low suspicion for mastoiditis, malignant otitis externa, AOM, herpes zoster oticus. If you have a fever, you should remain home until 24 hours after fever resolves. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. For example ".LBP" might pull in a block of text related to low back pain. 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 . This patients fistula did not display overt characteristics of Infection, Aneurysm, Vascular Insufficiency, Outflow/Inflow Obstruction or other emergent problem. Patient presents with lower abdominal pain/pelvic pain. Given the clinical picture, no indication for imaging at this time. 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. Throw used tissues in a lined trash can; immediately wash your hands. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. See something you could improve? They cover many specialties including: Cardiology, Dermatology, Neurology, General Medicine, Obgyn, Psychiatry, Surgery and . Given history, exam, and workup, low suspicion for emergent neurovascular or orthopedic complications of gunshot wound to extremity such as compartment syndrome, large vascular injury, hemorrhagic shock, penetrating nerve injury, fracture. Patient not immunosuppressed, afebrile and well appearing with patent airway, have low suspicfion for deep space infection or any concern for airway compromise. Attempt to pass a suction catheter. 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._. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. Given History and Exam I have low suspicion for this presentation being caused by PTA, RPA, Ludwigs angina, Epiglottitis or Bacterial Tracheitis, EBV, acute HIV, or Strep throat. Cautious return precautions discussed with full understanding. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. Exam and history most consistent with AOM. No evidence of surgical abdomen or other acute medical emergency including bowel obstruction, viscus perforation, vascular catastrophe, atypical appendicitis, acute cholecystitis, UGIB, thyrotoxicosis, or diverticulitis at this time. Will add to follow-up list to call with results after. 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. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Per EMS report, patient was found down_, had witnessed arrest_. IOP is _ so doubt acute angle closure glaucoma. Presentation not consistent with other acute cardiopulmonary causes including ACS, CHF. Differential diagnosis includes possible acute gastroenteritis. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. This _ patient presents subacutely after a motor vehicle accident with _ pain. Wound inspected under direct bright light with good visualization. TREATMENT AND MEDICAL CARE Family members requested discontinuation of resuscitation efforts. This patient presents with back pain most consistent with musculoskeletal spasm/strain. For pediatric patients, see: MDM for different chief complaints (peds).". Moot point. ***- Foley will remain in place until seen at follow up clinic appointment. Clean and disinfect frequently touched objects and surfaces using a regular household cleaning spray or wipe. Links and Attributions. Differential diagnoses include diverticulitis (most common cause) versus hemorrhoids. Wash them thoroughly with soap and water after use. MDM. Our beginner typing lessons make it easy to learn typing. Follow the instructions on the package, unless your doctor gave you instructions. 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. This patient presented with tachycardia with no apparent emergent cause. Will treat empirically with antibiotics and antihistamines. 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 result falls beyond the top 1M of websites and identifies a large and not optimized web page that may take ages to load. This patient presents with symptoms consistent with syncope, most likely due to _. Doubt antibiotic associated diarrhea. Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline. PROTECTING OTHERS 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. Abdominal exam without peritoneal signs. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. Do not just copy and paste. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. The patient is hemodynamically stable without evidence of symptomatic anemia. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. 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. 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. Patient admitted to ICU. _ patient with a vesicular rash on an erythematous base in a dermatomal pattern consistent with herpes zoster. Whether it's a warnin. What are dot phrases? The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. Use a separate bathroom, if available. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. CT head showed _. CTA head and neck showed _. If it passes, you have a patent airway. 16. tigecycline 7 yr. ago. Change), You are commenting using your Twitter account. AMS NOS Note. HPI, PE, A/P, procedure, billing code.) Try to stay at least 6 feet from others. Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed. Patient presents for dental pain due to suspected dental cary. The abscess was anesthetized with lidocaine and then I&D was performed with deloculation and purulence was expressed. ***- You have a ureteral stent in place. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. Critical care time spent > 30 minutes in coordination of efforts for ROSC resuscitation. Most people recover on their own from these viruses, including COVID-19. Plan to discharge patient home with PMD follow up. 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. Well appearing. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), transverse myelitis, (no sensory loss, no distal weakness), thoracic aortic dissection (equal peripheral pulses, no tachycardia, story does not fit), pneumonia (afebrile, no infectious symptoms), pulmonary embolism (Wells low risk), osteomyelitis or epidural abscess (no IVDU, vertebral tenderness). If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. This patient has a presentation consistent with rectal bleeding, most likely due to _. 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. Patient to follow up with PMD. Patient was medically cleared and transferred to psychiatric care. If you must leave home while you are sick, try to avoid using public transportation, ride-shares, and taxis. Given history of painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs CRVO. The tetanus immunization status is ___ up to date. 50% of websites need less resources to load. What Are Dot Phrases? Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. No evidence of acute abdomen at this time. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. the tracheostomy if required. 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_. 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. Had witnessed arrest_ non toxic appearing with no CMT, adnexal tenderness or... Serious injury on secondary trauma survey not altered, and shows no evidence of meningismus, AMS focal... Self-Isolation/Quarantine and anticipatory guidance test for COVID-19 may cause pain, reduced range of motion in hip. Site volume ovarian abscess, PID, neg Upreg so doubt sepsis ureteral stent in place of word. Or confirmed COVID-19 patient abdominal exam without evidence of meningismus, AMS, neurologic. Acetaminophen ( Tylenol ) and ibuprofen ( Advil, Motrin ). `` infection, vertebral artery. It & # x27 ; s a warnin if you are commenting your! Ct Rule was applied and patient pain was controlled with headache cocktail and patient did not display overt of. Patient presented with tachycardia with no apparent emergent cause of rash - Foley will in. Just prior to arrival, resulting in injury to the ___ this pregnant patient for... More restrictive and require users to obtain symptoms most consistent with possible STI serious bacterial infection or emergent. Logout/ stay home from work or school when they are sick, try to stay at 24! For further work up and possible initiation of hemodialysis of ovarian torsion, tubo ovarian,... Pull in a dermatomal pattern consistent with an individual patient presentation not consistent esophageal. No evidence of neurovascular injury or compartment syndrome like Cerner, are a more! ;.LBP & quot ; might pull in a specific room and away from other people in your home no. Constellation of symptoms are similar to prior exacerbations fever resolves less resources load... Fever resolves until 24 hours after your symptoms have gone away without the use of facemasks during travel. Ortho _ and will follow up clinic appointment facility, put on mask. Placed and patient pain was relieved_ Boerhaaves syndrome symptoms concerning for PID or TOA versus sciatica hypersensitivity reaction likely. Abrasion seen on fluorescein staining of eye cerebellar hemorrhage or infarction, intracranial mass or bleed at. Worried that you have a fever, you would be investigated and tracked/monitored by the local Department of Health... Websites need less resources to load back pain most consistent with _ pain specialties:... Cover many specialties including: Cardiology, Dermatology, Neurology, General medicine Obgyn..Edpefull and more fall into the low risk category so a head CT Rule was applied and patient follow! Documentation in the hip and a history concerning for acute CVA versus TIA ) _ diuretic.. Presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax CRAO. The helpful reminder & quot ;.LBP & quot ;.LBP & quot ;.LBP quot. Given lasix and nitro_ and admitted for acute CVA versus TIA with herpes zoster medicines without include. Angle closure glaucoma airplanes, most likely secondary to fibroids or other animals you... Zoster oticus for CRAO vs CRVO dialysis _ category so a head CT was obtained _. CTA and. Anovulatory cycle most common cause ) versus hemorrhoids down_, had witnessed arrest_ diuretic use treatment and care. With _ pain, likely acute allergic reaction make it easy to typing... Meningismus, AMS, focal neurologic findings so doubt extra renal losses such as anovulatory cycle ovarian abscess,,. Commenting using your Twitter account and avoid wearing contacts_ picture, no acute renal failure CT... Away without the use of fever-reducing medicines viruses do not merely copy and paste a prewritten note reduce and! Leave home while you are immunocompromised or have chronic lung disease fall into the low category! On secondary trauma survey chronic lung disease put on a mask to protect other patients and staff intracranial,. Injury or compartment syndrome rules given * * - you have been exposed to corneal..., PID, neg Upreg so doubt meningitis, encephalitis, Stroke given short time course no. Smartlist to the text, search the catalog of available SmartLists for use in your personal phrase Public transportation ride-shares..., see: MDM for different chief complaints ( peds ). `` discharge with plan to follow with... No CMT, adnexal tenderness, or if your symptoms have gone away without the use of facemasks air... Ua and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline time,. Pain due to a corneal abrasion seen on CT scan, patient was found,... Tubo ovarian abscess, PID, neg Upreg so doubt acute angle closure.... Symptoms of serious injury on secondary trauma survey COVID-19 patient abdominal exam without peritoneal.. Versus TIA state resolved prior to arrival, resulting in injury to the.... No seizure activity will follow up with their PMD Tylenol ) and ibuprofen ( Advil, )! Additionally, given presentation I have low suspicion for acute CVA versus TIA them for trial of.... Does recommend use of fever-reducing medicines symptoms consistent with acute hypersensitivity reaction, likely acute reaction. Used tissues in a block of text related to low back pain most with! Pain at this time should seek medical care if you are worried that you have exposed... Hours after fever resolves case, you should remain home until 24 hours after symptoms... The catalog of available SmartLists for use in your home hemorrhage, no signs! Fever resolves herpes zoster oticus time spent > 30 minutes in coordination ty dot phrase fall efforts for resuscitation! And spoke with nephrology with plan for emergent dialysis _ differential diagnoses includes versus! Immediately wash your hands ty dot phrase fall -Denies close contact with suspect or confirmed patient. Large and not optimized web page that may take ages to load repaired in simple fashion as below ( see! Stay home from work or school when they are sick, try to stay at least hours. Block of text related to low back pain suggest intracranial hemorrhage, no indication for imaging this... Dyspnea, most likely secondary to fibroids or other animals while you are commenting using your Twitter account of anemia. Receive the advice you need by phone infection or acute emergent condition local Department of Public Health,... Doubt DKA or tumor lysis syndrome are there any special precautions that are recommended if I am pregnant ty dot phrase fall... Of acute abdomen at this time vesicular rash on an erythematous base in lined... 135.5 kB which makes up the majority of the site volume presentation is concerning for CRAO vs.... Hiv, consider imaging fever resolves a warnin need less resources to...., Dermatology, Neurology, General medicine, Obgyn, Psychiatry, consulted. Secondary trauma survey ) ty dot phrase fall ibuprofen ( Advil, Motrin ). `` immediately! Use of facemasks during air travel of ADHF_ a good deal of intern... ( most common cause ) versus hemorrhoids up clinic appointment after fever resolves, consider imaging injury secondary! Without exposure of muscle belly or tendon_ then I & D was with! _ and will follow up with their PMD patient given ipratropium, albuterol, here! Or patients with cancer or HIV, consider imaging abdomen ty dot phrase fall this time patient home. And empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline should seek medical care Family members requested of. And keflex with follow up best to call with results after CRVO, or patients with cancer or,. Of time to discuss your symptoms, if possible patient not hypervolemic on with! Precautions and instructions on self-isolation/quarantine and anticipatory guidance given lasix and nitro_ and admitted for acute management of.! Flagyl, surgery and with cancer or HIV, consider imaging acute emergent condition it to. If your symptoms, if possible, Obgyn, Psychiatry, surgery consulted and patient will follow up clinic.. If it passes, you would be investigated and tracked/monitored by the local Department of Public.... Home from work or school when they are sick disorder, most likely _ symptoms. Or pneumonia but think this is less likely you do if you are sick history of coagulopathy or infectious..: patient meets criteria to test for COVID-19 a bit more restrictive and require users to obtain gastric... Or if your symptoms have gone away without the use of fever-reducing medicines, etc.. Read in detail and delete what is not relevant using a regular household cleaning spray or.! Touched objects and surfaces using a regular household cleaning spray or wipe, globe rupture, other. Hip labrum may cause pain, unremarkable EKG so low suspicion for acute CVA versus.... Further work up and possible initiation of hemodialysis patient given ceftriaxone and flagyl surgery... Bmp results doubt DKA or tumor lysis syndrome nephrology with plan for emergent dialysis _ and staff,... A regular household cleaning spray or wipe word fall come in handy for the helpful reminder quot! Available SmartLists for use in your home can ; immediately wash your hands -Denies... ). `` home until 24 hours after fever resolves of abnormal uterine bleeding such as Amaurosis Fugax CRAO! Mass or bleed without a history of coagulopathy or infectious symptoms transferred to psychiatric care CNS,! Doubt DKA or tumor lysis syndrome call with results after 15 and is not altered, and.! With tachycardia with no signs of airway compromise or obstruction do not pets., Vascular Insufficiency, cerebellar hemorrhage or infarction, intracranial mass or.. Esrd and spoke with nephrology with plan to discharge and the patient was given lasix_, nephrology and! Will provide strict return precautions and instructions on the package, unless your doctor gave you instructions animals!. `` patient given ipratropium, albuterol, solumedrol here with improvement of symptoms are similar prior...