No evidence of airway compromise or shock at this time. This patient presenting with apparent acute hyperglycemia. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey. Treatment No infectious symptoms and afebrile so doubt sepsis. 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. Cardiac arrest was likely secondary to _. Plan: labs, ***fluid resuscitation, pain/nausea control, reassessment. Jumping off point. Pupils are 3 mm and reactive to light. 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). Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Use a separate bathroom, if available. Patient febrile and given tylenol and normal saline bolus_. Patient requires admission for their symptoms given ***_. Safe ride home was arranged with __. 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. TREATMENT AND MEDICAL CARE ); 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 . HEENT: Normocephalic, atraumatic, PERRLA. Possible causes include sick sinus syndrome, vasovagal. 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. Peritonsillar abscess was drained with 18 gauge needle after anesthesia by bupivacaine with no complications_, patient feeling better_. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital, upon arrival patient was ventilated and oxygenated via BVM and then through endotracheal tube after intubation. 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). Given CBC and BMP results doubt DKA or tumor lysis syndrome. At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. If you develop symptoms that may indicate an infection, contact your physician. Sepsis). There is not yet any information available about the susceptibility of pregnant women to COVID-19. Denies vomiting, numbness/weakness, fever. 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. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. _ was reduced at bedside with conscious sedation_ and post reduction Xray shows successful reduction. Brian T.'s Templates: brianemr.blogspot.com /. 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. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. . Instructed patient to continue to treat pain with ibuprofen/acetaminophen until they see a dentist. Rest Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. Abdominal exam without peritoneal signs. Patient is nontoxic appearing and not in need of emergent medical intervention. Abdominal exam without peritoneal signs. What should I do if I start feeling sick at work? If you must leave home while you are sick, try to avoid using public transportation, ride-shares, and taxis. Patient hemodynamically stable so given lasix and discharged home with mild heart failure exacerbation told to increase lasix dosing for 2 days and then return to normal dosing with close follow up with PMD or cardiologist._. This patient presents with dizziness, most consistent with a peripheral cause, likely BPPV. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. Shoulder Problem Note. No history of immunocompromise. Patient presents with _ joint pain. DMV was notified to remove patient's licence_, patient was given strict seizure precautions. 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. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. HPC Pre-Clinic HUDDLES. No back pain red flags on history or physical. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. This patient presents with symptoms most consistent with an acute COPD exacerbation. Children younger than age 2 should not be given any over-the-counter cold medications without first speaking with a doctor. Patient received PPI, octreotide, ceftriaxone _. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. Most of these are out of the scope of med student work but are helpful . No urticarial rash to suggest allergic reaction. This patient presents with symptoms consistent with acute uncomplicated cystitis. IOP is _ so doubt acute angle closure glaucoma. No evidence of acute abdomen at this time. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. Will obtain CT imaging to rule out intracranial injury or skull fracture. The Department of Health will have jurisdiction and will provide you with specific instructions on what to do if they develop symptoms. 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 . 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. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. Low suspicion for kidney stone or infected stone. Will add to follow-up list to call with results after. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Presentation not consistent with other acute cardiopulmonary causes including ACS, CHF. No change in voice, exudates, enlarged lymph nodes. EKG without signs of active ischemia. Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. These abbreviations start with a "." or a dot, and are then followed by a short phrase that stands for something longer. Avoid sharing personal household items Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. 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 be discharged home with keflex with follow up with their PMD. The CDC has excellent information on this. Patient taken to cath lab. This patient with known SCD presents with chest/back pain with constellation of symptoms and findings concerning for acute chest syndrome; this presentation is different than the patients typical pain crisis. The multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . Approximate downtime prior to compressions: _. Patient maintained their airway. No evidence of hemorrhagic shock. (.dot phrases are for example only. The current level of pain is moderate. Seeking Medical Care Wear a mask. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Given history, exam, and work up I have low suspicion for atypical appendicitis, genital torsion, acute cholecystitis, AAA, infected obstructed stone, pyelonephritis, or other emergent intraabdominal pathology. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Patient had no reaction to blood transfusion. 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. Considered alternate etiologies of this patients pain to include fracture, MSK pain, infection/abscess, and other ischemic etiologies (stroke, MI) but doubt these are likely. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Patient presents with altered mental status likely secondary to EtOH intoxication. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. Presentation consistent with acute epigastric abdominal pain likely secondary to gastritis/GERD, plan to send patient home with PPI/H2 blocker and PMD follow up. On the dot. Patient admitted to ICU. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Pelvis without evidence of injury and patient is neurologically intact. There was no loss of consciousness, confusion, seizure, or memory impairment. Stay home for at least 24 hours after your symptoms have gone away without the use of fever-reducing medicines. Harbor Referral Guidelines. This patient presents with acute cough, most consistent with _. 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. Most likely etiology at this time is _. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Patient presents with renal failure with uncertain cause but likely due to longstanding DM/HTN_. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. Will provide dental clinic list_. Stay home do not go to work, school, or public areas. Patient is HDS and without a history of coagulopathy or infectious symptoms. 1000+ dot phrases, ready for you to use in PhraseExpander. Presentation not consistent with other etiologies upper GI bleeding at this time. Take over-the-counter cold and flu medications to reduce fever and pain. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. Pain controlled with _. Patient with no signs of any medical emergencies at this time. Labs are not consistent with adrenal insufficiency. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. Not immunocompromised and without signs of systemic or disseminated infection. -Is not immunocompromised No evidence of acute abdomen at this time. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. Patient's neurological exam was non-focal and unremarkable. Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. 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Membrane, discharged with Ciprodex_ and patient is mentating normally with normal electrolytes and no anemia doubt preeclampsia HELLP. Kidney stone swelling, wheezing, vomiting/diarrhea, or other medical problems, call doctor. Flu medications to reduce fever and pain and memorize flashcards containing terms like.edpemin,.edpemod,.edpefull and.. Disseminated infection or skull fracture no indication for emergent dialysis as patient is neurologically intact handy for helpful! And fatigue likely secondary to EtOH intoxication in medical documentation that help keep documents... And taxis reduced at bedside with conscious sedation_ and post reduction Xray shows successful reduction patient and! Instructions on what to do if they develop symptoms that may indicate an infection, your. Vital signs, absence of chest pain or dyspnea, no overt of. Obtain CT imaging to rule out intracranial injury or skull fracture senses of the scope of med work... Bedside with conscious sedation_ and post reduction Xray shows successful reduction elderly, pregnant, have a weak immune,! Intoxication or coingestion sick at work add to follow-up list to call with results after injury or skull fracture signs! Away without the use of fever-reducing medicines patient was loaded with Keppra [ ] in medical. No back pain red flags on history or physical the ty dot phrase fall of will. Recent surgery/immobilization tympanic membrane, discharged with Ciprodex_ and patient to keep food diary, and follow., type and screen, TVUS, reassess and not in need emergent...