This patient presents with symptoms consistent with acute anxiety reaction / panic attack. This page is for adult patients. Wash your hands often with soap and water for at least 20 seconds. Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). 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. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Create a free website or blog at WordPress.com. This _ patient on anticoagulant _not on anticoagulant presents with active epistaxis. 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. No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. -No cluster status (SNF, group home, etc), COVID-19 (Novel Coronavirus) FAQs for Inquiring Patients. 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 . 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. No evidence of acute abdomen at this time. Patient offered transferred to rehab facility but declined. 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 alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. Pupils are 3 mm and reactive to light. 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. Patient presents with _ joint pain. Patient with no signs of heart failure. This patient who presents with rash for _, consistent with _. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: _). Given painless vision loss low suspicion for normally painful syndromes such as corneal abrasion/ulcer, complex migraine, globe rupture, acute angle closure glaucoma, optic neuritis, temporal arteritis, uveitis, endophthalmitis, iritis. Come up with your top 10 conditions. Considered, but think unlikely, CVT given no cranial nerve deficits, blurry vision, diplopia. Doubt alternate acute emergent pathology. Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge. Oropharynx pink and moist. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). -Denies close contact with suspect or confirmed COVID-19 patient Patient is nontoxic-appearing and although symptomatic, otherwise safe to go home. Microsoft 365 & HomeBase. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes. Low suspicion for ovarian torsion, PID, or appendicitis. Patient received empiric Ancef and orthopedics was consulted who reduced the fracture under conscious sedation and placed in splint with plan to admit patient for likely orthopedic operation. I had a "normal physical exam" dot phrase when I was an intern doing a TY year. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. Also, clean any surfaces that may have body fluids on them. Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage (stable hgb). No infectious symptoms and afebrile so doubt sepsis. Patient tachycardic with tremors and tongue fasciculations. Patient given fluids and started on insulin drip, admitted to MICU _. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. (LogOut/ Urology was consulted_ and patient will follow up with them for trial of void. No recent eye trauma or suspected microtrauma (dust, sand, etc). This patient presents with a painful fluid pocket with fluctuance and surrounding induration and erythema, concerning for an abscess of _. Normal IOP so doubt acute angle closure glaucoma. Well appearing. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. This patient presents with acute cough, most consistent with _. Javascripts take 135.5 kB which makes up the majority of the site volume. Attempt to pass a suction catheter. Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess. Based on canadian syncope rule, patient is low risk and well appearing here, plan to discharge the patient home with PMD follow up. Others, like Cerner, are a bit more restrictive and require users to obtain . Considered but low risk for SBO (normal BM, passing flatus, no abdominal surgeries), no signs of DKA in labs. Cover your coughs and sneezes The name fall was commonly used in England until about the end of the 1600s, when it was ousted by autumn. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. Patient euvolemic with no trismus. Suction, and consider partial obstruction. Patient with no signs of any medical emergencies at this time. No indication for abdominal imaging. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. PE = .edVS and .personal PE template (mine is default to level 5 just via visual and basic exam of heat lungs) MDM. Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. Psychiatry Referral Update (9/3/19) Referral Guidelines. Patient had no reaction to blood transfusion. 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_. Given history of painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs CRVO. We need you! Patient tolerated procedure well and neurovascular exam intact and unchanged post repair with intact distal pulses and cap refill_. Ipswich Journal (Suffolk), 25 Mar 1873. Quickly learn how to type the Home Row Keys: A, S, D, F, J, K, L and ; with the correct finger position. No evidence of acute abdomen at this time. Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. XR obtained and is negative. Also if there are any phrases you use frequently (e.g. Code Blue Note. Harbor Referral Guidelines. Patient denies suicidal intention or coingestion. Intervention needed The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. -Denies HCW status Given patient had increased IOP and concerning ocular exam likely cause is acute angle closure glaucoma. 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. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Ddx includes allergic reaction vs. preseptal cellulitis. Doubt intrinsic renal dysfunction or obstructive nephropathy. 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. A lengthy list of discharge instructions, albeit a . Each hospital has its own names for these things) .ed meds Safe ride home was arranged with __. ROS = .personal ROS phrase having most coveted in HPI prose Past hxs = .phrase to populate automatically same with allergies, meds. (This step will immediately resolve any respiratory distress resulting from an obstructed inner cannula.) Approximate downtime prior to compressions: _. 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. 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. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. Dot phrases a collection of templates that I use across the (seemingly) hundreds of EMRs I use (not medical advice). If you develop symptoms that may indicate an infection, contact your physician. 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. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Given history and physical presentation not consistent with overt toxidrome, ingestion. Moot point. Autotext Dot Phrases for Cerner EHR. This patient presents with symptoms concerning for acute CVA versus TIA. Safe ride home was arranged with __. Patient given temperazing measures of calcium gluconate, bicarb, insulin, as well as lasix and lokelma_ to reduce potassium level. There is not yet any information available about the susceptibility of pregnant women to COVID-19. 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. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. This result falls beyond the top 1M of websites and identifies a large and not optimized web page that may take ages to load. Abdominal exam without peritoneal signs. Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. HPI dot phrase. 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