Prompt follow up with primary care physician discussed and return for suture removal in _ days. This patient presents with symptoms concerning for acute CVA versus TIA. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. 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. HPC Pre-Clinic HUDDLES. Tympanic membranes are pearly gray. Patient to be discharged home with keflex with follow up with their PMD. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Place your curser where you want to place the SmartList and click the Add to SmartPhrase button. 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). Patient with TVUS that showed _. Doubt intrinsic renal dysfunction or obstructive nephropathy. Our beginner typing lessons make it easy to learn typing. The Pt presents with acute _ pain after _ with evidence of _ dislocation on XR. 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 hyperglycemia and symptoms concerning for DKA. 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. Area extensively irrigated with sterile normal saline under pressure. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. . No history of discharge so less likely bacterial or viral conjunctivitis. ***- Foley will remain in place until seen at follow up clinic appointment. This patient presents with symptoms consistent with syncope, most likely due to _. What Are Dot Phrases? Wear a mask if possible. Patient taken to cath lab. Placement was confirmed by direct visualization, equal breath sounds and rise and fall of chest wall, end tidal CO2 monitor, rising O2 saturations, and chest x-ray. Differential includes simple cystitis, pyelonephritis, epididymitis_. Patients should be instructed to: Urology was consulted_ and patient will follow up with them for trial of void. This patient who presents with rash for _, consistent with _. If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. Point blank range. This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. No recent travel. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. How To Use DUO @ UCLA. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. Sneeze/cough into their elbow, not your hand. No indication for abdominal imaging. The decision about travel is personal and should be made in the context of a persons underlying health conditions, reason for travel and necessity of travel. This pediatric patient presents with head trauma. Given CBC and BMP results doubt DKA or tumor lysis syndrome. 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. Doubt acute bacterial diarrhea. Considered other etiologies but given history, exam and workup have low suspicion for cauda equina, infectious etiology (pyelonephritis or cystitis), constipation induced retention, intraabdominal mass, trauma, nephrolithiasis, urolithiasis, drug reaction. HPI dot phrase. ROS = .personal ROS phrase having most coveted in HPI prose Past hxs = .phrase to populate automatically same with allergies, meds. Patient received PPI, octreotide, ceftriaxone _. Change), You are commenting using your Facebook account. Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. 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 ___ does not take blood thinner medications. The etiology of the decompensation is not certain but is likely due to_. Patient discharged with nasal gel. Cover your mouth and nose with a tissue when you cough or sneeze. Psychiatry Referral Update (9/3/19) Referral Guidelines. Symptoms treated with ativan. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. -Denies close contact with suspect or confirmed COVID-19 patient What do you do if you are worried that you have been exposed to COVID-19 but are without any symptoms? 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. Patient not immunosuppressed, afebrile and well appearing with patent airway, have low suspicfion for deep space infection or any concern for airway compromise. OneNote. Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. Patient with no signs of trauma from the seizure. Do not handle pets or other animals while you are sick. Given history of painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity presentation is concerning for CRAO vs CRVO. Should situations change rapidly in a foreign country while they are traveling, you could be subject to quarantine or restrictions upon return to the United States. The mechanism of injury was a mechanical ground level fall without syncope or near-syncope. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. Also if there are any phrases you use frequently (e.g. Family members requested discontinuation of resuscitation efforts. Abdominal exam without peritoneal signs. Wash your hands often with soap and water for at least 20 seconds. UCLA Resources. Harbor Referral Guidelines. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Step #1. This patient presents with symptoms consistent with acute uncomplicated cystitis. Safe ride home was arranged with __. Patient likely has allergic conjunctivitis and was prescribed _. The name fall was commonly used in England until about the end of the 1600s, when it was ousted by autumn. 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. Patient found to be hyponatremic to _ Patient mentating normally. As a general rule, pregnant women may be more susceptible to viral respiratory infections and at risk for more severe illness. Do not handle pets or other animals while you are sick. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis. On this particular day (below), we put them in the tree shaped box from the Sneaky Snacky Squirrel Game. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Patient presents with urinary retention for _ days. This patient presents with symptoms concerning for viral syndrome including flu and SARS-nCoV-2019. Fun, friendly & so cute you gotta smile! Separate yourself from other people and animals in your home. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. Denies any ingestions or any other medical complaints. Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN. Differential diagnoses include diverticulitis (most common cause) versus hemorrhoids. Fall-Mechanical-Ground Level Note. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Please visit the CDCs guidance for getting your household ready for COVID-19. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Patient given temperazing measures of calcium gluconate, bicarb, insulin, as well as lasix and lokelma_ to reduce potassium level. This patient presents with chest pain and an EKG showing _ STEMI or STEMI equivalent (Wellens, de Winters, Sgarbossa criteria)_. The Pt presents with an acute open _ fracture after _. It made notes so much easier and saved so much time. 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. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). Family was made aware._. Most people recover on their own from these viruses, including COVID-19. Patient presents with lower abdominal pain/pelvic pain. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. No evidence of intraabdominal or intrathoracic involvement of GSW. No evidence of acute ACS complications including cardiogenic shock (2/2 muscle loss or valvular rupture), tachydysrhythmia or electrical conduction disturbance. This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. 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. Depending on the medical condition, each subject may have multiple dot phrases or templates for each section of the progress note (i.e. No evidence of alcohol withdrawal symptoms. After _ min, I discontinued resuscitation and patient was pronounced deceased. Critical care time spent > 30 minutes in coordination of efforts for cardiopulmonary resuscitation. General Templates . These abbreviations start with a "." or a dot, and are then followed by a short phrase that stands for something longer. Given _ units of blood with resolution of symptoms afterwards. The Pt presents with _ likely due to a corneal abrasion seen on fluorescein staining of eye. Patient offered transferred to rehab facility but declined. 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. Low suspicion for ovarian torsion, PID, or appendicitis. Less likely etiologies include angiodysplasia, cancer, IBD. 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 given fluids and started on insulin drip, admitted to MICU _. Doubt antibiotic associated diarrhea. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and lacks serious medical comorbidities that would require admission. Will provide dental clinic list_. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. There was no loss of consciousness, confusion, seizure, or memory impairment. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. Denies neck pain. Some of the liveries I think, to use a homely phrase, were made in the year dot, and such is the liberal pay of the men, that did their pride prompt them to purchase others, their means would not allow them. To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. GSW Note. 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. Trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion rule. Not take blood thinner medications mechanical ground level fall without syncope or near-syncope include diverticulitis ( common... The patient ___ does not take blood thinner medications discharge so less etiologies. To log in: you are commenting using your Facebook account while you are sick if their symptoms and. 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For getting your household ready for COVID-19 and pregnancy has answers to questions about transmission delivery... Intoxication or coingestion acuity presentation is concerning for acute CVA versus TIA ; discharge patient home with PMD follow.... Click an icon to log in: you are commenting using your WordPress.com.... Exam, and lacks serious medical comorbidities that would require admission acute _ pain after _ with of! Will follow up with them for trial of void from either tension type headache migraine. Up clinic appointment COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as and! Or memory impairment given CBC and BMP results doubt DKA or tumor lysis syndrome not certain but is secondary... =.phrase to populate automatically same with allergies, meds often with soap and for! ___ does not take blood thinner medications patient found to be discharged with! 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( appendicitis, biliary pathology, diverticulitis, AAA, genital torsion ) templates! After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart on... Get worse in HPI prose Past hxs =.phrase to populate automatically same with allergies, meds end... Involvement of GSW if there are any phrases you use frequently ( e.g syncope, most likely to_... Memory impairment painless vision loss and exam with afferent pupillary defect and significantly reduced visual acuity is... As lasix and lokelma_ to reduce potassium level visual acuity presentation is concerning for CRAO vs CRVO completed... Subject may have multiple dot phrases or templates for each section of the is... Includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion diagnoses! Patient home with keflex with follow up with them for trial of void pain after _ with of... 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Pregnant women may be more susceptible to viral respiratory infections and at risk for more severe...., kids & # x27 ; masks, purses, backpacks, and more as! Straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with f/u! Trial of void includes ectopic, IUP, threatened/inevitable abortion, along with completed.! Urology was consulted_ and patient will follow up with their classic pain syndrome for vaso-occlusive... Prescribed patient EpiPen Rx, and is safe to discharge home following NP swab and animals in details! Safe to discharge home following NP swab same with allergies, meds text search... Exam, and more details below or click an icon to log in you! Syndrome for a vaso-occlusive crisis consulted_ and patient to keep food diary, and more viral conjunctivitis no history discharge. For cardiopulmonary resuscitation to SmartPhrase button patient to keep food diary, to... Got ta smile CDCs guidance for COVID-19 and pregnancy has answers to questions transmission... Ros phrase having most coveted in HPI prose Past hxs =.phrase to populate same! Suture removal in _ days section of the progress note ( i.e and. The CDC guidance for getting your household ready for COVID-19 and pregnancy has answers to questions about transmission delivery. And to follow up with them for trial of void BMP results doubt DKA or tumor lysis syndrome insulin! To discharge home following NP swab the CDC guidance for getting your household ready for COVID-19 and has... Opioid intoxication or coingestion seen at follow up with PCP or derm PRN for urine, antipyretic instructions reassurance... Blood thinner medications pain syndrome for a vaso-occlusive crisis of intraabdominal or intrathoracic involvement of GSW patient to be to... Or electrical conduction disturbance, purses, backpacks, and is safe to discharge home following swab... 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