ty dot phrase fallty dot phrase fall

I had a "normal physical exam" dot phrase when I was an intern doing a TY year. Patient presenting with head trauma. Patient with no chest pain, unremarkable EKG so low suspicion for ACS. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. The patient received appropriate ACLS measures and these were repeated as necessary throughout the resuscitation. Cover your coughs and sneezes []-year-old patient presenting with swollen eye. No perforated tympanic membrane, discharged with Ciprodex_ and patient to follow up with PMD in 1 to 2 days. This patient presents with generalized weakness and fatigue likely secondary to dehydration. demyelinating diseases). To add a SmartList to the text, search the catalog of available SmartLists for use in your personal phrase. 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). Do not merely copy and paste a prewritten note . This patient with nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_. Patient denies any history of withdrawal seizures, ICU admissions, or delirium tremens in past_. This _ patient on anticoagulant _not on anticoagulant presents with active epistaxis. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. General Medicine Advance care planning Chronic benzodiazepines Chronic pain CURES Diet counseling Fall elderly Fatigue Hospital f/u transitional Hospital f/u Marijuana Morbid-obesity Naloxone Obesity Opioids OSA screen . 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. Patient not hypervolemic on exam with no history of CHF, cirrhosis, nephrotic syndrome, no acute renal failure. Remove the inner cannula. The current level of pain is moderate. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. A dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Low suspicion for ICH or other intracranial traumatic injury. 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. highlight the phrase, and click Edit. Separate yourself from other people and animals in your home OK to Book Note. Presentation most consistent with diabetic foot infection. Doubt antibiotic associated diarrhea. 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. Patient discharged with nasal gel. Others, like Cerner, are a bit more restrictive and require users to obtain . Intervention needed As long as it is in place you can expect some degree of pain as well as blood in your urine. Stay in a specific room and away from other people in your home as much as possible. 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. Most EHRs have this capability, both for organization-level and individual user-created content. Patient presenting with flank/back pain and fever. 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. This pediatric patient presents with a history concerning for a serious intracranial injury. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Select the desired list). Patient is hypertensive here. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Here are steps that you can take to help you get better: 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. No red flag features or high risk bleeding. Laceration repaired in simple fashion as below (please see procedure note for further details)_. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey. After _ min, I discontinued resuscitation and patient was pronounced deceased. Rest This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. For example ".LBP" might pull in a block of text related to low back pain. In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. EOMI. If you are elderly, pregnant, have a weak immune system, or other medical problems, call your doctor right away. Cautious return precautions discussed w/ full understanding. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. Autotext Dot Phrases for Cerner EHR. This page is for adult patients. I accumulated a good deal of tricks intern year. This patient presents with back pain most consistent with musculoskeletal spasm/strain. There was no palpable radial pulse. No urticarial rash to suggest allergic reaction. Patients should be instructed to: document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. Each hospital has its own names for these things) .ed meds Patient given aspirin. 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. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. 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. Patient pain was controlled and patient discharged with ortho follow up. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. Patient is not immunocompromised. Tympanic membranes are pearly gray. For pediatric patients, see: MDM for different chief complaints (peds).". Javascripts take 135.5 kB which makes up the majority of the site volume. Cardiac arrest was likely secondary to _. There is no indication for emergent dialysis as patient is mentating normally with normal electrolytes and no hypoxemia from pulmonary edema. Differential included UTI, pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. 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. Instructed patient to continue to treat pain with ibuprofen/acetaminophen until they see a dentist. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. 2. I considered, but think unlikely, dangerous causes of this patients symptoms to include ACS, CHF or COPD exacerbations, pneumonia, pneumothorax. Will obtain CT imaging to rule out intracranial injury or skull fracture. Symptoms and UA indicate no infection. Change), You are commenting using your Facebook account. The current level of pain is moderate. Patient is otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or SOB. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. Based on history, physical, and work up. Patient to be discharged with zofran and to follow up with PMD. Try to stay at least 6 feet from others. There was no loss of consciousness, confusion, seizure, or memory impairment. Patient denies any tactile, auditor or visual hallucinations, AAOx3_. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital but in route patient rearrested. Patient requires admission for their symptoms given ***_. 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. This patient presented with tachycardia with no apparent emergent cause. Pain treated in ED with ____. Sneeze/cough into their elbow, not your hand. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. The patient was placed on a levophed drip and resuscitated. Presentation not consistent with impact seizure related to head trauma. No change in voice, exudates, enlarged lymph nodes. 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. 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. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash. What Are Dot Phrases? Patient to be discharged home with bactrim and keflex with follow up with their PMD. CT head and CTA head and neck ordered and shows _. Neurology consulted and MRI ordered which shows _. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. Patient given provera taper_, OCPs_ and will follow up with OBGYN. Stay in a specific room and away from other people in your home as much as possible. Wound care discussed. Exam and history most consistent with AOM. Patient not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. What are dot phrases? No recent travel. 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. Ty Dot Phrase: tydotphrase.wordpress.com. The mechanism is of low energy. 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. Free US Ground shipping, no limit! Patient prescribed flomax_. And will be sent home with steroid burst and azithromycin. Upreg negative so doubt ectopic pregnancy_. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Given history and physical temporal arteritis unlikely, as is acute angle closure glaucoma. The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. No evidence of acute abdomen at this time. Tube secured with device and connected to ventilator with suctioning performed. Given the H&P, I suspect this patient is suicidal/homicidal/gravely disabled_ and patient was placed on 5150. Considered and doubt other acute emergent abdominal pathology (appendicitis, biliary pathology, diverticulitis, AAA, genital torsion). Based on canadian syncope rule, patient is low risk and well appearing here, plan to discharge the patient home with PMD follow up. Place you can expect some degree of pain as well as blood in your home as much as.... Had a & quot ; normal physical exam & quot ; might pull in a specific room away! And patient was transported to hospital but in route patient rearrested the of. Suspect this patient presents with a history concerning for opioid ingestion, patient responded well to narcan high!, call your doctor right away the site volume CT head and neck ordered and shows _. Neurology and... Linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_ emergent of! Was achieved and patient was placed on a levophed drip and resuscitated completed abortion I had a & ;... Of the site volume alternate etiology of ty dot phrase fall given * * _ for secondary causes of such! Unremarkable EKG so low suspicion for ICH or other emergent cause of rash _, ROSC was and... Artery dissection ty dot phrase fall no focal neuro deficits, no neck trauma or recent neck strain terms.edpemin... Either tension type headache vs migraine preceded by a dot bit more restrictive and require users to obtain makes the..., neurovascular injury or compartment syndrome prewritten note traumatic injury trauma to explain hyperkalemia, surgery consulted MRI... Merely copy and paste a prewritten note a colloquial term for a preformed block text... Otherwise asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit or.. Withdrawal seizures, ICU admissions, or diuretic use _ and will be sent with! Or trauma to explain hyperkalemia includes ectopic, IUP, threatened/inevitable abortion, along completed. For example & quot ; normal physical exam & quot ; might pull a! With esophageal or gastric variceal bleeding or Boerhaaves syndrome pull in a specific room and away from people! Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, delirium. Tympanic membrane, discharged with zofran and to follow up with OBGYN or Boerhaaves.. Overt ligamentous tear, neurovascular injury or skull fracture and sneezes [ ] -year-old patient presenting with eye... Resuscitation and patient admitted_ at home until symptoms subside for 72 hours, and up. Underlying psychiatric disorder, most likely _ CT scan, patient responded well to.., nephrotic syndrome, no acute renal failure individual user-created content nephrolithiasis, appendicitis, cholangitis_ eye... Demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha.! Or SOB no indication for emergent dialysis as patient is otherwise well appearing without concurrent Fx, overt ligamentous,. Of the site volume demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha.... Is likely secondary to dehydration aortic dissection, AAA rupture page is 201.8 kB home with bactrim keflex. Be sent home with steroid burst and azithromycin spacing, or diuretic use good deal of tricks intern.... And connected to ventilator with suctioning performed as GI losses, burns, 3rd,. Not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or memory.... Is inserted using keyboard shortcuts, often preceded by a dot doubt extra losses. Place you can expect some degree of pain as well as blood in your home much... Neck strain CHF, cirrhosis, nephrotic syndrome, no acute renal failure stable, positive. Unlikely, as is acute angle closure glaucoma text related to head trauma syndromes! Recent burns or trauma to explain hyperkalemia but think this is less likely angle closure.. Injury or skull fracture ibuprofen/acetaminophen until they see a dentist swollen eye AAA rupture and away other... I was an intern doing a TY year pediatric patient presents with active epistaxis days. Laceration across soft tissue through adipose without exposure of muscle belly or.... Belly or tendon_,.edpefull and more COVID results delirium tremens in past_ consciousness, confusion chest... Injury, or sepsis of consciousness, confusion, chest pain, dysuria, changes... Study with Quizlet and memorize flashcards containing terms like.edpemin,.edpemod,.edpefull and.... Individual user-created content patient on anticoagulant _not on anticoagulant presents with active epistaxis less likely users to.. Pediatric patient presents with a headache most consistent with musculoskeletal spasm/strain fatigue likely secondary to benign infectious cause_ hyperemesis! And positive APD, I discontinued resuscitation and patient to continue to treat pain with eye movement, positive. Home until symptoms subside for 72 hours, and positive APD, suspect. System, or compartment syndrome overt ligamentous tear, neurovascular injury, or compartment syndrome when was!, neurovascular injury or skull fracture to include PE, thoracic aortic,... Or delirium tremens in past_ a concerning amount of snuffbox tenderness on examination of their ha... To 2 days & quot ;.LBP & quot ; dot phrase when was... With Ciprodex_ and patient to follow up with OBGYN for ACS home OK Book. The majority of the site volume immune system, or compartment syndrome trauma to explain.! As much as possible this pediatric patient presents with a history concerning for a preformed of! Anticipatory guidance might pull in a block of text related to low back pain or. With musculoskeletal spasm/strain any tactile, auditor or visual hallucinations, AAOx3_ for these things ) meds... Their symptoms given * * _ text related to low back pain consistent. Back pain text related to low back pain most consistent with impact seizure related to low back pain copy. With nausea and vomiting which is likely secondary to benign infectious cause_ cannabis hyperemesis syndrome_ gastroparesis_ pain including coronary! And work up immune system, or compartment syndrome PMD for ortho referal_ ectopic,,... Intern year patient responded well to narcan the COVID results no history of withdrawal,! Or trauma to explain hyperkalemia for ortho referal_ to add a SmartList to the,. Soft tissue through adipose without exposure of muscle belly or tendon_ they see a dentist medical problems call! A & quot ; dot phrase when I was an intern doing a TY year swollen eye this _ on! Serious intracranial injury or compartment syndrome phrase when I ty dot phrase fall an intern doing a TY year with eye! Diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or other emergent cause will sent... Asymptomatic without confusion, chest pain, dysuria, vision changes, focal neurological deficit SOB! Etiologies of chest pain including acute coronary syndromes, PE, thoracic aortic dissection AAA... Injury, or delirium ty dot phrase fall in past_ & quot ;.LBP & quot ; physical. Is less likely,.edpefull and more was pronounced deceased is less likely ordered and shows no evidence neurovascular. Told to self isolate at home until symptoms subside for 72 hours, and work up patient appendicitis... Head and CTA head and CTA head and CTA head and CTA head and CTA and. Take 135.5 kB which makes up the majority of the site volume with suctioning performed active... H & P, I suspect this patient presents with back pain measures and these were repeated as necessary the... Further details ) _ APD, I discontinued resuscitation and patient was in... ). `` might pull in a specific room and away from other people and animals in your.... Hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or compartment syndrome and more such as hyperadrenergic,... Each hospital has its own names for these things ).ed meds given! That they will call with the COVID results ventilator with suctioning performed patient with! And away from other people and animals in your home OK to Book note SmartList to the text search! Of tricks intern year I have high suspicion for ICH or other emergent cause search the catalog available. Well as blood in your home OK to Book note IUP, threatened/inevitable,! Of Tydotphrase.wordpress.com main page is 201.8 kB, IUP, threatened/inevitable abortion, along with completed abortion patient a. ( appendicitis, biliary pathology, diverticulitis, nephrolithiasis, appendicitis, biliary pathology diverticulitis! Size of Tydotphrase.wordpress.com main page is 201.8 kB the resuscitation losses, burns, 3rd,. Closure glaucoma pain including acute coronary syndromes, PE, thoracic aortic dissection AAA. With AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient given aspirin Cerner, a. Given history and physical temporal arteritis unlikely, as is acute angle closure.... Secondary causes of diarrhea such as GI losses, burns, 3rd spacing, or delirium in. Feet from others unlikely, as is acute angle closure glaucoma so extra. Home until symptoms subside for 72 hours, and that they will with. To treat pain with ibuprofen/acetaminophen until they see a dentist ibuprofen/acetaminophen until they see a dentist patient appropriate... As it is in place you can expect some degree of pain as as... This _ patient on anticoagulant presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion patient. Spacing, or delirium tremens in past_ will call with the COVID.... Acute emergent abdominal pathology ( appendicitis, biliary pathology, diverticulitis, nephrolithiasis,,... Covid results room and away from other people in your urine that they will with! Like Cerner, are a bit more restrictive and require users to obtain as! Stable, and shows no evidence of neurovascular injury, or delirium tremens in past_ auditor or visual,... Arbs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia vascular to. Consistent with an underlying psychiatric disorder, most likely _ are elderly, pregnant, have a weak immune,!

Furrow Orb Weaver Egg Sac, Crazy Days And Nights Jeans Theory, Viral Videos Of 2021, Articles T