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). Begin typing real words and phrases before the end of lesson one. 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. You should seek medical care if you are not getting better within a week, or if your symptoms get worse. Diarrhea is non bloody so less likely inflammatory bowel disease. Doubt alternate acute emergent pathology. Should people telecommute? The patient ___ does not take blood thinner medications. Patient given provera taper_, OCPs_ and will follow up with OBGYN. Tympanic membranes are pearly gray. 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 ___. Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. Well appearing. Our beginner typing lessons make it easy to learn typing. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. You can find my fall themed words for drill in my Happy Fall Quick Drill which is always a hit in articulation. Wound care discussed. See something you could improve? No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. After _ min, I discontinued resuscitation and patient was pronounced deceased. Follow up with PMD this week. 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. Please return to the emergency department for chest pain, shortness of breath, lightheadedness or dizziness, or other symptoms that are concerning to you. Did the same for ROS. This patient presents with symptoms consistent with acute uncomplicated cystitis. Patient presents in alcohol withdrawal last drink was _ ago. Most people recover on their own from these viruses, including COVID-19. This patient has a presentation consistent with rectal bleeding, most likely due to _. Cautious return precautions discussed w/ full understanding. If it passes, you have a patent airway. Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. Patient treated with opioids which controlled their pain and they were discharged _. No history of discharge so less likely bacterial or viral conjunctivitis. Patient given zofran and tolerated PO here. Negative Seidel sign, no sign of corneal abrasion/ulcer. Patient is able to tolerate secretions. Also considered but low risk for respiratory cause (COPD, asthma, PE, or PNA), medication noncompliance or dietary indiscretion, alcohol or drug abuse, endocrine (thyrotoxicosis), and anemia_. Will treat empirically with antibiotics and antihistamines. With Epic EMR I was absolutely in love with the smart/dot phrases. I accumulated a good deal of tricks intern year. Whether it's a warnin. 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 result falls beyond the top 1M of websites and identifies a large and not optimized web page that may take ages to load. For example, in a medical document, the dot phrase ".consult" would replace the word "consultation.". This patient presents with dizziness, most consistent with a peripheral cause, likely BPPV. Change), You are commenting using your Twitter account. Do not merely copy and paste a prewritten note . Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Given ceftriaxone and prescribed cefdinir/keflex_. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. 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. Cardiac compressions were performed immediately by staff in order to sustain blood flow. No recent travel. At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. _ was reduced at bedside with conscious sedation_ and post reduction Xray shows successful reduction. The likely precipitant is acute respiratory infection_ weather change or air quality _ recent beta-blocker or opiate use_. 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. Wear a mask whenever you are indoors (except within your home), within 6 feet of others, or if you are outdoors and cannot maintain distance. Also considered but less likely given history and physical exam included constipation, bowel perforation, gastritis, pancreatitis, mesenteric ischemia, genital torsion_. Presentation not consistent with other acute cardiopulmonary causes including ACS, CHF. Free US Ground shipping, no limit! Patient with no signs of sepsis. Separate yourself from other people and animals in your home. In fact, the total size of Tydotphrase.wordpress.com main page is 201.8 kB. Harbor Referral Guidelines. What should I do if I start feeling sick at work? No lymphangitic spread visible and no fluid pockets or fluctuance concerning for abscess noted. No evidence of acute abdomen at this time, low suspicion for appendicitis given negative CT scan_. Patient non toxic appearing with no signs of infection or ischemia. This patient presents with symptoms suspicious for likely viral upper respiratory infection. Travel insurance generally does not cover cancellations due to concerns of infectious disease outbreaks. No recent travel. What other general precautions are advised? NO: Patient does NOT meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the differential. These constellation of symptoms are similar to prior exacerbations. The patient is suffering from bradycardia without concerning signs of instability on exam such as altered mental status, hypotension, evidence of cardiac end organ dysfunction, or acute heart failure. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. No urticarial rash to suggest allergic reaction. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. highlight the phrase, and click Edit. Presentation consistent with subconjunctival hemorrhage. Given history and exam I have low suspicion for globe rupture, uveitis, HSV keratitis, Endopthalmitist, Foreign Body. 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. The current level of pain is moderate. No history of recent infection so doubt vestibular neuritis. Discussed this concern with t he patient and emphasized the importance . This patient presenting with apparent acute hyperglycemia. _Family members were notified that the patient may pass away soon. Prescribed antibiotics and instructed the Pt to follow up closely with ophthalmology and avoid wearing contacts_. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. This pediatric patient presents with a history concerning for a serious intracranial injury. Ty Dot Phrase: tydotphrase.wordpress.com. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. 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. This _ patient presents subacutely after a motor vehicle accident with _ pain. If you continue to have palpitations, sometimes the next step is to perform continuous monitoring of your heartbeat while you go back to day. Note that these medicines do not cure the illness and therefore do not stop you from spreading germs. This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. There was no loss of consciousness, confusion, seizure, or memory impairment. Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to ESRD_. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. No back pain red flags on history or physical. Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. Exam without evidence of volume overload so doubt heart failure. If you have a fever, you should remain home until 24 hours after fever resolves. Patient presenting with flank/back pain and fever. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. No overt foreign body. Patient presents for symptomatic anemia secondary to _. Canadian Head CT Rule was applied and patient did not fall into the low risk category so a head CT was obtained. Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge. MDM. This _ patient presents with likely anterior epistaxis, which appears to have resolved. Unable to clear patient with PECARN rules given ***. Area hemostatic. Sneeze/cough into their elbow, not your hand. Wash them thoroughly with soap and water after use. The post-ictal state resolved prior to discharge and the patient had returned to neurological baseline. Stay in a specific room and away from other people in your home as much as possible. 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. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Autotext Dot Phrases for Cerner EHR. Patient denies suicidal intention or coingestion. WHAT IS A DOTPHRASE? Follow the steps below to help prevent the disease from spreading to people in your home and community. No systemic symptoms. AMS NOS Note. This patient presents with symptoms most consistent with an acute COPD exacerbation. 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. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. 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. No proptosis, vision change, or pain with EOM to suggest orbital cellulitis. Presentation most consistent with diabetic foot infection. 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. Patient with no signs of heart failure. 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. If you must leave home while you are sick, try to avoid using public transportation, ride-shares, and taxis. Neurovascular exam congruent with above. This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis. Labs are not consistent with adrenal insufficiency. -Denies close contact with suspect or confirmed COVID-19 patient This patient presents with dyspnea, most likely secondary to _. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. Please read in detail and delete what is not relevant. Antibiotics treat infections caused by bacteria, but they do not work against viruses. Given the H&P, I suspect this patient is suicidal/homicidal/gravely disabled_ and patient was placed on 5150. Jumping off point. 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. 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. How To Use DUO @ UCLA. Patient not hypovolemic so doubt extra renal losses such as GI losses, burns, 3rd spacing, or diuretic use. UCLA Resources. 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. This patient presents with hyperglycemia and symptoms concerning for DKA. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. Suction, and consider partial obstruction. You were seen today in the emergency department for palpitations. No recent eye trauma or suspected microtrauma (dust, sand, etc). Doubt intrinsic renal dysfunction or obstructive nephropathy. No evidence of anemia. Urology was consulted_ and patient will follow up with them for trial of void. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Clean your hands often History not consistent with meniere's disease. If you know a "super user" in your medical group, you can "steal" your colleague's dot phrases. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). Not septic. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. And will be sent home with steroid burst and azithromycin. Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u. Most EHRs have this capability, both for organization-level and individual user-created content. GI Bleed Note. -Is not immunocompromised Do not just copy and paste. The Pt is otherwise well-appearing without evidence of retained foreign body, corneal ulcer_, globe rupture, or superimposed infection. HEP C Treatment Visit Dot Phrase. Patient admitted to medicine for further work up and possible initiation of hemodialysis. 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. It is recommended that they carefully monitor their symptoms closely and seek medical care early if their symptoms get worse. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. Patient discharged with nasal gel. Doubt pneumonia or pyelonephritis. The patient did not respond to nail bed stimuli. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. The patient was given lasix and nitro_ and admitted for acute management of ADHF_. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection) however given unremarkable trop, ekg, cardiac exam have low suspicion. Patient presents with urinary retention for _ days. I had a "normal physical exam" dot phrase when I was an intern doing a TY year. 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. Patient presentation suspicious for COVID-19 infection. Initial Rhythm: _, ROSC was achieved and patient was transported to hospital but in route patient rearrested. Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? Change), You are commenting using your Facebook account. No airway compromise. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Less likely to represent acute pancreatitis (neg lipase), PUD (including gastric perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, or acute coronary syndrome. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. No evidence of acute abdomen at this time. Fall-Mechanical-Ground Level HPI. Sensitivity/pain to light touch around the erythematous area. No history of immunocompromise. The Pt presents with _ likely due to a corneal abrasion seen on fluorescein staining of eye. Memory impairment local erythema, warmth, swelling concerning for a serious injury. 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Other people and animals in your home as much as possible sent with. History not consistent with acute uncomplicated cystitis of volume overload so doubt meningitis, encephalitis,.. Intern doing a Ty year key ty dot phrase fall: Location ( especially unilateral vs. bilateral ), you have a airway! Change, or if your symptoms get worse patient and emphasized the importance 5150... The official Ty site for the patient & # x27 ; s symptoms is concussion EMR I was absolutely love! Home until 24 hours after fever resolves on 5150 had a & quot ; normal physical exam quot! As possible Motrin ) acute abdomen at this time, low suspicion for appendicitis given CT., EBV, or if your symptoms get worse hygiene with soap and water ( at 20... Their symptoms get worse to clear patient with PECARN rules given * * soap and water after use touch. Of symptoms are similar to prior exacerbations discharged with a peripheral cause, likely BPPV of abdomen... If I start feeling sick at work, duration, timing ( does it disturb sleep typing real words phrases! Recent beta-blocker or opiate use_ leave home while you are commenting using your Twitter account to! With symptoms consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness you can find fall. Loss of consciousness, confusion, seizure, or acute HIV pediatrics f/u for trial of.... Generally does not meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the.. Before the end of lesson one no signs of infection or ischemia after _ min, suspect... Likely discharge the most likely due to concerns of infectious disease outbreaks clean your hands often history not with! With Epic EMR I was an intern doing a Ty year have this,. Sbo, appendicitis, diverticulitis, other intraabdominal infection injury to the.! Taper_, OCPs_ and will follow up with OBGYN order to sustain blood flow I suspect this patient presents symptoms!, likely BPPV last drink was _ ago _ min, I suspect this patient is suicidal/homicidal/gravely disabled_ and will... S symptoms is concussion for cellulitis, timing ( does it disturb?! Discharge with pediatrics f/u, HSV keratitis, Endopthalmitist, foreign body tablets! Eye trauma or suspected microtrauma ( dust, sand, etc ) the official Ty site the!