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Low suspicion for PE given normal vital signs, absence of chest pain or dyspnea, no evidence of DVT, no recent surgery/immobilization. Patient presents with _ joint pain. This patient presents with symptoms concerning for a lower GI bleed. 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 . Presentation not consistent with acute cardiac etiologies to include ACS (non ischemic ekg, unremarkable trop), CHF, pericardial effusion / tamponade . Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. Patient appropriate for discharge with outpatient follow-up and ___ for pain. Low suspicion for gastric or esophageal dysmotility as cause_. 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. It is best to call ahead of time to discuss your symptoms, if possible. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). It is still influenza (flu) season and influenza remains far more common. Plan: CT scan head/neck, pain control, reassess. If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. Explained to patient that they will likely be sore for the coming days and can use tylenol/ibuprofen to control the pain, patient given return precautions. 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. Patient had no reaction to blood transfusion. Did the same for ROS. Cover your coughs and sneezes 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. This patient presents with nausea, vomiting & diarrhea. Patient observed for until clinically sober. The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. If possible, put on a facemask before emergency medical services arrive. Suspect acute kidney injury of prerenal origin. Patient was given lasix_, nephrology consulted and patient was dialyzed. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. --DELETE EVERYTHING ABOVE HERE-- Clinic Note and Treatment Plan HPI - No H/o Jaundice, GIB, Varices, Encephalopathy, SBP, or Ascites Review of Systems - The Patient relates the following as they may pertain to medication use - No Fatigue, No Headache, No Nausea, No Diarrhea, No . Pain controlled with _. Patient presents with flank pain likely secondary to renal colic from likely non-obstructed non infected kidney stone. 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. Denies vomiting, numbness/weakness, fever. Will give wait and see prescription for amoxicillin. Patient given fluids and ceftriaxone. No evidence of intraabdominal or intrathoracic involvement of GSW. Given history, I have low suspicion for giardia or other parasites. Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed. Based on history, physical, and work up. Differential included UTI, pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_. Doubt intrinsic renal dysfunction or obstructive nephropathy. BMP witohut evidence of AKI. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), cauda equina (no bowel or urinary incontinence/retention, no saddle anesthesia, no distal weakness), AAA, viscus perforation, osteomyelitis or epidural abscess (no IVDU, vertebral tenderness), renal colic, pyelonephritis (afebrile, no CVAT, no urinary symptoms). Patient feels well on discharge with plan to follow up with PMD. Given history and story considered but low risk for aortic dissection, pneumonia, or PE. At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. 3. Begin typing real words and phrases before the end of lesson one. I had a "normal physical exam" dot phrase when I was an intern doing a TY year. Moot point. Will obtain CT imaging to rule out intracranial injury or skull fracture. Patient treated with opioids which controlled their pain and they were discharged _. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. Patient offered transferred to rehab facility but declined. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Tympanic membranes are pearly gray. Should food, water, or medications be stockpiled? Otherwise well-appearing.No history of trauma. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Fall-Mechanical-Ground Level HPI. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. The patient was placed on a levophed drip and resuscitated. No infectious symptoms and afebrile so doubt sepsis. Given the clinical picture, no indication for imaging at this time. This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. This patient presents with symptoms concerning for acute CVA versus TIA. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. News for nerds, stuff that matters ( Slashdot advertising slogan ) Not to put too fine a point on it. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. There is not yet any information available about the susceptibility of pregnant women to COVID-19. This patient presents with symptoms suspicious for likely viral upper respiratory infection. Urology was consulted_ and patient will follow up with them for trial of void. Well appearing. Note that these medicines do not cure the illness and therefore do not stop you from spreading germs. Also, clean any surfaces that may have body fluids on them. Avoid close contact with people who are sick. Most people recover on their own from these viruses, including COVID-19. 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. History, physical, and work up with low suspicion for temporal arteritis, optic neuritis, complex migraine, or stroke. This patient presents with symptoms consistent with acute uncomplicated cystitis. Based on history and physical doubt sinusitis. 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 with symptoms and labs consistent with acute hypoglycemia, most likely due to _. We put all of the quick drill cards facedown on the table or in a container. DMV was notified to remove patient's licence_, patient was given strict seizure precautions. No history of immunocompromise. Avoid crowded places or mass gatherings, especially if you are immunocompromised or have chronic lung disease. It is recommended that you seek medical care for serious symptoms, such as: This patient presents with generalized weakness and fatigue likely secondary to dehydration. Patient presenting with flank/back pain and fever. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis. Differential diagnosis includes reflexive syncope (vasovagal). No need for epinephrine. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Pain was controlled with headache cocktail and patient discharged home with PMD follow up. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Given work up low suspicion for acute hepatobiliary disease (including acute cholecystitis), acute pancreatitis (neg lipase), PUD and gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, diverticulitis. Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline. Most EHRs have this capability, both for organization-level and individual user-created content. 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. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Description: Epic smart phrase with syncope differential diagnosis and initial workup plan. Testing is not available for asymptomatic individuals, regardless of travel history. Given history and exam I have low suspicion for globe rupture, uveitis, HSV keratitis, Endopthalmitist, Foreign Body. MDM. Patient with TVUS that showed _. No diabetes or immunosuppression. Sepsis). 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). 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). Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Discussed return precautions for odontogenic infections and other dental pain emergencies. Exam prior to discharge shows no evidence of Wernicke's encephalopathy. Given lack of a severe mechanism, GCS 15 or lack of AMS, no occipital/parietal scalp hematoma, and no LOC, risk of obtaining a CT scan outweighs the potential benefit. How Should A Phone Visit Be Done? Pain treated in ED with ____. Given work up have low suspicion for acute hepatobiliary disease (including acute cholecystitis or cholangitis), upper GI bleed, acute pancreatitis, gastric perforation, acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation, or acute coronary syndrome. No evidence of alcohol withdrawal symptoms. Javascripts take 135.5 kB which makes up the majority of the site volume. Patient has not been taking their HTN medication _. Patient without a history of coagulopathy or infectious symptoms. Uncategorized. 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. A dotphrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Separate yourself from other people and animals in your home. The etiology of the decompensation is not certain but is likely due to_. 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. The multiple senses of the word fall come in handy for the helpful reminder " Spring Forward, Fall . Differential diagnoses include diverticulitis (most common cause) versus hemorrhoids. Per EMS report, patient was found down_, had witnessed arrest_. Area hemostatic. Homely phrase implies that year dot was by then well-known, at least in the writer's experience. Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN. Depending on the medical condition, each subject may have multiple dot phrases or templates for each section of the progress note (i.e. Given RUQ US findings patient likely has biliary colic_with no signs of acute cholecystitis or cholangitis_ patient likely has cholecystitis with no signs of cholangitis, patient given ceftriaxone and flagyl, surgery consulted and patient to be admitted_. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. Given vision loss is painless I have low suspicion for normally painful syndromes such as Corneal Abrasion/Ulcer, Complex Migraine, Globe Rupture, Acute Angle Glaucoma, Uveitis, Endopthalmitis, Iritis. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Patient given empiric vanc, cipro, flagyl_.

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