Patient found to have asymptomatic hyperkalemia with no ecg changes likely secondary to ESRD_. Pain was controlled with headache cocktail and patient discharged home with PMD follow up. Patient presents with urinary retention for _ days. They cover many specialties including: Cardiology, Dermatology, Neurology, General Medicine, Obgyn, Psychiatry, Surgery and . Avoid sharing personal household items ***- Foley will remain in place until seen at follow up clinic appointment. Abdominal exam without peritoneal signs. Do not share dishes, drinking glasses, cups, eating utensils, towels, or bedding with other people or pets in your home. Doubt alternate acute emergent pathology. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Safe ride home was arranged with __. Stay home from work or school when they are sick. Will give wait and see prescription for amoxicillin. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. The Pt is otherwise well appearing, hemodynamically stable, and shows no evidence of neurovascular injury or compartment syndrome. 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._. No headache red flags. If symptoms worsen or persist for 48-72 then pt to fill the prescription_. No change in voice, exudates, enlarged lymph nodes. Plan: CT scan head/neck, pain control, reassess. Your evaluation, which included a history and physical, an EKG and ***chest x-ray, and blood work, showed no emergency cause for your symptoms. Simple discharge The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd. Differential diagnosis includes possible acute gastroenteritis. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. The patient is suffering from testicular pain, but based on the history, exam, and work up, I do not suspect that the patient has testicular torsion, abscess, severe cellulitis, Fourniers gangrene, orchitis, epididymitis, inguinal hernia or other emergent cause. This patient presents with dizziness, most consistent with a peripheral cause, likely BPPV. No back pain red flags on history or physical. Patient is nontoxic-appearing and although symptomatic, otherwise safe to go home. Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. Use a household cleaning spray or wipe, according to the product label instructions. Considered and doubt RPA, ludwings, epiglottitis, EBV, or acute HIV. CT head and CTA head and neck ordered and shows _. Neurology consulted and MRI ordered which shows _. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy. For example ".LBP" might pull in a block of text related to low back pain. Patient observed for until clinically sober. No recent eye trauma or suspected microtrauma (dust, sand, etc). Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis. People with potentially life-threatening symptoms should call 911. There was no loss of consciousness, confusion, seizure, or memory impairment. How To Use DUO @ UCLA. 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. Patient taken to cath lab. This patient presents with back pain most consistent with _. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. Use a separate bathroom, if available. 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. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey. Doubt meningitis or appendicitis. Given _ units of blood with resolution of symptoms afterwards. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. No history of discharge so less likely bacterial or viral conjunctivitis. Currently euvolemic without evidence of dehydration. Follow the steps below to help prevent the disease from spreading to people in your home and community. if pregnant add _ Patient is normotensive with no proteinuria, LFT abnormalities, and no anemia doubt preeclampsia, HELLP. Based on History, Exam, and ED Workup patients presentation not consistent with ectopic pregnancy, molar pregnancy, life-threatening coagulopathy, trauma, serious bacterial infection. 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. Given patient had pain with eye movement, and positive APD, I have high suspicion for optic neuritis. OneNote. Autotext Dot Phrases for Cerner EHR. Patient discharged with nasal gel. After _ min, I discontinued resuscitation and patient was pronounced deceased. No airway swelling, wheezing, vomiting/diarrhea, or tachycardia/hypotension to suggest anaphylaxis. The name of its inverse season, spring, is thought to come from the phrase spring of the leaf the time when everything is blossoming. Practice frequent hand hygiene with soap and water (at least 20 seconds) or alcohol-based hand rub. This patient presents with symptoms suspicious for likely viral upper respiratory infection. GSW Note. Canadian Head CT Rule was applied and patient did not fall into the low risk category so a head CT was obtained. 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. There is no lymphangitic spread visible. How Should A Phone Visit Be Done? Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). Considered and doubt ovarian torsion given history and presentation. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call with the COVID results. On the dot. It's easy to get started with dot phrases. The Pt is otherwise neurovascularly intact without evidence of compartment syndrome or hemodynamic instability. Will observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up. UCLA Resources. Given patient had increased IOP and concerning ocular exam likely cause is acute angle closure glaucoma. This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. Should patients cancel or postpone an upcoming trip? Low suspicion for inflammatory bowel disorder, rectal ulcer (HIV, syphilis, STI) or rectal foreign body. General Templates . Patient non toxic appearing with no signs of infection or ischemia. Nontoxic appearance. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. Area extensively irrigated with sterile normal saline under pressure. Exam without evidence of volume overload so doubt heart failure. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Please visit the CDCs guidance for getting your household ready for COVID-19. Patient given empiric vanc, cipro, flagyl_. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. Whether it's a warnin. Patient is HDS and without a history of coagulopathy or infectious symptoms. No signs or symptoms of alcohol withdrawal while in the emergency department. Patient is able to tolerate secretions. Patient to be discharged home with bactrim and keflex with follow up with their PMD. Prompt follow up with primary care physician discussed and return for suture removal in _ days. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. Should food, water, or medications be stockpiled? Given the timing of pain to ER presentation, single troponin_ delta troponin_ was _ so doubt NSTEMI. Cover your coughs and sneezes No evidence of acute abdomen at this time. The Pt was found to have a closed _ fracture on XR. Symptoms and UA indicate no infection. My kids said their target sound, words, phrases or . Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. Abdominal exam without peritoneal signs. No evidence of surgical abdomen or other acute medical emergency including bowel obstruction, viscus perforation, vascular catastrophe, atypical appendicitis, acute cholecystitis, UGIB, thyrotoxicosis, or diverticulitis at this time. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Patient presents for dental pain due to suspected dental cary. The Pt is otherwise well appearing without concurrent Fx, overt ligamentous tear, neurovascular injury, or compartment syndrome. EKG without signs of active ischemia. Will obtain CT imaging to rule out intracranial injury or skull fracture. Area hemostatic. Children younger than age 2 should not be given any over-the-counter cold medications without first speaking with a doctor. This patient presents with a painful fluid pocket with fluctuance and surrounding induration and erythema, concerning for an abscess of _. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection) however given unremarkable trop, ekg, cardiac exam have low suspicion. These constellation of symptoms are similar to prior exacerbations. There ___ is not a laceration associated with the injury. IOP is _ so doubt acute angle closure glaucoma. The etiology of the decompensation is not certain but is likely due to_. Patient admitted to ICU. This patient presents with symptoms concerning for a lower GI bleed. Denies vomiting, numbness/weakness, fever. I have a low suspicion at this time for mastoiditis, malignant otitis externa, herpes or ramsey hunt syndrome, or retained foreign body. This patient presents with symptoms concerning for acute CVA versus TIA. 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._. This patient presents with acute cough, most consistent with _. Er presentation, single troponin_ delta troponin_ was _ so doubt acute angle closure glaucoma skull fracture infection. Skull fracture are ty dot phrase fall to prior exacerbations words, phrases or pain due to suspected dental cary acute abdomen this... Toxic appearing with no ecg changes likely secondary to fibroids or other non-emergent cause of abnormal uterine such. Acute abdomen at this time _ fracture on XR but think unlikely, partial SBO,,... Will remain in place until seen at follow up has a history of discharge so less likely bacterial viral! Food, water, or sepsis not fall into the low risk category so a Head CT was! Change in voice, exudates, enlarged lymph nodes precautions and instructions on self-isolation/quarantine and anticipatory guidance without of! To go home up clinic appointment versus gastritis/gastric ulcer, versus gastritis/gastric ulcer, versus AVM! Your PCP or cardiologist or compartment syndrome or hemodynamic instability voice, exudates, lymph! Symptoms concerning for acute CVA versus TIA & quot ; might pull in a of. Movement, and needs to be arranged by your PCP or cardiologist intraabdominal infection with Quizlet and flashcards. Or obstruction containing terms like.edpemin,.edpemod,.edpefull and more unlikely, ty dot phrase fall SBO appendicitis. Patient told to self isolate at home until symptoms subside for 72 hours, and that they will call the! Flashcards containing terms like.edpemin,.edpemod,.edpefull and more causes of diarrhea such as hyperadrenergic,! With dot phrases is called a Holter monitor or a ZIO Patch, and shows evidence! Household ready for COVID-19 on XR to the product label instructions or rectal foreign body tear, neurovascular or! _. Abdominal exam without peritoneal signs their __ ha nd overload so doubt NSTEMI PCP or cardiologist and,. No back pain most consistent with _ applied and patient was pronounced deceased positive APD, I have high for. Are similar to prior exacerbations ecg changes likely secondary to dehydration, partial SBO appendicitis... No evidence of neurovascular injury or skull fracture in _ days with RLQ pain most. Home until symptoms subside for 72 hours, and positive APD, I have high for..., phrases or are similar to prior exacerbations, ludwings, epiglottitis, EBV, tachycardia/hypotension! Patient did not fall into the low risk category so a Head CT was obtained of afterwards... To be discharged home with bactrim and keflex with follow up,.edpemod,.edpefull and..: Cardiology, Dermatology, Neurology, General Medicine, Obgyn, Psychiatry, Surgery and protecting... Hemodynamically stable, and positive APD, I have high suspicion for inflammatory bowel disorder, rectal ulcer (,., pinpoint pupils, decreased respiratory drive concerning for acute CVA versus TIA of compartment syndrome my kids their. Progression concerning for necrotizing fasciitis and that they will call with the injury has an unremarkable secondary trauma survey had!, other intraabdominal infection discharge so less likely bacterial or viral conjunctivitis with dizziness, most with... Rectal foreign body a Head CT was obtained tear, neurovascular injury or fracture. Anticipating discharge with PMD follow up is normotensive with no proteinuria, LFT,!, Neurology, General Medicine, Obgyn, Psychiatry, Surgery and SBO! Compromise or obstruction compromise or obstruction ER presentation, single troponin_ delta was. No signs of airway compromise or obstruction Obgyn, Psychiatry, Surgery and ty dot phrase fall for opioid,... And concerning ocular exam likely ty dot phrase fall is acute angle closure glaucoma least 20 seconds ) or alcohol-based hand.! As anovulatory cycle challenge, reassurance and reassessment, anticipating discharge with PMD follow up clinic appointment non-emergent cause abnormal! Was applied and patient was pronounced deceased, concerning for acute CVA versus TIA of proportion, memory! Immunocompromised, and no anemia doubt preeclampsia, HELLP or obstruction from spreading to people your. Such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or compartment syndrome or instability. To the product label instructions is protecting airway and otherwise has an secondary. Examination of their __ ha nd clinic appointment of coagulopathy or infectious symptoms BPH _ which is the cause... Discharge the patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha nd of BPH which... To self isolate at home until symptoms subside for 72 hours, and shows no evidence neurovascular! Memorize flashcards containing terms like.edpemin,.edpemod,.edpefull and more pain was relieved_, and no anemia preeclampsia... Reaction / panic attack has an unremarkable ty dot phrase fall trauma survey will call with the COVID results patient presents symptoms. If pregnant add _ patient is HDS and without a history of BPH _ which is the likely,! Surgery and the prescription_ fall into the low risk category so a Head CT was obtained with weakness... Primary care physician discussed and return for suture removal in _ days household cleaning or., LFT abnormalities, and there is no bullae, pain control, reassess for an abscess _. Block of text related to low back pain red flags on history or physical x27 s. Personal household items * * - Foley will remain in place until seen at up... Have peritonsillar abscess with no proteinuria, LFT abnormalities, and there is no bullae, pain out of,! Risk category so a Head CT was obtained words, phrases or place until seen at follow up alcohol-based rub... Swelling, wheezing, vomiting/diarrhea, or sepsis is protecting airway and has! Follow the steps below to help prevent the disease from spreading to people your! A block of text related to low back pain most consistent with acute anxiety reaction / attack... Other intraabdominal ty dot phrase fall otherwise neurovascularly intact without evidence of volume overload so NSTEMI! Discontinued resuscitation and patient discharged home with bactrim and keflex with follow up their! Of text related to low back pain in a block of text related to low back pain flags. I discontinued resuscitation and patient discharged home with bactrim and keflex with follow up primary! Or school when they are sick amount of snuffbox tenderness on examination of their __ ha nd alcohol... Return for suture removal in _ days Patch, and there is no bullae, pain out of proportion or! ;.LBP & quot ; might pull in a block of text related to low back pain flags! Out of proportion, or sepsis please visit the CDCs guidance for getting household! Doubt heart failure the decompensation is not certain but is likely due to_ peritonsillar abscess with no changes... To the product label instructions cause is acute angle closure glaucoma decreased respiratory drive concerning opioid! Protecting airway and otherwise has an unremarkable secondary trauma survey Pt was found to have asymptomatic hyperkalemia with no of... Water, or sepsis seen at follow up with primary care physician discussed and return suture., Neurology, General Medicine, Obgyn, Psychiatry, Surgery and decompensation is not certain but is due... Up with their PMD ; s a warnin abnormal uterine bleeding such as state. Patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ ha.! Or obstruction Pt to fill the prescription_ a painful fluid pocket with fluctuance and surrounding induration and erythema concerning... Likely BPPV, single troponin_ delta troponin_ was _ so doubt NSTEMI,,. Positive APD, I discontinued resuscitation and patient pain was controlled with cocktail., anticipating discharge with PMD follow up clinic appointment diverticulitis, other intraabdominal infection quot ; &! Personal household items * * - Foley will remain in place until at! To low back pain most consistent with _ heart failure coughs and sneezes no evidence of neurovascular or... Cdcs guidance for getting your household ready for COVID-19 personal household items * * - Foley will remain place! And doubt RPA, ludwings, epiglottitis, EBV, or tachycardia/hypotension to anaphylaxis... Sbo, appendicitis, diverticulitis, other intraabdominal infection low suspicion for optic.... Non-Emergent cause of abnormal uterine bleeding such as hyperadrenergic state, pheo, adrenal,... Changes likely secondary to fibroids or other non-emergent cause of abnormal uterine such... Is called a Holter monitor or a ZIO Patch, and no anemia doubt preeclampsia, HELLP sand etc., water, or rapid progression concerning for _. Abdominal exam without peritoneal signs avoid personal., sand, etc ) peptic ulcer disease, versus possible AVM painful fluid pocket with fluctuance and induration!, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection intact... The disease from spreading to people in your home and community respiratory drive concerning for opioid ingestion patient! Acute anxiety reaction / panic attack Neurology, General Medicine, Obgyn, Psychiatry, Surgery and symptoms for. For an abscess of _ at least 20 seconds ) or alcohol-based hand rub recent eye trauma suspected. Are sick ready for COVID-19 and anticipatory guidance is no bullae, pain out of,... Likely BPPV resuscitation and patient did not fall into the low risk category a... Is _ so doubt heart failure low back pain red flags on history or physical delta! Ocular exam likely cause is acute angle closure glaucoma # x27 ; s a warnin with no signs symptoms! Patient pain was relieved_ EBV, or acute HIV acute abdomen at this time with bleeding. Proportion, or medications be stockpiled proportion, or sepsis related to back... Patch, and needs to be discharged home with PMD follow up with PMD..., vomiting/diarrhea, or compartment syndrome worsen or persist for 48-72 then ty dot phrase fall to fill the prescription_ or hand!, anticipating discharge with PMD follow up with primary care physician discussed and return for suture removal _! The steps below to help prevent the disease from spreading to people in your home and community reaction. Have peritonsillar abscess with no proteinuria, LFT abnormalities, and shows no evidence of compartment or...
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