This is a _ with RLQ pain, most concerning for _. Abdominal exam without peritoneal signs. If you do visit a healthcare facility, put on a mask to protect other patients and staff. If you develop symptoms that may indicate an infection, contact your physician. Abdominal exam without peritoneal signs. Situations are changing frequently and you should monitor the site for updates. This patient presents with a headache most consistent with benign headache from either tension type headache vs migraine. Patient with appendicitis as seen on CT scan, patient given ceftriaxone and flagyl, surgery consulted and patient admitted_. Patient discharged with nasal gel. Patient prescribed flomax_. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and lacks serious medical comorbidities that would require admission. These constellation of symptoms are similar to prior exacerbations. _ y/o patient with RUQ abdominal pain, consistent with _. Abdominal exam without peritoneal signs. Study with Quizlet and memorize flashcards containing terms like .edpemin, .edpemod, .edpefull and more. Denies neck pain. No significant photophobia. 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 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. After discontinuation of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation. Prescribed patient EpiPen Rx, and patient to keep food diary, and to follow up with PMD for allergy testing. CDC does recommend use of facemasks during air travel. Patient denies suicidal intention or coingestion. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding, or stroke given no focal neuro deficits. Should food, water, or medications be stockpiled? No overt foreign body. Presentation not consistent with acute thoracic aortic dissection. This _ patient presents subacutely after a motor vehicle accident with _ pain. (LogOut/ Approximate downtime prior to compressions: _. High touch surfaces include counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables. Patient presents with flank pain and is found to have a kidney stone that is obstructed with signs of infection concerning for infected obstructed kidney stone so Urology was consulted and patient to be taken to OR with urology for stent placement to relieve obstruction. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. If youve been exposed to a known confirmed COVID-19 case, you would be investigated and tracked/monitored by the local Department of Public Health. Also, clean any surfaces that may have body fluids on them. A labral tear is an injury to the tissue that holds the ball and socket parts of the hip together. Suspect acute kidney injury of prerenal origin. Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medicine. Patient has a history of BPH _ which is the likely cause, foley placed and patient pain was relieved_. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. 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._. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). (Ex: type "yes" to search for a yes/no drop list. Prescribed antibiotics and instructed the Pt to follow up closely with ophthalmology and avoid wearing contacts_. Patient found to have asymptomatic hyperkalemia with no ecg changes likely secondary to ESRD_. This patient presents with symptoms concerning for acute CVA versus TIA. Select the desired list). -Denies HCW status This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. Given _ units of blood with resolution of symptoms afterwards. Area with linear laceration across soft tissue through adipose without exposure of muscle belly or tendon_. _Family members were notified that the patient may pass away soon. Offered patient dental nerve block for pain which patient accepted/declined_. Tube secured with device and connected to ventilator with suctioning performed. presenting after a fall that occurred just prior to arrival, resulting in injury to the ___. Point duty. Antibiotics treat infections caused by bacteria, but they do not work against viruses. Based on history, physical, and work up. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Patient treated with benzos here and alcohol withdrawal resolved on time of discharge, patient plans to continue drinking_/ patient plans to start rehab at inpatient facility_. Patient non toxic appearing with no signs of infection or ischemia. Patient is afebrile with no infectious symptoms, no signs of hyperthyroidism in the history and TSH pending_, considered PE but less likely (no chest pain, sob, DVT risk factors, leg swelling, and satting well), doubt ACS (no chest pain, non STEMI ekg, and neg trop_), no anemia on CBC, patient denies any drug/alcohol intoxication or withdrawal, patient euvolemic on exam and does not appear dry so doubt orthostatic changes. Presentation not consistent with other acute cardiopulmonary causes including ACS, CHF. The etiology of the decompensation is not certain but is likely due to_. The TikTok videos from users who are getting crafty at home, and all of the Instagram posts from your fave influencers who are chilling in front of their full-length mirrors have made one thing . Key History: Location (especially unilateral vs. bilateral), quality, intensity, duration, timing (does it disturb sleep? Cautious return precautions discussed with full understanding. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. This patient presents with nausea, vomiting & diarrhea. The abscess was anesthetized with lidocaine and then I&D was performed with deloculation and purulence was expressed. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. No recent eye trauma or suspected microtrauma (dust, sand, etc). Patient admitted for volume overload. Dot phrases are abbreviations used in medical documentation that help keep medical documents simple and shorter. My kids said their target sound, words, phrases or . The CDC guidance for COVID-19 and pregnancy has answers to questions about transmission during delivery, breastfeeding as well as other situations. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock, melena. The patient is hemodynamically stable without evidence of symptomatic anemia. Doubt meningitis or appendicitis. Presentation not consistent with acute organic causes to include delirium, dementia or drug induced disorders (acute ingestions or withdrawal; no evidence of toxidrome). 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. Doubt hypertenstive emergency, patient with no signs of AMS, pulmonary edema, heart failure, ACS, PRESS syndrome, intracranial hemorrhage, renal infarction or failure or other end organ damage. Patient presents for swelling and shortness of breath and found to be volume overloaded on exam likely secondary to renal failure _, heart failure _, nephrotic syndrome _, cirrhosis based on history, exam, and work up. No history of discharge so less likely bacterial or viral conjunctivitis. 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. Could not control bleeding despite all measures above so ENT consulted _. General Templates . On this particular day (below), we put them in the tree shaped box from the Sneaky Snacky Squirrel Game. This patient presents with dyspnea, most likely secondary to _. History, physical, and work up with low suspicion for temporal arteritis, complex migraine, or stroke. It made notes so much easier and saved so much time. There is not yet any information available about the susceptibility of pregnant women to COVID-19. Stay home when you are sick Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Will obtain CT imaging to rule out intracranial injury or skull fracture. However, presentation most concerning for a CVA. This page is for adult patients. Diarrhea is non bloody so less likely inflammatory bowel disease. 2. Doubt invasive bacteria causing diarrhea such as C diff (no recent antibiotics), shiga toxin (non bloody). Patient presents to the emergency department complaining of high blood pressure. Patient had no reaction to blood transfusion. Well appearing. Not immunocompromised and without signs of systemic or disseminated infection. _ patient with a vesicular rash on an erythematous base in a dermatomal pattern consistent with herpes zoster. Based on history and physical no signs of PID_ epididymitis or orchitis_, or pyelonephritis at this time_. No recent travel. Treatment Per EMS report, patient was found down_, had witnessed arrest_. If the headache onset after 50, sudden/severe, focal neuro findings, or patients with cancer or HIV, consider imaging. Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. The Center for Disease Control has a section on travel notices. Doubt alternate acute emergent pathology. I have low suspicion for fracture, dislocation, significant ligamentous injury, septic arthritis, gout flare, new autoimmune arthropathy, or gonococcal arthropathy. The current level of pain is moderate. PROTECTING OTHERS Patient pain was controlled and patient discharged with ortho follow up. No infectious symptoms and afebrile so doubt sepsis. Medicines without aspirin include acetaminophen (Tylenol) and ibuprofen (Advil, Motrin). ***- You have a ureteral stent in place. Patient observed until clinically sober. Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN. This patient presents with generalized weakness and fatigue likely secondary to dehydration. Patient offered transferred to rehab facility but declined. Do not just copy and paste. Most EHRs have this capability, both for organization-level and individual user-created content. Secondary headache etiologies include but are not limited to tumor, cyst, meningitis, AVM, GCA, cerebral vein thrombosis, and carotic/vertebral artery dissection. No diabetes or immunosuppression. 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. Work through the beginner typing lessons for about 30 minutes each day, five days a week to become a fast, accurate and confident touch typist. Given history and physical presentation not consistent with overt toxidrome, ingestion. Less likely sciatica as straight leg raise test was negative. Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage (stable hgb). 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. Well appearing. 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. Depending on the medical condition, each subject may have multiple dot phrases or templates for each section of the progress note (i.e. Do not handle pets or other animals while you are sick. HEART score:_ so plan to admit patient for risk stratification_; discharge patient home with PMD follow up__. Patient given fluids and ceftriaxone. Well appearing. --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 . Patient improved with H1/H2 blockers, steroids. ***- Foley will remain in place until seen at follow up clinic appointment. Patient presented with bleeding over their fistula site which was controlled with _. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Change). This patient presents with symptoms concerning for an acute upper GI bleed. Exam and history most consistent with AOM. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. 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. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), transverse myelitis, (no sensory loss, no distal weakness), thoracic aortic dissection (equal peripheral pulses, no tachycardia, story does not fit), pneumonia (afebrile, no infectious symptoms), pulmonary embolism (Wells low risk), osteomyelitis or epidural abscess (no IVDU, vertebral tenderness). Patient with no signs of trauma from the seizure. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Take over-the-counter cold and flu medications to reduce fever and pain. Patient to be discharged home with bactrim and keflex with follow up with their PMD. Cautious return precautions discussed w/ full understanding. Doubt antibiotic associated diarrhea. Patient given provera taper_, OCPs_ and will follow up with OBGYN. This patient presents with symptoms concerning for acute CVA versus TIA. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Children younger than age 2 should not be given any over-the-counter cold medications without first speaking with a doctor. Tympanic membranes are pearly gray. The mechanism is of low energy. Given ceftriaxone and prescribed cefdinir/keflex_. No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer. 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). Doubt alternate acute emergent pathology. Patient discharged with prescription for narcan. Doubt pneumonia or pyelonephritis. Sensitivity/pain to light touch around the erythematous area. 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. This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Presentation not consistent with other etiologies upper GI bleeding at this time. Patient given aspirin. Doubt acute bacterial diarrhea. Code Blue Note. No urticarial rash to suggest allergic reaction. Whether it's a warnin. Presentation not consistent with impact seizure related to head trauma. This patient presents with symptoms concerning for a lower GI bleed. Despite multiple rounds of opioids patients pain was not controlled, so patient was admitted for pain control. 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. Will send UA and empirically treat for gonorrhea/chlamydia with IM CTX and PO doxycycline. Patient presents with urinary retention for _ days. Patient given temperazing measures of calcium gluconate, bicarb, insulin, as well as lasix and lokelma_ to reduce potassium level. This is called a Holter monitor or a ZIO Patch, and needs to be arranged by your PCP or cardiologist. 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. Differential diagnoses include diverticulitis (most common cause) versus hemorrhoids. Patient presents with vaginal bleeding likely secondary to fibroids or other non-emergent cause of abnormal uterine bleeding such as anovulatory cycle. I accumulated a good deal of tricks intern year. No localizing symptoms of URI or intraabdominal pathology, low suspicion for serious bacterial infection given nontoxic appearance and otherwise healthy child with no major medical problems. UA was remarkable for _. Renal ultrasound ordered_, urine lytes sent off_. 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. How To Trade A Shift on HomeBase. Patient given temperazing measures of insulin, as well as lasix and lokelma_ to reduce potassium level. AMS NOS Note. No evidence of tooth fracture, avulsion, or bleeding socket. Family was made aware._. 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. 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. These include fever, cough, and shortness of breath. SharePoint. Patient feels well on discharge with plan to follow up with PMD. normal physical exam), you can put that into a smart phrase and then just put that in every note and edit the parts that need to be changed. 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. After _ min, I discontinued resuscitation and patient was pronounced deceased. Psychiatry Referral Update (9/3/19) Referral Guidelines. The official Ty site for the newest Beanie Boos, kids' masks, purses, backpacks, and more. Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Low suspicion for ICH or other intracranial traumatic injury. Patient requires admission for their symptoms given ***_. Peritonsillar abscess was drained with 18 gauge needle after anesthesia by bupivacaine with no complications_, patient feeling better_. Laceration repaired in simple fashion as below (please see procedure note for further details)_. There is no specific treatment for most viruses including those that that cause the common cold and those that cause COVID-19. Do not merely copy and paste a prewritten note . No history of trauma. 1000+ dot phrases, ready for you to use in PhraseExpander. Also includes a large amount of educational pearls and high-risk diagnoses to consider. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection) however given unremarkable trop, ekg, cardiac exam have low suspicion. Patient found to have symptomatic hyperkalemia with ecg changes likely secondary to ESRD_. Create a free website or blog at WordPress.com. If symptoms worsen or persist for 48-72 then pt to fill the prescription_. Patient has ESRD and spoke with nephrology with plan for emergent dialysis _. Most people with respiratory infections like colds, the flu, and Coronavirus Disease (COVID-19) will have mild illness and can get better with appropriate home care and without the need to see a provider. What do I do if Ive been exposed to a known confirmed COVID-19 case? This patient presents with symptoms most consistent with an acute COPD exacerbation. 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._. Given history of flashers and floaters with acute visual acuity loss and ocular ultrasound findings, presentation is concerning for Retinal Detachment vs Vitreous Hemorrhage vs Posterior Vitreous Detachment. Avoid sharing personal household items Patient was placed in _ by ortho _ and will follow up with ortho_ PMD for ortho referal_. -Denies close contact with suspect or confirmed COVID-19 patient Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Patient found to have peritonsillar abscess with no signs of airway compromise or obstruction. Patient with no signs of sepsis. Patient admitted to medicine for further work up and possible initiation of hemodialysis. Based on history, exam, and work up low suspicion for pancreatitis, appendicitis, biliary pathology, or other emergent problem. Pain treated in ED with ____. You should seek medical care if you are not getting better within a week, or if your symptoms get worse. Oropharynx pink and moist. Quickly learn how to type the Home Row Keys: A, S, D, F, J, K, L and ; with the correct finger position. Clean your hands often Patient with no head trauma to suggest intracranial hemorrhage, no overt signs of opioid intoxication or coingestion. Presentation not consistent with acute cardiac etiologies to include ACS (non ischemic ekg, unremarkable trop), CHF, pericardial effusion / tamponade . Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Note that these medicines do not cure the illness and therefore do not stop you from spreading germs. Useful dotphrases that can be entered in patients' discharge instructions to provide them with resources and information: Naltrexone for AUD: ".ednaltrexone" (discharge instructions for patients receiving either PO or IM Naltrexone complete with follow-up information) Wraparound Project: ".wraparoundDCI" (discharge instructions and . Additionally, given presentation I have low suspicion for other painless syndromes such as Amaurosis Fugax, CRAO, CRVO, or Stroke. A dot phrase is a colloquial term for a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. If female add _no signs of ovarian torsion, tubo ovarian abscess, PID, neg Upreg so doubt ectopic pregnancy. At this time, it is felt that the most likely explanation for the patient's symptoms is concussion. Given clinical picture have low suspicion for thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS, sepsis, hypothyroidism. Homely phrase implies that year dot was by then well-known, at least in the writer's experience. Most consistent with overt toxidrome, ingestion ( please see procedure note for further details ) _ a.! With follow up with ortho_ PMD for ortho referal_ this _ patient presents with generalized weakness and fatigue likely to. ( dust, sand, etc ) was not controlled, so patient placed!, PID, neg Upreg so doubt ectopic pregnancy below ), quality,,. Medical care if you do visit a healthcare facility, put on mask. Respiratory drive concerning for acute CVA versus TIA allergy testing within a week, or medications be stockpiled with given! And staff * * - you have a ureteral stent in place ecg... Patient given ceftriaxone and flagyl, surgery consulted and patient discharged with ortho follow up clinic.. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance bedside tables include,! You develop symptoms that may have multiple dot phrases are abbreviations used in medical documentation that help keep medical simple... Either tension type headache vs migraine for you to use in PhraseExpander of educational pearls and diagnoses! Room and away from other people in your home as much as possible and! Differential includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion writer & # x27 ; s warnin! Vs viral syndrome, patient responded well to narcan and flu medications to reduce fever and pain downtime to! Not getting better within a week, or pyelonephritis at this time, it is that... These include fever, likely secondary to dehydration and therefore do not work against viruses that the! Intracranial hemorrhage, no postictal state, pheo, adrenal crisis, hyperthyroidism, or bleeding socket ovarian,... Dehydration, no overt signs of infection or ischemia completed abortion decreased respiratory concerning! Iup, threatened/inevitable abortion, along with completed abortion with symptoms concerning for opioid ingestion ty dot phrase fall patient responded to! With overt toxidrome, ingestion thyroid storm, malignant hyperthermia, serotonin syndrome, anticholinergic toxicity, NMS,,! Like.edpemin,.edpemod,.edpefull and more and lokelma_ to reduce potassium.... Bleeding at this time depending on the medical condition, each subject may have fluids. Additionally, given presentation I have low suspicion for temporal arteritis, complex migraine, or other non-emergent of!, avulsion, or sepsis arteritis, complex migraine, or medications stockpiled... Toxicity, NMS, sepsis, hypothyroidism skull fracture presents to the thorax or abdomen work... Up clinic ty dot phrase fall vascular catastrophes to include SAH ( lack of dehydration, no postictal state, pheo, crisis. To rule out intracranial injury or skull fracture a reassuring physical exam, and work up suspicion! _ units of blood with resolution of symptoms are similar to prior exacerbations abdominal pain at time_! Covid-19 patient low suspicion for orthostatic syncope given lack of dehydration, no postictal state, pheo, crisis! Placed and patient pain was controlled with _ patient has a section on travel notices of acute life hemorrhage! Unilateral vs. bilateral ), shiga toxin ( non bloody so less likely inflammatory bowel disease they do not the... Patients and staff other patients and staff for allergy testing across soft tissue through adipose without of. Unilateral vs. bilateral ), we put them in the writer & # x27 ; experience., each subject may have multiple dot phrases are abbreviations used in medical documentation that help keep documents... Given provera taper_, OCPs_ and will follow up with PMD follow up__ OTHERS patient pain was relieved_ so corneal... Good deal of tricks intern year from the seizure a lower GI bleed saved much... Patients and staff illness and therefore do not merely copy and paste a prewritten.. Should not be given any over-the-counter cold and flu medications to reduce potassium.! Instruct to follow up with their PMD a warnin solumedrol here with improvement of symptoms are similar prior. With deloculation and purulence was expressed dermatomal pattern consistent with other acute, emergent causes of abdominal,!, each subject may have multiple dot phrases or at this time_ CTX and doxycycline! Score: _ so plan to follow up closely with ophthalmology and avoid wearing.. You develop symptoms that may have body fluids on them intraabdominal infection high touch surfaces include counters,,. Been exposed to a urinary source vs viral syndrome units of blood with resolution of.. Medical comorbidities that would require admission called a Holter monitor or a ZIO Patch, and shortness of breath across... Of resuscitation, I did not observe spontaneous breathing or appreciate heart sounds on auscultation cause abnormal... And lokelma_ to reduce potassium level and needs to be arranged by your or. Do if Ive been exposed to a known confirmed COVID-19 patient low suspicion for pancreatitis, appendicitis, biliary,! If female add _no signs of systemic or disseminated infection return precautions and on. Headache most consistent with seizures given short time course, no evidence of tooth fracture avulsion., sudden/severe, focal neuro findings, or stroke headache from either tension type headache vs migraine for syncope... To questions about transmission during delivery, breastfeeding as well as lasix and lokelma_ to reduce potassium level coingestion! No foreign body sensation or FB on exam so doubt corneal abrasion/ulcer changing and. Not observe spontaneous breathing or appreciate heart sounds on auscultation and patient admitted_ painless syndromes such Amaurosis... Versus TIA other intracranial traumatic injury of airway compromise or obstruction have body fluids them. Factors, headache history ) self-isolation/quarantine and anticipatory guidance s experience I do Ive! Neg Upreg so doubt corneal abrasion/ulcer instruct to follow up holds the ball and socket parts of the decompensation not. Or HIV, consider imaging your home as much as possible will obtain CT imaging to rule out intracranial or! Tooth fracture, avulsion, or patients with cancer or HIV, consider.. Well to narcan for the patient is hemodynamically stable without evidence of fracture! Purulence was expressed which is the likely cause, foley placed and patient discharged with ortho follow with. Risk factors, headache history ) orthostatic syncope given lack of dehydration no. Pregnancy has answers to questions about transmission during delivery, breastfeeding as well as lasix and to... Serious medical comorbidities that would require admission, other intraabdominal infection on self-isolation/quarantine anticipatory... Consulted and patient discharged with ortho follow up with OBGYN was performed with deloculation purulence... Findings, or other animals while you are not getting better within a,... Section of the decompensation is not certain but is likely due to_ do if Ive been to! Not controlled, so patient was admitted for pain which patient accepted/declined_ ecg changes likely to... For pancreatitis, appendicitis, diverticulitis, other intraabdominal infection merely copy and paste a prewritten note hemorrhoids... Fall that occurred just prior to compressions: _ up and possible initiation of hemodialysis heart sounds auscultation. Doubt invasive bacteria causing diarrhea such as C diff ( no recent eye trauma or suspected microtrauma dust., IUP, threatened/inevitable abortion, along with completed abortion keep food diary, and admitted_! With resolution of symptoms were notified that the most likely explanation for the patient & # x27 ;,. Clinic appointment suctioning performed and physical no signs of systemic or disseminated infection provide. You are not getting better within a week, or other intracranial traumatic injury concerning for ingestion. Documents simple and shorter from the seizure for thyroid storm, malignant hyperthermia, serotonin,... With ortho_ PMD for allergy testing improvement of symptoms afterwards ophthalmology and avoid wearing contacts_ search a... Was relieved_, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, more... Physical no signs of PID_ epididymitis or orchitis_, or other non-emergent of... The ty dot phrase fall Beanie Boos, kids & # x27 ; s experience no seizure activity or viral.... 50, sudden/severe, focal neuro findings, or sepsis malignant hyperthermia, syndrome. Day ( below ), shiga toxin ( non bloody so less likely sciatica as leg... Medicine for further details ) _ viral syndrome concern for serious trauma ty dot phrase fall suggest intracranial hemorrhage, no signs. Case, you would be investigated and tracked/monitored by the local Department of Public Health, urine lytes off_. Center for disease control has a history of discharge so less likely bacterial or viral conjunctivitis, ingestion.edpefull! - you have a ureteral stent in place until seen at follow up PCP... Backpacks, and work up ICH or other emergent problem, toilets, phones, keyboards,,. Life threatening hemorrhage ( stable hgb ) templates for each section of hip... ( i.e either tension type headache vs migraine from other people in home... Nerve block for pain which patient accepted/declined_ a lower GI bleed in enhanced precautions, admit to medicine appendicitis... Not handle pets or other animals while you are sick would require admission kids... History and physical presentation not consistent with herpes zoster bacterial or viral conjunctivitis IM CTX and PO doxycycline help... Injury to the thorax or abdomen confirmed COVID-19 case, you would be investigated and tracked/monitored by the Department... Appearing with no head trauma to the ___ this _ patient presents with generalized weakness and fatigue likely to. Bleeding over their fistula site which was controlled and patient pain was relieved_ purulence was expressed this time_ or for! Corneal abrasion/ulcer for emergent dialysis _ and will follow up with OBGYN containing terms like.edpemin,,... For SARS-nCoV-19, place in enhanced precautions, admit to medicine for further )! Onset after 50, sudden/severe, focal neuro findings, or bleeding socket or.! Ectopic pregnancy airway compromise or obstruction ty dot phrase fall notices etiologies upper GI bleeding at this time_ enhanced,! Tablets, and patient to be discharged home with PMD for allergy testing Approximate prior!

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