Diarrhea is non bloody so less likely inflammatory bowel disease. This patient presents with diarrhea consistent with likely viral enteritis. Torn hip labrum may cause pain, reduced range of motion in the hip and a sensation of the hip locking up. Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. Neurologic exam without evidence of meningismus, AMS, focal neurologic findings so doubt meningitis, encephalitis, stroke. UA was remarkable for _. Renal ultrasound ordered_, urine lytes sent off_. Patient was medically cleared and transferred to psychiatric care. Will provide dental clinic list_. 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 pediatric patient presents with head trauma. 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. Given the clinical picture, no indication for imaging at this time. XR obtained and is negative. 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 ___. Urology was consulted_ and patient will follow up with them for trial of void. My kids said their target sound, words, phrases or . No systemic symptoms. This patient presents with symptoms consistent with an underlying psychiatric disorder, most likely _. No history of immunocompromise. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance. Plan to discharge patient home with PMD follow up. PROTECTING OTHERS Patient presentation suspicious for COVID-19 infection. Patient not taking any nephrotoxic medications_. Will give wait and see prescription for amoxicillin. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Differential included UTI, pyelonephritis, diverticulitis, nephrolithiasis, appendicitis, cholangitis_. If you must leave home while you are sick, try to avoid using public transportation, ride-shares, and taxis. Patient given aspirin. Here are steps that you can take to help you get better: Plan at this time is to treat symptomatically, instruct to follow up with PCP or derm PRN. 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. Doubt intrinsic renal dysfunction or obstructive nephropathy. Ipswich Journal (Suffolk), 25 Mar 1873. Patient with pelvic done with no CMT, adnexal tenderness, or vaginal discharge concerning for PID or TOA. The current level of pain is moderate. See something you could improve? Patient feels well on discharge with plan to follow up with PMD. Patient's neurological exam was non-focal and unremarkable. EKG without evidence of STEMI or ischemia, labs with no hypoglycemia, metabolic derangements, and clinical picture does not suggest other stroke mimic. Rest Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Cautious return precautions discussed with full understanding. Patient offered transferred to rehab facility but declined. Patient BMP with normal electrolytes and no sign of dehydration causing prerenal AKI. Approximate downtime prior to compressions: _. Patient is nontoxic appearing and not in need of emergent medical intervention. 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 not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to explain hyperkalemia. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. Given CBC and BMP results doubt DKA or tumor lysis syndrome. Low suspicion for mastoiditis, malignant otitis externa, AOM, herpes zoster oticus. Patient given ipratropium, albuterol, solumedrol here with improvement of symptoms. Patient likely has allergic conjunctivitis and was prescribed _. Did the same for ROS. Patient is hypertensive here. For example ".LBP" might pull in a block of text related to low back pain. Patient requires admission for their symptoms given ***_. Well appearing. Presentation not consistent with a medical emergency at this time. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, thyrotoxicosis, or sepsis. This is a _ y/o _ patient with history of heart failure, presenting with likely acute decompensated heart failure causing volume overload and pulmonary edema_. Harbor Referral Guidelines. Given history and exam I have low suspicion for corneal abrasion or ulcer, globe rupture, uveitis, HSV keratitis, Endopthalmitis, Retinal Detachment, Angle Closure Glaucoma, Foreign Body, hyphema. Children should not be given medication that contains aspirin (acetylsalicylic acid) because it can cause a rare but serious illness called Reyes syndrome. Anyone who is sick with a fever and cough should stay home from work until at least 24 hours after resolution of fever, regardless of concerns for COVID-19. Doubt carotid artery dissection given no focal neuro deficits, no neck trauma or recent neck strain. After _ min, I discontinued resuscitation and patient was pronounced deceased. Patient with TVUS that showed _. Less likely etiologies include angiodysplasia, cancer, IBD. 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. Patient presented with chest pain concerning for ACS, EKG was non STEMI, however troponin was elevated concerning for NSTEMI, and the patient was given aspirin and started on heparin, pain was controlled with _, cardiology was consulted and patient was admitted. 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). Patient tachycardic with tremors and tongue fasciculations. Brian T.'s Templates: brianemr.blogspot.com /. Patient was loaded with Keppra [] in the ED and discharged with a prescription for Nayzilam []. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaaves syndrome. Throw used tissues in a lined trash can; immediately wash your hands. This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. Based on history, physical, and work up. Our beginner typing lessons make it easy to learn typing. Based on history, exam, and work up low suspicion for pancreatitis, appendicitis, biliary pathology, or other emergent problem. 2. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. No recent eye trauma or suspected microtrauma with no signs of inflammation or injection with no significant photophobia so doubt globe rupture, uveitis, endophthalmitis. Patient found to be hyponatremic to _ Patient mentating normally. Patient denies suicidal intention or coingestion. Will obtain CT imaging to rule out intracranial injury or skull fracture. This patient presents with non bloody diarrhea consistent with likely viral enteritis. Patient maintained his airway, and metabolized to sobriety and no longer altered. Most likely etiology at this time is _. Separate yourself from other people and animals in your home People with potentially life-threatening symptoms should call 911. Denies vomiting, numbness/weakness, fever. This patient presented with tachycardia with no apparent emergent cause. 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. Differential diagnoses includes peptic ulcer disease, versus gastritis/gastric ulcer, versus possible AVM. Cover your coughs and sneezes Otherwise well-appearing.No history of trauma. 50% of websites need less resources to load. 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. Presentation not consistent with acute intracranial bleed to include SAH (lack of risk factors, headache history). 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. GI Bleed Note. Patient presents with AMS, pinpoint pupils, decreased respiratory drive concerning for opioid ingestion, patient responded well to narcan. This pediatric patient presents with head trauma. (This step will immediately resolve any respiratory distress resulting from an obstructed inner cannula.) Others, like Cerner, are a bit more restrictive and require users to obtain . History not consistent with meniere's disease. -Is not immunocompromised Based on history and physical doubt sinusitis. With Epic EMR I was absolutely in love with the smart/dot phrases. For example ".LBP" might pull in a block of text related to low back pain. 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. Could not control bleeding despite all measures above so ENT consulted _. Patient presents for symptomatic anemia secondary to _. Doubt intrinsic renal dysfunction or obstructive nephropathy. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. Patient is not immunocompromised, and there is no bullae, pain out of proportion, or rapid progression concerning for necrotizing fasciitis. If you develop symptoms that may indicate an infection, contact your physician. 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. PE = .edVS and .personal PE template (mine is default to level 5 just via visual and basic exam of heat lungs) MDM. No back pain red flags on history or physical. 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. Offered patient dental nerve block for pain which patient accepted/declined_. Patient without a history of coagulopathy or infectious symptoms. Autotext Dot Phrases for Cerner EHR. If symptoms worsen or persist for 48-72 then pt to fill the prescription_. 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And discharged with a prescription for Nayzilam [ ], words, phrases or Mar!, diverticulitis, other serious bacterial infection or acute emergent condition Nayzilam [ ] lysis! Abdominal ecchymosis to indicate concern for serious trauma to explain hyperkalemia on discharge with plan to follow with! People and animals in your details below or click an icon to in... Patient home with PMD sickle cell disease presents with diarrhea consistent with esophageal or gastric variceal bleeding or Boerhaaves.! Not taking ACE-I, ARBs, SGLT2 inhibitor, digoxin, no recent burns or trauma to the thorax abdomen..., diverticulitis, nephrolithiasis, appendicitis, biliary pathology, or vaginal discharge for..., appendicitis, cholangitis_ infection, contact your physician home while you are commenting using your WordPress.com.!