DOT PHRASES AND MACROS

.jkabdominalpain

No pulsatile abdominal mass to suggest AAA.
No Point RLQ tenderness to suggest appy.
No pain out of proportion to suggest ischemic colitis.
No reported vomiting or diarrhea.
No reported dysuria or hematuria to suggest pyelo.
No reported chest pain, pleuritic chest pain or shortness of breath.
No hematemesis/melena/hematochezia reported.
Able to tolerate PO.
Still passing gas/stools.
No reported pulmonary symptoms.
No tachypnea.
No suprapubic or CVA tenderness.
No fever/ruq pain/jaundice.

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.jkinformedrefusal
The patient was informed about the recommended procedure ******** and its benefits.
I thoroughly explained the potential risks and complications of not undergoing the procedure, including *********.
The patient demonstrated understanding of the information provided and was able to verbalize the risks and benefits.
Despite understanding the risks, the patient has elected to refuse the recommended procedure.
I discussed alternative options and the patient’s questions were addressed to their satisfaction.
The patient was advised to follow up with their primary care provider and return to the emergency department if symptoms worsen or new symptoms develop.
The patient’s decision was made voluntarily and without coercion.
Documentation of this informed refusal was completed, and the patient’s understanding and decision were acknowledged.

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.jkabdominalpaindiscussion

Gave specific abdominal pain discharge instructions to the patient. No obvious cause of patients symptoms found on workup. While this most likely means that there is no concerning pathology, there is still the chance that we could be missing something in the CT and blood work. Encouraged patient to followup with primary care doctor and return if symptoms worsen or new symptoms develop. Discussed with the patient who agrees with the workup and plan, understands return precautions and followup instructions.

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.jkdentalpain

No systemic fevers, chills, sweats. No focal neurological defects. No visual disturbance. No hearing loss/tinnitus/vertigo. No pain behind the ear. No parotid gland tenderness. No neck pain or trouble swallowing. No deviation of the tonsils to suggest peritonsillar abscess. No obvious drainable intraoral abscess. No facial rash or blisters. No woodiness or swelling underneath the tongue. No claudication when chewing. No headache.

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.jkekg

• EKG does not suggest:

• Ischemia (STE, or DeWinters T waves).

• Wellens (symetrically deeply inverted T waves in V2 and V3 or Biphasic T waves in V2, V3)

• Heart block

• ARVD (epsilon wave, large TWI, localized qrs widening of 110ms in V1-V3, paroxysmal episodes of VT, prolonged s wave upstroke in v1-v3)

• HOCM (massive TWI, dagger Qs in lateral/inferior leads)

• Arrhythmia

• WPW (delta wave)

• Long QT syndrome from drugs such as TCAs, fluconazole, Reglan, methadone, SSRIs etc

• Short QT

• Brugada (coved st elevation with TWI, saddleback STE or a small amount of STE)

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.jkfever

Lungs clear, no cough to suggest PNA.
No skin rash, cellulitis or other.
No neck pain or neck stiffness to suggest meningitis or brain bleed resulting in SIRS response.
No crepitus.
No ear pain or facial swelling.
No urinary symptoms to suggest pyelo or UTI. .
No severe confusion to suggest encephalitis.
No URI symptoms.
Doubt acute HIV.
No headache to suggest cavernous sinus thrombosis or intracranial infection.
No neurological abnormalities.
No tick bites.
No abdominal pain, rlq pain, or diarrhea to suggest intraabdominal/GI infection.
No joint swelling.
No history of rheumatological disorders, no headache to suggest temporal arteritis.
Doubt NMS or Serotonin syndrome.
No unilateral LE edema.
No pleuritic chest pain.
No sick contacts to suggest flu/non-specific viral syndrome.
No back pain or IVDA to suggest spinal abscess.
No loud murmur to suggest endocarditis.

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.jkpalpitations

Patient does not meet any the criteria for hospitalization for palpitations.

• diagnostic purposes

• severe structural heart disease suspected her ascertained

• primary electrical heart disease suspected her ascertained

• family history of sudden death

• need to perform EPS, invasive investigations or in-hospital telemetric monitoring-

• therapeutic purposes

• bradyarrhythmia requiring implantation of pacemaker

• pacemaker/ICD malfunction not rectify will by reprogramming

• ventricular tachyarrhythmia requiring immediate interruption and or ICD implantation or catheter

• supraventricular tachycardia requiring interruption immediately or in a short time or catheter ablation

• presence of heart failure other symptoms of hemodynamic compromise

• severe structural heart disease requiring surgery or interventional procedures

• severe systemic cause

• psychiatric decompensation

• No associated chest pain

• No associated neuro symptoms

• No severe associated SOB

• No severe associated weakness or lightheadedness

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.jkpediredflags

Child appears well. No external signs of trauma. Feeding normally. Appears well hydrated. No episodes of inconsolability. Eating, peeing, pooping normally according to family. Up-to-date in vaccinations.
Normal capillary refill. Moist mucous membranes. Normal tympanic membranes. No episodes of turning blue. No cyanosis currently. No heart murmur. Normal lung and abdominal exam. Normal genitourinary exam. No rashes. No skin desquamation or jaundice. Normal pupils. Normal reflexes. Normal conjunctiva. Trachea midline. No hepatosplenomegaly. No abdominal rebound or guarding. Normal appearing external genitalia.

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.jkeyecomplaitredflag

Denies change in visual acuity. No ciliary flush. No photophobia. No foreign body sensation. No corneal opacity. Pupil is reactive. No headache with nausea. No trauma to the eye. No proptosis. No pain with EOM.

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.jksyncope

The history is suggestive of syncope.
The patient lacks the following red flags:
Old age
No prodrome
FH of sudden cardiac death
Evidence of bleeding
Exertional syncope
Palpitations prior to syncope
Loud Murmur
Persistently abnormal vitals
No Abnormal ECG
CHF
Suspicion of structural heart disease
Ischemic, dysrhythmic, obstructive, valvular
HCT <30
SOB
Hypotension (SBP <90)
Associated chest pain
Doubt CO poisoning

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.jkvertigoredflags

History is not suggestive of central vertigo. Doubt stroke, cerebellopontine tumor or MS.
.jkneuro***
Recent viral illness (yes or no) – *** If yes consider Vestibular neuronitis
This is purely isolated vertigo – no other central symptoms. 
Doubt MS- no LE weakness, normal Babinski, normal pain/temp sensation, no Lhermitte sign, no visual changes, no urinary symptoms, no incontinence, no sexual dysfunction
Doubt Meniere’s Disease – no tinnitus, no hearing loss, no obvious clusters of attacks or long symptom free intervals.
Doubt Acoustic Neuroma – no hearing loss or tinnitus
The patient does not have the following to suggest central cause:

• ill-defined less intense nature

• constant/ persistent (although this can be seen in acute vestibular syndromes)

• CNS symptoms

• vertical nystagmus

• ataxia

Furthermore, the patient does have some of the symptoms to suggest a peripheral cause:

• sudden onset

• intense spinning

• paroxysmal

• aggravated by mvmt

• fatigue of symptoms

Normal test of skew. No vertical nystagmus. No herpetic lesions in the external auditory canal to suggest Ramsay hunt. 
Patient is having vertiginous symptoms with a broad differential.
***The patient’s history indicates short episodic symptoms that worsens with any head movement. The patient has a physical exam reassuring for a peripheral pathology. As such, most likely consistent with BPPV.
***The patient’s history of sudden onset symptoms that are non-fatiguable and has a physical exam concerning for potential central pathology.
***Patient’s history with gradual onset symptoms and a physical exam reassuring for a peripheral pathology, most consistent with an acute vestibular syndrome.

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.jknotanaphylaxis

Not anaphylaxis.
No wheezing.
No shortness of breath.
No diarrhea.
No abdominal pain.
No throat swelling.
No tongue swelling.

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.jklocalanesthetictoxicity

Will administer no more than the max safe dose of local acting anesthetic.
Lidocaine: 3-4.5 mg/kg (max 300mg)
Lidocaine w/ epi: 6-7 mg/kg (max 500mg)
Bupivacaine: 2-2.5 mg/kg (max 175mg)
Bupivacaine w/ epi: 2.5-3mg/kg (max 225mg)

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.jkasymptomatichypertension

The patients history of indicative of asymptomatic hypertension.
No chest pain/ exertional sob to suggest cardiac ischemia.
Non pregnant, not HELLP/preeclampsia.
No pleuritic pain.
No sweats. No vomiting.
No ripping tearing chest pain or chest/abdominal pain to suggest dissection.
No decrease in urine output.
No severe headache to suggest ICH.
No altered mental status.
No crackles on lungs or sob to suggest pulm edema.
No seizures.
No vision changes or neurological symptoms to suggest stroke or retinal hemorrhage.

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.jkbackpain

Denies fevers, chills, sweats. No saddle anesthesia. Full strength and sensation bilateral lower extremities. No loss of bowel or bladder function. Denies IV drug use. Denies history of cancer. Denies direct trauma. No unexpected weight loss. No long term steroid use. No pulsatile abdominal mass. No hematuria. No HIV, Transplant or systemic corticosteroids. No midline tenderness.

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.jkchestpain

No radiation to the back. No tearing pain going to the back. Normal bilat UE pulses.
No pleuritic pain. No history of PE. No new unilateral leg swelling.
Non exertional. No sweats. No right sided pain. No vomiting.
No fever or cough to suggest pneumonia.
No vomiting or subcue crepitus.
Equal breath sounds.
No skin rash.
No syncope.
No new murmur to suggest symptomatic valvular stenosis/ regurg or ruptured chordae.
Vitals do not suggest tamponade.
No palpable crepitus on exam.
No recent viral syndromes to suggest Peri/Myocarditis.

 

.jkheadacheredflag

HA was gradual onset. No f/c/s. No neck stiffness. No focal neurological symptoms. No temporal artery pain/tenderness. No vision changes. Headaches are not increasing in severity or frequency. Not worse in the AM. No head trauma. Doubt IIH.
Patient is well appearing and neurologically intact. Headache was not acute or maximal in onset. Do not suspect SAH, temporal arteritis, meningitis, encephalitis, CO poisoning, acute angle closure glaucoma, dural venous sinus thrombosis as cause of headache. Do not feel that further imaging or workup (including LP) are warranted at this time.

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.jkneckpainredflags

No neck trauma.
No cervical manipulation.
No sudden onset pain with coughing.
No known history of connective tissue disease.
No nausea
No miosis.
No ataxia.
No nausea/vomiting.
No facial paresthesia.
Normal pain/temperature sensation.
No dysphagia or hoarseness.
No diplopia.
No vertigo.
No nystagmus.
No ipsilateral slow constant headache.
No tenderness to ICA.
No syncope.
No neck swelling.
No bruit either subjective or auscultated.
No pulsatile tinnitus.
No scalp tenderness.
Discussed plan with patient. No atypical posterior headache and cervicalgia associated with recent minor trauma, however, vertebral artery dissection can present in a vague array of symptoms. Most common presenting symptoms of VAD are vertigo, dizziness, headache, and neck pain. Patient understands this. Discussed risks and benefits of imaging. Offered CT scan. For now, will defer from CTA – treat symptoms. Followup with pcp and/or return to ER if necessary.

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.jkpregnancyredflags

Denies vaginal bleeding.
Denies gush of water from vagina.
Denies vaginal discharge.
Denies UTI symptoms.
Denies severe nausea and vomiting to suggest severe dehydration requiring IV fluids.
Denies decrease movement that would require observation.
Denies fevers/chills/foul smelling discharge to suggest chorioamnionitis, septic abortion.
Denies pallor, lightheadedness, syncope to suggest blood loss.
No severe RUQ pain, shortness of breath, easy bruising, RUQ pain, new onset hypertension, decreased urine output, severe headache or visual disturbance to suggest preeclampsia, HELLP or eclampsia.
No trauma that would require further fetal monitoring.
No painful vaginal bleeding, pelvis/uterine pain, hypotension, severe back pain, uterine contractions, to suggest placental abruption.
No vaginal bleeding, shock, uterine defect, abdominal pain/peritoneal signs, loss of fetal station or fetal bradycardia to suggest placental rupture.

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.jkrash

Lacking classical rash red flags:
Toxic appearance
Fever
Hypotension
New medication
Mucosal lesions
Severe pain
Very old or young age
Immunosuppressed
No skin sloughing. No rashes in the mouth. No redness in the eyes. No bullae. No petechiae. No central clearing/ targetoid lesions to suggest erythema multiforme. No mucosal involvement. No neck stiffness. No hemorrhagic lesions. No lesions with central necrosis. No current fevers. No desquamation of the skin to suggest staph scalded skin syndrome. No blistering. No strawberry tongue. No recent tick bites to suggest Rocky Mountain spotted fever. No headache or other systemic autoimmune symptoms to suggest developing vasculitis. No crepitus.
Doubt DRESS – no facial edema, fever, systemic symptoms or tense bullae
Doubt SJS/TEN – no bullae, no atypical target lesions, no mucocutaneous erosions
Doubt AGEN Acute generalized exanthematous pustulosis – does not have the typical pustular appearance of AGEN nor is there positive nikolsky sign, no fever, no facial edema, no bullae, no mucosal involvement.
Doubt erythroderma – no diffuse erythematous plaques or edema, no diffuse exfoliation

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.jkrashfebrilechild

No drug ingestion. Up-to-date on immunizations.
No skin sloughing. No rashes in the mouth. No redness in the eyes. No bullae. No petechiae. No central clearing/ targetoid lesions to suggest erythema multiforme. No mucosal involvement. No neck stiffness. No hemorrhagic lesions. No lesions with central necrosis. No desquamation of the skin to suggest staph scalded skin syndrome. No blistering. No strawberry tongue. No recent tick bites to suggest Rocky Mountain spotted fever. No crepitus.
No slapped cheek. Doubt Measles or Rubella given that she is up-to-date on her vaccines. This does not appear to be hand-foot-mouth disease. No rashes on the palms. No redness to the eyes. No petechiae to suggest meningococemia.
No skin desquamation, tonsillar infection, linear petechiae in the antecubital or axillary folds (pastias sign), white strawberry tongue or red strawberry tongue to suggest scarlet fever.
No strawberry tongue, arthritis, rash on hands and feet, red eyes, strawberry tongue to suggest Kawasaki’s disease.

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Disease-Based Dot Phrases

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.jkpedieczema

Please verify ALL soaps/detergents are free from dyes/scents etc.
Consider Dove as soap and All free and clear for detergent.
Bath the child one a week only.
After bathing, WHILE STILL WET. APPLY the ointment liberally. We want to LOCK IN THE MOISTURE.
Apply ointment liberally daily. Either pure petroleum jelly or Eucerin Ointment.
Start triamcinolone daily. No triamcinolone on the face.
Continue mupirocin daily.
Apply these in the AM.
PUT THE OINTMENT ON TOP OF BOTH OF THESE TO LOCK THEM IN.
Then at night…
Consider wet wraps at night. Do no wrap too tight.
Do loose wet curlex, then wrap the arms in a long sleeve onsie and let baby soak with moisture and ointment.

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.jkclaviclefxredflags

No concerning clavicular findings that would warrant urgent ortho evaluation in the ER.
Displaced fracture with skin tenting
Open fracture
Neurovascular compromise

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.jkfebrileseizure

This appears to be a simple febrile seizure.
No red flags to suggest complex febrile seizure.
No family history of long QT or Brugada.
No FH of sudden cardiac death.
No developmental delay.
No focal symptoms.
No trauma.
Doubt meningitis, back to baseline other than fever.
No neck pain.
Does not have a VP shunt.
No drug ingestion/
Doubt severe electrolyte abnormality, hypoglycemia, hyponatremia (water intoxication, dilution of formula), hypocalcemia, hypomagnesemia.
Not ill appearing.
Furthermore, this was a single seizure, duration <15min and is now at baseline with only a breif post-ictal period.
No signs to suggest meningitis – no petechiae, child is well appearing, child is UTD on immunizations, no meningeal signs, no bulging fontanelle, no neck stiffness. Child is well appearing. No dry mucus membranes. No recent abx use that would mask meningitis.

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.jkfoodimpaction

Patient with obvious history of esophageal food impaction. Treated with multiple rounds of carbonated diet soda which resulted in complete resolution of the patients symptoms. Able to tolerate PO easily after treatment. No crepitus or continued discomfort/pain. No sweats or lightheadedness/chest pain.

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.jkkawasaki

• Classic Kawasaki Disease Fever for 5 days or more plus four of the following symptoms

• Bilateral nonexudative conjunctivitis

• Mucous membrane changes (erythema, peeling, cracking of lips, “strawberry tongue,” or diffuse oropharyngeal mucosae)

• Changes of the extremities (erythema or swelling of hands/feet, peeling of finger tips/toes in the convalescent stage)

• Rash

• Cervical adenopathy (more than one node >1.5 cm unusually unilateral anterior cervical)

Incomplete Kawasaki Disease Fever for 5 days and two to three clinical criteria of classic Kawasaki disease plus
C-reactive protein 3.0 milligrams/L and/or erythrocyte sedimentation rate 40 mm/h plus positive echocardiogram or three or more of the following:

• Albumin  grams/dL

• Anemia

• Elevated alanine aminotransferase (ALT)

• Platelets >450,000/mm3 7d after fever onset

• White blood cell count >12,000/mm3

• Pyuria

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.jksicklecell

• Will do Trop/EKG/CXR to r/o acute chest crisis

• Will do hemoglobin to r/o severe anemia

• Will do CXR to r/o pneumonia

• Will do reticulocyte count to r/o aplastic crisis. No recent exposures suggesting Parvo.

• Will do pain control with opiods (patient’s normal first bolus). If no improvement of symptoms after 30 minutes, will do a second dose at time 30 minutes. If no improvement, will do third dose and admit or discharge at that point

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.jkshockdifferential

Vasodilatory/Distributive
Sepsis
Anaphylaxis
Neurogenic
Burns
Other
Pheochromocytoma
Obstructive/Mechanical
Tension pneumo
PE
Tamponade
Dissection
Cardiogenic
Arrhythmia
Ischemia
Valvulopathy
Myopathy
CHF
Toxicologic
CCB
BB
Clonidine
Dig
Opiates
Sedatives
Valproic acid
Tca phenothiazine
CO, CN
Hypovolemic
Hemorrhage (chest/abd/retroperitoneal/subcue/Gi/thigh/street/scalp)
Vomiting/diarrhea
Diuresis, hyperglycemia
Diaphoresis, hyperthermia
Cirrhosis
Pancreatitis
Burns
Inadequate fluid intake
Metabolic
Hypoadrenalism
Hypo/hyperthyroid
DKA
Still Unsure?
Repeat History
Repeat Full Head to Toe Skin exam/physical
Review Meds Line by Line for culprits

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.jkbrue

Low Risk BRUE:

• Age >60 days.

• If premature, was born at gestational age =32 weeks and current postconceptional age is =45 weeks.

• Occurrence of only one BRUE (no prior BRUE, and BRUE did not occur in clusters).

• Duration of BRUE <1 minute.

• No cardiopulmonary resuscitation (CPR) by a trained medical provider was required

• No concerning historical features – Concerning historical features include social risk factors for child abuse, respiratory illness or exposure, recent injury, other symptoms in days preceding the event (fever, fussiness, diarrhea, or decreased intake), administration or access to medications, history of episodic vomiting or lethargy, developmental delay or congenital anomalies, and family history of BRUE or sudden unexplained death in a sibling

• No concerning physical examination findings: Concerning physical examination findings include any signs of injury, including bleeding, bruising (especially on the scalp, trunk, face, or ears), or bulging anterior fontanel; altered sensorium; fever or toxic appearance; respiratory distress; heart murmur or gallop; decreased pulses; hepatomegaly or splenomegaly; and abdominal distension or vomiting

Management of low risk brue:

• Educate caregivers about BRUEs, and the low risk for infants with these characteristics.

• Offer resources for training in cardiopulmonary resuscitation (CPR).

• Engage in shared decision-making about further evaluation and disposition.

• Arrange for a follow-up check with a medical provider within 24 hours to identify infants with evolving medical concerns that would require further evaluation and treatment.

Optional steps:

• A brief period of in-hospital observation (eg, one to four hours) with continuous pulse oximetry and serial observations.

• 12-lead electrocardiogram with attention to QT interval.

• Testing for pertussis (especially for infants with suggestive symptoms). Respiratory virus testing, such as for respiratory syncytial virus, is reasonable if a rapid testing method is available. However, this testing is not required in these low-risk infants, who by definition have no respiratory symptoms and are >2 months of age.

Management of BRUE that does not meet low risk:

• Pulse oximetry monitoring for at least four hours

• Electrocardiogram

• Hematocrit

• Blood glucose, bicarbonate or venous blood gas, lactic acid (to evaluate for inborn errors of metabolism)

• Respiratory virus testing panel (including respiratory syncytial virus)

• Testing for pertussis – If the infant has suggestive symptoms, has not been completely immunized, and/or has been exposed in an endemic region or outbreak

• Review of results of newborn screening tests (eg, for inborn errors of metabolism)

If after workup, we are able to determine a diagnosis then no longer considered a BRUE, managed per the diagnosis. However, if diagnosis remains unclear, consider admission to the hospital for observation, pulse ox monitoring, social work evaluation, further evaluation.
Ddx of BRUE Includes:
Transient choke/gagging
Periodic breathing or respiratory pauses
Respiratory infection including pertusses, RSV, bronchiolitis
Sepsis, meningitis, encephalitis, pneumonia, UTI
Child abuse
GERD or swallowing dysfunction
Anatomic or functional abnormality
Epilepsy, structural brain abnormality, neuromuscular disorder
Airway obstruction
Central or obstructive sleep apnea
Arrhythmia
Inborn error of metabolism
Acute gastrointestinal instruction including intussusception or volvulus
Toxic ingestion
Disorder of central respiratory control (CCHS)

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.jkasymptomatichypertension

The patients history of indicative of asymptomatic hypertension.
No chest pain/ exertional sob to suggest cardiac ischemia.
Non pregnant, not HELLP/preeclampsia.
No pleuritic pain.
No sweats. No vomiting.
No ripping tearing chest pain or chest/abdominal pain to suggest dissection.
No decrease in urine output.
No severe headache to suggest ICH.
No altered mental status.
No crackles on lungs or sob to suggest pulm edema.
No seizures.
No vision changes or neurological symptoms to suggest stroke or retinal hemorrhage.

 

Documentation Stuff

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.jkphysicalbrief

The patient is awake, alert and oriented
Normocephalic/atraumatic
External examination of the ears is unremarkable
Pupils are equal round and reactive to light, there is no conjunctival injection or scleral icterus noted
Nares are patent without rhinorrhea.
The oropharynx is moist without injection
The neck is supple
Clear to auscultation bilaterally
No murmurs rubs or gallops
Soft and nontender. There are positive bowel sounds. there is no rebound or guarding
Musculoskeletal: Normal range of motion with grossly normal strength
Nonfocal neuro exam
No rash noted

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.jkstrokebpranges

Will keep BP within range per  guidelines.
Acute ischemic stroke, no reperfusion: max BP 220/110
Acute ischemic stroke, TPA – no thrombectomy: max BP 185/105
During transport pending thrombectomy: SBP >140, <180
Acute ischmic stroke s/p thrombectomy: max SBP 160
SAH: max SBP 160
ICH: max SBP 140

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.jkros

CONSTITUTIONAL: no fever, chills, or weight loss.
EYES: no injury, redness, or discharge.
ENT: no injury, pain, or discharge.
NECK: no injury, pain, or swelling.
CARDIOVASCULAR: no chest pain, palpitations, or edema.
RESPIRATORY: no SOB, cough, or pleuritic chest pain.
ABDOMEN/GI: no abdominal pain, nausea, vomiting, diarrhea
BACK: no injury or pain.
GU: no injury, no dysuria or hematuria
MS/EXTREMITY: no injury or deformity.
SKIN: no injury, rash or discoloration.
NEURO: no headache, weakness, numbness
PSYCH: no SI, no HI, no hallucinations
ALLERGY/IMMUNOLOGY: no hives, rash, or allergies.
ENDOCRINE: no polyuria or marked weight changes.
HEMATOLOGIC/LYMPHATIC: no swollen nodes, abnormal bleeding, or unusual bruising

 

.jktraumaphysical

No c/t/l spine tenderness.
Full ROM of neck.
No numbness/tingling to hands or arms.
No neuro deficits.
No abdominal tenderness or bruising.
No chest wall tenderness or tenderness with deep inspiration to suggest rib fractures.
No tenderness to extremities.
No signs of facial or cranial trauma.
TMs clear.
No bruising around eyes.

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.jkpediexam

General- well-appearing developmentally-appropriate child in NAD, playing in exam room
Head: atraumatic, normocephalic,
Eyes: no icterus, no discharge, no conjunctivitis
Ears: no discharge, tympanic membranes nml bilat
Nose: no discharge, moist nasal mucosa
Throat: moist oral mucosa, no exudates, uvula midline
Neck: no lymphadenopathy, no nuchal rigidity
CV- RRR, nml S1, S2 w no murmurs
Respiratory- CTAB, no wheezing or crackles
Abdomen- Soft, NTND, no rigidity, no rebound, no guarding.
Extremities- warm, symmetric tone, nml muscle development and strength
Skin- moist; without rash or erythema

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.jkperisk

No recent long plane flights or car rides.
Denies history of dvt or pe.
No unilateral LE edema.
No pleuritic chest pain.
No active cancer.
No tenderness to calf/swelling in calf or palpable venous cord.
No recent surgeries.

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.jkpneumonia

No fevers/chills/sweats.
No productive cough.
No documented fever.
No focal crackles on lung exam.
Doubt pneumonia.

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.jkcriticalcaretime

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Critical Care Procedure Note

Authorized and Performed by: Jordan Kapper, MD
Date performed: performed on date of ER visit.
Total critical care time: See below for total time

Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient’s response to treatment; frequent reassessment; and, discussions with other providers.

This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time.

Please see MDM section and the rest of the note for further information on patient assessment and treatment.
See diagnosis and pathology below.
See critical care time below.

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.jkproviderintriage

Presenting Complaint:

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Initial Assessment:

As the provider in triage, I conducted an initial evaluation of the patient’s presenting complaint. The objective of this brief encounter was to understand the patient’s immediate needs and establish a preliminary care plan.

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Ordered Labs and Investigations:

Based on the initial assessment, I have ordered the following lab tests and investigations - see below.

 

Recommendations:

Triage Category: Based on the initial evaluation, I recommend the patient (needs immediate attention and should be taken to the emergency department/ can wait in the waiting room until a bed is available). See below. 

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Monitoring: Given the nature of the presenting complaint, I recommend (telemetry monitoring is required/ telemetry monitoring is not required). See below.

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Disclaimer:

Please note, as the provider in triage, I will not be providing ongoing care for this patient. My role is to ensure that the patient receives the most appropriate initial attention based on their condition upon arrival.

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.jkhandexam

M/U/R/A nerve sensation intact.
GRIP strength 5/5. Finger abduction/adduction/opposition intact.
Suppination/Pronation intact without reproduction of pain.
Good capillary refill. 2+ radial pulses, bilaterally equal.
WE/WF/WRD/WUD 5/5, intact, without pain.
BICEPS/TRICEPS 5/5.
Shoulder abduction/adduction 5/5.

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.jkincidentalfindings

Discussed the incidental findings with the patient as well as gave very strict and specific verbal followup instructions.
These are my standard followup instructions given to patients with incidental findings.
The patient (and any family present) understand the importance of followup and the devastating medical, social and psychological implications that failure to followup could cause.
Patient understands that followup is now in their hands and it is their responsibility to followup.
They were able to repeat the instructions back to me.

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.jkneuroexam

No dysarthria, nystagmus, dysphagia, diplopia, aphasia, vertigo, ataxia, visions loss, dysmetria.
Normal finger to nose, gait, rapid alternating movement, tandem gait, strength and sensation in bilat upper and lower extremities. Normal upper and lower reflexes. No pronator drift. Normal heel to shin. EOMI, no visual field defects. CN 2-12 intact. GCS 15. AOx3. Normal babinski.

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.jkcprphysical

General: Ongoing CPR. + distress. 

Head and face: atraumatic, well developed.  
ENT: Atraumatic. No external abnormalities to ears/mouth. Neck: Trachea midline. No deformities or crepitus. Resp:  Coarse breath sounds. Intubated. + bilateral breath sounds. Abd: Soft, nondistended.  No guarding. No signs of trauma.Skin:Atraumatic. Intact. Warm, dry, no rashes. Back: unable to assess, ongoing CPR. Neuro: Unresponsive. Ongoing CPR. Psych: Unable to asses, ongoing CPR. 

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.jkphysical

GA: Well appearing NAD. 
Head & Face: Normocephalic. No trauma. 
Eyes: EOMI Normal Lids & lashes.  No Periorbital swelling, redness, or edema. 
ENT:  No nasal DC. No oropharyngeal swelling. MMM
Neck: Trachea midline. Normal ROM 
CW: N motion. No tenderness, deformity, or lesions. 
CARDIOVASCULAR: RRR. No gallops, murmurs, or rubs. 
Respiratory: Lungs CTAP. No rales. No wheezes. No rhonchi.
Abdomen GI: Soft, NTND No guarding or rebound. 
Back: No tenderness to c/t/l spine. 
Skin:  No rashes, lesions, or cellulitis. 
MS/EXT: Pulses equal, no cyanosis.
Neuro: A&Ox3. Moving all 4 extremities. 
Psych: No SI or HI, pleasant. 

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.jkama

 

SEE BOTTOM OF AMA TEMPLATE FOR DETAILS REGARDING STARRED SECTIONS

This patient has elected to leave against medical advice. In my opinion, the patient has capacity to leave AMA. The patient is clinically sober, free from distracting injury, appears to have intact insight and judgment and reason, and in my opinion has capacity to make decisions. I explained to the patient that his symptoms may represent *** and the patient verbalized understanding of my concerns.

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I had a discussion with the patient about their workup and results, and that they may still have *** despite ***. I informed the patient that the next step in diagnosis and treatment would be ***, and they verbalized understanding of this as well. I explained the risks of leaving without further workup or treatment, which included reasonably foreseeable complications such as death, serious injury, permanent disability, and ***. I also offered alternatives to departing AMA such as assigning the patient a different provider or an alternate workup pathway.

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The patient is refusing any further care, specifically ***, and is leaving against medical advice. I am unable to convince the patient to stay. I have asked them to return as soon as possible to complete their evaluation, and also explained that they were welcome to return to the ER for further evaluation whenever they choose. I have asked the patient to follow up with their primary doctor as soon as possible. I have answered all their questions. Patient signed***did not sign AMA paperwork.

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.jkcapacity

YES:

Capacity Assessment: In my medical opinion, this patient has capacity to make medical decisions. The patient has the ability to communicate their choice to me and others, understands the information relevant to this decision, appreciates the situation itself and the consequences inherent to their choice, and can logically explain their rationale for their decision.

NO:

In my medical opinion, this patient does NOT have capacity to make a medical decision regarding ***, because
a. The patient is unable to communicate a choice.
b. The patient is unable to understand the relevant information
c. The patient is unable to appreciate a situation and its consequences
d. The patient is unable to reason rationally.

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.jkattestresident

I have personally seen and examined this patient. I have reviewed the resident’s note, examined the patient, confirmed all findings, and agree with the assessment and plan as documented. I provided direct supervision of the resident during the evaluation and management of the patient’s condition. All the care provided was under my direct and immediate supervision

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#1 on ekg indicates a recommendation for the patient to go to a monitored bed. 

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.jkattestpa

I am documenting that the patient care provided by the PA/NP was completed independently. I was available in the Emergency Department during the time of care but was not consulted.

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.jkdischarge

Patient feels well and is okay with being discharged. Discussed diagnostic results and treatment plan in detail; patient demonstrates understanding. Informed patient of any incidental findings discovered through imaging or laboratory evaluation and their implications. Patient understands followup instructions and return precautions. 

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Note for all scribes Please ensure:

1. All notes are "ready to sign", meaning all mandatory fields are filled out. This varies depending on the EHR. 

2. Diagnosis is in for all patients. 

3. We document the names of all doctors I speak with. 

4. Make sure every patient has an EKG and Diagnosis. (keep track of these so as not to miss any).

5. Any "dot phrase" makes SENSE, like if I say .jktrauma which contains "no pain in extremities" but patient has a broken leg, please change this. 

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For Methodist use:
.jkgeneral
.jkattentresident

.jksignout