smartphrases
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abd pain
HISTORY OF PRESENT ILLNESS
@NAME@ is a @AGE@ @SEX@
w/ @PMH@
@CHIEFCOMPLAINT@
Quality of pain: {Symptoms; abdominal pain quality:618}.
Radiation of pain: {Symptoms; abdominal pain radiation:11077}.
Vital Signs Reviewed.
Nurse's notes reviewed and I agree with the documentation of the past medical, past surgical, social, and family histories.
REVIEW OF SYSTEMS
Constitutional: no fever, no chills
Skin: no rash, no pallor
Eyes: no vision changes.
HENT: no runny nose.
Respiratory: no shortness of breath, no cough.
Cardiovascular: no chest pain, no peripheral edema.
Gastrointestinal: No blood in stool, +abdominal pain, no vomiting, no diarrhea.
Genitourinary: No decrease in UOP, no dysuria, no frequency, no hematuria.
Musculoskeletal: No back pain, No swelling or pain.
Neurologic: No headache, no confusion, no numbness, no motor weakness
Heme/lymph: No coagulopathy or easy bruising
@VITALS@
PHYSICAL EXAM
General: Alert, no acute distress.
Skin: Warm, dry, no diaphoresis
Head: Normocephalic, atraumatic.
Neck: Supple. No JVD, no stridor
Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva.
Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate.
Cardiovascular: Regular rate and rhythm, no murmur, no gallop, brisk cap refill
Respiratory: No respiratory distress, no tachypnea, no labored breathing, Lungs are clear to auscultation, lung sounds are equal bilaterally, no rales, no wheezes
Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds.
Back: No costovertebral angle tenderness
Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity.
Neurological: oriented to person, place, time, and situation, normal speech observed, no facial droop. No focal neurological deficit observed
Psychiatric: Cooperative, appropriate mood & affect.
MEDICAL DECISION MAKING
The patient's complaints and exam findings will be addressed during the ER stay. We will {Blank multiple:19196:: "Check chemistries to rule out electrolyte abnormality", "Check blood counts for anemia or leukocytosis", "Will get ct abdomen to evaluation for intestinal pathology like obstruction, infection, appendicitis or kidney stone or other. ", "Check pregnancy test urine/serum", "Check urinalysis for presence of hematuria or urinary traction infection", "Give pain medication to address the patient's pain", "Give nausea medication for nausea/vomiting", "Give iv fluids to improve hydration status", "Check gallbladder ultrasound to rule out gallstones or cholecystitis", "We will check a CXR to evaluate for pneumonia, pneumothorax, pulm edema", " We will check cardiac enzymes to evaluate for myocardial injury."}.
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chest pain
HISTORY OF PRESENT ILLNESS
@NAME@ is a @AGE@ @SEX@
w/ @PMH@
@CHIEFCOMPLAINT@
Quality of pain: {Symptoms; abdominal pain quality:618}.
Radiation of pain: {Symptoms; abdominal pain radiation:11077}.
Vital Signs Reviewed.
Nurse's notes reviewed and I agree with the documentation of the past medical, past surgical, social, and family histories.
REVIEW OF SYSTEMS
Constitutional: no fever, no chills
Skin: no rash, no pallor
Eyes: no vision changes.
HENT: no runny nose.
Respiratory: no shortness of breath, no cough.
Cardiovascular: no chest pain, no peripheral edema.
Gastrointestinal: No blood in stool, +abdominal pain, no vomiting, no diarrhea.
Genitourinary: No decrease in UOP, no dysuria, no frequency, no hematuria.
Musculoskeletal: No back pain, No swelling or pain.
Neurologic: No headache, no confusion, no numbness, no motor weakness
Heme/lymph: No coagulopathy or easy bruising
@VITALS@
PHYSICAL EXAM
General: Alert, no acute distress.
Skin: Warm, dry, no diaphoresis
Head: Normocephalic, atraumatic.
Neck: Supple. No JVD, no stridor
Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva.
Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate.
Cardiovascular: Regular rate and rhythm, no murmur, no gallop, brisk cap refill
Respiratory: No respiratory distress, no tachypnea, no labored breathing, Lungs are clear to auscultation, lung sounds are equal bilaterally, no rales, no wheezes
Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds.
Back: No costovertebral angle tenderness
Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity.
Neurological: oriented to person, place, time, and situation, normal speech observed, no facial droop. No focal neurological deficit observed
Psychiatric: Cooperative, appropriate mood & affect.
MEDICAL DECISION MAKING
The patient's complaints and exam findings will be addressed during the ER stay. We will {Blank multiple:19196:: "Check chemistries to rule out electrolyte abnormality", "Check blood counts for anemia or leukocytosis", "Will get ct abdomen to evaluation for intestinal pathology like obstruction, infection, appendicitis or kidney stone or other. ", "Check pregnancy test urine/serum", "Check urinalysis for presence of hematuria or urinary traction infection", "Give pain medication to address the patient's pain", "Give nausea medication for nausea/vomiting", "Give iv fluids to improve hydration status", "Check gallbladder ultrasound to rule out gallstones or cholecystitis", "We will check a CXR to evaluate for pneumonia, pneumothorax, pulm edema", "We will check d-dimer to evaluate for risk of PE", " We will check cardiac enzymes to evaluate for myocardial injury."}.
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dc everyone
@NOW@
@VITALS@
Medications Administered in ED
@EDMEDS@
@ORDERSENC@
ED Final Impression
@WSEDDIAG@
Disposition
I have discussed the care plan and follow up instructions with the patient. Patient verbalizes understanding. Patient is stable, NAD, and non-toxic upon discharge. Patient to be discharged home. @NOW@
Follow up:
@FUP@
New Prescriptions
@EDPTMEDSTART@
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eye exam
Eyes: Pupils are equal, round, and reactive to light. EOM and lids are normal. Lids are everted and swept, no foreign bodies found. Right eye exhibits no chemosis, no discharge, no exudate and no hordeolum. No foreign body present in the right eye. Left eye exhibits no chemosis, no discharge, no exudate and no hordeolum. No foreign body present in the left eye. Right conjunctiva is not injected. Right conjunctiva has no hemorrhage. Left conjunctiva is not injected. Left conjunctiva has no hemorrhage. No scleral icterus.
Slit lamp exam:
The left eye shows no corneal abrasion, no corneal flare, no corneal ulcer, no foreign body, no hyphema, no hypopyon, no fluorescein uptake and no anterior chamber bulge.
IOP *** mmHg
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lbp
Pt denies fevers, chills, fall, trauma, motor weakness, sensory deficits, saddle anesthesia, bowel or bladder incontinence.
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no head CT
No need for CT
As no severe headache, no vomiting, age < 65, no skull fracture signs, no fnd, no coagulopathy, not on AC, no thrombocytopenia, no dangerous mechanism
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pecarn < 2
GCS 15
Mental status at baseline
No palpable skull fracture
No non-frontal scalp hematoma
No LOC
No severe injury mechanism
Acting normally as per parent
No indication for CT or observation for concerning TBI as per PECARN criteria
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pecarn > 2
GCS 15
Mental status at baseline - Acting normally as per parent
No palpable skull fracture and no signs of a basilar skull fracture
No vomiting
No LOC
No severe injury mechanism
No severe headache
No indication for CT or observation for concerning TBI as per PECARN criteria
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perc neg
Pt denies prior history of PE DVT, recent surgery or trauma, denies hemoptysis, estrogen use, leg swelling. Pt satting > 94%, and age < 50yr, HR <100.
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PE toddler
Physical Exam
Constitutional: She appears well-developed and well-nourished. She is active. No distress.
HENT:
Head: Atraumatic. No signs of injury.
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Nose: No nasal discharge.
Mouth/Throat: Mucous membranes are moist. Oropharynx is clear. Pharynx is normal.
Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and EOM are normal.
Neck: Normal range of motion. Neck supple. No neck rigidity or neck adenopathy.
Cardiovascular: Regular rhythm, S1 normal and S2 normal.
Pulmonary/Chest: Effort normal and breath sounds normal. No nasal flaring or stridor. No respiratory distress. She has no wheezes. She has no rhonchi. She has no rales. She exhibits no retraction.
Abdominal: Soft. She exhibits no distension. There is no abdominal tenderness.
Musculoskeletal: Normal range of motion.
General: No tenderness, deformity, signs of injury or edema.
Neurological: She is alert. No cranial nerve deficit. Coordination normal.
Skin: Skin is warm. Capillary refill takes less than 3 seconds. No petechiae, no purpura and no rash noted. She is not diaphoretic. No cyanosis. No jaundice or pallor.
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PE 14 mo
Physical Exam
Constitutional: He appears well-developed and well-nourished. He is active.
HENT:
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Nose: No nasal discharge.
Mouth/Throat: Mucous membranes are moist. No tonsillar exudate. Oropharynx is clear. Pharynx is normal.
Eyes: Pupils are equal, round, and reactive to light. EOM are normal.
Neck: Normal range of motion. Neck supple. No neck rigidity or neck adenopathy.
Cardiovascular: Regular rhythm, S1 normal and S2 normal.
Pulmonary/Chest: Effort normal and breath sounds normal. No nasal flaring or stridor. No respiratory distress. He has no wheezes. He has no rhonchi. He has no rales. He exhibits no retraction.
Abdominal: Soft. He exhibits no distension. There is no abdominal tenderness. There is no guarding.
Genitourinary: Penis normal.
Circumcised.
Musculoskeletal: Normal range of motion.
General: No tenderness, deformity or edema.
Neurological: He is alert. No cranial nerve deficit. Coordination normal.
Skin: Skin is warm. Capillary refill takes less than 3 seconds. No rash noted.
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priapism procedure
Procedure note for management of priapsim:
Verbal consent
Indication: Retractable priapism
Pre-procedure exam: See physical exam
Preparation:
Penial block performed for priaprism - lido 2% at 10 and 2 o'clock after betadine prep
Procedure:
1 attempt: Skin prepped with alcohol swabs. ***g needle to *** side with ***cc blood aspirated then injected ***cc of ***00mcg phenylephrine.
2 attempt: Skin prepped with alcohol swabs. ***g needle to *** side with ***cc blood aspirated then injected ***cc of ***00mcg phenylephrine.
Post-procedure exam: Improvement with pt reporting no additional mgmt needed.
Complications: None
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repeat dvt us
US vascular duplex is negative for DVT
But due to symptoms I discussed with the pt the need to repeat an US in 7 days due to r/o clot progression/occult distal DVT. Pt understand and will follow up.
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trauma note
HISTORY OF PRESENT ILLNESS
@NAME@ is a @AGE@ @SEX@
w/ @PMH@
@CHIEFCOMPLAINT@
Pt is presenting with *** pain that started *** and radiates to *** and is associated with ****.
Vital Signs Reviewed.
Nurse's notes reviewed and I agree with the documentation of the past medical, past surgical, social, and family histories.
REVIEW OF SYSTEMS
Constitutional: no fever, no chills
Skin: no rash, no pallor
Eyes: no vision changes.
HENT: no runny nose.
Respiratory: no shortness of breath, no cough.
Cardiovascular: no chest pain, no peripheral edema.
Gastrointestinal: No blood in stool, no abdominal pain, no vomiting, no diarrhea.
Genitourinary: No decrease in UOP, no dysuria, no frequency, no hematuria.
Musculoskeletal: No back pain, No extremity swelling or pain.
Neurologic: No headache, no confusion, no numbness, no motor weakness
Heme/lymph: No coagulopathy or easy bruising
@VITALS@
PHYSICAL EXAM
General: Alert, no acute distress.
Skin: Warm, dry, no diaphoresis
Head: Normocephalic, no facial bony tenderness, atraumatic.
Neck: Supple. No JVD, no stridor
Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva.
Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate.
Cardiovascular: Regular rate and rhythm, no murmur, no gallop, brisk cap refill
Respiratory: No respiratory distress, no tachypnea, no labored breathing, Lungs are clear to auscultation, lung sounds are equal bilaterally, no rales, no wheezes
Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds.
Back: No midline C T or L spine tenderness, no costovertebral angle tenderness
Musculoskeletal: No tenderness or bruising over thoracic chest wall, pelvis and hips stable and non-tender, extremity exam unremarkable, Normal ROM, normal strength, no swelling, no deformity.
Neurological: oriented to person, place, time, and situation, normal speech observed, no facial droop. No sensory, motor, no ataxia and other other focal neurological deficit observed
Psychiatric: Cooperative, appropriate mood & affect.
MEDICAL DECISION MAKING
Ddx: fracture, contusion, sprain, strain
The patient's complaints and exam findings will be addressed during the ER stay. We will {Blank multiple:19196:: "Check chemistries to rule out electrolyte abnormality", "Check blood counts for anemia or leukocytosis", "Will get ct to evaluate for injury and other pathology ", "Check pregnancy test urine/serum", "Check urinalysis for presence of hematuria or urinary traction infection", "Give pain medication to address the patient's pain", "Give nausea medication for nausea/vomiting", "Give iv fluids to improve hydration status", "Administer Tdap to update the patient's tetanus immunity"}.
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ECG
ECG 12 Lead
Date/Time: 4/21/2024 10:18 AM
Performed by: Yevheniy Lider, MD
Authorized by: Yevheniy Lider, MD Interpreted by ED physician
Rhythm: sinus rhythm
Rate: normal
QRS axis: normal
ST Segments: ST segments normal
Clinical impression: normal ECG
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CC note
Critical Care
Performed by: Yevheniy Lider, MD
Authorized by: Yevheniy Lider, MD
Critical care provider statement:
Critical care time (minutes): 30
Critical care time was exclusive of: Separately billable procedures and treating other patients and teaching time
Critical care was necessary to treat or prevent imminent or life-threatening deterioration of the following conditions: Respiratory failure
Critical care was time spent personally by me on the following activities: Development of treatment plan with patient or surrogate, discussions with consultants, discussions with primary provider, evaluation of patient's response to treatment, examination of patient, interpretation of cardiac output measurements, obtaining history from patient or surrogate, vascular access procedures, review of old charts, re-evaluation of patient's condition, pulse oximetry, ordering and review of radiographic studies, ordering and review of laboratory studies and ordering and performing treatments and interventions
:
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