Charting dot phrases Flashcards
UpToDate = KristaMooreMD !13
New Innovations = kmoore !22
MDM - Palomar
Dr. Moore, resident working with Dr. [***]
I, the resident physician, attest that I examined the patient and performed the services as described with the attending physician present during the critical or key portions of the service.
___________________________________________________________
NURSING NOTES REVIEWED.
History obtained from []
Additional information reviewed: [nursing home notes, EMS run sheets, previous hospitalizations, office records] and previous medical records reviewed via electronic health care record and were summarized in the HPI above in MDM below.
EMERGENCY DEPARTMENT COURSE
Based on chief complaint, I considered high risk diagnoses such as [ DDX]
___________________________________________________________
EMERGENT LABS AND DIAGNOSTIC STUDIES:
LAB RESULTS WERE REVIEWED AND INTERPRETED BY ME:
[***]
12-LEAD EKG REVIEWED AND INTERPRETED BY ME:
[***]
RADIOLOGY RESULTS REVIEWED and XRs INTERPRETED BY ME:
[***]
___________________________________________________________
Procedures/Critical Care: [***]
Observation/Re-Evaluation: [***]
Co-morbidities impacting complexity of my management for this patient: [***]
Medications requiring close monitoring by me: [***]
Treatments/tests Considered but Not Ordered: [], however, based on [], I did not feel the patient would benefit based on my risk/benefits discussion with the patient/their proxy.
Admission/surgery considered, but ultimately, after extensive workup and reevaluation, does not appear to be indicated at this time. I judge the possibility of clinical deterioration unlikely, and I believe the patient is a reasonable outpatient candidate. Plan for follow up with [***]
Social determinants of health impacting complexity of my management of this patient: [***]
___________________________________________________________
MEDICAL DECISION MAKING:
Based on the patient’s history and presentation, my work up and conclusions are as follows:
[***]
___________________________________________________________
Krista Moore, MD
NAVY Emergency Medicine PGY-4
Disclaimer: Inadvertent spelling and grammatical errors are likely due to EHR/dictation software use and do not reflect on the overall quality of patient care. Also, please note that the electronic time recorded on this note does not necessarily reflect the actual time of the patient encounter
PE - Basic
GENERAL: well appearing, in no apparent distress, non-diaphoretic
HEAD: normocephalic, atraumatic
EENT: EOM intact, pupils equal round and reactive to light, no scleral icterus. Hearing intact to normal conversation. Mucus membranes moist
CV: Regular rate and rhythm. Well perfused, no dependent edema
PULM: Lungs clear to auscultation bilaterally. Normal depth, rate and work of breathing
ABDOMEN: Soft, non-distended, non-tender to palpation
SKINS: Warm, dry. No active bleeding from skin.
PSYCH: Patient cooperative with normal mood and affect.
EXTREMITIES: No obvious deformities. No cyanosis
NEURO: Awake and alert, moving all extremities without focal motor deficit
PE - No touch
GENERAL: well appearing, in no apparent distress, non-diaphoretic
HEAD: normocephalic, atraumatic
EENT: EOM intact, pupils equal round, no scleral icterus. Hearing intact to normal conversation. Mucus membranes moist
CV: Well perfused, no dependent edema
PULM: Normal depth, rate and work of breathing
SKINS: Warm, dry. No active bleeding from skin.
PSYCH: Patient cooperative with normal mood and affect.
EXTREMITIES: No obvious deformities. No cyanosis
NEURO: Awake and alert, moving all extremities without focal motor deficit
PE - GU Female
Female Pelvic Exam:
Patient consented to sensitive exam and chaperoned by [HM/RN]
EXTERNAL GENITALIA: Normal hair distribution/trimmed/shaved pubic hair [] . No lesions, normal appearance, no prolapse/cystocele.
VAGINA: Speculum placed with visualization of the cervix. Pink vaginal vault, moist with normal appearing rugae. No lesions, blood, discharge, or yeast elements in vaginal vault. No amine odor present.
CERVIX: Parous/Non-parous cervix. No lesions, discharge from os, erythema or polyps. IUD strings []
BIMANUAL: Normal size, shape and contour. No obvious masses. No CMT or adnexal tenderness.
RECTAL: No external lesions, fissures, fistulas, or external hemorrhoids.
PE - GU Male
Male Genitourinary exam:
Patient consented to sensitive exam and chaperoned by [HM/RN]
Circumcised male/Foreskin retracts easily
Pubic hair: [***]
Cremasteric reflex intact.
Testicles descended bilaterally. No testicular masses, lesions or varicoceles. Epididymis nontender.
No palpable hernias via inguinal canal or abdominal wall or LAD.
Penis without lesions, urethral meatus without discharge or blood
PE - Rectal
Patient consented to sensitive exam and chaperoned by [HM/RN]
RECTAL: No external lesions, no fissures, no fistulas, no external hemorrhoids, no skin tags, no pilonidal cysts. Normal sphincter tone. No rectal masses, prostate smooth & normal in size. No blood on the glove.
PE - Neuro Full
NEURO: CN II-XII intact. SILT & 5/5 strength in bilateral upper and lower extremities. No pronator drift. No dysarthria. Gait and balance normal. Ambulated without difficulty.
PE - MSE
Mental Status Exam:
Patient described their mood as: “[]”
Patient described feeling: “[]”
The patient is alert and oriented. Dress and hygiene are fair. Looks stated age. Calm and cooperative. Good eye contact. No psychomotor agitation or retardation. Speech is normal, non-pressured. No thought disorder. Thoughts are goal directed. Affect is euthymic and congruent. No emotional blunting. The patient denied any audiovisual hallucinations. No delusions noted. Insight and judgment are fair. Impulse control is fair. The patient is cognitively intact. Denies SI/HI, auditory or visual hallucinations.
PE - Ophtho
Vital Signs Reviewed.
OPHTHO EXAM
Visual Acuity
- OD:
- OS:
- OU:
IOP:
- OD:
- OS:
No direct or consensual photophobia
PERRL
EOMI and nonpainful
Conjunctiva [injected]
No exudates, nodules or styes
No proptosis, chemosis
Fluorescein stain showed [no increased corneal uptake]
Topical anesthetic drops [relieved pain/irritation/FB sensation]
GENERAL: WN, WD, A&Ox4, sitting on bed in NAD, nondiaphoretic
HEENT: NCAT. Eye exam as above. Hearing intact to normal conversation
CV: Well perfused, no dependent edema
PULM: Normal depth, rate and work of breathing. No audible wheezes or tripoding
EXTREMITIES: Moves all extremities spontaneously without difficult.
SKIN: Pink, warm, dry.
PSYCH: Patient cooperative with normal mood and affect.
PE - ENT
GENERAL: Well nourished, well developed, alert & oriented x 4, sitting ER bed in no apparent distress, nondiaphoretic.
HEAD: NCAT, PERRL, EOMI, conjunctiva clear.
EARS: Normal appearing pinna and external auditory canal. No pain with pinna manipulation. EAC clear and nonerythematous. No TM bulging, erythema, or fluid. Hearing intact to conversation.
NOSE: No external nasal deformity. No frontal or maxillary sinus tenderness.
MOUTH: Uvula midline, posterior oropharynx nonerythematous. Tonsillar pilars unremarkable, without abscess or asymmetry. Voice normal. Teeth, gums and cheeks nontender to percussion, sublingual space soft and non-tender.
NECK: Normal appearance, supple, nontender. No lymphadenopathy.
CV: Regular rate and rhythm, no murmurs, rubs or gallops. Well perfused, no dependent edema
PULM: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Normal depth, rate and work of breathing.
EXTREMITIES: Moves all extremities spontaneously without difficult. No clubbing or cyanosis.
SKINS: Pink, warm, dry.
PSYCH: Patient cooperative with normal mood and affect.
PE - PEDS
Vital Signs Reviewed.
GENERAL: well nourished, developmentally appropriate child in NAD, playing in exam room in
HEENT: normocephalic, atraumatic, age appropriate fontanelles,
EYES: no icterus, discharge, or conjunctivitis. EOMI, PERRLA.
EARS: Hearing intact to normal conversation. TMs clear bilaterally, no pain with pinna manipulation.
NOSE: Normal nares, no discharge
THROAT: Mucus membranes moist. Normal gums and palate. Uvula midline, no exudates
NECK: no LAD, no nuchal rigidity
CV: Regular rate and rhythm, no murmurs, rubs or gallops. Well perfused, capillary refill <3 seconds, no dependent edema
PULM: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Normal depth, rate and work of breathing.
ABDOMEN: Soft, nontender, nondistended, no rigidity, no rebound, no guarding.
GU: [circumcised/not circumcised] normal genitalia. No rash.
BACK: No CVAT
EXTREMITIES: Normal appearing extremities, moves all extremities spontaneously without difficult. No clubbing or cyanosis.
NEURO: Normal muscle strength and tone.
SKINS: Pink, warm, dry. No rashes, normal skin turgor.
PE - Infant
GENERAL: Alert, active when aroused. NAD. Appropriately interactive.
HEENT: Anterior fontanelle open and flat. Conjunctiva clear, ears have normal shape and position with no pits or tags. Nares patent. Palate intact. Mucous membranes moist. TM’s clear bilaterally.
NECK: Full range of motion.
CARDIOVASCULAR: Normal precordium, regular rate and rhythm. No murmurs. Normal femoral pulses.
RESPIRATORY: Clear to auscultation bilaterally. No retractions.
ABDOMEN: Soft, nondistended. Normal bowel sounds. Umbilical stump is clean, dry, and intact without purulent drainage or surround redness.
GENITOURINARY: Normal external [female/+/- circumcised male] genitalia. Anus externally normal.
MUSCULOSKELETAL: Spine straight. No sacral dimple or hair tuft. Leg lengths grossly symmetric.
SKIN: Warm and pink with brisk peripheral and truncal capillary refill. No jaundice.
NEUROLOGICAL: Normal tone. Moves all extremities equally. [***Normal root, suck, grasp, and Moro reflexes (3-4 months)]
EKG
EKG (Interpreted by me, Krista Moore, MD):
Sinus rhythm with a ventricular rate of [#]
QTc [***]ms
No ST segment elevations/depressions, T wave inversions or other ischemic changes
CXR
Chest X-Ray (Interpreted by me, Krista Moore, MD):
Trachea midline. No free air under the diaphragm, no widened mediastinum/pneumomediastinum appreciated. No pneumothorax visualized.
**Cardiac borders and costophrenic angles clear.
**No focal consolidations or pleural effusions appreciated.
MDM - Scripps LJ
MDM - NMCSD
Insert Block
[***]
Labs
CBC: no leukocytosis/leukopenia, no anemia, or thrombocytopenia
CMP: [***] glucose, with no elevation in anion gap. No severe electrolyte abnormalities, evidence of renal dysfunction or acute liver/biliary disease or metabolic derangements.
[Lipase: patient’s lipase is normal and no indication of pancreatic dysfunction or pancreatitis]
[TROP: High sensitivity troponin not consistent with acute myocardial infarction]
[UA without evidence of infection or hematuria]
[HCG]
[***]
PE - Trauma
PRIMARY SURVEY
AIRWAY: intact, talking
BREATHING: equal, bilateral chest rise and fall, +breath sounds bilaterally, no chest wallcrepitus
CIRCULATION: peripheral pulses intact in BUE and BLE, pelvis stable, no signs of hemorrhage
DISABILITY: Moves all extremities equally, sensation intact to bilateral upper and lower extremities, GCS * (E, V **, M )
[GLUCOSE]
EXPOSURE: no abrasions/lacerations/contusions
FAST exam: ***
SECONDARY SURVEY
HEAD: normocephalic, no evidence of trauma to the face or scalp
EYES: Conjunctiva clear, pupils equal, round and reactive at * mm bilaterally, extra occular movements intact
ENT: midface stable, no nasal septal hematomas, no dental malocclusions or intraoral lesions
NECK: no C-spine midline or paraspinal tenderness to palpation, full and pain-free range of motion. [] In c-collar
CHEST: no chest wall tenderness or crepitus
ABDOMEN: soft, non-distended, non-tender, no rebound/guarding
PELVIS: non-tender, stable to compression
BACK: No midline or paraspinal tenderness to palpation, step offs or signs of trauma in the thoracic, lumbar and sacral sign. Sphincter tone present
EXTREMITIES: no deformities; pain free and normal range of motion at all joints; normal cap refill. [**] Compartments are soft, no muscle rigidity.
SKIN: no contusions, abrasions/lacerations, burns. No active bleeding from skin
Considered Admission
Admission considered, but ultimately, after extensive workup and reevaluation, does not appear to be indicated at this time. I judge the possibility of clinical deterioration unlikely, and I believe the patient is a reasonable outpatient candidate. Plan for follow up with [***]
C spine clearance
Cervical spine clearance: The patient is alert and oriented, GCS 15, does not appear clinically intoxicated, has no distracting/painful injury, no complaints of neck pain, a non-tender midline c-spine on palpation, no paresthesias in extremities, and no peripheral strength or sensory deficits. With c-collar removed, patient able to actively range neck through full flexion/extension without pain. C-spine cleared based on consideration of Canadian C-spine criteria, NEXUS criteria and clinical gestalt.
Admit Info - Message template
EMA DRAGON phrases to copy
My Sepsis
My Resident - at the top of every note
My ED Course
My Critical Care Time
My observations
My Restraints
