MDMs
aFIB paroxysmal, reverted
yo F w new onset paroxysmal aFIB symptomatic w SOB when in aFIB w RVR. No known underlying etiology, no h/o HF, CVA, hyperthyroidism; no symptoms of infection, unlikely MI.
In the ED we drew basic labs and assessed for infection with UA, CXR, and blood cultures as well as cardiac markers (Trop and BNP), TSH. Uncertain historical reliability w history of onset; will defer cardioversion.
CHADS VASC score:
Plan vagal maneuvers followed by 0.25mg/kg Diltiazem if aFIB w RVR recurs
aFIB + RVR + CHF
CHF, COPD, aFIB, and DM2 p/w 3d cough, worsening SOB, and one day of nausea/vomiting c/f acute decompensated HF. BUS shows moderately reduced EF though hard to assess given tachycardia. aFib w RVR present on admission. Active smoker.
Unlikely PE: sustained tachycardia more likely from afib, SOB but not on any exogenous estrogen, no recent travel or operations, no CA history, ambulatory at home.
Possible COPD exacerbation: new cough, h/o COPD, wheezing on initial exam
Unlikely tamponade. Unlikely MI- trop indeterminate, will trend trop and ekg inpatient, possibly demand ischemic elevation.
Not PTX: normal CXR, bilateral lung sounds
Not Esophageal rupture: no dysphagia
Not PNA: SOB, cough, but afebrile and CXR negative
Pt in mild to moderate acute decompensated HF currently in mild respiratory distress and has not responded to rate control with 10mg Dilt; Bblockers contraindicated. Treating for CHF with Lasix IV and considering amiodarone as well as digoxin as a secondary agent. Amiodarone 150 IV load, then 1mg /min 6 hr, then .5mg/18hr. 30 PO q6 dilt.
Ankle Pain
Traumatic:
Unlikely foot fracture: weight bearing, no malleolar tenderness, negative ottawa ankle criteria, low grade mechanism of trauma
Unlikely sprain/tendon injury: no history of trauma
Not an achilles tendon rupture - Negative Thompson's test
- XR foot and ankle
Infectious:
Unlikely septic arthritis: afebrile, WBC count nml, full ROM
Unlikely gonococcal arthropathy: no recent STD symptoms
- Joint aspirate
Other:
Unlikely gout: no focal joint swelling, no recent bouts of drinking or meat intake
Unlikely reactive arthritis: No vision changes, no dysuri, no migratory arthropathy
Unlikely Lupus: no malar rash, no other arthropathy
Abdominal pain General + Female AP
Unlikely AAA- location inconsistent, no bruits, no h/o HTN,
Unlikely cholecystitis - location inconsistent, no relation with meals, neegative murphy's
Unlikely SBO - pt having normal BMs and flatus. No N/V
Unlikely Appy - location inconsistent, no anorexia, no fever
Unlikely Mes Isch- HPI inconsistent, does not coincide with meals, other dx more likely
Unlikely kidney stone- no radiation to back or CVA tenderness, no dysuria, no hematuria
Unlikely Pancreatitis - no h/o alcohol abuse, unlikely gallstone obstructing, location inconsistent
Unlikely Diverticulitis - age and location not most common, no h/o diverticula, no fever, no WBC, no bloody stool
Unlikely TOA- no systemic symptoms, location inconsistent, pelvic exam benign
Not Ectopic - negative ICON
Unlikely torsion - no adnexal tenderness
Unlikely PID - no h/o STDs, monogamous w partner also expected to be monogamous, no vaginal discharge
Back pain
constellation of symptoms similar to prior flares.
Low suspicion for acute cord compression or cauda equina at this time, given presentation and symptoms, including epidural abscess or hematoma. Patient has no history of malignancy, active or distant history. Patient has no unexplained weight loss. No recent fevers, rigors, malaise, or recent infection. No history of IVDU or skin-popping. Patient does not have any history concerning for saddle anesthesia/perianal sensory loss or complaining of decreased rectal tone. Patient does not have urinary retention or inability to control urine from overflow. Patient has no tenderness overlying spinous process. Patient has no focal weakness on examination.
Given exam and history, low suspicion for cord compression, cauda equina, epidural abscess/hematoma. Distally neurovascuarly intact. Query likely musculoskeletal component versus sciatica. Discussed pain control, physical therapy and follow up with PMD. Cautious return precautions discussed w/ full
CP MDM
Pt w PMH MI s/p stent (currently not anticoagulated and not compliant w meds due to social issues) p/w CP 1day w radiation to left arm
Unlikely PE: Nml rate, no SOB, no recent immobilization, no recent surgery, nonsmoker
Not PNA: neg CXR findings, no leukocytosis, afebrile, no SOB, no cough, CTAB
Unlikely tamponade: normal EKG
Not STEMI: normal EKG
Possible NSTEMI: Trop ordered
Not PTX: normal CXR, bilateral lung sounds
Not Esophageal rupture: no dysphagia
Plan to treat pain with NTG, anticoagulate with ASA 324, Trop, CXR, repeat EKG, basic labs admit to OBS vs Cardiology
CPLOW RISK
with no history of tobacco abuse, otherwise healthy, p/w atypical chest pain, subacute worsening of chronic pain. No overt risk factors for ACS and serial EKGs and troponins without overt e/o NSTEMI. Pain reproducible on exam with likely musculoskeletal component. Low Wells score with low risk for PE and no significant hypoxia. Given chronicity, low s/f dissection. Pain controlled, well appearing. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
Dizziness
yo male with no known sig PMH p/w dizziness for one day described as lightheadedness.
Unlikely vertigo: Pt has negative dix hallpike nystagmus or recreation of symptoms, not described as room spinning, episodes last longer than 30minutes
Unlikely AOM: no ear pain, not the most common age, no TM bulging
Unlikely labyrinthitis: no hearing loss or preceding URI
Unlikely tumor/mass: more acute in onset
Unlikely meningitis: Pt afebrile, nontoxic appearing, no meningismus
Unlikely Stroke: no focal neuro deficits
Unlikely GI bleed
Unlikely other infectious process
DKA
Unlikely precipitated by infection, infarction, insulin changes or surgery. Pt is type 2 diabetic with changes in eating patterns, insulin regimen, and recent meth and cocaine use.
- IVF NS 1L/hr-->.45NS@200/hr-->D5 1/2NS @200/hr
- Potassium>3.3: check q2hr, if 3.3-5.3 include K20 in each liter of IVF
- Insulin 0.1U/kg bolus + 0.1U/kg/hr gtt
Red Eye
yo p/w eye redness and irritation ML Conjunctivitis with generalized scleral injection.
Unlikely corneal ulcer: no white/gray lesion or pooling on fluorescein exam.
Unlikely uveitis/iritis: no history of trauma, no cell and flare on silt lamp, no consensual photophobia.
Unlikely uveitis: Unlikely Acute angle glaucoma: minimal eye pain, minimal change in vision, no hazy cornea, PERRLA, normal IOP, no change in pain in dark vs light room.
Unlikely Scleritis: no h/o autoimmune disorder, no violet/blue discoloration on sclera, no scerla edema, minimal eye pain. No TTP in the globe.
Flank Pain
flank pain consistent with previous kidney stone pain. Patient otherwise well-appearing with low suspicion for sepsis, dissection or infected obstructed renal colic. US w/ mild hydronephrosis on affected side. Will obtain CT noncon, labs, UA, reassess. Low suspicion for atypical appendicitis, torsion, acute chole, or intraabdominal infection. Discussed conservative management, strict return precautions and follow up with urology. Will discharge with flomax, NSAIDs, opiates for breakthrough, strainer, and antiemetics. Patient tolerating PO and pain controlled prior to discharge. Strict return precautions for infected stone or po intolerance discussed. Low suspicion for AKI, obstructive nephropathy given exam and history.
GERD
No history of tobacco or alcohol abuse, otherwise healthy, p/w atypical chest pain, subacute worsening of chronic pain. No overt risk factors for ACS and EKG and troponinwithout overt e/o NSTEMI. Low Wells score with low risk for PE and no significant hypoxia. Unlikely PNA or PTX. Given chronicity, low s/f dissection. No RUQ pain c/f cholecystitis, murphy's negative. Unlikely pancreatitis.
GI Bleed
Presents to ED with mixed coffee ground and bright red hematemesis. Black stool per rectum.
Labs:
CBC
BMP: Anion gap acidosis--> but with elevated sugars
LFTs: Alcoholic hepatitis
PT/INR nml
Lipase: nml
Therapy:
Pain- morphine
Antiemetic/antinausea- zofran
Octreotide 80/8 mg push/drip
Protonix 50/50 mcg push/drip
Thiamine 100mg IM
Imaging:
CT Head noncon (for possible head trauma):
CT abdomen w IV contrast (for possible perforation):
Glasgow-Blatchford Bleeding Score (GBS): 16 indicating need for admission. Plan stepdown ICU if scans negative since patient is alcoholic, possibly withdrawing, and on a drip
Maddrey’s Discriminant Function for Alcoholic Hepatitis (>30 suggests poor prognosis and benefits from steroid Tx):
Headache
who presents with Headache. Most likely 2/2 tension headache, migraine, or headache of non-emergent etiology. No focal neurological symptoms. Neuro exam is benign. Pt is nontoxic. VSS.
Unlikely SAH: headache is non thunderclap. Headache is gradual, non-maximal at onset and similar to headaches in the past.
Unlikely Subdural/epidural hematoma: no history of trauma, no anticoagulation.
Unlikely Meningitis: afebrile, no meningismus, mild photophobia.
Unlikely Temporal arteritis: pt < 60 years old. no tenderness in temporal area
Unlikely Acute angle glaucoma: PEERL, no eye pain.
Unlikely Carbon Monoxide Poisoning: no other house members with similar symptoms.
Plan: Will give pain medication and reexamine
Laceration
Pt is a yo M who presents after causing a linear laceration to his , hours ago. XR shows no fracture, dislocation, or foreign body. Laceration unlikely contaminated requiring ABX. Clean bottom of a bloodless field was witnessed on exam. Neurosensory exams and circulation appropriate distal to the wound. FROM. Wound closed with nonabsorbable sutures and neurosensory + circulatory exams same after repair as before. Will Dc with return precautions, instructions for home care and follow up with PCP as well for suture removal. Pain is under control.
Sore Throat
pt p/w sore throat.
Unlikely strep throat: No LAD, cough present, afebrile, no pharyngeal exudate
Unlikely EBV/Mono: No prolonged course, no posterior LAD, no splenomegaly
Unlikely acute HIV: No LAD, No GI upset, no skin rash, not sexually active, not IVDU
No peritonsillar abscess: No LAD, no hot potato voice, no uvular displacement, no redness or swelling in tonsillar area, afebrile
No retropharyngeal abscess: No neck pain, no dysphagia, No LAD, no croup like cough, afebrile
No obstructive processes such as obstructive goiter or ludwigs angina
Testicular Pain
Unlikely hydrocele: no scrotal swelling
Unlikely torsion: No pain currently, cremasteric reflex present
Unlikely varicocele: no visibly or palpably enlarged vein
Unlikely epididymitis: no urethral discharge, no fever, no MSM, no epididymal TTP or swelling
TIA
Sxs concerning for re-expression of prior stroke sxs, and notably pt has had more urinary frequency concerning for infection from urinary source though UA neg***. Other infectious sources neg (CXR showed no evidence of PNA, and pt afebrile, no evidence of leukocytosis or other SIRS physiology). No e/o metabolic derangements. However would also consider TIA event, particularly in this higher risk patient with prior stroke hx and moderate ABCD2 score (4)***, despite currently therapeutic on warfarin. Doubt seizure as interactive/conversant throughtout and no witnessed GTC event (would be unusual to have Todd's paralysis without generalized event). warrant neurology admission for further stroke workup and risk factor stratification.
Chance trial- TIA
In the CHANCE (Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events) trial, a 21-day course of aspirin plus clopidogrel started immediately after a TIA or minor stroke outperformed aspirin alone in reducing the risk for a subsequent stroke, without significantly increasing the risk of major bleeding complications.[3] The hazard ratio for stroke-free survival at 90 days in the combination treatment group was 0.68. Severe bleeding occurred in about 0.2% of patients in both groups.
Urticaria
Pt is a 45yo F with h/o DM2 and R foot ulcer presenting today for 3 days of diffuse urticaria and RLE rash. She does not know of any new agents that she could have contacted through clothes/other or through ingestion with medication/other. She has no systemic symptoms, no fever, nausea, vomiting. Her main concern is over extreme pruritis. Better with benadryl in ED. Low concern for DVT or cellulitis. Likely vasculitis on RLE presenting with diffuse urticaria. Discharging with return precautions, known follow up with podiatry in less than a month, short course prednisone, and benadryl PRN.
Vaginal Bleeding
yo pt p/w one month vaginal bleeding
Hemorrhagic cystitis unlikely: No dysuria
PCOS unlikely: No changes in hair distribution, no weight change, no change in acne
Not PID: No CMT, no discharge
Unlikely pituitary changes
Not due to exogenous hormonal sources
Not pregnant
Possible fibroid: consider necrotic fibroid
Pelvic US. Type and screen, coags. IVF and repeat CBC - performed after 1/2L NS shows ***. Consult gyn
yo F w new onset paroxysmal aFIB symptomatic w SOB when in aFIB w RVR. No known underlying etiology, no h/o HF, CVA, hyperthyroidism; no symptoms of infection, unlikely MI.
In the ED we drew basic labs and assessed for infection with UA, CXR, and blood cultures as well as cardiac markers (Trop and BNP), TSH. Uncertain historical reliability w history of onset; will defer cardioversion.
CHADS VASC score:
Plan vagal maneuvers followed by 0.25mg/kg Diltiazem if aFIB w RVR recurs
aFIB + RVR + CHF
CHF, COPD, aFIB, and DM2 p/w 3d cough, worsening SOB, and one day of nausea/vomiting c/f acute decompensated HF. BUS shows moderately reduced EF though hard to assess given tachycardia. aFib w RVR present on admission. Active smoker.
Unlikely PE: sustained tachycardia more likely from afib, SOB but not on any exogenous estrogen, no recent travel or operations, no CA history, ambulatory at home.
Possible COPD exacerbation: new cough, h/o COPD, wheezing on initial exam
Unlikely tamponade. Unlikely MI- trop indeterminate, will trend trop and ekg inpatient, possibly demand ischemic elevation.
Not PTX: normal CXR, bilateral lung sounds
Not Esophageal rupture: no dysphagia
Not PNA: SOB, cough, but afebrile and CXR negative
Pt in mild to moderate acute decompensated HF currently in mild respiratory distress and has not responded to rate control with 10mg Dilt; Bblockers contraindicated. Treating for CHF with Lasix IV and considering amiodarone as well as digoxin as a secondary agent. Amiodarone 150 IV load, then 1mg /min 6 hr, then .5mg/18hr. 30 PO q6 dilt.
Ankle Pain
Traumatic:
Unlikely foot fracture: weight bearing, no malleolar tenderness, negative ottawa ankle criteria, low grade mechanism of trauma
Unlikely sprain/tendon injury: no history of trauma
Not an achilles tendon rupture - Negative Thompson's test
- XR foot and ankle
Infectious:
Unlikely septic arthritis: afebrile, WBC count nml, full ROM
Unlikely gonococcal arthropathy: no recent STD symptoms
- Joint aspirate
Other:
Unlikely gout: no focal joint swelling, no recent bouts of drinking or meat intake
Unlikely reactive arthritis: No vision changes, no dysuri, no migratory arthropathy
Unlikely Lupus: no malar rash, no other arthropathy
Abdominal pain General + Female AP
Unlikely AAA- location inconsistent, no bruits, no h/o HTN,
Unlikely cholecystitis - location inconsistent, no relation with meals, neegative murphy's
Unlikely SBO - pt having normal BMs and flatus. No N/V
Unlikely Appy - location inconsistent, no anorexia, no fever
Unlikely Mes Isch- HPI inconsistent, does not coincide with meals, other dx more likely
Unlikely kidney stone- no radiation to back or CVA tenderness, no dysuria, no hematuria
Unlikely Pancreatitis - no h/o alcohol abuse, unlikely gallstone obstructing, location inconsistent
Unlikely Diverticulitis - age and location not most common, no h/o diverticula, no fever, no WBC, no bloody stool
Unlikely TOA- no systemic symptoms, location inconsistent, pelvic exam benign
Not Ectopic - negative ICON
Unlikely torsion - no adnexal tenderness
Unlikely PID - no h/o STDs, monogamous w partner also expected to be monogamous, no vaginal discharge
Back pain
constellation of symptoms similar to prior flares.
Low suspicion for acute cord compression or cauda equina at this time, given presentation and symptoms, including epidural abscess or hematoma. Patient has no history of malignancy, active or distant history. Patient has no unexplained weight loss. No recent fevers, rigors, malaise, or recent infection. No history of IVDU or skin-popping. Patient does not have any history concerning for saddle anesthesia/perianal sensory loss or complaining of decreased rectal tone. Patient does not have urinary retention or inability to control urine from overflow. Patient has no tenderness overlying spinous process. Patient has no focal weakness on examination.
Given exam and history, low suspicion for cord compression, cauda equina, epidural abscess/hematoma. Distally neurovascuarly intact. Query likely musculoskeletal component versus sciatica. Discussed pain control, physical therapy and follow up with PMD. Cautious return precautions discussed w/ full
CP MDM
Pt w PMH MI s/p stent (currently not anticoagulated and not compliant w meds due to social issues) p/w CP 1day w radiation to left arm
Unlikely PE: Nml rate, no SOB, no recent immobilization, no recent surgery, nonsmoker
Not PNA: neg CXR findings, no leukocytosis, afebrile, no SOB, no cough, CTAB
Unlikely tamponade: normal EKG
Not STEMI: normal EKG
Possible NSTEMI: Trop ordered
Not PTX: normal CXR, bilateral lung sounds
Not Esophageal rupture: no dysphagia
Plan to treat pain with NTG, anticoagulate with ASA 324, Trop, CXR, repeat EKG, basic labs admit to OBS vs Cardiology
CPLOW RISK
with no history of tobacco abuse, otherwise healthy, p/w atypical chest pain, subacute worsening of chronic pain. No overt risk factors for ACS and serial EKGs and troponins without overt e/o NSTEMI. Pain reproducible on exam with likely musculoskeletal component. Low Wells score with low risk for PE and no significant hypoxia. Given chronicity, low s/f dissection. Pain controlled, well appearing. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
Dizziness
yo male with no known sig PMH p/w dizziness for one day described as lightheadedness.
Unlikely vertigo: Pt has negative dix hallpike nystagmus or recreation of symptoms, not described as room spinning, episodes last longer than 30minutes
Unlikely AOM: no ear pain, not the most common age, no TM bulging
Unlikely labyrinthitis: no hearing loss or preceding URI
Unlikely tumor/mass: more acute in onset
Unlikely meningitis: Pt afebrile, nontoxic appearing, no meningismus
Unlikely Stroke: no focal neuro deficits
Unlikely GI bleed
Unlikely other infectious process
DKA
Unlikely precipitated by infection, infarction, insulin changes or surgery. Pt is type 2 diabetic with changes in eating patterns, insulin regimen, and recent meth and cocaine use.
- IVF NS 1L/hr-->.45NS@200/hr-->D5 1/2NS @200/hr
- Potassium>3.3: check q2hr, if 3.3-5.3 include K20 in each liter of IVF
- Insulin 0.1U/kg bolus + 0.1U/kg/hr gtt
Red Eye
yo p/w eye redness and irritation ML Conjunctivitis with generalized scleral injection.
Unlikely corneal ulcer: no white/gray lesion or pooling on fluorescein exam.
Unlikely uveitis/iritis: no history of trauma, no cell and flare on silt lamp, no consensual photophobia.
Unlikely uveitis: Unlikely Acute angle glaucoma: minimal eye pain, minimal change in vision, no hazy cornea, PERRLA, normal IOP, no change in pain in dark vs light room.
Unlikely Scleritis: no h/o autoimmune disorder, no violet/blue discoloration on sclera, no scerla edema, minimal eye pain. No TTP in the globe.
Flank Pain
flank pain consistent with previous kidney stone pain. Patient otherwise well-appearing with low suspicion for sepsis, dissection or infected obstructed renal colic. US w/ mild hydronephrosis on affected side. Will obtain CT noncon, labs, UA, reassess. Low suspicion for atypical appendicitis, torsion, acute chole, or intraabdominal infection. Discussed conservative management, strict return precautions and follow up with urology. Will discharge with flomax, NSAIDs, opiates for breakthrough, strainer, and antiemetics. Patient tolerating PO and pain controlled prior to discharge. Strict return precautions for infected stone or po intolerance discussed. Low suspicion for AKI, obstructive nephropathy given exam and history.
GERD
No history of tobacco or alcohol abuse, otherwise healthy, p/w atypical chest pain, subacute worsening of chronic pain. No overt risk factors for ACS and EKG and troponinwithout overt e/o NSTEMI. Low Wells score with low risk for PE and no significant hypoxia. Unlikely PNA or PTX. Given chronicity, low s/f dissection. No RUQ pain c/f cholecystitis, murphy's negative. Unlikely pancreatitis.
GI Bleed
Presents to ED with mixed coffee ground and bright red hematemesis. Black stool per rectum.
Labs:
CBC
BMP: Anion gap acidosis--> but with elevated sugars
LFTs: Alcoholic hepatitis
PT/INR nml
Lipase: nml
Therapy:
Pain- morphine
Antiemetic/antinausea- zofran
Octreotide 80/8 mg push/drip
Protonix 50/50 mcg push/drip
Thiamine 100mg IM
Imaging:
CT Head noncon (for possible head trauma):
CT abdomen w IV contrast (for possible perforation):
Glasgow-Blatchford Bleeding Score (GBS): 16 indicating need for admission. Plan stepdown ICU if scans negative since patient is alcoholic, possibly withdrawing, and on a drip
Maddrey’s Discriminant Function for Alcoholic Hepatitis (>30 suggests poor prognosis and benefits from steroid Tx):
Headache
who presents with Headache. Most likely 2/2 tension headache, migraine, or headache of non-emergent etiology. No focal neurological symptoms. Neuro exam is benign. Pt is nontoxic. VSS.
Unlikely SAH: headache is non thunderclap. Headache is gradual, non-maximal at onset and similar to headaches in the past.
Unlikely Subdural/epidural hematoma: no history of trauma, no anticoagulation.
Unlikely Meningitis: afebrile, no meningismus, mild photophobia.
Unlikely Temporal arteritis: pt < 60 years old. no tenderness in temporal area
Unlikely Acute angle glaucoma: PEERL, no eye pain.
Unlikely Carbon Monoxide Poisoning: no other house members with similar symptoms.
Plan: Will give pain medication and reexamine
Laceration
Pt is a yo M who presents after causing a linear laceration to his , hours ago. XR shows no fracture, dislocation, or foreign body. Laceration unlikely contaminated requiring ABX. Clean bottom of a bloodless field was witnessed on exam. Neurosensory exams and circulation appropriate distal to the wound. FROM. Wound closed with nonabsorbable sutures and neurosensory + circulatory exams same after repair as before. Will Dc with return precautions, instructions for home care and follow up with PCP as well for suture removal. Pain is under control.
Mild Moderate MVA
otherwise healthy involved in restrained MVA with airbag deployment. Patient with pain predominantly to L paraspinal and L clavicular area. Hemodynamically appropriate with nonfocal neurologic exam. Given exam and history, low suspicion for traumatic dissection or ICH. CT c-spine without overt fracture or dislocation with low suspicion for ligamentous injury on re-examination. Serial abdominal exam without tenderness and FAST initially unremarkable. Observed for several hours in ED with clinical improvement. Stable gait and tolerating PO. Cautious return precautions discussed w/ full understanding. Prompt follow up with primary care physician discussed.
Seizure
Differential diagnosis for seizures include nonadherence to anti-epileptic drugs or lowered seizure threshold from infection but basic infectious workup is negative, so med noncompliance is most likely etiology. Per EMS no known Head trauma, however will CT head as pt altered and unable to give hx w family out of touch. Possible stroke though less likely given overarching symptoms of seizure and no overt focal neuro deficits. S/p midazolam 5mg IV x1 in the field.
SOB
p/w SOB 1day w concomitant generalized weakness
Possible PE: sustained tachycardia, SOB
Confirmed PNA: pos CXR findings, leukocytosis, febrile at home, SOB, cough, tachycardia
Possible COPD exacerbation: productive cough
Unlikely tamponade given normal EKG
Not MI: normal EKG, negative trop
Not PTX: normal CXR, bilateral lung sounds
Not Esophageal rupture: no dysphagia
Sore Throat
pt p/w sore throat.
Unlikely strep throat: No LAD, cough present, afebrile, no pharyngeal exudate
Unlikely EBV/Mono: No prolonged course, no posterior LAD, no splenomegaly
Unlikely acute HIV: No LAD, No GI upset, no skin rash, not sexually active, not IVDU
No peritonsillar abscess: No LAD, no hot potato voice, no uvular displacement, no redness or swelling in tonsillar area, afebrile
No retropharyngeal abscess: No neck pain, no dysphagia, No LAD, no croup like cough, afebrile
No obstructive processes such as obstructive goiter or ludwigs angina
Testicular Pain
Unlikely hydrocele: no scrotal swelling
Unlikely torsion: No pain currently, cremasteric reflex present
Unlikely varicocele: no visibly or palpably enlarged vein
Unlikely epididymitis: no urethral discharge, no fever, no MSM, no epididymal TTP or swelling
TIA
Sxs concerning for re-expression of prior stroke sxs, and notably pt has had more urinary frequency concerning for infection from urinary source though UA neg***. Other infectious sources neg (CXR showed no evidence of PNA, and pt afebrile, no evidence of leukocytosis or other SIRS physiology). No e/o metabolic derangements. However would also consider TIA event, particularly in this higher risk patient with prior stroke hx and moderate ABCD2 score (4)***, despite currently therapeutic on warfarin. Doubt seizure as interactive/conversant throughtout and no witnessed GTC event (would be unusual to have Todd's paralysis without generalized event). warrant neurology admission for further stroke workup and risk factor stratification.
Chance trial- TIA
In the CHANCE (Clopidogrel in High-risk patients with Acute Non-disabling Cerebrovascular Events) trial, a 21-day course of aspirin plus clopidogrel started immediately after a TIA or minor stroke outperformed aspirin alone in reducing the risk for a subsequent stroke, without significantly increasing the risk of major bleeding complications.[3] The hazard ratio for stroke-free survival at 90 days in the combination treatment group was 0.68. Severe bleeding occurred in about 0.2% of patients in both groups.
Urticaria
Pt is a 45yo F with h/o DM2 and R foot ulcer presenting today for 3 days of diffuse urticaria and RLE rash. She does not know of any new agents that she could have contacted through clothes/other or through ingestion with medication/other. She has no systemic symptoms, no fever, nausea, vomiting. Her main concern is over extreme pruritis. Better with benadryl in ED. Low concern for DVT or cellulitis. Likely vasculitis on RLE presenting with diffuse urticaria. Discharging with return precautions, known follow up with podiatry in less than a month, short course prednisone, and benadryl PRN.
Vaginal Bleeding
yo pt p/w one month vaginal bleeding
Hemorrhagic cystitis unlikely: No dysuria
PCOS unlikely: No changes in hair distribution, no weight change, no change in acne
Not PID: No CMT, no discharge
Unlikely pituitary changes
Not due to exogenous hormonal sources
Not pregnant
Possible fibroid: consider necrotic fibroid
Pelvic US. Type and screen, coags. IVF and repeat CBC - performed after 1/2L NS shows ***. Consult gyn
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