Author: Nate

Altered Mental Status – General

MDM

This is a @AGE@ @GENDER@ presenting with altered mental status, concerning for ***. The differential includes toxic metabolic etiologies such as electrolyte disturbances (Na/Ca), hypoglycemia, and uremia; acidosis states, infection (i.e. Sepsis); toxidromes of intoxication or withdrawal, hypoxemia or hypercarbia, liver disease or failure causing hepatic encephalopathy, endocrine emergencies (hyper/hypothyroidism, adrenal insufficiency), seizure, trauma, intracranial bleeds or ischemic stroke. Given this wide differential, will send basic labs and lytes to evaluate for metabolic causes, FSBS, LFTs,, TSH, ***CT head, ***blood gas. ***LP?/abx?

 

RLQ Abdominal Pain

MDM, Peds

This is a *** with RLQ pain, most concerning for ***. Differential diagnoses: appendicitis, ***. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Low suspicion for acute hepatobiliary disease (includng acute cholecystitis), acute infectious processes (pneumonia, hepatitis, pyelonephritis), vascular catastrophe, bowel obstruction or viscus perforation. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.

Plan: labs, UA, CT AP ***, pain control, fluids, serial reassessment

General Abdominal Pain – Lo Risk

MDM

Differential diagnosis includes: ***. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Low suspicion for acute hepatobiliary disease (includng acute cholecystitis), acute pancreatitis, PUD (including perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute appendicitis, vascular catastrophe, bowel obstruction or viscus perforation. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.

Plan: labs, UA, CT AP***, pain control, serial reassessment

Epigastric Pain – low risk

MDM

Presentation consistent with acute epigastric abdominal pain. Differential diagnosis includes ***. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Low suspicion for acute hepatobiliary disease (includng acute cholecystitis), acute pancreatitis, PUD (including perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), atypical appendicitis, vascular catastrophe, bowel obstruction or viscus perforation. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.

Plan: labs, UA, GI cocktail, RUQ US ***, serial reassessment

-Courtesy Adam Evans

Peds – Appy rule out

Peds

*** is a ***y/o child who presents with abdominal pain, vomiting, anorexia, concerning for appendicitis. Differential includes gastritis or early gastroenteritis, although history suggests appy is at least equally likely. Intussusception, Meckel’s also a possibility but would be atypical given patient age. Similarly volvulus or malrotation unlikely given otherwise well-appearing patient without peritonitic/rigid abdomen. Unlikely to represent UTI given no dysuria, no suprapubic tenderness. Would be an atypical presentation of pneumonia and patient is normoxemic without dyspnea or cough. Low index of suspicion for ***gynececological etiologies such as torsion, TOA, or ectopic given *** OR ***testicular torsion, orchitis/epididymitis given ***.

Plan: ***

Peds – Gastritis – Nontoxic

Peds

*** is a *** y/o otherwise healthy *** with midepigastric pain worsened with eating, most consistent with gastritis. Reassuring that his pain was relieved with OTC antacids. Differential includes GERD, early gastroenteritis, PUD. Low suspicion for referred cardiac etiologies given age and lack of fmhx early heart disease. Denying chest pain. No infectious symptoms (tachypnea, fever/chills, etc) to suggest bacterial infection such as PNA or biliary tree infection. No urinary symptoms to suggest UTI, no RLQ or migratory pain or fever to indicate a concern for appy. No blood/mucus in stool to suggest invasive bacterial species. Otherwise well-appearing child, tolerating adequate PO and not dehydrated.

Plan: discharge to home with return precautions, encourage PO hydration, ***recommend OTC meds such as ranitidine, tums

Peds – Gastro/AGE – Nontoxic

Peds

This is a *** pt presenting with abdominal pain, +fever, +myalgias, +diarrhea, and nausea most consistent with viral gastroenteritis. ***sick contacts with similar symptoms. Differential includes invasive/toxic diarrhea, sepsis, influenza, along with the far less likely surgical etiologies such as volvulus, appendicitis, malro, and SBO. No change in diet or abnormal exposures. No known stagnant water exposure, recent camping/hiking. No dietary history or bloody BM’s suggestive of B. Cereus, S. Aureus, or other invasive bacterial enteric pathogens. Pt with good capillary refill (<2 sec), MMM, and is nonseptic in appearance. Clinically is not dehydrated.  Unlikely to represent unusual manifestation of UTI, GERD, partial or complete anatomical obstruction, or other acute abdomen. Pt tolerating PO rehydration and is very well-appearing.

Plan: Presumed self-limited etiology; plan to DC home with return precautions and oral rehydration education.

Peds Cough – URI

Peds

*** year old *** presenting with cough. Patient is afebrile. Presentation consistent with uncomplicated viral URI given classic history and physical exam, positive sick contacts, and well-appearing child***. No warning signs of systemic infection (fevers, tachypnea) to suggest pneumonia, and lung sounds clear on exam. No photophobia or neck stiffness/pain to suggest meningitis. No rash. No clinical evidence of dehydration and child is taking excellent PO and making multiple wet diapers per day. Patient has attentive parents and good follow up.

Plan: Discharge to home with strict return precautions, encourage PO hydration, return to ***clinic/ER in 48 hours if no improvement