Author: Nate

MDM – MVA Discharge

MDM

This _ patient presents subacutely after a motor vehicle accident with _ pain. Normal appearing without any signs or symptoms of serious injury on secondary trauma survey. Low suspicion for ICH or other intracranial traumatic injury. No seatbelt signs or abdominal ecchymosis to indicate concern for serious trauma to the thorax or abdomen. Pelvis without evidence of injury and patient is neurologically intact.

Stable gait, tolerating PO. Will give pain control, plain films_, CT_, likely discharge

MDM – Vaginal Bleeding, NonPregnant

MDM

This patient presents with *** days vaginal bleeding most likely of nonemergent etiology.

ED Workup: CBC, BMP, UA, bHCG, Type&Screen

Based on History, Exam, and ED Workup patient’s presentation not consistent with ectopic pregnancy, molar pregnancy, life-threatening coagulopathy, trauma, serious bacterial infection, central process or other emergency.

Most likely, patient’s bleeding is secondary to fibroids or other non-emergent cause of abnormal uterine bleeding.

Disposition: Will discharge home with return precautions and instruction for prompt OBGYN follow up.

*courtesy tydotphrase.wordpress.com

MDM – Torsion/Pelvic Pain

MDM

This female patient presents with lateralized pelvic pain, concerning for torsion. DDX includes TOA, PID, and other infectious symptoms but patient has no constitutional symptoms of infection. Ectopic is on the differential but unlikely. Also includes UTI, pyelo, endometriosis, adenomyosis but these are less likely. Doubt appendicitis or other primary gastrointestinal process.

Plan: labs, upreg, pelvic US, consder CT scan, pain and nausea control, fluid resuscitation, reassess

MDM – Transplant Rejection

MDM

This *** patient with a history of transplant, on immunosuppression, presents with *** concerning for acute rejection vs infection. Differential diagnosis includes ***.  I considered, but think unlikely, emergent causes of these symptoms in an immunosuppressed patient, including opportunistic infections, donor-related infections such as CMV, but think these are unlikely.

Plan: basic labs, hold immunosuppression, gentle fluid resuscitation, discuss with transplant team, low threshold for empiric antibiotics and/or pulse dose steroids.

 

 

Pearls: 

  • Most immunosuppression regimens include steroids (out to about 6 months, but can be longer depending on the organ), calcineurin inhibitors (cyclosporine, tacro), and an antiproliferative med (MMF, AZA).
  • Post-transplant lymphoproliferative disorder: your meds knock down your T cell lines so much that your other cell lines escape their checkpoints. Can be mild (a few extra monos) to severe lymphoma.
  • Immunosuppressive medications also have a lot of other organ-specific side effects:
    • HTN/DM
    • GERD/gastritis/gastroparesis (from MMF, steroids).
    • Osteoporosis – easy fractures on the ddx
    • Renal: 25% will develop CKD w/in 1 year. This is from the calcineurin inhibitors.
  • Management:
    • get a tacro/CSA level if they are having an AKI; otherwise, not useful.
    • Hold immunosuppression until d/w transplant team
    • Give stress dose steroids IF on prednisone.
    • BSA and consider antifungals especially if infection source considered to be pulmonary, or if they’ve had prior fungal infections

MDM – Sick Neonate (Peds)

MDM, Peds

This is an ill-appearing *** who presents with lethargy. Differential includes sepsis, congenital heart disease, hypovolemia and hypoxemic states, endocrine emergencies like CAH or thyroiditis, trauma, inborn errors of metabolism, seizures, electrolyte derangements, or intestinal catastrophe. Given this undifferentiated sick neonate, will work up broadly, empiric broad-spectrum antibiotics***, trial of 10cc/kg fluid bolus, resuscitative measures and will consider early airway intervention.

 

Pearls: For a sick kid use THE MISFITS:

Trauma: consider FAST and CTH
– consider vitamin K and Ca if bleeding
Heart disease, hypovolemia, hypoxia
Endocrine (CAH, thyrotoxicosis)

Metabolic – lytes
Inborn errors
Seizures
Formula mishaps
Intestinal catastrophes (volvulus, intuss, NEC)
Toxins
Sepsis

MDM – Vomiting w VPS (Peds)

MDM, Peds

Differential diagnosis includes VPS malfunction or infection producing increased ICP. Other dagnerous causes of acute vomiting are also on the differential including pyloric stenosis, intussusception, appendicitis or SBO although in this patient they are unlikely. Considered viral syndromes (URI, gastritis, gastroenteritis) as well as other non-emergent causes of vomiting.

Given this patient’s shunt, will evaluate with shunt series // CT // limited MRI, discuss with neurosurgery for possible tap, supportive care, reassess.

MDM – Asthma, Mild (Peds)

MDM, Peds

Differential Diagnosis: Cough, wheezing, asthma exacerbation, pneumonia, seasonal allergies, viral syndrome, Pneumothorax.
Rationale: Given the history of cough, difficulty breathing, wheeze and history of asthma, the patient’s symptoms may be attributed to either viral syndrome, pneumonia, acute asthma exacerbation or pneumothorax. Most likely, this represents an acute asthma exacerbation.

1) STAT bronchodilator therapy and steroids will be given, with re-assessments between nebulized treatments.
2) If worsening or persistent symptoms occur, the patient may require critical care management or admission to the hospital.

MDM – Wrist Pain (Peds)

MDM, Peds

This patient presents with wrist pain after a trauma, suspicious for a Salter-Harris fracture. Will obtain plain films to evaluate; ortho consultation for high-grade or unstable fracture patterns, pain control, reassessment. Will likely splint with follow up in ortho clinic pending reassessment.

 

Pearls: SALTR
Grade 1: Straight: usually can’t see on XR
Grade 2: Above the physis (away from the joint)
Grade 3: Lower – below the physis (near the joint)
Grade 4: Through – through the physis. Unstable; will need operative repair.
Grade 5: Crush/Compression injury. Rare; difficult to pick up on initial XR. Usually from axial load force to extremity. Must consult ortho ASAP.

MDM – Cellulitis (DC)

Uncategorized

This patient presents with initial presentation of local erythema, warmth, swelling concerning for cellulitis.
Sensitivity/pain to light touch around the erythematous area.
No lymphangitic spread visible and no fluid pockets or fluctuance c/f abscess noted.
Low c/f osteomyelitis or DVT.
No immune compromise, bullae, pain out of proportion, or rapid progression c/f necrotizing fasciitis.

In ED: Erythema outlined
Rx: Cephalexin 500mg PO q6hrs,_

Disposition: No evidence of serious bacterial illness requiring admission for IV antibiotics. Nontoxic appearing, VSS. Low risk for treatment failure based on history. Will discharge home with PO antibiotics and return precautions discussed at bedside.

MDM – Biceps Tendon Problem

MDM, Physical Exam

This _ presents with upper arm pain and exam findings suspicious for a biceps tendon rupture. Differential includes bursitis, muscle strain, partial tear, fracture, and elbow pathology. Neurovascularly intact distal to the injury.

Plan: plain films, urgent orthopedic referral, pain control, reassessment, anticipating discharge

 

PEARLS:
– Classic mechanism for biceps tendon rupture:
— FOOSH – proximal rupture
— Elbow forced straight against resistance – distal
– Exam: “popeye’s sign” from rupturing of the long head of the biceps. Probably will be able to still flex a little if it’s proximal.
– If they have a distal rupture, they will have marked ecchymosis over the AC and marked weakness on flexion
– Hook test: you should be able to get about 1 cm under the biceps tendon with your finger as a ‘hook’

  • Proximal ruptures are usually managed nonop; distal ruptures require near-term urgent ortho f/u.