MDM

COVID MDM – Test/No Test (3/20)

MDM

This patient presents with symptoms concerning for viral syndrome including flu and SARS-nCoV-2019.

WELL-APPEARING/DISCHARGE

YES: Patient meets criteria to test for COVID-19. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and is safe to discharge home following NP swab. Will add to follow-up list to call with results after. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance.

NO: Patient does NOT meet our current criteria to test for COVID-19, although coronavirus infection is certainly on the differential. Doubt PNA, sepsis, other serious bacterial infection or acute emergent condition. Is otherwise well-appearing with acceptable vitals, a reassuring physical exam, and lacks serious medical comorbidities that would require admission. Patient is nontoxic-appearing and although symptomatic, otherwise safe to go home. Will provide strict return precautions and instructions on self-isolation/quarantine and anticipatory guidance.

ADMITTING (testing)

Patient presentation suspicious for COVID-19 infection. Patient requires admission for their symptoms given ***_. Differential diagnosis includes other viral causes of LRTI, pneumonia, less likely PE, PTX, primary cardiovascular causes, bacterial sepsis, or other severe metabolic/ischemic derangements. Will swab for SARS-nCoV-19, place in enhanced precautions, admit to medicine.

MDM – Peds Fever (Low Risk)

MDM, Peds, Uncategorized

This well-appearing child presents with fever, likely secondary to a urinary source vs viral syndrome. No localizing symptoms of URI or intraabdominal pathology, low suspicion for serious bacterial infection given nontoxic appearance and otherwise healthy child with no major medical problems. Doubt pneumonia or pyelonephritis. Doubt meningitis or appendicitis.

Plan: ***straight cath for urine, antipyretic instructions, reassurance and reassessment, discharge with pediatrics f/u

MDM – Peds Head Trauma

MDM, Peds

LOW RISK, <2 y old

This pediatric patient presents with head trauma. Given mechanism, history, and physical exam findings, we have a low probability of serious injury to include intracranial bleed or skull fracture, DAI, or high risk of decompensation. Given lack of a severe mechanism, GCS 15 or lack of AMS, no occipital/parietal scalp hematoma, and no LOC, risk of obtaining a CT scan outweighs the potential benefit. Will observe patient, PO challenge, reassurance and reassessment, anticipating discharge with PMD follow up.

LOW RISK, >2 y old

This pediatric patient presents with head trauma. Given mechanism, history, and physical exam findings, we have a low probability of serious injury to include intracranial bleed or skull fracture, DAI, or high risk of decompensation. The patient has a GCS of 15 and is not altered, and has no or minimal LOC history. The mechanism is of low energy. In this group, PECARN rules demonstrate an exceptionally low risk of serious intracranial injury and obtaining further imaging is likely to be of little or no benefit.

Plan: observation, pain control, PO challenge, reassurance/reassessment, likely discharge

HIGH RISK: 

This pediatric patient presents with a history concerning for a serious intracranial injury. Unable to clear patient with PECARN rules given ***. Will obtain CT imaging to rule out intracranial injury or skull fracture. Patient is protecting airway and otherwise has an unremarkable secondary trauma survey.

Plan: CT scan head/neck, pain control, reassess

MDM – AKI/Dehydration

MDM

Mild, Discharge: 

This patient presents with generalized weakness and fatigue likely secondary to dehydration. Suspect acute kidney injury of prerenal origin. Doubt intrinsic renal dysfunction or obstructive nephropathy. Considered alternate etiologies of the patient’s symptoms including infectious processes, severe metabolic derangements or electrolyte abnormalities, ischemia/ACS, heart failure, and intracranial/central processes but think these are unlikely given the history and physical exam.

Plan: labs, ***fluid resuscitation, pain/nausea control, reassessment

MDM – Diarrhea (Low Risk)

MDM, Uncategorized

This patient presents with diarrhea consistent with likely viral enteritis. Doubt acute bacterial diarrhea. Considered, but think unlikely, partial SBO, appendicitis, diverticulitis, other intraabdominal infection. Low suspicion for secondary causes of diarrhea such as hyperadrenergic state, pheo, adrenal crisis, hyperthyroidism, or sepsis. Doubt antibiotic associated diarrhea.

Plan: PO rehydration, reassess, discharge with OTC antidiarrheal meds//short course antibiotics

MDM – Toe Pain (Injury)

MDM

This patient presents after a soft tissue injury to the toe. Considered, but doubt, acute fracture including open fracture. Low index of suspicion for a dislocation or Lisfranc injury. Doubt other acute causes of toe pain at this time.

Plan: plain films, pain control, reassess, likely discharge with podiatry/orthopedics followup, WBAT***

MDM – Sickle Cell Pain Crisis, Acute Chest, Stroke

MDM

TYPICAL VASO-OCCLUSIVE CRISIS

This patient with known sickle cell disease presents with their classic pain syndrome for a vaso-occlusive crisis. Considered acute chest, stroke, splenic sequestration, and other emergent complications of sickle cell disease. Considered alternate etiologies of this patient’s pain to include fracture, MSK pain, infection/abscess, and other ischemic etiologies but doubt these are likely.

Will plan for pain control using patient’s pain management plan, basic labs/reticulocyte count, likely discharge

ACUTE CHEST SYNDROME

This patient with known SCD presents with chest/back pain consistent with vaso-occlusive crisis but concerning for acute chest syndrome; this presentation is different than the patient’s typical pain crisis. Considered alternate etiologies of chest pain including acute coronary syndromes, PE, pneumothorax or pneumonia but think this is less likely.

Plan: labs, pain control, fluids, low threshold to transfuse to Hb>9, CXR, discuss with hematology, likely admit

SPLENIC SEQUESTRATION OR STROKE

This patient with sickle cell disease presents with altered mental status, highly concerning for severe range anemia or stroke. Splenic sequestration is also on the differential, although ***given this patient’s age it is quite unlikely that they still have functioning splenic tissue. I considered, but think less likely, other etiologies of altered mental status such as infection, metabolic derangements, or ICH. This symptom constellation is concerning given the underlying medical comorbidities.

Plan: basic labs, reticulocyte count, consider hemolysis labs, XR chest, neuroimaging, probable stroke code activation, neuro and hematology consults, admit

MDM – Shingles

MDM

_ patient with a vesicular rash on an erythematous base in a dermatomal pattern consistent with herpes zoster. Not immunocompromised and without signs of systemic or disseminated infection. Low suspicion for alternate etiology of rash such as SJS, drug rash, viral exanthem, or other emergent cause of rash.

Plan: acyclovir 800mg 5x/day for a week, gabapentin and other pain control, reassessment, likely discharge

MDM – Knee Pain (+)

MDM

LOW RISK

This *** patient presents with knee pain, suspicious for ***. Able to flex and extend although somewhat limited by pain. Considered, but doubt, tibial plateau fracture, septic arthritis, other acute unstable fracture, or significant neurovascular compromise.

Plan: XR, pain control, reassessment

HI RISK – Tibial Plateau

This *** patient presents with knee pain suspicious for a tibial plateau fracture given history, exam, and mechanism. No e/o compartment syndrome, septic arthritis, other acute fracture. Range of motion is ***. Will get plain films, consider CT, likely ortho consultation, pain control, NWB.

PEARLS:

  • Knee EXTENSION is an extremely important motor finding to document. Inability to extend is a key indicator of serious pathology.
  • In peds, follow the medial tibial diaphysis up to the epiphysis – it should be smooth all the way. A bump should make you suspicious for a buckle fracture; it’s frequently missed by radiology.
  • Proximal fibular fractures are associated with a peroneal nerve injury (you should document its status)
  • Tibial plateau fractures are high risk for compartment syndrome.
  • Tibial spine fractures are a) associated with ACL tears and b) often missed unless you order a tunnel view plain film.