MDM

MDM – DVT Discharge

MDM

This _ presents with leg swelling of unclear etiology, concerning for DVT vs cellulitis. DDX includes chronic venous stasis changes, lymphedema, fracture or trauma, MSK pain, and other nonemergent causes of leg swelling. Doubt atypical presentation of CHF or other volume overload states. PE is low on the differential due to normal vital signs without symptoms. Low suspicion for constitutional infection or metabolic derangements.

Plan: basic labs, DVT US, consider plain films, reassess, likely discharge

 

MDM – Head Trauma, Not Sick

MDM

This _ presents with head trauma after a mechanical GLF. DDX includes MSK trauma, facial fractures, ICH or traumatic SAH, C-spine injury. Doubt other extracranial causes of injury. Considered nonmechanical causes of fall such as syncope, primary cardiopulmonary etiologies such as ACS/PE, but think these are unlikely. Will get head/face/neck CT, pain control, C-collar, basic labs, reassess, discharge

MDM – Withdrawal

MDM

This _ patient presents with tremulousness, vomiting, and recent ETOH abuse suspicious for withdrawal. DDx includes intoxication, other toxidromes or withdrawal states, infection, metabolic derangements. Nontoxic appearing_. Considered other causes of patient’s vital sign abnormalities including primary cardiopulmonary etiologies such as ACS, PE, PNA but think these are unlikely. Doubt acute intraabdominal process.

Plan: BZDs, fluid resuscitation, labs, monitoring, _

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.