MDM

Chest Pain, Atypical (No Troponin)

MDM

This patient presents with atypical chest pain, most likely secondary to ***. Differential diagnosis includes ***. Low suspicion for ACS, acute PE (PERC negative***), pericarditis / myocarditis, thoracic aortic dissection, pneumothorax, pneumonia or other acute infectious process. Presentation not consistent with other acute, emergent causes of chest pain at this time. No indication for cardiac enzyme testing.*** Plan to order CXR to evaluate for acute cardiopulmonary causes.***

Plan: labs***, EKG, CXR***, pain control

Chest Pain – Low Risk (Trop Out)

MDM

This patient presents with chest pain, with symptoms suggestive of noncardiac chest pain. History without high risk features (e.g., not substernal, no exertional component, not relieved with rest, *** ).

Minimal CAD risk factors (including age), recent negative stress test (<2 years).*** Exam without evidence of volume overload. EKG without signs of active ischemia. HEART score: ***. Given the timing of pain to ER presentation, plan to send single troponin // delta troponin to evaluate for NSTEMI.*** Presentation not consistent with acute PE (Wells low risk *** // PERC negative***), pneumothorax, thoracic arotic dissection, cardiac effusion or tamponade.

Plan: labs, troponin***, EKG, CXR, ASA***, pain control, serial reassessment

Chest Pain – Admit (High Risk)

MDM

This patient presents with chest pain, with a history suggestive of ***. No evidence of volume overload or shock on exam. EKG without signs of active ischemia. EKG without evidence of STEMI. Low suspicion for acute PE (Wells low risk ***), pneumothorax, thoracic aortic dissection, cardiac effusion / tamponade. Overall, ACS is being considered given higher risk features, ***, history & physical. HEART score: ***.

Patient will require admission for inpatient risk stratification and possible provocative testing.

Plan: cardiac monitor, EKG, troponins,CXR, ASA, heparin***, pain control, reassess, Cardiology consult***

UTI – Low Risk

MDM

This *** patient presents with symptoms consistent with acute uncomplicated cystitis. No systemic symptoms. Not septic. Well appearing. Low suspicion for acute pyelonephritis given lack of fever, CVAT, or systemic features. Low suspicion for kidney stone or infected stone. ***ICON negative; not consistent with pregnancy, including ectopic. No indication for labs or imaging at this time.

Plan: UA, UCx, antibiotics***

SYNCOPE – Admit

MDM

This *** patient presents with symptoms consistent with syncope, most likely due to ***. Differential diagnosis includes ***reflex syncope (i.e. vasovagal syncope). Low suspicion for orthostatic syncope given lack of dehydration, no evidence of acute life threatening hemorrhage. Presentation not consistent with seizures given short time course, no postictal state, no seizure activity. Low suspicion for acute neurologic catastrophes to include ICH given lack of trauma, risk factors for bleeding diatheses. Low suspicion for vascular catastrophes to include PE, thoracic aortic dissection, AAA rupture. Presentation not consistent with acute life threatening arrhythmia, structural heart disease, electrical conduction abnormalities, or ACS (HEART score: ***). However, given age, cardiovascular risk factors, history & physical, will workup and admit to telemetry.

Plan: labs, troponin, CXR, EKG, serial reassessment

STROKE – Code Activation

MDM

This *** patient presents with symptoms concerning for acute CVA versus TIA.***. Other items on the differential include dissection, AMI, hypoglycemia or other metabolic derangement such as hepatic/uremic encephalopathy, medication side effect, or post-ictal Todd’s paralysis. However, presentation most concerning for a CVA. EKG without evidence of STEMI or ischemia, fingerstick BS not hypoglycemic, and clinical picture does not suggest other stroke mimic. Plan to workup for acute CVA / TIA.

Plan: Code stroke protocol, MRI/MRA stroke protocol, stroke labs, Neurology stroke consult

DYSPNEA – General

MDM

This patient presents with dyspnea, most likely secondary to ***. Differential diagnosis includes ***. Presentation not consistent with acute cardiac etiologies to include ACS (HEART score ***), CHF, pericardial effusion / tamponade . Presentation not consistent with acute respiratory etiologies to include acute PE (Wells low risk ***), pneumothorax , asthma, COPD exacerbation, allergic etiologies, or infectious etiologies such as PNA. Presentation also not consistent with non-cardiopulmonary causes to include toxidromes, metabolic etiologies such as acidemia or electrolyte derangements, sepsis, neurologic causes (i.e. demyelinating diseases).

Plan: supplemental O2, NIPPV ***, CXR, labs, troponin, close hemodynamic monitoring, serial reassessment

SEIZURE – General

MDM

This patient presents with symptoms consistent with acute seizure, most likely due to ***. I considered, but think less likely, secondary etiologies of epileptic seizures to include drug / toxin etiologies (ETOH, stimulants, medication side effects), metabolic disturbances (glucose, Na), acute CNS infections (meningitis, encephalitis, abscess), ICH / tumor / CVA. Presentation not consistent with non-epileptic type seizure to include syncope, neurologic etiologies (vertebrobasilar insufficiency, movement disorder, migraine), impact seizure related to head trauma.

Plan: BZDs, labs***, CT brain***, seizure precautions, Neurology consult***, reassess

Pearls

Consider nonconvulsive status: persistent change in behavior that lasts 30 minutes after a seizure. Look for positive symptoms (twitching, eye deviation, jerking) and negative (aphasia, catatonia, mutism). Many patients will just not respond. Think about this in head trauma patients with a decreased GCS and a negative initial CT. Also consider this in a “septic” altered patient with a borderline positive UA that isn’t that convincing.

ALLERGIC RASH – Low Risk

MDM

This patient presents with symptoms consistent with acute hypersensitivity reaction, likely acute allergic reaction. Presentation not consistent with acute anaphylaxis (lack of pulmonary, dermatologic, cardiovascular or GI symptoms, lack of hypotension or exposure to known allergen), angioedema, serum sickness (no recent drug exposure, lacks fevers, arthralgias), ingestion of preformed toxin. No evidence of airway compromise or shock at this time. Plan to treat for an allergic reaction with H1/H2 blockers, steroids. No indication for epinephrine at this time.*** Given lack of respiratory symptoms, no indication for EpiPen Rx.***

Plan: ***H1/H2 blockers, steroids, close hemodynamic monitoring, serial reassessment