MDM

Gastroenteritis – Low Risk

MDM

This patient presents with *** nausea, vomiting & diarrhea. Differential diagnoses includes possible acute gastroenteritis. Abdominal exam without peritoneal signs. Currently ***euvolemic without evidence of dehydration. No evidence of surgical abdomen or other acute medical emergency including bowel obstruction, viscus perforation, vascular catastrophe, atypical appendicitis, acute cholecystitis at this time. Presentation not consistent with other acute, emergent causes of vomiting / diarrhea at this time. No indication for abdominal imaging.

Plan: supportive care, oral // IV rehydration ***, serial abdominal exam, reassess

Gallstones – Low Risk

MDM

This patient presents with abdominal pain, most consistent with acute, uncomplicated biliary colic. Bedside ultrasound demonstrating visible gallstones without overt signs of cholecystitis (thickened GB wall, pericholecystic fluid, CBD dilatation). Patient is afebrile and not jaundiced or altered, lowering my suspicion for cholangitis. Presentation not consistent with acute pancreatitis at this time. Low suspicion for bowel obstruction, viscus perforation, vascular catastrophe, or atypical appendicitis. Presentation not consistent with other acute, emergent causes of abdominal pain at this time. Plan for formal RUQ U/S to evaluate gallbladder pathology.***

Plan: labs, LFTs, lipase, RUQ U/S***, pain control, supportive care, serial reassessment

Vertigo – Low Risk

MDM

This patient presents with dizziness, most consistent with a peripheral cause, likely vertigo. Differential diagnoses includes: BPPV versus labrynthitis.*** No red flag features for central vertigo to include gradual onset, vertical/bidirectional or nonfatigable nystagmus, focal neurologic findings on exam (including inability to ambulate). Presentation not consistent with an acute CNS infection, vertebral basilar artery insufficiency, cerebellar hemorrhage or infarction, intracranial mass or bleed, temporal lobe epilepsy, multiple sclerosis, trauma, complex migraine headache. Other acute, emergent causes of vertigo are unlikely given at this time. No indication for head imaging at this time.

Plan: meclizine, supportive care, serial reassessment

Cough, Simple – Low Risk

MDM

This patient presents with acute cough, most consistent with ***. Differential diagnosis includes ***. Presentation not consistent with acute bacterial pneumonia, influenza, asthma, transient airway hyperresponsiveness. Presentation not consistent with chronic causes of cough (including GERD, asthma, postnasal discharge, medication side effect, CHF, lung cancer or mass).

Plan: ***CXR, supportive care, reassess

COPD Exacerbation – Admit

MDM

This patient presents with symptoms most consistent with an acute COPD exacerbation. These constellation of symptoms are similar to prior flares without overt deviations from normal exacerbations. The likely precipitant is acute respiratory infection // weather change or air quality // recent beta-blocker or opiate use.*** Low suspicion for alternate etiologies such as pneumothorax, acute PE. Presentation not consistent with other acute cardiopulmonary causes including ACS / CHF / cardiac effusion.

Pseudomonas risk factors: recent hospitalization // frequent antibiotic treatment // severe COPD // previously isolated Pseudomonas.*** Plan to maintain SaO2 ~90-94% with supplemental O2. Based on current presentation, including work of breathing, patient will need NIPPV (CPAP/BiPAP) // will not need NIPPV at this time. Plan for trial of duonebs, steroids. Antibiotics ***indicated given purulent sputum // increased sputum production // trial of NIPPV // No indication for antibiotic treatment at this time.*** Will evaluate for other acute cardiopulmonary processes with a CXR.

Anticipate hospitalization given marked increase in symptoms // significant co-morbidities and age // new arrhythmias.***

Plan: supplemental O2 (goal SaO2 ~90-94%), NIPPV***, duonebs, steroids, antibiotics***, CXR***, serial reassessment

Constipation – GI

MDM

This is a AGE YEAR presenting with symptoms consistent with constipation. Differential diagnosis includes ***. Presentation not consistent with acute bowel obstruction caused by tumor, stricture, hernia, adhesion, volvulus or fecal impaction. Low suspicion for etiology related to new medications including opiates, antipsychotics, anticholinergics, antacids, or antihistamines. Presentation not consistent with acute anorectal disorders. Low suspicion for chronic causes of constipation including hypothyroidism or electrolyte disorders. Presentation not consistent with other acute, emergent causes of constipation at this time.

Plan: supportive care, Rx ***, XR abdomen***, electrolytes***

CHF – Hypertensive Pulm Edema

MDM

This is a @AGE@ @SEX@ patient with history of *** sided, ***olic CHF, presenting with likely acute decompensated heart failure and ***pulmonary edema. The etiology of his decompensation is ***unclear but is likely due to ***. Alternative etiologies I considered include cardiac (ACS, valvular disease, arrhythmia, myocarditis/endocarditis, dissection), respiratory (COPD, PE, or PNA), medication noncompliance or dietary indiscretion, alcohol or drug abuse, endocrine (thyrotoxicosis), and anemia***. ***I considered ACS as a possible cause of the exacerbation but think this is unlikely given history and EKG without overt evidence of acute ischemia. Other acute, emergent etiologies of shortness of breath unlikely.

I plan for afterload reduction with nitrates given hypertension and possibly ACEi. Given respiratory status will also consider starting NIPPV. Will start diuresis after nitrate administration. The patient will require admission for acute management of ADHF.

Plan: labs, troponin, BNP, EKG, CXR, BUS, nitrates/diuretics, admission

AMS – Hepatic Encephalopathy

MDM

This is a @AGE@ @SEX@ with a presentation consistent with acute hepatic encephalopathy. Exam notable for stigmata of cirrhosis and portal hypertension. Likely precipitant: increased ammonia levels (GIB // excess protein // infection // electrolyte and/or acid base disturbance// constipation) // dehydration (vomiting, diuretic use) // medication induced (opioids, benzodiazepine overdose or withdrawal // ETOH use.*** Low suspicion for acute GIB, including evidence of life threatening hemorrhage. Low suspicion for acute infection including SBP (no fevers, abdominal pain). Presentation not consistent with other acute, emergent causes of altered mental status (including but not limited to renal failure, ICH) at this time.

Plan: labs, LFTs, ammonia level, PT/INR, UA, CXR, CT brain***, diagnostic paracentesis***, serial reassessment

RUQ Abdominal Pain

MDM

This is a @AGE@ @SEX@ with RUQ abdominal pain, consistent with ***. Differential diagnosis includes ***. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Moderate suspicion for acute hepatobiliary disease (includng acute cholecystitis). Less likely to represent 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, pain control, RUQ US***, serial reassessment

CHF with Shock – Admit

MDM

This patient with a hx of ***CHF presents with acute shortness of breath and peripheral edema, most consistent with acute decompensated heart failure and concerning for cardiogenic shock. Likely etiology is medication non-compliance // dietary indiscretion // HTN // infection // fluid overload // anemia //alcohol intoxication // thyroid disease.*** I considered ACS as a possible etiology but think this less likely. EKG without overt evidence of acute ischemia. Other acute, emergent etiologies of shortness of breath are unlikely at this time.

Given tenuous systolic function and hypotension, plan includes starting ionotrope such as dobutamine +/- ionopressor (i.e. Dopamine, levophed). Will give O2; would like to avoid utilizing NIPPV or intubation due to tenuous preload status. Will require admission for acute management of ADHF.

Plan: labs, troponin, BNP, EKG, CXR, BUS, vasopressors, Cardiology consult***