MDM

Back Pain – Low Risk

MDM

This patient presents with back pain most consistent with ***. Differential diagnoses includes lumbago versus musculoskeletal spasm / strain versus sciatica.*** No back pain red flags on history or physical. Presentation not consistent with malignancy (lack of history of malignancy, lack of B symptoms), fracture (no trauma, no bony tenderness to palpation), cauda equina (no bowel or urinary incontinence/retention, no saddle anesthesia, no distal weakness), AAA, viscus perforation , pulmonary embolism, renal colic, pyelonephritis (afebrile, no CVAT, no urinary symptoms). Given the clinical picture, no indication for imaging at this time.***

Plan: pain control, supportive care, reassess

Altered Mental Status – General

MDM

This is a @AGE@ @GENDER@ presenting with altered mental status, concerning for ***. The differential includes toxic metabolic etiologies such as electrolyte disturbances (Na/Ca), hypoglycemia, and uremia; acidosis states, infection (i.e. Sepsis); toxidromes of intoxication or withdrawal, hypoxemia or hypercarbia, liver disease or failure causing hepatic encephalopathy, endocrine emergencies (hyper/hypothyroidism, adrenal insufficiency), seizure, trauma, intracranial bleeds or ischemic stroke. Given this wide differential, will send basic labs and lytes to evaluate for metabolic causes, FSBS, LFTs,, TSH, ***CT head, ***blood gas. ***LP?/abx?

 

RLQ Abdominal Pain

MDM, Peds

This is a *** with RLQ pain, most concerning for ***. Differential diagnoses: appendicitis, ***. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Low suspicion for acute hepatobiliary disease (includng acute cholecystitis), acute infectious processes (pneumonia, hepatitis, pyelonephritis), vascular catastrophe, bowel obstruction or viscus perforation. Presentation not consistent with other acute, emergent causes of abdominal pain at this time.

Plan: labs, UA, CT AP ***, pain control, fluids, serial reassessment

General Abdominal Pain – Lo Risk

MDM

Differential diagnosis includes: ***. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Low suspicion for acute hepatobiliary disease (includng acute cholecystitis), acute pancreatitis, PUD (including perforation), acute infectious processes (pneumonia, hepatitis, pyelonephritis), acute 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, CT AP***, pain control, serial reassessment

Epigastric Pain – low risk

MDM

Presentation consistent with acute epigastric abdominal pain. Differential diagnosis includes ***. Abdominal exam without peritoneal signs. No evidence of acute abdomen at this time. Well appearing. Low suspicion for acute hepatobiliary disease (includng acute cholecystitis), 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, GI cocktail, RUQ US ***, serial reassessment

-Courtesy Adam Evans