This pregnant patient presents with vaginal bleeding in the first trimester. DDX includes ectopic, IUP, threatened/inevitable abortion, along with completed abortion. Patient is HDS and without a history of coagulopathy or infectious symptoms. Doubt alternate acute emergent pathology.
Plan: bHCG, +/- basic labs, type and screen, TVUS, reassess
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
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
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
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***
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
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:
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
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.
YES:
Capacity Assessment: In my medical opinion, this patient has capacity to make medical decisions. The patient has the ability to communicate their choice to me and others, understands the information relevant to this decision, appreciates the situation itself and the consequences inherent to their choice, and can logically explain their rationale for their decision.
NO:
In my medical opinion, this patient does NOT have capacity to make a medical decision regarding ***, because
a. The patient is unable to communicate a choice.
b. The patient is unable to understand the relevant information
c. The patient is unable to appreciate a situation and its consequences
d. The patient is unable to reason rationally.
EM DOT PHRASES 