MDM

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.

PANIC ATTACK – Low Risk

MDM

This patient presents with symptoms consistent with acute anxiety reaction / panic attack. Low suspicion for acute cardiopulmonary process including ACS, PE, or thoracic aortic dissection. Denies any ingestions or any other medical complaints. No evidence of alcohol withdrawal symptoms. Presentation not consistent with overt toxidrome, ingestion given history & physical. Presentation not consistent with organic or medical emergency at this time. No acute indication for psychiatric consultation (without SI/HI, AH/VH). Cautious return precautions discussed with full understanding.

Plan: Rx ***, Psych follow up PRN

PARESTHESIAS – Lo Risk

MDM

This *** patient presents with paresthesias, most likely due to ***. Differential diagnoses includes ***. Presentation not consistent with emergent neurologic etiologies to include brain / spinal cord nerve root or nerve problem given history & physical. Presentation not consistent with immune phenomenon to include GBS or vasculitis. Presentation not consistent with toxins to include botulism, diptheria, tick-borne illnesses, heavy metal poisoning. Presentation not consistent with acute drug toxicity or metabolic issues.

Plan: labs***, CT brain***, supportive care, reassessment

HYPOGLYCEMIA – General

MDM

This patient presents with symptoms and labs consistent with acute hypoglycemia, most likely due to ***. Differential diagnosis includes ***. Considered other etiologies of acute hypoglycemia to include drugs (anti-hyperglycemics, alcohol, beta blockers, ACE-I, APAP) or drug related error (missed meal, incorrect dosing, intentional overdose), systemic illness (sepsis, acute coronary syndrome, renal / hepatic failure, adrenal insufficiency), malignancy, or post-op complications (i.e. Gastric bypass). Presentation not consistent with other acute, emergencies related to hypoglycemia.

Plan: serial POC glucose, hypoglycemia protocol treatment per routine, labs***, consider observation/admission, serial reassessment

HYPERGLYCEMIA – Lo Risk

MDM

This patient is a @AGE@ @SEX@, presenting with apparent acute hyperglycemia. Differential diagnosis includes ***. Considered DKA versus HHS, sepsis as possible etiologies of the patient’s current presentation. However, given the current history & physical, including current glucose level, the current presentation is consistent with acute, asymptomatic hyperglycemia. Plan to treatment supportively. No indication for further workup at this time.

Plan: supportive care, serial POC glucose monitoring, labs***, serial reassessment

DKA – Admit

MDM

This patient presents with hyperglycemia and symptoms concerning for DKA. Differential diagnosis includes other metabolic causes of hyperglycemia such as HHS, worsened diabetes or medication noncompliance. Considered possible causes of DKA to include infection (pancreatitis, UTI, pneumonia), infarction / ischemia (acute coronary syndrome, cerebral vascular accident), medication non-compliance with insulin therapy, illicit substance abuse, iatrogenic (including prescription medications and drug-drug interactions), idiopathic causes. Most likely etiology at this time is ***. Plan to treat the hyperglycemia as below while simultaneously evaluating and treating potential underlying etiologies.

Plan: POC glucose monitoring (Q1H), BMP (Q2H), blood gas, UA, serum ketones, CBC, LFTs / lipase, infectious workup (lactate/blood cultures, CHEST X-RAY)***, IVF, IV Insulin therapy, serial reassessment, admission for treatment of hyperglycemia

Upper GI Bleed – General

MDM

This patient with *** presents with symptoms concerning for acute, upper GI bleed, likely secondary to ***.

Differential diagnoses includes peptic ulcer disease (PUD = most common) versus less likely gastritis versus Mallory-Weiss tear versus AVM. Presentation not consistent with esophageal or gastric variceal bleeding or Boerhaave’s syndrome. Presentation not consistent with other etiologies upper GI bleeding at this time. No red flag features or high risk bleeding. No evidence of hemorrhagic shock. Glasgow-Blatchford Bleeding (GBS) score: ***. Based on this well validated study, the patient can safely be discharged for outpatient therapy // is “high risk” for needing a medical intervention to include transfusion, endoscopy or surgery. Plan to check labs to evaluate the extent of bleeding, including H/H. Will initiate treatment with PPI. No indication for octreotide or antibiotics given low likelihood of variceal bleeding from portal hypertension and cirrhosis.*** No indication for abdominal imaging at this time.

Plan: labs, LFTs, close hemodynamic monitoring, serial reassessment, PPI therapy, Octrotide/CTX***

Rectal Bleed – Low Risk

MDM

This patient has a presentation consistent with rectal bleeding, most likely due to ***. Differential diagnosis includes ***. Low suspicion for hemorrhoids (external or internal, including thrombosed hemorrhoids), rectal ulcer (HIV, syphilis, STI) or rectal foreign body. Presentation not consistent with other acute, emergent causes of upper or lower GI bleeding. No evidence of hemorrhagic shock.

Plan to check labs to evaluate the extent of bleeding, including H/H. No indication for abdominal imaging at this time.***

Plan: CBC, serial reassessment, PMD / GI referral

Lower GIB – General

MDM

This patient presents with symptoms concerning for a lower GI bleed. Differential diagnoses include diverticulitis (most common cause) versus hemorrhoids. Less likely etiologies include angiodysplasia, cancer, IBD. Presentation not consistent with mesenteric ischemia or ischemic colitis, brisk or life threatening upper GIB as patient has no evidence of hemorrhagic shock. Plan to check labs to evaluate the extent of bleeding, including H/H. Will consent patient for blood and transfuse to goal Hb of >7 if necessary. No indication for abdominal imaging at this time.***

Plan: labs, LFTs, close hemodynamic monitoring, serial reassessment, CT AP***