MDM - Rhabdomyolysis (Admit)

[##]-year-old [male/female] with [back pain/dark/bloody urine/etc.] with history and exam consistent with rhabdomyolysis.

Initial consideration in this patient included rhabdomyolysis, acute kidney injury (AKI), hematuria from causes including kidney or ureteral stone, urinary tract infection (UTI), pyelonephritis, or malignancy, glomerulonephritis, musculoskeletal etiologies of back pain, cauda equina syndrome, intervertebral disc herniation, and change in urine color from foods such as beets, blackberries, rhubarb, food coloring, or fava beans among others. 

Patient presented with report of [back pain/change in urine color] concerning for rhabdomyolysis.  We obtained a urinalysis that was notable for being [grossly/moderately] positive for blood with [no/minimal] red blood cells noted on microscopic analysis.  Patient reports [describe recent exertion] within [12-72 hours/1-2 days] of presentation.  Labs were obtained to include a creatinine kinase (CK), which was noted to be [moderately/significantly] elevated.  Patient noted to have [no] evidence of hyperkalemia [specify].  A 12-lead EKG was obtained [and noted to be unremarkable/and notable for evidence of peaked T waves suggestive of hyperkalemia].  Patient noted to have [no] evidence of AKI [based on increase in creatinine from baseline/with an AKIN score/RIFLE classification of RIFLE-R/I/F/FO].

Patient treated with normal saline IV [with 1-2 liter bolus followed by an infusion at 2.5 mL/kg/hour] while monitoring urine output.  Patient felt to require admission based on [comorbdities/associated trauma/heat injury/associated kidney injury/consider admission in patient with CK >30,000].  Case discussed with Dr. [Name of Internal Medicine/the admitting hospitalist] who evaluated the patient in the ED and agreed with need for admission.  We discussed planned admission and treatment plan with the patient who demonstrated understanding and agreement with this plan.

http://www.emdocs.net/emdocs-cases-evidence-based-recommendations-for-rhabdomyolysis/
https://www.mdcalc.com/akin-classification-acute-kidney-injury-aki
https://www.mdcalc.com/rifle-criteria-acute-kidney-injury-aki#evidence

MDM - Rhabdomyolysis (Discharge)

[##]-year-old [male/female] with [back pain/dark/bloody urine/etc.] with history and exam consistent with rhabdomyolysis.

Initial consideration in this patient included rhabdomyolysis, acute kidney injury (AKI), hematuria from causes including kidney or ureteral stone, urinary tract infection (UTI), pyelonephritis, or malignancy, glomerulonephritis, musculoskeletal etiologies of back pain, cauda equina syndrome, intervertebral disc herniation, and change in urine color from foods such as beets, blackberries, rhubarb, food coloring, or fava beans among others. 

Patient presented with report of [back pain/change in urine color] concerning for rhabdomyolysis.  We obtained a urinalysis that was notable for being [grossly/moderately] positive for blood with [no/minimal] red blood cells noted on microscopic analysis.  Patient reports [describe recent exertion] within [12-72 hours/1-2 days] of presentation.  Labs were obtained to include a creatinine kinase (CK), which was noted to be [moderately/significantly] elevated.  Patient noted to have no significant evidence of hyperkalemia on labs [with an unremarkable EKG].  Patient noted to have no other evidence of significant electrolyte abnormalities on labs [look for hypophosphatemia, hypocalcemia, and hyperuricemia].  Patient noted ton have no evidence of associated AKI.

Patient treated with normal saline IV [with 1-2 liter bolus] given in ED in patient noted to be tolerating fluids by mouth prior to discharge.  Patient felt to be appropriate for outpatient management given likely exertional rhabdomyolysis and absence of associated comorbidities [including heat stress, dehydration, crush injury, trauma], electrolyte abnormalities, or renal failure [consider admission in patient with CK >30,000].  Prior to discharge we discussed the importance of increased intake of fluids, rest and avoidance of further exertion, and follow up with [primary care provider/here in this ED] for repeat CK to ensure this is downtrending within [24/48/72 hours].  We also discussed return precautions, specifically for evidence of renal failure, and the patient demonstrated understanding and agreement with this plan.

http://www.emdocs.net/emdocs-cases-evidence-based-recommendations-for-rhabdomyolysis/

Decision Rule - TWIST Score for Pediatric Testicular Torsion

TWIST Score for Pediatric Testicular Torsion:

-Testicular swelling . . . . . . . . . . . . . .  [Yes (+2 points)/No (0 points)]
-Hard testicle . . . . . . . . . . . . . . . . . . .  [Yes (+2 points)/No (0 points)]
-Absent cremasteric reflex  . . . . . . . .  [Yes (+1 point)/No (0 points)]
-Nausea or vomiting  . . . . . . . . . . . . .  [Yes (+1 point)/No (0 points)]
-High-riding testicle   . . . . . . . . . . . . .  [Yes (+1 point)/No (0 points)]

A score of >5 points had a positive predictive value for testicular torsion in the original derivation study, suggesting consideration of immediate urological consultation.
A score of <2 points had a negative predictive value of 100% in the original derivation study, suggesting these patients may be clinically cleared if they lack other concerning features.
Scores of 2-5 points should be considered for further evaluation with ultrasound in the appropriate clinical setting.

https://thesgem.com/2018/02/sgem205-twist-shout-testicular-torsion/

Caution should be used with this score, as it has not performed well on subsequent attempts at validation.  The only reason I consider it at all is that a high score would prompt me to consult a Pediatric Urologist earlier in the course of care, and this score MAY help convince them to see a patient emergently and prior to ultrasound.  I would not delay getting an ultrasound, and would be very cautious with a "low risk" score.

MDM - Testicular Torsion

[##]-year-old male with history and exam consistent with [right-sided/left-sided] testicular torsion.

Initial considerations in this patient included testicular torsion, epididymitis, orchitis, hematocele, hydrocele, spermatocele, hernias, scrotal abscess, sexually transmitted infections, urinary tract infection (UTI), scrotal abscess and cellulitis, and Fournier gangrene among others.  

Patient presented with report of [right-sided/left-sided testicular/scrotal] pain with report of onset of pain [## minutes/hours] prior to presentation concerning for torsion.  Patient [reported/denied] preceding trauma [describe].  Urology was consulted early in the course of care due to strong suspicion for testicular torsion [based on TWIST score greater than 5/with recommendation for emergent testicular ultrasound/evaluation in the ED].  A testicular ultrasound was obtained with evidence of torsion of the [right/left] testicle [as noted above].  A urinalysis was obtained and [noted to be unremarkable/notable for evidence of abnormal findings].

[Manual detorsion was considered/performed in this patient as a temporizing measure due to urologist not being immediately available.  The patient was given parenteral analgesic and the affected right/left testicle was twisted outward and laterally ("open the book") 180° with noted improvement in pain (if pain improves consider 2-3 rotations/if pain worsens consider twisting in opposite direction).]

Patient evaluated in the ED by Dr. [Name] of [Pediatric] Urology with plan for [admission to the OR for operative management/admission for serial examinations and likely operative management].  Patient reported [some/minimal/significant] improvement in pain after treatment with [analgesic] in the ED.  We discussed planned admission and treatment plan with the [patient/patient’s mother/father/parents], and they demonstrated understanding and agreement with this plan.

https://thesgem.com/2018/02/sgem205-twist-shout-testicular-torsion/

MDM - Supracondylar Fracture

[##]-year-old [male/female] with history and exam consistent with [right/left] supracondylar fracture.

Initial consideration in this patient included supracondylar and other fractures of the humerus, elbow fractures including olecranon and radial head fracture, forearm fractures, dislocations involving the elbow, soft tissue injuries, and non-accidental trauma (NAT) amongst others. 

Patient presented with [mother/father/parents] for pain and swelling to the [right/left] upper extremity following a [fall/describe injury].  Child noted to be refusing to move the affected arm.  A radial head subluxation (nursemaid’s elbow) was felt to be unlikely given mechanism and tenderness to palpation over the posterior aspect of the humerus of the [right/left] arm.  Plain films were obtained with evidence of [nondisplaced supracondylar fracture with evidence of elbow effusion (anterior sail sign and/posterior fat pad) consistent with type I fracture (Gartland Classification)/displaced supracondylar fracture with intact posterior periosteum and anterior displacement of the anterior humeral line relative to the capitellum consistent with type II fracture (Gartland Classification)/displaced supracondylar fracture with disruption of anterior and posterior periosteum consistent with type III (Gartland Classification)/displaced supracondylar fracture with complete periosteal disruption with instability in flexion and extension consistent with type IV (Gartland Classification)].  Patient noted to have [no] evidence of open fracture [with antibiotics initiated in the ED and case discussed with orthopedics].  Patient noted to have [no] evidence of associated radial nerve injury, [especially important to check for in distally displaced type III] median nerve, brachial artery injury [especially important to check in posterolaterally displaced type III] or other neurovascular injuries.

Patient was noted to have no other significant injuries on exam in the ED.  Doubt non-accidental trauma in patient with description of trauma from [mother/father/parents] consistent with noted injuries and absence of other concerning features on history and exam.

Patient placed in [double sugar tongue/long-arm posterior splint with elbow at 90°  and forearm in pronation/neutral position/long-arm cast by orthopedics] with neurovascular exam noted to be normal before and after immobilization [type II-IV fractures require orthopedics consult in the ED/type I can usually be discharged with 48-hour follow up].  We discussed appropriate [splint/cast] care prior to discharge home with the patient’s [mother/father/parents]. 

We discussed return precautions, specifically for evidence suggestive of compartment syndrome, symptomatic treatment [with analgesics/NSAIDs], and follow up with Orthopedics within 48-hours for further evaluation, and the patient’s [mother/father/parents] demonstrated understanding and agreement with this plan.

https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture--pediatric
https://orthoinfo.aaos.org/en/diseases--conditions/elbow-fractures-in-children/

MDM - Ovarian Torsion

[##]-year-old female with history and exam consistent with [right/left-sided] ovarian torsion.

Initial consideration in this patient included ovarian torsion, ovarian cyst (functional, follicular, and hemorrhagic), ovarian neoplasm, polycystic ovarian syndrome (PCOS), pregnancy, ectopic pregnancy, appendicitis, diverticulitis, other intra-abdominal etiologies, urinary tract infection (UTI), ureteral stone and pyelonephritis, and vaginitis among others.

Patient presented with [right-sided/left-sided] abdominal and pelvic pain [with/without] a history of prior ovarian cyst.  Patient was noted to have [no] evidence of peritonitis on exam in the ED [prompting early discussion with gynecology due to concern for ovarian torsion/bedside FAST exam due to concern for ruptured ectopic].  [Due to evidence of acute abdomen and high likelihood of ovarian torsion, gynecology was consulted prior to obtaining imaging.]  A pelvic [speculum/bimanual] exam was performed and notable for [right-sided/left-sided tenderness/mass/cervical motion tenderness (CMT)].  A pregnancy test was obtained and noted to be negative making pregnancy-related complications unlikely [specify torsion in pregnant patient].  A pelvic ultrasound was obtained and [notable for ## cm right-sided/left-sided ovarian cyst/evidence of dminished blood flow on Doppler ultrasound concerning for torsion/increased ovarian size concerning for ovarian torsion].  Patient [noted to have evidence of torsion on ultrasoungd/felt to be high risk for torsion despite equivocal findings on ultrasound/based on history and exam] with case discussed with Dr. [Name] of Gynecology who examined the patient in the ED.  

Patient noted to have no evidence of significant anemia on [exam/hemoglobin and hematocrit].  Patient noted to have no evidence of coagulopathy on [history/exam/labs].  No evidence of UTI on urinalysis in the ED.  Vaginitis considered unlikely based on history and exam.

We discussed plan for [confirmatory ultrasound/admission for likely operative management in the OR/admission for serial exams and further management per gynecology].  Patient reported improvement in pain with [treatment] in the ED, and demonstrated understanding and agreement with planned admission.

MDM - Chest Wall Pain

[##]-year-old [male/female] with chest pain with history and exam consistent with likely chest wall pain.

Initial consideration in this patient included chest wall pain including costochondritis, Tietze’s synbdrome, and precordial catch syndrome, angina pectoris, acute coronary syndromes (ACS), pulmonary embolism (PE), aortic dissection, spontaneous pneumothorax, pneumonia, and esophageal pathology amongst others. 

Patient presented with chest pain described as [localized/reproducible/sharp] and associated with [movement/recent increase in activity/describe strain/etc.].  The patient was felt to be low risk for PE based on a low risk Wells score and being PERC negative.  A 12-lead EKG was obtained with no evidence of dysrhythmia, ischemia, infarction, or other significant acute abnormalities.  Doubt cardiac etiology at this time given unremarkable EKG in patient without significant risk factors for acute coronary episode.  Plain films of the chest [were obtained with no evidence suggestive of dissection, pneumonia, pneumothorax, or other significant pathology/were not felt to be indicated at this time given absence of abnormal lung sounds or other significant risk factors for acute intrathoracic processes].  Considered esophageal etiology unlikely based on absence of relation to eating or other suggestive features.  Patient reported significant improvement with [treatment] prior to discharge from ED.

We discussed return precautions, specifically for evidence of persistent or worsening chest pain, symptomatic treatment [with analgesics/NSAIDs], and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

MDM - Ovarian Cyst

[##]-year-old female with [right/left lower quadrant abdominal/pelvic pain] with history and exam consistent with [right/left hemorrhagic] ovarian cyst.

Initial consideration in this patient included ovarian cyst (functional, follicular, and hemorrhagic), ovarian mass, polycystic ovarian syndrome (PCOS), ovarian neoplasm, pregnancy, ectopic pregnancy, appendicitis, diverticulitis, other intra-abdominal etiologies, urinary tract infection (UTI), ureteral stone and pyelonephritis, and vaginitis among others.

Patient presented with [right-sided/left-sided] abdominal and pelvic pain [with/without] a history of prior ovarian cyst.  Patient was noted to have [no] evidence of peritonitis on exam in the ED [prompting early discussion with gynecology due to concern for ovarian torsion/bedside FAST exam due to concern for ruptured ectopic].  A pelvic [speculum/bimanual] exam was performed and notable for [right-sided/left-sided tenderness/mass/cervical motion tenderness (CMT)].  A pregnancy test was obtained and noted to be negative making pregnancy-related complications unlikely.  A pelvic ultrasound was obtained and [notable for ## cm follicular/hemorrhagic right-sided/left-sided ovarian cyst/free fluid and findings consistent with ruptured ovarian cyst without evidence of ovarian torsion].  Patient felt to be at [low/moderate] risk for ovarian torsion based on ovarian cyst size [less than 2 cm (very low risk)/less than 4 cm (lower risk)/greater than 4 cm (higher risk)/greater than 6 cm (high risk consider discussion with gynecology)] with discussion [of specific return precautions/with Dr. Name of Gynecology with recommendations].  Ovarian neoplasm felt to be [unlikely/less likely/possible] in patient who is [still having regular menses/postmenopausal] with discussion of appropriate follow up.

Patient noted to have no evidence of significant anemia on [exam/hemoglobin and hematocrit].  Patient noted to have no evidence of coagulopathy on [history/exam/labs].  No evidence of UTI on urinalysis in the ED.  Vaginitis considered unlikely based on history and exam.  Patient noted to have improvement in pain with [NSAIDs/etc.] in the ED prior to discharge.

Prior to discharge, we discussed return precautions, specifically for evidence of anemia from significant bleeding and ovarian torsion, symptomatic treatment [with specify interventions], and follow up with [primary care doctor/Gynecology] within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

https://www.aafp.org/afp/2016/0415/p676.html

MDM - Seizure (First Time)

[##-year-old male/female] presents with history and exam consistent with seizure without prior history of epilepsy or other seizure disorder.

Initial considerations in this patient included seizure from epilepsy, syncope, alcohol withdrawal seizure, seizure secondary to metabolic etiologies including hypoglycemia, hyperglycemia, hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hepatic failure, and uremia among others, meningitis, encephalitis, complex migraine, and intracranial processes including hemorrhage among others.

Patient presented with [active/reported] seizure consistent with [focal/generalized tonic-clonic seizure] that resolved [spontaneously/after treatment with benzodiazepine by EMS/upon arrival in ED].  Patient noted to have no prior history of seizure disorder per [patient/family].  Patient [reported/denied] preceding trauma [describe].  Patient noted to have [no] evidence of significant injury to the head [or cervical spine].  Syncope felt to be unlikely in this patient due to witnessed convulsions with associated [tongue laceration, urinary/fecal incontinence/postictal period].  Patient noted to have no evidence of shoulder dislocations or other significant musculoskeletal injuries.  Patient noted to have [no] history of significant alcohol use [describe].  Labs obtained in the evaluation of this patient to include [basic/complete metabolic panel, complete blood count], which were [noted to be unremarkable/notable for describe electrolyte abnormality].  Patient felt to have [no] indication for acute neuroimaging based on [first time seizure/unremarkable neurologic exam/absence of significant associated head injury/report of fall/significant associated head trauma/fall and noted to be unremarkable].

Patient given [missed/loading] dose of [specify anticonvulsant] in the ED [after discussion with Dr. Name of Neurology].  Prior to discharge we discussed return precautions, [treatment with specify anticonvulsant and avoidance of alcohol/other precipitants,] and follow up with primary care provider [and Neurology] for further evaluation in [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement.

Prior to discharge we counseled the patient that they should not drive or operate machinery until [further discussion with their primary care provider/neurologist/until they have been seizure-free for one year and reported them to the department of motor vehicles (DMV) due to state requirement for mandatory reporting of seizure (California, Delaware, Nevada, New Jersey, Oregon and Utah)], and the patient demonstrated understanding and agreement with this plan.

https://www.acepnow.com/new-recommendations-issued-management-unprovoked-first-seizure-adults/?singlepage=1
https://www.acepnow.com/article/best-practices-seizure-management-emergency-department/?singlepage=1&theme=print-friendly

MDM - Kidney Stone (Male)

[##]-year-old female with [dysuria/hematuria/flank pain] with history and exam consistent with likely ureteral stone.

Initial consideration in this patient included ureteral/kidney stone, urinary tract infection (UTI), pelvic inflammatory disease (PID), pyelonephritis, testicular torsion, back pain (including herniated disc, musculoskeletal causes, and cauda equina), and sexually transmitted infections among others.

Patient presented with [left/right/bilateral] flank pain with report of [prior/no prior] episodes of kidney stones [additional details].  Patient was noted to have hematuria on urinalysis without findings suggestive of UTI.  Patient without fever or other systemic infectious symptoms.  [Formal/Bedside] ultrasound obtained with [no/evidence of stone/hydronephrosis].  Based on lack of evidence of hydronephrosis [in a patient with a history of passing prior stones without intervention], it was felt that the stone had a high likelihood of passing without intervention.  

CT was obtained with evidence of [describe stone], and [with/without significant] hydronephrosis.  Based on stone size [1-4 mm (78% passage rate)/5-7 mm (60% passage rate/>8 mm (39% passage rate) it was felt that the stone had a high likelihood of passing without intervention/a consult was placed for Urology follow up/case was discussed with Dr. NAME of Urology].  Labs were obtained and [noted to be unremarkable/notable for specific abnormalities].  Pain improved  with [Kertorolac (Toradol)/intravenous lidocaine/opioids] in the ED.  [Discussed with Dr. [NAME] of Urology with discuss recommendation].  Referral placed for Urology follow up, and discussed with patient prior to discharge. 

Discussed return precautions, specifically for evidence of infected stone or worsening pain, treatment with analgesics and [Tamsulosin (Flomax)], and follow up with primary care doctor within [2-3 days/1 week] and Urology [at the next available appointment/time/date] for further evaluation, and the patient demonstrated understanding and agreement.

http://www.emdocs.net/nephrolithiasis-diagnosis-management-ed/

https://rebelem.com/can-tamsulosin-get-that-stone-to-drop/

MDM - Kidney Stone (Female)

[##]-year-old male with [dysuria/hematuria/flank pain] with history and exam consistent with likely ureteral stone.

Initial consideration in this patient included ureteral/kidney stone, urinary tract infection (UTI), pelvic inflammatory disease (PID), pyelonephritis, testicular torsion, back pain (including herniated disc, musculoskeletal causes, and cauda equina), and sexually transmitted infections among others.

Patient presented with [left/right/bilateral] flank pain with report of [prior/no prior] episodes of kidney stones [additional details].  Patient was noted to have hematuria on urinalysis without findings suggestive of UTI.  Patient without fever or other systemic infectious symptoms.  [Formal/Bedside] ultrasound obtained with [no/evidence of stone/hydronephrosis].  Based on lack of evidence of hydronephrosis [in a patient with a history of passing prior stones without intervention], it was felt that the stone had a high likelihood of passing without intervention.  

CT was obtained with evidence of [describe stone], and [with/without significant] hydronephrosis.  Based on stone size [1-4 mm (78% passage rate)/5-7 mm (60% passage rate/>8 mm (39% passage rate) it was felt that the stone had a high likelihood of passing without intervention/a consult was placed for Urology follow up/case was discussed with Dr. NAME of Urology].  Negative pregnancy test in the ED making pregnancy-related complications unlikely.  No significant pelvic pain, vaginal bleeding, or vaginal discharge to suggest PID.  Labs were obtained and [noted to be unremarkable/notable for specific abnormalities].  Pain improved  with [Kertorolac (Toradol)/intravenous lidocaine/opioids] in the ED.  [Discussed with Dr. [NAME] of Urology with discuss recommendation].  Referral placed for Urology follow up, and discussed with patient prior to discharge. 

Discussed return precautions, specifically for evidence of infected stone or worsening pain, treatment with analgesics and [Tamsulosin (Flomax)], and follow up with primary care doctor within [2-3 days/1 week] and Urology [at the next available appointment/time/date] for further evaluation, and the patient demonstrated understanding and agreement.

http://www.emdocs.net/nephrolithiasis-diagnosis-management-ed/

https://rebelem.com/can-tamsulosin-get-that-stone-to-drop/

MDM - Retained Vaginal Foreign Body

[##]-year-old female presents with history and exam consistent with retained vaginal foreign body.

Initial considerations in this patient included retained vaginal foreign bodies including condom and tampon, various etiologies of vaginitis, and infectious etiologies including toxic shock syndrome among others.

Patient presented with report of suspicion of retained [condom/tampon] for [##] days with associated vaginal irritation and discharge.  Pelvic exam was performed in the ED with a female standby as noted above with removal of retained [condom/tampon].  Patient noted to have [no findings suggestive of associated vaginitis/associated foul smelling discharge and findings on wet prep and KOH evaluation consistent with candidal/bacterial vaginitis with discussion of appropriate treatment on discharge].  Patient noted to have no associated fever, rash or other systemic symptoms suggestive of toxic shock syndrome.

Prior to discharge we discussed return precautions, appropriate treatment and follow up plan, and the patient demonstrated understanding and agreement with this plan.

MDM - Seizure (Breakthrough)

[##-year-old male/female] presents with history and exam consistent with breakthrough seizure [likely secondary to non-compliance].

Initial considerations in this patient included seizure with known seizure disorder, syncope, non-compliance with anticonvulsant medication, alcohol withdrawal seizure, seizure secondary to metabolic etiologies including hypoglycemia, hyperglycemia, hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hepatic failure, and uremia among others, meningitis, encephalitis, complex migraine, and intracranial processes including hemorrhage among others.

Patient presented with [active/reported] seizure consistent with [focal/generalized tonic-clonic seizure] that resolved [spontaneously/after treatment with benzodiazepine by EMS/upon arrival in ED].  Patient noted to have [no] evidence of significant injury to the head [or cervical spine.]  Syncope felt to be unlikely in this patient due to witnessed convulsions with associated [tongue laceration, urinary/fecal incontinence/postictal period] and known history of seizure disorder.  Patient noted to have no evidence of shoulder dislocations or other significant musculoskeletal injuries.  Patient noted to have a history of seizures for which they are prescribed [specify medication] with [reported/suspected compliance/non-compliance].  Labs obtained in the evaluation of this patient to include [basic/complete metabolic panel, complete blood count, and anticonvulsant drug level (phenytoin, carbamazapine, phenobarbital, valproic acid)], which were [noted to be unremarkable/notable for describe electrolyte abnormality/sub-therapeutic level of anticonvulsant].  Patient felt to have [no] indication for acute neuroimaging based on [unremarkable neurologic exam/absence of significant associated head injury/report of fall/significant associated head trauma/fall and noted to be unremarkable].

Patient given [missed/loading] dose of [specify anticonvulsant] in the ED, and we ensured the patient had refills of prescribed anticonvulsant prior to discharge.  Prior to discharge we discussed return precautions, treatment with continued use of [specify anticonvulsant and avoidance of alcohol/other precipitants], and follow up with primary care provider [and Neurology] for further evaluation in [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement.

Prior to discharge we counseled the patient that they should not drive or operate machinery until [further discussion with their primary care provider/neurologist/until they have been seizure-free for one year and reported them to the department of motor vehicles (DMV) due to state requirement for mandatory reporting of seizure (California, Delaware, Nevada, New Jersey, Oregon and Utah)], and the patient demonstrated understanding and agreement with this plan.

https://www.acepnow.com/article/best-practices-seizure-management-emergency-department/?singlepage=1&theme=print-friendly

MDM - Benign Palpitations

[##-year-old male/female] with history and exam consistent with likely benign palpitations.

Initial considerations in this patient included benign etiologies of palpitations including premature ventricular contractions (PVCs), premature atrial contractions (PACs) and premature junctional contractions (PJCs), more significant dysrhythmias including long QT syndrome, Wolff-Parkinson-White syndrome, and Brugada syndrome among others, atrioventricular blocks, acute coronary syndromes, anxiety disorders, thyroid disorders, and palpitations secondary to drugs and medications among others.


Patient presented with report of [## hours/days] of palpitations described as [irregular/rapid and irregular heartbeat/"skipping" heartbeats].  A 12-lead EKG was obtained [with evidence of occasional/frequent PACs/PJCs/PVCs/no evidence of significant dysrhythmia, ectopy or accessory pathways and no evidence of acute ischemia or infarction as noted above].  Labs were obtained in the evaluation of this patient to include [a basic/complete metabolic panel and thyroid studies], which were [noted to be unremarkable/notable for describe abnormality].  Patient [with/without] significant [caffeine/supplement] use [with discussion of decreased use or cessation]. Patient [reported/denied] associated chest pain, and was noted to have no significant risk factors for acute coronary syndrome.

Prior to discharge, we discussed return precautions, specifically for chest pain or other symptoms suggestive of significant cardiac illness, and follow up with primary care doctor for further evaluation and consideration of referral to Cardiology, and the patient demonstrated understanding and agreement with this plan. [A consult was placed for a Holter/event monitor prior to discharge from the ED.]

MDM - Epididymitis

[##]-year-old male with history and exam consistent with likely epididymitis.

Initial considerations in this patient included epididymitis, testicular torsion, hematocele, hydrocele, spermatocele, hernias, scrotal abscess, sexually transmitted infections, urinary tract infection (UTI), scrotal abscess and cellulitis, Fournier gangrene, and testicular mass or neoplasm among others.  

Patient presented with report of [testicular/scrotal] pain with associated [dysuria/fever/urinary frequency] and pain on palpation of the epididymitis [relieved with elevation of the testicle (Prehn sign)] suggestive of epididymitis.  [A scrotal ultrasound was obtained due to patient report of testicular pain, and was notable for evidence of epididymitis without findings suggestive of torsion.]  A urinalysis was obtained and [noted to be unremarkable/notable for evidence of pyuria consistent with epididymitis].  In addition, urine tests for gonorrhea and chlamydia were sent with discussion of [follow up with primary care doctor for results of these tests/treatment with antibiotics to cover these organisms prophylactically and recommendation that sexual partners are tested].  

Prior to discharge, we discussed return precautions and discharge with antibiotics to cover [sexually transmitted infections/enteric organisms], and the patient demonstrated understanding and agreement with this plan.

MDM - Post-Lumbar Puncture Headache

[##-year-old male/female] with headache with history and exam consistent with likely post-lumbar puncture (LP) headache (also known as a postdural puncture headache).

Initial consideration in this patient included post-LP headache, tension headache, migraine, cluster headache, meningitis, encephalitis, and intracranial hemorrhage or tumor among others.

Patient presented with report of headache that is worsened with upright position and improved with lying supine within [24-48] hours of having undergone LP.  Patient noted to have a normal neurologic exam without report of any other preceding trauma.  Treatment initiated in the ED with [oral/intravenous] caffeine with [minimal/significant/no] improvement.  We discussed therapeutic blood patch with anesthesia and the patient, and after discussion of risks, benefits and alternatives the patient was [transferred to anesthesia/treated in the ED] with [significant improvement/resolution of headache].

Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time.  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement.

https://rebelem.com/post-lumbar-puncture-headaches/

MDM - Tension Headache

[##-year-old male/female] with headache with history and exam consistent with likely tension headache.

Initial consideration in this patient included tension headache, migraine, cluster headache, meningitis, encephalitis, subarachnoid hemorrhage (SAH), venous sinus thrombosis, and intracranial hemorrhage or tumor among others.

Patient presented with headache and a normal neurologic exam without report of preceding trauma.  Headache described as [tightness/pressure] in the [right/left/bilateral temporal/frontal/parietal] head without report of associated [nausea/blurred vision/photophobia], or other features suggestive of migraine headache.  Patient reports recent [decreased caffeine intake/insomnia/stress] suggestive of tension-type headache.  Patient reported onset of headache was gradual, with no report of headache that was maximal at onset or thunderclap in nature.  Doubt subarachnoid hemorrhage at this time [in patient meeting none of the Ottawa SAH rules as noted above].  No fever, evidence of meningismus, or systemic infectious symptoms suggestive of meningitis or encephalitis at this time.  No indication for neuroimaging at this time based on normal neurologic exam in patient with headache with features suggestive of tension-type headache.  Patient reported significant improvement with [treatment] prior to discharge from ED.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening headache or neurologic deficits, symptomatic treatment, and follow up with primary care doctor within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement.

https://www.mdcalc.com/ottawa-subarachnoid-hemorrhage-sah-rule-headache-evaluation
https://rebelem.com/the-ottawa-sah-clinical-decision-rule/

MDM - Low Risk Chest Pain

[##-year-old male/female] with chest pain with history and exam consistent with likely [presumptive diagnosis/chest wall pain].

Initial consideration in this patient included angina pectoris, acute coronary syndromes (ACS) including stable and unstable angina, dysrhythmias, pulmonary embolism (PE), aortic dissection, pneumothorax, pneumonia, esophageal etiologies, chest wall pain including costochondritis, and pleuritis among others.

Patient presented with complaint of chest pain described as [constant/intermittent sharp/pressure] for the past [duration].  A 12-lead EKG was obtained with [describe findings without evidence of acute ischemia or infarction/no evidence of dysrhythmia, ischemia, infarction, or other significant abnormalities].  The patient was felt to be low risk for PE based on a low risk Well’s score and being PERC negative.  We obtained a troponin in the evaluation of this patient, which was noted to be [undetectable/below the normal limit/etc. at presentation and on repeat assessment at 3 hour interval].  The patient was noted to have a HEART score of [##] as noted above.  Plain films of the chest were obtained with no evidence suggestive of dissection, pneumonia, pneumothorax, or other significant pathology.  Considered esophageal etiology [unlikely/likely] based on [absence of] relation to eating, and [no] significant improvement with GI cocktail in the ED. 

Patient reported improvement with [treatment] prior to discharge from ED.  We discussed appropriate follow up based on a HEART score of [##/0-3] with the patient as noted above.  After discussion of all of the risks and benefits of the available options with the patient demonstrating understanding, they wished to [be admitted to observation for further testing/follow up with their primary care provider within the next week for further evaluation/have a follow up appointment arranged in the next ## for further evaluation prior to discharge].

Prior to discharge, we discussed return precautions, specifically for evidence of persistent or worsening chest pain, treatment [with analgesics/antacids/NSAIDs], and follow up plan, and the patient demonstrated understanding and agreement.

https://rebelem.com/management-and-disposition-of-low-risk-chest-pain/

https://www.mdcalc.com/heart-score-major-cardiac-events

https://epmonthly.com/wp-content/uploads/2015/10/Feb_2015_CP_Shared_Medical_Decision_Making_5-1.pdf

https://shareddecisions.mayoclinic.org/decision-aid-information/chest-pain-choice-decision-aid/