MDM - Urinary Tract Infection (UTI) - Female

[##]-year-old female with [dysuria/hematuria/flank pain] with history and exam consistent with likely urinary tract infection (UTI).

Initial consideration in this patient included urinary tract infection (UTI), pyelonephritis, vaginitis, kidney stone, and sexually transmitted infections (STI) among others.

The patient was noted to have [WBCs/leukocyte esterase/nitrites/hematuria] on urinalysis consistent with a UTI.  No evidence of significant costovertebral angle (CVA) tenderness, fever, or other systemic symptoms suggestive of pyelonephritis or urosepsis noted at this time.  Doubt ureteral stone in patient without significant CVA tenderness, flank pain, or other findings suggestive or ureteral colic.  Doubt STI at this time in patient without significant risk factors.  Negative pregnancy test obtained in the ED making ectopic or other pregnancy-related complications unlikely.

We discussed return precautions, specifically for evidence of worsening infection, treatment with antibiotics [and bladder anesthetic/pyridium], and follow up with primary care doctor within 1-2 weeks as needed for further evaluation, and the patient demonstrated understanding and agreement with this plan.

MDM - Acute Cholecystitis (Female)

[##]-year-old female with abdominal pain [additional symptoms] with history and exam consistent with likely acute cholecystitis [additional].

Initial considerations in this patient included acute cholecystitis, cholangitis, symptomatic cholelithiasis, choledocholithiasis, pancreatitis, acute hepatitis, acute appendicitis, ovarian cyst, ovarian torsion, ectopic pregnancy and other pregnancy-related complications, gastroenteritis, ureteral stone, pyelonephritis, and bowel obstructions among others.

Patient presented with right upper quadrant pain with associated [nausea/vomiting/jaundice] suggestive of gallbladder pathology.  Patient noted to have [no] known history of gallstones.  Patient reported duration of pain of [##] hours at time of ED evaluation.  The patient was noted to have [no evidence of peritonitis/rebound tenderness and guarding] and a [positive/negative] Murphy sign on abdominal exam in the ED.  Labs were obtained to include a CBC, liver function tests [additional] and were [unremarkable/notable for leukocytosis and left shift/elevated, bilirubin/elevated transaminases].  Patient noted to have a negative pregnancy test in the ED making ectopic or other pregnancy-related complications unlikely.

Gallbladder pathology including acute cholecystitis was considered [likely/highly likely] based on [history and exam/labs], and [a formal/bedside ultrasound of the right upper quadrant was obtained/Surgery was consulted for further evaluation].  The patient was noted to have findings consistent with acute cholecystitis on [ultrasound including characteristic shadowing of stones, gallbladder wall thickening (>3 mm), pericholecystic fluid, and a sonographic Murphy’s sign/exam by Dr. NAME of Surgery].  Additional imaging was [not felt to be indicated at this time after discussion with Surgery/recommended by Surgery to include a HIDA scan/ERCP/MRCP].

We discussed the diagnosis of acute cholecystitis and plan for admission for further management to include possible surgical intervention with the patient, who demonstrated understanding and agreement.  We also discussed the case with Dr. [Name] of General Surgery who agreed with the diagnosis and need for admission to the [general floor/pre-operative unit/OR] for further management.

Patient noted to have [no] evidence of significant systemic infectious symptoms [including fever/etc.] with [initiation of antibiotics in the ED/holding off on antibiotics until OR/at this time].

https://www.facs.org/~/media/files/education/patient%20ed/cholesys.ashx
https://www.facs.org/-/media/files/education/patient-ed/quit_smoking.ashx

MDM - Acute Appendicitis (Female)

[##]-year-old female with abdominal pain [additional symptoms] with history and exam consistent with likely acute appendicitis.

Initial considerations in this patient included acute appendicitis, ovarian cyst, ovarian torsion, ectopic pregnancy and other pregnancy-related complications, mesenteric adenitis, gastroenteritis, inflammatory bowel disease (Crohn’s disease, ulcerative colitis), diverticulitis, ureteral stone, pyelonephritis, hernias, and bowel obstructions amongst others.

Patient presented with right lower quadrant pain [with characteristic migration of pain from initial periumbilical region] with associated [fever/nausea/vomiting/loss of appetite] suggestive of appendicitis.  The patient was noted to have [no evidence of peritonitis/rebound tenderness and guarding] on abdominal exam in the ED.  Labs were obtained to include a CBC [additional] and were [unremarkable/notable for leukocytosis and left shift].  A [bimanual/speculum] pelvic exam was performed in the ED with no evidence of ovarian mass, significant adnexal tenderness, cervical motion tenderness, or significant vaginal drainage to suggest pelvic etiology for patient’s pain.  Patient noted to have a negative pregnancy test in the ED making ectopic or other pregnancy-related complications unlikely.

Appendicitis was considered [likely/highly likely] based on [history and exam/Alvarado score >6], and [a CT scan of the abdomen was obtained/Surgery was consulted for further evaluation].  The patient was noted to have findings consistent with acute appendicitis on [exam by Dr. NAME of Surgery/CT scan of the abdomen with/without evidence of perforation].

We discussed the diagnosis of acute appendicitis and plan for admission for operative management with the patient, who demonstrated understanding and agreement.  We also discussed the case with Dr. [Name] of General Surgery who agreed with the diagnosis and need for admission to the [general floor/pre-operative unit/OR] for further likely operative management.

Patient noted to have [no] evidence of significant systemic infectious symptoms [including fever/etc.] with discussion with Surgery of [initiating antibiotics in the ED/holding off on antibiotics until OR/at this time].

https://www.mdcalc.com/alvarado-score-acute-appendicitis

https://www.mdcalc.com/appendicitis-inflammatory-response-air-score
https://www.facs.org/-/media/files/education/patient-ed/app.ashx