MDM - Subarachnoid Hemorrhage (SAH)

[##]-year-old [male/female] presents with [headache/altered mental status] with history and exam consistent with likely subarachnoid hemorrhage (SAH).

Initial considerations in this patient included SAH from ruptured aneurysm, non-aneurysmal bleeding, and trauma, epidural and subdural hemorrhage, intracranial mass, cerebrovascular accident (CVA), transient ischemic attack (TIA), meningitis, encephalitis, and cerebral venous thrombosis among others.

Patient presented [within 6/12/24 hours] of onset of headache concerning for SAH.  Patient noted to have associated [neuro deficits/nuchal rigidity].  CT scan obtained [with/without] clear evidence of SAH.  A lumbar puncture [was not performed due to clear evidence of SAH on CT/was performed with evidence of xanthochrmia consistent with SAH/was not performed due to patient refusal/was unsuccessful prompting us to obtain CT angiogram].  Patient was noted to have a Hunt & Hess Grade [I-V] score as noted above on presentation to the ED.  Patient noted to have [no] history of [anticoagulant or antiplatelet/anticoagulant/antiplatelet] use with [no indication for reversal/reversal of Coumadin initiated with prothrombin complex concentrate (Kcentra)/fresh frozen plasma (FFP) and vitamin K/reversal of Aspirin initiated with DDAVP/reversal of Plavix initiated with platelets/reversal of Dabigatran (Pradaxa) initiated with Idarucizumab (Praxbind)].

Patient was intubated [due to respiratory failure/evidence of inability to protect there airway] as noted above. 

Patient noted to be hypertensive on presentation with [some/minimal] improvement noted with administration of analgesics.  Despite absence of clear consensus recommendations on blood pressure control in the setting of SAH, we initiated treatment with [Nicardipine/Labetalol/Esmolol] with a goal systolic blood pressure of less than 160 mmHg [after consultation with neurosurgery].

Patient noted to be hypotensive on presentation with [IV fluids given/IV fluids and vasopressors initiated] to maintain a goal mean arterial pressure of greater than 80 mmHg.

Patient given Nimodipine via [oral route/NG/OG tube] to decrease incidence of delayed cerebral ischemia.  Seizure prophylaxis initiated in the ED with [Keppra/etc.].  Case discussed with Dr. [NAME] the neuro-interventionalist with plan to [admit/transfer] for endovascular [intervention/clipping/coiling].  We discussed concern for SAH and plan for admission with the [patient/family] with associated risks and benefits, and they demonstrated understanding and agreement with this plan and provided appropriate consent.

https://wikem.org/wiki/Subarachnoid_hemorrhage

https://emcrit.org/emcrit/sah/

https://www.mdcalc.com/hunt-hess-classification-subarachnoid-hemorrhage#use-cases

MDM - Stye (Hordeolum)

[##]-year-old [male/female] presents with history and exam consistent with stye (hordeolum) to the [right/left upper/lower] eyelid.

Initial considerations in this patient included stye, orbital and periorbital cellulitis, allergic reaction, chalazion, blepharitis, dacrocystitis, and conjunctivitis from allergic, bacterial and viral etiologies among others.

Patient presented with erythema and swelling to the [right/left upper/lower] eyelid [with/without] significant surrounding erythema.  Patient noted to have pustule to the affected eyelid consistent with stye.  Patient noted to have no evidence of associated purulent drainage from the affected eye.  Patient noted to have no associated visual deficits.

Prior to discharge, we discussed return precautions, specifically for evidence of progression to periorbital or orbital cellulitis, treatment with warm compresses [and topical antibiotic ointment/systemic antibiotics due to associated erythema suggestive of early periorbital cellulitis], and follow up with [primary care provider/ophthalmology] within [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement with this plan.

https://www.aafp.org/afp/1998/0601/p2695.html

MDM - Elderly Mechanical Fall (Negative CT)

[##]-year-old [male/female] presents with history and exam consistent with likely mechanical fall [with soft tissue abrasions] without evidence of significant intracranial injury at this time.

Initial considerations in this patient included intracranial hemorrhages including subarachnoid, subdural epidural hemorrhages, brain contusions, delayed intracranial hemorrhages, cervical spine fractures and dislocations, spinal cord injuries, musculoskeletal injuries, syncope from cardiac etiologies including dysrhythmia and other neurologic etiologies including cerebrovascular accident (CVA) and transient ischemic attack (TIA), and fall syndromes (history of recurrent falls) among others.

Patient presented after [## hours] after a fall [at home/assisted living facility/public place] described by the [patient/bystanders] as “[tripping/stumbling/etc.]” consistent with likely mechanical fall (non-syncopal fall from standing).  A 12-lead EKG was obtained with [no evidence of dysrhythmia, ischemia or infarction/atrial fibrillation without evidence of rapid ventricular response/describe finding].  The patient [reported/denied] current use of anticoagulants [specifically Warfarin (Coumadin)/Rivaroxaban (Xarelto)/Apixaban (Eliquis)/Dabigatran (Pradaxa)/Enoxaparin (Lovenox)/but did report use of anti-platelet agent (aspirin/Plavix)].  Patient was noted to have a neurological exam with [no evidence of focal deficits/other].  CT scans of the head [and cervical spine] were obtained with no evidence of significant intracranial hemorrhage [and no evidence of acute spinal injuries].

The patient [and family] were questioned on fall history with [no report of frequent/prior falls/report of prior episodes and discussion of the importance of close follow up with primary care provider to discuss what can be done to decrease fall risk].  A gait assessment was performed in the ED [with mobility device/cane/walker] and [noted to be unremarkable/notable for slow, unsteady gait].  The patient lives [alone/with family] and was noted to have [a family member/friend who is able to check up on them over the next several days/no family or friends who are able to check up on them consistently on discharge].

Prior to discharge, we discussed return precautions, specifically emphasizing the signs of delayed intracranial hemorrhage, and close follow up with primary care provider in the next [2-3 days/week] to discuss ways to decrease fall risk [and consideration of whether the benefits of anticoagulation outweigh the risks, and the patient [and family] demonstrated understanding and agreement with this plan.

[Due to concern for delayed hemorrhage in a patient who remains a fall risk and has limited social support, we discussed admission for observation and consideration of repeat CT scans with the patient [and family].  We discussed admission with [Dr. Name/admitting hospitalist] who evaluated the patient in the ED, and agreed with planned admission.]

https://www.hippoed.com/em/ercast/episode/mechanicalfalls/mechanicalfalls

Timed Up & Go Test: https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf
https://gempodcast.com/2018/11/09/retiring-the-term-mechanical-fall-for-older-patients/

MDM - Electrical Injury

[##]-year-old [male/female] presents with history and exam consistent with [low/high voltage] electrical injury [with dysrhythmia/superficial cutaneous burns/etc.].

Initial considerations in this patient included complications from electrical injury including dysrhythmias including ventricular and atrial arrhythmias, cutaneous burns, cardiovascular and central nervous system injuries, orthopedic injuries including fractures, dislocations and compartment syndrome, and rhabdomyolysis among others.

Patient presented with report of electrical injury from [household/industrial] source consistent with [low voltage (<1000 Volts)/high voltage (>1000 Volts) DC/AC current] exposure.  A 12-lead EKG was obtained with [no evidence of dysrhythmia, ischemia or infarction/notable for evidence of atrial fibrillation/frequent premature atrial/ventricular contractions/other specific abnormality].  Patient was noted to have [no evidence of significant cutaneous burns/first degree burns at the point of contact with electrical source with appropriate burn care provided in the ED].  Patient felt to have [no other concerning features with electrical exposure/high risk features including prolonged exposure/wet skin/loss of consciousness (LOC)].  Labs were [not obtained in patient felt to have no high risk features or findings on exam to suggest significant injury/obtained to include electrolytes/creatinine kinase/troponin/etc. and noted to be normal/notable for abnormality].  Patient noted to have [no focal deficits/subjective complaints of numbness/tingling with no significant focal deficits/describe abnormality] on neurological exam in the ED.

Prior to discharge, we discussed return precautions, specifically for evidence of significant electrical injury, symptomatic treatment, and recommended follow up with primary care provider in [1-2 weeks/2-3 days], and the patient demonstrated understanding and agreement with this plan.

https://www.ebmedicine.net/topics/burns/electric-shock-burns
http://www.emdocs.net/electrical-injury/

MDM - Influenza (Admit)

[##]-year-old [male/female] presents with [fever/body aches/upper respiratory symptoms] with history and exam consistent with [seasonal] influenza.

Initial considerations in this patient included influenza, bacterial and viral etiologies of upper respiratory infection (URI), bronchitis, pneumonia, sinusitis, toxic exposure, sepsis, meningitis, encephalitis, and other pulmonary or cardiac etiologies among others.

Patient presented with symptoms suggestive of influenza during appropriate season.  Patient noted to [not] have significant risk factors for complications from influenza [specifically age less than 2 years/age greater than 65 years/pregnancy through to 2 weeks after delivery/chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus)/immunosuppression, including that caused by medications or HIV/persons younger than 19 years of age who are receiving long-term aspirin therapy/American Indians and Alaska Natives/extreme obesity (BMI ≥40 kg/m²)/patients in nursing homes or chronic care facilities].  A chest x-ray was obtained in the evaluation of this patient and was notable for [right/left/upper/middle/bilateral/multifocal consolidation(s) with/without associated effusion].  Labs were obtained and were notable for [leukocytosis with a leftward shift/etc.].  Patient was noted to have evidence of [fever/tachycardia/tachypnea/etc.] on presentation [with/without significant improvement] after treatment with [IV fluids/anti-pyretics/antibiotics].  Blood cultures [were/were not] obtained due to planned admission.  Confirmatory testing for influenza obtained in patient felt to require admission and noted to be [negative/positive].

Influenza felt to be likely cause of symptoms with antiviral treatment initiated in the ED [with Oseltamavir (Tamiflu)/Zanamivir (Relenza)/Peramivir (Rapivab) and empiric antibiotic coverage due to evidence of sepsis].  Patient felt to not be appropriate for outpatient treatment based on [evidence of sepsis, absence of good social support].  We discussed planned admission with the patient who demonstrates understanding and agreement with this plan.  We discussed case with Dr. [NAME] who evaluated the patient and agrees with need for admission to [general floor/telemetry unit/step-down unit/ICU].

Note: This is based on the 2018 recommendations for treatment of seasonal influenza from the Infectious Disease Society of America (IDSA).

https://rebelem.com/idsa-guideline-on-seasonal-influenza-management-2018/

https://www.idsociety.org/practice-guideline/influenza/

MDM - Influenza (Discharge)

[##]-year-old [male/female] presents with [fever/body aches/upper respiratory symptoms] with history and exam consistent with [seasonal] influenza.

Initial considerations in this patient included influenza, bacterial and viral etiologies of upper respiratory infection (URI), bronchitis, pneumonia, sinusitis, toxic exposure, sepsis, meningitis, encephalitis, and other pulmonary or cardiac etiologies among others.

Patient presented with symptoms suggestive of influenza during appropriate season.  Patient noted to [not] have significant risk factors for complications from influenza [specifically age less than 2 years/age greater than 65 years/pregnancy through to 2 weeks after delivery/chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological (including sickle cell disease), neurologic, neuromuscular, or metabolic disorders (including diabetes mellitus)/immunosuppression, including that caused by medications or HIV/persons younger than 19 years of age who are receiving long-term aspirin therapy/American Indians and Alaska Natives/extreme obesity (BMI ≥40 kg/m²)/patients in nursing homes or chronic care facilities].  Confirmatory testing for influenza felt [not to be indicated as the results were unlikely to change management/obtained in patient felt to be high risk and noted to be negative/positive].  No evidence of pneumonia on history or exam [and no evidence of consolidations on chest x-ray]. 

Influenza felt to be likely cause of symptoms in patient presenting [within 48 hours of onset of symptoms/over 48 hours from onset of symptoms] with antiviral treatment felt to be [indicated after discussion of potential benefits and risks with the patient/indicated in patient with risk factors for complications/indicated in patient with household contacts who are high risk for complications/indicated in a healthcare worker caring for high risk individuals].  Prior to discharge, we discussed return precautions, specifically for symptoms suggestive of bacterial co-infection or worsening illness, and recommended follow up with primary care provider within [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement with this plan.

Note: This is based on the 2018 recommendations for treatment of seasonal influenza from the Infectious Disease Society of America (IDSA).

https://rebelem.com/idsa-guideline-on-seasonal-influenza-management-2018/
https://www.idsociety.org/practice-guideline/influenza/

MDM - Acetaminophen Overdose

[##]-year-old [male/female] presents with history and exam consistent with acetaminophen overdose [as a suicide attempt/additional].

Initial considerations in this patient included acetaminophen intentional and accidental overdose, other intentional ingestions and co-ingestions including salicylates, alcohol, toxic alcohols, opioids, benzodiazepines, anticholinergic medications, and antidepressant medications including tricyclic antidepressant (TCA) among others, other self-injury, and other infectious and toxicologic etiologies among others.

Patient presented with [suspected/reported] overdose of acetaminophen [## hours/days] prior to presentation.  Patient felt to have [no indication for intubation or more aggressive airway management on presentation/indication for intubation due to altered mental status].  Patient noted to be [unstable with appropriate resuscitation initiated/hemodynamically stable] on presentations.  Gastrointestinal decontamination with activated charcoal [felt to not be indicated given presentation over 3 hours from reported/suspected ingestion/administered in patient presenting within 3 hours from reported/suspected ingestion].  Initial labs were obtained including an ethyl alcohol level, salicylate level, [others] and liver function tests, which were [noted to be unremarkable/notable for elevated hepatic enzymes/specify].  A 12-lead EKG was obtained [with no evidence of acute ischemia, infarction or other QRS, ST, or T wave changes associated with tricyclic antidepressant overdose/notable for specify abnormality].

An [initial/4-hour] acetaminophen level was obtained and [noted to be elevated based on Rumack-Matthew nomogram/noted to be elevated in the setting of unknown time of ingestion].  Treatment with N-acetylcysteine (NAC) initiated via [oral/intravenous] route along with supportive care as noted above.  Patient felt to have [no] indication for transfer to transplant center by King's Criteria at this time.

Case discussed with [ICU team/admitting hospitalist and Poison Control] with plan for admission to the [ICU/telemetry unit/etc.].  Planned admission and treatment [was/was not] discussed with the patient [who demonstrated understanding and agreement with plan/who is involuntary for admission at this time/due to altered mental status].

https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity
https://edsmartchart.blogspot.com/2020/06/decision-rule-kings-college-criteria.html
http://www.emdocs.net/toxcard-acetaminophen-toxicity-and-management/

MDM - Suicidal Ideations (Discharge)

[##]-year-old [male/female] with [depression/suicidal ideations] with history and exam consistent with likely [presumptive diagnosis].

Initial consideration in this patient included major depressive disorder, adjustment disorder, suicide attempt (intentional overdose and self-injury amongst others), alcohol or other substance related mood disorders, and organic causes of altered mental status among others.

Patient presented to the ED [due to concerns over suicidal thoughts/after police were called due to suicidal comments/after his coworkers/supervisor noted suicidal comments].  On initial exam the patient was noted to be hemodynamically stable [with/without] evidence of intoxication.  Patient noted to have [no] evidence of [likely] self-injury [specify].  Labs [were/were not] ordered [and unremarkable as noted above/notable for elevated ethanol level without other evidence of overdose, illicit drugs or significant toxins].  The patient expressed [passive suicidal ideations/no suicidal ideations] in the ED [without/and no specific] plan [specify].

The patient was considered to be [low/moderate] risk for suicide based on consideration of risk factors, including [absence of suicidal plan/report of good social support].  Prior to discharge the patient [and family/bystanders] were questioned on access to firearms, which was [denied/planned for removal/secured].

The patient demonstrated a willingness to form a safety contract prior to discharge, as detailed in the discharge instructions below.  Return precautions for any concerns for safety were discussed, as well as follow up with [Mental Health] on [date] with the patient demonstrating understanding and agreement prior to discharge.

http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/
https://edsmartchart.blogspot.com/2020/06/physical-exam-psychiatric-mental-status.html
https://edsmartchart.blogspot.com/2020/06/discharge-instructions-contract-for.html

MDM - Suicidal Ideations (Admit)

[##]-year-old [male/female] with [depression/suicidal ideations] with history and exam consistent with likely [presumptive diagnosis].

Initial consideration in this patient included major depressive disorder, adjustment disorder, suicide attempt (intentional overdose and self-injury amongst others), alcohol or other substance related mood disorders, and organic causes of altered mental status among others.

Patient presented to the ED [due to concerns over suicidal thoughts/after police were called due to suicidal comments/after his coworkers/supervisor noted suicidal comments].  On initial exam the patient was noted to be hemodynamically stable [with/without] evidence of intoxication.  Patient noted to have [no] evidence of [likely] self-injury [specify].  Labs [were/were not] ordered [and unremarkable as noted above/notable for elevated ethanol level without other evidence of overdose, illicit drugs or significant toxins].  The patient expressed [passive suicidal ideations/no suicidal ideations] in the ED [with/without] plan [specify].

Patient medically cleared based on history, exam, and workup as noted above with no evidence of significant medical instability or medical condition causing or contributing to psychiatric condition at this time.  The patient was considered to be [moderate/high] risk for suicide based on consideration of risk factors, including [access to a firearm/suicidal plan involving lethal means/poor access to outpatient care or social support/unwillingness to safety contract in the ED/a SAD PERSONS score of ## points consistent with high risk]. 

Patient was evaluated by [mental health provider name] who agreed with need for admission.  Concerns for safety and plan for admission were discussed with the patient, who is [voluntary/involuntary] with plan for admission at this time.

http://www.emdocs.net/medical-clearance-of-psychiatric-patients-pearls-pitfalls/
https://edsmartchart.blogspot.com/2020/06/physical-exam-psychiatric-mental-status.html
https://edsmartchart.blogspot.com/2020/06/decision-rule-sad-persons-score.html

MDM - Bell's Palsy

[##]-year-old [male/female] presents with complaint of [right-sided/left-sided] facial asymmetry with history and exam consistent with Bell's palsy.

Initial considerations in this patient included Bell's palsy, cerebrovascular accident CVA), transient ischemic attack (TIA), trigeminal neuralgia, intracranial mass or hemorrhage, tick paralysis and the Lyme disease, and other infectious and toxicologic etiologies among others.

Patient presented with [## hours/days] of facial asymmetry without other associated neurologic deficits.  Patient noted to have complete [right-sided/left-sided] facial droop and weakness in the distribution of the facial nerve (cranial nerve VII), specifically including inability to raise the eyebrow or wrinkle her forehead on the affected side.  Patient reported associated [alteration in taste/hyperacusis/subjective facial numbness with no objective findings on exam/retroauricular pain].  Patient noted to have otherwise unremarkable neurologic exam.  Patient [reported/denied] prior similar episodes in the past.  Patient denied any preceding trauma.  Doubt significant intracranial process at this time with no indication for acute imaging.

Given onset of symptoms [within the past 72 hours/greater than 72 from time of presentation] we discussed plan for discharge [with/without] Prednisone.  We also discussed plan for discharge with [Valacyclovir/Acyclovir] despite limited evidence of benefit with no significant associated harm.  We also discussed covering the eye overnight and provided patient with lubricating eye-drops on discharge.  We discussed return precautions and recommended follow up with primary care provider in [time frame], and the patient demonstrated understanding and agreement.

http://www.emdocs.net/bells-palsy-pearls-and-pitfalls-in-evaluation-and-management/

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/

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/