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.