5— ABDOMINAL PAIN 61 Abdominal Pain—Key Points = Abdominal pain is commonly tested on the CCS. Expect one or more CCS cases of a patient presenting with abdominal pain. = In most cases, the diagnosis should be evident from the history and initial examination. Additional diagnostic studies should confirm the suspected diagnosis and rule out other diagnoses. = Some general rules to follow in patients with abdominal pain: = If vital signs are abnormal, begin with monitoring orders, = If the patient is in acute distress, perform only a limited physical exam, = If the patient is a reproductive-age woman, check urine hCG and avoid CTT for ultra~ sound if possible. = If the patient is in severe pain, order pain relief early. = Do not order surgical consult too early. A surgical consult may not do anything if you order that up front but may take the patient to surgery after you have confirmed the diagnosis. = In patients who present acutely, when the clock is advanced, patient update screens will happen fairly quickly to help you determine whether you are managing the patient correctly. If you get a negative update on a patient, reevaluate whether your suspected diagnosis is correct.B—ALTERED MENTAL STATUS 123 Altered Mental Status—Key Points = For patients who present in coma, the majority of cases can be diagnosed on history, exam, and initial workup. Table 8-1 lists basic features to help separate the most common diagno- ses, Alll patients should be treated with ABCs and supportive measures in addition to the treatments listed. = For patients that present with altered mental status, consider the following tests to help aid in the diagnosis: = Fingerstick glucose = ECG, 12-lead = ABG = Head CT without contrast = Urinalysis = Urine culture = Blood culture = Ammonia = CBC ® Vitamin By, serum = BMP = Depression index = Toxicology screens TABLE 8-1 Ml Diagnosis Vital signs Exam Diagnostic Studies Treatment Tricycic Tachycardia. Dilated pupils ECG showsQRS —Socium antidepressant Bradyenea (mydriasis) prolongation bicarbonate overdose Hypotension Absent Lowel sounds Benzodiazepine _Bradlypnea Vertical ECG, CT to Flumazenil overdoss Hypotension nystagmus rule out other Diminished diagnoses reflexes Opioid overdose Bradycardia_- Constricied pupils. ECG, CT to Naloxone Bradypnoa (miosis) Tue out other reer diagnoses Subarachnoid Hypertension Funduscopyshows Head CT is Labstalol hemonthage papiledema diagnostic and retinal hemorrhages13—BACK PAN 191 Back Pain—Key Points = In male patients who present with back pain, be on the lookout for prostate abnormalities (prostate cancer, prostatitis). = In female patients who present with back pain, watch for fracture related to osteoporosis or arthritis. = In the office setting, orders to keep in mind that can help evaluate the cause of back pain include: Spine X-ray, lumbosacral Urinalysis Urine Gram stain Prostate ultrasound Prostate, fine-needle aspirate (prostate biopsy) SPEP DEXA scan16—SRUISNG 223 Bruising—Key Points = Look for key features in the history to help differentiate abuse from a pathologic cause of bruising (Table 16-1): = Family history of bruising Disruptive family members = Bruises in multiple sites «= Previous visits to the emergency department m= Most cases of bruising or bleeding can be triaged with basic labs that provide results in 30 minutes: = CBC with differential = PITT TABLE 16-1 i Common Disorders Seen in Patients Who Present with Bruising or Bleeding Platelet Basie Treatment Diagnosis Count = PT PIT Additional Studies Options. mp Low Normal Normal Platelet antbody Steroids Bone marrow biopsy MG Hemophilia Normal Normal High Factor Vil activity DDAVP. Factor IX activity Factor VIl or 1x ‘concentrate ‘Abuse Normal Normal Normal Gonsult, social services Admit to inpatient unit Advise patient, safoty plan Von Wilebrand Normal Normal. High or Factor Vill activity DDAVP. isease Tonmal Ristooetin cofactor ‘Factor Vill \on Willebrand factor concentrate antigen7—CHEST PAIN 7 Chest Pain—Key Points For most cases, the diagnosis should be evident from the history. However, even if you are sure of the diagnosis, you still need to rule out other differentials and confirm the diagnosis. For example, you may know the patient has aortic dissection, but you still need to rule out myocardial infarction, pulmonary embolism, and so forth Important diagnostic studies to consider in patients who present with chest pain include: = ECG, 12-ead = Chest X-ray, PAVIateral = Troponin (‘cardiac enzymes” can also be ordered, but take longer and CPK fractions do not really add much more to the troponin results in most cases). = D-dimer = CBC = BMP For cases needing urgent surgical intervention, such as aortic dissection, make sure to stabi- lize the blood pressure and pain before ordering surgical consult or surgery.10—COUGH 153 Cough—Key Points = Many different types of cases can present with cough, including a variety of infections and cancers. Orders to keep in mind to aid in the differential include: Peak flow Chest X-ray Chest CT scan Neck X-ray, soft tissue Bronchoscopy PPD Sputum stains and cultures HIV rapid antibody test and ELISA14—DARRHEA Diarrhea—Key Points = Important orders to keep in mind if you get a case of a patient with diarrhea: Colonoscopy CT, abdomen P-ANCA Stool C&S Stool Clostridium difficile toxin assay Stool ova and parasites Stool Giardia antigen Sweat test Cystic fibrosis DNA detection, blood 2039—PAIN IN THE EXTREMITIES 137 Pain in the Extremities—Key Points Be on the lookout for abuse presenting as pain in an extremity after a fall. Child abuse, spousal abuse, and elder abuse can all present with injury or pain in an extremity. Important orders to keep in mind for pain in an extremity or joint include: Arthrocentesis Synovial fluid, Gram stain Synovial fluid, cell count Synovial fluid, crystals Synovial fluid, culture X-ray of the extremity D-dimer, plasma ESR Skeletal survey Duplex scan, leg, venous Rheumatoid factor ANA, serum6_FAl 87 Fatigue—Key Points = A wide variety of diseases can present with fatigue. Common causes to consider include cancer, endacrine disorders (diabetes, hypothyroidism), anemia, and blood loss (peptic ulcer disease, colon cancer). = A general panel of tests to keep in mind for patients who present with fatigue includes: = Fasting glucose ‘TSH CBC BMP LET Depression index Urinalysis = Most of the screening studies are resulted in 1 to 2 days, so initial management often involves rescheduling a stable patient for a return visit. However, for children with fatigue, it is generally best to get a stat CBC on the first office visit (1 hour), then plan for additional follow-up depending on the results. = Some patients will have more than one diagnosis, so even if one diagnosis is evident on the initial presentation, it is generally useful to screen for other causes of fatigue (e.g., a patient ‘who appears to have lead poisoning may also have iron deficiency anemia).15—HEADACHE 215 Headache —Key Points = Most cases of headache can be diagnosed on history and exam. = Important orders to keep in mind if you get a CCS case of a patient who presents with headache include: = ESR = Temporal artery biopsy a Depression index = Head CT21—MISCELLANEOUS OBSTETRICS/GYNECOLOGY CASES: 275 Key Points— Miscellaneous Obstetrics/Gynecology Cases For a reproductive-age woman, always consider ordering a urine hCG for pregnancy. It is not uncommon for a CCS case to present as UTI or breast mass but then also have an unrecognized new pregnancy. For a newly pregnant patient, order the following screening studies CBC Urinalysis Type and screen, blood Rubella serology RPR, serum Hepatitis B surface antigen, serum HIV test, ELISA, serum Pap smear Cervical DNA probe test, chlamydia Cervical DNA probe test, gonorthea Varicella-zoster virus, IgG antibody22—PEDIATRIC FEVER Pediatric Fever—Key Points 283 The diagnostic evaluation of a pediatric patient with fever is dependent on age, temperature and appearance (Table 22-1). For pediatric patients 1 month to 3 years of age who present to the office with a fever >39° C and appear nontoxic, in general, order a CBC, urinalysis, and urine culture (Table 22-1). The results of the CBC and urinalysis can be seen at the first visit. Ifthe CBC shows WBC >15,000/mm} or ANC >10,000/mm:‘, consider changing location to inpatient unit, completing workup with blood cultures and CSF studies, and starting antibiotic therapy. If the WBC and ANC are not elevated, follow up in 24 hours and manage with observation. TABLE 22-1 _ General Diagnostic Evaluation of Fever in a Child Age <1 month Temperature >38°C Appearance — Toxic or nontoxic Workup cac Urinalysis Urine cuture Blood culture CSF, gram stain CSF, culture CSE, protein CSE, glucose CSF call count >1 month 338°C Toxic cBC Urinalysis Urine culture Blood culture CSF, gram stain CSF, culture CSE, protein CSF, glucose CSF. cell count 4-3 months >a0°C Nontoxic CBC Urinalysis Urine culture Optional: Blood cultures Stool studies Chest X-ray CSF studies 3.36 months 330°C Nontoxic Optional: cBC Urinalysis Urine culture 3-36 months 38° C-39°.C Nontoxic Observation47—ROUTINE HEALTH EXAM 233 Routine Health Exam—Key Points = Itisvery unlikely you will get a “normal” patient with no abnormality: If you do get a patient with no chief complaint who presents for a routine screening examination, look for the following: Increased weight/BMI for obesity History of weight loss for underlying cancer Smoking history Increased blood pressure for systemic hypertension Subtle findings suggestive of pulmonary hypertension Menstrual history suggesting an undiagnosed pregnancy Lab studies to consider include: Lipid profile cBc Fasting blood glucose ACG, beta, urine, qualitative TSH Urinalysis12—SHOR OF BREATH 179 Shortness of Breath—Key Points & Shortness of breath can represent an underlying cardiac or respiratory abnormality. Impor- tant orders to keep in mind for diagnosis include: = Chest X-ray = Troponin x3 = CBC = ECG, 12-4ead = BNP = Echocardiography = RSV antigen = D-dimer = Chest CT with contrast11—TRAUMA Trauma—Key Points 159 © Monitoring orders (pulse oximetry, blood pressure monitor, cardiac monitor) do not take time off the clock and should be ordered before the physical exam based on abnormal vital signs. = The diagnosis in trauma/MVA cases can often be determined from a limited physical exam therefore, often the treatment should be initiated before any imaging or lab studies. a Trauma cases should provide rapid (in minutes) patient feedback. These cases usually last only a few minutes to a couple of hours of simulated time. ‘Symptoms Vial Signs Physical Exam Diagnostio Test of Choice Treatment Tension Pneumothorax (Case #1) Dyspnea, agitation, restlessness Tachycardia, hypotension, tachypnea Chest exam with absent breath sounds and ce on affected side; tracheal deviation Lung exam + chest X-ray or FAST utrasound Needle thoragostomy for immediate raiaf and to confirm diagnosis, Tubs thoracostomy to Prevent recurrence Cardiac Tamponade Third-Degree AV (Case #64) Dyspnea, dizziness, chest pain, drowsiness and palpitations Tachycardia, hypotension, tachyonea Heart exam with soft or distant heart sounds Cardiac exam + FAST ultrasound Paericardiocentesis, Block (Case #85) Fatigue, dizziness, chest pain, dyspnoa, ‘confusion, syncope Bradycardia, hypotension, tachypnea Weak pulsas ECG, 12-4ead Temporary transthoracic pacemaker for initial stabilzation foloned by permanent pacemaker ™ Ancillary orders, such as pain relief and routine trauma orders, are appropriate but optional during the time frame of these cases appropriate primary management is quickly insti- tuted. Most of these orders will likely not add significantly to your score. = In addition, transferring patients and counseling orders are generally optional in the time frame of these cases.19—VAGNAL BLEEDING. 255 Vaginal Bleeding—Key Points = Vaginal bleeding may represent gynecologic pathology or an underlying bleeding disorder. = Important orders to keep in mind include: cBC PTPTT Pap smear HPV DNA, cervix ACG, beta, urine, qualitative Endometrial biopsy (if age >35 years) ‘Transvaginal ultrasound20—VAGINAL DISCHARGE 263 Vaginal Discharge—Key Points = Generally; these patients present in the office with stable vital signs, so begin management with a physical exam. = For most patients, order the rapid S-minute tests (vaginal pH, wet mount, KOH prep, hCG; Table 20-1), Vaginal Gram stain is optional but can be helpful in the diagnosis of bacterial vaginosis. = For patients who have had multiple partners or unprotected sex, consider adding tests for HIV, hepatitis, gonorrhea, and chlamydia. = Forpatients who have not had a recent evaluation and meet criteria, consider ordering a Pap smear and/or HPV testing, = Ifa patient hasa positive hCG test result and is pregnant, the treatments remain the same but include additional pregnancy management (see Case #109). Ifa patient has recurrent Candida infections or signs of infection in other areas, order a follow-up HIV test if the rapid test results negative and order a fasting glucose for diabetes mellitus. (See case #59 and Case #25.) IFHIV positive, manage Candide infection with oral Auconazole. TABLE 20-1 mi Summary of Causes of Vaginal Discharge Bacterial Vaginosis Candida Vulvovaginitis_Trichomoniasis Symptoms Fishy vaginal odor Vaginal burning and itching, Vaginal itching, pain after (particularly ater ‘Pain after intercourse, or intercourse, or pain intercourse), vulvar itching pain with urination with urination less common History Fisk factors include recent Patients may have history History of multiple ‘anibioic use, |UD use, of mmunosuppression partners and ‘increased numbers of or antibioticusa but not —_unpratacted sax ‘somal pariners, ornew necessarily a history of sexual partner ‘muftiple partners or unprotacted sax Vaginal discharge Thin, gray or white Thick, white, curdike Frothy, yellow-green, “cottage cheeso”™ ‘malodorous Physicalexam Thin, gray discharge Erythema and edema of Vulvar erythema, adherent to vaginal walls the viva and vagna, “strawberry” canvx, bbealy red mucosa with lower abdominal ‘white plaques, cervix tenderness often normal pH 345 45 M48 Wet mount (Clue cals (epithelial calls May benormalorshow _Motile organisms with covered with bacteria) yphas and budding large numbers of white: yeast forms cals KOH prep Fishy odor, positive whi Hyphae and yeast present Normnal or may show test recut osttive whif tost Treatment Metronidazole, oral, Miconazole nitrate, vaginal, Metronidazole, oral, continuous for7 days continuous for days | continuous for 7 days Counseling ‘Avoid alcohol, avoid sex Advise no tight-fitting Treat partners, avoid Garments ‘alcohol, avoid sax