1. Cases to ponder…..
ACEP 2017

2. 42yo chest pain/cough
4 days of URI symptoms, cough, congestion and pleuritic left chest pain. SOB with coughing spells, occasional “dizzy spells” with coughing. Multiple ill exposures with some similar symptoms.
Pharyngitis on exam. Exp wheezes diffusely. Tender left sternal border. Rest exam negative
HR 92 BP 155/57 RR 18 Temp 99.7 Sat 92%RA ??

3. 3yo URI
HPI: NP cough, congestion, sore throat, rhinorrhea, and intermittent fevers up to 103F for 4 days. Rash for 2 days but not seem to bother him. Sick siblings. Eating less but drinking “OK”. Fully immunized.
PE: HR 145, BP 85/45, RR 35, Sat 95%, T 102F Red throat, post nasal drip. Mild enlarged tonsils with small exudate. Mild post nodes. Moist cough prominent. Lungs CTA and no retractions. Rash scant diffuse cheek/torso blanching rash without mucous membrane involvement
???

4. 9yo abd pain
HPI: 5 hours of intermittent cramping diffuse abd pain. More on left. Eating well prior. No n/v/d but not hungry currently. Occasional constipation issues in past “but never this bad”. Last BM 2 days ago and was “normal”. O/w healthy child.
PE: Smiling playful child with occasional grimaces in pain. Vitals unremarkable. Benign exam although does grimace when pushing in abdomen although not consistent.

5. 75yo fall
HPI: At home, slipped and fell in kitchen. Bumped head on side of cupboard but denies LOC, N/V, headache or neck pain. On Xarelto for a fib. Minor skin tear to hand but otherwise no other injuries
PE: Vitals unremarkable. Small abrasion to forehead. Minor tenderness over C4-5 area. Normal exam otherwise
??imaging

6. 92yo PNeumonia
HPI: Living in NH for last 2y as failing health. Now with dementia and difficulty with depression since loss of wife. Frequent pneumnonias in past and last 2 days with cough, fevers and worsening troubles breathing. Full CODE and family out of state.
PE: Confused male staring at ceiling and seems to be struggling for air. Fever of 102F, rhonchi diffuse but also diminished sounds on right base. RR 35, HR 105, BP 85/35 and Sat 88 on NRB

7. 22yo F chest pain
HPI: Few days of intermittent chest discomfort. Worse on left with deep breath. Occasional cough. SOB with coughing spells but otherwise no other symptoms. No PMH sig otherwise
PE: HR 87, BP 128/70, RR 18 T99F Sat 95%. Lungs CTAB, chest mild tender on left. Discomfort seems worse with laying back and better sitting forward. Rest of exam neg

8. 2yo fall
HPI: O/w healthy child who fell down stairs. Egg sized bump to front of forehead. He is acting normally but vomited twice. Running around room playing and wants to drink.
PE: 2cm bump to forehead in otherwise well appearing child. Playing in room but did vomit on arrival small amount. Vitals unremarkable and exam otherwise normal.
?? CT, imaging

9. 37yo m cp
HPI: 425lb male eating fried chicken when developed epigastric pain. Pain goes into mid back. Chronic SOB but not sig worse than normal. Occasional np cough but not changed. No n/v/d, fevers, or other complaints. Chronic HTN and supposed to take meds for often noncompliant. Smoker “Otherwise healthy”
PE: HR 103, BP 210/120, RR 18, Sat 93%RA, T 99F Chronically ill appearing male sitting on edge of bed with persistent cough. Lungs with scant exp wheeze and diminished throughout. Mild tenderness in epigastrium.

10. 18yo vag bleed
HPI: 6 days of vaginal bleeding heavier than normal menses. Went through 5-6 pads a day. Intermittent cramps. No lightheadedness and eating normally. No meds taken.
PE: HR 75, BP 105/70, RR 16, T 98 Benign exam. Occasional cramping grimace on exam but otherwise neg. Min bleeding on pelvic and no masses.