PI Case Summary – April 20, 2021

1. 13 y/o female presents with ovarian torsion. There was debate as to who takes to OR – so we have referred to OB-gyn and peds surgery so they can define age criteria similar to our peds appendicitis cases. Patient was sent home initially by OB-gyn, but had great return instructions and returned 2 hours later with worsening sxs and no flow on US.
2. 31 y/o female presents with fall from scooter. Mandible XR was negative. Patient f/u’ed with dentist and had fracture on panorex. Remember that mandible XR are not great at finding mandible fractures. Consider doing easy bedside test – the tongue blade test (video here). If you are concerned for fracture, go straight to CT scan.
3. 57 y/o male presents with headache. Had normal neuro exam and had resolution of sxs with migraine meds. Returned 2 days later with persistent headaches and found to have subacute subdural hemorrhage requiring neurosurg intervention. Remember red flags for imaging for new and progressive headaches – subacute head trauma, exertional HA, neuro deficits, cancer, immunocompromise, pregnancy and age >50.
4. 93 y/o male with non-traumatic hip pain. Significant delays with blood draw and imaging. Started to become hypotensive, CT abd/pelvis done with ruptured AAA. Further delays because vascular surgery requested CTA. Ultimately, he coded en route to OR and died. Remember that AAA doesn’t frequently present with classic triad of abdominal pain, hypotension and pulsatile mass. Have low threshold to look for other etiologies, especially in our older patients.
5. 38 y/o female with recent dx of covid-19 presents with pleuritic chest pain. CTA done with acute PE as well as ground glass opacities concerning for covid-19 pna. Patient in no resp distress with no hypoxia. Discharged home by hospitalist due to negative Hestia criteria. Educational case about PESI and Hestia criteria. If all criteria are found to be negative, patients are considered low risk and could be managed as outpatient. Despite these scoring systems, in the US, only 4% of patients are currently being discharged. If you are considering discharging these patients home, use shared decision making and ensure they have good follow-up. Check out www.goodrx.com to get coupon for 1 month of free anticoagulation.