You’ve got a seemingly straightforward complaint. Should you reach for your Foley or your ultrasound probe?
New patient is a 5-year-old male with a history of a circumcision three months ago for recurrent UTIs. His mom states he has been having intermittent generalized abdominal pain associated with dysuria and urinary urgency. Despite being potty trained since he was 3, he is now having urinary incontinence as well. There has been no fever or flank or back pain and he is otherwise healthy and not on any medications regularly. Mom states he sometimes starts crying from the pain.
A 25-year-old female presents to the ED with her boyfriend after she developed sudden onset pelvic pain during sexual intercourse at around 10 pm. The pain gradually worsened and spread to her ribs and she felt bloated and had the urge to defecate, so she got up from bed and went to the bathroom. Unfortunately she fainted on the way there, though she landed on carpet without injury.
It’s a busy Monday morning, and you watch as a new patient awkwardly limps onto your only open bed. You immediately wonder what is causing him to walk with such a strange gait. After Glancing at the EMR, you find a helpful hint in the nurse’s note about his chief complaint — testicular pain.
They say that things come in threes, and at least for today, you agree. You just finished sending home three young women with first trimester vaginal bleeding and reassuring bedside ultrasounds. Prior to that you actually had three cardiac arrests, one that you remarkably brought back with tPA after your bedside echo showed a severely dilated right ventricle but normal left ventricle from a presumed acute PE.
“Technology has become so disruptive!” your veteran charge nurse exclaims. “Every time I have to answer one of these mass emails to our department, our organization loses money. My time is very valuable!” she bemoans. “How am I supposed to concentrate on patient care when my work email account dings every 2 minutes with an ‘Urgent’ message?”
A 54-year-old male is in the ED for a paracentesis because he states he is uninsured and has nowhere else to go. He states his last “tap” was about 4 weeks ago and he is starting to feel short of breath even at rest because of all the fluid. He states these are the same symptoms he always gets and denies any issues that are atypical for him. Just to be sure, you run down a list of pertinent negatives and he politely denies fever, pain, melena, confusion, vomiting, and chest pain.
An 84-year-old woman is brought to the emergency department by ambulance for evaluation of altered mental status and syncope. Per family, the patient had complaints of abdominal pain for two days, tactile fevers, decreased PO intake and one episode of non-bloody, non-bilious vomiting. The patient also fell from her bed to the carpet with loss of consciousness for 10 seconds.
A 22-year-old G4P2 female is brought to the emergency department by her boyfriend for pleuritic right sided lower chest pain that she has had for approximately 18 hours. The pain is in the low anterior right side of the chest and radiates to the scapula and upper abdomen. It has been constant, but is not associated with nausea, vomiting, fever, chills, diarrhea or shortness of breath.
“If you are given a second chance in life, don’t blow it,” you advise
your eager resident. It has been an overwhelmingly busy day in the
department. Interspersed between the motor vehicle collisions, hypoxic
and hypotensive CHF exacerbations, and patients with florid sepsis, your
team is trying to see and help all of the ankle pains, throat pains,
and dysuria that have also walked through the waiting room doors.