Medical Decision Making

Abdominal Pain

Abdominal pain contains a wide differential diagnosis to include bowel dysfunction, renal colic, urine infection, hernia, hepatic, gastric, or gallbladder dysfunction.

CBC to look for evidence of an infection or anemia. Urinalysis to look for infection or hematuria. Electrolytes, liver function tests, and lipase to look for evidence of end organ damage.

[-In males: consideration for testicular torsion. Will perform an ultrasound.-]

[-In females: consideration of reproductive organs as a cause of pain. Work Up includes: BhCG for pregnancy level, RH factor, and other laboratory values if concerned for other non-pregnant related causes of pain in pregnancy. Ultrasound if pregnant, or for evaluation of ovarian cyst.-]

 Will consider advanced imaging with concerns for an acute abdominal process.

Abscess

History and exam is consistent with an abscess.  As the patient has [-fluctuance/induration-], an incision and drainage with culture of the wound is appropriate.  No evidence for sepsis, bacteremia, necrotizing fasciitis.  No proximal streaking or symptoms of systemic infection. Will treat with oral antibiotics as an outpatient, covering for Streptococcus and Staphylococcal infections (including MRSA) pending culture results. Tetanus is [-up to date-].

Abrasion

Abrasions are superficial, well approximated, and hemostasis is intact. They are not conducive to suture repair. Will manage the wound with conservative management, using antibiotic ointment and bandaging. No evidence for tendon damage or neurovascular compromise, nor for bony injury (xrays not indicated). Tetanus prophylaxis is [-up-to-date-].

Allergic Reaction

Patient presents with a rash consistent with allergic response. Allergen [-of unclear etiology-]. The patient has no systemic symptoms to suggest viral xanthem, no headache or other symptoms suggestive of meningococcal  infection. Rash does not resemble urticarial vasculitis. The patient has taken taken no medications to cause a drug eruption. No evidence for respiratory involvement. Will treat with histamine blockers. Consider prednisone if not improving.

Asthma

Patient with a history of asthma presents with signs and symptoms consistent with an exacerbation.  Patient is afebrile, no productive cough, tachypnea, or chest pain.  Pneumonia unlikely, but chest x-ray will help rule this out.  No suggestion of a cardiac etiology.

 Will provide nebulizer treatment for symptomatic relief and reassess.  Will provide prescription for inhaler medication and a steroid burst treatment.

Anxiety

The patient presents with a chief complaint of anxiety.  The patient denies stimulant or substance abuse which could cause anxiety.  [-No rapid cycling alternations with depression.-]  No signs or symptoms suggestive of psychosis.  With no suicidal or homicidal ideation, or hallucinations, this patient is safe for outpatient management.  Consider thyroid testing, electrolyte evaluations, and a baseline CBC as an inpatient or with a primary care provider.  The patient understands that psychiatric evaluation may also be helpful.

Back Pain

Tenderness consistent with a muscle strain or sprain of the back.  No mechanism to suggest fracture or subluxation, no point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. No evidence for cauda equina syndrome. No indication for imaging. No radicular pain or focal neurologic finding to suggest disk injury or nerve impingement. Nothing in history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.

Back X-ray

Pain is most consistent with muscle strain, sprain, or contusion. Given the significant mechanism, we will perform an x-ray to exclude a fracture. No point tenderness to suggest osteomyelitis, other infection, bone lesion or tumor. No evidence for cauda equina syndrome. No radicular pain or focal neurologic finding to suggest disc injury or nerve impingement. Nothing in history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.

Bat Bite

Bat exposure, bat unavailable for testing, so must be treated as exposed [-though there is no evident bite wound-]. Will need HRIG and HR vaccine. Current recommendation for rabies vaccination at day 0, 3, 7, and 14.  No evidence of infection from a wound. Tetanus [-is up-to-date-]. No pain. Will have the patient follow-up as appropriate.

Bell’s Palsy

The patient  presents with unilateral facial weakness, an isolated deficit without other neurologic findings on exam or by history. This is unlikely to represent tumor given the fairly rapid onset, lack of hearing change, ataxia, nystagmus or other neurologic symptoms or findings. I Will treat with prednisone. Currently, there is equivocal benefit for use of antivirals. I reviewed eye precautions (including avoidance of contact lenses, and saline drops), and provided a neurology referral.

 Bee Sting

Patient without prior history of bee sting allergy, but with similar local reaction. Timing and lack of proximal streaking or fever argue against secondary infection. No evidence of systemic allergic reaction or impending respiratory difficulty. Will treat with histamine blockers.

Body Fluid Exposure Without PEP

The patient was counseled regarding HIV and hepatitis testing, and given informed consent. The patient was counseled regarding PEP and declines. Patient understands changes in his plan can occur, but timeliness is important. I discussed at length with the patient the diagnosis and expected follow-up with infectious disease.

Body Fluid Exposure PEP Treatment

Patient presents with [-percutaneous, mucous membrane, skin-] body fluid exposure [-highest, increased, no risk-]. Postexposure chemoprophylaxis with [-Truvada, Norvirm Reyataz-]. HIV and hepatitis testing indicated to establish baseline. Tetanus prophylaxis is [-up-to-date-]. Will provide infectious disease referral for follow-up.

Bronchitis

Patient presents with productive cough and general malaise. Although patient has no evidence of respiratory distress or significant hypoxia, I will obtain chest x-ray to help rule out infiltrate and pneumonia. Patient’s symptoms are likely related to bronchitis and there is no evidence of infiltrate so I will not use antibiotics at this time. However I will provide patient with symptomatic relief. Patient has no other evidence of serious bacterial illness to include meningitis.

Patient appears well-hydrated and is able to tolerate fluids and I do not feel IV fluid hydration is needed at this time.

Burn

History and exam consistent with first and second-degree burns. [-Will debride ruptured blisters/Will pad existing Blisters/No blisters requiring padding-]. Will treat with topical antibiotics, and consider narcotic analgesia for breakthrough pain. Tetanus prophylaxis is [-up-to-date-].

Cat Bite

Patient with a cat bite injury. Exam consistent with infection. There is no puncture over a flexor tendon, no circumferential swelling and no tenderness over the flexor tendons. No evidence for neurovascular compromise in the hand. The patient has no immunocompromise or impaired wound healing, therefore will treat as an outpatient with oral antibiotics (Augmentin to cover for P. multocida). Will consider splinting for comfort and to slow spread of infection. Tetanus prophylaxis is [-up to date-].

Cellulitis

The patient presents with a localized rash. Appearance is most consistent with cellulitic reaction. No medication changes or contact with new soaps, perfumes, detergents, or plants to suggest allergic component. No identifiable target lesion. Viral xanthem unlikely in absence of viral symptoms. Distribution, appearance and lack of pruritis make scabies or pityriasis rosea unlikely. Appearance doesn’t suggest guttate psoriasis or vasculitis. Will treat for Strep and Staph, including MRSA. With a wide differential, a follow-up for failure of the rash to clear is appropriate. Tetanus prophylaxis is [-up-to-date-].

Chest Pain

[-Chest pain-] evaluation contains a wide differential diagnosis. [-D-dimer to screen for pulmonary embolism-].

Ordered electrolytes for baseline assessment and to guide management if CT scan becomes necessary. CBC to assess for infection or anemia that may contribute to presentation. [-BNP to evaluate for congestive heart failure. -] Chest x-ray to evaluate for pneumonia, pulmonary edema, or  signs of CHF.

EKG and troponin to evaluate for cardiac injury. [-Will consider serial studies for evolving cardiac injury.-]

[-Prophylactic aspirin and nitroglycerin considered. Nebulizer for possible reactive airway process. Lasix for possible CHF.-]

Coccyx Contusion

Mechanism and exam suggest coccygeal contusion or fracture. No evidence for cauda equina syndrome. No radicular pain or focal neurologic finding to suggest disc injury or nerve impingement. No hematochezia to suggest rectal injury. Nothing in history or exam to suggest renal, urinary, or intra-abdominal/pelvic etiology for pain.

Croup

Patient presents with a barking cough and a history consistent with croup. No suggestion of foreign body ingestion. No trismis with epiglottis easily visualized, making epiglottitis or strep unlikely.  However I will provide patient with symptomatic relief. Patient has no other evidence of serious bacterial illness to include meningitis.

Will consider a CBC to look for early signs of leukopenia or late signs of leukocytosis. No hypoxia to suggest a need for admission.

Will consider steroids.

Epistaxis

Epistaxis. Will attempt to clear blood clots, and if the location is anterior or septal, attempts at silver nitrate cautery will be undertaken. Packing may be considered if persistent bleeding. Conservative management with antibiotic ointment to decrease risk of recurrent bleeding due to dryness. Consideration of  URI symptoms as an exacerbating factor of symptoms. 

Cerumen Impaction

History and exam consistent with cerumen impaction. No recent upper respiratory infection symptoms to suggest otitis media and no evidence on exam for peritonsilar abscess or cellulitis. No ear canal sensitivity to suggest otitis externa. No tap tenderness to teeth to suggest dental infection or pain. Patient has no diabetes or immunocompromise. Will attempt at removal of cerumen. Patient trained on hygiene of the ear.

Chest Contusion

Chest pain after injury. Differential diagnoses includes rib contusion, intercostal contusion, rib fracture, or pneumothorax. We will perform a chest x-ray to rule out pneumothorax and to help clarify whether there is rib fracture. Cardiac event is unlikely, as the pain is reproducible, intermittent, and associated with an injury.

Conjunctivitis

Patient presents with complaints of red eyes and exam consistent with conjunctivitis, which will be treated with topical antibiotics.  No evidence for visual disturbance, no evidence of foreign body by history. Will have the patient followup with ophthalmology if not improving in 2-5 days.

Contact Dermatitis

Patient reports rash consistent with urticaria, etiology [-unclear-]. The patient has no systemic symptoms to suggest viral exanthem, no headache or other symptoms suggestive of meningococcal infection. Rash does not resemble urticarial vasculitis.  The patient has taken no medications to cause a drug eruption. No evidence for respiratory involvement. Will treat with histamine blockers.  Consider prednisone if not improving. With wide differential diagnoses, timely followup is appropriate if not improving within one week.

Corneal Abrasion

Patient presents with complaints of eye discomfort and exam consistent with corneal abrasion, which will be treated with topical antibiotics. Will arrange timely follow-up with ophthalmology if not improving. Pain management for breakthrough discomfort with narcotic analgesia [-is declined-].

Dermatitis

Patient reports rash consistent with urticaria, etiology [-unclear-]. The patient has no systemic symptoms to suggest viral exanthem, no headache or other symptoms suggestive of meningococcal infection. Rash does not resemble urticarial vasculitis. The patient has taken no medications to cause a drug eruption. No evidence for respiratory involvement. Will treat with histamine blockers. Consider prednisone if not improving.

DVT

The patient presents with lower extremity pain, edema, or calf tenderness, and a positive Homans sign.  No history of recent trauma.  Differential does include muscle strain or myalgia, however, it also includes deep vein thrombosis.  Will perform a d-dimer, to help rule out a deep vein thrombosis, and in the setting of a positive study, will obtain a duplex of the lower extremity to rule out DVT.  With a negative d-dimer, and a low Wells criteria, a blood clot would be unlikely.

Epistaxis

Epistaxis:  Will attempt to clear blood clots, and if the location is anterior or septal, attempts at silver nitrate cautery will be considered.  Packing may be considered if persistent bleeding.

Consideration to URI symptoms as potential exacerbator of symptoms.

Fracture vs Sprain

Differential diagnosis: Contusion, strain, sprain, or fracture [-of the joint-]. X-ray indicated to rule out the latter. No evidence of neurovascular compromise of the extremity.

Gastroenteritis

Vomiting and diarrhea. Without frank abdominal pain, likely viral syndrome (gastroenteritis). Cannot exclude food poisoning or other infectious colitis.

No history or suggestion of inflammatory bowel disease, dietary changes, medication changes, irritable bowel syndrome, or surgical concerns. No evidence of obstruction

[-Will consider stool studies either in the department are as an outpatient. Will consider performing a CBC to look for evidence of dehydration or infection. Will perform electrolytes, liver function testing, and pancreatic testing to look for evidence of end organ damage or imbalance.-]

Gout

Differential diagnosis: gout or pseudogout likely given past history of same, presence of focal pain [-area-], positive risk factors including [-family history, obesity, hypertension, past history-]. Lack of point of entry for infection, lack of fever makes cellulitis less likely.

No risk factors for osteomyelitis. No bleeding disorder or anticoagulation to cause hemarthropathy. No recent STD, tick exposure, immunocompromise, diabetes, arthritis, recent joint injury or joint prosthesis to place patient at risk for septic arthritis. [-Will consider consider arthrocentesis-]. Other acute arthritides unlikely given abrupt onset. [-Consideration of further labs where appropriate-].

Head Injury  (with imaging)

Differential diagnoses: [-Scalp, Facial-] Contusion. Concussion. Due to [-loss of consciousness, symptoms, age, anticoagulants-], I felt a CT scan of the head was warranted. The patient will continue to monitor for, and return with, changes in behavior, decreased level of consciousness, or increased pain. The patient should also return with poorly controlled nausea, vomiting, or dizziness.

Head Injury  (no imaging)

Differential diagnoses: [-Scalp, Facial-] Contusion. [-Evidence for Mild-] Concussion. In the setting of no loss of consciousness, Glascow coma scale of 15 and normal neurologic exam, I did not feel a CT scan of the head was needed.  The patient is instructed to return with changes in behavior, decreased level of consciousness, or increased pain. The patient may also return with poorly controlled nausea, vomiting, or dizziness.

Hemorrhoid

Signs and symptoms consistent with an external hemorrhoid. No hematochezia prompting further workup. With thrombosis, patient was offered an incision, [-and declines/accepts-].  Conservative management to be followed. Will consider surgical consult in follow up, especially if there are worsening symptoms. I spent a significant amount of time reviewing sitz baths, hygiene, and use of Preparation H. Patient may consider using a donut pillow.

Hypertension

Hypertension is either related to pain, or a chronic condition. Patient will follow up with a regular provider for further evaluation. Patient is advised that long term elevations in blood pressure can lead to complications such as heart disease or stroke.

Influenza

Presumed H1N1 or seasonal flu. Strep pharyngitis unlikely based on exam and symptom. No evidence for acute bronchitis, sinusitis, pneumonia, otitis. Symptoms consistent with viral URI which will be treated symptomatically. [-Testing for influenza is of limited value with up to a 50% error margin, and little change in most patients care-]. Will counsel the patient regarding isolation.

Intoxicated

Patient is a chronically inebriated [-man/woman-]. Will perform blood alcohol testing. Patient demonstrates no desire to stop the use of alcohol. Is chronically at risk for injury and alcohol related complications. I feel that an enforced stay in the emergency department places the patient at risk for withdrawal, and will not improve the patient’s care. Patient would like to go home. Will wait until the patient is able to demonstrate ambulation unassisted. Patient has clearly demonstrated the ability to obtain medical care. Will consider providing vitamin supplements by mouth or IV.

Laceration

Laceration will require closure to achieve and maintain hemostasis and to promote optimal wound healing. No evidence for tendon damage or neurovascular compromise, nor for bony injury (xrays not indicated). Tetanus prophylaxis is [-variable-]

The patient verbally consents to a wound repair. Side and sight are verified.  Patient identification is verified.  The wound is anesthetized with [-variable-] for a [-variable-] block. It is then copiously irrigated.

It is approximated using simple interrupted sutures with [-variable-]. Total number [-variable-]. Good approximation is achieved. Hemostasis is maintained. It is dressed with Bacitracin and a bulky dressing.

Laceration Without Repair

Laceration is [-superficial, well approximated, presents too late for wound care-] and hemostasis is intact. There would likely be minimal improvement with suture repair. Will manage the wound with conservative management, using good wound care. No evidence for tendon damage or neurovascular compromise, nor for bony injury (xrays not indicated). Tetanus prophylaxis is [-up-to-date/ordered-].

Meningitis

Patient is here for worse headache of life. This is a change in character from previous headaches but with a benign neurologic exam. There is evidence for an infectious process such as meningitis or encephalitis, with notable meningismus. No evidence for an inflammatory process such as temporal arteritis, increased cranial pressure, trauma, or chronic process such as tumor formation. No recent trauma to cause SDH or post-concussive syndrome. [-CT or fundal exam-] with subsequent LP is indicated to rule out SAH or other intracranial process.

Will treat prophylactically for meningismus with 1 g of ceftriaxone. Will treat for analgesia with narcotics, consider nonsteroidal anti-inflammatories if the head CT is negative for a bleed. With flulike symptoms, will swab for influenza. CBC and limited panel of chemistries may be useful to differentiate this type of headache.

Mental Health Inpatient

The patient’s history reveals significant [-anxiety, depression-]. The patient denies stimulant or substance abuse which could cause anxiety.  No rapid cycling between mania and depression, making bipolar disorder unlikely.  No signs or symptoms suggestive of psychosis.  With [-suicidal/homicidal ideation/hallucinations-] this patient requires screening for inpatient management. Will perform [-blood alcohol and drug screen-] and consider supplemental testing for organic cause with [-thyroid testing, electrolyte evaluations, and a baseline CBC-]. The patient [-does/does not-] contract for safety. There is risk for involuntary departure. Will consider restraints, safe enviroment, and medical management only if appropriate for patient and staff safety.

Mental Health Outpatient

The patient’s history reveals significant [-anxiety, depression-]. The patient denies stimulant or substance abuse which could cause anxiety.  No rapid cycling between mania and depression, making bipolar disorder unlikely.  No signs or symptoms suggestive of psychosis.  With no suicidal or homicidal ideation, or hallucinations, this patient is safe for outpatient management.  Will start with a primary care provider, consideration of thyroid testing, electrolyte evaluations, and a baseline CBC may be appropriate.  The patient understands that psychiatric evaluation may also be helpful.

Migraine

Patient is here for typical migraine, no significant change in character from previous headaches and with a benign exam. There is no evidence for an infectious process such as sinusitis, meningitis/encephalitis, inflammatory process such as temporal arteritis, increased cranial pressure, trauma, intracranial hemorrhage, or chronic process such as tumor formation. No recent trauma to cause SDH or post-concussive syndrome. No recent chiropractic neck manipulation to cause vertebral or carotid artery dissection. There is no indication for CT or further radiographic study at this time. Will medicate for pain and nausea.

Neck Pain

No recent upper respiratory infection symptoms to suggest infectious cause for pain. No direct blow or midline tenderness, as such x-rays are not indicated. No radicular pain or focal neurologic finding to suggest disc herniation or nerve impingement. History and exam consistent with a strain or sprain.

Nose Injury  Making

Patient presents with probable nasal fracture with associated soft tissue swelling. Patient has no other identifiable facial trauma and at this point I do not feel that further imaging is necessary. Patient has no evidence of septal hematoma or ongoing significant epistaxis. Patient may need referral to otolaryngology for definitive management for probable fracture after swelling has subsided. [-I will consider antibiotics at this time because of  significant epistaxis and the possibility of open fracture-]. Tetanus is [-up to date-]

Nursemaid’s Elbow

History and physical consistent with a nursemaid’s elbow/subluxation of the radial head. No evidence of neurovascular damage. No gross evidence of fracture. Will attempt reduction.

Otitis Media Medical

History and exam consistent with otitis media. No evidence on exam for peritonsilar abscess or cellulitis without radicular pain to the ear. No tap tenderness to teeth to suggest dental infection or pain. Patient has no diabetes or immunocompromise. Will discuss symptomatic management, and the equivocal effectiveness of antibiotics.

Otitis Externa Medical

History and exam consistent with otitis externa, nonmalignant. No recent URI symptoms to suggest otitis media.  No evidence on exam for peritonsilar abscess or cellulitis without radicular pain to the ear. No tap tenderness to teeth to suggest dental infection or pain. Patient has no diabetes or immunocompromise.

Psychiatric Evaluation

Patient presents with a non-focal neurologic exam presents with [-suicidal, homicidal ideation, or hallucinations-]. Patient denies and has no evidence of alcohol or drug intoxication and denies polysubstance abuse. Patient has had no recent head trauma, seizure, and has no infectious complaints or evidence for metabolic derangement. No evidence of acute medical issues. Urine tox screen, blood alcohol and TSH screening indicated. No medical illness that would preclude psychiatric evaluation treatment. Social Work to see; disposition to be discussed.

Puncture Wound

Puncture wound with hemostasis, no evidence of bony injury and no history for FB. X-rays would likely not be helpful. This wound is not amenable to copious irrigation. No repair is indicated. The patient is neurovascularly intact. No evidence for tendon injury. Tetanus prophylaxis is [-up-to-date-].

Rabies

Potential rabies exposure, with animal unavailable for testing. This must be treated as an exposure, although there is no evident bite wound. Will need HRIG and HR vaccine. Follow-up with infectious disease. Will receive further injections on day 3, 7, 14. Tetanus is [-up-to-date-].

Sciatica

History and exam support the diagnosis for sciatica. No evidence for cauda equina syndrome. No mechanism to suggest fracture or subluxation. No evidence of osteomyelitis or other infection, bone lesion, or tumor.

No acute requirements for imaging. If symptoms persist or worsen, an outpatient MRI may be appropriate. Will medicate with steroids and consider pain management options.

Sinusitis

Signs and symptoms are consistent with sinusitis. Will explain the lack of benefit in 97-99% of cases when using antibiotics. Will discuss treatment with sinus irrigation, nasal steroids, decongestants and pain management for breakthrough discomfort.

Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, pneumonia, otitis. Underlying symptoms consistent with a viral URI which will be treated symptomatically. No indication for diagnostic testing.

Strep Throat

Differential diagnoses: viral or strep pharyngitis. No lesions to suggest coxsackie infection, oral herpes. No evidence for peritonsilar cellulitis or abscess. No evidence of dehydration due to poor po intake. With trismus, Sore throat, isolated symptoms, Cervical adenopathy, and vocal changes, will treat empirically.

Syncope

There are [-no risk factors such as: Abnormal EKG, history of cardiac disease/heart failure, Persistently low blood pressure, shortness of breath with event or during evaluation, no hematocrit less than 30, no age related or associated comorbidities, and no family history of sudden cardiac death.-]

Bilateral blood pressures performed to evaluate for thoracic vascular process.

EKG and cardiac chemistry evaluation to evaluate for a cardiac component.

[-Will consider CT scan as a screen for a neurological event.-]

No tongue injury or incontinence to suggest seizure

CBC to look for anemia or evidence of infection. Electrolytes to look for evidence of endorgan damage or acidosis.

Anxiety does not appear to be a source of the patient’s symptoms by history, will check a TSH to look for an atypical cause of syncope.

Common but with less mortality can include a neurocardiogenic, carotid sinus sensitivity, orthostasis, and medication-related or substance abuse process. [-No evidence for this on history or physical exam.-]

Tachycardia

Tachycardia. Differential diagnosis includes dehydration, and the patient will receive 1 L of normal saline IV. Cardiac component will be evaluated by an EKG. Hyperthyroidism will be screened with a TSH. Electrolyte imbalance will be evaluated with laboratory testing. A CBC will be performed to look for anemia. Will evaluate a d-dimer to decrease the likelihood of a pulmonary embolism or deep vein thrombosis. Will perform a urinalysis to evaluate for infection or drug use.

Testicular Pain Medical

Testicular Pain. Differential diagnosis: Epididymitis, orchitis. Consideration for torsion and consider doppler ultrasound. Trauma is a consideration. Less likely would be referred pain from renal colic. Also consider testicular mass as possibility as well. Urine tract pathology to be investigated with urine dip. For younger males with risk factors, consider STD.

Upper Respiratory Infection (Cold)

Upper respiratory infection symptoms are consistent with viral process which will be treated symptomatically.  Strep pharyngitis unlikely based on exam and symptoms. No evidence for acute bronchitis, sinusitis, pneumonia, otitis. No indication for diagnostic testing.

Urinary Retention

Foley catheter to be placed if felt clinically appropriate and effect monitored. Urine dip/urinalysis to be sent as well for signs of infection or blood. If concerns about renal function, consider limited profile.

UTI

Lower urinary tract or symptoms are suggestive of a simple urinary tract infection. Urinalysis is indicated. No evidence for pyelonephritis or symptoms to suggest vaginitis. Will consider urine pregnancy testing where appropriate.

Vaginal Bleeding in Pregnancy

Differential diagnosis: Threatened abortion, missed abortion, fetal demise, consideration for ectopic. Consideration of pain secondary to corpus luteum. Other considerations include causes not associated with pregnancy such as ovarian pathology, fibroids, other entities such as appendicitis, UTI.

Work Up includes: BhCG for pregnancy level, CBC if there is concern for anemia, RH factor, and other laboratory values if concerned for other non-pregnant related causers of pain in pregnancy. Will perform ultrasound to evaluate fetal status.

Vertigo

Vertigo. Differential diagnosis: Positional vertigo, acute labyrinthitis, vestibular neuronitis, acoustic neuroma, otitis media. Central Vertigo more concerning with cranial nerve complaints or the inability to ambulate (particularly if elderly). Further elder risk could include cerebellar hemorrhage or CVA.

Atypical differential to include pre-syncope, dehydration, anemia, medication reaction, trauma, head injury, viral syndromes.

If concerns with metabolic causes, laboratory abnormalities will be investigated. If elderly and unable to ambulate, severe headache, central vertigo, persistent symptoms, or confusion (among other concerns) will consider CT imaging of brain or MRI imaging of brain. 

Zoster

The patient presents with a painful rash, no systemic symptoms.  There are no recent upper respiratory infective symptoms that suggest a viral exanthem.  No new ingestions or exposures to suggest allergic or drug reaction.  No purpura or petechia to suggest vasculitis. No other symptoms to suggest systemic illness.  Distribution of the pain and lesions are consistent with herpes zoster.  No evidence of secondary infection.  Patient presents within 72 hours of rash onset, so we will utilize antiviral therapy and pain palliation for reduction of symptoms and posttherpetic neuralgia risk. Current studies do not endorse  corticosteroid use.