{"_note":"© 2026 Kim Trinh, MD. All rights reserved. The original work of Kim Trinh, MD — not to be copied, reproduced, or redistributed without written permission. Original, generalized educational content; synthetic phrasing only; no institution-specific protocols, no PHI. Validated decision instruments are referenced by name and cited to source literature; clinicians must apply local protocol and judgment.","common":["abdominal-pain","chest-pain","dyspnea","asthma-copd","heart-failure","fever","headache","back-pain","cough","dizziness","gastroenteritis","laceration","extremity-injury","uti-dysuria","syncope","atrial-fibrillation","flank-pain","allergic-reaction","cellulitis"],"packs":[{"id":"chest-pain","title":"Chest Pain","aliases":["cp","chest","chest pain","heart attack","mi","acs","angina","chest pressure","chest tightness","pe","dissection","noncardiac","costochondritis"],"opening":"The patient was evaluated for chest pain. A focused history and physical examination were performed, and the life-threatening and common causes below were actively considered.","ddx":[{"id":"acs","group":"lifethreat","label":"Acute coronary syndrome","default":true,"tags":["acs"],"ruleout":"Acute coronary syndrome was considered; the pain was non-exertional and non-pressure in quality, without radiation, diaphoresis, or associated nausea, the ECG showed no ischemic changes, and serial troponin was not elevated, making it unlikely.","treatment":{"items":["Aspirin; antithrombotic therapy per protocol","Serial ECG and troponin; cardiac monitoring"],"subtypes":[{"label":"STEMI","items":["Activate cath lab — primary PCI","Fibrinolysis if timely PCI is unavailable"]},{"label":"NSTEMI","items":["Anticoagulation and anti-ischemic therapy","Early invasive strategy / cardiology"]},{"label":"Unstable angina","items":["Risk-stratify (HEART); serial troponin/ECG","Admit/observe; cardiology follow-up"]}]},"miss":4},{"id":"dissection","group":"lifethreat","label":"Aortic dissection","default":true,"tags":["dissection"],"ruleout":"Aortic dissection was considered; there was no tearing or migratory pain, no inter-arm blood-pressure differential or pulse deficit, and no focal neurologic deficit or new diastolic murmur, making it unlikely.","treatment":{"items":["Control heart rate, then blood pressure (e.g., esmolol then a vasodilator)","Pain control; type and crossmatch"],"subtypes":[{"label":"Type A (ascending)","items":["Emergent cardiothoracic surgery"]},{"label":"Type B (descending)","items":["Medical management; endovascular/surgery for complications"]}]},"miss":4},{"id":"pe","group":"lifethreat","label":"Pulmonary embolism","default":true,"tags":["pe"],"ruleout":"Pulmonary embolism was considered; there was no pleuritic pain, dyspnea, hemoptysis, or unilateral leg swelling, no immobilization, recent surgery, malignancy, or prior VTE, and the patient was not tachycardic or hypoxic, placing pretest probability low.","treatment":{"items":["Anticoagulation unless contraindicated"],"subtypes":[{"label":"Massive (unstable)","items":["Systemic thrombolysis (e.g., tenecteplase / TNK)","Embolectomy if thrombolysis is contraindicated"]},{"label":"Submassive","items":["Anticoagulation; close monitoring","Consider thrombolysis if deterioration"]},{"label":"Low-risk","items":["Anticoagulation; consider outpatient management"]}]},"miss":4},{"id":"ptx","group":"lifethreat","label":"Tension/spontaneous pneumothorax","default":false,"tags":[],"ruleout":"Pneumothorax was considered; there was no sudden pleuritic pain or dyspnea, breath sounds were symmetric without hyperresonance, the trachea was midline, and there were no signs of tension physiology, making it unlikely.","treatment":{"items":["High-flow oxygen"],"subtypes":[{"label":"Tension","items":["Immediate needle/finger decompression, then chest tube"]},{"label":"Spontaneous (stable)","items":["Observation, aspiration, or small-bore chest tube by size/symptoms"]}]},"miss":3},{"id":"perf","group":"lifethreat","label":"Esophageal perforation","default":false,"tags":[],"ruleout":"Esophageal perforation was considered; there was no antecedent forceful vomiting, instrumentation, or caustic ingestion, and no subcutaneous emphysema, severe odynophagia, or systemic toxicity, making it unlikely.","treatment":{"items":["NPO; broad-spectrum antibiotics; IV fluids","Urgent surgical/GI consult; CT or contrast esophagram"]},"miss":4},{"id":"tamponade-cp","group":"lifethreat","label":"Cardiac tamponade","default":false,"tags":["tamponade-cp"],"ruleout":"Cardiac tamponade was considered; there were no distended neck veins, muffled heart sounds, or pulsus paradoxus, the patient was hemodynamically stable, and no pericardial effusion was seen on bedside echo where obtained, making it unlikely.","treatment":{"items":["IV fluids as a temporizing measure","Urgent echo; pericardiocentesis for instability","Cardiology / cardiac surgery"]},"miss":4},{"id":"pericarditis","group":"common","label":"Pericarditis / myocarditis","default":false,"tags":[],"ruleout":"Pericarditis was considered; the ECG and clinical picture were not characteristic.","treatment":{"items":["NSAID plus colchicine","Investigate and treat the underlying cause","Echo if effusion is suspected"]},"miss":2},{"id":"pna","group":"common","label":"Pneumonia","default":false,"tags":[],"ruleout":"Pneumonia was considered and felt to be unlikely given the history, examination, and available imaging.","treatment":{"items":["Antibiotics per severity and setting","Oxygen; assess severity (e.g., CURB-65)"]},"miss":2},{"id":"gerd","group":"other","label":"GERD / musculoskeletal chest pain","default":false,"tags":[],"ruleout":"A gastrointestinal or musculoskeletal source was considered as a more benign explanation after the serious causes above were addressed.","treatment":{"items":["Symptomatic therapy once emergencies are excluded","Outpatient follow-up; return precautions"]},"miss":1}],"risk":[{"id":"heart","label":"HEART score","tags":["acs"],"scale":"low","line":"A HEART score was documented to risk-stratify this chest pain presentation and to inform disposition.","cite":"Six AJ, Backus BE, Kelder JC. Neth Heart J. 2008.","calc":{"fields":[{"label":"History","opts":[["Slightly suspicious",0],["Moderately suspicious",1],["Highly suspicious",2]]},{"label":"ECG","opts":[["Normal",0],["Non-specific repolarization",1],["Significant ST deviation",2]]},{"label":"Age","opts":[["< 45",0],["45–64",1],["≥ 65",2]]},{"label":"Risk factors","opts":[["None known",0],["1–2 factors",1],["≥ 3 or known atherosclerotic disease",2]]},{"label":"Troponin","opts":[["≤ normal limit",0],["1–3× normal",1],["> 3× normal",2]]}],"bands":[[3,"low risk","","Low risk (0–3) with a negative troponin: an accelerated-discharge pathway with shared decision-making is reasonable."],[6,"moderate risk","","Moderate risk (4–6): observation with serial troponin rather than direct discharge."],[10,"high risk","","High risk (7–10): admit and involve cardiology for an ischemia-driven workup."]],"line":"HEART score {score}/10 ({band}); risk stratification documented and used to inform disposition.","applies":"Adults with undifferentiated chest pain and suspected ACS, to risk-stratify for 30-day MACE. Not for STEMI, unstable vitals, or an obvious non-cardiac cause, and not once ACS is already confirmed."},"short":"HEART {band}","bandNotes":{"low":"validated ≈2% 6-week MACE (Backus 2013)","moderate":"validated ≈17% 6-week MACE (Backus 2013)","high":"validated ≈50% 6-week MACE (Backus 2013)"}},{"id":"ecg","label":"ECG reviewed","tags":["acs"],"scale":"low","line":"The ECG was personally reviewed and showed no acute ischemic changes.","short":"ECG non-ischemic"},{"id":"trop","label":"Serial troponin","tags":["acs"],"scale":"low","line":"Serial troponin values were obtained and reviewed, and were reassuring in the clinical context.","short":"troponin negative"},{"id":"wells","label":"Wells score (PE)","tags":["pe"],"scale":"low","line":"Pretest probability for pulmonary embolism was assessed and was low.","cite":"Wells PS, et al. Thromb Haemost. 2000.","calc":{"fields":[{"label":"Signs of DVT","opts":[["No",0],["Yes",3]]},{"label":"PE most likely","opts":[["No",0],["Yes",3]]},{"label":"HR > 100","opts":[["No",0],["Yes",1.5]]},{"label":"Immobil./surgery","opts":[["No",0],["Yes",1.5]]},{"label":"Prior PE/DVT","opts":[["No",0],["Yes",1.5]]},{"label":"Hemoptysis","opts":[["No",0],["Yes",1]]},{"label":"Malignancy","opts":[["No",0],["Yes",1]]}],"bands":[[4,"PE unlikely","low","PE unlikely: apply PERC, or an (age-adjusted) D-dimer, rather than going straight to CT angiography."],[12.5,"PE likely","high","PE likely: proceed to CT pulmonary angiography — D-dimer cannot exclude in this group."]],"line":"Wells score for PE = {score} ({band}); used with d-dimer and clinical judgment to guide imaging.","applies":"Adults with suspected pulmonary embolism, to set pre-test probability before D-dimer or imaging. Not validated in pregnancy or on ongoing anticoagulation."},"short":"Wells {band}","bandNotes":{"pe unlikely":"with a negative D-dimer, 3-month VTE risk ≈0.5% (Christopher study)"}},{"id":"perc","label":"PERC rule (PE)","tags":["pe"],"scale":"low","line":"The PERC rule was applied in this low-probability patient.","cite":"Kline JA, et al. J Thromb Haemost. 2004.","calc":{"fields":[{"label":"Age ≥ 50","opts":[["No",0],["Yes",1]]},{"label":"HR ≥ 100","opts":[["No",0],["Yes",1]]},{"label":"SaO₂ < 95%","opts":[["No",0],["Yes",1]]},{"label":"Unilat. leg swelling","opts":[["No",0],["Yes",1]]},{"label":"Hemoptysis","opts":[["No",0],["Yes",1]]},{"label":"Recent surgery/trauma","opts":[["No",0],["Yes",1]]},{"label":"Prior PE/DVT","opts":[["No",0],["Yes",1]]},{"label":"Estrogen use","opts":[["No",0],["Yes",1]]}],"bands":[[0,"PERC negative — no criteria met","low","Low pretest probability and PERC-negative: PE can be excluded without D-dimer or imaging."],[8,"PERC positive","high","Does not diagnose PE — continue with D-dimer or imaging per pretest probability."]],"line":"PERC rule applied: {score} of 8 criteria present ({band}).","applies":"Low-risk adults (gestalt PE risk under ~15%) being considered to avoid any PE testing. Only valid when pre-test probability is already low -- not for moderate/high suspicion or in pregnancy."},"short":"PERC {band}","bandNotes":{"negative":"with low pretest probability, missed-PE rate <2% in validation (Kline 2008)"}}],"checks":[{"if":"acs","needs":["heart","ecg","trop"],"mode":"any","warn":"ACS is on the differential but no rule-out data is documented. Linking a risk tool or ECG/troponin makes the exclusion defensible."},{"if":"pe","needs":["wells","perc"],"mode":"any","warn":"PE is on the differential — documenting a pretest-probability rule shows why imaging was or wasn’t pursued."}],"guide":"../learn/complaints/chest-pain.html","history":[{"id":"cp-hx-onset-character","dx":"general","q":"Pain onset and character — sudden vs. gradual, quality (pressure, sharp, tearing, pleuritic), severity?","answers":[{"label":"Gradual, non-specific","tone":"neg","sets":[],"ddx":[],"mdm":"Pain onset was gradual and the character was non-specific, without the pressure, sharp, tearing, or pleuritic quality or severe intensity that would point to a single high-risk diagnosis.","frag":"gradual, non-specific onset"},{"label":"Sudden / maximal at onset","tone":"pos","sets":[],"ddx":[],"mdm":"Pain onset was sudden and maximal at onset, a high-risk feature requiring active exclusion of aortic dissection and other catastrophic causes.","frag":"sudden maximal-at-onset pain"},{"label":"Pleuritic (sharp, worse with breathing)","tone":"pos","sets":[],"ddx":[],"mdm":"Pain was pleuritic in character, sharp and worse with breathing, raising consideration of pulmonary embolism, pericarditis, or pleuritis.","frag":"pleuritic character"}]},{"id":"cp-hx-acs-character","dx":"acs","q":"Ischemic features — substernal pressure/heaviness, exertional, radiation to arm/jaw/shoulder, with diaphoresis or nausea (vs. sharp, positional, or reproducible)?","answers":[{"label":"Atypical","tone":"neg","sets":[{"risk":"heart","field":0,"opt":0}],"ddx":[],"mdm":"The history was atypical for cardiac chest pain (non-exertional, without radiation or diaphoresis).","frag":"atypical, non-exertional pain without radiation or diaphoresis"},{"label":"Somewhat typical","tone":"pos","sets":[{"risk":"heart","field":0,"opt":1}],"ddx":[],"mdm":"The history was moderately suspicious for a cardiac cause, with some but not all typical ACS features such as exertional onset, pressure or heaviness, radiation to the arm or jaw, or associated diaphoresis or nausea.","frag":"moderately suspicious cardiac history"},{"label":"Typical","tone":"pos","sets":[{"risk":"heart","field":0,"opt":2}],"ddx":[],"mdm":"The history was typical for cardiac chest pain (exertional, pressure-like, with radiation and diaphoresis).","frag":"typical cardiac pain (exertional, pressure-like, with radiation)"}]},{"id":"cp-hx-cardiac-risk","dx":"acs","q":"Atherosclerotic risk factors — hypertension, diabetes, hyperlipidemia, current smoking, or family history of premature CAD (used in HEART score risk stratification)?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"heart","field":3,"opt":0}],"ddx":[],"mdm":"No cardiac risk factors were identified: no hypertension, diabetes, hyperlipidemia, smoking, family history of early CAD, or known atherosclerotic disease.","frag":"no cardiac risk factors"},{"label":"1–2 factors","tone":"pos","sets":[{"risk":"heart","field":3,"opt":1}],"ddx":[],"mdm":"One to two cardiac risk factors were present among hypertension, diabetes, hyperlipidemia, smoking, family history of early CAD, and known atherosclerotic disease.","frag":"1–2 cardiac risk factors"},{"label":"≥3 / known CAD","tone":"pos","sets":[{"risk":"heart","field":3,"opt":2}],"ddx":[],"mdm":"Three or more cardiac risk factors (among hypertension, diabetes, hyperlipidemia, smoking, and family history of early CAD) or known atherosclerotic disease were present.","frag":"≥3 cardiac risk factors / known CAD"}]},{"id":"cp-hx-prior-cad","dx":"acs","q":"Prior coronary artery disease — prior MI, PCI, CABG, or abnormal stress test?","answers":[{"label":"No prior CAD","tone":"neg","sets":[],"ddx":[],"mdm":"No prior coronary artery disease, myocardial infarction, revascularization procedure, or known abnormal coronary workup was reported.","frag":"no prior CAD"},{"label":"Prior CAD / revascularization","tone":"pos","sets":[{"risk":"heart","field":3,"opt":2}],"ddx":[{"id":"acs","keep":true}],"mdm":"A history of prior coronary artery disease or revascularization (prior MI, PCI, CABG, or abnormal stress test) was present, significantly increasing concern for an acute coronary event.","frag":"prior CAD / revascularization"}]},{"id":"cp-hx-syncope","dx":"acs","q":"Associated syncope or near-syncope?","answers":[{"label":"No syncope","tone":"neg","sets":[],"ddx":[],"mdm":"No associated syncope or near-syncopal episode was reported.","frag":"no syncope"},{"label":"Syncope / near-syncope","tone":"pos","sets":[],"ddx":[],"mdm":"The episode was associated with syncope or near-syncope, a high-risk feature requiring broadened evaluation.","frag":"syncope / near-syncope"}]},{"id":"cp-hx-stimulant","dx":"acs","q":"Cocaine or other stimulant use — a precipitant of both coronary vasospasm/ACS and catecholamine-driven aortic dissection?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"No cocaine or stimulant use was reported.","frag":"no cocaine use"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"acs","keep":true},{"id":"dissection","keep":true}],"mdm":"Cocaine or stimulant use was reported, which can precipitate coronary vasospasm or acute coronary syndrome and, through a catecholamine-driven hypertensive surge, aortic dissection.","frag":"cocaine / stimulant use"}]},{"id":"cp-hx-dissection-pain","dx":"dissection","q":"Aortic-type pain — abrupt onset, maximal at onset, severe, tearing/ripping, or migrating to back/neck/abdomen (ADD-RS pain feature)?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was not tearing or ripping, was not maximal at onset, and did not migrate, making aortic dissection less likely on this feature.","frag":"no tearing or migratory pain"},{"label":"Yes — tearing / migratory / maximal-at-onset","tone":"pos","sets":[],"ddx":[{"id":"dissection","keep":true}],"mdm":"The pain was described as tearing or ripping, maximal at onset, and/or migrated to the back or abdomen, raising strong concern for aortic dissection.","frag":"tearing / migratory / maximal-at-onset pain"}]},{"id":"cp-hx-dissection-conditions","dx":"dissection","q":"High-risk conditions for aortic dissection — Marfan or other connective-tissue disorder, known thoracic aortic aneurysm / bicuspid aortic valve / prior aortic surgery, severe or uncontrolled hypertension, or pregnancy (third trimester / peripartum)?","answers":[{"label":"None of these","tone":"neg","sets":[],"ddx":[],"mdm":"None of the major predisposing conditions for aortic dissection were present: no connective-tissue disorder or Marfanoid habitus, no known thoracic aortic aneurysm, bicuspid aortic valve, or prior aortic surgery, no severe or uncontrolled hypertension, and no pregnancy.","frag":"no connective-tissue disease or known aneurysm, no severe hypertension"},{"label":"One or more present","tone":"pos","sets":[],"ddx":[{"id":"dissection","keep":true}],"mdm":"One or more high-risk conditions for aortic dissection were present (connective-tissue disorder or Marfanoid habitus, known thoracic aortic aneurysm / bicuspid aortic valve / prior aortic surgery, severe or uncontrolled hypertension, or pregnancy), elevating the pretest probability of dissection.","frag":"high-risk condition for dissection present"}]},{"id":"cp-hx-hemoptysis","dx":"pe","q":"Hemoptysis?","answers":[{"label":"No","tone":"neg","sets":[{"risk":"wells","field":5,"opt":0},{"risk":"perc","field":4,"opt":0}],"ddx":[],"mdm":"No hemoptysis was reported.","frag":"no hemoptysis"},{"label":"Yes","tone":"pos","sets":[{"risk":"wells","field":5,"opt":1},{"risk":"perc","field":4,"opt":1}],"ddx":[],"mdm":"Hemoptysis was reported, a criterion in both the Wells score and PERC rule for PE.","frag":"hemoptysis"}]},{"id":"cp-hx-immobil","dx":"pe","q":"VTE provocation — surgery requiring anesthesia, major trauma, or immobilization/bedrest within ~4 weeks (Wells/Geneva criterion)?","answers":[{"label":"No","tone":"neg","sets":[{"risk":"wells","field":3,"opt":0},{"risk":"perc","field":5,"opt":0}],"ddx":[],"mdm":"No recent surgery, trauma, or prolonged immobilization was reported.","frag":"no immobilization or recent surgery"},{"label":"Yes","tone":"pos","sets":[{"risk":"wells","field":3,"opt":1},{"risk":"perc","field":5,"opt":1}],"ddx":[],"mdm":"Recent surgery, trauma, or immobilization was reported, increasing VTE risk.","frag":"recent surgery / immobilization"}]},{"id":"cp-hx-priorvte","dx":"pe","q":"Prior DVT or PE?","answers":[{"label":"No","tone":"neg","sets":[{"risk":"wells","field":4,"opt":0},{"risk":"perc","field":6,"opt":0}],"ddx":[],"mdm":"No prior DVT or pulmonary embolism was reported.","frag":"no prior VTE"},{"label":"Yes","tone":"pos","sets":[{"risk":"wells","field":4,"opt":1},{"risk":"perc","field":6,"opt":1}],"ddx":[],"mdm":"A history of prior venous thromboembolism was reported.","frag":"prior DVT / PE"}]},{"id":"cp-hx-legswelling","dx":"pe","q":"Unilateral leg swelling or pain suggestive of DVT?","answers":[{"label":"No","tone":"neg","sets":[{"risk":"wells","field":0,"opt":0},{"risk":"perc","field":3,"opt":0}],"ddx":[],"mdm":"No unilateral leg swelling or signs of DVT were reported.","frag":"no leg swelling"},{"label":"Yes","tone":"pos","sets":[{"risk":"wells","field":0,"opt":1},{"risk":"perc","field":3,"opt":1}],"ddx":[],"mdm":"Unilateral leg swelling or calf pain was reported, raising the possibility of DVT and increasing PE pretest probability.","frag":"unilateral leg swelling / DVT signs"}]},{"id":"cp-hx-estrogen","dx":"pe","q":"Estrogen use — oral contraceptives, hormone replacement therapy, or other exogenous estrogen?","answers":[{"label":"No","tone":"neg","sets":[{"risk":"perc","field":7,"opt":0}],"ddx":[],"mdm":"No exogenous estrogen use was reported: no oral contraceptives, hormone replacement therapy, or other estrogen.","frag":"no estrogen use"},{"label":"Yes","tone":"pos","sets":[{"risk":"perc","field":7,"opt":1}],"ddx":[],"mdm":"Exogenous estrogen use (oral contraceptives, hormone replacement therapy, or other estrogen) was reported, a PERC criterion increasing VTE risk.","frag":"estrogen / OCP use"}]},{"id":"cp-hx-malignancy","dx":"pe","q":"Active malignancy — undergoing treatment, treated within past 6 months, or palliative?","answers":[{"label":"No active malignancy","tone":"neg","sets":[{"risk":"wells","field":6,"opt":0}],"ddx":[],"mdm":"No active malignancy was reported: none currently undergoing treatment, treated within the past 6 months, or palliative.","frag":"no active malignancy"},{"label":"Active malignancy","tone":"pos","sets":[{"risk":"wells","field":6,"opt":1}],"ddx":[],"mdm":"Active malignancy was present (undergoing treatment, treated within the past 6 months, or palliative), a Wells criterion for elevated PE pretest probability.","frag":"active malignancy"}]},{"id":"cp-hx-ptx-risk","dx":"ptx","q":"Pneumothorax risk — tall thin habitus, prior pneumothorax, Marfan syndrome, smoking history, or recent invasive procedure?","answers":[{"label":"No risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No recognized risk factors for spontaneous pneumothorax were identified: no tall thin habitus, prior pneumothorax, Marfan syndrome, smoking history, or recent invasive procedure.","frag":"no PTX risk factors"},{"label":"Risk factors present","tone":"pos","sets":[],"ddx":[{"id":"ptx","keep":true}],"mdm":"Risk factors for spontaneous pneumothorax were identified, including tall thin body habitus, prior pneumothorax, or a history of smoking.","frag":"PTX risk factors present"}]},{"id":"cp-hx-perf-risk","dx":"perf","q":"Esophageal perforation risk — recent forceful vomiting (Boerhaave), esophageal instrumentation or dilation, or foreign body ingestion?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"No history of forceful emesis, recent esophageal instrumentation, or foreign body ingestion was reported, making esophageal perforation unlikely.","frag":"no forceful emesis or instrumentation"},{"label":"Yes — vomiting / instrumentation / ingestion","tone":"pos","sets":[],"ddx":[{"id":"perf","keep":true}],"mdm":"A history of forceful vomiting, recent esophageal instrumentation, or foreign body ingestion was present, raising concern for esophageal perforation.","frag":"forceful emesis / esophageal instrumentation"}]},{"id":"cp-hx-pericarditis","dx":"pericarditis","q":"Pericarditis features — positional pleuritic chest pain (better leaning forward), recent viral illness, or fever?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"No positional pleuritic pain and no preceding viral illness or fever to suggest pericarditis were reported.","frag":"no positional pain or viral prodrome"},{"label":"Yes — positional pain / viral prodrome / fever","tone":"pos","sets":[],"ddx":[{"id":"pericarditis","keep":true}],"mdm":"Pleuritic chest pain improving when leaning forward, a recent viral illness, or fever was reported, consistent with pericarditis.","frag":"positional pleuritic pain / viral prodrome"}]},{"id":"cp-hx-gerd-msk","dx":"gerd","q":"GERD / MSK features — burning epigastric discomfort with meals, acid regurgitation, or reproducible chest wall tenderness?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"No GERD or musculoskeletal features were reported: no burning epigastric discomfort with meals, acid regurgitation, or reproducible chest wall tenderness.","frag":"no reflux symptoms or chest wall tenderness"},{"label":"Yes — reflux symptoms or chest wall tenderness","tone":"pos","sets":[],"ddx":[{"id":"gerd","keep":true}],"mdm":"Burning epigastric discomfort, acid regurgitation, or reproducible chest wall tenderness was reported, supporting a gastrointestinal or musculoskeletal etiology. Reproducible chest-wall tenderness lowers the likelihood of ACS (LR− ≈0.3) but does not exclude it, and says nothing about pulmonary embolism.","frag":"reflux symptoms / chest wall tenderness"}]},{"id":"cp-hx-acs-anginal-equivalent","dx":"acs","q":"Anginal equivalent — new or worsening exertional dyspnea, unexplained fatigue, nausea, or diaphoresis as the dominant symptom, especially in women, diabetics, or elderly who often present without classic chest pain?","answers":[{"label":"Classic chest pain, no atypical equivalent","tone":"neg","sets":[],"ddx":[],"mdm":"Patient reported typical chest discomfort without an isolated anginal equivalent, and the higher-risk demographic for atypical, silent ischemia was considered.","frag":"no anginal-equivalent symptoms; not a silent-MI demographic"},{"label":"Atypical / anginal equivalent present","tone":"pos","sets":[],"ddx":[],"mdm":"Patient presented with an anginal equivalent (dyspnea, fatigue, nausea, or diaphoresis) in a demographic prone to atypical or silent MI, raising concern for ACS despite the absence of typical chest pain.","frag":"anginal-equivalent presentation; atypical-MI risk demographic"}]},{"id":"cp-hx-acs-symptom-response","dx":"acs","q":"Symptom response to therapeutic trial — was relief with antacid/GI cocktail or nitroglycerin used to reason toward a benign cause (response is not reliable to exclude ACS)?","answers":[{"label":"No diagnostic weight placed on trial response","tone":"neg","sets":[],"ddx":[],"mdm":"Response to antacid, GI cocktail, or nitroglycerin was not used to exclude ACS, consistent with evidence that symptom relief from these agents does not reliably distinguish cardiac from non-cardiac chest pain.","frag":"trial response not used to risk-stratify"},{"label":"Relief with antacid/GIc/NTG (not reassuring)","tone":"pos","sets":[],"ddx":[],"mdm":"Symptoms improved with antacid, GI cocktail, or nitroglycerin; this was explicitly not interpreted as evidence against ACS, since up to a third of MI patients report relief with antacids and nitroglycerin response lacks diagnostic value.","frag":"relief with antacid/NTG; not used to exclude ACS"}]},{"id":"cp-hx-dissection-painless","dx":"dissection","q":"Atypical aortic syndrome — syncope, focal neurologic deficit/stroke-like symptoms, limb ischemia, or abdominal/flank pain as the presenting feature, even when classic tearing chest pain is absent?","answers":[{"label":"No atypical malperfusion or painless features","tone":"neg","sets":[],"ddx":[],"mdm":"Patient had no syncope, neurologic deficit, limb ischemia, or migratory pain to suggest a painless or atypical aortic dissection presentation.","frag":"no syncope/neuro/malperfusion features of atypical dissection"},{"label":"Syncope / neuro / malperfusion feature present","tone":"pos","sets":[],"ddx":[],"mdm":"Patient presented with a malperfusion or atypical feature (syncope, neurologic deficit, or limb/visceral ischemia) that can signal aortic dissection even without classic tearing pain, a presentation associated with high rates of missed diagnosis.","frag":"atypical/painless dissection feature (syncope, neuro, or malperfusion)"}]},{"id":"cp-hx-pe-dyspnea-syncope","dx":"pe","q":"PE presenting symptom — acute dyspnea, pleuritic pain, or unexplained syncope/near-syncope (syncope may signal a hemodynamically significant central PE)?","answers":[{"label":"No dyspnea, pleuritic pain, or syncope","tone":"neg","sets":[],"ddx":[],"mdm":"Patient reported no dyspnea, pleuritic pain, or syncope, lowering pretest probability for pulmonary embolism.","frag":"no dyspnea/pleuritic pain/syncope"},{"label":"Dyspnea / pleuritic pain / syncope","tone":"pos","sets":[],"ddx":[],"mdm":"Patient reported dyspnea, pleuritic pain, or syncope; syncope in particular raised concern for a hemodynamically significant pulmonary embolism and was factored into Wells/PERC risk stratification.","frag":"dyspnea/pleuritic pain/syncope; PE considered"}]},{"id":"cp-hx-pna-symptoms","dx":"pna","q":"Pneumonia features — productive cough, fever/chills, dyspnea, or pleuritic pain, particularly in elderly or immunocompromised patients who may lack classic febrile symptoms?","answers":[{"label":"No cough, fever, or pleuritic features","tone":"neg","sets":[],"ddx":[],"mdm":"Patient denied cough, fever, dyspnea, and pleuritic pain, making pneumonia unlikely, with awareness that elderly or immunocompromised patients can present atypically.","frag":"no cough/fever/pleuritic symptoms"},{"label":"Cough / fever / dyspnea / pleuritic pain","tone":"pos","sets":[],"ddx":[],"mdm":"Patient reported cough, fever, dyspnea, or pleuritic pain consistent with a pneumonic process warranting chest imaging and infection workup.","frag":"productive cough/fever/pleuritic pain; pneumonia considered"}]},{"id":"cp-hx-myocarditis-redflags","dx":"pericarditis","q":"Myocarditis red flags — recent viral illness now with new dyspnea, exertional intolerance, palpitations/arrhythmia, or signs of heart failure (suggesting myocardial, not just pericardial, involvement)?","answers":[{"label":"No HF, arrhythmia, or exertional decline","tone":"neg","sets":[],"ddx":[],"mdm":"Patient had no dyspnea, exertional intolerance, palpitations, or heart-failure signs to suggest myocardial involvement complicating a pericardial process.","frag":"no myocarditis red flags (HF/arrhythmia/exertional decline)"},{"label":"Dyspnea / HF / arrhythmia after viral illness","tone":"pos","sets":[],"ddx":[],"mdm":"Following a viral prodrome the patient developed dyspnea, exertional intolerance, or arrhythmia/heart-failure features, raising concern for myocarditis and prompting troponin, ECG, and cardiac evaluation.","frag":"post-viral dyspnea/HF/arrhythmia; myocarditis concern"}]}],"exam":[{"id":"cp-exam-vitals-hr-bp","dx":"general","q":"Vital signs — heart rate, blood pressure, respiratory rate, and oxygen saturation stable and within normal limits?","answers":[{"label":"Stable / within normal limits","tone":"neg","sets":[{"risk":"perc","field":1,"opt":0}],"ddx":[],"mdm":"Vital signs were stable: heart rate was below 100, blood pressure was within acceptable range, and the patient was not in distress.","frag":"vitals stable, HR < 100"},{"label":"Tachycardia (HR ≥ 100)","tone":"pos","sets":[{"risk":"perc","field":1,"opt":1}],"ddx":[],"mdm":"Tachycardia (HR ≥ 100) was present, a PERC criterion and a general high-risk feature warranting further evaluation.","frag":"tachycardia (HR ≥ 100)"},{"label":"Hemodynamically unstable","tone":"pos","sets":[],"ddx":[],"mdm":"The patient was hemodynamically unstable on arrival, with abnormal heart rate, blood pressure, respiratory rate, or oxygen saturation, requiring urgent stabilization and expedited workup for life-threatening causes.","frag":"hemodynamic instability"}]},{"id":"cp-exam-spo2","dx":"general","q":"SpO₂ ≥ 95% and not tachypneic?","answers":[{"label":"SpO₂ ≥ 95%, not tachypneic","tone":"neg","sets":[{"risk":"perc","field":2,"opt":0}],"ddx":[],"mdm":"Oxygen saturation was 95% or greater and the patient was not tachypneic.","frag":"SpO₂ ≥ 95%, not tachypneic"},{"label":"SpO₂ < 95% or tachypneic","tone":"pos","sets":[{"risk":"perc","field":2,"opt":1}],"ddx":[],"mdm":"Oxygen saturation was below 95% or tachypnea was present on examination, a PERC criterion and a sign of potential cardiopulmonary compromise.","frag":"SpO₂ < 95% or tachypnea"}]},{"id":"cp-exam-acs-cardiac","dx":"acs","q":"Cardiac exam — JVD, new or changed murmur, S3 gallop, or diaphoretic/distressed appearance?","answers":[{"label":"No adverse findings","tone":"neg","sets":[],"ddx":[],"mdm":"No jugular venous distension, no new or changed cardiac murmur, no S3 gallop, and no diaphoresis or distressed appearance were noted.","frag":"no JVD, murmur, S3, or distress"},{"label":"JVD present","tone":"pos","sets":[],"ddx":[],"mdm":"Jugular venous distension was noted on examination, suggesting elevated right-sided filling pressures.","frag":"JVD"},{"label":"New murmur / S3","tone":"pos","sets":[],"ddx":[{"id":"acs","keep":true}],"mdm":"A new or changed cardiac murmur or S3 gallop was appreciated on examination, raising concern for ACS-related mechanical complication.","frag":"new murmur / S3"},{"label":"Diaphoretic / distressed","tone":"pos","sets":[],"ddx":[],"mdm":"The patient appeared diaphoretic and in distress on examination, a high-risk feature.","frag":"diaphoretic / distressed appearance"}]},{"id":"cp-exam-dissection-bp","dx":"dissection","q":"Pulse or pressure deficit — inter-arm systolic BP differential ≥20 mmHg or asymmetric/absent pulse in any extremity (ADD-RS perfusion deficit)?","answers":[{"label":"No BP differential, pulses symmetric","tone":"neg","sets":[],"ddx":[],"mdm":"Blood pressure was measured in both arms without a significant inter-arm differential, and peripheral pulses were symmetric. Because a pulse or pressure deficit is present in only about 20-30% of aortic dissections, its absence was not used to exclude the diagnosis; risk scoring and imaging thresholds carried the decision.","frag":"symmetric pulses, no inter-arm BP differential (a pulse or pressure deficit is present in only ~20-30% of dissections, so risk scoring and imaging carried the decision)"},{"label":"BP differential ≥ 20 mmHg or pulse deficit","tone":"pos","sets":[],"ddx":[{"id":"dissection","keep":true}],"mdm":"A significant inter-arm blood pressure differential or unilateral pulse deficit was present, raising strong concern for aortic dissection with branch vessel involvement.","frag":"inter-arm BP differential / pulse deficit"}]},{"id":"cp-exam-dissection-ar","dx":"dissection","q":"New diastolic murmur of aortic regurgitation (decrescendo diastolic blowing murmur at LUSB)?","answers":[{"label":"No AR murmur","tone":"neg","sets":[],"ddx":[],"mdm":"No diastolic murmur of aortic regurgitation was appreciated.","frag":"no diastolic AR murmur"},{"label":"New diastolic murmur (AR)","tone":"pos","sets":[],"ddx":[{"id":"dissection","keep":true}],"mdm":"A new decrescendo diastolic murmur consistent with acute aortic regurgitation was present, raising high concern for proximal (Type A) aortic dissection.","frag":"new diastolic murmur (aortic regurgitation)"}]},{"id":"cp-exam-dissection-neuro","dx":"dissection","q":"Focal neurologic deficit on examination — hemiplegia, hemisensory loss, facial droop, Horner syndrome?","answers":[{"label":"No focal deficit","tone":"neg","sets":[],"ddx":[],"mdm":"No focal neurologic deficit was identified on examination: no hemiplegia, hemisensory loss, facial droop, or Horner syndrome.","frag":"no focal neurologic deficit"},{"label":"Focal neuro deficit present","tone":"pos","sets":[],"ddx":[{"id":"dissection","keep":true}],"mdm":"A focal neurologic deficit was present, including hemiplegia, hemisensory loss, or Horner syndrome, raising concern for aortic dissection with carotid or spinal artery malperfusion.","frag":"focal neurologic deficit"}]},{"id":"cp-exam-pe-dvt","dx":"pe","q":"Unilateral calf swelling, erythema, or tenderness on examination?","answers":[{"label":"No DVT signs","tone":"neg","sets":[{"risk":"wells","field":0,"opt":0},{"risk":"perc","field":3,"opt":0}],"ddx":[],"mdm":"No unilateral calf swelling, erythema, or tenderness was found on examination.","frag":"no DVT signs on exam"},{"label":"Unilateral calf swelling / tenderness","tone":"pos","sets":[{"risk":"wells","field":0,"opt":1},{"risk":"perc","field":3,"opt":1}],"ddx":[],"mdm":"Unilateral calf swelling or tenderness was present on examination, consistent with possible DVT and increasing Wells score for PE.","frag":"unilateral calf swelling / tenderness"}]},{"id":"cp-exam-ptx-breath","dx":"ptx","q":"Breath sounds equal bilaterally with trachea midline — any unilateral decrease, hyperresonance, or tension signs (deviation, hypotension, distended neck veins)?","answers":[{"label":"Equal breath sounds, no tension signs","tone":"neg","sets":[],"ddx":[],"mdm":"Breath sounds were equal bilaterally, the trachea was midline, and no signs of tension pneumothorax were detected.","frag":"breath sounds equal"},{"label":"Unilateral decreased breath sounds","tone":"pos","sets":[],"ddx":[{"id":"ptx","keep":true}],"mdm":"Decreased or absent breath sounds unilaterally were noted, raising concern for pneumothorax.","frag":"unilateral decreased breath sounds"},{"label":"Tension PTX signs — tracheal deviation / hypotension","tone":"pos","sets":[],"ddx":[{"id":"ptx","keep":true}],"mdm":"Signs consistent with tension pneumothorax were present, including tracheal deviation and hemodynamic compromise, requiring immediate decompression.","frag":"tension PTX signs (tracheal deviation / hypotension)"}]},{"answers":[{"ddx":[],"frag":"no JVD, muffled sounds, or pulsus, hemodynamically stable (these signs are insensitive, so echo rather than the exam excluded tamponade)","label":"No tamponade signs","mdm":"There were no distended neck veins, muffled heart sounds, or pulsus paradoxus, and the patient was hemodynamically stable. Because these examination signs are insensitive for tamponade, exclusion rested on bedside echocardiography rather than the physical findings.","sets":[],"tone":"neg"},{"ddx":[{"id":"tamponade-cp","keep":true}],"frag":"JVD, muffled heart sounds, or pulsus paradoxus","label":"Tamponade signs present","mdm":"Distended neck veins, muffled heart sounds, or pulsus paradoxus were present, raising concern for cardiac tamponade and warranting urgent echocardiography.","sets":[],"tone":"pos"}],"dx":"tamponade-cp","id":"cp-exam-tamponade-cp","q":"Tamponade signs — distended neck veins, muffled heart sounds, pulsus paradoxus, or hypotension?"},{"id":"cp-exam-perf-crepitus","dx":"perf","q":"Subcutaneous emphysema or mediastinal crunch — palpable crepitus over the neck/chest wall or a Hamman crunch on auscultation suggesting pneumomediastinum from esophageal perforation?","answers":[{"label":"No crepitus or mediastinal crunch","tone":"neg","sets":[],"ddx":[],"mdm":"No subcutaneous crepitus or Hamman crunch was appreciated, though their absence does not exclude esophageal perforation given the low sensitivity of the classic triad.","frag":"no subcutaneous emphysema or Hamman crunch"},{"label":"Crepitus / Hamman crunch present","tone":"pos","sets":[],"ddx":[],"mdm":"Palpable subcutaneous crepitus or a Hamman crunch was present, raising strong concern for pneumomediastinum and esophageal perforation requiring urgent imaging.","frag":"subcutaneous crepitus / Hamman crunch; perforation concern"}]},{"id":"cp-exam-pericarditis-rub","dx":"pericarditis","q":"Pericardial friction rub — scratchy/triphasic rub at the left sternal border, best heard sitting forward at end-expiration?","answers":[{"label":"No friction rub","tone":"neg","sets":[],"ddx":[],"mdm":"No pericardial friction rub was auscultated, though its intermittent nature means absence does not exclude pericarditis.","frag":"no pericardial friction rub"},{"label":"Friction rub present","tone":"pos","sets":[],"ddx":[],"mdm":"A pericardial friction rub was auscultated at the left sternal border, supporting pericarditis and prompting ECG and evaluation for effusion.","frag":"pericardial friction rub present"}]},{"id":"cp-exam-cxr-mediastinum","dx":"dissection","q":"Diagnostic review — chest radiograph for dissection: widened mediastinum or abnormal aortic contour? (A normal chest x-ray does not exclude dissection — the mediastinum is normal in roughly 1 in 5.)","answers":[{"label":"Mediastinum normal (not relied on to exclude)","tone":"neg","sets":[],"ddx":[],"mdm":"The chest radiograph showed a normal mediastinum and aortic contour, noting a normal film does not exclude dissection (normal in roughly 20%), so it was not used as a rule-out.","frag":"normal mediastinum on CXR (not used to exclude dissection)"},{"label":"Widened mediastinum / abnormal contour","tone":"pos","sets":[],"ddx":[],"mdm":"The chest radiograph showed a widened mediastinum or abnormal aortic contour, sharply raising concern for aortic dissection and driving definitive aortic imaging.","frag":"widened mediastinum on CXR"}]}],"conclusions":["noncardiac chest pain","musculoskeletal chest pain","GERD / reflux","chest pain NOS (low-risk)"],"specs":["cards","pulm","vasc"],"algorithm":{"immediate":["12-lead ECG within 10 minutes of arrival; continuous cardiac monitor, IV access, and full vitals including bilateral blood pressure and SpO₂.","If unstable (hypotension, hypoxia, or severe distress): resuscitate while considering STEMI, massive pulmonary embolism, tension pneumothorax, and aortic dissection in parallel."],"criticalTests":["12-lead ECG, repeated if pain is ongoing or evolving","Serial high-sensitivity troponin","Chest X-ray","Targeted CT angiography (dissection or PE) and bedside echo / lung ultrasound"],"cantMiss":[{"dx":"acs","trigger":"Ischemic ECG changes, or ongoing pain with a suggestive risk story","test":"ECG plus serial troponin; HEART score to risk-stratify","intervention":"Aspirin; activate the cath lab for STEMI; cardiology and anticoagulation for high-risk NSTE-ACS"},{"dx":"dissection","trigger":"Tearing or migratory pain, a pulse or blood-pressure differential, or a widened mediastinum","test":"CT angiography of the aorta","intervention":"Impulse control — IV beta-blocker (esmolol or labetalol) to a heart rate below 60, then a vasodilator to SBP 100–120; emergent surgery for type A"},{"dx":"pe","trigger":"Pleuritic pain, dyspnea, or VTE risk factors","test":"Pretest probability (Wells / PERC), then d-dimer or CT pulmonary angiography","intervention":"Anticoagulation; consider thrombolysis for massive PE with shock"},{"dx":"ptx","trigger":"Decreased breath sounds; hypotension with tracheal deviation signals tension","test":"Chest X-ray or lung ultrasound — do not delay decompression for tension","intervention":"Immediate needle or finger thoracostomy, then chest tube"},{"dx":"perf","trigger":"Forceful vomiting followed by chest pain with subcutaneous emphysema","test":"CT chest with contrast or esophagram","intervention":"NPO, broad-spectrum antibiotics, and urgent surgical / GI consultation"}],"disposition":"Risk-stratify with HEART (plus Wells/PERC when PE is in play): a low score with negative serial troponin supports shared-decision discharge; intermediate warrants observation with serial troponin; high risk is admitted with cardiology involvement."},"decisionTree":{"title":"Chest pain — initial approach","intro":"An original, evidence-based decision aid for undifferentiated chest pain. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Immediate assessment","items":["12-lead ECG within 10 minutes; cardiac monitor; IV access; vitals","Focused history and exam; aspirin if ACS is suspected and no contraindication"],"next":"q_stemi"},"q_stemi":{"type":"decision","q":"STEMI or a STEMI-equivalent on the ECG?","cantmiss":"Obtain and read the ECG within 10 minutes — a STEMI mandates immediate reperfusion.","yes":"a_stemi","no":"q_mimic"},"a_stemi":{"type":"action","tone":"danger","title":"Activate cath lab — reperfusion","terminal":true,"items":["Primary PCI (fibrinolysis if timely PCI is unavailable)","Aspirin plus antithrombotic therapy per protocol","Serial ECGs; treat arrhythmias and complications"]},"q_mimic":{"type":"decision","q":"Unstable, or a non-ACS emergency suspected?","pitfall":"Don't anchor on ACS — aortic dissection, pulmonary embolism, tension pneumothorax, tamponade, and esophageal rupture are the can't-miss mimics.","yes":"a_mimic","no":"q_highrisk"},"a_mimic":{"type":"action","tone":"danger","title":"Resuscitate & target the mimic","terminal":true,"items":["Stabilize ABCs; bedside ultrasound and CT angiography as indicated","Dissection: heart-rate/BP control and surgery; PE: anticoagulation ± thrombolysis","Tension pneumothorax: decompression; tamponade: pericardiocentesis"]},"q_highrisk":{"type":"decision","q":"Ongoing ischemic symptoms or dynamic/high-risk ECG changes?","yes":"a_acs","no":"q_troponin"},"q_troponin":{"type":"decision","q":"Initial troponin elevated?","yes":"a_acs","no":"q_lowrisk"},"a_acs":{"type":"action","tone":"danger","title":"Treat as ACS (NSTEMI/UA)","terminal":true,"items":["Aspirin; anticoagulation and anti-ischemic therapy per protocol","Serial troponin and ECG","Early cardiology / risk-based invasive strategy"]},"q_lowrisk":{"type":"decision","q":"Low risk by a validated pathway (e.g., HEART) with a non-ischemic ECG and negative serial troponin?","yes":"a_dc","no":"a_observe"},"a_dc":{"type":"action","tone":"branch","title":"Discharge with follow-up","terminal":true,"items":["Shared decision-making; outpatient testing as indicated","Clear return precautions"]},"a_observe":{"type":"action","title":"Observe / serial testing","terminal":true,"items":["Serial troponin and ECG; reassess","Admit or observation unit; consider provocative or anatomic testing"]}}},"pearls":[{"text":"A normal or non-ischemic initial ECG does not exclude ACS — it is nondiagnostic in a large share of early presentations. Serial troponin plus a validated score (HEART) drives disposition, not a single normal value.","dx":"acs","src":"HEART: Six 2008"},{"text":"When the story fits but the 12-lead looks normal, get posterior (V7–V9) and right-sided (V4R) leads — isolated ST depression in V1–V3 can be a posterior STEMI, and inferior MI can hide RV involvement.","dx":"acs"},{"text":"In cocaine or stimulant-associated chest pain, avoid beta-blockers (unopposed alpha vasoconstriction); benzodiazepines and nitrates are first-line. Young age and a low HEART score do not rule out infarction.","dx":"acs"},{"text":"A normal chest x-ray does not exclude aortic dissection, and D-dimer is not sensitive enough to rule it out alone. Use the ADD risk score and image with CTA when suspicion is genuine.","dx":"dissection","src":"AHA/ACC aortic guideline"},{"text":"PERC only applies once your gestalt pretest probability is already low — it is a rule-out for low-risk patients, not a screen. Unexplained syncope can be the sole presenting sign of a central PE.","dx":"pe","src":"PERC: Kline 2004"},{"text":"Tension pneumothorax is a clinical diagnosis — decompress before you image. Hypotension with unilateral absent breath sounds and tracheal deviation should not wait for a chest x-ray.","dx":"ptx"},{"text":"Think Boerhaave when chest pain follows forceful vomiting — subcutaneous emphysema or a Hamman crunch is the tell. Diagnostic delay drives mortality; get a CT chest with contrast or esophagram.","dx":"perf"}]},{"id":"abdominal-pain","title":"Abdominal Pain","aliases":["abd","belly","abdominal pain","belly pain","stomach pain","stomach ache","abd pain","gastritis","appendicitis","epigastric","rlq","luq","tummy","nos","pid","pelvic inflammatory disease","rlq pain","right lower quadrant"],"opening":"The patient was evaluated for abdominal pain. A focused history and abdominal examination were performed, and the diagnoses below were actively considered.","ddx":[{"id":"aaa","group":"lifethreat","label":"Abdominal aortic aneurysm","default":true,"tags":[],"ruleout":"A ruptured or symptomatic abdominal aortic aneurysm was considered; there was no sudden abdominal, flank, or back pain, no pulsatile mass on palpation, the patient was hemodynamically stable, and no syncope, making it unlikely.","miss":4},{"id":"mesenteric","group":"lifethreat","label":"Mesenteric ischemia","default":true,"tags":[],"ruleout":"Mesenteric ischemia was considered; the pain was not out of proportion to a benign abdominal examination, there was no atrial fibrillation or vascular history, no bloody stool, and bowel sounds and perfusion were normal, making it unlikely.","miss":4},{"id":"ectopic","group":"lifethreat","label":"Ectopic pregnancy","default":true,"tags":["preg"],"ruleout":"Ectopic pregnancy was considered in this patient of reproductive potential; a pregnancy test was obtained and was negative, effectively excluding the diagnosis.","miss":4,"sex":"f"},{"id":"pid-abd","group":"lifethreat","label":"PID / tubo-ovarian abscess","default":false,"tags":["pid-abd"],"ruleout":"Pelvic inflammatory disease and tubo-ovarian abscess were considered; there was no cervical motion, uterine, or adnexal tenderness, no purulent discharge or fever, and no palpable adnexal mass, making them unlikely.","miss":3,"sex":"f"},{"id":"perf-abd","group":"lifethreat","label":"Perforated viscus","default":false,"tags":[],"ruleout":"Perforated viscus was considered; the abdomen was soft without rigidity, guarding, or rebound, there was no free air on imaging where obtained, and the patient was non-toxic, making it unlikely.","miss":4},{"id":"ectopic-ruptured-ap","group":"lifethreat","label":"Ruptured ectopic pregnancy","default":false,"tags":["ectopic-ruptured-ap"],"ruleout":"Ruptured ectopic pregnancy was considered in this patient of reproductive potential; a pregnancy test was negative and there was no hemodynamic instability or peritonism, effectively excluding it.","miss":4,"sex":"f"},{"id":"appy","group":"common","label":"Appendicitis","default":false,"tags":[],"ruleout":"Appendicitis was considered and assessed by examination, laboratory studies, and imaging as indicated.","miss":2},{"id":"biliary","group":"common","label":"Biliary disease","default":false,"tags":[],"ruleout":"Biliary disease was considered and evaluated with examination and imaging as appropriate.","miss":2},{"id":"sbo","group":"common","label":"Small-bowel obstruction","default":false,"tags":[],"ruleout":"Bowel obstruction was considered; the history and available imaging did not support it.","miss":2},{"id":"renal","group":"other","label":"Renal colic","default":false,"tags":[],"ruleout":"Ureterolithiasis was considered as a more benign cause once the serious diagnoses above were addressed.","miss":1}],"risk":[{"id":"preg","label":"Pregnancy test","tags":["preg"],"scale":"low","line":"A pregnancy test was obtained in this patient of reproductive potential and the result was reviewed.","short":"pregnancy test reviewed"},{"id":"alvarado","label":"Alvarado score","tags":[],"scale":"low","line":"An Alvarado score was documented to support the clinical assessment of appendicitis risk.","cite":"Alvarado A. Ann Emerg Med. 1986.","short":"Alvarado score documented","calc":{"fields":[{"label":"Migration to RLQ","opts":[["No",0],["Yes",1]]},{"label":"Anorexia","opts":[["No",0],["Yes",1]]},{"label":"Nausea or vomiting","opts":[["No",0],["Yes",1]]},{"label":"RLQ tenderness","opts":[["No",0],["Yes",2]]},{"label":"Rebound tenderness","opts":[["No",0],["Yes",1]]},{"label":"Temp ≥ 37.3 °C","opts":[["No",0],["Yes",1]]},{"label":"WBC > 10,000","opts":[["No",0],["Yes",2]]},{"label":"Neutrophils > 75%","opts":[["No",0],["Yes",1]]}],"bands":[[4,"low — appendicitis unlikely","low","Low (≤4): appendicitis unlikely — observation or discharge with return precautions over immediate imaging."],[6,"equivocal","mod","Equivocal (5–6): imaging (ultrasound or CT) or a period of observation with reassessment."],[8,"probable","high","Probable (7–8): imaging and surgical consultation."],[10,"high probability","high","High (9–10): surgical consultation — imaging is often confirmatory."]],"line":"Alvarado score {score}/10 ({band}); used to support the assessment of appendicitis risk.","applies":"Adults and older children with suspected appendicitis -- a supportive aid, not a rule-out. Lower discrimination in women and young children; imaging still drives equivocal cases."}},{"id":"lactate","label":"Lactate / labs","tags":[],"scale":"low","line":"Relevant laboratory studies, including a lactate, were obtained and reviewed in the clinical context.","short":"lactate reviewed"},{"id":"serial-exam","label":"Serial abdominal exam / observation","tags":["appy"],"scale":"low","line":"Serial abdominal examinations were performed during the ED course and documented, and the examination and the patient's trajectory were reassessed before disposition.","cite":"Cole MA, Maldonado N. Emerg Med Pract (EB Medicine). 2011;13(10).","short":"serial exam documented"}],"checks":[{"if":"ectopic","needs":["preg"],"mode":"any","warn":"Ectopic is on the differential — document the pregnancy test RESULT: negative is the rule-out; positive is an ectopic until located by hCG and ultrasound."},{"if":"appy","needs":["alvarado","serial-exam"],"mode":"any","warn":"Appendicitis is on the differential — an Alvarado score, imaging, or a documented serial abdominal exam shows how it was risk-stratified. A normal WBC does not exclude it."}],"history":[{"id":"abd-hx-onset-character","dx":"general","q":"Pain onset and character — sudden vs. gradual, quality (colicky, constant, crampy, tearing), severity, and location?","answers":[{"label":"Gradual, non-specific","tone":"neg","sets":[],"ddx":[],"mdm":"Pain onset was gradual and the character was non-specific, without features pointing strongly to a single etiology.","frag":"gradual, non-specific onset"},{"label":"Sudden / severe at onset","tone":"pos","sets":[],"ddx":[],"mdm":"Pain onset was sudden and severe, a high-risk feature requiring active exclusion of perforation, vascular catastrophe, and ectopic rupture.","frag":"sudden, severe-at-onset pain"},{"label":"Colicky / crampy","tone":"pos","sets":[],"ddx":[],"mdm":"The pain was colicky and crampy in character, consistent with visceral distension from obstruction or ureterolithiasis.","frag":"colicky, crampy pain"}]},{"id":"abd-hx-immunosuppression","dx":"general","q":"Immunocompromised state — transplant recipient, active chemotherapy, systemic steroids, or known HIV?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was screened for an immunocompromised state (transplant recipient, active chemotherapy, systemic steroids, or known HIV), none of which was present; the peritoneal and inflammatory response were expected to be intact.","frag":"no immunocompromised state"},{"label":"Immunocompromised","tone":"pos","sets":[],"ddx":[],"mdm":"An immunocompromised state (transplant, active chemotherapy, systemic steroids, or known HIV) was present, which can blunt the peritoneal response and lower the threshold for imaging and specialist consultation.","frag":"immunocompromised"}]},{"id":"abd-hx-aaa-age-risk","dx":"aaa","q":"Age ≥ 60 with vascular risk factors — hypertension, tobacco use, hyperlipidemia, known peripheral arterial disease?","answers":[{"label":"None / age < 60 with no vascular risk","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was under 60 years of age with none of the vascular risk factors screened for: hypertension, tobacco use, hyperlipidemia, or known peripheral arterial disease; the background probability of AAA was low.","frag":"no AAA risk factors"},{"label":"Age ≥ 60 with vascular risk factors","tone":"pos","sets":[],"ddx":[{"id":"aaa","keep":true}],"mdm":"The patient was 60 years of age or older with vascular risk factors including hypertension and/or tobacco use, raising the pre-test probability of AAA.","frag":"age ≥60 with vascular risk factors"}]},{"id":"abd-hx-aaa-known","dx":"aaa","q":"Known abdominal aortic aneurysm, prior aortic repair, or prior aortic imaging showing dilation?","answers":[{"label":"No known AAA or aortic history","tone":"neg","sets":[],"ddx":[],"mdm":"No prior diagnosis of abdominal aortic aneurysm and no prior aortic surgery or instrumentation was reported.","frag":"no known AAA or aortic history"},{"label":"Known AAA or prior aortic repair","tone":"pos","sets":[],"ddx":[{"id":"aaa","keep":true}],"mdm":"A known abdominal aortic aneurysm or prior aortic repair was reported; a symptomatic, expanding, or ruptured aneurysm was given high priority in the differential.","frag":"known AAA or prior aortic repair"}]},{"id":"abd-hx-aaa-pain-character","dx":"aaa","q":"Sudden tearing or severe abdominal, back, or flank pain — with syncope, presyncope, or transient hypotension suggesting a contained or ruptured AAA?","answers":[{"label":"No tearing / no syncope / no pulsatile sensation","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was not tearing in quality, was not associated with syncope, and no pulsatile abdominal sensation was reported.","frag":"no tearing pain, syncope, or pulsatile sensation"},{"label":"Tearing or severe back/flank pain with syncope or pulsatile sensation","tone":"pos","sets":[],"ddx":[{"id":"aaa","keep":true}],"mdm":"Sudden tearing or severe back/flank pain with associated syncope or a pulsatile abdominal sensation was reported: classic features of a ruptured or rapidly expanding AAA requiring emergent evaluation.","frag":"tearing back/flank pain with syncope or pulsatile sensation"}]},{"id":"abd-hx-mesenteric-pain-proportion","dx":"mesenteric","q":"Pain out of proportion to a soft, minimally tender abdomen on exam — severe pain with sparse findings, the early hallmark of acute mesenteric ischemia?","answers":[{"label":"No — pain proportionate to exam findings","tone":"neg","sets":[],"ddx":[],"mdm":"Pain severity appeared proportionate to the abdominal examination findings; the hallmark discordance of mesenteric ischemia was not present.","frag":"pain proportionate to exam"},{"label":"Pain markedly out of proportion to exam","tone":"pos","sets":[],"ddx":[{"id":"mesenteric","keep":true}],"mdm":"Pain was markedly out of proportion to examination findings: a cardinal feature of acute mesenteric ischemia that mandated urgent vascular evaluation.","frag":"pain out of proportion to exam"}]},{"id":"abd-hx-mesenteric-afib-vascular","dx":"mesenteric","q":"Atrial fibrillation, known vascular disease, or hypercoagulable state (prior VTE, inherited thrombophilia, malignancy)?","answers":[{"label":"None identified","tone":"neg","sets":[],"ddx":[],"mdm":"No atrial fibrillation, peripheral vascular disease, or hypercoagulable state was identified; embolic or thrombotic mesenteric ischemia was less likely on this basis.","frag":"no AF, vascular disease, or hypercoagulable state"},{"label":"Atrial fibrillation, vascular disease, or hypercoagulable state","tone":"pos","sets":[],"ddx":[{"id":"mesenteric","keep":true}],"mdm":"Atrial fibrillation, known vascular disease, or a hypercoagulable state was present, substantially raising the concern for embolic or thrombotic mesenteric ischemia.","frag":"AF, vascular disease, or hypercoagulable state"}]},{"id":"abd-hx-mesenteric-postprandial","dx":"mesenteric","q":"Postprandial abdominal pain or food fear with associated weight loss ('intestinal angina')?","answers":[{"label":"No postprandial pattern or weight loss","tone":"neg","sets":[],"ddx":[],"mdm":"No postprandial pain pattern or unintentional weight loss was reported; chronic mesenteric ischemia was not suggested by history.","frag":"no postprandial pain or weight loss"},{"label":"Postprandial pain and/or weight loss","tone":"pos","sets":[],"ddx":[{"id":"mesenteric","keep":true}],"mdm":"A pattern of postprandial abdominal pain with food fear and weight loss was reported, consistent with chronic mesenteric ischemia (intestinal angina) and raising concern for acute-on-chronic occlusion.","frag":"postprandial pain with weight loss"}]},{"id":"abd-hx-hcg-result","dx":"ectopic","q":"Pregnancy status — reproductive potential and the test result (the ectopic branch point: negative effectively excludes; positive is ectopic until located)?","answers":[{"label":"hCG negative / not applicable","tone":"neg","sets":[{"risk":"preg"}],"ddx":[],"mdm":"The pregnancy test was negative (or not applicable), effectively excluding ectopic pregnancy.","frag":"pregnancy test negative (or not applicable), ectopic effectively excluded"},{"label":"hCG positive","tone":"pos","sets":[{"risk":"preg"}],"ddx":[{"id":"ectopic","keep":true}],"mdm":"The pregnancy test was positive; with abdominal pain this is an ectopic pregnancy until the location is established, and quantitative hCG with pelvic ultrasound was pursued."}]},{"id":"abd-hx-ectopic-prior-risk","dx":"ectopic","q":"Prior ectopic pregnancy, tubal surgery, tubal ligation, or history of pelvic inflammatory disease (PID)?","answers":[{"label":"No prior ectopic, tubal surgery, or PID","tone":"neg","sets":[],"ddx":[],"mdm":"No prior ectopic pregnancy, tubal surgery or ligation, or history of pelvic inflammatory disease was reported; anatomic risk factors for ectopic implantation were absent.","frag":"no prior ectopic, tubal surgery, or PID"},{"label":"Prior ectopic, tubal surgery, or PID","tone":"pos","sets":[],"ddx":[{"id":"ectopic","keep":true}],"mdm":"A history of prior ectopic pregnancy, tubal surgery, or pelvic inflammatory disease was present, substantially elevating the risk of ectopic implantation.","frag":"prior ectopic, tubal surgery, or PID"}]},{"id":"abd-hx-ectopic-symptoms","dx":"ectopic","q":"Vaginal bleeding or spotting with amenorrhea — or shoulder tip pain (diaphragmatic irritation from hemoperitoneum)?","answers":[{"label":"No vaginal bleeding, amenorrhea, or shoulder pain","tone":"neg","sets":[],"ddx":[],"mdm":"No vaginal bleeding, amenorrhea, or referred shoulder tip pain was reported.","frag":"no vaginal bleeding, amenorrhea, or shoulder-tip pain"},{"label":"Vaginal bleeding with amenorrhea and/or shoulder tip pain","tone":"pos","sets":[],"ddx":[{"id":"ectopic","keep":true}],"mdm":"Vaginal bleeding or spotting in the setting of missed menses, or referred shoulder tip pain suggesting hemoperitoneum, was reported: high-risk features for ruptured ectopic pregnancy requiring urgent workup.","frag":"vaginal bleeding with amenorrhea or shoulder-tip pain"}]},{"id":"abd-hx-perf-sudden-pain","dx":"perf-abd","q":"Sudden severe diffuse abdominal pain — instantaneous or maximal at onset?","answers":[{"label":"No — gradual onset","tone":"neg","sets":[],"ddx":[],"mdm":"The abdominal pain was not sudden or instantaneous in onset; the presentation was not typical for free perforation.","frag":"no sudden or instantaneous onset"},{"label":"Sudden severe diffuse pain — maximal at onset","tone":"pos","sets":[],"ddx":[{"id":"perf-abd","keep":true}],"mdm":"The pain was sudden, severe, and diffuse, or reached maximal intensity at onset: a high-risk feature for perforated viscus requiring urgent evaluation.","frag":"sudden, severe, diffuse maximal-at-onset pain"}]},{"id":"abd-hx-perf-nsaid-pud","dx":"perf-abd","q":"NSAID or aspirin use, known peptic ulcer disease, or prior upper GI bleeding?","answers":[{"label":"No NSAIDs, no PUD history","tone":"neg","sets":[],"ddx":[],"mdm":"No NSAID or aspirin use and no history of peptic ulcer disease or upper gastrointestinal bleeding were reported; risk for peptic perforation was lower.","frag":"no NSAID use or PUD history"},{"label":"NSAID use or known PUD","tone":"pos","sets":[],"ddx":[{"id":"perf-abd","keep":true}],"mdm":"Regular NSAID use or a history of peptic ulcer disease was present, raising concern for perforated peptic ulcer as a cause of the acute abdomen.","frag":"NSAID use or known PUD"}]},{"id":"abd-hx-perf-prior-abd-surgery","dx":"perf-abd","q":"Prior abdominal surgery, known diverticular disease, or recent colonoscopy/procedure?","answers":[{"label":"No prior surgery, no diverticulosis, no recent procedure","tone":"neg","sets":[],"ddx":[],"mdm":"No prior abdominal surgery, known diverticular disease, or recent gastrointestinal procedure was reported.","frag":"no prior abdominal surgery, diverticulosis, or recent procedure"},{"label":"Prior surgery, diverticulosis, or recent procedure","tone":"pos","sets":[],"ddx":[{"id":"perf-abd","keep":true}],"mdm":"Prior abdominal surgery, known diverticular disease, or a recent gastrointestinal procedure was reported, raising concern for perforation at an anastomosis, diverticulum, or procedure site.","frag":"prior surgery, diverticulosis, or recent procedure"}]},{"id":"abd-hx-appy-migration","dx":"appy","q":"Migratory pain — periumbilical or diffuse onset that localized to the right lower quadrant over hours?","answers":[{"label":"No migratory pattern — pain non-migratory or in another location","tone":"neg","sets":[],"ddx":[],"mdm":"The pain did not follow a migratory pattern from the periumbilical region to the right lower quadrant, which is less typical for appendicitis.","frag":"no periumbilical-to-RLQ migration"},{"label":"Classic migration from periumbilical to RLQ","tone":"pos","sets":[],"ddx":[{"id":"appy","keep":true}],"mdm":"A classic migratory pain pattern from the periumbilical region to the right lower quadrant over several hours was reported, a hallmark feature of acute appendicitis.","frag":"classic periumbilical-to-RLQ migration"}]},{"id":"abd-hx-appy-anorexia-nausea","dx":"appy","q":"Anorexia and/or nausea and vomiting accompanying the abdominal pain?","answers":[{"label":"No anorexia or nausea","tone":"neg","sets":[],"ddx":[],"mdm":"No anorexia or associated nausea was reported alongside the abdominal pain.","frag":"no anorexia or nausea"},{"label":"Anorexia and/or nausea/vomiting present","tone":"pos","sets":[],"ddx":[{"id":"appy","keep":true}],"mdm":"Anorexia and nausea with or without vomiting were reported in conjunction with the abdominal pain, consistent with an appendicitis presentation.","frag":"anorexia with nausea or vomiting"}]},{"id":"abd-hx-appy-fever","dx":"appy","q":"Low-grade fever (≥ 38°C / 100.4°F) with the pain?","answers":[{"label":"No fever reported","tone":"neg","sets":[],"ddx":[],"mdm":"No fever was reported; absence of fever slightly lowers the probability of appendicitis, though early or atypical presentations can be afebrile.","frag":"no fever"},{"label":"Fever present","tone":"pos","sets":[],"ddx":[{"id":"appy","keep":true}],"mdm":"A low-grade fever was reported alongside the abdominal pain, a finding consistent with appendiceal inflammation.","frag":"low-grade fever"}]},{"id":"abd-hx-biliary-ruq-postprandial","dx":"biliary","q":"Right upper quadrant or epigastric pain after fatty meals — colicky, lasting 30 minutes to several hours?","answers":[{"label":"No postprandial RUQ/epigastric pain","tone":"neg","sets":[],"ddx":[],"mdm":"No right upper quadrant or epigastric pain following fatty meals was reported; a biliary cause was not suggested by this feature.","frag":"no postprandial RUQ/epigastric pain"},{"label":"Postprandial RUQ/epigastric pain after fatty foods","tone":"pos","sets":[],"ddx":[{"id":"biliary","keep":true}],"mdm":"Right upper quadrant or epigastric pain precipitated by fatty meals and lasting 30 minutes to several hours was reported, consistent with biliary colic or cholecystitis.","frag":"postprandial RUQ/epigastric pain after fatty meals"}]},{"id":"abd-hx-biliary-fever-jaundice","dx":"biliary","q":"Fever with chills and/or jaundice (Charcot's triad — RUQ pain, fever, jaundice suggesting cholangitis)?","answers":[{"label":"No fever or jaundice","tone":"neg","sets":[],"ddx":[],"mdm":"No fever with chills or jaundice was reported. Because the full Charcot triad is present in only about a quarter of cholangitis cases, its absence was not used to exclude the diagnosis; laboratory studies and imaging set the threshold.","frag":"no fever, chills, or jaundice (the Charcot triad appears in only ~25% of cholangitis, so labs and imaging set the threshold)"},{"label":"Fever and/or jaundice with RUQ pain","tone":"pos","sets":[],"ddx":[{"id":"biliary","keep":true}],"mdm":"Fever with chills and jaundice accompanying right upper quadrant pain were reported; Charcot's triad for ascending cholangitis was present and urgent biliary decompression was considered.","frag":"fever and jaundice with RUQ pain (Charcot's triad)"}]},{"id":"abd-hx-sbo-prior-surgery","dx":"sbo","q":"Prior abdominal or pelvic surgery (risk of adhesive SBO) — type and approximate year of procedure?","answers":[{"label":"No prior abdominal or pelvic surgery","tone":"neg","sets":[],"ddx":[],"mdm":"No prior abdominal or pelvic surgery was reported; adhesive small-bowel obstruction was less likely without a prior operative history.","frag":"no prior abdominal or pelvic surgery"},{"label":"Prior abdominal/pelvic surgery","tone":"pos","sets":[],"ddx":[{"id":"sbo","keep":true}],"mdm":"A history of prior abdominal or pelvic surgery was present, increasing the risk of adhesive small-bowel obstruction as the cause of the current presentation.","frag":"prior abdominal/pelvic surgery"}]},{"id":"abd-hx-sbo-hernia","dx":"sbo","q":"Known hernia (inguinal, femoral, umbilical, incisional) — has it been reducible in the past? Any current difficulty reducing it?","answers":[{"label":"No known hernia","tone":"neg","sets":[],"ddx":[],"mdm":"No known hernia was reported; an incarcerated or strangulated hernia was less likely by history.","frag":"no known hernia"},{"label":"Known hernia — possibly incarcerated","tone":"pos","sets":[],"ddx":[{"id":"sbo","keep":true}],"mdm":"A known hernia was reported and the patient could not reduce it or noted it had changed in character; an incarcerated or strangulated hernia causing bowel obstruction was a primary concern.","frag":"known hernia, possibly incarcerated"}]},{"id":"abd-hx-sbo-vomiting-obstipation","dx":"sbo","q":"Nausea and vomiting (bilious), obstipation (no flatus or bowel movement), and abdominal distension?","answers":[{"label":"No vomiting or obstipation","tone":"neg","sets":[],"ddx":[],"mdm":"No bilious vomiting, obstipation, or abdominal distension was reported; a complete small-bowel obstruction was less likely on history.","frag":"no bilious vomiting, obstipation, or distension"},{"label":"Bilious vomiting, obstipation, and/or distension","tone":"pos","sets":[],"ddx":[{"id":"sbo","keep":true}],"mdm":"Bilious vomiting, obstipation, and abdominal distension were reported together, strongly suggesting small-bowel obstruction and warranting imaging evaluation.","frag":"bilious vomiting, obstipation, and distension"}]},{"id":"abd-hx-renal-colicky-flank","dx":"renal","q":"Colicky flank pain radiating to the groin or scrotum/labia — waxing and waning in waves?","answers":[{"label":"No colicky flank-to-groin pain","tone":"neg","sets":[],"ddx":[],"mdm":"No colicky flank pain radiating toward the groin was reported; a renal colic presentation was not supported by the pain pattern.","frag":"no colicky flank-to-groin pain"},{"label":"Colicky flank-to-groin pain","tone":"pos","sets":[],"ddx":[{"id":"renal","keep":true}],"mdm":"Colicky flank pain radiating toward the groin or genitalia, waxing and waning in waves, was reported: a characteristic presentation of ureterolithiasis.","frag":"colicky flank-to-groin pain"}]},{"id":"abd-hx-renal-hematuria","dx":"renal","q":"Gross hematuria or passage of a stone (or prior nephrolithiasis)?","answers":[{"label":"No hematuria or prior stone","tone":"neg","sets":[],"ddx":[],"mdm":"No gross hematuria was reported and no prior history of nephrolithiasis was identified.","frag":"no hematuria or prior stone"},{"label":"Hematuria or prior stone passage","tone":"pos","sets":[],"ddx":[{"id":"renal","keep":true}],"mdm":"Gross hematuria or a prior history of kidney stone passage was reported, supporting ureterolithiasis as the diagnosis.","frag":"hematuria or prior stone passage"}]},{"answers":[{"ddx":[],"frag":"negative pregnancy test","label":"Negative pregnancy test","mdm":"A pregnancy test was negative in this patient of reproductive potential, with no hemodynamic instability or peritonism, effectively excluding ruptured ectopic pregnancy.","sets":[],"tone":"neg"},{"ddx":[{"id":"ectopic-ruptured-ap","keep":true}],"frag":"positive or unconfirmed pregnancy status","label":"Pregnant or test positive","mdm":"Pregnancy was confirmed or could not be excluded, requiring active evaluation for ectopic pregnancy with quantitative hCG and pelvic ultrasound.","sets":[],"tone":"pos"}],"dx":"ectopic-ruptured-ap","id":"abd-hx-ectopic-ruptured-ap","q":"Reproductive potential — last menstrual period, possibility of pregnancy, and pregnancy test result?"},{"id":"abd-hx-aaa-renal-mimic","dx":"aaa","q":"New flank or back pain attributed to a kidney stone in a patient over 60 with no prior nephrolithiasis — was symptomatic AAA actively considered before settling on renal colic?","answers":[{"label":"Prior stone history or low-risk age","tone":"neg","sets":[],"ddx":[],"mdm":"Patient had an established prior stone history or was low-risk by age, so the first-time-stone AAA mimic was not a leading concern.","frag":"prior stones, lower AAA risk"},{"label":"First 'stone' over 60","tone":"pos","sets":[],"ddx":[],"mdm":"Patient over 60 presented with a first episode of flank pain and no prior nephrolithiasis, a classic symptomatic-AAA mimic, prompting aortic imaging rather than presumptive renal colic.","frag":"first stone >60, AAA mimic"}]},{"id":"abd-hx-mesenteric-gut-emptying","dx":"mesenteric","q":"Abrupt forceful vomiting or diarrhea (gut emptying) at the onset of severe pain in an older or vasculopathic patient — recognizing that a normal lactate does not exclude early mesenteric ischemia?","answers":[{"label":"No abrupt gut emptying","tone":"neg","sets":[],"ddx":[],"mdm":"Patient reported no abrupt vomiting or diarrhea accompanying pain onset, and lacked the gut-emptying pattern that raises concern for acute mesenteric ischemia.","frag":"no gut emptying"},{"label":"Abrupt gut emptying with pain","tone":"pos","sets":[],"ddx":[],"mdm":"Patient had abrupt forceful vomiting or diarrhea at pain onset, a gut-emptying clue to acute mesenteric ischemia that warrants CT angiography regardless of a normal lactate.","frag":"gut emptying, normal lactate not reassuring"}]},{"id":"abd-hx-ectopic-fertility-heterotopic","dx":"ectopic","q":"Fertility-assisted conception (IVF, ovulation induction) — heterotopic pregnancy risk, so a confirmed intrauterine pregnancy does not exclude a coexisting ectopic?","answers":[{"label":"Spontaneous conception","tone":"neg","sets":[],"ddx":[],"mdm":"Pregnancy was spontaneously conceived without assisted reproduction, making coexisting heterotopic pregnancy unlikely once an intrauterine pregnancy is seen.","frag":"spontaneous, low heterotopic risk"},{"label":"Assisted reproduction","tone":"pos","sets":[],"ddx":[],"mdm":"Patient conceived via assisted reproduction, raising heterotopic pregnancy risk, so a documented intrauterine pregnancy did not exclude a concurrent ectopic.","frag":"IVF, heterotopic possible"}]},{"id":"abd-hx-ectopic-pul-empty-uterus","dx":"ectopic","q":"Positive pregnancy test with pain or bleeding and no confirmed intrauterine pregnancy — was pregnancy of unknown location treated as possible ectopic rather than excluded by a single hCG below a discriminatory threshold?","answers":[{"label":"IUP confirmed","tone":"neg","sets":[],"ddx":[],"mdm":"An intrauterine pregnancy was sonographically confirmed in a patient without heterotopic risk factors, substantially lowering ectopic concern.","frag":"IUP confirmed"},{"label":"PUL, no IUP seen","tone":"pos","sets":[],"ddx":[],"mdm":"Patient had a positive test without a confirmed intrauterine pregnancy, managed as pregnancy of unknown location and possible ectopic rather than excluded by a single low hCG, since ectopics occur at any hCG level.","frag":"PUL, ectopic until located"}]},{"id":"abd-hx-elderly-atypical-severity","dx":"general","q":"Older adult whose reported pain or systemic symptoms seem mild relative to concern — recognizing blunted pain perception and unreliable vitals can understate serious intra-abdominal pathology?","answers":[{"label":"Young, reliable presentation","tone":"neg","sets":[],"ddx":[],"mdm":"Patient was younger with a reliable history and physiologic response, so reported symptom severity reasonably reflected the underlying process.","frag":"reliable presentation"},{"label":"Older, blunted presentation","tone":"pos","sets":[],"ddx":[],"mdm":"Older patient had blunted pain and unreliable vital signs, so mild-appearing symptoms were not used to downgrade concern for serious intra-abdominal pathology.","frag":"elderly, blunted/atypical"}]}],"exam":[{"id":"abd-exam-vitals","dx":"general","q":"Vital signs — hemodynamically stable? No tachycardia, hypotension, or fever?","answers":[{"label":"Hemodynamically stable, afebrile","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable with no tachycardia and no hypotension, and the patient was afebrile at the time of examination.","frag":"hemodynamically stable, afebrile"},{"label":"Hemodynamically unstable — tachycardia and/or hypotension","tone":"pos","sets":[],"ddx":[],"mdm":"Hemodynamic instability with tachycardia and/or hypotension was present, a high-risk feature requiring urgent evaluation for vascular catastrophe, sepsis, or hemorrhage.","frag":"unstable: tachycardia or hypotension"},{"label":"Fever (≥ 38°C)","tone":"pos","sets":[],"ddx":[],"mdm":"Fever (≥ 38°C) was present on vital signs, raising concern for an inflammatory or infectious intra-abdominal process.","frag":"fever"}]},{"id":"abd-exam-pulsatile-mass","dx":"aaa","q":"Pulsatile expansile abdominal mass on palpation, midline or left of midline — recognizing that a normal abdominal exam does not exclude AAA, especially with higher body habitus?","answers":[{"label":"No pulsatile mass","tone":"neg","sets":[],"ddx":[],"mdm":"No pulsatile abdominal mass was detected, noting palpation is only ~68% sensitive for AAA and cannot exclude one; imaging thresholds were set by risk factors and the clinical picture.","frag":"no pulsatile mass (palpation not relied on to exclude AAA)"},{"label":"Pulsatile mass felt","tone":"pos","sets":[],"ddx":[{"id":"aaa","keep":true}],"mdm":"A pulsatile abdominal mass was palpated, raising strong concern for an abdominal aortic aneurysm; emergent vascular imaging was indicated.","frag":"pulsatile abdominal mass"}]},{"id":"abd-exam-peritoneal","dx":"perf-abd","q":"Peritoneal signs — rebound tenderness, involuntary guarding, or board-like rigidity?","answers":[{"label":"Absent — soft abdomen, no peritoneal signs","tone":"neg","sets":[],"ddx":[],"mdm":"No rebound tenderness, involuntary guarding, or rigidity was elicited; peritoneal signs were absent.","frag":"no rebound, guarding, or rigidity"},{"label":"Peritoneal signs present","tone":"pos","sets":[],"ddx":[{"id":"perf-abd","keep":true}],"mdm":"Peritoneal signs (rebound tenderness, involuntary guarding, and/or board-like rigidity) were present on examination, raising strong concern for perforated viscus or peritonitis requiring surgical evaluation.","frag":"peritoneal signs: rebound or rigidity"}]},{"id":"abd-exam-rlq-appy","dx":"appy","q":"RLQ tenderness at McBurney's point — Rovsing sign (RLQ pain with LLQ palpation) or psoas sign (pain with right hip extension)?","answers":[{"label":"No RLQ tenderness, Rovsing or psoas sign absent","tone":"neg","sets":[],"ddx":[],"mdm":"No right lower quadrant point tenderness, Rovsing sign, or psoas sign was elicited on examination.","frag":"no RLQ tenderness, Rovsing, or psoas sign"},{"label":"RLQ tenderness and/or positive Rovsing or psoas sign","tone":"pos","sets":[],"ddx":[{"id":"appy","keep":true}],"mdm":"Right lower quadrant tenderness at McBurney's point was present; Rovsing sign and/or psoas sign was positive, increasing concern for acute appendicitis.","frag":"RLQ tenderness with positive Rovsing or psoas sign"}]},{"id":"abd-exam-murphy-ruq","dx":"biliary","q":"Murphy sign — inspiratory arrest with deep palpation at the right upper quadrant? RUQ tenderness?","answers":[{"label":"Murphy sign absent, no RUQ tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"Murphy sign was absent and no right upper quadrant tenderness was elicited on examination. Because the Murphy sign is imperfectly sensitive (roughly 60-65%, lower in older adults), its absence was not used to exclude cholecystitis; the ultrasound threshold was set by the overall clinical picture.","frag":"Murphy sign absent, no RUQ tenderness (Murphy is only ~60-65% sensitive (worse in older adults), so the ultrasound threshold was set by the picture)"},{"label":"Positive Murphy sign or RUQ tenderness","tone":"pos","sets":[],"ddx":[{"id":"biliary","keep":true}],"mdm":"Murphy sign was positive and/or right upper quadrant tenderness was present on examination, consistent with acute cholecystitis.","frag":"positive Murphy sign or RUQ tenderness"}]},{"id":"abd-exam-distension-bowel-sounds","dx":"sbo","q":"Abdominal distension, high-pitched or tinkling bowel sounds, or a reducible/incarcerated hernia?","answers":[{"label":"No distension, normal bowel sounds, no hernia","tone":"neg","sets":[],"ddx":[],"mdm":"No abdominal distension, no abnormal bowel sounds, and no hernia were identified on examination; bowel obstruction was less supported by the physical exam.","frag":"no distension, abnormal bowel sounds, or hernia"},{"label":"Distension, high-pitched bowel sounds, or incarcerated hernia","tone":"pos","sets":[],"ddx":[{"id":"sbo","keep":true}],"mdm":"Abdominal distension, high-pitched or tinkling bowel sounds, or an incarcerated hernia was identified on examination, supporting a diagnosis of small-bowel obstruction.","frag":"distension, high-pitched bowel sounds, or incarcerated hernia"}]},{"id":"abd-exam-pelvic","dx":"pid-abd","q":"Pelvic exam as indicated — cervical motion, uterine, or adnexal tenderness (the PID minimum criteria), or a unilateral adnexal mass?","answers":[{"label":"No CMT, uterine/adnexal tenderness, or mass","tone":"neg","sets":[],"ddx":[],"mdm":"Pelvic examination showed no cervical motion, uterine, or adnexal tenderness and no adnexal mass.","frag":"no cervical motion, uterine, or adnexal tenderness; no adnexal mass"},{"label":"CMT / uterine or adnexal tenderness","tone":"pos","sets":[],"ddx":[{"id":"pid-abd","keep":true}],"mdm":"Cervical motion, uterine, or adnexal tenderness was present (the minimum criteria for pelvic inflammatory disease) and PID/tubo-ovarian abscess was evaluated and treated accordingly.","frag":"cervical motion / uterine / adnexal tenderness (PID minimum criteria met)"},{"label":"Unilateral adnexal mass / focal adnexal tenderness","tone":"pos","sets":[],"ddx":[{"id":"pid-abd","keep":true},{"id":"ectopic","keep":true}],"mdm":"A unilateral adnexal mass or focal adnexal tenderness was present, raising ectopic pregnancy (in the appropriate hCG context), tubo-ovarian abscess, and ovarian torsion.","frag":"unilateral adnexal mass or focal adnexal tenderness"}]},{"id":"abd-exam-cva","dx":"renal","q":"Costovertebral angle (CVA) tenderness on percussion?","answers":[{"label":"CVA tenderness absent bilaterally","tone":"neg","sets":[],"ddx":[],"mdm":"Costovertebral angle tenderness was absent bilaterally on percussion.","frag":"no CVA tenderness bilaterally"},{"label":"CVA tenderness present","tone":"pos","sets":[],"ddx":[{"id":"renal","keep":true}],"mdm":"Costovertebral angle tenderness was present on percussion, raising the possibility of ureterolithiasis or upper urinary tract infection.","frag":"CVA tenderness"}]},{"id":"abd-exam-perf-masked-elderly-immuno","dx":"perf-abd","q":"Elderly, diabetic, or immunosuppressed patient with a deceptively soft, non-rigid abdomen — recognizing that lax musculature and blunted inflammatory response can mask peritonitis from a perforated viscus?","answers":[{"label":"Reliable exam, low-risk host","tone":"neg","sets":[],"ddx":[],"mdm":"Patient was an immunocompetent host with a reliable abdominal exam, so absence of peritoneal signs carried its usual reassuring weight.","frag":"reliable exam"},{"label":"Masked exam, vulnerable host","tone":"pos","sets":[],"ddx":[],"mdm":"Elderly or immunosuppressed patient lacked guarding and rigidity despite concerning history, so a benign exam was not relied upon to exclude perforation and imaging was pursued.","frag":"masked peritonitis, vulnerable host"}]},{"id":"abd-exam-appy-atypical-location","dx":"appy","q":"Atypical appendiceal localization on exam — flank or pelvic tenderness, positive obturator or psoas sign without classic McBurney point pain (retrocecal or pelvic appendix)?","answers":[{"label":"No atypical localizing signs","tone":"neg","sets":[],"ddx":[],"mdm":"Patient had no flank, pelvic, or psoas/obturator localizing signs to suggest an atypically positioned appendix.","frag":"no atypical signs"},{"label":"Retrocecal/pelvic signs","tone":"pos","sets":[],"ddx":[],"mdm":"Patient demonstrated flank or pelvic tenderness with positive psoas or obturator sign without classic McBurney pain, consistent with a retrocecal or pelvic appendix that can present atypically.","frag":"retrocecal/pelvic appendicitis"}]},{"id":"abd-exam-freeair","dx":"perf-abd","q":"Diagnostic review — upright chest or left-lateral-decubitus film: free air under the diaphragm? (Absent in up to a third of perforations — a negative film does not exclude a perforated viscus.)","answers":[{"label":"No free air (not relied on to exclude)","tone":"neg","sets":[],"ddx":[],"mdm":"No free air was seen under the diaphragm, noting plain films miss up to a third of perforations, so the absence of free air was not used to exclude a perforated viscus.","frag":"no free air on upright film (not used to exclude perforation)"},{"label":"Free air present","tone":"pos","sets":[],"ddx":[],"mdm":"Free air was visible under the diaphragm, confirming a perforated viscus: surgical consultation was engaged immediately.","frag":"free air under the diaphragm"}]}],"conclusions":["gastroenteritis","nonspecific abdominal pain (NOS)","constipation","gastritis / dyspepsia"],"specs":["gi","surg"],"algorithm":{"immediate":["IV access and full vitals; a urine or serum pregnancy test in any patient of reproductive potential; titrated analgesia does not obscure the surgical exam.","If unstable with abdominal pain: resuscitate while considering ruptured AAA, ruptured ectopic, perforation with sepsis, and GI hemorrhage — bedside ultrasound and emergent surgical/OB consultation."],"criticalTests":["Pregnancy test in any patient of reproductive potential","Lactate, CBC, lipase, renal panel and LFTs","Upright/decubitus X-ray or CT for free air; CT angiography when AAA or mesenteric ischemia is suspected","Bedside ultrasound (aorta, FAST, pelvic) when unstable"],"cantMiss":[{"dx":"aaa","trigger":"Older patient with flank/back pain, a pulsatile mass, or hypotension","test":"Bedside aortic ultrasound, then CT angiography if stable","intervention":"Permissive hypotension, type and cross, emergent vascular surgery"},{"dx":"mesenteric","trigger":"Pain out of proportion to exam, atrial fibrillation or vascular disease, rising lactate","test":"CT angiography of the mesenteric vessels","intervention":"Resuscitation, broad-spectrum antibiotics, anticoagulation, emergent surgery/IR"},{"dx":"ectopic-ruptured-ap","trigger":"Positive pregnancy test with peritonism or hemodynamic instability","test":"Transvaginal ultrasound and quantitative hCG","intervention":"Type and cross, emergent OB consultation, to the OR"},{"dx":"perf-abd","trigger":"Sudden severe pain with peritonitis","test":"Upright X-ray or CT for free air","intervention":"NPO, IV fluids and antibiotics, emergent surgical consultation"}],"disposition":"Surgical or OB pathology to the OR or admission; an undifferentiated but reassuring abdomen with normal labs and tolerated oral intake may be discharged with explicit return precautions and short-interval recheck."},"decisionTree":{"title":"Abdominal pain — initial approach","intro":"An original, evidence-based decision aid for abdominal pain. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Assess & resuscitate","items":["Vitals; analgesia; IV access","Pregnancy test in anyone who could be pregnant","Focused serial abdominal exam"],"next":"q_unstable"},"q_unstable":{"type":"decision","q":"Unstable or a surgical abdomen (peritonitis, hemodynamic instability)?","yes":"a_surgical","no":"q_ectopic","cantmiss":"Ruptured AAA, mesenteric ischemia, perforation, and ruptured ectopic kill quickly — resuscitate and involve surgery/imaging early."},"a_surgical":{"type":"action","title":"Resuscitate & emergent surgery/imaging","items":["Large-bore IV, blood products","Emergent surgical consult; bedside ultrasound / CT","Antibiotics for suspected perforation"],"tone":"danger","terminal":true},"q_ectopic":{"type":"decision","q":"Pregnant (or possibly pregnant) with abdominal/pelvic pain?","yes":"a_ectopic","no":"q_vasc"},"a_ectopic":{"type":"action","title":"Exclude ectopic pregnancy","items":["Quantitative hCG and pelvic ultrasound","OB consult","Treat a ruptured ectopic as a surgical emergency"],"tone":"danger","terminal":true},"q_vasc":{"type":"decision","q":"Pain out of proportion, AAA risk, or vascular features?","yes":"a_vasc","no":"q_local","pitfall":"Mesenteric ischemia (pain out of proportion, AF, vascular disease) and AAA (older, back/flank pain) are easily missed."},"a_vasc":{"type":"action","title":"Vascular workup","items":["CT angiography; lactate","Surgery/vascular consult","Resuscitate"],"tone":"danger","terminal":true},"q_local":{"type":"decision","q":"Localizing surgical cause likely (appendicitis, cholecystitis, SBO, diverticulitis)?","yes":"a_local","no":"a_supportive"},"a_local":{"type":"action","title":"Targeted workup & surgery","items":["Labs; ultrasound or CT","Antibiotics and surgical consult as indicated"],"terminal":true},"a_supportive":{"type":"action","title":"Symptomatic care & reassessment","items":["Analgesia/antiemetics; labs/urinalysis","Serial exams","Discharge with return precautions if benign and improving"],"terminal":true}}},"guide":"../learn/complaints/abdominal-pain.html","pearls":[{"text":"In anyone over 50 with abdominal, flank, or back pain — especially with syncope or hypotension — get a bedside aortic ultrasound. A ruptured AAA is misread as renal colic; do not anchor on 'stone' without imaging the aorta.","dx":"aaa"},{"text":"Suspect mesenteric ischemia when pain is out of proportion to a benign exam, particularly with atrial fibrillation or vascular disease. A normal lactate and soft abdomen are falsely reassuring early; CT angiography is the test.","dx":"mesenteric"},{"text":"Every woman of childbearing age with abdominal pain gets a pregnancy test — no exceptions. A ruptured ectopic can present with a near-normal abdomen, and being below the β-hCG discriminatory zone does not exclude it.","dx":"ectopic"},{"text":"Free air can be absent on a supine film — an upright chest x-ray or CT is far more sensitive for perforation. Elderly, diabetic, and immunosuppressed patients perforate with a soft, unimpressive abdomen.","dx":"perf-abd"},{"text":"A normal WBC does not exclude appendicitis, and retrocecal or pelvic positions blunt the classic signs. Serial exam or CT beats a single reassuring snapshot; in pregnancy the point of tenderness shifts upward.","dx":"appy"},{"text":"Treat PID on clinical suspicion — cervical-motion, uterine, or adnexal tenderness in a young woman — without waiting for confirmatory testing; a missed case risks infertility and a tubo-ovarian abscess.","dx":"pid-abd"}]},{"id":"headache","title":"Headache","aliases":["ha","head","headache","head pain","migraine","worst headache","thunderclap","sah","meningitis"],"opening":"The patient was evaluated for headache. A focused history and neurologic examination were performed, and the serious and common causes below were actively considered.","ddx":[{"id":"sah","group":"lifethreat","label":"Subarachnoid hemorrhage","default":true,"tags":["sah"],"ruleout":"Subarachnoid hemorrhage was considered; the headache was not thunderclap or maximal at onset, there was no neck stiffness, vomiting, syncope, or focal deficit, and the neurologic examination was normal, making it unlikely.","miss":4},{"id":"meningitis","group":"lifethreat","label":"Meningitis / encephalitis","default":true,"tags":[],"ruleout":"Meningitis or encephalitis was considered; there was no fever, neck stiffness, photophobia, rash, or altered mentation, and no immunocompromise, making CNS infection unlikely while recognizing meningeal signs are insensitive.","miss":4},{"id":"mass","group":"lifethreat","label":"Mass lesion / elevated ICP","default":true,"tags":[],"ruleout":"A mass lesion with elevated intracranial pressure was considered; there was no progressive or positional headache, no early-morning vomiting, no new seizure, and the neurologic examination and fundoscopy showed no papilledema or focal deficit, making it unlikely.","miss":3},{"id":"stroke","group":"lifethreat","label":"Stroke / ICH","default":false,"tags":[],"ruleout":"Stroke or intracranial hemorrhage was considered; there was no focal weakness, sensory loss, aphasia, visual field deficit, or ataxia, and the neurologic examination was non-focal, making it unlikely.","miss":4},{"id":"cvst-ha","group":"lifethreat","label":"Cerebral venous sinus thrombosis","default":false,"tags":["cvst-ha"],"ruleout":"Cerebral venous sinus thrombosis was considered; there was no progressive or positional headache, no seizure, focal deficit, or visual change, and no prothrombotic state such as pregnancy, postpartum, or hormonal therapy, making it unlikely.","miss":4},{"id":"gca-ha","group":"lifethreat","label":"Giant cell arteritis","default":false,"tags":["gca-ha"],"ruleout":"Giant cell arteritis was considered in the older patient; there was no new temporal headache, scalp tenderness, jaw claudication, or visual disturbance, and no temporal artery abnormality, making it unlikely.","miss":4},{"id":"co-ha","group":"lifethreat","label":"Carbon monoxide poisoning","default":false,"tags":["co-ha"],"ruleout":"Carbon monoxide poisoning was considered; there was no exposure to combustion sources or faulty heating, no co-occurring symptoms among cohabitants, and no associated nausea or confusion, making it unlikely.","miss":4},{"id":"gca","group":"common","label":"Giant cell arteritis","default":false,"tags":[],"ruleout":"Giant cell arteritis was considered in the patient over 50; there was no new temporal or lateralizing headache, scalp tenderness, jaw claudication, visual disturbance, or polymyalgia, the temporal arteries were non-tender with preserved pulse, and inflammatory markers were not elevated where checked, making it unlikely.","miss":4},{"id":"migraine","group":"other","label":"Primary headache / migraine","default":false,"tags":[],"ruleout":"A primary headache disorder was considered as the likely cause after the serious diagnoses above were addressed.","miss":1}],"risk":[{"id":"ottawa-sah","label":"Ottawa SAH rule","tags":["sah"],"scale":"low","line":"The Ottawa SAH rule was applied to this alert patient with acute headache to support the decision regarding further imaging.","cite":"Perry JJ, et al. JAMA. 2013.","short":"Ottawa SAH rule applied","calc":{"fields":[{"label":"Age ≥ 40","opts":[["No",0],["Yes",1]]},{"label":"Neck pain or stiffness","opts":[["No",0],["Yes",1]]},{"label":"Witnessed loss of consciousness","opts":[["No",0],["Yes",1]]},{"label":"Onset during exertion","opts":[["No",0],["Yes",1]]},{"label":"Thunderclap (instantly peaking)","opts":[["No",0],["Yes",1]]},{"label":"Limited neck flexion on exam","opts":[["No",0],["Yes",1]]}],"bands":[[0,"no high-risk feature — rule applied","low","No high-risk feature: in this alert, non-focal patient the rule does not mandate further SAH workup."],[6,"cannot exclude SAH — investigate","high","≥1 high-risk feature: SAH cannot be excluded — non-contrast head CT, with LP or CTA if indicated."]],"line":"Ottawa SAH rule applied to this alert, non-focal headache patient: {score} of 6 high-risk features present ({band}).","applies":"Alert adults >= 15y with acute non-traumatic headache peaking within 1 hour. Excludes new neuro deficits, prior aneurysm/SAH, known brain tumor, or chronic recurrent headaches."},"bandNotes":{"no high-risk feature — rule applied":"100% sensitivity for SAH in derivation and validation (Perry)"}},{"id":"neuroexam","label":"Documented neuro exam","tags":[],"scale":"low","line":"A focused neurologic examination was performed and documented, and was non-focal.","short":"non-focal neuro exam"}],"checks":[{"if":"sah","needs":["ottawa-sah","neuroexam"],"mode":"any","warn":"SAH is on the differential — a documented neuro exam and/or a validated rule shows the basis for the exclusion."}],"history":[{"id":"ha-hx-onset-general","dx":"general","q":"Headache onset and character — gradual vs. abrupt, quality (pressure, throbbing, stabbing), severity (1–10), and location?","answers":[{"label":"Gradual onset, familiar character","tone":"neg","sets":[],"ddx":[],"mdm":"The headache was gradual in onset and the character was familiar to the patient, without features pointing strongly to a secondary cause.","frag":"gradual onset, familiar character"},{"label":"Abrupt or unfamiliar headache","tone":"pos","sets":[],"ddx":[],"mdm":"The headache was abrupt in onset or qualitatively different from prior headaches, a red flag requiring active exclusion of a serious secondary cause.","frag":"abrupt or unfamiliar headache"}]},{"id":"ha-hx-sah-thunderclap","dx":"sah","q":"Thunderclap onset — did the headache reach maximal intensity at or within seconds of onset ('worst headache of life')?","answers":[{"label":"No — gradual buildup over minutes or longer","tone":"neg","sets":[],"ddx":[],"mdm":"The headache was not thunderclap in onset; it did not reach maximal intensity instantaneously, which substantially lowers the likelihood of subarachnoid hemorrhage on this feature.","frag":"no thunderclap onset"},{"label":"Yes — instantaneous maximal intensity ('worst headache of life')","tone":"pos","sets":[],"ddx":[{"id":"sah","keep":true}],"mdm":"The headache reached maximal intensity instantaneously (a thunderclap presentation), the most important historical feature for subarachnoid hemorrhage.","frag":"thunderclap onset"}]},{"id":"ha-hx-sah-exertional","dx":"sah","q":"Onset during exertion, sexual activity, cough, or Valsalva maneuver?","answers":[{"label":"Not associated with exertion or Valsalva","tone":"neg","sets":[],"ddx":[],"mdm":"The headache was not triggered by exertion, sexual activity, cough, or the Valsalva maneuver.","frag":"no exertional or Valsalva onset"},{"label":"Onset with exertion, sexual activity, or Valsalva","tone":"pos","sets":[],"ddx":[{"id":"sah","keep":true}],"mdm":"The headache began during exertion, sexual activity, or a Valsalva maneuver: recognized precipitants of aneurysmal rupture and a high-risk feature for subarachnoid hemorrhage.","frag":"onset with exertion or Valsalva"}]},{"id":"ha-hx-sah-loc-seizure","dx":"sah","q":"Brief loss of consciousness or seizure at the time of headache onset?","answers":[{"label":"No loss of consciousness or seizure at onset","tone":"neg","sets":[],"ddx":[],"mdm":"No loss of consciousness or seizure occurred at the time of headache onset.","frag":"no LOC or seizure at onset"},{"label":"LOC or seizure at headache onset","tone":"pos","sets":[],"ddx":[{"id":"sah","keep":true}],"mdm":"A brief loss of consciousness or seizure occurred at the onset of the headache, a high-risk feature associated with a sudden surge in intracranial pressure from subarachnoid hemorrhage.","frag":"LOC or seizure at onset"}]},{"id":"ha-hx-sah-neck-stiffness","dx":"sah","q":"Neck pain or stiffness developing after the headache onset (meningeal irritation from blood)?","answers":[{"label":"No neck pain or stiffness","tone":"neg","sets":[],"ddx":[],"mdm":"No neck pain or neck stiffness was reported following the headache onset.","frag":"no neck pain or stiffness"},{"label":"Neck pain or stiffness after headache onset","tone":"pos","sets":[],"ddx":[{"id":"sah","keep":true}],"mdm":"Neck pain or stiffness developing after the headache onset was reported; meningeal irritation from subarachnoid blood was considered.","frag":"neck pain or stiffness after onset"}]},{"id":"ha-hx-meningitis-fever","dx":"meningitis","q":"Fever, neck stiffness, and photophobia — classic triad for bacterial meningitis?","answers":[{"label":"No fever, neck stiffness, or photophobia suggesting infection","tone":"neg","sets":[],"ddx":[],"mdm":"No fever, neck stiffness, or photophobia was reported; the clinical triad for bacterial meningitis was absent.","frag":"no fever, neck stiffness, or photophobia"},{"label":"Fever with neck stiffness and/or photophobia","tone":"pos","sets":[],"ddx":[{"id":"meningitis","keep":true}],"mdm":"Fever with neck stiffness and/or photophobia was reported; the clinical triad for bacterial meningitis was present and empiric coverage was considered urgently.","frag":"fever with neck stiffness or photophobia"}]},{"id":"ha-hx-meningitis-immunocompromise","dx":"meningitis","q":"Immunocompromised state — HIV/AIDS, solid organ or bone marrow transplant, active chemotherapy, or prolonged systemic steroids?","answers":[{"label":"Not immunocompromised","tone":"neg","sets":[],"ddx":[],"mdm":"No immunocompromised state was identified (no HIV/AIDS, solid organ or bone marrow transplant, active chemotherapy, or prolonged systemic steroids); so the risk of opportunistic CNS infection was not elevated by this history.","frag":"not immunocompromised"},{"label":"Immunocompromised","tone":"pos","sets":[],"ddx":[{"id":"meningitis","keep":true}],"mdm":"An immunocompromised state was present (HIV/AIDS, solid organ or bone marrow transplant, active chemotherapy, or prolonged systemic steroids); substantially broadening the differential for CNS infection to include opportunistic pathogens such as Cryptococcus, Listeria, and viral encephalitides.","frag":"immunocompromised"}]},{"id":"ha-hx-meningitis-rash","dx":"meningitis","q":"Petechial or purpuric non-blanching rash — or preceding URI symptoms suggesting bacterial meningococcemia?","answers":[{"label":"No rash and no URI prodrome suggesting meningococcemia","tone":"neg","sets":[],"ddx":[],"mdm":"No petechial or purpuric rash was reported and no URI prodrome consistent with meningococcemia was identified.","frag":"no petechial rash or URI prodrome"},{"label":"Petechial or purpuric rash","tone":"pos","sets":[],"ddx":[{"id":"meningitis","keep":true}],"mdm":"A petechial or purpuric non-blanching rash was reported alongside headache and fever; meningococcal meningitis with bacteremia was a primary concern requiring immediate empiric treatment.","frag":"petechial or purpuric rash"}]},{"id":"ha-hx-meningitis-neurosurgical","dx":"meningitis","q":"Recent neurosurgery, lumbar puncture, CSF shunt (VP or VA), or cranial hardware?","answers":[{"label":"No recent neurosurgery, LP, or CSF device","tone":"neg","sets":[],"ddx":[],"mdm":"No recent neurosurgical procedure, lumbar puncture, or CSF diversion device was reported.","frag":"no recent neurosurgery, LP, or CSF device"},{"label":"Recent neurosurgery or CSF device present","tone":"pos","sets":[],"ddx":[{"id":"meningitis","keep":true}],"mdm":"A recent neurosurgical procedure or indwelling CSF device was present, raising concern for healthcare-associated or device-related meningitis.","frag":"recent neurosurgery or CSF device"}]},{"id":"ha-hx-mass-progressive","dx":"mass","q":"Progressive headache worsening over weeks to months — new pattern or clearly escalating severity?","answers":[{"label":"Not progressive — stable or acute pattern","tone":"neg","sets":[],"ddx":[],"mdm":"The headache did not follow a progressive pattern of worsening over weeks; this feature did not suggest an expanding mass lesion.","frag":"no progressive worsening"},{"label":"Progressive worsening over weeks to months","tone":"pos","sets":[],"ddx":[{"id":"mass","keep":true}],"mdm":"A progressively worsening headache over weeks to months was reported: a pattern raising concern for a space-occupying lesion with or without elevated intracranial pressure.","frag":"progressive worsening over weeks to months"}]},{"id":"ha-hx-mass-morning-valsalva","dx":"mass","q":"Headache worse in the morning, with lying down, or with coughing/straining/bending (elevated ICP pattern)?","answers":[{"label":"No morning or positional/Valsalva worsening","tone":"neg","sets":[],"ddx":[],"mdm":"No morning predominance or worsening with recumbency, coughing, or straining was reported; an elevated ICP pattern was not supported by history.","frag":"no morning or positional worsening"},{"label":"Morning or Valsalva-worsened headache","tone":"pos","sets":[],"ddx":[{"id":"mass","keep":true}],"mdm":"The headache was worst in the morning or worsened with coughing, straining, or lying down: an elevated intracranial pressure pattern associated with mass lesions or CSF flow obstruction.","frag":"morning or Valsalva-worsened headache"}]},{"id":"ha-hx-mass-seizure-new","dx":"mass","q":"New-onset seizure with or without focal onset (not a known seizure disorder)?","answers":[{"label":"No new seizure activity","tone":"neg","sets":[],"ddx":[],"mdm":"No new-onset seizure activity was reported.","frag":"no new seizure"},{"label":"New seizure — not previously diagnosed with epilepsy","tone":"pos","sets":[],"ddx":[{"id":"mass","keep":true}],"mdm":"A new seizure was reported in a patient without a prior seizure diagnosis, a finding that substantially raises the concern for an intracranial mass, vascular malformation, or other structural lesion.","frag":"new-onset seizure without prior epilepsy"}]},{"id":"ha-hx-mass-known-cancer","dx":"mass","q":"Personal history of malignancy — particularly lung, breast, melanoma, renal cell, or colon cancer (most common to metastasize to brain)?","answers":[{"label":"No known malignancy","tone":"neg","sets":[],"ddx":[],"mdm":"No personal history of malignancy was reported, including the cancers most prone to brain metastasis (lung, breast, melanoma, renal cell, and colon), making metastatic disease less likely by history.","frag":"no known malignancy"},{"label":"Prior or active malignancy","tone":"pos","sets":[],"ddx":[{"id":"mass","keep":true}],"mdm":"A history of malignancy was present; given the propensity of lung, breast, melanoma, renal cell, and colon cancer to metastasize to brain, metastasis was considered as a cause of the new headache and contrast neuroimaging was indicated.","frag":"prior or active malignancy"}]},{"id":"ha-hx-stroke-focal-sudden","dx":"stroke","q":"Sudden focal neurologic deficit at onset — unilateral weakness, aphasia or dysarthria, unilateral visual loss or diplopia, or facial droop?","answers":[{"label":"No sudden focal deficit","tone":"neg","sets":[],"ddx":[],"mdm":"No sudden focal neurologic deficit was reported at headache onset: no unilateral weakness, aphasia or dysarthria, unilateral visual loss or diplopia, or facial droop.","frag":"no sudden focal deficit at onset"},{"label":"Sudden focal weakness, speech, or vision deficit","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true}],"mdm":"A sudden focal neurologic deficit (including unilateral weakness, aphasia, dysarthria, or visual loss) was reported at headache onset, raising high concern for acute stroke or intracerebral hemorrhage.","frag":"sudden focal deficit at onset"}]},{"id":"ha-hx-stroke-anticoagulation","dx":"stroke","q":"Anticoagulation or antiplatelet therapy — or known coagulopathy (thrombocytopenia, liver disease, hemophilia)?","answers":[{"label":"No anticoagulation or coagulopathy","tone":"neg","sets":[],"ddx":[],"mdm":"No anticoagulant or antiplatelet therapy and no known coagulopathy (thrombocytopenia, liver disease, or hemophilia) was reported, which did not independently elevate the risk of intracranial hemorrhage.","frag":"no anticoagulation or coagulopathy"},{"label":"Anticoagulation or coagulopathy present","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true}],"mdm":"Anticoagulant or antiplatelet therapy or a known coagulopathy (thrombocytopenia, liver disease, or hemophilia) was present, substantially elevating the risk of spontaneous intracranial hemorrhage and lowering the threshold for neuroimaging.","frag":"anticoagulation or coagulopathy"}]},{"id":"ha-hx-stroke-vascular-risk","dx":"stroke","q":"Vascular risk factors — hypertension, diabetes, hyperlipidemia, tobacco use, atrial fibrillation, or prior stroke/TIA?","answers":[{"label":"No significant vascular risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No significant vascular risk factors were identified (no hypertension, diabetes, hyperlipidemia, tobacco use, atrial fibrillation, or prior stroke/TIA), lowering the pretest probability of ischemic stroke or intracerebral hemorrhage.","frag":"no vascular risk factors"},{"label":"Vascular risk factors present","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true}],"mdm":"Vascular risk factors including hypertension, diabetes, atrial fibrillation, or prior cerebrovascular disease were present, increasing the probability of an ischemic or hemorrhagic stroke.","frag":"vascular risk factors present"}]},{"id":"ha-hx-gca-age-temporal","dx":"gca","q":"Age ≥ 50 with a new temporal or occipital headache — different from any prior headaches?","answers":[{"label":"Age < 50 or no new temporal/occipital headache","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was under 50 years of age or did not have a new temporal or occipital headache pattern; giant cell arteritis was not a primary concern on this criterion.","frag":"no new temporal headache in age ≥50"},{"label":"Age ≥ 50 with new temporal or occipital headache","tone":"pos","sets":[],"ddx":[{"id":"gca","keep":true}],"mdm":"The patient was 50 years of age or older with a new-onset temporal or occipital headache: the demographic and anatomic profile most characteristic of giant cell arteritis.","frag":"age ≥50 with new temporal headache"}]},{"id":"ha-hx-gca-jaw-scalp","dx":"gca","q":"Jaw claudication (pain with sustained chewing) or scalp tenderness (pain combing hair or touching temples)?","answers":[{"label":"No jaw claudication or scalp tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"No jaw claudication and no scalp tenderness were reported; these characteristic features of giant cell arteritis were absent.","frag":"no jaw claudication or scalp tenderness"},{"label":"Jaw claudication or scalp tenderness","tone":"pos","sets":[],"ddx":[{"id":"gca","keep":true}],"mdm":"Jaw claudication and/or scalp tenderness were reported; these symptoms are highly specific for giant cell arteritis and mandate urgent ESR/CRP and ophthalmology consultation.","frag":"jaw claudication or scalp tenderness"}]},{"id":"ha-hx-gca-vision","dx":"gca","q":"Visual symptoms — transient monocular visual loss (amaurosis fugax), diplopia, or sudden permanent vision loss?","answers":[{"label":"No visual symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No visual symptoms including amaurosis, diplopia, or sudden vision loss were reported.","frag":"no visual symptoms"},{"label":"Amaurosis, diplopia, or sudden vision loss","tone":"pos","sets":[],"ddx":[{"id":"gca","keep":true}],"mdm":"Visual symptoms including transient monocular vision loss, diplopia, or sudden permanent visual loss were reported: the most feared complications of giant cell arteritis requiring same-day corticosteroid treatment and ophthalmologic evaluation.","frag":"amaurosis, diplopia, or vision loss"}]},{"id":"ha-hx-gca-pmr","dx":"gca","q":"Polymyalgia rheumatica symptoms — bilateral shoulder and hip girdle aching and stiffness, especially in the morning?","answers":[{"label":"No shoulder or hip girdle symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No proximal shoulder or hip girdle aching or morning stiffness was reported; polymyalgia rheumatica was not identified as a concurrent diagnosis.","frag":"no girdle pain or morning stiffness"},{"label":"Bilateral proximal girdle pain and morning stiffness","tone":"pos","sets":[],"ddx":[{"id":"gca","keep":true}],"mdm":"Bilateral proximal girdle pain and morning stiffness consistent with polymyalgia rheumatica were reported; up to 40–60% of GCA patients have concurrent PMR, strengthening the concern for giant cell arteritis.","frag":"proximal girdle pain with morning stiffness"}]},{"id":"ha-hx-migraine-prior","dx":"migraine","q":"Prior identical headaches — same quality, location, and associated symptoms, with at least one previous episode more than a few months ago? (A single 'similar' attack in the prior weeks may itself be a sentinel bleed, not reassurance.)","answers":[{"label":"No prior identical headaches — new or different","tone":"neg","sets":[],"ddx":[],"mdm":"No prior identical headaches were reported; the current headache differed in quality, location, or associated symptoms from prior episodes, requiring evaluation for a secondary cause.","frag":"no prior identical headaches"},{"label":"Prior identical headaches with same pattern","tone":"pos","sets":[],"ddx":[{"id":"migraine","keep":true}],"mdm":"Prior identical headaches with the same character, location, and associated symptoms were reported; this pattern is highly reassuring for a primary headache disorder such as migraine.","frag":"prior identical headaches"}]},{"id":"ha-hx-migraine-aura","dx":"migraine","q":"Preceding aura — visual (scintillating scotoma, zigzag lines), sensory (unilateral tingling), or speech symptoms lasting 20–60 minutes before the headache?","answers":[{"label":"No aura","tone":"neg","sets":[],"ddx":[],"mdm":"No preceding aura was reported (no visual scintillating scotoma or zigzag lines, sensory tingling, or speech symptoms in the 20–60 minutes before onset); consistent with migraine without aura if other features were present.","frag":"no preceding aura"},{"label":"Classic migraine aura preceding headache","tone":"pos","sets":[],"ddx":[{"id":"migraine","keep":true}],"mdm":"A typical migraine aura with gradual visual or sensory symptoms preceding the headache and resolving within 60 minutes was reported: strongly supporting a primary migraine diagnosis.","frag":"classic migraine aura"}]},{"id":"ha-hx-migraine-photo-nausea","dx":"migraine","q":"Photophobia, phonophobia, and nausea or vomiting accompanying the headache?","answers":[{"label":"No photophobia, phonophobia, or nausea","tone":"neg","sets":[],"ddx":[],"mdm":"No photophobia, phonophobia, or nausea was reported alongside the headache.","frag":"no photophobia, phonophobia, or nausea"},{"label":"Photophobia, phonophobia, and/or nausea present","tone":"pos","sets":[],"ddx":[{"id":"migraine","keep":true}],"mdm":"Photophobia, phonophobia, and nausea or vomiting were reported with the headache, features that in the context of a prior identical headache history are characteristic of migraine.","frag":"photophobia, phonophobia, or nausea"}]},{"id":"ha-hx-migraine-family","dx":"migraine","q":"Family history of migraine — parent or sibling with diagnosed migraine headaches?","answers":[{"label":"No family history of migraine","tone":"neg","sets":[],"ddx":[],"mdm":"No family history of migraine was identified.","frag":"no family history of migraine"},{"label":"Family history of migraine","tone":"pos","sets":[],"ddx":[{"id":"migraine","keep":true}],"mdm":"A family history of migraine was reported; migraine has a strong hereditary component and this further supports a primary headache diagnosis.","frag":"family history of migraine"}]},{"answers":[{"ddx":[],"frag":"no progressive/positional headache or prothrombotic state","label":"No CVST features","mdm":"There was no progressive or positional headache, no seizure, focal deficit, or visual change, and no prothrombotic state such as pregnancy, postpartum, or hormonal therapy, making cerebral venous sinus thrombosis unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"cvst-ha","keep":true}],"frag":"progressive/positional headache or prothrombotic state","label":"CVST features present","mdm":"A progressive or positional headache, seizure, focal deficit, or prothrombotic state was present, raising concern for cerebral venous sinus thrombosis and warranting venographic imaging.","sets":[],"tone":"pos"}],"dx":"cvst-ha","id":"ha-hx-cvst-ha","q":"CVST risk and pattern — prothrombotic state (pregnancy, peripartum, estrogen/OCP, malignancy, thrombophilia, dehydration), with progressive or positional headache, seizure, focal deficit, or visual change?"},{"answers":[{"ddx":[],"frag":"no combustion exposure or affected cohabitants","label":"No CO exposure","mdm":"There was no exposure to combustion sources or faulty heating, no co-occurring symptoms among cohabitants, and no associated nausea or confusion, making carbon monoxide poisoning unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"co-ha","keep":true}],"frag":"combustion exposure or affected cohabitants","label":"CO exposure present","mdm":"A combustion source, faulty heating, or similarly affected cohabitants were identified, raising concern for carbon monoxide poisoning and warranting a carboxyhemoglobin level.","sets":[],"tone":"pos"}],"dx":"co-ha","id":"ha-hx-co-ha","q":"Carbon monoxide exposure — combustion source or faulty heating, cohabitants with similar symptoms, or an indoor/seasonal pattern?"},{"id":"ha-hx-sah-sentinel","dx":"sah","q":"Sentinel headache — any abrupt, severe, or unusual headache in the preceding days to weeks that resolved, possibly representing a warning leak?","answers":[{"label":"Recent sentinel/warning headache","tone":"pos","sets":[],"ddx":[],"mdm":"Patient reported a preceding abrupt severe headache within the prior 2 to 8 weeks, raising concern for an aneurysmal sentinel leak and prompting evaluation for subarachnoid hemorrhage despite interval improvement.","frag":"sentinel headache reported"},{"label":"No prior warning headache","tone":"neg","sets":[],"ddx":[],"mdm":"Patient denied any preceding abrupt or unusually severe headache in the prior weeks, with no sentinel-leak history identified.","frag":"no sentinel headache"}]},{"id":"ha-hx-stroke-dissection","dx":"stroke","q":"Arterial dissection risk — neck or face pain with recent neck trauma, manipulation, chiropractic adjustment, or sudden head turning, especially in a younger patient?","answers":[{"label":"Neck pain with dissection trigger","tone":"pos","sets":[],"ddx":[],"mdm":"Patient described neck or facial pain following recent neck trauma or manipulation, raising concern for cervical artery dissection as a cause of headache and stroke and prompting vascular imaging.","frag":"dissection-risk neck pain"},{"label":"No dissection trigger","tone":"neg","sets":[],"ddx":[],"mdm":"Patient denied neck pain, recent neck trauma, or cervical manipulation, with no clear trigger for cervical artery dissection.","frag":"no dissection trigger"}]},{"id":"ha-hx-stroke-posterior-dizziness","dx":"stroke","q":"Posterior-circulation symptoms — headache with dizziness or vertigo, imbalance, diplopia, dysarthria, dysphagia, or unilateral incoordination?","answers":[{"label":"Posterior-circulation symptoms present","tone":"pos","sets":[],"ddx":[],"mdm":"Patient reported headache accompanied by vertigo, imbalance, or other posterior-circulation symptoms, a presentation associated with high rates of missed stroke and warranting a dedicated central-versus-peripheral assessment.","frag":"posterior-circulation symptoms"},{"label":"No brainstem/cerebellar symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"Patient denied vertigo, imbalance, diplopia, dysarthria, dysphagia, or incoordination, with no posterior-circulation features identified.","frag":"no posterior-circulation symptoms"}]},{"id":"ha-hx-cvst-pregnancy","dx":"cvst-ha","q":"Pregnancy or postpartum status — currently pregnant or within 6 weeks of delivery, a state raising concern for cerebral venous thrombosis, preeclampsia, or PRES rather than benign headache?","answers":[{"label":"Pregnant or peripartum","tone":"pos","sets":[],"ddx":[],"mdm":"Patient was pregnant or within the peripartum period, a recognized red flag prompting evaluation for cerebral venous sinus thrombosis, preeclampsia, and posterior reversible encephalopathy rather than attribution to primary headache.","frag":"pregnant/peripartum"},{"label":"Not pregnant or peripartum","tone":"neg","sets":[],"ddx":[],"mdm":"Patient was neither pregnant nor recently postpartum, removing the peripartum-specific secondary-headache risks from immediate consideration.","frag":"not peripartum"}],"sex":"f"},{"id":"ha-hx-co-cohabitant","dx":"co-ha","q":"Carbon monoxide clustering — do cohabitants, coworkers, or pets have simultaneous headache or flu-like symptoms, with improvement away from the building?","answers":[{"label":"Shared symptoms / improves away","tone":"pos","sets":[],"ddx":[],"mdm":"Patient reported that cohabitants or pets had concurrent headache or flu-like symptoms that improved away from the dwelling, a pattern suggesting carbon monoxide exposure and prompting a carboxyhemoglobin level.","frag":"shared/positional CO symptoms"},{"label":"Isolated, no positional pattern","tone":"neg","sets":[],"ddx":[],"mdm":"Patient's symptoms were isolated to the individual without a household cluster or improvement away from the dwelling, lowering suspicion for carbon monoxide exposure.","frag":"no CO clustering"}]}],"exam":[{"id":"ha-exam-vitals","dx":"general","q":"Vital signs — blood pressure, heart rate, temperature, and pulse oximetry; noting that standard SpO2 reads normal in carbon monoxide poisoning and that markedly elevated BP may signal hypertensive emergency, preeclampsia, or elevated ICP?","answers":[{"label":"Vital signs stable, afebrile, normotensive","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable and within normal limits: the patient was afebrile, normotensive, and with a normal heart rate and oxygen saturation.","frag":"afebrile, normotensive, normal SpO2"},{"label":"Hypertensive emergency (SBP > 180/DBP > 120 with symptoms)","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true}],"mdm":"Blood pressure was severely elevated (SBP > 180 / DBP > 120) with end-organ symptoms; hypertensive emergency with intracranial hemorrhage or hypertensive encephalopathy was considered.","frag":"hypertensive emergency with end-organ symptoms"},{"label":"Fever","tone":"pos","sets":[],"ddx":[{"id":"meningitis","keep":true}],"mdm":"Fever was present on vital signs, elevating concern for a CNS infectious process alongside the headache.","frag":"febrile"}]},{"id":"ha-exam-meningismus","dx":"meningitis","q":"Meningismus — nuchal rigidity, Kernig sign (inability to extend knee with hip flexed), or Brudzinski sign (hip flexion on neck flexion)?","answers":[{"label":"Neck supple, Kernig and Brudzinski signs negative","tone":"neg","sets":[],"ddx":[],"mdm":"The neck was supple without Kernig or Brudzinski signs, noting these signs are insensitive (nuchal rigidity ~30%, Kernig/Brudzinski ~5%), so their absence was not used alone to exclude meningitis; mentation, the overall clinical picture, and the lumbar-puncture threshold carried the decision.","frag":"neck supple, no meningismus (insensitive signs, not relied on alone)"},{"label":"Nuchal rigidity or positive Kernig/Brudzinski","tone":"pos","sets":[],"ddx":[{"id":"meningitis","keep":true},{"id":"sah","keep":true}],"mdm":"Meningismus was present (nuchal rigidity or a positive Kernig or Brudzinski sign was elicited), raising strong concern for subarachnoid hemorrhage or CNS infection.","frag":"nuchal rigidity or positive Kernig/Brudzinski"}]},{"id":"ha-exam-neuro-focal","dx":"stroke","q":"Focal neurologic deficits — motor weakness, facial droop, speech difficulty (aphasia/dysarthria), or limb ataxia?","answers":[{"label":"Neurologic exam non-focal — strength, speech, cranial nerves intact","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal; motor strength, speech, and cranial nerve function were intact bilaterally.","frag":"non-focal neuro exam"},{"label":"Focal deficit — weakness, aphasia, facial droop, or ataxia","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true},{"id":"mass","keep":true}],"mdm":"A focal neurologic deficit was identified on examination, including unilateral weakness, aphasia, facial droop, or limb ataxia, requiring urgent neuroimaging to evaluate for stroke or intracranial mass.","frag":"focal deficit on exam"}]},{"id":"ha-exam-papilledema","dx":"mass","q":"Fundoscopic examination — papilledema (blurred disc margins, disc edema), or visual field defect on confrontation testing?","answers":[{"label":"No papilledema, visual fields full to confrontation","tone":"neg","sets":[],"ddx":[],"mdm":"Fundoscopic examination did not reveal papilledema; optic disc margins were sharp and visual fields were full to confrontation.","frag":"no papilledema, full visual fields"},{"label":"Papilledema or visual field defect","tone":"pos","sets":[],"ddx":[{"id":"mass","keep":true}],"mdm":"Papilledema or a visual field deficit was identified on fundoscopic or confrontation examination, raising concern for elevated intracranial pressure from a mass lesion, venous sinus thrombosis, or other process.","frag":"papilledema or visual field defect"}]},{"id":"ha-exam-temporal-artery","dx":"gca","q":"Temporal artery tenderness, nodularity, or absent/reduced pulsation on palpation bilaterally?","answers":[{"label":"Temporal arteries non-tender, no nodularity, pulsatile","tone":"neg","sets":[],"ddx":[],"mdm":"The temporal arteries were non-tender and without nodularity or reduced pulsation bilaterally. Because a normal temporal artery examination does not exclude giant cell arteritis, inflammatory markers and the clinical picture carried the decision when suspicion existed.","frag":"temporal arteries non-tender with normal pulsation (a normal exam does not exclude GCA, so ESR/CRP and the picture carried the decision)"},{"label":"Temporal artery tenderness, nodularity, or absent pulse","tone":"pos","sets":[],"ddx":[{"id":"gca","keep":true}],"mdm":"Temporal artery tenderness, palpable nodularity, or absent pulsation was found on examination: physical findings with strong specificity for giant cell arteritis requiring urgent inflammatory markers and specialist input.","frag":"temporal artery tenderness, nodularity, or absent pulse"}]},{"id":"ha-exam-gait","dx":"stroke","q":"Cerebellar and gait testing — tandem gait, truncal stability, finger-nose and rapid alternating movements; isolated truncal ataxia or inability to stand can be the only sign of posterior-circulation stroke?","answers":[{"label":"Normal gait, no cerebellar signs","tone":"neg","sets":[],"ddx":[],"mdm":"Gait was assessed and was normal; tandem gait was intact and no truncal ataxia or cerebellar signs were observed.","frag":"normal gait, no cerebellar signs"},{"label":"Ataxia or cerebellar signs present","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true},{"id":"mass","keep":true}],"mdm":"Gait ataxia or cerebellar signs on finger-nose or rapid alternating movement testing were present, raising concern for a posterior-fossa stroke, mass, or other structural process.","frag":"ataxia or cerebellar signs"}]},{"id":"ha-exam-co-cooximetry","dx":"co-ha","q":"Carbon monoxide assessment — was a carboxyhemoglobin level obtained by blood co-oximetry rather than relying on standard pulse oximetry, which reads falsely normal in CO poisoning?","answers":[{"label":"Elevated COHb on co-oximetry","tone":"pos","sets":[],"ddx":[],"mdm":"Blood co-oximetry demonstrated an elevated carboxyhemoglobin level despite a normal pulse-oximetry reading, confirming carbon monoxide exposure as a cause of the headache.","frag":"elevated COHb"},{"label":"COHb normal / not indicated","tone":"neg","sets":[],"ddx":[],"mdm":"Carboxyhemoglobin by co-oximetry was normal or the exposure history did not support testing, making carbon monoxide poisoning unlikely; standard pulse oximetry alone was noted to be unreliable for this diagnosis.","frag":"COHb normal"}]},{"id":"ha-exam-hints-central","dx":"stroke","q":"Acute vestibular syndrome exam — in continuous vertigo, does the HINTS battery (head impulse, nystagmus direction, test of skew) show any central feature, or is there truncal instability?","answers":[{"label":"Central HINTS or truncal instability","tone":"pos","sets":[],"ddx":[],"mdm":"Exam of the acutely dizzy patient revealed a central HINTS pattern or inability to sit or stand unassisted, findings more sensitive than early CT for posterior-circulation stroke and prompting MRI and neurology involvement.","frag":"central HINTS"},{"label":"Peripheral HINTS, stable gait","tone":"neg","sets":[],"ddx":[],"mdm":"In continuous vertigo the HINTS battery showed a peripheral pattern with an abnormal head-impulse test, unidirectional nystagmus, absent skew, and preserved gait. This was interpreted noting HINTS is validated only in acute vestibular syndrome and in trained hands, and it was not used alone to exclude posterior stroke.","frag":"HINTS peripheral pattern (valid only in acute vestibular syndrome and in trained hands, so not used alone to exclude posterior stroke)"}]},{"id":"ha-exam-gca-afferent","dx":"gca-ha","q":"Visual and pupillary exam for giant cell arteritis — reduced acuity, a relative afferent pupillary defect, or a pale/swollen optic disc in a patient over 50 with new headache?","answers":[{"label":"RAPD, vision loss, or disc pallor","tone":"pos","sets":[],"ddx":[],"mdm":"Exam showed reduced acuity, a relative afferent pupillary defect, or optic disc pallor or edema in a patient over 50, raising concern for ischemic optic neuropathy from giant cell arteritis and prompting urgent ESR and CRP.","frag":"RAPD/disc pallor"},{"label":"Vision and pupils normal","tone":"neg","sets":[],"ddx":[],"mdm":"Visual acuity, pupillary responses, and optic discs were normal, with no afferent defect to suggest giant cell arteritis-related optic ischemia.","frag":"normal vision/pupils"}]}],"conclusions":["benign primary headache","migraine","tension-type headache"],"specs":["neuro"],"algorithm":{"immediate":["Vitals including blood pressure and a fingerstick glucose; focused neurologic exam.","If thunderclap, focal deficit, altered mentation, or fever with meningismus: expedite imaging and treatment for the can’t-miss causes below."],"criticalTests":["Non-contrast head CT for thunderclap or focal/abnormal exam","Lumbar puncture when SAH is suspected and CT is non-diagnostic (or for suspected CNS infection)","ESR/CRP when giant cell arteritis is considered","Carboxyhemoglobin when carbon monoxide exposure is plausible"],"cantMiss":[{"dx":"sah","trigger":"Thunderclap or maximal-at-onset headache","test":"Non-contrast head CT (highest yield early); LP or CT angiography if non-diagnostic","intervention":"Blood-pressure control, neurosurgery consultation, reverse coagulopathy"},{"dx":"meningitis","trigger":"Fever, meningismus, or altered mentation","test":"Lumbar puncture (do not delay antibiotics for it)","intervention":"Early empiric antibiotics ± acyclovir; dexamethasone where indicated"},{"dx":"stroke","trigger":"Focal neurologic deficit","test":"Emergent non-contrast CT ± CT angiography","intervention":"Stroke pathway; reverse anticoagulation for hemorrhage"},{"dx":"gca-ha","trigger":"Age ≥50 with new temporal headache, jaw claudication, or visual symptoms","test":"ESR/CRP; temporal artery biopsy to confirm","intervention":"High-dose corticosteroids promptly to protect vision"},{"dx":"co-ha","trigger":"Exposure source or co-affected cohabitants","test":"Carboxyhemoglobin level","intervention":"High-flow or hyperbaric oxygen"}],"disposition":"A benign primary-headache pattern with a normal exam and reassuring red-flag screen may be discharged after symptom control; any can’t-miss feature mandates the matching workup before disposition."},"decisionTree":{"title":"Headache — red-flag triage","intro":"An original, evidence-based decision aid for headache. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Assess & screen for red flags","items":["Vitals, neuro exam, fundoscopy","Ask: thunderclap onset, fever, immunocompromise, anticoagulation, age >50 with new headache, pregnancy/postpartum"],"next":"q_thunder"},"q_thunder":{"type":"decision","q":"Thunderclap (maximal at onset) or worst-ever headache?","yes":"a_sah","no":"q_infx","cantmiss":"Thunderclap headache → urgent non-contrast CT; if non-diagnostic and within the window, LP (xanthochromia) or CTA for SAH."},"a_sah":{"type":"action","title":"Rule out SAH / vascular cause","items":["Non-contrast head CT now","If non-diagnostic: LP for xanthochromia, or CTA","Consider CVST (CT/MR venography) in the right context"],"tone":"danger","terminal":true},"q_infx":{"type":"decision","q":"Fever, neck stiffness, or immunocompromise?","yes":"a_meningitis","no":"q_focal"},"a_meningitis":{"type":"action","title":"Suspect CNS infection","items":["Empiric antibiotics ± antivirals and steroids without delay","Blood cultures","LP (CT first if focal deficit, immunocompromise, or papilledema)"],"tone":"danger","terminal":true},"q_focal":{"type":"decision","q":"Focal deficit, papilledema, or other red flag (age >50 new headache, anticoagulation, cancer, pregnancy/postpartum)?","yes":"a_workup","no":"a_primary","pitfall":"GCA in >50 (ESR/CRP, start steroids), CO poisoning, CVST (postpartum/thrombophilia), and mass lesions hide here."},"a_workup":{"type":"action","title":"Neuroimaging & targeted workup","items":["CT/MRI as indicated","ESR/CRP and steroids for suspected GCA; carboxyhemoglobin for CO; MRV for CVST","BP management for hypertensive emergency"],"tone":"danger","terminal":true},"a_primary":{"type":"action","title":"Likely primary headache","items":["Treat (e.g., migraine therapy); avoid opioids","Observe response","Discharge with return precautions and follow-up"],"tone":"branch","terminal":true}}},"guide":"../learn/complaints/headache.html","pearls":[{"text":"A non-contrast head CT within 6 hours of a thunderclap headache, read competently, effectively excludes SAH; beyond 6 hours sensitivity falls and you need an LP (xanthochromia) or CTA.","dx":"sah","src":"Perry, BMJ 2011"},{"text":"Thunderclap means maximal intensity within seconds to a minute — that instantaneous peak, not just 'worst of life,' is the feature that drives the SAH workup, along with exertional or sudden onset.","dx":"sah"},{"text":"Do not delay antibiotics for CT or LP in suspected bacterial meningitis — give them first. The classic triad of fever, neck stiffness, and altered mental status is present in under half of cases.","dx":"meningitis"},{"text":"New headache over age 50: ask about jaw claudication, scalp tenderness, and visual symptoms and check ESR/CRP. Start high-dose steroids on suspicion to save vision — do not wait for temporal artery biopsy.","dx":"gca"},{"text":"Consider carbon monoxide when headache is worse indoors, seasonal with heating, or shared by cohabitants or pets. Pulse oximetry reads normal — you need a co-oximetry carboxyhemoglobin level.","dx":"co-ha"},{"text":"Cerebral venous sinus thrombosis hides as a progressive headache in a hypercoagulable patient (pregnancy/postpartum, OCPs); a normal non-contrast CT does not exclude it — get CT or MR venography.","dx":"cvst-ha"}]},{"id":"dyspnea","title":"Dyspnea","aliases":["sob","shortness of breath","dyspnea","cant breathe","can't breathe","trouble breathing","copd","chf","pe","winded","wheezing","hypoxia"],"opening":"The patient was evaluated for shortness of breath. A focused cardiopulmonary history and examination were performed, and the diagnoses below were actively considered.","ddx":[{"id":"pe-d","group":"lifethreat","label":"Pulmonary embolism","default":true,"tags":["pe"],"ruleout":"Pulmonary embolism was considered; there was no pleuritic pain, hemoptysis, or unilateral leg swelling, no immobilization, surgery, malignancy, or prior VTE, and the patient was not tachycardic or hypoxic, placing pretest probability low.","miss":4},{"id":"acs-d","group":"lifethreat","label":"Acute coronary syndrome / heart failure","default":true,"tags":["acs"],"ruleout":"A cardiac cause including acute coronary syndrome and decompensated heart failure was considered; there was no chest pain, orthopnea, paroxysmal nocturnal dyspnea, or edema, the ECG showed no ischemia, lungs were clear, and biomarkers were not elevated, making it unlikely.","miss":4},{"id":"tension","group":"lifethreat","label":"Tension pneumothorax","default":false,"tags":[],"ruleout":"Tension pneumothorax was considered; breath sounds were symmetric without hyperresonance, the trachea was midline, the patient was hemodynamically stable without distended neck veins, and there was no respiratory distress, making it unlikely.","miss":4},{"id":"airway","group":"lifethreat","label":"Upper-airway / anaphylaxis","default":false,"tags":[],"ruleout":"An upper-airway process including angioedema and anaphylaxis was considered; there was no stridor, voice change, lip or tongue swelling, urticaria, or drooling, and the airway was patent, making it unlikely.","miss":4},{"id":"sepsis-dyspnea","group":"lifethreat","label":"Sepsis / pneumonia","default":false,"tags":["sepsis-dyspnea"],"ruleout":"Sepsis or severe pneumonia was considered; the patient was afebrile and hemodynamically stable, lungs were clear without focal findings, and there was no productive cough or hypoxia, making it unlikely.","miss":3},{"id":"pna-d","group":"common","label":"Pneumonia","default":false,"tags":[],"ruleout":"Pneumonia was considered and evaluated with examination and imaging as appropriate.","miss":2},{"id":"copd","group":"common","label":"COPD / asthma exacerbation","default":false,"tags":[],"ruleout":"An obstructive airway exacerbation was considered and treated and reassessed accordingly.","miss":2},{"id":"anemia","group":"other","label":"Anemia / metabolic","default":false,"tags":[],"ruleout":"A non-pulmonary contributor such as anemia or a metabolic disturbance was considered and evaluated with laboratory studies as indicated.","miss":1}],"risk":[{"id":"wells-d","label":"Wells score (PE)","tags":["pe"],"scale":"low","line":"Pretest probability for pulmonary embolism was assessed and was low.","cite":"Wells PS, et al. Thromb Haemost. 2000.","calc":{"fields":[{"label":"Signs of DVT","opts":[["No",0],["Yes",3]]},{"label":"PE most likely","opts":[["No",0],["Yes",3]]},{"label":"HR > 100","opts":[["No",0],["Yes",1.5]]},{"label":"Immobil./surgery","opts":[["No",0],["Yes",1.5]]},{"label":"Prior PE/DVT","opts":[["No",0],["Yes",1.5]]},{"label":"Hemoptysis","opts":[["No",0],["Yes",1]]},{"label":"Malignancy","opts":[["No",0],["Yes",1]]}],"bands":[[4,"PE unlikely","low","PE unlikely: apply PERC, or an (age-adjusted) D-dimer, rather than going straight to CT angiography."],[12.5,"PE likely","high","PE likely: proceed to CT pulmonary angiography — D-dimer cannot exclude in this group."]],"line":"Wells score for PE = {score} ({band}); used with d-dimer and clinical judgment to guide imaging.","applies":"Adults with a suspected first lower-limb DVT, to set pre-test probability before D-dimer or ultrasound. Less reliable with prior DVT; not for suspected PE."},"short":"Wells {band}","bandNotes":{"pe unlikely":"with a negative D-dimer, 3-month VTE risk ≈0.5% (Christopher study)"}},{"id":"sat","label":"Oxygen saturation / work of breathing","tags":[],"scale":"low","line":"Oxygen saturation and work of breathing were assessed and documented, and were reassuring after evaluation.","short":"oxygenation and work of breathing reassuring"},{"id":"ecg-d","label":"ECG reviewed","tags":["acs"],"scale":"low","line":"The ECG was personally reviewed and showed no acute ischemic changes.","short":"ECG non-ischemic"},{"id":"perc","label":"PERC rule (PE)","tags":["pe"],"scale":"low","line":"The PERC rule was applied in this low-probability patient.","cite":"Kline JA, et al. J Thromb Haemost. 2004.","calc":{"fields":[{"label":"Age ≥ 50","opts":[["No",0],["Yes",1]]},{"label":"HR ≥ 100","opts":[["No",0],["Yes",1]]},{"label":"SaO₂ < 95%","opts":[["No",0],["Yes",1]]},{"label":"Unilat. leg swelling","opts":[["No",0],["Yes",1]]},{"label":"Hemoptysis","opts":[["No",0],["Yes",1]]},{"label":"Recent surgery/trauma","opts":[["No",0],["Yes",1]]},{"label":"Prior PE/DVT","opts":[["No",0],["Yes",1]]},{"label":"Estrogen use","opts":[["No",0],["Yes",1]]}],"bands":[[0,"PERC negative — no criteria met","low","Low pretest probability and PERC-negative: PE can be excluded without D-dimer or imaging."],[8,"PERC positive","high","Does not diagnose PE — continue with D-dimer or imaging per pretest probability."]],"line":"PERC rule applied: {score} of 8 criteria present ({band}).","applies":"Low-risk adults (gestalt PE risk under ~15%) being considered to avoid any PE testing. Only valid when pre-test probability is already low -- not for moderate/high suspicion or in pregnancy."},"short":"PERC {band}","bandNotes":{"negative":"with low pretest probability, missed-PE rate <2% in validation (Kline 2008)"}}],"checks":[{"if":"pe-d","needs":["wells-d","perc"],"mode":"any","warn":"PE is on the differential — a documented pretest-probability rule (Wells, plus PERC in low-probability patients) shows why d-dimer or imaging was or wasn't pursued."}],"history":[{"id":"dysp-hx-pe-pleuritic","dx":"pe-d","q":"Pleuritic chest pain — sharp pain worse with inspiration or coughing, suggesting pulmonary infarct?","answers":[{"label":"No pleuritic pain","tone":"neg","sets":[],"ddx":[],"mdm":"No pleuritic chest pain (sharp pain worse with inspiration or coughing) was reported; a pulmonary infarct pattern was not suggested by history.","frag":"no pleuritic chest pain"},{"label":"Pleuritic chest pain present","tone":"pos","sets":[],"ddx":[{"id":"pe-d","keep":true}],"mdm":"Pleuritic chest pain (sharp pain worse with inspiration or coughing) was reported, raising concern for pulmonary embolism with associated infarction.","frag":"pleuritic chest pain"}]},{"id":"dysp-hx-pe-syncope","dx":"pe-d","q":"Syncope or near-syncope coinciding with the onset of dyspnea?","answers":[{"label":"No syncope","tone":"neg","sets":[],"ddx":[],"mdm":"No syncope or near-syncope was associated with the dyspnea.","frag":"no syncope or near-syncope"},{"label":"Syncope with dyspnea","tone":"pos","sets":[],"ddx":[{"id":"pe-d","keep":true}],"mdm":"Syncope coincided with the onset of dyspnea, a high-risk feature associated with massive or sub-massive pulmonary embolism causing acute right-heart strain.","frag":"syncope with dyspnea onset"}]},{"id":"dysp-hx-hemoptysis","dx":"pe-d","q":"Hemoptysis — any blood-tinged or frank bloody sputum?","answers":[{"label":"No hemoptysis","tone":"neg","sets":[{"risk":"wells-d","field":5,"opt":0}],"ddx":[],"mdm":"No hemoptysis was reported.","frag":"no hemoptysis"},{"label":"Hemoptysis present","tone":"pos","sets":[{"risk":"wells-d","field":5,"opt":1}],"ddx":[{"id":"pe-d","keep":true}],"mdm":"Hemoptysis was reported, a Wells criterion that raises the pretest probability of pulmonary embolism.","frag":"hemoptysis"}]},{"id":"dysp-hx-immobil","dx":"pe-d","q":"PE provoking factor in the past 4 weeks — surgery, trauma, immobilization ≥3 days, long-haul travel, pregnancy/postpartum, or estrogen/hormone use?","answers":[{"label":"No recent surgery or immobilization","tone":"neg","sets":[{"risk":"wells-d","field":3,"opt":0}],"ddx":[],"mdm":"No recent surgery, trauma, or prolonged immobilization was reported.","frag":"no recent surgery or immobilization"},{"label":"Recent surgery or immobilization","tone":"pos","sets":[{"risk":"wells-d","field":3,"opt":1}],"ddx":[{"id":"pe-d","keep":true}],"mdm":"Recent surgery or prolonged immobilization was reported, a Wells criterion that increases pretest probability for pulmonary embolism.","frag":"recent surgery or immobilization"}]},{"id":"dysp-hx-priorvte","dx":"pe-d","q":"Prior DVT or pulmonary embolism?","answers":[{"label":"No prior VTE","tone":"neg","sets":[{"risk":"wells-d","field":4,"opt":0}],"ddx":[],"mdm":"No history of prior venous thromboembolism was reported.","frag":"no prior VTE"},{"label":"Prior DVT or PE","tone":"pos","sets":[{"risk":"wells-d","field":4,"opt":1}],"ddx":[{"id":"pe-d","keep":true}],"mdm":"A prior deep-vein thrombosis or pulmonary embolism was reported, a Wells criterion associated with substantially increased risk of recurrent VTE.","frag":"prior DVT or PE"}]},{"id":"dysp-hx-malignancy","dx":"pe-d","q":"Active malignancy — currently receiving treatment, treated within 6 months, or palliative?","answers":[{"label":"No active malignancy","tone":"neg","sets":[{"risk":"wells-d","field":6,"opt":0}],"ddx":[],"mdm":"No active malignancy (current treatment, treatment within 6 months, or palliative disease) was identified.","frag":"no active malignancy"},{"label":"Active malignancy","tone":"pos","sets":[{"risk":"wells-d","field":6,"opt":1}],"ddx":[{"id":"pe-d","keep":true}],"mdm":"An active malignancy (under current treatment, treated within 6 months, or palliative) was present, a hypercoagulable state that is a Wells criterion and substantially raises the risk of pulmonary embolism.","frag":"active malignancy"}]},{"id":"dysp-hx-acs-chest-pain","dx":"acs-d","q":"Ischemic-type chest pain or pressure — exertional, radiating to arm/jaw, with diaphoresis OR an anginal equivalent (isolated dyspnea, nausea, fatigue) in a diabetic, elderly, or female patient?","answers":[{"label":"No ischemic chest pain","tone":"neg","sets":[],"ddx":[],"mdm":"No ischemic chest pain or pressure (exertional, radiating to the arm or jaw, or with diaphoresis) was reported; an acute coronary syndrome presentation was not suggested by history.","frag":"no ischemic chest pain, radiation, or diaphoresis"},{"label":"Ischemic-type chest pain","tone":"pos","sets":[],"ddx":[{"id":"acs-d","keep":true}],"mdm":"Ischemic-type chest pain or pressure (exertional, radiating to the arm or jaw, or with diaphoresis) was reported alongside the dyspnea, raising concern for an acute coronary syndrome as the primary etiology.","frag":"ischemic-type pain with radiation or diaphoresis"}]},{"id":"dysp-hx-orthopnea-pnd","dx":"acs-d","q":"Orthopnea (unable to lie flat) or paroxysmal nocturnal dyspnea? Bilateral lower-extremity edema?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"No orthopnea, paroxysmal nocturnal dyspnea, or bilateral leg swelling was reported; features of decompensated heart failure were absent by history.","frag":"no orthopnea, PND, or bilateral leg swelling"},{"label":"Orthopnea, PND, or bilateral edema","tone":"pos","sets":[],"ddx":[{"id":"acs-d","keep":true}],"mdm":"Orthopnea, paroxysmal nocturnal dyspnea, or bilateral leg edema was reported, raising concern for decompensated heart failure as the cause of dyspnea.","frag":"orthopnea, PND, or bilateral edema"}]},{"id":"dysp-hx-cad-chf-hx","dx":"acs-d","q":"Known CAD, prior MI, prior revascularization, or established heart failure with reduced ejection fraction?","answers":[{"label":"No prior CAD or CHF","tone":"neg","sets":[],"ddx":[],"mdm":"No prior coronary artery disease, myocardial infarction, revascularization, or known heart failure was reported.","frag":"no prior CAD or heart failure"},{"label":"Known CAD or CHF","tone":"pos","sets":[],"ddx":[{"id":"acs-d","keep":true}],"mdm":"A history of coronary artery disease, prior myocardial infarction, revascularization, or established heart failure was present, substantially raising concern for an ACS or decompensated heart failure presentation.","frag":"known CAD or heart failure"}]},{"id":"dysp-hx-ptx-pain","dx":"tension","q":"Sudden-onset pleuritic chest pain with dyspnea — abrupt, not preceded by exertion?","answers":[{"label":"No sudden pleuritic onset","tone":"neg","sets":[],"ddx":[],"mdm":"No sudden-onset pleuritic chest pain was reported; a spontaneous pneumothorax presentation was not indicated by history.","frag":"no sudden pleuritic onset"},{"label":"Sudden pleuritic pain and dyspnea","tone":"pos","sets":[],"ddx":[{"id":"tension","keep":true}],"mdm":"Sudden-onset pleuritic chest pain with dyspnea was reported, a characteristic presentation of spontaneous or tension pneumothorax.","frag":"sudden pleuritic pain with dyspnea"}]},{"id":"dysp-hx-ptx-risk","dx":"tension","q":"Tall thin habitus, known bullous emphysema (blebs), prior pneumothorax, or recent thoracic procedure or trauma?","answers":[{"label":"No pneumothorax risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No risk factors for spontaneous or traumatic pneumothorax were identified by history.","frag":"no pneumothorax risk factors"},{"label":"Pneumothorax risk factor present","tone":"pos","sets":[],"ddx":[{"id":"tension","keep":true}],"mdm":"A risk factor for pneumothorax was identified (tall thin habitus, known bullous disease, prior pneumothorax, or recent procedure), increasing the pretest probability of this diagnosis.","frag":"pneumothorax risk factor present"}]},{"id":"dysp-hx-allergen","dx":"airway","q":"Allergen or food exposure, insect sting, or new medication immediately preceding dyspnea onset?","answers":[{"label":"No allergen exposure","tone":"neg","sets":[],"ddx":[],"mdm":"No precipitating allergen, food, insect sting, or new medication was identified; anaphylaxis was not suggested by the exposure history.","frag":"no allergen, sting, or new-medication exposure"},{"label":"Allergen or sting exposure","tone":"pos","sets":[],"ddx":[{"id":"airway","keep":true}],"mdm":"An allergen, food, insect sting, or new medication immediately preceded the onset of dyspnea; anaphylaxis with potential airway compromise was placed high on the differential.","frag":"allergen, sting, or new-medication exposure"}]},{"id":"dysp-hx-angioedema","dx":"airway","q":"Lip, tongue, or throat swelling, voice change (hoarseness/muffling), stridor, or drooling?","answers":[{"label":"No oropharyngeal swelling or voice change","tone":"neg","sets":[],"ddx":[],"mdm":"No lip, tongue, or oropharyngeal swelling, voice change, stridor, or drooling was reported; upper-airway compromise was not indicated by history.","frag":"no oropharyngeal swelling, voice change, stridor, or drooling"},{"label":"Oropharyngeal swelling or voice change","tone":"pos","sets":[],"ddx":[{"id":"airway","keep":true}],"mdm":"Lip, tongue, or throat swelling or a voice change was reported, indicating potential upper-airway angioedema or anaphylaxis with impending airway compromise.","frag":"oropharyngeal swelling or voice change"}]},{"id":"dysp-hx-fever-cough","dx":"pna-d","q":"Fever, chills, or productive cough with purulent or discolored sputum?","answers":[{"label":"No fever or productive cough","tone":"neg","sets":[],"ddx":[],"mdm":"No fever, chills, or productive cough was reported; an infectious pulmonary source was not suggested by history.","frag":"no fever or productive cough"},{"label":"Fever and/or productive cough","tone":"pos","sets":[],"ddx":[{"id":"pna-d","keep":true}],"mdm":"Fever and productive cough were reported, raising concern for pneumonia as the etiology of the dyspnea.","frag":"fever and productive cough"}]},{"id":"dysp-hx-copd-hx","dx":"copd","q":"Known COPD or asthma, prior similar exacerbations requiring bronchodilators or steroids, or significant smoking history?","answers":[{"label":"No obstructive lung disease history","tone":"neg","sets":[],"ddx":[],"mdm":"No history of COPD, asthma, prior exacerbations, or significant obstructive lung disease was reported.","frag":"no COPD, asthma, or obstructive lung disease"},{"label":"Known COPD or asthma with exacerbations","tone":"pos","sets":[],"ddx":[{"id":"copd","keep":true}],"mdm":"A known obstructive lung disease with prior exacerbations was identified, supporting an acute COPD or asthma exacerbation as a primary or contributing cause of dyspnea.","frag":"known COPD or asthma with prior exacerbations"}]},{"id":"dysp-hx-wheeze-trigger","dx":"copd","q":"Wheeze, known trigger exposure (allergen, smoke, cold air, URI), or medication non-adherence?","answers":[{"label":"No wheeze or trigger","tone":"neg","sets":[],"ddx":[],"mdm":"No wheeze and no identifiable trigger or medication non-adherence was reported.","frag":"no wheeze or identifiable trigger"},{"label":"Wheeze or trigger identified","tone":"pos","sets":[],"ddx":[{"id":"copd","keep":true}],"mdm":"Wheeze or a specific exacerbating trigger was identified, consistent with an acute obstructive airway exacerbation.","frag":"wheeze or exacerbating trigger"}]},{"id":"dysp-hx-bleeding","dx":"anemia","q":"Active bleeding, melena, hematemesis, or recent blood loss — GI, gynecologic, or traumatic?","answers":[{"label":"No bleeding or blood loss","tone":"neg","sets":[],"ddx":[],"mdm":"No active bleeding, melena, hematemesis, or recent blood loss was reported; anemia from acute hemorrhage was not suggested by history.","frag":"no bleeding or recent blood loss"},{"label":"Bleeding or blood loss present","tone":"pos","sets":[],"ddx":[{"id":"anemia","keep":true}],"mdm":"Active or recent bleeding was reported; acute hemorrhagic anemia causing dyspnea was considered.","frag":"active or recent bleeding"}]},{"id":"dysp-hx-fatigue-exertional","dx":"anemia","q":"Progressive exertional dyspnea, fatigue, or pallor out of proportion to acute illness — suggesting chronic anemia?","answers":[{"label":"No exertional fatigue or pallor","tone":"neg","sets":[],"ddx":[],"mdm":"No progressive exertional fatigue, dyspnea on exertion out of proportion, or pallor was reported; chronic anemia was not suggested by history.","frag":"no progressive exertional fatigue or pallor"},{"label":"Exertional dyspnea, fatigue, or pallor","tone":"pos","sets":[],"ddx":[{"id":"anemia","keep":true}],"mdm":"Progressive exertional dyspnea, fatigue, or pallor was reported, raising concern for anemia as a contributing or primary cause of dyspnea.","frag":"progressive exertional dyspnea, fatigue, or pallor"}]},{"id":"dysp-hx-pe-estrogen","dx":"pe-d","q":"Estrogen exposure — combined oral contraceptive, hormone replacement, recent IVF, current pregnancy, or postpartum within 6 weeks?","answers":[{"label":"No estrogen/hormonal exposure","tone":"neg","sets":[],"ddx":[],"mdm":"Patient denied estrogen-containing contraception, hormone therapy, pregnancy, and recent postpartum status, removing this PERC and Wells risk factor for venous thromboembolism.","frag":"no estrogen/pregnancy exposure"},{"label":"Estrogen/pregnancy exposure","tone":"pos","sets":[],"ddx":[],"mdm":"Patient reported a hormonal/pregnancy-related prothrombotic state (estrogen use, pregnancy, or postpartum), a PERC-positive criterion raising pretest probability for pulmonary embolism.","frag":"estrogen/pregnancy prothrombotic state"}]},{"id":"dysp-hx-pe-pretest","dx":"pe-d","q":"PE pretest probability formally assessed — clinical gestalt plus a structured tool (Wells/Geneva) and PERC applied before deciding on testing?","answers":[{"label":"Pretest probability stratified","tone":"pos","sets":[],"ddx":[],"mdm":"Pulmonary embolism pretest probability was explicitly risk-stratified using clinical gestalt with a structured score, and PERC was applied where appropriate to guide rational testing.","frag":"PE pretest probability stratified"},{"label":"Not risk-stratified","tone":"neg","sets":[],"ddx":[],"mdm":"Pulmonary embolism pretest probability was not formally estimated; documented clinical gestalt was low and no structured score or PERC was applied.","frag":"PE pretest probability not formalized"}]},{"id":"dysp-hx-acs-equivalent","dx":"acs-d","q":"Anginal-equivalent screen — isolated exertional dyspnea, unexplained fatigue, nausea, or diaphoresis without chest pain in a diabetic, elderly, or female patient?","answers":[{"label":"No anginal equivalent","tone":"neg","sets":[],"ddx":[],"mdm":"Patient denied dyspnea on exertion, unexplained fatigue, nausea, or diaphoresis as an isolated complaint, lowering concern for a painless anginal-equivalent acute coronary syndrome.","frag":"no anginal-equivalent symptoms"},{"label":"Anginal equivalent present","tone":"pos","sets":[],"ddx":[],"mdm":"Patient described an anginal-equivalent presentation (isolated dyspnea, fatigue, nausea, or diaphoresis) in a higher-risk diabetic/elderly/female profile, raising concern for painless acute coronary syndrome.","frag":"anginal-equivalent ACS pattern"}]}],"exam":[{"id":"dysp-exam-wob","dx":"general","q":"Work of breathing — accessory muscle use, tripod positioning, intercostal retractions, or nasal flaring?","answers":[{"label":"No increased work of breathing","tone":"neg","sets":[],"ddx":[],"mdm":"No accessory muscle use, tripod positioning, retractions, or nasal flaring was observed; work of breathing was not increased.","frag":"work of breathing not increased"},{"label":"Increased work of breathing","tone":"pos","sets":[],"ddx":[],"mdm":"Increased work of breathing (accessory muscle use, tripod positioning, intercostal retractions, or nasal flaring) was observed on examination, indicating significant respiratory distress requiring urgent evaluation.","frag":"increased work of breathing"}]},{"id":"dysp-exam-spo2-rr","dx":"general","q":"Full vital set quantified — SpO₂ on room air, respiratory rate, heart rate, and blood pressure? (Note tachycardia ≥100 and SBP extremes, not SpO₂ alone.)","answers":[{"label":"SpO₂ ≥ 95%, RR normal","tone":"neg","sets":[],"ddx":[],"mdm":"Oxygen saturation was 95% or greater on room air and the respiratory rate was within normal limits.","frag":"SpO₂ ≥95% on room air, RR normal"},{"label":"SpO₂ < 95% or tachypnea","tone":"pos","sets":[],"ddx":[],"mdm":"Oxygen saturation below 95% or tachypnea was present, indicating hypoxia or significant respiratory compromise requiring urgent workup.","frag":"hypoxia or tachypnea"}]},{"id":"dysp-exam-leg-dvt","dx":"pe-d","q":"Unilateral calf or leg swelling, erythema, or tenderness on palpation suggesting DVT?","answers":[{"label":"No unilateral leg swelling","tone":"neg","sets":[{"risk":"wells-d","field":0,"opt":0}],"ddx":[],"mdm":"No unilateral leg swelling, erythema, or tenderness suggesting deep-vein thrombosis was identified on examination.","frag":"no unilateral leg swelling or tenderness"},{"label":"Unilateral leg swelling or tenderness","tone":"pos","sets":[{"risk":"wells-d","field":0,"opt":1}],"ddx":[{"id":"pe-d","keep":true}],"mdm":"Unilateral leg swelling or calf tenderness was present on examination, a Wells criterion for DVT that increases the pretest probability of pulmonary embolism.","frag":"unilateral leg swelling or calf tenderness"}]},{"id":"dysp-exam-breath-sounds","dx":"tension","q":"Breath sounds equal bilaterally? Absent or markedly decreased on one side? Trachea midline?","answers":[{"label":"Equal bilaterally, trachea midline","tone":"neg","sets":[],"ddx":[],"mdm":"Breath sounds were equal and clear bilaterally and the trachea was midline; pneumothorax was not supported by examination.","frag":"breath sounds equal, trachea midline"},{"label":"Absent/decreased unilaterally or tracheal deviation","tone":"pos","sets":[],"ddx":[{"id":"tension","keep":true}],"mdm":"Absent or markedly decreased breath sounds unilaterally and/or tracheal deviation was detected on examination, raising urgent concern for tension pneumothorax.","frag":"unilateral absent breath sounds or tracheal deviation"}]},{"id":"dysp-exam-stridor-angioedema","dx":"airway","q":"Stridor on auscultation? Visible lip, tongue, or oropharyngeal swelling (angioedema)?","answers":[{"label":"No stridor, no angioedema","tone":"neg","sets":[],"ddx":[],"mdm":"No stridor was heard and no lip, tongue, or oropharyngeal swelling was visible; upper-airway compromise was absent on examination.","frag":"no stridor or angioedema"},{"label":"Stridor or angioedema present","tone":"pos","sets":[],"ddx":[{"id":"airway","keep":true}],"mdm":"Stridor or visible angioedema was present on examination, indicating imminent upper-airway compromise from anaphylaxis or angioedema.","frag":"stridor or visible angioedema"}]},{"id":"dysp-exam-jvd-edema-s3","dx":"acs-d","q":"Jugular venous distension, bilateral peripheral edema, or S3 gallop on cardiac auscultation?","answers":[{"label":"No JVD, edema, or S3","tone":"neg","sets":[],"ddx":[],"mdm":"No jugular venous distension, bilateral peripheral edema, or S3 gallop was identified; signs of elevated filling pressures or decompensated heart failure were absent on examination.","frag":"no JVD, peripheral edema, or S3"},{"label":"JVD, bilateral edema, or S3 gallop","tone":"pos","sets":[],"ddx":[{"id":"acs-d","keep":true}],"mdm":"Jugular venous distension, bilateral lower-extremity edema, or an S3 gallop was present, consistent with elevated left-sided filling pressures and decompensated heart failure.","frag":"JVD, bilateral edema, or S3 gallop"}]},{"id":"dysp-exam-wheeze-expiration","dx":"copd","q":"Air movement on auscultation — diffuse expiratory wheeze and prolonged expiration, OR a quiet/silent chest with poor air entry signaling severe obstruction?","answers":[{"label":"No wheeze, normal expiration","tone":"neg","sets":[],"ddx":[],"mdm":"No expiratory wheeze and no prolonged expiratory phase were detected; obstructive airway disease was not supported by auscultation.","frag":"no wheeze or prolonged expiration"},{"label":"Diffuse wheeze or prolonged expiration","tone":"pos","sets":[],"ddx":[{"id":"copd","keep":true}],"mdm":"Diffuse expiratory wheeze or a prolonged expiratory phase was present on auscultation, consistent with obstructive airway disease.","frag":"diffuse wheeze or prolonged expiration"}]},{"answers":[{"ddx":[],"frag":"lungs clear, no productive cough or hypoxia, hemodynamically stable (afebrile, but older and immunocompromised patients are often afebrile, so not relied on alone)","label":"No sepsis/pneumonia signs","mdm":"The patient was hemodynamically stable, the lungs were clear without focal findings, and there was no productive cough or hypoxia, making severe pneumonia unlikely. The patient was also afebrile, noting that older and immunocompromised patients with serious infection are often afebrile, so absence of fever was not relied on alone.","sets":[],"tone":"neg"},{"ddx":[{"id":"sepsis-dyspnea","keep":true}],"frag":"fever, focal crackles, or hypoxia","label":"Sepsis/pneumonia signs present","mdm":"Fever, hypoxia, focal crackles, or septic physiology was present, raising concern for sepsis or severe pneumonia and warranting prompt source evaluation.","sets":[],"tone":"pos"}],"dx":"sepsis-dyspnea","id":"dysp-exam-sepsis-dyspnea","q":"Infection signs — fever, hypoxia, focal crackles or consolidation, productive cough, or septic physiology?"},{"id":"dysp-exam-hr-tachy","dx":"pe-d","q":"Heart rate quantified — sustained tachycardia ≥100 unexplained by fever or pain (a PERC criterion and PE severity marker)?","answers":[{"label":"No unexplained tachycardia","tone":"neg","sets":[],"ddx":[],"mdm":"Heart rate was below 100 without unexplained tachycardia, keeping this PERC criterion negative and not raising the pretest probability for pulmonary embolism.","frag":"HR <100, no unexplained tachycardia"},{"label":"Unexplained tachycardia ≥100","tone":"pos","sets":[],"ddx":[],"mdm":"Sustained tachycardia at or above 100 was documented without an alternative explanation, a PERC-positive finding and potential marker of right-heart strain from pulmonary embolism.","frag":"unexplained tachycardia ≥100"}]},{"id":"dysp-exam-silent-chest","dx":"copd","q":"Severe-obstruction warning signs — silent chest with poor air entry, inability to speak full sentences, fatigue, drowsiness, or paradoxical/abdominal breathing?","answers":[{"label":"No silent chest or fatigue","tone":"neg","sets":[],"ddx":[],"mdm":"Patient moved air well with audible breath sounds, spoke in full sentences, and showed no fatigue or paradoxical respiration, arguing against impending respiratory failure.","frag":"good air entry, no fatigue"},{"label":"Silent chest / fatigue","tone":"pos","sets":[],"ddx":[],"mdm":"Examination revealed ominous severe-obstruction signs (silent chest, fragmented speech, fatigue, or paradoxical breathing) indicating impending respiratory failure despite a deceptively quiet auscultation.","frag":"silent chest / impending failure"}]},{"id":"dysp-exam-scape","dx":"acs-d","q":"Flash pulmonary edema phenotype — abrupt severe hypertension (SBP ≥160) with diffuse crackles and marked distress (SCAPE) rather than gradual volume overload?","answers":[{"label":"No hypertensive flash edema","tone":"neg","sets":[],"ddx":[],"mdm":"Blood pressure was not severely elevated and the presentation lacked the abrupt diffuse crackles of sympathetic crashing acute pulmonary edema, favoring a non-SCAPE heart-failure phenotype.","frag":"no SCAPE physiology"},{"label":"SCAPE physiology","tone":"pos","sets":[],"ddx":[],"mdm":"Patient exhibited sympathetic crashing acute pulmonary edema physiology with abrupt severe hypertension, diffuse crackles, and acute respiratory distress reflecting afterload-driven fluid redistribution rather than total-body volume overload.","frag":"SCAPE / flash pulmonary edema"}]},{"id":"dysp-exam-tamponade","dx":"acs-d","q":"Tamponade screen — pulsus paradoxus >10 mmHg, muffled heart sounds, and distended neck veins, especially with malignancy, uremia, or recent cardiac procedure?","answers":[{"label":"No tamponade signs","tone":"neg","sets":[],"ddx":[],"mdm":"No pulsus paradoxus, muffled heart sounds, or jugular venous distension was appreciated. Because the Beck triad and pulsus paradoxus are insensitive for tamponade, their absence was not used alone to exclude it; bedside echocardiography set the threshold when suspicion remained.","frag":"no pulsus paradoxus, muffled sounds, or JVD (insensitive for tamponade, so bedside echo set the threshold)"},{"label":"Tamponade signs present","tone":"pos","sets":[],"ddx":[],"mdm":"Findings suggestive of tamponade were present (pulsus paradoxus, muffled sounds, or distended neck veins), prompting urgent echocardiographic evaluation given the unreliability of the full Beck triad.","frag":"tamponade physiology / pulsus"}]},{"id":"dysp-exam-tension-shock","dx":"tension","q":"Tension physiology — unilateral absent breath sounds with hypotension, severe hypoxia, or distended neck veins (not waiting for late tracheal deviation)?","answers":[{"label":"No tension physiology","tone":"neg","sets":[],"ddx":[],"mdm":"Breath sounds were preserved without accompanying hypotension, severe hypoxia, or neck-vein distension, arguing against tension pneumothorax requiring immediate decompression.","frag":"no tension physiology"},{"label":"Tension physiology present","tone":"pos","sets":[],"ddx":[],"mdm":"Unilateral absent breath sounds combined with hypotension, severe hypoxia, or distended neck veins indicated tension physiology warranting immediate decompression without awaiting late tracheal deviation or imaging.","frag":"tension physiology / decompress"}]}],"conclusions":["viral upper respiratory infection","acute bronchitis","mild reactive airway disease (improved)"],"specs":["pulm","cards"],"algorithm":{"immediate":["Continuous pulse oximetry and cardiac monitor; supplemental oxygen titrated to target; IV access; ECG.","If in extremis: prepare for airway support and treat the reversible killers — tension pneumothorax (decompress), anaphylaxis (epinephrine), and flash pulmonary edema (NIV/nitrates) — empirically."],"criticalTests":["ECG and chest X-ray","Troponin and BNP when cardiac cause is considered","Bedside lung and cardiac ultrasound","CT pulmonary angiography when PE pretest probability warrants"],"cantMiss":[{"dx":"pe-d","trigger":"Pleuritic pain, hypoxia, or unilateral leg swelling","test":"Pretest probability (Wells/PERC) then d-dimer or CTPA","intervention":"Anticoagulation; thrombolysis for massive PE with shock"},{"dx":"tension","trigger":"Unilateral absent breath sounds with hypotension/tracheal deviation","test":"Clinical — lung ultrasound or CXR only if it does not delay","intervention":"Immediate needle/finger thoracostomy, then chest tube"},{"dx":"airway","trigger":"Stridor, urticaria, angioedema, or exposure","test":"Clinical diagnosis","intervention":"Intramuscular epinephrine; prepare a difficult airway"},{"dx":"acs-d","trigger":"Orthopnea, crackles, elevated JVP","test":"ECG, BNP, lung ultrasound (B-lines)","intervention":"NIV, nitrates, diuresis; treat ischemic precipitant"},{"dx":"sepsis-dyspnea","trigger":"Fever, focal consolidation, septic physiology","test":"Lactate, cultures, chest imaging","intervention":"Early antibiotics and fluid resuscitation"}],"disposition":"Disposition follows the cause and the response to therapy; hypoxia, work of breathing, or an unresolved can’t-miss diagnosis drives admission or a higher level of care."},"decisionTree":{"title":"Dyspnea — initial approach","intro":"An original, evidence-based decision aid for dyspnea. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Stabilize & assess","items":["Oxygen/airway; vitals, SpO2; ECG; cardiac monitor","Focused exam; bedside ultrasound as available"],"next":"q_airway"},"q_airway":{"type":"decision","q":"Airway compromise or impending respiratory failure?","yes":"a_airway","no":"q_tension","cantmiss":"Manage the airway first — anaphylaxis/angioedema, severe bronchospasm, and exhaustion need immediate intervention."},"a_airway":{"type":"action","title":"Secure the airway / support ventilation","items":["Positioning, high-flow O2, NIV or intubation","IM epinephrine for anaphylaxis","Decompress a tension pneumothorax if present"],"tone":"danger","terminal":true},"q_tension":{"type":"decision","q":"Tension pneumothorax (hypotension, absent breath sounds, distended neck veins)?","yes":"a_tension","no":"q_cardiopulm"},"a_tension":{"type":"action","title":"Decompress immediately","items":["Needle/finger thoracostomy, then chest tube","Do not wait for imaging"],"tone":"danger","terminal":true},"q_cardiopulm":{"type":"decision","q":"Suspected PE, ACS, or pulmonary edema?","yes":"a_cardiopulm","no":"q_obstr","pitfall":"Dyspnea is often cardiac or embolic — get an ECG, consider PE, and look for flash pulmonary edema."},"a_cardiopulm":{"type":"action","title":"Target the cause","items":["PE: anticoagulation ± thrombolysis","ACS: ACS pathway","Pulmonary edema: NIV, nitrates, diuresis"],"tone":"danger","terminal":true},"q_obstr":{"type":"decision","q":"Wheezing / obstructive pattern (asthma or COPD)?","yes":"a_obstr","no":"a_workup"},"a_obstr":{"type":"action","title":"Bronchodilators & steroids","items":["Nebulized bronchodilators and systemic steroids","NIV for COPD","Treat triggers (e.g., infection)"],"terminal":true},"a_workup":{"type":"action","title":"Broaden the workup","items":["CXR, labs; consider pneumonia, effusion, anemia","Treat the identified cause","Admit per severity"],"terminal":true}}},"guide":"../learn/complaints/dyspnea.html","pearls":[{"text":"Dyspnea can be an anginal equivalent — especially in women, diabetics, and the elderly who infarct without chest pain. Get an ECG and troponin on unexplained new dyspnea.","dx":"acs-d"},{"text":"Clear lungs, a normal chest x-ray, and a normal SpO2 do not exclude PE. Unexplained dyspnea or tachycardia with risk factors warrants Wells/PERC and, when indicated, CT pulmonary angiography.","dx":"pe-d"},{"text":"Tension pneumothorax is a clinical diagnosis — hypotension with unilateral absent breath sounds means needle or finger decompression before imaging.","dx":"tension"},{"text":"Stridor, drooling, voice change, or lip/tongue swelling signals an airway threat — prepare for a difficult airway early and call for help. Anaphylaxis gets IM epinephrine immediately, not just antihistamines.","dx":"airway"},{"text":"Tachypnea is the earliest and most overlooked sign of sepsis and decompensation — a rising respiratory rate precedes hypotension. Do not discharge a persistently tachypneic patient.","dx":"sepsis-dyspnea"},{"text":"In a hypercapnic COPD patient, titrate oxygen to an SpO2 of 88–92% — over-oxygenation worsens CO2 retention. Trial non-invasive ventilation before intubation when the patient can protect the airway.","dx":"copd"}]},{"id":"syncope","title":"Syncope","aliases":["syncope","passed out","fainting","faint","loss of consciousness","blackout","collapse","loc","near syncope","presyncope"],"opening":"The patient was evaluated for a transient loss of consciousness. A focused cardiovascular and neurologic history and examination were performed, and the diagnoses below were actively considered.","ddx":[{"id":"arrhythmia","group":"lifethreat","label":"Arrhythmia / cardiac syncope","default":true,"tags":["card"],"ruleout":"Cardiac arrhythmia was considered; the episode was not exertional or sudden without prodrome, there was no palpitations, chest pain, or family history of sudden death, and the ECG showed normal intervals without ischemia or pre-excitation, making it unlikely.","miss":3},{"id":"pe-s","group":"lifethreat","label":"Pulmonary embolism","default":true,"tags":["pe"],"ruleout":"Pulmonary embolism was considered as a cause of syncope; there was no dyspnea, pleuritic pain, or leg swelling, no VTE risk factors, and the patient was not tachycardic or hypoxic, making it unlikely.","miss":4},{"id":"bleed","group":"lifethreat","label":"Occult hemorrhage (incl. AAA, GI, ectopic)","default":true,"tags":[],"ruleout":"Occult hemorrhage including ruptured aneurysm, gastrointestinal, or ectopic source was considered; vital signs were stable without orthostatic change, there was no abdominal or back pain, no melena, and hemoglobin was at baseline, making it unlikely.","miss":4},{"id":"sah-s","group":"lifethreat","label":"Subarachnoid hemorrhage","default":false,"tags":[],"ruleout":"Subarachnoid hemorrhage was considered; there was no associated severe or thunderclap headache, neck stiffness, or neurologic deficit, and the neurologic examination was normal, making it unlikely.","miss":4},{"id":"aortic-stenosis-syn","group":"lifethreat","label":"Aortic stenosis / outflow obstruction","default":false,"tags":["aortic-stenosis-syn"],"ruleout":"Aortic stenosis or outflow obstruction was considered; the syncope was not exertional, there was no crescendo-decrescendo systolic murmur radiating to the carotids, and no dyspnea or angina, making it unlikely.","miss":3},{"id":"vasovagal","group":"common","label":"Vasovagal / orthostatic","default":false,"tags":[],"ruleout":"A reflex-mediated or orthostatic cause was considered as the likely explanation after the serious causes above were addressed.","miss":2}],"risk":[{"id":"canadian-syncope","label":"Canadian Syncope Risk Score","tags":["card"],"scale":"low","line":"The Canadian Syncope Risk Score was documented to support risk stratification and disposition for this syncope presentation.","cite":"Thiruganasambandamoorthy V, et al. CMAJ. 2016.","short":"Canadian Syncope Risk Score documented","calc":{"fields":[{"label":"Vasovagal predisposition","opts":[["No",0],["Yes",-1]]},{"label":"History of heart disease","opts":[["No",0],["Yes",1]]},{"label":"Systolic BP < 90 or > 180","opts":[["No",0],["Yes",2]]},{"label":"Troponin > 99th percentile","opts":[["No",0],["Yes",2]]},{"label":"Abnormal QRS axis","opts":[["No",0],["Yes",1]]},{"label":"QRS duration > 130 ms","opts":[["No",0],["Yes",1]]},{"label":"QTc > 480 ms","opts":[["No",0],["Yes",2]]},{"label":"ED diagnosis","opts":[["Neither",0],["Vasovagal syncope",-2],["Cardiac syncope",2]]}],"bands":[[-1,"very low","low","Very low risk: discharge with outpatient follow-up is generally appropriate."],[0,"low","low","Low risk: discharge with outpatient follow-up is generally appropriate."],[3,"medium","mod","Medium risk: a period of monitored ED/observation before disposition is reasonable."],[5,"high","high","High risk: admit or arrange close monitored evaluation."],[11,"very high","high","Very high risk: admit for monitored evaluation."]],"line":"Canadian Syncope Risk Score {score} ({band}); used to guide disposition and monitoring.","applies":"Adults seen within 24h of syncope, after initial ED workup, to predict 30-day serious outcomes. Not for syncope already explained by a serious finding, or for seizure/intoxication/trauma-related loss of consciousness."},"bandNotes":{"very low":"≈0.4% 30-day serious outcome (CSRS validation)","low":"≈1% 30-day serious outcome (CSRS validation)","medium":"≈3% 30-day serious outcome (CSRS validation)","high":"≈8% 30-day serious outcome (CSRS validation)","very high":"≈20% 30-day serious outcome (CSRS validation)"}},{"id":"ecg-s","label":"ECG reviewed","tags":["card"],"scale":"low","line":"The ECG was personally reviewed for conduction, ischemic, and high-risk features, which were absent.","short":"ECG non-ischemic without high-risk features"},{"id":"orthos","label":"Orthostatic vitals","tags":[],"scale":"low","line":"Orthostatic vital signs were obtained and interpreted in the clinical context.","short":"orthostatic vitals obtained"}],"checks":[{"if":"arrhythmia","needs":["canadian-syncope","ecg-s"],"mode":"any","warn":"Cardiac syncope is on the differential — an ECG and/or validated score documents the basis for risk stratification."}],"history":[{"id":"syn-hx-exertional","dx":"arrhythmia","q":"Syncope during exertion or in the supine position — not while standing or with postural change?","answers":[{"label":"Not exertional, not supine (position non-specific/unknown)","tone":"neg","sets":[],"ddx":[],"mdm":"Syncope was not reported during exertion and did not occur supine; these high-risk features for an arrhythmic/structural cardiac cause were absent.","frag":"not exertional, not supine"},{"label":"Exertional syncope","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia","keep":true}],"mdm":"Syncope occurred during exertion, a high-risk feature associated with structural cardiac disease and potentially lethal arrhythmia.","frag":"exertional syncope"},{"label":"Syncope while supine","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia","keep":true}],"mdm":"Syncope occurred in the supine position, which is strongly associated with a primary cardiac arrhythmia rather than a reflex or orthostatic mechanism.","frag":"syncope while supine"}]},{"id":"syn-hx-palpitations","dx":"arrhythmia","q":"Palpitations, racing heartbeat, or irregular heartbeat immediately before the episode?","answers":[{"label":"No palpitations","tone":"neg","sets":[],"ddx":[],"mdm":"No palpitations or presyncopal cardiac symptoms were reported before the event.","frag":"no palpitations"},{"label":"Palpitations preceding event","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia","keep":true}],"mdm":"Palpitations or a racing heartbeat immediately preceded the syncopal event, raising concern for a primary arrhythmia as the etiology.","frag":"palpitations preceding event"}]},{"id":"syn-hx-no-prodrome","dx":"arrhythmia","q":"Abrupt, unheralded loss of consciousness — no warning prodrome of diaphoresis, nausea, or progressive lightheadedness?","answers":[{"label":"No abrupt/unheralded onset — prodrome (diaphoresis, nausea, or lightheadedness) was present","tone":"neg","sets":[],"ddx":[],"mdm":"A warning prodrome of diaphoresis, nausea, or progressive lightheadedness preceded the loss of consciousness; an abrupt arrhythmic event was not supported by the episode description.","frag":"no abrupt unheralded LOC"},{"label":"Abrupt — no warning prodrome","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia","keep":true}],"mdm":"Loss of consciousness was abrupt with no preceding prodrome of diaphoresis, nausea, or progressive lightheadedness, characteristic of a primary cardiac arrhythmia rather than a reflex-mediated event.","frag":"abrupt, unheralded LOC"}]},{"id":"syn-hx-family-sudden-death","dx":"arrhythmia","q":"Family history of sudden cardiac death or unexplained premature death before age 50 (channelopathy or cardiomyopathy)?","answers":[{"label":"No family history of sudden death","tone":"neg","sets":[],"ddx":[],"mdm":"No family history of sudden cardiac death or unexplained premature death was reported.","frag":"no family history of sudden death"},{"label":"Family history of sudden death < 50","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia","keep":true}],"mdm":"A family history of sudden cardiac death or unexplained premature death at age under 50 was reported, raising concern for an inherited channelopathy or cardiomyopathy.","frag":"family history of sudden death < 50"}]},{"id":"syn-hx-structural-hx","dx":"arrhythmia","q":"Known structural heart disease (cardiomyopathy, prior MI, valvular disease) or prior abnormal ECG?","answers":[{"label":"No structural disease or abnormal ECG","tone":"neg","sets":[],"ddx":[],"mdm":"No known structural heart disease and no prior abnormal ECG was reported.","frag":"no structural heart disease or prior abnormal ECG"},{"label":"Known structural disease or abnormal ECG","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia","keep":true}],"mdm":"Known structural heart disease or a prior abnormal ECG was identified, significantly raising the risk of an arrhythmic cause of syncope.","frag":"known structural disease or abnormal ECG"}]},{"id":"syn-hx-pe-chest-dyspnea","dx":"pe-s","q":"Pleuritic chest pain or dyspnea coinciding with the syncopal event?","answers":[{"label":"No chest pain or dyspnea","tone":"neg","sets":[],"ddx":[],"mdm":"No pleuritic chest pain or dyspnea was associated with the syncopal episode; a pulmonary embolic cause was not suggested by these symptoms.","frag":"no pleuritic chest pain or dyspnea"},{"label":"Pleuritic pain or dyspnea with event","tone":"pos","sets":[],"ddx":[{"id":"pe-s","keep":true}],"mdm":"Pleuritic chest pain or dyspnea coincided with the syncopal event, raising concern for pulmonary embolism causing hemodynamic compromise.","frag":"pleuritic pain or dyspnea with event"}]},{"id":"syn-hx-pe-vte-risk","dx":"pe-s","q":"VTE risk factors — recent immobilization or surgery, prior DVT or PE, active malignancy, or estrogen use?","answers":[{"label":"No VTE risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No VTE risk factors were identified (no recent immobilization or surgery, prior DVT or PE, active malignancy, or estrogen use) and pulmonary embolism was not strongly supported by the risk factor profile.","frag":"no VTE risk factors"},{"label":"VTE risk factor present","tone":"pos","sets":[],"ddx":[{"id":"pe-s","keep":true}],"mdm":"A VTE risk factor (recent immobilization or surgery, prior DVT or PE, active malignancy, or estrogen use) was identified, increasing pretest probability for pulmonary embolism as a cause of syncope.","frag":"VTE risk factor present"}]},{"id":"syn-hx-anticoag-bleeding","dx":"bleed","q":"Anticoagulation or antiplatelet use, melena, hematemesis, or other GI symptoms suggesting hemorrhage?","answers":[{"label":"No anticoagulation or GI symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No anticoagulant or antiplatelet use and no symptoms of gastrointestinal hemorrhage were reported.","frag":"no anticoagulant use or GI bleeding symptoms"},{"label":"Anticoagulation use or GI bleeding symptoms","tone":"pos","sets":[],"ddx":[{"id":"bleed","keep":true}],"mdm":"Anticoagulant use or symptoms of gastrointestinal hemorrhage were reported; occult blood loss as a cause of syncope was evaluated.","frag":"anticoagulant use or GIB symptoms"}]},{"id":"syn-hx-aaa-risk","dx":"bleed","q":"Age > 60 with vascular risk factors, back or abdominal pain, or known aortic aneurysm — AAA considered?","answers":[{"label":"No AAA risk profile or abdominal pain","tone":"neg","sets":[],"ddx":[],"mdm":"The patient's age, vascular risk profile, and absence of back or abdominal pain did not raise concern for a ruptured aortic aneurysm.","frag":"no AAA risk profile, no back or abdominal pain"},{"label":"AAA risk profile with abdominal or back pain","tone":"pos","sets":[],"ddx":[{"id":"bleed","keep":true}],"mdm":"An older patient with vascular risk factors and back or abdominal pain was present; ruptured abdominal aortic aneurysm was considered as a cause of syncope.","frag":"older with vascular risk factors and back/abdominal pain"}]},{"id":"syn-hx-ectopic","dx":"bleed","q":"Reproductive potential — could ectopic or intrauterine pregnancy with hemorrhage explain this presentation?","answers":[{"label":"Not applicable or pregnancy addressed","tone":"neg","sets":[],"ddx":[],"mdm":"Pregnancy as a contributor to occult hemorrhage and syncope was assessed; the possibility was low or appropriately addressed.","frag":"pregnancy addressed, low likelihood"},{"label":"Reproductive age — pregnancy not excluded","tone":"pos","sets":[],"ddx":[{"id":"bleed","keep":true}],"mdm":"The patient was of reproductive potential and pregnancy could not be excluded by history; ectopic pregnancy with occult hemorrhage was kept on the differential and a pregnancy test was obtained.","frag":"reproductive age, pregnancy not excluded"}]},{"id":"syn-hx-severe-headache","dx":"sah-s","q":"Severe, sudden ('thunderclap') headache at or immediately before the time of syncope?","answers":[{"label":"No severe or sudden headache","tone":"neg","sets":[],"ddx":[],"mdm":"No severe or sudden-onset headache was associated with the syncopal event, making subarachnoid hemorrhage less likely by history.","frag":"no severe or sudden-onset headache"},{"label":"Severe sudden headache with event","tone":"pos","sets":[],"ddx":[{"id":"sah-s","keep":true}],"mdm":"A severe, sudden-onset headache coincided with the syncopal event; subarachnoid hemorrhage was urgently considered.","frag":"severe sudden headache with event"}]},{"id":"syn-hx-vasovagal-features","dx":"vasovagal","q":"Clear prodrome (diaphoresis, nausea, pallor, progressive lightheadedness), situational trigger (pain, fear, prolonged standing, Valsalva), or postural onset — without high-risk features above?","answers":[{"label":"No clear reflex or orthostatic features","tone":"neg","sets":[],"ddx":[],"mdm":"No clear situational trigger, prodromal symptoms of vasovagal syncope, or postural onset was identified; a benign reflex mechanism was not established by history.","frag":"no clear reflex or orthostatic features"},{"label":"Prodrome or situational trigger present","tone":"pos","sets":[],"ddx":[{"id":"vasovagal","keep":true}],"mdm":"A clear prodrome of diaphoresis, nausea, and lightheadedness or a situational trigger was present, supporting a vasovagal or orthostatic mechanism after higher-risk causes were addressed.","frag":"clear prodrome or situational trigger"}]}],"exam":[{"id":"syn-exam-vitals","dx":"general","q":"Vital signs — heart rate, blood pressure, and oxygen saturation stable and within normal limits on arrival?","answers":[{"label":"Vital signs stable","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable on arrival; heart rate, blood pressure, and oxygen saturation were within acceptable limits.","frag":"vital signs stable on arrival"},{"label":"Hemodynamically unstable","tone":"pos","sets":[],"ddx":[],"mdm":"The patient was hemodynamically unstable on arrival, with abnormal heart rate, blood pressure, or oxygen saturation, requiring urgent resuscitation and expedited evaluation for a life-threatening cause of syncope.","frag":"hemodynamically unstable"}]},{"id":"syn-exam-murmur","dx":"arrhythmia","q":"Cardiac murmur on auscultation — systolic ejection murmur, particularly at the right upper sternal border (aortic stenosis)?","answers":[{"label":"No murmur detected","tone":"neg","sets":[],"ddx":[],"mdm":"Cardiac auscultation revealed no murmur; heart sounds were regular in rate and rhythm without adventitious sounds.","frag":"no murmur, regular rate and rhythm"},{"label":"Murmur present","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia","keep":true}],"mdm":"A cardiac murmur was detected; a systolic ejection murmur at the right upper sternal border raises concern for hemodynamically significant aortic stenosis as a cause of syncope.","frag":"systolic ejection murmur"}]},{"id":"syn-exam-orthostatic","dx":"bleed","q":"Orthostatic vital signs — systolic drop ≥ 20 mmHg or HR rise ≥ 20 bpm on standing?","answers":[{"label":"No orthostatic change","tone":"neg","sets":[],"ddx":[],"mdm":"No significant blood pressure drop or compensatory heart rate increase on standing was demonstrated; orthostatic hypotension was not identified.","frag":"no orthostatic change"},{"label":"Orthostatic change present","tone":"pos","sets":[],"ddx":[{"id":"bleed","keep":true},{"id":"vasovagal","keep":true}],"mdm":"A significant orthostatic blood pressure drop was present, consistent with volume depletion or occult hemorrhage; occult hemorrhage was actively evaluated before attributing this to a benign cause.","frag":"orthostatic BP drop present"}]},{"id":"syn-exam-pallor-abdomen","dx":"bleed","q":"Pallor, tachycardia, abdominal or flank tenderness, or rectal exam suggesting occult hemorrhage?","answers":[{"label":"No signs of hemorrhage","tone":"neg","sets":[],"ddx":[],"mdm":"No pallor, persistent tachycardia, abdominal tenderness, or rectal bleeding was identified on examination; occult hemorrhage was not supported by the physical exam.","frag":"no pallor, tachycardia, or abdominal tenderness"},{"label":"Signs of occult hemorrhage","tone":"pos","sets":[],"ddx":[{"id":"bleed","keep":true}],"mdm":"Pallor, tachycardia, or abdominal tenderness was present on examination, raising concern for occult hemorrhage (including a gastrointestinal, vascular, or gynecologic source); as the etiology of syncope.","frag":"pallor, tachycardia, or abdominal tenderness"}]},{"id":"syn-exam-neuro","dx":"sah-s","q":"Focal neurologic deficits on examination — lateralizing motor, sensory, or cranial nerve findings?","answers":[{"label":"Non-focal neurologic exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal; no lateralizing motor, sensory, or cranial nerve deficits were identified.","frag":"non-focal neuro exam"},{"label":"Focal neurologic deficit","tone":"pos","sets":[],"ddx":[{"id":"sah-s","keep":true}],"mdm":"A focal neurologic deficit (lateralizing motor, sensory, or cranial nerve findings) was identified after the syncopal event, requiring urgent neuroimaging to evaluate for a cerebrovascular cause including subarachnoid hemorrhage.","frag":"focal neurologic deficit"}]},{"answers":[{"ddx":[],"frag":"no exertional syncope or ejection murmur","label":"No outflow-obstruction signs","mdm":"The syncope was not exertional, there was no crescendo-decrescendo systolic murmur radiating to the carotids, and no dyspnea or angina, making aortic stenosis or outflow obstruction unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"aortic-stenosis-syn","keep":true}],"frag":"exertional syncope or ejection murmur","label":"Outflow-obstruction signs present","mdm":"Exertional syncope or a crescendo-decrescendo systolic murmur radiating to the carotids was present, raising concern for aortic stenosis or outflow obstruction and warranting echocardiography.","sets":[],"tone":"pos"}],"dx":"aortic-stenosis-syn","id":"syn-exam-aortic-stenosis-syn","q":"Outflow obstruction — exertional syncope, crescendo-decrescendo systolic murmur radiating to the carotids, or associated angina or dyspnea?"}],"conclusions":["vasovagal / reflex syncope","orthostatic syncope","syncope NOS (low-risk)"],"specs":["cards","neuro"],"algorithm":{"immediate":["Immediate 12-lead ECG and continuous monitoring; orthostatic vitals; fingerstick glucose; pregnancy test in patients of reproductive potential.","If hypotensive or with ongoing symptoms: consider occult hemorrhage (AAA, GI, ectopic) and massive PE; resuscitate and obtain bedside ultrasound."],"criticalTests":["12-lead ECG (the single highest-yield test)","Hemoglobin and a pregnancy test where relevant","Targeted imaging — bedside aorta/FAST, CT for PE or SAH — driven by the history"],"cantMiss":[{"dx":"arrhythmia","trigger":"Exertional or supine syncope, palpitations, structural heart disease, abnormal ECG","test":"ECG, telemetry; echo for structural disease","intervention":"Monitored bed; treat the underlying rhythm; cardiology"},{"dx":"bleed","trigger":"Syncope with abdominal/back pain, melena, or positive pregnancy test","test":"Hemoglobin, bedside ultrasound, type and cross","intervention":"Resuscitation and emergent surgical/OB consultation"},{"dx":"pe-s","trigger":"Syncope with dyspnea, hypoxia, or tachycardia","test":"Pretest probability then CTPA","intervention":"Anticoagulation; thrombolysis if massive"},{"dx":"sah-s","trigger":"Syncope with severe headache","test":"Non-contrast head CT","intervention":"Blood-pressure control and neurosurgery"}],"disposition":"A reflex/vasovagal pattern with a normal ECG and exam in a low-risk patient is dischargeable; cardiac features, exertional events, or an abnormal ECG warrant monitoring and risk stratification."},"decisionTree":{"title":"Syncope — risk stratification","intro":"An original, evidence-based decision aid for syncope. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Resuscitate & screen","items":["Vitals/orthostatics; ECG; glucose","History: exertional onset, prodrome, family history of sudden death"],"next":"q_unstable"},"q_unstable":{"type":"decision","q":"Hemodynamically unstable or ongoing symptoms?","yes":"a_resus","no":"q_ecg"},"a_resus":{"type":"action","title":"Resuscitate & find the killer","items":["Treat shock; large-bore access, blood products","Consider PE, ruptured AAA/ectopic, GI bleed, arrhythmia","Targeted imaging and consults"],"tone":"danger","terminal":true},"q_ecg":{"type":"decision","q":"High-risk ECG (arrhythmia, ischemia, long/short QT, Brugada, blocks) or cardiac features?","yes":"a_cardiac","no":"q_vasc","cantmiss":"Cardiac syncope carries the highest mortality — read the ECG and ask about exertional onset and family history of sudden death."},"a_cardiac":{"type":"action","title":"Cardiac syncope pathway","items":["Telemetry/monitoring; cardiology","Treat arrhythmia/ischemia","Echo for structural disease"],"tone":"danger","terminal":true},"q_vasc":{"type":"decision","q":"Features of a vascular catastrophe (PE, AAA, ectopic, SAH, GI bleed)?","yes":"a_vasc","no":"a_low","pitfall":"Syncope can be the only herald of PE, ruptured AAA, ectopic pregnancy, or SAH — don't discharge these."},"a_vasc":{"type":"action","title":"Target the vascular cause","items":["CTA / ultrasound / pregnancy test / CT head as indicated","Resuscitate and consult"],"tone":"danger","terminal":true},"a_low":{"type":"action","title":"Likely reflex / orthostatic","items":["Reassure; review medications; hydration","Outpatient follow-up","Return precautions if recurrent or red flags develop"],"tone":"branch","terminal":true}}},"guide":"../learn/complaints/syncope.html","pearls":[{"text":"Get a 12-lead ECG on essentially everyone with syncope — hunt for QTc >480 ms, QRS >130 ms, Brugada pattern, pre-excitation, and ischemia. A normal ECG lowers but does not exclude an arrhythmic cause.","dx":"arrhythmia"},{"text":"Syncope can be the only presenting sign of pulmonary embolism — a clear chest exam and normal vitals do not exclude it when risk factors are present.","dx":"pe-s"},{"text":"Order a targeted workup, not a shotgun panel — labs/CT/echo only where the history, exam, or ECG point (hCG for occult ectopic, troponin for suspected ACS, echo for a murmur).","src":"ACEP clinical policy 2007"},{"text":"Admit or monitor when you suspect a dysrhythmia that observation could capture and act on — a single normal ECG does not close the case on a concerning story.","dx":"arrhythmia"},{"text":"Aortic stenosis syncope is typically exertional — a systolic murmur with exertional syncope, angina, or dyspnea warrants echo before clearing the patient for discharge.","dx":"aortic-stenosis-syn"}]},{"id":"back-pain","title":"Low Back Pain","aliases":["back","low back pain","lbp","back pain","lower back pain","lumbar","sciatica","cauda equina","epidural abscess"],"opening":"The patient was evaluated for low back pain. A focused history including red-flag screening, with a neurologic and musculoskeletal examination, was performed, and the diagnoses below were actively considered.","ddx":[{"id":"epidural-abscess","group":"lifethreat","label":"Spinal epidural abscess","default":true,"tags":["infx"],"ruleout":"Spinal epidural abscess was considered; there was no fever, injection drug use, immunosuppression, recent bacteremia, or spinal instrumentation, no point tenderness or progressive deficit, and inflammatory markers were unremarkable where obtained, making it unlikely.","miss":4},{"id":"cauda","group":"lifethreat","label":"Cauda equina syndrome","default":true,"tags":["neuro"],"ruleout":"Cauda equina syndrome was considered; there was no urinary retention or incontinence, no saddle anesthesia, no bilateral or progressive leg weakness, and rectal tone and perineal sensation were intact, making it unlikely.","miss":4},{"id":"aaa-back","group":"lifethreat","label":"Abdominal aortic aneurysm","default":true,"tags":[],"ruleout":"A symptomatic or ruptured abdominal aortic aneurysm was considered; there was no sudden tearing back or flank pain, no pulsatile abdominal mass, the patient was hemodynamically stable, and no syncope, making it unlikely.","miss":4},{"id":"cord-malignancy","group":"lifethreat","label":"Malignant cord compression","default":false,"tags":[],"ruleout":"Malignant cord compression or pathologic fracture was considered; there was no history of cancer, no unexplained weight loss, no night or progressive pain, and the neurologic examination was non-focal, making it unlikely.","miss":4},{"id":"vert-osteo","group":"lifethreat","label":"Vertebral osteomyelitis / discitis","default":false,"tags":["infx"],"ruleout":"Vertebral osteomyelitis or discitis was considered; there was no fever, focal spinal tenderness, injection drug use, or recent infection or instrumentation, making spinal infection unlikely.","miss":3},{"id":"msk-back","group":"other","label":"Mechanical / musculoskeletal back pain","default":false,"tags":[],"ruleout":"A mechanical or musculoskeletal source was considered as the likely cause after the serious diagnoses above were addressed.","miss":1}],"risk":[{"id":"redflags-back","label":"Red-flag screening documented","tags":["neuro"],"scale":"low","line":"Red-flag screening for low back pain (significant trauma, infection risk, neurologic deficit, malignancy history, age extremes) was documented and was negative.","short":"red-flag screen negative"},{"id":"neuroexam-back","label":"Documented neuro exam","tags":["neuro"],"scale":"low","line":"A focused neurologic examination, including strength, sensation, reflexes, and gait, was performed and documented, and was non-focal.","short":"non-focal neuro exam"},{"id":"inflammatory-back","label":"ESR / CRP (if infection suspected)","tags":["infx"],"scale":"low","line":"Inflammatory markers (ESR and/or CRP) were obtained when spinal infection was a consideration and reviewed in the clinical context.","short":"ESR/CRP reviewed"},{"id":"pvr-cauda","label":"Post-void residual (if CES suspected)","tags":["neuro"],"scale":"low","line":"A post-void residual was measured by catheter or bladder scan given concern for cauda equina syndrome; urinary retention is the most sensitive finding (absence makes CES very unlikely).","cite":"Borczuk P. Emerg Med Pract (EB Medicine). 2013;15(7).","short":"post-void residual checked"}],"checks":[{"if":"cauda","needs":["neuroexam-back","redflags-back","pvr-cauda"],"mode":"any","warn":"Cauda equina is on the differential — a documented neurologic/perineal exam and a post-void residual show the basis for excluding it."},{"if":"epidural-abscess","needs":["redflags-back","inflammatory-back"],"mode":"any","warn":"Spinal epidural abscess is on the differential — documenting red-flag screening (± inflammatory markers) makes the exclusion defensible."}],"history":[{"id":"back-hx-onset-character","dx":"general","q":"Pain onset, duration, and character — sudden vs. gradual, severity, constant vs. positional, any preceding trauma or activity?","answers":[{"label":"Gradual, positional, no red flags","tone":"neg","sets":[],"ddx":[],"mdm":"Pain onset was gradual and positional without features suggesting a serious underlying cause.","frag":"gradual, positional onset without red flags"},{"label":"Sudden, severe, or constant at rest","tone":"pos","sets":[],"ddx":[],"mdm":"The pain was sudden in onset, severe, or constant at rest: features that raise concern for a serious spinal or vascular etiology rather than a benign mechanical cause.","frag":"sudden, severe, or rest-predominant pain"}]},{"id":"back-hx-ivdu-immunosuppression","dx":"epidural-abscess","q":"IV drug use, immunocompromise (transplant, chemotherapy, systemic steroids, HIV), recent bacteremia, or prior spinal procedure / hardware?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"No injection drug use, immunocompromised state, recent bacteremia, or prior spinal instrumentation was identified; the risk profile for spinal epidural abscess was low.","frag":"no IVDU, immunocompromise, recent bacteremia, or prior spinal instrumentation"},{"label":"Risk factor present","tone":"pos","sets":[],"ddx":[{"id":"epidural-abscess","keep":true},{"id":"vert-osteo","keep":true}],"mdm":"A risk factor for spinal infection was identified (injection drug use, immunocompromise, recent bacteremia, or prior spinal instrumentation), raising concern for spinal epidural abscess or vertebral osteomyelitis.","frag":"spinal-infection risk factor present"}]},{"id":"back-hx-fever-infection","dx":"epidural-abscess","q":"Fever, rigors, or recent infection in the weeks before back pain onset (UTI, skin or dental infection, endocarditis workup)?","answers":[{"label":"No fever or antecedent infection","tone":"neg","sets":[],"ddx":[],"mdm":"No fever, rigors, or antecedent infection was reported.","frag":"no fever, rigors, or antecedent infection"},{"label":"Fever or recent infection","tone":"pos","sets":[],"ddx":[{"id":"epidural-abscess","keep":true},{"id":"vert-osteo","keep":true}],"mdm":"Fever or a recent infectious source was reported before pain onset, raising concern for hematogenous seeding of the spine (epidural abscess or vertebral osteomyelitis).","frag":"fever or recent infectious source before onset"}]},{"id":"back-hx-spinal-procedure","dx":"epidural-abscess","q":"Recent spinal injection, epidural, surgery, or lumbar puncture (direct inoculation risk)?","answers":[{"label":"No recent spinal procedure","tone":"neg","sets":[],"ddx":[],"mdm":"No recent spinal injection, epidural anesthesia, or spinal surgery was reported.","frag":"no recent spinal procedure"},{"label":"Recent spinal procedure","tone":"pos","sets":[],"ddx":[{"id":"epidural-abscess","keep":true}],"mdm":"A recent spinal procedure was reported; direct inoculation is a recognized mechanism for spinal epidural abscess.","frag":"recent spinal procedure"}]},{"id":"back-hx-cauda-bladder","dx":"cauda","q":"Urinary retention or new urinary incontinence (inability to void, overflow dribbling, or loss of urge sensation)?","answers":[{"label":"Normal voiding, no retention or incontinence","tone":"neg","sets":[],"ddx":[],"mdm":"Normal voiding was reported without urinary retention or new incontinence; this cauda equina red-flag symptom was absent.","frag":"no urinary retention or new incontinence"},{"label":"Urinary retention or new incontinence","tone":"pos","sets":[],"ddx":[{"id":"cauda","keep":true}],"mdm":"New urinary retention or incontinence was reported: the highest-yield red-flag symptom for cauda equina syndrome, requiring emergent imaging.","frag":"new urinary retention or incontinence"}]},{"id":"back-hx-cauda-saddle","dx":"cauda","q":"Saddle anesthesia — numbness or tingling in the perineum, inner thighs, or buttocks?","answers":[{"label":"No saddle numbness","tone":"neg","sets":[],"ddx":[],"mdm":"No saddle-distribution numbness or tingling was reported in the perineum, inner thighs, or buttocks.","frag":"no saddle numbness"},{"label":"Saddle anesthesia present","tone":"pos","sets":[],"ddx":[{"id":"cauda","keep":true}],"mdm":"Saddle anesthesia involving the perineum, inner thighs, or buttocks was reported, a pathognomonic symptom of cauda equina compression.","frag":"saddle anesthesia"}]},{"id":"back-hx-cauda-bowel","dx":"cauda","q":"New fecal incontinence or loss of rectal sphincter sensation?","answers":[{"label":"No bowel dysfunction","tone":"neg","sets":[],"ddx":[],"mdm":"No new fecal incontinence or loss of rectal sensation was reported.","frag":"no new fecal incontinence or loss of rectal sensation"},{"label":"New fecal incontinence","tone":"pos","sets":[],"ddx":[{"id":"cauda","keep":true}],"mdm":"New fecal incontinence was reported, a red-flag symptom for cauda equina syndrome requiring emergent MRI.","frag":"new fecal incontinence"}]},{"id":"back-hx-cauda-bilateral-leg","dx":"cauda","q":"Bilateral sciatica or bilateral lower-extremity numbness/weakness, or a unilateral deficit that is worsening hour-to-hour? (Bilateral sciatica plus subjective retention markedly raises cauda equina odds.)","answers":[{"label":"No bilateral or rapidly progressive deficit","tone":"neg","sets":[],"ddx":[],"mdm":"No bilateral leg weakness, bilateral numbness, or rapidly progressive neurologic deficit was reported.","frag":"no bilateral or rapidly progressive deficit"},{"label":"Bilateral weakness / numbness or rapid progression","tone":"pos","sets":[],"ddx":[{"id":"cauda","keep":true},{"id":"cord-malignancy","keep":true}],"mdm":"Bilateral lower-extremity weakness, bilateral numbness, or rapidly progressive motor deficit was reported, requiring urgent imaging to exclude cauda equina or cord compression.","frag":"bilateral weakness/numbness or rapid progression"}]},{"id":"back-hx-aaa-risk","dx":"aaa-back","q":"Age ≥ 60, hypertension, tobacco use, known aortic aneurysm, or pain radiating to flank, groin, or abdomen?","answers":[{"label":"None / low risk","tone":"neg","sets":[],"ddx":[],"mdm":"No significant vascular risk factors and no radiation to the flank, groin, or abdomen were identified; the probability of an aortic cause was low.","frag":"no vascular risk factors or flank/groin/abdominal radiation"},{"label":"Vascular risk + flank / abdominal radiation","tone":"pos","sets":[],"ddx":[{"id":"aaa-back","keep":true}],"mdm":"Vascular risk factors (age ≥ 60, hypertension, tobacco use) with pain radiating to the flank, groin, or abdomen raised concern for a symptomatic or ruptured abdominal aortic aneurysm.","frag":"vascular risk with flank/abdominal radiation"}]},{"id":"back-hx-aaa-tearing-syncope","dx":"aaa-back","q":"Sudden tearing/ripping back or flank pain, any syncope/near-syncope or a transient hypotensive or 'vagal' episode, or a pulsatile abdominal sensation? (Flank pain mimicking renal colic is the most common AAA misdiagnosis.)","answers":[{"label":"No tearing quality, no syncope","tone":"neg","sets":[],"ddx":[],"mdm":"The pain had no tearing or ripping quality, and there was no syncope, near-syncope, or pulsatile abdominal sensation reported.","frag":"no tearing pain, syncope, or pulsatile sensation"},{"label":"Tearing pain with syncope or pulsatile sensation","tone":"pos","sets":[],"ddx":[{"id":"aaa-back","keep":true}],"mdm":"Sudden tearing back pain with syncope or a perceived pulsatile abdominal sensation was reported: the classic presentation of a ruptured abdominal aortic aneurysm, requiring emergent evaluation.","frag":"tearing pain with syncope or pulsatile sensation"}]},{"id":"back-hx-malignancy","dx":"cord-malignancy","q":"Known cancer (especially breast, prostate, lung, kidney, thyroid, myeloma) or pain that is worse at night or recumbent, unrelieved by rest, or band-like/thoracic? (Back pain precedes most metastatic cord compression.)","answers":[{"label":"No cancer history, no night / rest pain","tone":"neg","sets":[],"ddx":[],"mdm":"No history of malignancy and no nocturnal or rest-predominant pain were identified, making a neoplastic cause unlikely on history.","frag":"no cancer history or night/rest pain"},{"label":"Cancer history or night / rest pain","tone":"pos","sets":[],"ddx":[{"id":"cord-malignancy","keep":true}],"mdm":"A history of malignancy or pain worst at night unrelieved by rest was present, raising concern for metastatic cord compression or a pathologic vertebral fracture.","frag":"cancer history or night/rest pain"}]},{"id":"back-hx-weight-loss","dx":"cord-malignancy","q":"Unexplained weight loss (> 10 lb / 4.5 kg in 6 months) or progressive pain without mechanical features?","answers":[{"label":"No unexplained weight loss","tone":"neg","sets":[],"ddx":[],"mdm":"No unexplained weight loss was reported.","frag":"no unexplained weight loss"},{"label":"Unexplained weight loss or progressive non-mechanical pain","tone":"pos","sets":[],"ddx":[{"id":"cord-malignancy","keep":true}],"mdm":"Unexplained weight loss or progressive non-mechanical back pain was reported, a red flag for occult malignancy requiring further evaluation (Oncologic Back Pain criteria, Deyo & Diehl 1992).","frag":"unexplained weight loss or progressive non-mechanical pain"}]},{"id":"back-hx-osteo-risk","dx":"vert-osteo","q":"Risk for vertebral osteomyelitis/discitis — IV drug use, diabetes, recent S. aureus bacteremia or endocarditis, dialysis, or a distant infection, with new focal back pain (often without fever)?","answers":[{"label":"No recent bacteremia or known infection","tone":"neg","sets":[],"ddx":[],"mdm":"No recent bacteremia, endocarditis, or distant infectious source was reported.","frag":"no recent bacteremia or distant infection"},{"label":"Recent bacteremia or known infection","tone":"pos","sets":[],"ddx":[{"id":"vert-osteo","keep":true},{"id":"epidural-abscess","keep":true}],"mdm":"A recent episode of bacteremia or a known infectious source was reported alongside new focal back pain, raising concern for hematogenous vertebral osteomyelitis or discitis.","frag":"recent bacteremia or known infection with focal back pain"}]},{"id":"back-hx-msk-mechanical","dx":"msk-back","q":"Mechanical features — pain worse with movement or certain positions, improved with rest or positional change, onset related to activity or lifting?","answers":[{"label":"Clearly mechanical and positional","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was mechanical and positional (worse with movement and improved with rest) without red-flag features, consistent with a musculoskeletal etiology.","frag":"mechanical, positional pain without red flags"},{"label":"Not clearly mechanical or mixed features","tone":"pos","sets":[],"ddx":[],"mdm":"The pain lacked clear mechanical features (it was not reliably worse with movement or certain positions, not improved with rest or positional change, and not clearly tied to activity or lifting), which lowered confidence in a benign musculoskeletal diagnosis and maintained a broader differential.","frag":"pain not clearly mechanical"}]},{"id":"back-hx-trauma-osteoporosis","dx":"msk-back","q":"Significant trauma (fall from height, MVA), or history of osteoporosis or chronic corticosteroid use (fragility fracture risk)?","answers":[{"label":"No significant trauma, no osteoporosis","tone":"neg","sets":[],"ddx":[],"mdm":"No significant traumatic mechanism and no history of osteoporosis or chronic steroid use were reported.","frag":"no significant trauma, osteoporosis, or chronic steroids"},{"label":"Significant trauma","tone":"pos","sets":[],"ddx":[],"mdm":"A significant traumatic mechanism was reported, prompting evaluation for bony injury.","frag":"significant traumatic mechanism"},{"label":"Osteoporosis / chronic steroids with low-mechanism injury","tone":"pos","sets":[],"ddx":[{"id":"cord-malignancy","keep":true}],"mdm":"Osteoporosis or chronic corticosteroid use was present; a fragility or pathologic vertebral fracture was considered even with a low-energy mechanism.","frag":"osteoporosis/chronic steroids with low-energy mechanism"}]},{"id":"back-hx-sea-recurrent-visits","dx":"epidural-abscess","q":"Is this a repeat or escalating ED/clinic visit for the same back pain, or pain progressing despite treatment? (The classic fever-pain-deficit triad appears in only a minority; most spinal epidural abscess is missed on the first visit.)","answers":[{"label":"First presentation, not escalating","tone":"neg","sets":[],"ddx":[],"mdm":"Patient presented for the first time with non-escalating back pain and no prior visits for the same complaint, lowering concern for an evolving occult infection.","frag":"first visit, non-escalating"},{"label":"Repeat or escalating presentation","tone":"pos","sets":[],"ddx":[],"mdm":"Patient had a repeat or escalating presentation for the same back pain, a recognized pattern in missed spinal epidural abscess, prompting inflammatory markers and contrast MRI consideration.","frag":"repeat/escalating visit"}]},{"id":"back-hx-cauda-sexual","dx":"cauda","q":"New erectile dysfunction or loss of genital sensation during sexual activity (an early autonomic clue to cauda equina that often precedes overt retention)?","answers":[{"label":"No new sexual dysfunction","tone":"neg","sets":[],"ddx":[],"mdm":"Patient denied new erectile dysfunction or genital sensory loss, an early autonomic marker, modestly lowering cauda equina concern.","frag":"no sexual dysfunction"},{"label":"New ED or genital sensory loss","tone":"pos","sets":[],"ddx":[],"mdm":"Patient reported new erectile dysfunction or genital sensory loss, an early autonomic feature of cauda equina that can precede urinary retention, supporting urgent MRI.","frag":"new sexual/genital sensory loss"}]},{"id":"back-hx-aaa-renal-colic-mimic","dx":"aaa-back","q":"In a patient over 50 with vascular risk, is this presentation being attributed to renal colic or first-time flank pain without prior stone history? (Renal colic is the most common label given to a ruptured AAA.)","answers":[{"label":"Established stone history, low vascular risk","tone":"neg","sets":[],"ddx":[],"mdm":"Flank pain occurred in a younger patient with established nephrolithiasis and low vascular risk, making a ruptured aneurysm mimic unlikely.","frag":"known stone, low risk"},{"label":"First flank pain, age >50, vascular risk","tone":"pos","sets":[],"ddx":[],"mdm":"First-episode flank pain in an older patient with vascular risk raised concern for a ruptured aortic aneurysm masquerading as renal colic, prompting bedside aortic ultrasound before anchoring on stone.","frag":"new flank pain, AAA risk"}]},{"id":"back-hx-cord-progressive-neuro","dx":"cord-malignancy","q":"Progressive leg weakness, gait change, or new bowel/bladder symptoms over days to weeks in a patient with cancer risk? (Ambulatory status at diagnosis is the strongest predictor of recovery in cord compression.)","answers":[{"label":"No progressive neuro change, fully ambulatory","tone":"neg","sets":[],"ddx":[],"mdm":"Patient remained fully ambulatory without progressive weakness or sphincter change, favorable given that pre-treatment neurologic status drives cord-compression outcomes.","frag":"ambulatory, no progression"},{"label":"Progressive weakness or gait/sphincter change","tone":"pos","sets":[],"ddx":[],"mdm":"Patient described progressive weakness or gait and sphincter change concerning for evolving malignant cord compression, where ambulation at diagnosis predicts recovery, prompting emergent whole-spine MRI.","frag":"progressive deficit"}]}],"exam":[{"id":"back-exam-vitals-general","dx":"general","q":"Vital signs — temperature, heart rate, blood pressure, respiratory rate within normal limits?","answers":[{"label":"Vitals within normal limits","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were within normal limits: the patient was afebrile with a normal heart rate, blood pressure, and respiratory rate.","frag":"vitals within normal limits, afebrile"},{"label":"Fever (T ≥ 38.3 °C) present","tone":"pos","sets":[],"ddx":[{"id":"epidural-abscess","keep":true},{"id":"vert-osteo","keep":true}],"mdm":"Fever (T ≥ 38.3 °C) was present on vital signs review; an infectious spinal process such as epidural abscess or osteomyelitis was elevated in the differential.","frag":"fever present"},{"label":"Hemodynamic instability","tone":"pos","sets":[],"ddx":[{"id":"aaa-back","keep":true}],"mdm":"Hemodynamic instability was present on vital signs, raising urgent concern for a ruptured aortic aneurysm or other catastrophic cause.","frag":"hemodynamic instability"}]},{"id":"back-exam-motor-sensory","dx":"general","q":"Lower-extremity motor strength (hip flexion, knee extension, ankle dorsiflexion / plantarflexion) and sensation — symmetric and intact?","answers":[{"label":"Strength and sensation intact, symmetric","tone":"neg","sets":[],"ddx":[],"mdm":"Lower-extremity motor strength and sensation were intact and symmetric bilaterally; no focal motor or sensory deficit was detected.","frag":"lower-extremity strength and sensation intact and symmetric"},{"label":"Asymmetric weakness or sensory loss","tone":"pos","sets":[],"ddx":[{"id":"cauda","keep":true},{"id":"cord-malignancy","keep":true}],"mdm":"Asymmetric lower-extremity weakness or a dermatomal sensory deficit was present on examination, requiring further evaluation for cord or nerve-root compression.","frag":"asymmetric weakness or dermatomal sensory loss"}]},{"id":"back-exam-reflexes-slr","dx":"general","q":"Patellar and Achilles reflexes symmetric, no upper-motor-neuron signs (hyperreflexia, clonus, Babinski) or a sensory level? Straight-leg raise reproducing radicular pain below the knee at <60 degrees?","answers":[{"label":"Reflexes symmetric, SLR negative","tone":"neg","sets":[],"ddx":[],"mdm":"Deep tendon reflexes were present and symmetric; straight-leg raise, when performed, was negative.","frag":"reflexes symmetric, SLR negative"},{"label":"Reflex asymmetry or hyperreflexia","tone":"pos","sets":[],"ddx":[{"id":"cauda","keep":true},{"id":"cord-malignancy","keep":true}],"mdm":"Reflex asymmetry or hyperreflexia was found; hyperreflexia with a Babinski sign points toward upper motor neuron (cord) pathology rather than cauda equina.","frag":"reflex asymmetry or hyperreflexia"},{"label":"Positive SLR (radicular reproduction < 60°)","tone":"pos","sets":[],"ddx":[],"mdm":"A positive straight-leg raise reproducing radicular symptoms below 60° was present, consistent with nerve-root tension.","frag":"positive SLR reproducing radicular symptoms <60°"}]},{"id":"back-exam-gait","dx":"general","q":"Gait assessment — normal ambulation? Antalgic gait, footdrop, or inability to toe/heel walk?","answers":[{"label":"Normal gait, full weight-bearing","tone":"neg","sets":[],"ddx":[],"mdm":"The patient ambulated with a normal gait and full weight-bearing, without antalgic gait, footdrop, or inability to toe- or heel-walk.","frag":"normal gait, full weight-bearing"},{"label":"Antalgic gait or footdrop","tone":"pos","sets":[],"ddx":[{"id":"cauda","keep":true}],"mdm":"An antalgic gait or footdrop was observed, indicating significant nerve-root or cauda equina motor involvement.","frag":"antalgic gait or footdrop"}]},{"id":"back-exam-saddle-pvr","dx":"cauda","q":"Saddle sensation (perineum / inner thighs) intact bilaterally? Post-void residual checked when retention is suspected? (Anal-sphincter tone is unreliable for cauda equina — do not rely on it.)","answers":[{"label":"Perineal sensation intact, anal tone normal","tone":"neg","sets":[],"ddx":[],"mdm":"Perineal sensation was intact bilaterally and urinary retention was excluded (post-void residual where indicated), noting that rectal tone was not relied on, since digital tone assessment performs poorly for cauda equina and false reassurance from it is a recognized trap.","frag":"saddle sensation intact; retention excluded by PVR (rectal tone not relied on)"},{"label":"Saddle anesthesia, decreased anal tone, or urinary retention","tone":"pos","sets":[],"ddx":[{"id":"cauda","keep":true}],"mdm":"Saddle anesthesia, diminished anal tone, or urinary retention was identified on examination: findings consistent with cauda equina compromise requiring emergent MRI.","frag":"saddle anesthesia, decreased anal tone, or retention"}]},{"id":"back-exam-spinal-tenderness","dx":"epidural-abscess","q":"Focal midline or paraspinal point tenderness on percussion/palpation — localized to a single vertebral level?","answers":[{"label":"No focal spinal tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"No focal midline or paraspinal tenderness was elicited on percussion or palpation.","frag":"no focal spinal tenderness"},{"label":"Focal vertebral point tenderness present","tone":"pos","sets":[],"ddx":[{"id":"epidural-abscess","keep":true},{"id":"vert-osteo","keep":true}],"mdm":"Focal vertebral point tenderness was present on percussion, raising concern for vertebral osteomyelitis or spinal epidural abscess at that level.","frag":"focal vertebral point tenderness"}]},{"id":"back-exam-pulsatile-mass","dx":"aaa-back","q":"Pulsatile abdominal mass or epigastric / periumbilical bruit on examination?","answers":[{"label":"No pulsatile mass, no bruit","tone":"neg","sets":[],"ddx":[],"mdm":"No pulsatile abdominal mass was detected, noting palpation is only ~68% sensitive for AAA and cannot exclude one; imaging thresholds were set by risk factors and the clinical picture.","frag":"no pulsatile mass (palpation not relied on to exclude AAA)"},{"label":"Pulsatile mass or bruit present","tone":"pos","sets":[],"ddx":[{"id":"aaa-back","keep":true}],"mdm":"A pulsatile abdominal mass or epigastric bruit was identified, raising strong concern for a symptomatic abdominal aortic aneurysm.","frag":"pulsatile abdominal mass or bruit"}]},{"id":"back-exam-pvr-bladder-scan","dx":"cauda","q":"Post-void residual measured by bladder scan or catheter when cauda equina is considered? (A PVR above roughly 200 mL is a sensitive objective adjunct; a normal PVR does not exclude incomplete cauda equina.)","answers":[{"label":"PVR low / not indicated by presentation","tone":"neg","sets":[],"ddx":[],"mdm":"Post-void residual was low or not indicated by the presentation, an objective point reducing concern for cauda equina with retention while not fully excluding the incomplete form.","frag":"PVR low/normal"},{"label":"Elevated PVR (>~200 mL)","tone":"pos","sets":[],"ddx":[],"mdm":"An elevated post-void residual was documented, a sensitive objective marker that raised concern for cauda equina and prompted urgent MRI rather than reliance on history alone.","frag":"elevated PVR"}]},{"id":"back-exam-umn-sensory-level","dx":"cord-malignancy","q":"Upper-motor-neuron signs (hyperreflexia, clonus, extensor plantar response) or a discrete sensory level on the trunk suggesting cord rather than root involvement?","answers":[{"label":"No UMN signs, no sensory level","tone":"neg","sets":[],"ddx":[],"mdm":"Examination showed no upper-motor-neuron signs or sensory level, lowering concern for cord-level compression as opposed to isolated radiculopathy.","frag":"no UMN signs/level"},{"label":"UMN signs or sensory level present","tone":"pos","sets":[],"ddx":[],"mdm":"Upper-motor-neuron signs or a truncal sensory level localized the lesion to the cord and prompted emergent MRI for compression, including thoracic levels where myelopathy is common.","frag":"UMN signs / sensory level"}]},{"id":"back-exam-fever-deficit-combo","dx":"epidural-abscess","q":"Documented fever or focal neurologic deficit on exam in a patient with infectious risk — the combination that should trigger emergent whole-spine contrast MRI rather than observation?","answers":[{"label":"Afebrile, neurologically intact","tone":"neg","sets":[],"ddx":[],"mdm":"Patient was afebrile and neurologically intact on examination; with risk factors present, inflammatory markers were considered given the unreliable sensitivity of the classic triad.","frag":"afebrile, neuro intact"},{"label":"Fever and/or focal deficit","tone":"pos","sets":[],"ddx":[],"mdm":"Fever and/or a focal neurologic deficit in a patient with infectious risk triggered emergent whole-spine contrast MRI for spinal epidural abscess, since deficit is a late and ominous finding.","frag":"fever and/or deficit"}]}],"conclusions":["musculoskeletal low back pain","lumbar strain","back pain NOS (low-risk)"],"specs":["nsgy","ortho"],"pearls":[{"text":"Urinary retention is the most sensitive finding for cauda equina (~90%); CES without retention is roughly 1:10,000. \"Able to urinate\" does not exclude it — measure a post-void residual.","dx":"cauda","src":"EB Medicine 2024;26(11)"},{"text":"Fever is absent in over half of spinal epidural abscess cases and ~20% have no classic risk factor; a normal WBC does not exclude it — ESR is the most sensitive lab. Get MRI with contrast.","dx":"epidural-abscess","src":"EB Medicine 2024;26(11)"},{"text":"Image the whole spine when epidural abscess or cord compression is suspected — noncontiguous skip lesions are common and a lumbar-only MRI can miss the lesion.","dx":"epidural-abscess","src":"EB Medicine 2024;26(11)"},{"text":"In an older patient with new back/flank pain, palpate the aorta and get a bedside ultrasound. A leaking AAA is read as \"muscular\" until syncope or transient hypotension gives it away.","dx":"aaa-back","src":"EB Medicine 2024;26(11)"},{"text":"Know what each study can't exclude: a negative x-ray does not rule out fracture (CT is the test for bone), and a negative CT does not rule out cord compression or abscess (MRI is the test for soft tissue).","src":"EB Medicine 2024;26(11)"},{"text":"NSAIDs are first-line for nonspecific back pain; opioids add no meaningful relief and increase length of stay and return visits. Bed rest does not improve outcomes — advise resuming normal activity.","dx":"msk-back","src":"EB Medicine 2024;26(11)"}],"guide":"../learn/complaints/low-back-pain.html"},{"id":"fever","title":"Fever / Possible Sepsis","aliases":["fever","febrile","sepsis","infection","high temperature","septic"],"opening":"The patient was evaluated for fever and possible infection. Vital signs were trended, a source-directed history and examination were performed, and the diagnoses below were actively considered.","ddx":[{"id":"septic-shock","group":"lifethreat","label":"Sepsis / septic shock","default":true,"tags":["sep"],"ruleout":"Sepsis with end-organ hypoperfusion was considered; the patient was not hypotensive or tachycardic beyond fever, mentation was normal, capillary refill and urine output were adequate, and lactate was not elevated, making septic shock unlikely.","miss":3},{"id":"meningitis-f","group":"lifethreat","label":"Meningitis / encephalitis","default":true,"tags":[],"ruleout":"Meningitis or encephalitis was considered; there was no neck stiffness, photophobia, altered mentation, rash, or focal deficit, and no immunocompromise, making CNS infection unlikely while recognizing meningeal signs are insensitive.","miss":4},{"id":"necrotizing","group":"lifethreat","label":"Necrotizing soft-tissue infection","default":false,"tags":[],"ruleout":"A necrotizing soft-tissue infection was considered; there was no pain out of proportion, no rapidly spreading erythema, crepitus, bullae, or skin necrosis, and the patient was non-toxic, making it unlikely.","miss":4},{"id":"meningococcemia-f","group":"lifethreat","label":"Meningococcemia","default":false,"tags":["meningococcemia-f"],"ruleout":"Meningococcemia was considered; there was no petechial or purpuric rash, no hemodynamic instability, and no meningismus, making it unlikely.","miss":4},{"id":"uti-f","group":"common","label":"Urinary source","default":false,"tags":[],"ruleout":"A urinary source was considered and evaluated with urinalysis and examination as appropriate.","miss":2},{"id":"pna-f","group":"common","label":"Pulmonary source","default":false,"tags":[],"ruleout":"A pulmonary source was considered and evaluated with examination and imaging as appropriate.","miss":2},{"id":"viral-f","group":"other","label":"Self-limited viral syndrome","default":false,"tags":[],"ruleout":"A self-limited viral syndrome was considered as the likely cause after the serious sources above were addressed.","miss":1}],"risk":[{"id":"qsofa","label":"qSOFA","tags":["sep"],"scale":"low","line":"A qSOFA assessment was documented to flag risk of a poor outcome in suspected infection.","cite":"Seymour CW, et al. JAMA. 2016.","calc":{"fields":[{"label":"Respiratory rate ≥ 22","opts":[["No",0],["Yes",1]]},{"label":"Altered mentation (GCS < 15)","opts":[["No",0],["Yes",1]]},{"label":"Systolic BP ≤ 100","opts":[["No",0],["Yes",1]]}],"bands":[[1,"low risk","low","qSOFA <2: lower risk, but does not rule out sepsis — continue clinical assessment."],[3,"≥ 2 — elevated risk","high","qSOFA ≥2: flag for sepsis — escalate assessment, check lactate, and consider a higher level of care."]],"line":"qSOFA {score}/3 ({band}); used to flag risk of poor outcome in suspected infection and to inform escalation and monitoring.","applies":"Adults with suspected infection, as a bedside prompt for organ dysfunction and reassessment -- not a sepsis rule-in and not a substitute for lactate and clinical judgment."},"short":"qSOFA {band}"},{"id":"lactate-f","label":"Lactate","tags":["sep"],"scale":"low","line":"A lactate was obtained and reviewed as a marker of perfusion in the clinical context.","short":"lactate normal"},{"id":"source-f","label":"Source-directed workup","tags":[],"scale":"low","line":"A source-directed workup (cultures and targeted studies) was obtained before or alongside empiric therapy as indicated.","short":"source-directed cultures and studies obtained"}],"checks":[{"if":"septic-shock","needs":["qsofa","lactate-f"],"mode":"any","warn":"Sepsis is on the differential — a perfusion marker and/or a documented severity score supports the risk assessment and escalation decision."}],"history":[{"id":"fever-hx-onset-duration","dx":"general","q":"Fever onset and duration — how many days, maximum temperature measured at home, and any preceding exposures (sick contacts, recent travel, animals)?","answers":[{"label":"Brief, low-grade, no unusual exposures","tone":"neg","sets":[],"ddx":[],"mdm":"Fever was brief and low-grade, of short duration with a modest maximum home temperature and no unusual exposures such as sick contacts, recent travel, or animal contact; a self-limited process was considered most likely pending further evaluation.","frag":"brief, low-grade fever without unusual exposures"},{"label":"High or prolonged fever, or unusual exposures","tone":"pos","sets":[],"ddx":[],"mdm":"Either a high or prolonged fever or an unusual exposure (sick contacts, recent travel, or animal contact) was reported; a broader infectious workup was undertaken.","frag":"high or prolonged fever, or unusual exposures"}]},{"id":"fever-hx-immunosuppression","dx":"septic-shock","q":"Immunocompromised state — transplant recipient, active chemotherapy, prolonged systemic steroids (≥ 20 mg/day), or known HIV with low CD4 count?","answers":[{"label":"Not immunocompromised","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was assessed for an immunocompromised state (transplant, active chemotherapy, prolonged systemic steroids (≥ 20 mg/day), or HIV with a low CD4 count), none of which was present, and the threshold for standard source workup was applied.","frag":"not immunocompromised"},{"label":"Immunocompromised","tone":"pos","sets":[],"ddx":[{"id":"septic-shock","keep":true}],"mdm":"An immunocompromised state (transplant, active chemotherapy, prolonged systemic steroids (≥ 20 mg/day), or HIV with a low CD4 count) was identified; the threshold for escalated workup, empiric broad-spectrum coverage, and specialist consultation was lowered accordingly.","frag":"immunocompromised"}]},{"id":"fever-hx-lines-hardware","dx":"septic-shock","q":"Indwelling vascular catheter (central or PICC), urinary catheter, orthopedic or cardiac hardware, or invasive procedure within the past 4 weeks?","answers":[{"label":"No indwelling hardware or recent procedure","tone":"neg","sets":[],"ddx":[],"mdm":"No indwelling vascular or urinary catheters and no recent invasive procedures were identified.","frag":"no indwelling catheters or recent invasive procedure"},{"label":"Indwelling line, hardware, or recent procedure","tone":"pos","sets":[],"ddx":[{"id":"septic-shock","keep":true}],"mdm":"An indwelling catheter, orthopaedic or cardiac hardware, or recent invasive procedure was identified; a device-related infectious source was considered and blood cultures were obtained.","frag":"indwelling line, hardware, or recent procedure"}]},{"id":"fever-hx-travel-exposure","dx":"septic-shock","q":"Travel to or residence in an endemic area within the past 4 weeks, or exposure to ill contacts, livestock, or untreated water sources?","answers":[{"label":"No relevant travel or unusual exposures","tone":"neg","sets":[],"ddx":[],"mdm":"No relevant travel history or unusual exposures were reported; endemic or travel-related infections were not a primary concern.","frag":"no relevant travel or unusual exposures"},{"label":"Travel to endemic region or unusual exposure","tone":"pos","sets":[],"ddx":[{"id":"septic-shock","keep":true}],"mdm":"Travel to an endemic region or an unusual environmental exposure was reported; travel-related pathogens including malaria and rickettsial disease were included in the differential.","frag":"travel to endemic region or unusual exposure"}]},{"id":"fever-hx-meningitis-triad","dx":"meningitis-f","q":"Severe headache, neck stiffness, or photophobia — the classic meningitis triad — with fever?","answers":[{"label":"No headache, neck stiffness, or photophobia","tone":"neg","sets":[],"ddx":[],"mdm":"No severe headache, neck stiffness, or photophobia was reported; the classic meningitis triad was absent by history.","frag":"no headache, neck stiffness, or photophobia"},{"label":"Severe headache, neck stiffness, or photophobia","tone":"pos","sets":[],"ddx":[{"id":"meningitis-f","keep":true}],"mdm":"Severe headache, neck stiffness, or photophobia was reported alongside fever; bacterial meningitis was a primary diagnostic concern requiring urgent evaluation.","frag":"headache, neck stiffness, or photophobia"}]},{"id":"fever-hx-meningitis-rash","dx":"meningitis-f","q":"Non-blanching petechial or purpuric rash with fever (meningococcal disease)?","answers":[{"label":"No petechial or purpuric rash","tone":"neg","sets":[],"ddx":[],"mdm":"No non-blanching petechial or purpuric rash was reported.","frag":"no petechial or purpuric rash"},{"label":"Non-blanching petechiae or purpura","tone":"pos","sets":[],"ddx":[{"id":"meningitis-f","keep":true}],"mdm":"A non-blanching petechial or purpuric rash was reported with fever; meningococcal disease was a critical concern requiring emergent evaluation and empiric antibiotic administration.","frag":"non-blanching petechiae or purpura"}]},{"id":"fever-hx-meningitis-immune-device","dx":"meningitis-f","q":"Immunocompromise, neurosurgical procedure, CSF shunt, cochlear implant, or basilar skull fracture — conditions that increase CNS infection risk?","answers":[{"label":"No CNS infection risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No specific risk factors for CNS infection were identified.","frag":"no CNS infection risk factors"},{"label":"CNS infection risk factor present","tone":"pos","sets":[],"ddx":[{"id":"meningitis-f","keep":true}],"mdm":"A risk factor for CNS infection was identified (immunocompromise, neurosurgical device, or basilar skull fracture); meningitis was maintained on the differential.","frag":"CNS infection risk factor present"}]},{"id":"fever-hx-necrotizing-pop","dx":"necrotizing","q":"Pain out of proportion to visible skin findings — or rapidly spreading redness / swelling at a wound, surgical site, perineum, or extremity?","answers":[{"label":"No pain out of proportion or rapid spread","tone":"neg","sets":[],"ddx":[],"mdm":"By history there was no pain out of proportion to visible findings and no rapidly spreading redness or swelling at a wound, surgical site, perineum, or extremity to suggest a necrotizing soft-tissue infection.","frag":"no pain out of proportion or rapid spread"},{"label":"Pain out of proportion or rapidly spreading erythema","tone":"pos","sets":[],"ddx":[{"id":"necrotizing","keep":true}],"mdm":"Pain out of proportion to visible findings or rapidly spreading erythema was reported; necrotizing soft-tissue infection was given high priority and urgent surgical evaluation was initiated.","frag":"pain out of proportion or rapidly spreading erythema"}]},{"id":"fever-hx-necrotizing-risk","dx":"necrotizing","q":"Diabetes, peripheral vascular disease, obesity, or recent minor trauma / insect bite in the affected area (NSTI predisposing factors)?","answers":[{"label":"No predisposing factors","tone":"neg","sets":[],"ddx":[],"mdm":"No predisposing factors for necrotizing soft-tissue infection were identified.","frag":"no NSTI predisposing factors"},{"label":"Predisposing factor present","tone":"pos","sets":[],"ddx":[{"id":"necrotizing","keep":true}],"mdm":"A predisposing factor for NSTI (diabetes, vascular disease, or local trauma) was identified; clinical vigilance for early necrotizing infection was maintained.","frag":"NSTI predisposing factor present"}]},{"id":"fever-hx-uti","dx":"uti-f","q":"Dysuria, urinary frequency or urgency, suprapubic pain, or costovertebral angle tenderness / flank pain (pyelonephritis)?","answers":[{"label":"No urinary symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No dysuria, urinary frequency, suprapubic pain, or flank pain was reported; a urinary source was not suggested by history.","frag":"no urinary symptoms"},{"label":"Urinary symptoms present","tone":"pos","sets":[],"ddx":[{"id":"uti-f","keep":true}],"mdm":"Urinary symptoms including dysuria, frequency, or flank pain were reported; a urinary source was considered and urinalysis and urine culture were obtained.","frag":"dysuria, frequency, or flank pain"}]},{"id":"fever-hx-pna","dx":"pna-f","q":"Productive cough, purulent sputum, pleuritic chest pain, or dyspnea (pulmonary source)?","answers":[{"label":"No respiratory symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No productive cough, pleuritic chest pain, or dyspnea was reported; a pulmonary source was not suggested by history.","frag":"no cough, pleuritic pain, or dyspnea"},{"label":"Productive cough, pleuritic pain, or dyspnea","tone":"pos","sets":[],"ddx":[{"id":"pna-f","keep":true}],"mdm":"A productive cough, pleuritic chest pain, or dyspnea was reported; a pulmonary infectious source was considered and a chest radiograph was obtained.","frag":"productive cough, pleuritic pain, or dyspnea"}]},{"id":"fever-hx-viral","dx":"viral-f","q":"Viral prodrome — myalgias, headache, rhinorrhea, sore throat, or sick contacts — without localizing source symptoms?","answers":[{"label":"Clear viral prodrome, no localizing symptoms","tone":"pos","sets":[],"ddx":[],"mdm":"A typical viral prodrome (myalgias, headache, rhinorrhea, or sore throat, with or without sick contacts) was present without a localizing source; a self-limited viral etiology was supported after serious causes were excluded.","frag":"typical viral prodrome without localizing source"},{"label":"No viral prodrome / no localizing source identified","tone":"neg","sets":[],"ddx":[],"mdm":"No viral prodrome (myalgias, headache, rhinorrhea, sore throat, or sick contacts) was identified and a self-limited viral source was not confidently established; serious and bacterial sources were actively sought.","frag":"no viral prodrome or localizing source"}]}],"exam":[{"id":"fever-exam-rr","dx":"septic-shock","q":"Respiratory rate ≥ 22 breaths per minute (qSOFA criterion 1)?","answers":[{"label":"RR < 22","tone":"neg","sets":[{"risk":"qsofa","field":0,"opt":0}],"ddx":[],"mdm":"Respiratory rate was below 22 breaths per minute; this qSOFA criterion was not met.","frag":"RR < 22"},{"label":"RR ≥ 22","tone":"pos","sets":[{"risk":"qsofa","field":0,"opt":1}],"ddx":[{"id":"septic-shock","keep":true}],"mdm":"Respiratory rate was 22 breaths per minute or greater, meeting a qSOFA criterion and indicating an elevated risk of poor outcome in suspected infection (Singer et al. JAMA 2016).","frag":"RR ≥ 22"}]},{"id":"fever-exam-mentation","dx":"septic-shock","q":"Altered mentation — GCS < 15, new confusion, or acute behavioral change from baseline (qSOFA criterion 2)?","answers":[{"label":"Alert and oriented, GCS 15","tone":"neg","sets":[{"risk":"qsofa","field":1,"opt":0}],"ddx":[],"mdm":"The patient was alert and oriented with a GCS of 15, without new confusion or acute behavioral change from baseline; the altered mentation qSOFA criterion was not met.","frag":"alert and oriented, GCS 15"},{"label":"Altered mentation or GCS < 15","tone":"pos","sets":[{"risk":"qsofa","field":1,"opt":1}],"ddx":[{"id":"septic-shock","keep":true},{"id":"meningitis-f","keep":true}],"mdm":"Altered mentation (a GCS below 15, new confusion, or acute behavioral change from baseline) was present, meeting a qSOFA criterion and raising concern for septic encephalopathy or CNS infection.","frag":"altered mentation or GCS < 15"}]},{"id":"fever-exam-sbp","dx":"septic-shock","q":"Systolic BP ≤ 100 mmHg — hypotension (qSOFA criterion 3)?","answers":[{"label":"SBP > 100 mmHg","tone":"neg","sets":[{"risk":"qsofa","field":2,"opt":0}],"ddx":[],"mdm":"Systolic blood pressure was above 100 mmHg; the hypotension qSOFA criterion was not met.","frag":"SBP > 100"},{"label":"SBP ≤ 100 mmHg","tone":"pos","sets":[{"risk":"qsofa","field":2,"opt":1}],"ddx":[{"id":"septic-shock","keep":true}],"mdm":"Systolic blood pressure was 100 mmHg or below, meeting the qSOFA hypotension criterion and indicating hemodynamic compromise consistent with septic shock.","frag":"SBP ≤ 100"}]},{"id":"fever-exam-perfusion","dx":"septic-shock","q":"Mottling, capillary refill > 3 seconds, or cold clammy extremities suggesting impaired perfusion?","answers":[{"label":"Normal perfusion, capillary refill ≤ 2 s","tone":"neg","sets":[],"ddx":[],"mdm":"Peripheral perfusion was intact; no mottling and a capillary refill time of 2 seconds or less were noted.","frag":"perfusion intact, capillary refill ≤ 2 s"},{"label":"Mottling or delayed capillary refill","tone":"pos","sets":[],"ddx":[{"id":"septic-shock","keep":true}],"mdm":"Mottling or a capillary refill time greater than 3 seconds was present, indicating impaired peripheral perfusion consistent with septic shock physiology.","frag":"mottling or capillary refill > 3 s"}]},{"id":"fever-exam-meningismus","dx":"meningitis-f","q":"Meningismus — nuchal rigidity, Kernig sign (pain/resistance on knee extension with hip flexed 90°), or Brudzinski sign (reflex hip flexion on neck flexion)?","answers":[{"label":"Neck supple, Kernig and Brudzinski negative","tone":"neg","sets":[],"ddx":[],"mdm":"The neck was supple without Kernig or Brudzinski signs, noting these signs are insensitive (nuchal rigidity ~30%, Kernig/Brudzinski ~5%), so their absence was not used alone to exclude meningitis; mentation, the overall clinical picture, and the lumbar-puncture threshold carried the decision.","frag":"neck supple, no meningismus (insensitive signs, not relied on alone)"},{"label":"Nuchal rigidity or positive meningeal signs","tone":"pos","sets":[],"ddx":[{"id":"meningitis-f","keep":true}],"mdm":"Nuchal rigidity or positive Kernig or Brudzinski signs were present, raising strong concern for bacterial meningitis requiring emergent lumbar puncture (after neuroimaging if indicated).","frag":"nuchal rigidity or positive meningeal signs"}]},{"id":"fever-exam-meningitis-rash","dx":"meningitis-f","q":"Petechial or purpuric rash on skin examination — non-blanching on diascopy?","answers":[{"label":"No petechiae or purpura on skin exam","tone":"neg","sets":[],"ddx":[],"mdm":"No petechial or purpuric lesions were identified on skin examination.","frag":"no petechiae or purpura on skin exam"},{"label":"Non-blanching petechiae or purpura","tone":"pos","sets":[],"ddx":[{"id":"meningitis-f","keep":true}],"mdm":"Non-blanching petechiae or purpura were identified on skin examination; meningococcal disease was a critical concern requiring immediate empiric antibiotic administration without delay for imaging or LP.","frag":"non-blanching petechiae or purpura on exam"}]},{"id":"fever-exam-skin-nsti","dx":"necrotizing","q":"Soft-tissue examination — crepitus on palpation, bullae, woody induration, or skin margin advancing rapidly (> 1 cm/hr)?","answers":[{"label":"No crepitus, bullae, or rapidly advancing erythema","tone":"neg","sets":[],"ddx":[],"mdm":"No crepitus, bullae, woody induration, or rapidly advancing erythema was identified; the skin examination did not suggest necrotizing soft-tissue infection.","frag":"no crepitus, bullae, or rapidly advancing erythema"},{"label":"Crepitus, bullae, or rapidly advancing margin","tone":"pos","sets":[],"ddx":[{"id":"necrotizing","keep":true}],"mdm":"Crepitus, bullae, or a rapidly advancing erythematous margin was identified on examination: findings consistent with necrotizing soft-tissue infection requiring emergent surgical consultation.","frag":"crepitus, bullae, or rapidly advancing margin"}]},{"id":"fever-exam-source-general","dx":"general","q":"Directed source examination — oropharynx, neck nodes, lungs, abdomen, costovertebral angles, skin/wounds, and joint tenderness — revealing a focal infectious source?","answers":[{"label":"No focal source identified on examination","tone":"neg","sets":[],"ddx":[],"mdm":"A directed examination of the oropharynx, neck nodes, lungs, abdomen, costovertebral angles, skin and wounds, and joints did not reveal a focal infectious source.","frag":"no focal infectious source on exam"},{"label":"Focal source identified (specify)","tone":"pos","sets":[],"ddx":[],"mdm":"A focal infectious source was identified on directed examination of the oropharynx, neck nodes, lungs, abdomen, costovertebral angles, skin and wounds, or joints; source-directed diagnostic and therapeutic measures were initiated.","frag":"focal infectious source identified"}]},{"answers":[{"ddx":[],"frag":"no petechiae, purpura, or meningismus (but the rash is often absent early and meningeal signs are insensitive, so toxicity and reassessment carried it)","label":"No meningococcemia signs","mdm":"There was no petechial or purpuric rash, meningismus, or hemodynamic instability. Because the rash may be absent early in meningococcemia and meningeal signs are insensitive, these findings were not used alone to exclude it; the overall toxicity assessment and reassessment carried the decision.","sets":[],"tone":"neg"},{"ddx":[{"id":"meningococcemia-f","keep":true}],"frag":"petechial/purpuric rash or meningismus","label":"Meningococcemia signs present","mdm":"A petechial or purpuric rash, meningismus, or hemodynamic instability was present, raising strong concern for meningococcemia and warranting immediate empiric therapy.","sets":[],"tone":"pos"}],"dx":"meningococcemia-f","id":"fever-exam-meningococcemia-f","q":"Meningococcemia — petechial or purpuric rash, meningismus, or hemodynamic instability?"}],"conclusions":["viral syndrome","uncomplicated viral infection"],"specs":["id"],"algorithm":{"immediate":["Full vitals with a perfusion assessment; obtain lactate and blood cultures, then start broad-spectrum antibiotics early for suspected sepsis.","Balanced-crystalloid resuscitation for hypotension or hyperlactatemia; identify and control the source."],"criticalTests":["Lactate and blood cultures (before antibiotics when feasible)","CBC, renal/LFTs, urinalysis; chest imaging","Lumbar puncture when meningitis is suspected (do not delay antibiotics)","Imaging of any suspected deep/necrotizing source"],"cantMiss":[{"dx":"septic-shock","trigger":"Infection with hypotension or organ dysfunction","test":"Lactate, cultures, source imaging","intervention":"Early antibiotics, fluid resuscitation, vasopressors if fluid-refractory"},{"dx":"meningitis-f","trigger":"Headache, meningismus, or altered mentation","test":"Lumbar puncture","intervention":"Early empiric antibiotics ± acyclovir; dexamethasone where indicated"},{"dx":"necrotizing","trigger":"Pain out of proportion, crepitus, bullae, rapid spread","test":"Clinical; CT should not delay surgery","intervention":"Broad-spectrum antibiotics and emergent surgical debridement"},{"dx":"meningococcemia-f","trigger":"Petechial/purpuric rash with toxicity","test":"Clinical; cultures","intervention":"Immediate antibiotics and droplet precautions"}],"disposition":"Septic or toxic-appearing patients are admitted (often to a monitored bed); a well-appearing patient with an identified minor source and reassuring vitals may be discharged with precautions."},"decisionTree":{"title":"Sepsis — recognition & early management","intro":"An original, evidence-based decision aid for suspected sepsis. Apply local protocol (e.g., Surviving Sepsis) and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Recognize & screen","items":["Full vitals with a perfusion assessment","Identify the suspected source of infection","Obtain lactate and blood cultures"],"next":"q_sepsis"},"q_sepsis":{"type":"decision","q":"Sepsis physiology? (infection plus organ dysfunction or hypoperfusion — hypotension, altered mentation, tachypnea, or a high lactate)","cantmiss":"Sepsis can present without fever — the elderly and immunocompromised may be normothermic or even hypothermic.","yes":"a_bundle","no":"q_highrisk"},"a_bundle":{"type":"action","tone":"danger","title":"Early sepsis care","items":["Blood cultures before antibiotics when feasible","Broad-spectrum antibiotics early","Balanced-crystalloid resuscitation for hypotension or hyperlactatemia","Source control"],"next":"q_refractory"},"q_refractory":{"type":"decision","q":"Hypotension persists after fluid resuscitation?","yes":"a_pressors","no":"a_admit"},"a_pressors":{"type":"action","tone":"danger","title":"Septic shock","terminal":true,"items":["Vasopressors (norepinephrine first-line) to a perfusion target","Reassess fluid responsiveness; ICU-level care","Ongoing source control"]},"a_admit":{"type":"action","tone":"branch","title":"Admit & monitor","terminal":true,"items":["Reassess lactate and perfusion after resuscitation","Continue antibiotics; level of care by severity"]},"q_highrisk":{"type":"decision","q":"Toxic-appearing or high-risk host (immunocompromised, asplenia, indwelling line, recent chemotherapy)?","pitfall":"Neutropenic fever is an emergency — give antibiotics within the hour; don't wait for the count.","yes":"a_lowthresh","no":"a_source"},"a_lowthresh":{"type":"action","title":"Treat with a low threshold","terminal":true,"items":["Cultures and early empiric antibiotics; observe","Pursue can't-miss sources (meningitis -> LP; necrotizing infection -> surgery)"]},"a_source":{"type":"action","title":"Identify & treat the source","terminal":true,"items":["Targeted workup for the focal infection","Treat and, if well-appearing with reassuring vitals, discharge with precautions"]}}},"guide":"../learn/complaints/fever.html","pearls":[{"text":"Septic shock is defined by organ dysfunction and vasopressor need, not by hypotension — hypotension is a late marker. Don't wait for a falling blood pressure to start the sepsis bundle.","dx":"septic-shock","src":"Sepsis-3"},{"text":"qSOFA is specific but insensitive — a normal qSOFA does not exclude sepsis. Don't rely on it (or SIRS) alone as a screen; look for hypoxia, altered mentation, rising creatinine, low platelets, or lactate ≥2.","src":"SSC 2021"},{"text":"Fully undress every febrile patient, especially the older or diabetic one with minimal tenderness — an occult abdominal source or a missed sacral/toe necrosis is easy to overlook on a covered exam.","dx":"septic-shock"},{"text":"Pain out of proportion to exam findings, with crepitus, means necrotizing soft-tissue infection until proven otherwise — broad antibiotics plus clindamycin and emergent surgical consultation, not observation.","dx":"necrotizing"},{"text":"Never let blood cultures delay antibiotics in a severely ill patient — draw two sets, then give antibiotics; in probable septic shock, antibiotics belong within one hour.","dx":"septic-shock"},{"text":"An indwelling line, hardware, or recent chemotherapy changes the source hunt — culture the line and peripherally, and lower your threshold for broad coverage in the immunocompromised febrile patient.","dx":"meningococcemia-f"}]},{"id":"ams","title":"Altered Mental Status","aliases":["ams","altered","confusion","aloc","altered mental status","delirium","encephalopathy","unresponsive","lethargy","not acting right"],"opening":"The patient was evaluated for altered mental status. A collateral history, vital signs, a point-of-care glucose, and a neurologic examination were obtained, and the reversible and dangerous causes below were actively considered.","ddx":[{"id":"hypoglycemia","group":"lifethreat","label":"Hypoglycemia","default":true,"tags":["glu"],"ruleout":"Hypoglycemia was considered and excluded by a normal point-of-care glucose.","miss":3},{"id":"stroke-ams","group":"lifethreat","label":"Stroke","default":true,"tags":["neuro"],"ruleout":"Acute stroke was considered; there was no focal weakness, facial droop, aphasia, gaze deviation, or visual field deficit, the examination was non-focal, and last-known-well was established, making it unlikely.","miss":4},{"id":"ich-ams","group":"lifethreat","label":"Intracranial hemorrhage","default":true,"tags":[],"ruleout":"Intracranial hemorrhage was considered; there was no anticoagulant use, head trauma, severe headache, vomiting, or focal deficit, and the neurologic examination was non-focal, making it unlikely.","miss":4},{"id":"cns-infection","group":"lifethreat","label":"CNS infection","default":false,"tags":[],"ruleout":"CNS infection was considered; there was no fever, neck stiffness, rash, immunocompromise, or focal deficit, making it unlikely while recognizing meningeal signs are insensitive and their absence alone does not exclude meningitis.","miss":3},{"id":"hypoxia-ams","group":"lifethreat","label":"Hypoxia / hypercapnia","default":false,"tags":[],"ruleout":"Hypoxia or hypercapnia was considered; oxygen saturation was normal on room air, there was no respiratory distress or cyanosis, and blood gas where obtained showed no hypercapnia, making it unlikely.","miss":3},{"id":"tox-ams","group":"lifethreat","label":"Toxic ingestion / withdrawal","default":false,"tags":[],"ruleout":"Toxic ingestion or withdrawal was considered; there was no suggestive medication or exposure history, vital signs and pupils were normal, and no coherent toxidrome was present, making it unlikely.","miss":3},{"id":"metabolic-ams","group":"common","label":"Metabolic / electrolyte disturbance","default":false,"tags":[],"ruleout":"A metabolic or electrolyte disturbance was considered and evaluated with laboratory studies as indicated.","miss":2},{"id":"delirium","group":"other","label":"Delirium from systemic trigger","default":false,"tags":[],"ruleout":"Delirium was considered; there was no fluctuating alertness, nocturnal worsening, or inattention, and a systematic search for reversible precipitants (infection, new medication or polypharmacy, constipation, recent surgery or hospitalization) was unrevealing, making an underlying structural or metabolic cause more likely than delirium alone.","miss":4}],"risk":[{"id":"glucose","label":"Point-of-care glucose","tags":["glu"],"scale":"low","line":"A point-of-care glucose was obtained and was within normal limits.","short":"POC glucose normal"},{"id":"gcs","label":"GCS / level of consciousness","tags":["neuro"],"scale":"low","line":"The level of consciousness was quantified (e.g., Glasgow Coma Scale) and documented.","cite":"Teasdale G, Jennett B. Lancet. 1974;2(7872):81-4.","short":"GCS documented","calc":{"fields":[{"label":"Eye opening","opts":[["Spontaneous",4],["To voice",3],["To pain",2],["None",1]]},{"label":"Verbal response","opts":[["Oriented",5],["Confused",4],["Inappropriate words",3],["Incomprehensible",2],["None",1]]},{"label":"Motor response","opts":[["Obeys commands",6],["Localizes pain",5],["Withdraws",4],["Abnormal flexion",3],["Extension",2],["None",1]]}],"bands":[[8,"severe (≤ 8)","high","GCS ≤8: airway at risk — consider intubation for airway protection."],[12,"moderate (9–12)","mod","GCS 9–12: close monitoring with serial neurologic checks."],[15,"mild / normal (13–15)","low","GCS 13–15: continue assessment in the clinical context."]],"line":"Glasgow Coma Scale {score}/15 ({band}); level of consciousness quantified and documented.","applies":"Any age, to track and communicate level of consciousness serially. Confounded by sedation, intubation, intoxication, and aphasia -- trend it rather than treating one value as fixed."}},{"id":"neuroexam-ams","label":"Documented neuro exam","tags":["neuro"],"scale":"low","line":"A focused neurologic examination was performed and documented, with attention to focality.","short":"focused neuro exam documented"}],"checks":[{"if":"hypoglycemia","needs":["glucose"],"mode":"any","warn":"Hypoglycemia is on the differential — a documented glucose is the fastest reversible cause to exclude."},{"if":"stroke-ams","needs":["neuroexam-ams","gcs"],"mode":"any","warn":"Stroke is on the differential — a documented neuro exam and last-known-well time anchor the assessment."},{"if":"cns-infection","needs":["neuroexam-ams"],"mode":"any","warn":"CNS infection is on the differential — a documented neurologic examination supports the decision to pursue (or defer) lumbar puncture."}],"history":[{"id":"ams-hx-baseline","dx":"general","q":"Baseline mental status — has the patient's mentation returned to their pre-morbid baseline? Prior history of cognitive impairment or psychiatric illness?","answers":[{"label":"Cognition at baseline, no prior impairment","tone":"neg","sets":[],"ddx":[],"mdm":"The patient's mental status was reported to be at their established baseline; no prior cognitive impairment or psychiatric illness was identified.","frag":"at established baseline, no prior cognitive or psychiatric impairment"},{"label":"Acutely below baseline","tone":"pos","sets":[],"ddx":[],"mdm":"The current mentation was acutely below the patient's established baseline, confirming genuine altered mental status requiring evaluation for an organic cause.","frag":"acutely below baseline"}]},{"id":"ams-hx-onset-course","dx":"general","q":"Onset and course — sudden vs. gradual onset? Fluctuating or progressive course?","answers":[{"label":"Gradual onset, fluctuating course","tone":"neg","sets":[],"ddx":[],"mdm":"Onset was gradual with a fluctuating course, a pattern more consistent with a metabolic, infectious, or toxic etiology than with an acute structural event.","frag":"gradual onset, fluctuating course"},{"label":"Sudden onset","tone":"pos","sets":[],"ddx":[],"mdm":"Onset was sudden, raising concern for a vascular cause such as stroke or intracranial hemorrhage and warranting urgent neuroimaging.","frag":"sudden onset"}]},{"id":"ams-hx-hypoglycemia-rx","dx":"hypoglycemia","q":"Hypoglycemia risk — diabetes on insulin or sulfonylurea? Last meal and timing of most recent dose?","answers":[{"label":"No diabetes or not on insulin/sulfonylurea","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was not diabetic or was not on insulin or a sulfonylurea; pharmacologic hypoglycemia was not a primary concern.","frag":"no insulin or sulfonylurea use"},{"label":"Insulin or sulfonylurea use with poor recent intake","tone":"pos","sets":[],"ddx":[{"id":"hypoglycemia","keep":true}],"mdm":"The patient was on insulin or a sulfonylurea with reported poor recent oral intake, placing them at high risk for hypoglycemia; a point-of-care glucose was obtained immediately.","frag":"insulin/sulfonylurea use with poor intake"}]},{"id":"ams-hx-stroke-onset","dx":"stroke-ams","q":"Stroke — sudden onset with focal neurologic deficit (facial droop, unilateral arm or leg weakness, speech difficulty)? Last-known-well time established?","answers":[{"label":"Gradual onset, no focal deficits","tone":"neg","sets":[],"ddx":[],"mdm":"Onset was gradual without focal neurologic deficits (no facial droop, unilateral arm or leg weakness, or speech difficulty) and the presentation was not consistent with an acute ischemic stroke.","frag":"gradual onset, no focal deficit"},{"label":"Sudden onset with focal deficits — LKW established","tone":"pos","sets":[],"ddx":[{"id":"stroke-ams","keep":true}],"mdm":"Sudden-onset focal neurologic deficits were reported: facial droop, unilateral arm or leg weakness, or speech difficulty; last-known-well time was established and the patient was evaluated urgently for acute stroke and thrombolytic eligibility.","frag":"sudden focal deficit, LKW established"}]},{"id":"ams-hx-stroke-vascular-risk","dx":"stroke-ams","q":"Vascular risk factors — hypertension, diabetes, hyperlipidemia, tobacco, atrial fibrillation, prior stroke or TIA?","answers":[{"label":"None / low vascular risk","tone":"neg","sets":[],"ddx":[],"mdm":"No significant vascular risk factors (hypertension, diabetes, hyperlipidemia, tobacco use, atrial fibrillation, or prior stroke or TIA) were identified, lowering the baseline probability of ischemic stroke.","frag":"no cerebrovascular risk factors"},{"label":"Vascular risk factors or known atrial fibrillation","tone":"pos","sets":[],"ddx":[{"id":"stroke-ams","keep":true}],"mdm":"Significant vascular risk factors or known atrial fibrillation were present, raising the prior probability of cardioembolic or atherosclerotic stroke.","frag":"vascular risk factors or known AFib"}]},{"id":"ams-hx-ich-anticoag","dx":"ich-ams","q":"Anticoagulation or antiplatelet therapy — warfarin, DOAC, dual antiplatelet? Recent INR or therapeutic level known?","answers":[{"label":"No anticoagulation or antiplatelet use","tone":"neg","sets":[],"ddx":[],"mdm":"No anticoagulant or antiplatelet therapy (warfarin, a DOAC, or dual antiplatelet therapy) was reported, reducing (though not eliminating) the concern for anticoagulant-related intracranial hemorrhage.","frag":"no anticoagulant or antiplatelet use"},{"label":"Anticoagulation or antiplatelet use","tone":"pos","sets":[],"ddx":[{"id":"ich-ams","keep":true}],"mdm":"Anticoagulant or antiplatelet therapy (warfarin, a DOAC, or dual antiplatelet therapy) was identified, substantially raising the risk of intracranial hemorrhage and lowering the threshold for emergent neuroimaging.","frag":"on anticoagulant or antiplatelet"}]},{"id":"ams-hx-ich-trauma-headache","dx":"ich-ams","q":"Recent head trauma (including low-mechanism falls in elderly)? Sudden severe headache at onset ('worst of life' or thunderclap)?","answers":[{"label":"No head trauma; no thunderclap headache","tone":"neg","sets":[],"ddx":[],"mdm":"No recent head trauma and no sudden severe or thunderclap headache were reported; a traumatic or spontaneous ICH was less likely on history.","frag":"no head trauma or thunderclap headache"},{"label":"Head trauma or sudden severe/thunderclap headache","tone":"pos","sets":[],"ddx":[{"id":"ich-ams","keep":true}],"mdm":"Recent head trauma or a sudden severe (thunderclap) headache was reported at onset; emergent non-contrast head CT was obtained to evaluate for intracranial hemorrhage.","frag":"head trauma or thunderclap headache"}]},{"id":"ams-hx-cns-infection-fever","dx":"cns-infection","q":"CNS infection — fever with headache and neck stiffness? Photophobia or phonophobia?","answers":[{"label":"No fever, headache, or neck stiffness","tone":"neg","sets":[],"ddx":[],"mdm":"No fever, headache, or neck stiffness was reported; a CNS infectious cause was not strongly suggested by history.","frag":"no fever, headache, or neck stiffness"},{"label":"Fever with headache or neck stiffness","tone":"pos","sets":[],"ddx":[{"id":"cns-infection","keep":true}],"mdm":"Fever with headache or neck stiffness was reported, raising significant concern for bacterial meningitis or encephalitis; empiric antibiotics were considered while awaiting further evaluation.","frag":"fever with headache or neck stiffness"}]},{"id":"ams-hx-cns-infection-immune","dx":"cns-infection","q":"Immunocompromised state — HIV/AIDS, solid-organ transplant, chemotherapy, or high-dose systemic steroids?","answers":[{"label":"Immunocompetent","tone":"neg","sets":[],"ddx":[],"mdm":"No immunocompromising condition (HIV/AIDS, solid-organ transplant, chemotherapy, or high-dose systemic steroids) was identified; opportunistic CNS infections such as cryptococcal meningitis, PML, or toxoplasmosis were not a primary concern.","frag":"no immunocompromise"},{"label":"Immunocompromised","tone":"pos","sets":[],"ddx":[{"id":"cns-infection","keep":true}],"mdm":"An immunocompromised state (HIV/AIDS, solid-organ transplant, chemotherapy, or high-dose systemic steroids) was present, broadening the differential to include opportunistic CNS infections; empiric antifungal and antiviral coverage was considered alongside antibacterial therapy.","frag":"immunocompromised"}]},{"id":"ams-hx-hypoxia-lung-disease","dx":"hypoxia-ams","q":"Hypoxia risk — known COPD, obstructive sleep apnea, or established CO₂ retainer? Acute respiratory illness or worsening dyspnea?","answers":[{"label":"No significant lung disease or hypoxia history","tone":"neg","sets":[],"ddx":[],"mdm":"No history of chronic lung disease (COPD, obstructive sleep apnea, or established CO₂ retention) and no acute respiratory illness or worsening dyspnea were identified; hypoxic or hypercapnic AMS was not suggested by history.","frag":"no chronic lung disease, CO₂ retention, or acute respiratory illness"},{"label":"Known COPD/CO₂ retainer or acute respiratory illness","tone":"pos","sets":[],"ddx":[{"id":"hypoxia-ams","keep":true}],"mdm":"A history of COPD, obstructive sleep apnea, or established CO₂ retention, or an acute respiratory illness with worsening dyspnea, was present; oxygen saturation and ABG were obtained to assess for hypoxia or hypercapnia as a driver of the altered mental status.","frag":"CO₂ retainer or acute respiratory decompensation"}]},{"id":"ams-hx-co-exposure","dx":"hypoxia-ams","q":"Carbon monoxide exposure risk — gas appliances, running vehicles in enclosed space, housemates or coworkers with similar symptoms?","answers":[{"label":"No CO exposure risk identified","tone":"neg","sets":[],"ddx":[],"mdm":"No plausible source of carbon monoxide exposure (gas appliances or a running vehicle in an enclosed space) and no housemates or coworkers with similar symptoms were identified; CO poisoning was not suggested by history.","frag":"no CO exposure source or symptomatic cohabitants"},{"label":"Possible CO exposure (enclosed space, co-victim)","tone":"pos","sets":[],"ddx":[{"id":"hypoxia-ams","keep":true}],"mdm":"A plausible source of carbon monoxide exposure (gas appliances or a running vehicle in an enclosed space) or housemates or coworkers with similar symptoms was identified; CO oximetry or a carboxyhemoglobin level was obtained and high-flow oxygen was applied.","frag":"possible CO exposure or co-victim"}]},{"id":"ams-hx-tox-meds-ingestion","dx":"tox-ams","q":"New medications, recent dose change, or possible toxic ingestion — opioids, benzodiazepines, anticholinergics, sedative-hypnotics, recreational drugs?","answers":[{"label":"No new medications or ingestion identified","tone":"neg","sets":[],"ddx":[],"mdm":"No new medication, recent dose change, or possible toxic ingestion (opioids, benzodiazepines, anticholinergics, sedative-hypnotics, or recreational drugs) was identified; a pharmacologic cause was not suggested by history.","frag":"no new meds, dose change, or ingestion"},{"label":"New medication, dose change, or possible ingestion","tone":"pos","sets":[],"ddx":[{"id":"tox-ams","keep":true}],"mdm":"A new medication, recent dose change, or possible toxic ingestion (opioids, benzodiazepines, anticholinergics, sedative-hypnotics, or recreational drugs) was identified; a directed toxidrome evaluation was performed and toxicology consultation was considered.","frag":"new med, dose change, or possible ingestion"}]},{"id":"ams-hx-tox-alcohol","dx":"tox-ams","q":"Alcohol use — heavy or daily use? Time of last drink? Prior alcohol withdrawal seizure or delirium tremens? Poor nutritional status (Wernicke risk)?","answers":[{"label":"None / social use only","tone":"neg","sets":[],"ddx":[],"mdm":"No heavy or daily alcohol use was reported; alcohol intoxication, withdrawal, and Wernicke encephalopathy were not primary concerns.","frag":"no heavy or daily alcohol use"},{"label":"Heavy use — last drink > 24–48 hours ago","tone":"pos","sets":[],"ddx":[{"id":"tox-ams","keep":true}],"mdm":"Heavy or daily alcohol use was reported with the last drink more than 24 hours prior; alcohol withdrawal was a significant concern and the patient was monitored for escalating autonomic instability and seizure.","frag":"heavy use, last drink >24h ago"},{"label":"Chronic use with poor nutrition (Wernicke risk)","tone":"pos","sets":[],"ddx":[{"id":"tox-ams","keep":true}],"mdm":"Chronic alcohol use with poor nutritional intake raised concern for Wernicke encephalopathy; empiric thiamine was administered before any glucose-containing solution to avoid precipitating encephalopathy.","frag":"chronic use with poor nutrition (Wernicke risk)"}]},{"id":"ams-hx-metabolic-renal-hepatic","dx":"metabolic-ams","q":"Known renal or hepatic disease — end-stage renal disease, dialysis-dependent, cirrhosis, or known hepatic encephalopathy?","answers":[{"label":"No known renal or hepatic disease","tone":"neg","sets":[],"ddx":[],"mdm":"No history of end-stage renal disease, dialysis dependence, cirrhosis, or prior hepatic encephalopathy was identified.","frag":"no known ESRD, dialysis, cirrhosis, or hepatic encephalopathy"},{"label":"ESRD, dialysis, or cirrhosis with prior encephalopathy","tone":"pos","sets":[],"ddx":[{"id":"metabolic-ams","keep":true}],"mdm":"A history of end-stage renal disease or cirrhosis with prior hepatic encephalopathy was present; uremia and hepatic encephalopathy were considered as contributors to the altered mental status.","frag":"ESRD or cirrhosis with prior encephalopathy"}]},{"id":"ams-hx-metabolic-electrolyte-endocrine","dx":"metabolic-ams","q":"Electrolyte or endocrine history — known hyponatremia, hypercalcemia, or thyroid disease? Symptoms consistent with myxedema (cold intolerance, bradycardia, constipation)?","answers":[{"label":"No electrolyte or endocrine history","tone":"neg","sets":[],"ddx":[],"mdm":"No prior electrolyte disturbance (hyponatremia or hypercalcemia) or thyroid disease, and no myxedema symptoms such as cold intolerance, bradycardia, or constipation, were identified; a metabolic-endocrine cause was not suggested by history alone.","frag":"no prior electrolyte or endocrine disorder"},{"label":"Known electrolyte disorder or thyroid disease","tone":"pos","sets":[],"ddx":[{"id":"metabolic-ams","keep":true}],"mdm":"A history of electrolyte disturbance (hyponatremia or hypercalcemia) or thyroid disease was present; serum sodium, calcium, thyroid function, and other metabolic markers were included in the evaluation.","frag":"known electrolyte disorder or thyroid disease"}]},{"id":"ams-hx-delirium-precipitants","dx":"delirium","q":"Delirium precipitants — older adult (≥ 65) with acute-on-chronic cognitive change? Recent infection, surgery, hospitalization, or constipation? New medication or polypharmacy?","answers":[{"label":"No clear delirium precipitants","tone":"neg","sets":[],"ddx":[],"mdm":"No classic delirium precipitants in an older adult (recent infection, surgery, hospitalization, constipation, or a new medication or polypharmacy) were identified by history.","frag":"no delirium precipitants identified"},{"label":"Older adult with infection, polypharmacy, or functional change","tone":"pos","sets":[],"ddx":[{"id":"delirium","keep":true}],"mdm":"A classic delirium presentation was suggested: an older adult with new infection, polypharmacy, or recent functional decline and a fluctuating course; a systematic search for reversible precipitants was undertaken.","frag":"older adult with infection, polypharmacy, or functional decline"}]},{"id":"ams-hx-delirium-fluctuation","dx":"delirium","q":"Course fluctuation — waxing and waning level of alertness over hours? Worse at night (sundowning)?","answers":[{"label":"Consistent level of consciousness","tone":"neg","sets":[],"ddx":[],"mdm":"The level of consciousness was reported to be consistent without significant hour-to-hour fluctuation; sundowning was not described.","frag":"consistent level of consciousness, no sundowning"},{"label":"Fluctuating alertness or nocturnal worsening","tone":"pos","sets":[],"ddx":[{"id":"delirium","keep":true}],"mdm":"Fluctuating alertness with waxing and waning periods, or nocturnal worsening, was reported: a hallmark of delirium, distinguishing it from dementia and structural AMS.","frag":"fluctuating alertness or nocturnal worsening"}]}],"exam":[{"id":"ams-exam-vitals","dx":"general","q":"Vital signs — temperature, heart rate, blood pressure, respiratory rate, oxygen saturation?","answers":[{"label":"All vital signs within normal limits","tone":"neg","sets":[],"ddx":[],"mdm":"All vital signs (temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation) were within normal limits; no fever, hemodynamic instability, or abnormal respiratory rate was identified.","frag":"vital signs within normal limits"},{"label":"Fever","tone":"pos","sets":[],"ddx":[{"id":"cns-infection","keep":true}],"mdm":"Fever was present; combined with the altered mental status, this raised concern for a CNS infection or severe systemic infection as a cause.","frag":"fever"},{"label":"Hemodynamic instability or significant bradycardia/tachycardia","tone":"pos","sets":[],"ddx":[],"mdm":"Hemodynamic instability with significant bradycardia or tachycardia was present; systemic causes including sepsis, cardiovascular compromise, and metabolic derangement were prioritized.","frag":"hemodynamic instability"}]},{"id":"ams-exam-gcs","dx":"general","q":"Level of consciousness — GCS documented? Alert and oriented, or significantly depressed?","answers":[{"label":"Alert, GCS 15","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was alert with a GCS of 15; the level of consciousness was not significantly depressed.","frag":"alert, GCS 15"},{"label":"Depressed consciousness (GCS < 15)","tone":"pos","sets":[],"ddx":[],"mdm":"A depressed level of consciousness was documented (GCS < 15); the degree and trajectory were recorded and urgent evaluation for structural, metabolic, and toxic causes was initiated.","frag":"depressed consciousness, GCS <15"}]},{"id":"ams-exam-pocglucose","dx":"hypoglycemia","q":"Point-of-care glucose — obtained immediately? Result normal (70–180 mg/dL)?","answers":[{"label":"POC glucose normal (70–180 mg/dL) — hypoglycemia excluded","tone":"neg","sets":[],"ddx":[],"mdm":"Point-of-care glucose, when obtained, was within normal limits; hypoglycemia was excluded as a cause of the altered mental status.","frag":"POC glucose normal, hypoglycemia excluded"},{"label":"Hypoglycemic (< 70 mg/dL)","tone":"pos","sets":[],"ddx":[{"id":"hypoglycemia","keep":true}],"mdm":"Point-of-care glucose was critically low, consistent with hypoglycemia; dextrose was administered and the response was monitored.","frag":"hypoglycemic, glucose <70"},{"label":"Markedly elevated (> 300 mg/dL) or hyperglycemic","tone":"pos","sets":[],"ddx":[{"id":"metabolic-ams","keep":true}],"mdm":"Point-of-care glucose was markedly elevated; a hyperglycemic state (DKA, HHS) was considered as a contributor to the altered mental status.","frag":"markedly elevated glucose >300"}]},{"id":"ams-exam-focal-deficit","dx":"stroke-ams","q":"Focal neurologic deficit — facial asymmetry, pronator drift, arm or leg weakness, speech deficit? GCS trajectory?","answers":[{"label":"No focal deficit; non-focal exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal; no facial asymmetry, pronator drift, limb weakness, or speech deficit was identified.","frag":"non-focal neuro exam"},{"label":"Focal deficit present (lateralizing)","tone":"pos","sets":[],"ddx":[{"id":"stroke-ams","keep":true},{"id":"ich-ams","keep":true}],"mdm":"A lateralizing focal neurologic deficit (facial asymmetry, pronator drift, arm or leg weakness, or a speech deficit) was present on examination, requiring urgent neuroimaging to differentiate ischemic stroke from intracranial hemorrhage.","frag":"lateralizing focal deficit"}]},{"id":"ams-exam-head-trauma-signs","dx":"ich-ams","q":"External signs of head trauma — scalp laceration, periorbital ecchymosis (raccoon eyes), hemotympanum, or Battle sign?","answers":[{"label":"No external head-trauma signs","tone":"neg","sets":[],"ddx":[],"mdm":"No external signs of head trauma were identified; scalp, periorbital regions, and tympanic membranes were normal.","frag":"no external head-trauma signs"},{"label":"External signs of head trauma present","tone":"pos","sets":[],"ddx":[{"id":"ich-ams","keep":true}],"mdm":"External signs of head trauma were present (scalp laceration, periorbital ecchymosis, hemotympanum, or Battle sign), raising concern for intracranial injury and prompting emergent CT.","frag":"external signs of head trauma"}]},{"id":"ams-exam-meningismus","dx":"cns-infection","q":"Meningismus — nuchal rigidity, Kernig sign, or Brudzinski sign? Fever confirmed on exam?","answers":[{"label":"Neck supple, no meningeal signs","tone":"neg","sets":[],"ddx":[],"mdm":"The neck was supple without Kernig or Brudzinski signs, noting these signs are insensitive (nuchal rigidity ~30%, Kernig/Brudzinski ~5%), so their absence was not used alone to exclude meningitis; mentation, the overall clinical picture, and the lumbar-puncture threshold carried the decision.","frag":"neck supple, no meningismus (insensitive signs, not relied on alone)"},{"label":"Nuchal rigidity or positive meningeal signs","tone":"pos","sets":[],"ddx":[{"id":"cns-infection","keep":true}],"mdm":"Meningeal signs (nuchal rigidity, a positive Kernig sign, or a positive Brudzinski sign) were present, raising significant concern for bacterial meningitis or subarachnoid hemorrhage; empiric antibiotics were initiated and LP was planned.","frag":"nuchal rigidity or positive meningeal signs"}]},{"id":"ams-exam-pupils-toxidrome","dx":"tox-ams","q":"Pupils — equal, reactive, normal size? Signs of a toxidrome: miosis (opioid/cholinergic), mydriasis (sympathomimetic/anticholinergic), skin flushing/diaphoresis, characteristic odor?","answers":[{"label":"Pupils equal, reactive; no toxidrome signs","tone":"neg","sets":[],"ddx":[],"mdm":"Pupils were equal, round, and reactive to light; no toxidrome pattern (miosis, mydriasis, diaphoresis, flushing, or characteristic odor) was identified.","frag":"pupils equal and reactive, no toxidrome"},{"label":"Miosis (opioid or cholinergic toxidrome)","tone":"pos","sets":[],"ddx":[{"id":"tox-ams","keep":true}],"mdm":"Bilateral miosis was present, consistent with an opioid or cholinergic toxidrome; empiric naloxone was considered and administered.","frag":"miosis (opioid/cholinergic toxidrome)"},{"label":"Mydriasis (sympathomimetic or anticholinergic toxidrome)","tone":"pos","sets":[],"ddx":[{"id":"tox-ams","keep":true}],"mdm":"Bilateral mydriasis with accompanying toxidrome signs (skin flushing, diaphoresis, or a characteristic odor) was present, consistent with a sympathomimetic or anticholinergic ingestion.","frag":"mydriasis (sympathomimetic/anticholinergic toxidrome)"}]},{"id":"ams-exam-oxygenation","dx":"hypoxia-ams","q":"Oxygenation — SpO₂ ≥ 94% on room air? Work of breathing: tachypnea, accessory muscle use, cyanosis?","answers":[{"label":"SpO₂ ≥ 94%, no respiratory distress","tone":"neg","sets":[],"ddx":[],"mdm":"Oxygen saturation was 94% or greater on room air with no increased work of breathing: no tachypnea, accessory muscle use, or cyanosis; hypoxia as a cause of the altered mental status was not supported by examination.","frag":"SpO₂ ≥94% on room air, no distress"},{"label":"SpO₂ < 94%, cyanosis, or respiratory distress","tone":"pos","sets":[],"ddx":[{"id":"hypoxia-ams","keep":true}],"mdm":"Oxygen saturation was below 94% or signs of increased work of breathing (tachypnea, accessory muscle use, or cyanosis) were present; supplemental oxygen was applied and hypoxia/hypercapnia was evaluated as a cause of the altered mental status.","frag":"SpO₂ <94% or respiratory distress"}]}],"specs":["neuro","tox","geri"],"guide":"../learn/complaints/altered-mental-status.html","pearls":[{"text":"Check glucose and pulse oximetry with the vitals — the pathway starts here. Fixing hypoglycemia and hypoxia/hypercarbia comes before any other workup.","dx":"hypoglycemia"},{"text":"Establish the baseline and confirm an acute change — this almost always needs a proxy (family, caregiver, EMS, prior notes). Don't accept the patient's 'I'm fine' as confirmation of their own baseline.","dx":"delirium"},{"text":"Screen for delirium with the CAM or the DTS→bCAM 2-step — a validated 2-minute bedside tool, not a gestalt impression. Document the result either way.","dx":"delirium"},{"text":"A head CT is low-yield (~5%) in undifferentiated delirium without focal findings or fall/trauma — image when those are present, but a normal CT does not end the search for a systemic cause.","dx":"stroke-ams"},{"text":"Sepsis/infection is the most common driver of AMS in elders and is often hypoactive, not agitated — a quiet, withdrawn elder can be as septic as an agitated one.","dx":"cns-infection"},{"text":"Benzodiazepines are an independent risk factor for delirium — reserve them for alcohol/benzodiazepine withdrawal, not general agitation management.","dx":"delirium"}]},{"id":"head-injury","title":"Head Injury","aliases":["head injury","head trauma","tbi","traumatic brain injury","head strike","hit head","fall and hit head","closed head injury","intracranial hemorrhage","subdural","epidural","concussion","knocked out","loss of consciousness","anticoagulated fall","ground level fall head","blow to head","scalp laceration","minor head injury","skull fracture"],"opening":"Most head strikes are minor, but a small number harbor an intracranial bleed, a skull or cervical-spine fracture, or are amplified by anticoagulation — and the benign-looking ground-level fall in an older, anticoagulated patient is the classic miss.","ddx":[{"id":"ich","group":"lifethreat","label":"Traumatic intracranial hemorrhage","default":true,"tags":["ich"],"ruleout":"Traumatic intracranial hemorrhage was considered; there was no loss of consciousness, amnesia, repeated vomiting, severe headache, seizure, or focal deficit, no anticoagulation, and the patient was GCS 15, satisfying a validated decision rule against imaging.","miss":4},{"id":"cspine","group":"lifethreat","label":"Cervical spine injury","default":true,"tags":["cspine"],"ruleout":"Cervical spine injury was considered; there was no midline tenderness, no focal neurologic deficit, the patient was alert without distracting injury or intoxication, and painless range of motion was demonstrated, clearing the spine clinically.","miss":4},{"id":"skull-fx","group":"lifethreat","label":"Depressed / basilar skull fracture","default":false,"tags":["skull-fx","ich"],"ruleout":"Skull fracture was considered; there was no palpable depression, no hemotympanum, periorbital or mastoid ecchymosis, and no CSF rhinorrhea or otorrhea, making depressed or basilar fracture unlikely.","miss":4},{"id":"shaken-nat-hi","group":"lifethreat","label":"Cervical/vascular injury and abuse in vulnerable patients","default":false,"tags":["shaken-nat-hi"],"ruleout":"Inflicted or occult injury was considered where the mechanism was inconsistent with the findings; the history was congruent, there were no patterned or unexplained injuries, and the examination was otherwise reassuring, making it unlikely.","miss":4},{"id":"concussion","group":"common","label":"Concussion / mTBI","default":false,"tags":["concussion"],"ruleout":"Concussion / mild traumatic brain injury was considered as the working diagnosis once structural injury was felt unlikely.","miss":2},{"id":"scalp","group":"other","label":"Scalp laceration / soft-tissue injury","default":false,"tags":["scalp"],"ruleout":"Isolated scalp / soft-tissue injury was considered.","miss":1}],"risk":[{"id":"canadian-ct","label":"Canadian CT Head Rule","tags":["ich","skull-fx"],"scale":"low","line":"The Canadian CT Head Rule was applied to this minor head injury to guide imaging.","cite":"Stiell IG, et al. Lancet. 2001.","calc":{"fields":[{"label":"GCS < 15 at 2 h","opts":[["No",0],["Yes",1]]},{"label":"Open / depressed skull fx","opts":[["No",0],["Yes",1]]},{"label":"Sign of basilar skull fx","opts":[["No",0],["Yes",1]]},{"label":"≥ 2 vomiting episodes","opts":[["No",0],["Yes",1]]},{"label":"Age ≥ 65","opts":[["No",0],["Yes",1]]},{"label":"Retrograde amnesia ≥ 30 min","opts":[["No",0],["Yes",1]]},{"label":"Dangerous mechanism","opts":[["No",0],["Yes",1]]}],"bands":[[0,"no criteria met","low","No criterion met: the rule does not mandate a head CT for this minor head injury."],[7,"criteria met — CT indicated","high","≥1 criterion met: obtain a non-contrast head CT."]],"line":"Canadian CT Head Rule applied ({score}/7 high- or medium-risk criteria present): {band}.","applies":"Minor head injury (GCS 13-15) in adults with witnessed LOC, amnesia, or disorientation. Excludes age under 16, anticoagulation/bleeding disorder, and seizure after injury -- image those regardless."},"short":"Canadian CT Head: {band}","bandNotes":{"no criteria met":"the rule is ≈100% sensitive for injury requiring neurosurgical intervention (Stiell 2001)"}},{"id":"nexus","label":"NEXUS C-spine criteria","tags":["cspine"],"scale":"low","line":"NEXUS low-risk criteria were documented to support clinical clearance of the cervical spine.","cite":"Hoffman JR, et al. N Engl J Med. 2000.","short":"NEXUS {band}","calc":{"fields":[{"label":"Posterior midline cervical tenderness","opts":[["Absent",0],["Present",1]]},{"label":"Focal neurologic deficit","opts":[["Absent",0],["Present",1]]},{"label":"Altered level of alertness","opts":[["Absent",0],["Present",1]]},{"label":"Evidence of intoxication","opts":[["Absent",0],["Present",1]]},{"label":"Distracting painful injury","opts":[["Absent",0],["Present",1]]}],"bands":[[0,"negative","low","All five criteria absent: the cervical spine can be cleared clinically — no imaging required by NEXUS."],[5,"positive","high","≥1 criterion present: NEXUS cannot clear the C-spine — obtain CT cervical spine."]],"line":"NEXUS C-spine criteria: {score} of 5 present ({band}).","applies":"Blunt trauma, alert and stable, to clear the cervical spine clinically. Use caution at the extremes of age; a distracting injury or intoxication makes it inapplicable."}},{"id":"anticoag","label":"Anticoagulation / antiplatelet status","tags":["ich"],"scale":"low","line":"The patient's anticoagulation / antiplatelet status was reviewed; given the bleeding risk, imaging, an observation period, and reversal availability were addressed.","short":"anticoagulation addressed"}],"checks":[{"if":"ich","needs":["canadian-ct","anticoag"],"mode":"any","warn":"Intracranial hemorrhage is on the differential but no decision rule or anticoagulation status is documented — apply the Canadian CT Head Rule and address anticoagulation."},{"if":"cspine","needs":["nexus"],"mode":"any","warn":"Cervical spine injury is on the differential — document NEXUS (or Canadian C-Spine) clearance or the imaging rationale."}],"history":[{"id":"hi-hx-mech","dx":"ich","q":"Mechanism — ground-level fall vs. dangerous mechanism (fall > 3 ft / > 5 stairs, ejection, pedestrian struck, high-impact assault)?","answers":[{"label":"Low-energy / ground-level","tone":"neg","sets":[{"risk":"canadian-ct","field":6,"opt":0}],"ddx":[],"mdm":"The mechanism was a low-energy ground-level event, without a fall greater than 3 ft or more than 5 stairs, ejection, pedestrian strike, or high-impact assault.","frag":"ground-level mechanism"},{"label":"Dangerous mechanism","tone":"pos","sets":[{"risk":"canadian-ct","field":6,"opt":1}],"ddx":[{"id":"ich","keep":true}],"mdm":"A dangerous mechanism was reported: a fall greater than 3 ft or more than 5 stairs, ejection, pedestrian strike, or high-impact assault.","frag":"dangerous mechanism (fall >3 ft, ejection, pedestrian struck)"}]},{"id":"hi-hx-loc","dx":"ich","q":"Loss of consciousness, amnesia, or disorientation — and any retrograde amnesia ≥ 30 min before impact?","answers":[{"label":"Brief or none, no significant amnesia","tone":"neg","sets":[{"risk":"canadian-ct","field":5,"opt":0}],"ddx":[],"mdm":"There was no significant loss of consciousness and no ≥30-minute retrograde amnesia.","frag":"no significant LOC or pre-impact amnesia"},{"label":"Retrograde amnesia ≥ 30 min","tone":"pos","sets":[{"risk":"canadian-ct","field":5,"opt":1}],"ddx":[{"id":"ich","keep":true}],"mdm":"There was ≥30 minutes of retrograde amnesia before impact.","frag":"≥30 min retrograde amnesia before impact"}]},{"id":"hi-hx-vomit","dx":"ich","q":"Repeated vomiting since the injury (≥ 2 episodes)?","answers":[{"label":"No or single episode","tone":"neg","sets":[{"risk":"canadian-ct","field":3,"opt":0}],"ddx":[],"mdm":"There were fewer than two episodes of vomiting.","frag":"no repeated vomiting"},{"label":"≥ 2 episodes","tone":"pos","sets":[{"risk":"canadian-ct","field":3,"opt":1}],"ddx":[{"id":"ich","keep":true}],"mdm":"There were two or more episodes of vomiting.","frag":"≥2 episodes of vomiting"}]},{"id":"hi-hx-age","dx":"ich","q":"Age ≥ 65?","answers":[{"label":"Under 65","tone":"neg","sets":[{"risk":"canadian-ct","field":4,"opt":0}],"ddx":[],"mdm":"The patient is under 65.","frag":"age under 65"},{"label":"65 or older","tone":"pos","sets":[{"risk":"canadian-ct","field":4,"opt":1}],"ddx":[{"id":"ich","keep":true}],"mdm":"The patient is 65 or older.","frag":"age ≥ 65"}]},{"id":"hi-hx-anticoag","dx":"ich","q":"On anticoagulation or antiplatelet therapy (warfarin, a DOAC, clopidogrel, or dual antiplatelet)?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not on anticoagulation or antiplatelet therapy.","frag":"not on anticoagulation or antiplatelet therapy"},{"label":"On anticoagulation / antiplatelet","tone":"pos","sets":[{"risk":"anticoag"}],"ddx":[{"id":"ich","keep":true}],"mdm":"The patient is on anticoagulation or antiplatelet therapy; the heightened bleeding risk was factored into imaging and observation.","frag":"on anticoagulation/antiplatelet therapy"}]},{"id":"hi-hx-headache","dx":"ich","q":"Severe, worsening, or progressive headache?","answers":[{"label":"Mild / improving","tone":"neg","sets":[],"ddx":[],"mdm":"The headache is mild and improving.","frag":"headache mild and improving"},{"label":"Severe / progressive","tone":"pos","sets":[],"ddx":[{"id":"ich","keep":true}],"mdm":"The headache is severe or progressive.","frag":"severe or progressive headache"}]},{"id":"hi-hx-seizure","dx":"ich","q":"Post-traumatic seizure?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There was no post-traumatic seizure.","frag":"no post-traumatic seizure"},{"label":"Seizure after injury","tone":"pos","sets":[],"ddx":[{"id":"ich","keep":true}],"mdm":"A post-traumatic seizure occurred.","frag":"post-traumatic seizure"}]},{"id":"hi-hx-nexus","dx":"cspine","q":"NEXUS low-risk check — no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no distracting injury?","answers":[{"label":"All five negative — NEXUS low-risk","tone":"neg","sets":[{"risk":"nexus","field":0,"opt":0},{"risk":"nexus","field":1,"opt":0},{"risk":"nexus","field":2,"opt":0},{"risk":"nexus","field":3,"opt":0},{"risk":"nexus","field":4,"opt":0}],"ddx":[],"mdm":"All five NEXUS low-risk criteria were met (no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no distracting injury), supporting clinical clearance of the cervical spine.","frag":"NEXUS low-risk: no midline tenderness, focal deficit, altered alertness, intoxication, or distracting injury"},{"label":"≥ 1 criterion present","tone":"pos","sets":[],"ddx":[{"id":"cspine","keep":true}],"mdm":"At least one NEXUS criterion was present, so the cervical spine could not be cleared clinically.","frag":"NEXUS criterion present"}]},{"answers":[{"ddx":[],"frag":"history congruent, no patterned injuries","label":"History congruent","mdm":"The history was congruent with the injuries, there were no patterned or unexplained findings, and the examination was otherwise reassuring, making inflicted or occult injury unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"shaken-nat-hi","keep":true}],"frag":"mechanism inconsistent or patterned injury","label":"Mechanism inconsistent","mdm":"The history was inconsistent with the injuries or patterned or unexplained findings were present, raising concern for inflicted or occult injury and warranting protective evaluation.","sets":[],"tone":"pos"}],"dx":"shaken-nat-hi","id":"hi-hx-shaken-nat-hi","q":"Mechanism congruence — history consistent with the injuries, no patterned or unexplained findings, plausible account (especially in vulnerable patients)?"}],"exam":[{"id":"hi-ex-gcs","dx":"ich","q":"GCS and mental status — GCS 15 and at neurologic baseline at 2 h after injury?","answers":[{"label":"GCS 15, at baseline","tone":"neg","sets":[{"risk":"canadian-ct","field":0,"opt":0}],"ddx":[],"mdm":"The GCS is 15 and the patient is at neurologic baseline at 2 hours.","frag":"GCS 15 at neurologic baseline"},{"label":"GCS < 15 or not at baseline","tone":"pos","sets":[{"risk":"canadian-ct","field":0,"opt":1}],"ddx":[{"id":"ich","keep":true}],"mdm":"The GCS is below 15 or the patient is altered from baseline.","frag":"GCS <15 or altered from baseline"}]},{"id":"hi-ex-focal","dx":"ich","q":"Focal neurologic deficit — pupils, motor, speech, or coordination?","answers":[{"label":"Non-focal exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal, with normal pupils, motor function, speech, and coordination.","frag":"non-focal neurologic exam"},{"label":"Focal deficit","tone":"pos","sets":[],"ddx":[{"id":"ich","keep":true}],"mdm":"A focal neurologic deficit was present on examination of the pupils, motor function, speech, or coordination.","frag":"focal neurologic deficit"}]},{"id":"hi-ex-depressed","dx":"skull-fx","q":"Palpable, open, or depressed skull fracture?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"canadian-ct","field":1,"opt":0}],"ddx":[],"mdm":"There is no palpable, open, or depressed skull fracture.","frag":"no palpable, open, or depressed skull fracture"},{"label":"Present","tone":"pos","sets":[{"risk":"canadian-ct","field":1,"opt":1}],"ddx":[{"id":"skull-fx","keep":true},{"id":"ich","keep":true}],"mdm":"An open or depressed skull fracture is suspected.","frag":"open or depressed skull fracture"}]},{"id":"hi-ex-basilar","dx":"skull-fx","q":"Signs of basilar skull fracture — hemotympanum, raccoon eyes, Battle sign, or CSF rhinorrhea/otorrhea?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"canadian-ct","field":2,"opt":0}],"ddx":[],"mdm":"There were no signs of basilar skull fracture: no hemotympanum, raccoon eyes, Battle sign, or CSF rhinorrhea or otorrhea.","frag":"no basilar skull-fracture signs"},{"label":"Present","tone":"pos","sets":[{"risk":"canadian-ct","field":2,"opt":1}],"ddx":[{"id":"skull-fx","keep":true},{"id":"ich","keep":true}],"mdm":"Signs of basilar skull fracture (hemotympanum, raccoon eyes, Battle sign, or CSF rhinorrhea or otorrhea) were present.","frag":"basilar skull-fracture signs"}]},{"id":"hi-ex-cspine","dx":"cspine","q":"Cervical spine exam — midline tenderness or limited / painful range of motion?","answers":[{"label":"No tenderness, full painless ROM","tone":"neg","sets":[],"ddx":[],"mdm":"There is no cervical midline tenderness and range of motion is full and painless.","frag":"no cervical midline tenderness; full painless range of motion"},{"label":"Tenderness / limited ROM","tone":"pos","sets":[],"ddx":[{"id":"cspine","keep":true}],"mdm":"There is cervical midline tenderness or limited range of motion.","frag":"cervical midline tenderness or limited range of motion"}]},{"id":"hi-ex-scalp","dx":"scalp","q":"Scalp / soft tissue — laceration, large hematoma, or active bleeding?","answers":[{"label":"No significant scalp injury","tone":"neg","sets":[],"ddx":[],"mdm":"There was no significant scalp or soft-tissue injury, with no laceration, large hematoma, or active bleeding.","frag":"no significant scalp injury"},{"label":"Laceration / hematoma","tone":"pos","sets":[],"ddx":[{"id":"scalp","keep":true}],"mdm":"A scalp laceration, large hematoma, or active bleeding was present.","frag":"scalp laceration or hematoma"}]}],"conclusions":["concussion / mTBI","minor head injury, CT not indicated by rule","scalp laceration, no intracranial injury","head injury NOS (low-risk)"],"specs":["nsgy","geri","trauma"],"pearls":[{"text":"A negative initial head CT does not exclude a slowly expanding subdural or epidural hematoma — a patient on anticoagulation or antiplatelets with a concerning mechanism warrants a lower threshold for repeat imaging or observation.","dx":"ich"},{"text":"Clear the cervical spine by validated criteria (NEXUS or Canadian C-spine), not by gestalt — distracting injury and intoxication are exactly the situations where clinical clearance is least reliable.","dx":"cspine"},{"text":"A normal neurologic exam does not exclude a skull fracture in an infant or young child — a boggy scalp hematoma, especially temporal/parietal, warrants a lower threshold for CT even with a reassuring exam.","dx":"skull-fx"},{"text":"Consider abusive head trauma when the history doesn't match the injury pattern or developmental stage (e.g., a history of rolling off a couch in a non-mobile infant) — retinal hemorrhages and other-organ injury should be actively sought, not just noted if found.","dx":"shaken-nat-hi"},{"text":"PECARN and similar decision rules apply to blunt head trauma with a reliable history and exam — a young child with an unwitnessed fall or a vague history deserves a lower imaging threshold than the rule alone suggests.","dx":"skull-fx"}]},{"id":"dizziness","title":"Dizziness / Vertigo","aliases":["dizzy","vertigo","dizziness","lightheaded","room spinning","presyncope","imbalance","off balance"],"opening":"The patient was evaluated for dizziness. A history characterizing the symptom and its triggers, a neurologic examination, and a gait assessment were performed, and the central and peripheral causes below were actively considered.","ddx":[{"id":"post-stroke","group":"lifethreat","label":"Posterior-circulation stroke","default":true,"tags":["central"],"ruleout":"Posterior-circulation stroke was considered; gait was steady, there was no direction-changing or vertical nystagmus, no dysarthria, diplopia, or focal deficit, and the HINTS examination was reassuring where applicable, making it unlikely.","miss":4},{"id":"vert-dissection-d","group":"lifethreat","label":"Vertebral artery dissection","default":true,"tags":[],"ruleout":"Vertebral artery dissection was considered; there was no neck pain or occipital headache, no recent trauma or manipulation, and no focal neurologic deficit, making it unlikely.","miss":4},{"id":"cardiac-dizzy","group":"lifethreat","label":"Cardiac / pre-syncopal cause","default":false,"tags":["card"],"ruleout":"A cardiac or pre-syncopal cause was considered; there was no chest pain, palpitations, exertional onset, or syncope, vital signs were stable, and the ECG showed no arrhythmia or ischemia, making it unlikely.","miss":3},{"id":"bppv","group":"common","label":"BPPV","default":false,"tags":[],"ruleout":"Benign paroxysmal positional vertigo was considered based on the positional, brief, and triggered character of the symptoms.","miss":2},{"id":"vestibular-neuritis","group":"common","label":"Vestibular neuritis / labyrinthitis","default":false,"tags":[],"ruleout":"Vestibular neuritis or labyrinthitis was considered after central causes were addressed.","miss":2},{"id":"ortho-dizzy","group":"other","label":"Orthostatic / medication-related","default":false,"tags":[],"ruleout":"An orthostatic or medication-related cause was considered and evaluated as appropriate.","miss":1}],"risk":[{"id":"hints","label":"HINTS exam (acute vestibular syndrome only)","tags":["central"],"scale":"low","line":"In a patient with continuous vertigo and nystagmus, a HINTS examination was performed and was reassuring for a peripheral cause.","cite":"Kattah JC, et al. Stroke. 2009.","short":"HINTS {band}","calc":{"fields":[{"label":"Head impulse test","opts":[["Abnormal — corrective saccade (peripheral)",0],["Normal — no saccade (central)",1]]},{"label":"Nystagmus","opts":[["Direction-fixed horizontal (peripheral)",0],["Direction-changing or vertical/torsional (central)",1]]},{"label":"Test of skew","opts":[["Absent (peripheral)",0],["Present — vertical skew (central)",1]]}],"bands":[[0,"peripheral pattern","low","All three reassuring (HINTS 'peripheral'): supports a peripheral cause — in continuous acute vestibular syndrome with nystagmus this out-performs early MRI for stroke. Valid only when performed appropriately in true AVS."],[3,"central pattern","high","Any central finding (HINTS 'central' / INFARCT): concerning for posterior-circulation stroke — obtain MRI and manage on the stroke pathway."]],"line":"HINTS exam in continuous acute vestibular syndrome: {band} ({score} of 3 central findings).","applies":"Acute vestibular syndrome (continuous vertigo with nystagmus) in a currently symptomatic patient, by a trained examiner. Not for episodic/positional vertigo or a patient without nystagmus, where a reassuring HINTS is falsely reassuring."}},{"id":"gait-dizzy","label":"Gait assessment","tags":["central"],"scale":"low","line":"Gait was assessed; the patient was able to ambulate without truncal ataxia.","short":"ambulates without truncal ataxia"},{"id":"neuroexam-dizzy","label":"Documented neuro exam","tags":["central"],"scale":"low","line":"A focused neurologic examination, including cranial nerves and cerebellar testing, was performed and documented.","short":"focused neuro exam, CN and cerebellar, documented"}],"checks":[{"if":"post-stroke","needs":["hints","gait-dizzy","neuroexam-dizzy"],"mode":"any","warn":"Central vertigo is on the differential — gait testing and/or a documented HINTS exam show the basis for favoring a peripheral cause. (HINTS is validated only for continuous vertigo with nystagmus, not for triggered or resolved symptoms.)"},{"if":"vert-dissection-d","needs":["neuroexam-dizzy","hints"],"mode":"any","warn":"Vertebral artery dissection can cause central vertigo — a documented neurologic exam (and HINTS where applicable) supports excluding a central cause, especially with neck pain or headache."}],"history":[{"id":"dizzy-hx-character","dx":"general","q":"Dizziness character — continuous vertigo present at rest vs. episodic/positional (triggered only by head movement or change in position)? Duration of each episode?","answers":[{"label":"Episodic / positional — resolves within 1 minute","tone":"neg","sets":[],"ddx":[],"mdm":"The dizziness was episodic and positional (triggered only by head movement or change in position) and resolved within one minute of provocation rather than being continuous and present at rest, a pattern most consistent with BPPV rather than a central cause.","frag":"episodic positional vertigo, resolves < 1 min"},{"label":"Continuous — present at rest (acute vestibular syndrome)","tone":"pos","sets":[],"ddx":[{"id":"post-stroke","keep":true},{"id":"vestibular-neuritis","keep":true}],"mdm":"The dizziness was continuous and present at rest rather than episodic or positional, consistent with acute vestibular syndrome and requiring differentiation between a central process (posterior-circulation stroke) and vestibular neuritis.","frag":"continuous vertigo at rest"}]},{"id":"dizzy-hx-sudden-onset","dx":"general","q":"Sudden vs. gradual onset? Severity at onset — was it maximal at onset?","answers":[{"label":"Gradual onset, mild-to-moderate severity","tone":"neg","sets":[],"ddx":[],"mdm":"Onset was gradual and severity was mild-to-moderate; this pattern did not suggest a sudden vascular event.","frag":"gradual onset, mild-to-moderate severity"},{"label":"Sudden onset, severe at onset","tone":"pos","sets":[],"ddx":[{"id":"post-stroke","keep":true},{"id":"vert-dissection-d","keep":true}],"mdm":"Onset was sudden and severe at onset: a high-risk feature raising concern for posterior-circulation stroke or vertebral artery dissection.","frag":"sudden onset, severe at onset"}]},{"id":"dizzy-hx-vascular-risk","dx":"post-stroke","q":"Vascular risk factors — hypertension, diabetes, hyperlipidemia, tobacco, atrial fibrillation, prior stroke or TIA, age ≥ 50?","answers":[{"label":"None / low vascular risk","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was assessed for cerebrovascular risk factors (hypertension, diabetes, hyperlipidemia, tobacco use, atrial fibrillation, prior stroke or TIA, and age ≥ 50), none of which were present, lowering the prior probability of posterior-circulation stroke.","frag":"no cerebrovascular risk factors"},{"label":"Vascular risk factors or known atrial fibrillation","tone":"pos","sets":[],"ddx":[{"id":"post-stroke","keep":true}],"mdm":"Significant vascular risk factors or known atrial fibrillation were present, raising the prior probability of a posterior-circulation stroke as the etiology.","frag":"vascular risk factors or known AF"}]},{"id":"dizzy-hx-focal-neuro","dx":"post-stroke","q":"Focal brainstem or cerebellar symptoms — diplopia, dysarthria, dysphagia, facial numbness, unilateral limb weakness, or limb ataxia?","answers":[{"label":"No focal neurologic symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No brainstem or cerebellar symptoms were reported; there was no diplopia, dysarthria, dysphagia, facial numbness, limb weakness, or limb ataxia.","frag":"no brainstem or cerebellar symptoms"},{"label":"Brainstem or cerebellar symptoms present","tone":"pos","sets":[],"ddx":[{"id":"post-stroke","keep":true}],"mdm":"Focal brainstem or cerebellar symptoms (including diplopia, dysarthria, dysphagia, or limb ataxia) were reported, raising strong concern for a posterior-circulation stroke.","frag":"brainstem or cerebellar symptoms"}]},{"id":"dizzy-hx-gait-stability","dx":"post-stroke","q":"Gait instability or inability to walk independently since symptom onset? Falls?","answers":[{"label":"No gait instability — able to walk unaided","tone":"neg","sets":[],"ddx":[],"mdm":"No gait instability was reported; the patient was able to walk independently without falls since symptom onset.","frag":"no gait instability, walks independently"},{"label":"Significant gait instability or unable to walk","tone":"pos","sets":[],"ddx":[{"id":"post-stroke","keep":true}],"mdm":"Significant gait instability or inability to ambulate independently was reported: a feature associated with central pathology and posterior-circulation stroke.","frag":"gait instability or unable to walk"}]},{"id":"dizzy-hx-neck-pain-trauma","dx":"vert-dissection-d","q":"Neck pain, occipital headache, or recent neck trauma, chiropractic manipulation, or forceful rapid neck rotation?","answers":[{"label":"No neck pain or neck trauma/manipulation","tone":"neg","sets":[],"ddx":[],"mdm":"No neck pain, occipital headache, or recent neck trauma or manipulation was reported; vertebral artery dissection was not suggested by history.","frag":"no neck pain, occipital headache, or neck trauma/manipulation"},{"label":"Neck pain, occipital headache, or recent neck manipulation","tone":"pos","sets":[],"ddx":[{"id":"vert-dissection-d","keep":true}],"mdm":"Neck pain, occipital headache, or recent neck manipulation was reported, raising concern for vertebral artery dissection as the cause of dizziness and headache.","frag":"neck pain, occipital headache, or recent neck manipulation"}]},{"id":"dizzy-hx-dissection-age","dx":"vert-dissection-d","q":"Age — younger patient (< 45–50) with absence of classic vascular risk factors? Connective tissue disorder (Marfan, Ehlers-Danlos)?","answers":[{"label":"No dissection risk factors (no neck trauma/manipulation, no connective-tissue disorder)","tone":"neg","sets":[],"ddx":[],"mdm":"No neck trauma, cervical manipulation, or connective-tissue disorder was reported, and the profile did not specifically favor arterial dissection.","frag":"no neck trauma, manipulation, or connective-tissue disorder"},{"label":"Younger patient or connective tissue disorder","tone":"pos","sets":[],"ddx":[{"id":"vert-dissection-d","keep":true}],"mdm":"The patient was younger or had a known connective tissue disorder, supporting vertebral artery dissection as a cause of posterior-circulation ischemia.","frag":"younger age or connective-tissue disorder"}]},{"id":"dizzy-hx-cardiac","dx":"cardiac-dizzy","q":"Palpitations, irregular heartbeat, or chest pain accompanying the dizziness? Exertional onset? Known arrhythmia, structural heart disease, or prior syncopal episodes?","answers":[{"label":"No palpitations, chest pain, or cardiac history","tone":"neg","sets":[],"ddx":[],"mdm":"No palpitations, chest pain, or cardiac symptoms were associated with the dizziness, and no significant cardiac history was identified.","frag":"no palpitations, chest pain, or cardiac history"},{"label":"Palpitations, chest pain, exertional onset, or known cardiac disease","tone":"pos","sets":[],"ddx":[{"id":"cardiac-dizzy","keep":true}],"mdm":"Palpitations, chest pain, exertional onset, or known cardiac disease was reported, raising concern for a cardiac or pre-syncopal cause including arrhythmia or structural disease.","frag":"palpitations, chest pain, exertional onset, or cardiac disease"}]},{"id":"dizzy-hx-bppv","dx":"bppv","q":"BPPV pattern — brief vertigo (< 1 minute) triggered specifically by head position change (rolling over in bed, looking up, bending forward)? Prior similar episodes?","answers":[{"label":"Not triggered by head position; duration > 1 minute","tone":"neg","sets":[],"ddx":[],"mdm":"The dizziness was not specifically triggered by head position changes such as rolling over in bed, looking up, or bending forward, and each episode exceeded one minute; a classic BPPV pattern was not identified.","frag":"not positionally triggered, duration > 1 min"},{"label":"Brief positional vertigo triggered by head movement — resolves < 1 min","tone":"pos","sets":[],"ddx":[{"id":"bppv","keep":true}],"mdm":"Brief vertigo lasting under one minute and triggered specifically by head position changes (rolling over in bed, looking up, or bending forward) was reported, a pattern characteristic of BPPV; the Dix-Hallpike maneuver was planned for confirmation.","frag":"brief positional vertigo, resolves < 1 min"}]},{"id":"dizzy-hx-vestibular-neuritis","dx":"vestibular-neuritis","q":"Vestibular neuritis pattern — continuous vertigo preceded by viral illness (URI, gastroenteritis) within past 1–2 weeks? No brainstem or focal neurologic symptoms?","answers":[{"label":"No viral prodrome preceding continuous vertigo","tone":"neg","sets":[],"ddx":[],"mdm":"No antecedent viral illness such as a URI or gastroenteritis within the prior 1–2 weeks was reported to precede the vertigo; a vestibular neuritis or labyrinthitis pattern was not supported by history.","frag":"no antecedent viral illness"},{"label":"Continuous vertigo following viral prodrome, no focal symptoms","tone":"pos","sets":[],"ddx":[{"id":"vestibular-neuritis","keep":true}],"mdm":"Continuous vertigo following a recent viral illness, without focal neurologic symptoms, suggested vestibular neuritis or labyrinthitis; central causes were still actively excluded by examination.","frag":"continuous vertigo after viral prodrome, no focal symptoms"}]},{"id":"dizzy-hx-ortho","dx":"ortho-dizzy","q":"Postural onset — dizziness occurring immediately on standing from sitting or lying? Symptoms of volume depletion (poor intake, vomiting, diarrhea, blood loss)?","answers":[{"label":"Not postural — present at rest or unrelated to standing","tone":"neg","sets":[],"ddx":[],"mdm":"The dizziness was not triggered by standing from sitting or lying, and no symptoms of volume depletion (poor intake, vomiting, diarrhea, or blood loss) were reported; an orthostatic cause was not suggested by history.","frag":"not triggered by standing"},{"label":"Lightheadedness on standing; volume depletion symptoms","tone":"pos","sets":[],"ddx":[{"id":"ortho-dizzy","keep":true}],"mdm":"Lightheadedness occurring immediately on standing, together with symptoms of volume depletion (poor intake, vomiting, diarrhea, or blood loss), was consistent with orthostatic hypotension; culprit medications and volume status were evaluated.","frag":"lightheadedness on standing with volume depletion"}]},{"id":"dizzy-hx-ortho-meds","dx":"ortho-dizzy","q":"Culprit medications — antihypertensives, alpha-blockers, diuretics, nitrates, or recent up-titration of any blood pressure agent?","answers":[{"label":"No culprit medications identified","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was assessed for medications that precipitate orthostatic hypotension (antihypertensives, alpha-blockers, diuretics, nitrates, or recent up-titration of a blood pressure agent), none of which were identified.","frag":"no culprit orthostatic medications"},{"label":"Antihypertensive, diuretic, or vasodilator in use","tone":"pos","sets":[],"ddx":[{"id":"ortho-dizzy","keep":true}],"mdm":"An antihypertensive, alpha-blocker, diuretic, or nitrate was in use, identified as a potential contributor to orthostatic hypotension; medication review and dose adjustment were considered.","frag":"antihypertensive, diuretic, or vasodilator in use"}]}],"exam":[{"id":"dizzy-exam-vitals","dx":"general","q":"Vital signs — heart rate, blood pressure, respiratory rate, oxygen saturation, temperature?","answers":[{"label":"Vital signs normal","tone":"neg","sets":[],"ddx":[],"mdm":"Heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature were all within normal limits; no hemodynamic instability, arrhythmia, or hypoxia was identified on initial assessment.","frag":"vital signs normal"},{"label":"Hemodynamic instability, significant bradycardia, or irregular rhythm","tone":"pos","sets":[],"ddx":[{"id":"cardiac-dizzy","keep":true}],"mdm":"Hemodynamic instability, significant bradycardia, or an irregular rhythm was noted on vital signs, raising concern for a cardiac cause of the dizziness.","frag":"hemodynamic instability, bradycardia, or irregular rhythm"}]},{"id":"dizzy-exam-neuro-screen","dx":"general","q":"Brief neurologic screen — mental status, strength in all extremities, sensation, speech fluency?","answers":[{"label":"Neurologic screen normal","tone":"neg","sets":[],"ddx":[],"mdm":"The brief neurologic screen was normal; mental status was intact, strength was symmetric, sensation was intact, and speech was fluent.","frag":"non-focal neuro screen"},{"label":"Focal neurologic deficit on screen","tone":"pos","sets":[],"ddx":[{"id":"post-stroke","keep":true}],"mdm":"A focal deficit in mental status, extremity strength, sensation, or speech fluency was identified on the screening examination, raising concern for posterior-circulation stroke and prompting targeted cerebellar and cranial nerve evaluation.","frag":"focal neurologic deficit on screen"}]},{"id":"dizzy-exam-hints","dx":"post-stroke","q":"HINTS exam — apply ONLY if acute vestibular syndrome (continuous vertigo with nystagmus at rest). Head-impulse test: abnormal (catch-up saccade)? Nystagmus: unidirectional? Test of skew: absent?","answers":[{"label":"Peripheral HINTS pattern: abnormal HIT + unidirectional nystagmus + skew absent","tone":"pos","sets":[{"risk":"hints","field":0,"opt":0},{"risk":"hints","field":1,"opt":0},{"risk":"hints","field":2,"opt":0}],"ddx":[],"mdm":"HINTS examination was performed in this acute vestibular syndrome presentation. The pattern was peripheral: abnormal head-impulse test (catch-up saccade), unidirectional nystagmus, and absent skew deviation, reassuring against posterior-circulation stroke. Note: HINTS is valid only in continuous vertigo with spontaneous nystagmus; sensitivity requires examiner training.","frag":"peripheral HINTS: abnormal HIT, unidirectional nystagmus, no skew"},{"label":"Central HINTS pattern: normal HIT, direction-changing nystagmus, or positive skew","tone":"pos","sets":[{"risk":"hints"}],"ddx":[{"id":"post-stroke","keep":true}],"mdm":"HINTS examination revealed a central pattern: a normal (negative) head-impulse test, direction-changing nystagmus, or a positive test of skew, raising strong concern for posterior-circulation stroke, with sensitivity exceeding early MRI-DWI when performed by a trained examiner. (HINTS applies only to continuous vertigo with nystagmus.)","frag":"central HINTS: normal HIT, direction-changing nystagmus, or skew"},{"label":"HINTS not applicable (not acute vestibular syndrome)","tone":"neg","sets":[],"ddx":[],"mdm":"HINTS examination was not applied; the presentation was not consistent with acute vestibular syndrome (continuous vertigo with spontaneous nystagmus at rest), which is the prerequisite for the test.","frag":"HINTS not applicable, not acute vestibular syndrome"}]},{"id":"dizzy-exam-gait-ataxia","dx":"post-stroke","q":"Gait assessment — can the patient walk unaided (standard or tandem)? Truncal ataxia?","answers":[{"label":"Able to walk unaided, no truncal ataxia","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was able to ambulate unaided without truncal ataxia; gait testing did not suggest a central vestibular or cerebellar process.","frag":"ambulates unaided, no truncal ataxia"},{"label":"Unable to walk unaided or truncal ataxia present","tone":"pos","sets":[],"ddx":[{"id":"post-stroke","keep":true}],"mdm":"The patient was unable to ambulate without support or demonstrated truncal ataxia: a feature strongly associated with a central (posterior-circulation) cause and not explained by a peripheral vestibular disorder alone.","frag":"unable to ambulate unaided or truncal ataxia"}]},{"id":"dizzy-exam-cerebellar-cn","dx":"post-stroke","q":"Cerebellar testing and cranial nerve screen — finger-nose, rapid alternating movements intact? Facial symmetry, extra-ocular movements, palatal elevation normal?","answers":[{"label":"Cerebellar testing normal, cranial nerves intact","tone":"neg","sets":[],"ddx":[],"mdm":"Finger-nose testing and rapid alternating movements were intact; the cranial nerve examination including facial symmetry, extra-ocular movements, and palatal elevation was normal.","frag":"cerebellar testing and CN exam normal"},{"label":"Cerebellar dysmetria or focal cranial-nerve deficit","tone":"pos","sets":[],"ddx":[{"id":"post-stroke","keep":true},{"id":"vert-dissection-d","keep":true}],"mdm":"Cerebellar dysmetria on finger-nose testing or a focal cranial-nerve deficit (facial asymmetry, diplopia, palatal deviation) was identified, consistent with a posterior-fossa or brainstem lesion requiring urgent neuroimaging.","frag":"cerebellar dysmetria or focal CN deficit"}]},{"id":"dizzy-exam-orthostatics","dx":"cardiac-dizzy","q":"Orthostatic vital signs — systolic BP drop ≥ 20 mmHg or HR rise ≥ 20 bpm on standing within 3 minutes?","answers":[{"label":"No orthostatic change","tone":"neg","sets":[],"ddx":[],"mdm":"No significant orthostatic drop in blood pressure was identified; a hemodynamic or volume-depleted cause was not supported by the postural assessment.","frag":"no orthostatic BP drop"},{"label":"Orthostatic hypotension present","tone":"pos","sets":[],"ddx":[{"id":"ortho-dizzy","keep":true}],"mdm":"A significant orthostatic drop in blood pressure or compensatory tachycardia on standing was documented, consistent with orthostatic hypotension as the cause of dizziness.","frag":"orthostatic hypotension"}]}],"conclusions":["benign paroxysmal positional vertigo (BPPV)","peripheral vertigo","dizziness NOS (low-risk)"],"specs":["neuro","ent"],"guide":"../learn/complaints/dizziness.html","pearls":[{"text":"HINTS only applies to acute vestibular syndrome with nystagmus present, examined by a trained clinician — applying it without nystagmus gives a false-reassuring 'central' or 'peripheral' read.","src":"HINTS: Kattah 2009"},{"text":"In true acute vestibular syndrome, a normal head impulse, direction-changing or vertical nystagmus, or any skew deviation is central until proven otherwise — a skilled HINTS exam outperforms early MRI for stroke.","dx":"post-stroke"},{"text":"Screen for the dangerous Ds — diplopia, dysarthria, dysmetria, dysphonia, dysphagia — any one raises concern for a central/posterior-circulation cause.","dx":"post-stroke"},{"text":"Test gait in every dizzy patient — inability to walk unaided is a red flag independent of the rest of the exam.","dx":"post-stroke"},{"text":"Do not order non-contrast CT or CTA to distinguish central from peripheral vertigo — it lacks the resolution and will falsely reassure; MRI (or a proper HINTS exam) is the tool.","dx":"post-stroke"},{"text":"Upbeat-torsional nystagmus toward the down ear on Dix-Hallpike is benign posterior-canal BPPV — treat with the Epley maneuver, not meclizine, which does not address the mechanism.","dx":"bppv"}]},{"id":"gi-bleed","title":"GI Bleeding","aliases":["gi bleed","gib","melena","hematemesis","brbpr","hematochezia","blood in stool","vomiting blood","black stool","rectal bleeding","coffee ground"],"opening":"The patient was evaluated for gastrointestinal bleeding. Hemodynamics were assessed and trended, a focused history and examination were performed, and the diagnoses below were actively considered.","ddx":[{"id":"hemorrhagic-shock","group":"lifethreat","label":"Hemodynamically significant hemorrhage","default":true,"tags":["hgb"],"ruleout":"Hemodynamically significant hemorrhage was considered; the patient was normotensive without tachycardia, there was no orthostatic change or syncope, mentation and perfusion were normal, and hemoglobin was at baseline, making shock unlikely.","miss":3},{"id":"variceal","group":"lifethreat","label":"Variceal bleeding","default":true,"tags":[],"ruleout":"A variceal source was considered; there was no history of cirrhosis, alcohol use, or portal hypertension, no stigmata of liver disease, and the bleeding was not large-volume hematemesis, making it unlikely.","miss":3},{"id":"aortoenteric","group":"lifethreat","label":"Aortoenteric fistula","default":false,"tags":[],"ruleout":"Aortoenteric fistula was considered; there was no prior aortic graft or aneurysm repair and no herald bleed of brisk hematemesis or hematochezia, making it unlikely.","miss":4},{"id":"pud","group":"common","label":"Peptic ulcer disease","default":false,"tags":[],"ruleout":"Peptic ulcer disease was considered as a common upper-GI source and managed accordingly.","miss":2},{"id":"lower-gi","group":"common","label":"Lower-GI source","default":false,"tags":[],"ruleout":"A lower-GI source (diverticular or vascular) was considered and evaluated as appropriate.","miss":2},{"id":"anorectal","group":"other","label":"Benign anorectal source","default":false,"tags":[],"ruleout":"A benign anorectal source was considered as the likely cause after the serious sources above were addressed.","miss":1}],"risk":[{"id":"gbs","label":"Glasgow-Blatchford score","tags":["hgb"],"scale":"low","line":"A Glasgow-Blatchford score was documented to support the decision about admission versus outpatient management.","cite":"Blatchford O, et al. Lancet. 2000.","short":"Glasgow-Blatchford documented","calc":{"fields":[{"label":"BUN (mg/dL)","opts":[["< 18.2",0],["18.2–22.3",2],["22.4–27.9",3],["28–69.9",4],["≥ 70",6]]},{"label":"Hemoglobin","opts":[["Normal (≥13 M /≥12 F)",0],["Mild ↓",1],["Moderate ↓ (10–12)",3],["Severe ↓ (<10)",6]]},{"label":"Systolic BP","opts":[["≥ 110",0],["100–109",1],["90–99",2],["< 90",3]]},{"label":"Pulse ≥ 100","opts":[["No",0],["Yes",1]]},{"label":"Melena","opts":[["No",0],["Yes",1]]},{"label":"Syncope","opts":[["No",0],["Yes",2]]},{"label":"Hepatic disease","opts":[["No",0],["Yes",2]]},{"label":"Cardiac failure","opts":[["No",0],["Yes",2]]}],"bands":[[0,"very low — consider outpatient","low","Score 0: low-risk — outpatient management may be appropriate for selected patients."],[3,"low","low","Low: observation; admission threshold low if comorbid or social concern."],[7,"intermediate","mod","Intermediate: admit for evaluation and likely endoscopy."],[23,"high","high","High: admit — resuscitate and arrange early endoscopy."]],"line":"Glasgow-Blatchford score {score}/23 ({band}); used to guide admission versus outpatient management.","applies":"Adults with upper GI bleeding, to identify very-low-risk patients who may avoid admission or early endoscopy (0-1 is the safe-for-outpatient threshold). It does not assess rebleeding after endoscopy."},"bandNotes":{"very low — consider outpatient":"score 0–1: <1% risk of needing intervention in validation (Blatchford)"}},{"id":"typescreen","label":"Type & screen / serial Hgb","tags":["hgb"],"scale":"low","line":"A type and screen and serial hemoglobin were obtained and reviewed.","short":"type and screen sent, serial Hgb"},{"id":"hemodynamics","label":"Hemodynamic response documented","tags":["hgb"],"scale":"low","line":"The hemodynamic response to initial resuscitation was assessed and documented.","short":"hemodynamic response to resuscitation assessed"}],"checks":[{"if":"hemorrhagic-shock","needs":["hemodynamics","typescreen"],"mode":"any","warn":"Significant hemorrhage is on the differential — documenting hemodynamics and a type & screen shows the resuscitation was anticipated."}],"history":[{"id":"gib-hx-hemodynamic-symptoms","dx":"hemorrhagic-shock","q":"Lightheadedness, presyncope, or syncope with or after the bleeding episode?","answers":[{"label":"No — no lightheadedness or syncope","tone":"neg","sets":[],"ddx":[],"mdm":"No lightheadedness, presyncope, or syncope was reported in association with the bleeding; hemodynamic compromise was not suggested by history.","frag":"no lightheadedness, presyncope, or syncope"},{"label":"Lightheadedness or presyncope","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock","keep":true}],"mdm":"Lightheadedness or presyncope was reported, indicating significant volume depletion from hemorrhage requiring urgent assessment and resuscitation.","frag":"lightheadedness or presyncope"},{"label":"Syncope or near-syncope","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock","keep":true}],"mdm":"Syncope or near-syncope was reported in the setting of GI bleeding, indicating hemodynamically significant hemorrhage; emergent resuscitation and expedited workup were initiated.","frag":"syncope or near-syncope with bleed"}]},{"id":"gib-hx-bleeding-volume","dx":"hemorrhagic-shock","q":"Estimated bleeding volume — large-volume hematemesis (toilet bowl full, soaked towels, multiple clots)?","answers":[{"label":"Small or moderate volume","tone":"neg","sets":[],"ddx":[],"mdm":"The reported bleeding volume was small to moderate, without large-volume hematemesis such as a toilet bowl full of blood, soaked towels, or multiple clots; a catastrophic hemorrhage was not suggested by history alone.","frag":"small to moderate volume"},{"label":"Large volume — toilet bowl full, soaked linens, or multiple clots","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock","keep":true}],"mdm":"A large-volume bleeding episode was reported (a toilet bowl full of blood, soaked linens, or multiple clots), raising immediate concern for hemodynamically significant hemorrhage; volume resuscitation and emergent specialist consultation were initiated.","frag":"large-volume bleed"}]},{"id":"gib-hx-anticoagulation","dx":"hemorrhagic-shock","q":"Anticoagulant or antiplatelet therapy — warfarin, DOAC (apixaban, rivaroxaban, dabigatran), aspirin, or P2Y12 inhibitor (clopidogrel, ticagrelor)?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"No anticoagulant or antiplatelet therapy was reported: no warfarin, DOAC (apixaban, rivaroxaban, dabigatran), aspirin, or P2Y12 inhibitor (clopidogrel, ticagrelor).","frag":"no anticoagulant or antiplatelet"},{"label":"Antiplatelet agent (aspirin or P2Y12 inhibitor)","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock","keep":true}],"mdm":"Antiplatelet therapy (aspirin or a P2Y12 inhibitor such as clopidogrel or ticagrelor) was identified, which impairs hemostasis and amplifies bleeding severity; this was factored into resuscitation and specialist consultation planning.","frag":"on antiplatelet"},{"label":"Anticoagulant (warfarin or DOAC)","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock","keep":true}],"mdm":"Anticoagulant use (warfarin or a DOAC such as apixaban, rivaroxaban, or dabigatran) was identified; reversal agent consideration, INR or anti-Xa level, and urgent gastroenterology or surgical consultation were initiated given the amplified hemorrhagic risk.","frag":"on anticoagulant"}]},{"id":"gib-hx-cirrhosis-varices","dx":"variceal","q":"Known cirrhosis, portal hypertension, esophageal or gastric varices, or prior variceal hemorrhage?","answers":[{"label":"No known liver disease or varices","tone":"neg","sets":[],"ddx":[],"mdm":"No known cirrhosis, portal hypertension, or varices were reported; a variceal source was less likely by history.","frag":"no known cirrhosis, portal HTN, or varices"},{"label":"Known cirrhosis or portal hypertension","tone":"pos","sets":[],"ddx":[{"id":"variceal","keep":true}],"mdm":"A history of cirrhosis or portal hypertension was reported, substantially raising the concern for variceal hemorrhage; early octreotide, antibiotic prophylaxis, and gastroenterology consultation were initiated.","frag":"known cirrhosis or portal HTN"},{"label":"Prior variceal hemorrhage or known varices","tone":"pos","sets":[],"ddx":[{"id":"variceal","keep":true}],"mdm":"A history of prior variceal hemorrhage or endoscopically confirmed varices was identified; this was treated as a high-risk variceal bleed with emergent gastroenterology consultation and bridge pharmacotherapy.","frag":"prior variceal hemorrhage or known varices"}]},{"id":"gib-hx-alcohol-use","dx":"variceal","q":"Heavy or chronic alcohol use — daily use, or history of alcohol-related liver disease?","answers":[{"label":"No significant alcohol use","tone":"neg","sets":[],"ddx":[],"mdm":"No significant or chronic alcohol use was reported; alcohol-related liver disease was not a primary concern by history.","frag":"no significant alcohol use"},{"label":"Heavy or chronic alcohol use","tone":"pos","sets":[],"ddx":[{"id":"variceal","keep":true}],"mdm":"Heavy or chronic alcohol use was reported, raising concern for underlying alcoholic liver disease and portal hypertension as contributors to a variceal hemorrhage.","frag":"heavy or chronic alcohol use"}]},{"id":"gib-hx-aortic-graft","dx":"aortoenteric","q":"Prior abdominal aortic aneurysm (AAA) repair or indwelling aortic graft — open or endovascular (EVAR)?","answers":[{"label":"No prior aortic surgery or graft","tone":"neg","sets":[],"ddx":[],"mdm":"No prior aortic surgery or indwelling aortic graft was reported; an aortoenteric fistula was not a primary concern by history.","frag":"no prior aortic surgery or graft"},{"label":"Prior AAA repair or aortic graft present","tone":"pos","sets":[],"ddx":[{"id":"aortoenteric","keep":true}],"mdm":"A history of prior abdominal aortic aneurysm repair or indwelling aortic graft was identified; this presentation was managed as a herald bleed from an aortoenteric fistula until proven otherwise, with vascular surgery consultation initiated emergently.","frag":"prior AAA repair or aortic graft"}]},{"id":"gib-hx-bleeding-character","dx":"pud","q":"Bleeding character — hematemesis, coffee-ground emesis, or melena (black, tarry stool)?","answers":[{"label":"No hematemesis, coffee-ground emesis, or melena","tone":"neg","sets":[],"ddx":[],"mdm":"No hematemesis, coffee-ground emesis, or melena was reported; an overt upper-GI source was not confirmed by history.","frag":"no hematemesis, coffee-ground emesis, or melena"},{"label":"Hematemesis or coffee-ground emesis","tone":"pos","sets":[],"ddx":[{"id":"pud","keep":true},{"id":"variceal","keep":true}],"mdm":"Hematemesis or coffee-ground emesis was reported, confirming an upper-GI source and broadening the differential to include peptic ulcer disease and variceal hemorrhage.","frag":"hematemesis or coffee-ground emesis"},{"label":"Melena (black, tarry stool)","tone":"pos","sets":[],"ddx":[{"id":"pud","keep":true}],"mdm":"Melena (black, tarry stool) was reported, pointing toward an upper-GI source; peptic ulcer disease was the leading consideration.","frag":"melena"}]},{"id":"gib-hx-nsaid-ulcer","dx":"pud","q":"NSAID use (ibuprofen, naproxen, ketorolac, high-dose aspirin), prior peptic ulcer disease, or known H. pylori?","answers":[{"label":"No NSAID use, no prior ulcer, no H. pylori history","tone":"neg","sets":[],"ddx":[],"mdm":"No NSAID use, prior peptic ulcer, or known H. pylori was reported; PUD risk factors were absent by history.","frag":"no NSAID use, prior ulcer, or H. pylori"},{"label":"Regular NSAID use","tone":"pos","sets":[],"ddx":[{"id":"pud","keep":true}],"mdm":"Regular NSAID use was identified, an established risk factor for peptic ulcer disease and gastropathy as a source of upper-GI hemorrhage.","frag":"regular NSAID use"},{"label":"Prior ulcer or known H. pylori","tone":"pos","sets":[],"ddx":[{"id":"pud","keep":true}],"mdm":"A history of prior peptic ulcer disease or known H. pylori infection was reported, substantially raising the pretest probability of PUD as the hemorrhagic source.","frag":"prior ulcer or known H. pylori"}]},{"id":"gib-hx-epigastric-pain","dx":"pud","q":"Epigastric pain or burning — preceding the bleeding, or at the time of presentation?","answers":[{"label":"No epigastric pain","tone":"neg","sets":[],"ddx":[],"mdm":"No epigastric pain or burning was reported; a symptomatic peptic ulcer was not specifically suggested by history, though painless ulcers occur.","frag":"no epigastric pain"},{"label":"Epigastric pain or burning present","tone":"pos","sets":[],"ddx":[{"id":"pud","keep":true}],"mdm":"Epigastric pain or burning was reported in association with the bleeding episode, raising concern for peptic ulcer disease or gastritis as the hemorrhagic source.","frag":"epigastric pain or burning"}]},{"id":"gib-hx-hematochezia","dx":"lower-gi","q":"Hematochezia — bright-red or maroon blood per rectum, with or without clots?","answers":[{"label":"No bright-red blood or hematochezia","tone":"neg","sets":[],"ddx":[],"mdm":"No hematochezia (no bright-red or maroon blood per rectum) was reported; a lower-GI source was not the primary presentation by history.","frag":"no hematochezia"},{"label":"Hematochezia — bright-red or maroon blood per rectum","tone":"pos","sets":[],"ddx":[{"id":"lower-gi","keep":true}],"mdm":"Hematochezia (bright-red or maroon blood per rectum) was reported; this most commonly indicates a lower-GI source (diverticulosis, angiodysplasia, colitis), though a brisk upper-GI bleed must be excluded in the hemodynamically unstable patient.","frag":"hematochezia"}]},{"id":"gib-hx-lower-gi-risk","dx":"lower-gi","q":"Age ≥ 50, known diverticulosis, or prior lower-GI bleeding episode (diverticular or angiodysplastic)?","answers":[{"label":"Age < 50, no known diverticulosis or prior lower-GI bleed","tone":"neg","sets":[],"ddx":[],"mdm":"No age-related or structural lower-GI risk factors were identified; a diverticular or angiodysplastic source was less likely by history.","frag":"no age-related or structural lower-GI risk factors"},{"label":"Age ≥ 50 or known diverticulosis","tone":"pos","sets":[],"ddx":[{"id":"lower-gi","keep":true}],"mdm":"Age 50 or older or a known history of diverticulosis was present; diverticular hemorrhage was the leading lower-GI diagnostic consideration.","frag":"age ≥50 or known diverticulosis"},{"label":"Prior lower-GI bleed or known angiodysplasia","tone":"pos","sets":[],"ddx":[{"id":"lower-gi","keep":true}],"mdm":"A prior lower-GI hemorrhagic episode or known angiodysplasia was reported, raising recurrence as the most likely etiology; gastroenterology consultation and colonoscopy planning were prioritized.","frag":"prior lower-GI bleed or known angiodysplasia"}]},{"id":"gib-hx-anorectal","dx":"anorectal","q":"Small-volume bright-red blood on tissue or surface of stool — with known hemorrhoids, anal fissure, or straining?","answers":[{"label":"No small-volume surface bleeding or anorectal symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No small-volume bright-red blood on the tissue or stool surface, and no known hemorrhoids, anal fissure, or straining were reported; a benign anorectal source was not supported by history alone.","frag":"no surface bleeding or anorectal symptoms"},{"label":"Small-volume bright-red blood on tissue, known hemorrhoids or fissure","tone":"pos","sets":[],"ddx":[{"id":"anorectal","keep":true}],"mdm":"Small-volume bright-red blood on tissue or the stool surface was reported in the setting of known hemorrhoids or anal fissure; a benign anorectal source was a leading consideration, though a more proximal source was not excluded without further evaluation.","frag":"small-volume surface blood with hemorrhoids or fissure"}]}],"exam":[{"id":"gib-exam-hemodynamics","dx":"hemorrhagic-shock","q":"Vital signs — hypotension (SBP < 90 mmHg), tachycardia (HR > 100), or orthostatic change (SBP drop ≥ 20 mmHg or HR rise ≥ 20 bpm on standing)?","answers":[{"label":"Hemodynamically stable, no orthostatic change","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable with no hypotension, tachycardia, or significant orthostatic change; hemodynamic stability was confirmed at the time of evaluation.","frag":"hemodynamically stable, no orthostatic change"},{"label":"Tachycardia or orthostatic hypotension","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock","keep":true}],"mdm":"Tachycardia or an orthostatic blood pressure drop was identified, indicating clinically significant volume depletion from hemorrhage; resuscitation and urgent specialist involvement were initiated.","frag":"tachycardia or orthostatic hypotension"},{"label":"Frank hypotension (SBP < 90 mmHg)","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock","keep":true}],"mdm":"Frank hypotension (SBP < 90 mmHg) was present, indicating hemorrhagic shock; emergent volume resuscitation, blood product administration, and immediate gastroenterology or surgical consultation were initiated.","frag":"frank hypotension"}]},{"id":"gib-exam-pallor","dx":"hemorrhagic-shock","q":"Pallor — conjunctival pallor or mucosal pallor on examination?","answers":[{"label":"No conjunctival or mucosal pallor","tone":"neg","sets":[],"ddx":[],"mdm":"No conjunctival or mucosal pallor was identified on examination; exam findings did not suggest severe anemia at the time of presentation.","frag":"no conjunctival or mucosal pallor"},{"label":"Conjunctival or mucosal pallor present","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock","keep":true}],"mdm":"Conjunctival or mucosal pallor was present on examination, consistent with significant anemia from blood loss; serial hemoglobin monitoring and resuscitative measures were pursued.","frag":"conjunctival or mucosal pallor"}]},{"id":"gib-exam-liver-stigmata","dx":"variceal","q":"Stigmata of chronic liver disease — jaundice, scleral icterus, ascites, spider angiomata, palmar erythema, or caput medusae?","answers":[{"label":"No stigmata of chronic liver disease","tone":"neg","sets":[],"ddx":[],"mdm":"No jaundice, scleral icterus, ascites, spider angiomata, or other stigmata of chronic liver disease were identified; a variceal source was not supported by physical findings.","frag":"no stigmata of chronic liver disease"},{"label":"Stigmata of chronic liver disease present","tone":"pos","sets":[],"ddx":[{"id":"variceal","keep":true}],"mdm":"Stigmata of chronic liver disease (jaundice, scleral icterus, ascites, spider angiomata, palmar erythema, or caput medusae) were identified on examination, substantially raising concern for portal hypertension and variceal hemorrhage; octreotide, antibiotic prophylaxis, and gastroenterology consultation were prioritized.","frag":"stigmata of chronic liver disease"}]},{"id":"gib-exam-abd-tenderness","dx":"general","q":"Abdominal tenderness — epigastric tenderness, diffuse tenderness, guarding, or rigidity on palpation?","answers":[{"label":"Abdomen soft and non-tender","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen was soft and non-tender without guarding or rigidity; a peritoneal process was not supported by examination.","frag":"soft, non-tender abdomen"},{"label":"Epigastric tenderness","tone":"pos","sets":[],"ddx":[{"id":"pud","keep":true}],"mdm":"Epigastric tenderness was present on palpation, raising concern for peptic ulcer disease or gastritis as the hemorrhagic source.","frag":"epigastric tenderness"},{"label":"Diffuse tenderness, guarding, or rigidity","tone":"pos","sets":[],"ddx":[{"id":"aortoenteric","keep":true}],"mdm":"Diffuse abdominal tenderness with guarding or rigidity was present; a perforated viscus or vascular catastrophe, including aortoenteric fistula, was considered alongside the bleeding source evaluation.","frag":"diffuse tenderness, guarding, or rigidity"}]},{"id":"gib-exam-rectal","dx":"general","q":"Rectal examination — melena, bright-red blood, or palpable mass on exam?","answers":[{"label":"No melena or gross blood found, no mass palpated","tone":"neg","sets":[],"ddx":[],"mdm":"No melena, gross bright-red blood, or palpable mass was found on rectal examination.","frag":"no melena, gross blood, or mass on rectal exam"},{"label":"Melena confirmed on rectal exam","tone":"pos","sets":[],"ddx":[{"id":"pud","keep":true}],"mdm":"Melena was confirmed on rectal examination, consistent with an upper-GI source; peptic ulcer disease and variceal hemorrhage remained the leading considerations.","frag":"melena on rectal exam"},{"label":"Bright-red blood or clots on rectal exam","tone":"pos","sets":[],"ddx":[{"id":"lower-gi","keep":true}],"mdm":"Bright-red blood or clots were present on rectal examination, consistent with brisk lower-GI bleeding from diverticulosis, angiodysplasia, or colitis.","frag":"bright-red blood or clots on rectal exam"},{"label":"Palpable rectal mass","tone":"pos","sets":[],"ddx":[{"id":"lower-gi","keep":true}],"mdm":"A palpable rectal mass was identified on examination; colorectal malignancy was added to the differential as a potential source of lower-GI hemorrhage.","frag":"palpable rectal mass"}]}],"conclusions":["minor / self-limited GI bleeding (hemodynamically stable)","hemorrhoidal bleeding"],"specs":["gi"],"algorithm":{"immediate":["Two large-bore IVs, type and cross, and continuous monitoring; assess volume status and signs of shock.","Resuscitate with blood products using a restrictive strategy; correct coagulopathy and hold/reverse anticoagulants as appropriate."],"criticalTests":["Hemoglobin, platelets, coagulation studies, and type and cross","ECG to screen for demand ischemia","Early GI consultation for endoscopy; CT angiography for brisk obscure bleeding"],"cantMiss":[{"dx":"hemorrhagic-shock","trigger":"Hypotension, tachycardia, or large-volume bleeding","test":"Serial hemoglobin, type and cross","intervention":"Massive-transfusion protocol, restrictive transfusion target, urgent endoscopy"},{"dx":"variceal","trigger":"Known liver disease or portal hypertension","test":"Clinical with urgent endoscopy","intervention":"Octreotide and antibiotics (e.g., ceftriaxone); emergent endoscopy; balloon tamponade if exsanguinating"},{"dx":"aortoenteric","trigger":"Prior aortic graft with GI bleeding","test":"CT angiography","intervention":"Emergent vascular surgery"}],"disposition":"Unstable or high-risk bleeding is admitted for urgent endoscopy, often to an ICU; a low-risk upper GI bleed (e.g., low Glasgow-Blatchford) may be considered for outpatient management."},"decisionTree":{"title":"GI bleeding — initial approach","intro":"An original, evidence-based decision aid for acute GI bleeding. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Resuscitate & assess","items":["Two large-bore IVs; type and cross; cardiac monitor","Assess for shock and estimate blood loss","ECG to screen for demand ischemia"],"next":"q_unstable"},"q_unstable":{"type":"decision","q":"Hemodynamically unstable or signs of massive bleeding?","cantmiss":"Don't be reassured by a normal blood pressure — younger patients compensate, and re-bleeding can decompensate suddenly.","yes":"a_resus","no":"q_upper"},"a_resus":{"type":"action","tone":"danger","title":"Resuscitate the unstable bleeder","items":["Restrictive transfusion target unless actively exsanguinating or ischemic","Activate the massive-transfusion protocol when needed","Reverse anticoagulants and correct coagulopathy","Urgent endoscopy; involve GI/surgery early"],"next":"q_variceal"},"q_upper":{"type":"decision","q":"Upper-GI source likely? (hematemesis, melena, known ulcer or varices)","pitfall":"With a prior aortic graft, consider an aortoenteric fistula — a small herald bleed can precede catastrophic hemorrhage (CT angiography, vascular surgery).","yes":"q_variceal","no":"a_lower"},"q_variceal":{"type":"decision","q":"Cirrhosis or portal hypertension (suspect varices)?","yes":"a_variceal","no":"a_upper"},"a_variceal":{"type":"action","tone":"danger","title":"Variceal bleeding","terminal":true,"items":["Start octreotide","Give prophylactic antibiotics (e.g., ceftriaxone) — they reduce mortality","Urgent endoscopy for banding","Balloon tamponade as a bridge if exsanguinating"]},"a_upper":{"type":"action","title":"Non-variceal upper-GI bleed","terminal":true,"items":["IV proton-pump inhibitor","Risk-stratify (e.g., Glasgow-Blatchford) for disposition","GI for endoscopy"]},"a_lower":{"type":"action","title":"Lower-GI bleeding","terminal":true,"items":["Resuscitate as needed; most lower-GI bleeds settle spontaneously","CT angiography for brisk ongoing bleeding","Colonoscopy via GI; IR or surgery for uncontrolled bleeding"]}}},"guide":"../learn/complaints/gi-bleed.html","pearls":[{"text":"Normal vital signs do not exclude major hemorrhage — the young compensate, beta-blockers/nodal agents blunt tachycardia, and altered mental status may be the first sign of shock in the elderly.","dx":"hemorrhagic-shock"},{"text":"A prior aortic graft or endograft with any GI bleed — even a small 'sentinel' bleed — is an aortoenteric fistula until proven otherwise; it precedes catastrophic hemorrhage.","dx":"aortoenteric"},{"text":"Give prophylactic IV ceftriaxone to every suspected variceal bleed — it carries a proven survival benefit, in addition to octreotide.","dx":"variceal","src":"NEJM/Cochrane variceal antibiotic data"},{"text":"A single CBC can be falsely normal early in an acute bleed before hemodilution occurs — trend vitals, mental status, and serial hematocrits rather than trusting one draw.","dx":"hemorrhagic-shock"},{"text":"Do the rectal exam — it can reveal a distal source (hemorrhoid, fissure) and confirm melena/hematochezia; NG lavage is not routinely indicated and a negative aspirate doesn't exclude an upper source.","dx":"lower-gi"},{"text":"Target a restrictive transfusion threshold (hemoglobin >7 g/dL) — a restrictive strategy improves survival and reduces rebleeding versus liberal transfusion, absent active cardiac ischemia.","src":"Villanueva, NEJM 2013"}]},{"id":"sore-throat","title":"Sore Throat","aliases":["sore throat","pharyngitis","throat","throat pain","odynophagia","epiglottitis","peritonsillar abscess","trouble swallowing"],"opening":"The patient was evaluated for sore throat. A history and an oropharyngeal and neck examination, with attention to the airway and to deep-space infection, were performed, and the diagnoses below were actively considered.","ddx":[{"id":"epiglottitis","group":"lifethreat","label":"Epiglottitis / supraglottitis","default":true,"tags":["airway"],"ruleout":"Epiglottitis or supraglottitis was considered; there was no drooling, muffled voice, tripoding, stridor, or respiratory distress, the patient could swallow secretions, and the airway was patent, making it unlikely.","miss":4},{"id":"deep-space","group":"lifethreat","label":"Deep-space neck infection","default":true,"tags":["airway"],"ruleout":"A deep-space neck infection was considered; there was no trismus, uvular deviation, asymmetric tonsillar swelling, floor-of-mouth induration, or neck rigidity, making peritonsillar, retropharyngeal, or Ludwig involvement unlikely.","miss":4},{"id":"strep","group":"common","label":"Streptococcal pharyngitis","default":false,"tags":[],"ruleout":"Streptococcal pharyngitis was considered and risk-stratified to guide testing and treatment.","miss":2},{"id":"mono","group":"common","label":"Infectious mononucleosis","default":false,"tags":[],"ruleout":"Infectious mononucleosis was considered in the appropriate age group based on history and examination.","miss":2},{"id":"viral-throat","group":"other","label":"Viral pharyngitis","default":false,"tags":[],"ruleout":"A self-limited viral pharyngitis was considered as the likely cause after the serious diagnoses above were addressed.","miss":1}],"risk":[{"id":"centor","label":"Centor / McIsaac score","tags":[],"scale":"low","line":"A modified Centor (McIsaac) score was documented to guide testing and antibiotic decisions for pharyngitis.","cite":"McIsaac WJ, et al. CMAJ. 1998.","calc":{"fields":[{"label":"Tonsillar exudate or swelling","opts":[["No",0],["Yes",1]]},{"label":"Tender anterior cervical nodes","opts":[["No",0],["Yes",1]]},{"label":"History of fever > 38°C","opts":[["No",0],["Yes",1]]},{"label":"Cough absent","opts":[["No",0],["Yes",1]]},{"label":"Age","opts":[["15–44",0],["3–14",1],["≥ 45",-1]]}],"bands":[[1,"low risk","low","Low (≤1): no testing or antibiotics — symptomatic care."],[3,"intermediate risk","mod","Intermediate (2–3): rapid strep / throat culture and treat if positive."],[5,"higher risk","high","Higher (≥4): testing, or empiric treatment per local guidance."]],"line":"Modified Centor (McIsaac) score {score} ({band}); used to guide streptococcal testing and antibiotic decisions.","applies":"Adults with acute sore throat, to estimate group-A strep likelihood (McIsaac adds the age adjustment). Not for children under 3, and not a substitute for testing where it changes management."},"short":"Centor {band}"},{"id":"airway-assess","label":"Airway assessment documented","tags":["airway"],"scale":"low","line":"The airway was assessed and documented as patent, without stridor or signs of impending obstruction.","short":"airway patent, no stridor"}],"checks":[{"if":"epiglottitis","needs":["airway-assess"],"mode":"any","warn":"An airway-threatening infection is on the differential — a documented airway assessment shows it was actively evaluated."},{"if":"deep-space","needs":["airway-assess"],"mode":"any","warn":"Deep-space neck infection is on the differential — document the airway and neck examination that informed the assessment."},{"if":"strep","needs":["centor"],"mode":"any","warn":"Group A strep is on the differential — documenting Centor/McIsaac criteria shows the basis for testing or treating and supports antibiotic stewardship."}],"history":[{"id":"throat-hx-airway-symptoms","dx":"epiglottitis","q":"Drooling, pooling secretions, or inability to swallow saliva — suggesting impaired airway clearance?","answers":[{"label":"No drooling or secretion pooling","tone":"neg","sets":[],"ddx":[],"mdm":"No drooling or pooling of secretions was reported; impaired airway clearance was not suggested by history.","frag":"no drooling or pooling secretions"},{"label":"Drooling or pooling secretions","tone":"pos","sets":[],"ddx":[{"id":"epiglottitis","keep":true}],"mdm":"Drooling or inability to manage oral secretions was reported, a high-risk feature for supraglottic obstruction; the airway was treated as at-risk and resources for definitive airway management were mobilized without delay.","frag":"drooling, unable to manage secretions"}]},{"id":"throat-hx-voice-change","dx":"epiglottitis","q":"Muffled or hot-potato voice — or tripoding (leaning forward on hands to breathe)?","answers":[{"label":"Voice normal, no positional distress","tone":"neg","sets":[],"ddx":[],"mdm":"No muffled or hot-potato voice quality and no tripod positioning were reported; supraglottic airway compromise was not suggested by history.","frag":"no muffled voice or tripod positioning"},{"label":"Muffled voice or tripod positioning","tone":"pos","sets":[],"ddx":[{"id":"epiglottitis","keep":true}],"mdm":"A muffled voice or tripod positioning was reported, consistent with supraglottic swelling causing partial airway obstruction; emergent airway management planning and otolaryngology consultation were initiated.","frag":"muffled voice or tripod positioning"}]},{"id":"throat-hx-rapid-progression","dx":"epiglottitis","q":"Rapid progression over hours — symptoms worsening markedly within 6–12 hours of onset?","answers":[{"label":"Gradual or stable symptom progression","tone":"neg","sets":[],"ddx":[],"mdm":"The symptom course was gradual or stable; rapid supraglottic progression was not a feature of the presentation.","frag":"gradual, stable symptom course"},{"label":"Rapid worsening over hours","tone":"pos","sets":[],"ddx":[{"id":"epiglottitis","keep":true}],"mdm":"A rapid deterioration in symptoms over hours was reported, raising concern for an evolving supraglottic or deep-space process with impending airway compromise.","frag":"rapid worsening over hours"}]},{"id":"throat-hx-immunization","dx":"epiglottitis","q":"Immunization status — incomplete or unknown Haemophilus influenzae type b (Hib) immunization? Immunocompromised state?","answers":[{"label":"Immunizations up to date, immunocompetent","tone":"neg","sets":[],"ddx":[],"mdm":"Immunization status was reported as current and no immunocompromised state was identified; classic H. influenzae epiglottitis was less likely, though adult epiglottitis from other organisms remained possible.","frag":"immunizations current, immunocompetent"},{"label":"Incomplete Hib immunization or immunocompromised","tone":"pos","sets":[],"ddx":[{"id":"epiglottitis","keep":true}],"mdm":"Incomplete immunization or an immunocompromised state was identified, lowering the threshold for epiglottitis and unusual pathogens; early specialist consultation and airway monitoring were prioritized.","frag":"incomplete Hib or immunocompromised"}]},{"id":"throat-hx-trismus","dx":"deep-space","q":"Jaw stiffness or trismus — inability to fully open the mouth (limited jaw opening)?","answers":[{"label":"No jaw stiffness or trismus","tone":"neg","sets":[],"ddx":[],"mdm":"No jaw stiffness or trismus was reported; a peritonsillar or parapharyngeal abscess with masseteric involvement was not specifically suggested by history.","frag":"no jaw stiffness or trismus"},{"label":"Jaw stiffness or trismus present","tone":"pos","sets":[],"ddx":[{"id":"deep-space","keep":true}],"mdm":"Trismus was reported, a hallmark feature of peritonsillar abscess and parapharyngeal space infection; urgent otolaryngology consultation and cross-sectional imaging were initiated.","frag":"trismus"}]},{"id":"throat-hx-neck-swelling","dx":"deep-space","q":"Neck swelling, stiffness, or pain with neck movement — localized or diffuse?","answers":[{"label":"No neck swelling or neck stiffness","tone":"neg","sets":[],"ddx":[],"mdm":"No neck swelling or neck stiffness was reported; a deep-space neck infection with extrapharyngeal extension was not supported by history.","frag":"no neck swelling or stiffness"},{"label":"Neck swelling or stiffness present","tone":"pos","sets":[],"ddx":[{"id":"deep-space","keep":true}],"mdm":"Neck swelling or stiffness was reported, raising concern for a deep-space neck infection including retropharyngeal abscess or descending necrotizing mediastinitis; CT neck with contrast and urgent otolaryngology consultation were initiated.","frag":"neck swelling or stiffness"}]},{"id":"throat-hx-odynophagia","dx":"deep-space","q":"Odynophagia or dysphagia out of proportion to external throat appearance — including floor-of-mouth swelling or submandibular pain?","answers":[{"label":"Odynophagia mild or proportionate to exam","tone":"neg","sets":[],"ddx":[],"mdm":"Odynophagia was mild or consistent with the external examination findings; a deep-space infection was not specifically suggested by symptom severity.","frag":"odynophagia proportionate to exam"},{"label":"Severe odynophagia out of proportion, or floor-of-mouth pain or swelling","tone":"pos","sets":[],"ddx":[{"id":"deep-space","keep":true}],"mdm":"Odynophagia or dysphagia out of proportion to the oropharyngeal appearance, or floor-of-mouth swelling, was reported; Ludwig angina, retropharyngeal abscess, or a peritonsillar abscess was a leading concern and cross-sectional imaging was obtained.","frag":"odynophagia out of proportion or floor-of-mouth pain"}]},{"id":"throat-hx-fever","dx":"strep","q":"Subjective or measured fever > 38°C (100.4°F) during this illness?","answers":[{"label":"No fever reported","tone":"neg","sets":[{"risk":"centor","field":2,"opt":0}],"ddx":[],"mdm":"No fever was reported; this modified Centor criterion was not met.","frag":"no fever"},{"label":"Fever > 38°C reported or measured","tone":"pos","sets":[{"risk":"centor","field":2,"opt":1}],"ddx":[{"id":"strep","keep":true}],"mdm":"A history of fever greater than 38°C was reported, meeting a modified Centor criterion and raising the likelihood of bacterial streptococcal pharyngitis.","frag":"fever >38°C"}]},{"id":"throat-hx-cough","dx":"strep","q":"Is cough present as a symptom of this illness?","answers":[{"label":"Cough present","tone":"pos","sets":[{"risk":"centor","field":3,"opt":0}],"ddx":[],"mdm":"Cough is present, lowering the likelihood of streptococcal pharyngitis (Centor criterion: cough absent = not met).","frag":"cough present"},{"label":"No cough","tone":"neg","sets":[{"risk":"centor","field":3,"opt":1}],"ddx":[],"mdm":"Cough was absent, meeting a modified Centor criterion and raising the likelihood of bacterial pharyngitis over a viral etiology.","frag":"no cough"}]},{"id":"throat-hx-mono-demographics","dx":"mono","q":"Age 15–30 years (adolescent or young adult) — the peak demographic for primary Epstein-Barr virus infection?","answers":[{"label":"Outside peak mono age range (< 15 or > 30)","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was outside the classic peak demographic for primary EBV-associated infectious mononucleosis; a monolike syndrome remained possible but was less common.","frag":"no mononucleosis risk features"},{"label":"Age 15–30 years","tone":"pos","sets":[],"ddx":[{"id":"mono","keep":true}],"mdm":"The patient was in the 15–30 age range, the peak demographic for primary EBV-associated infectious mononucleosis; this diagnosis was included in the differential alongside streptococcal pharyngitis.","frag":"age 15–30"}]},{"id":"throat-hx-fatigue","dx":"mono","q":"Profound fatigue or malaise — disproportionate to the sore throat, or lasting more than 1 week?","answers":[{"label":"No profound or prolonged fatigue","tone":"neg","sets":[],"ddx":[],"mdm":"No profound or prolonged fatigue was reported; a systemic mono-like illness was not prominently suggested by this feature.","frag":"no profound or prolonged fatigue"},{"label":"Profound fatigue or malaise present","tone":"pos","sets":[],"ddx":[{"id":"mono","keep":true}],"mdm":"Profound fatigue or malaise out of proportion to the pharyngeal complaint was reported, a characteristic feature of infectious mononucleosis; EBV heterophile antibody testing and CBC with differential were ordered.","frag":"profound fatigue out of proportion"}]},{"id":"throat-hx-viral-features","dx":"viral-throat","q":"Coryza, rhinorrhea, hoarseness, or gradual onset over several days — viral upper respiratory features?","answers":[{"label":"No coryza, rhinorrhea, or hoarseness","tone":"neg","sets":[],"ddx":[],"mdm":"No coryza, rhinorrhea, or hoarseness was reported; the symptom constellation was not clearly pointing to a viral upper-respiratory etiology.","frag":"no coryza, rhinorrhea, or hoarseness"},{"label":"Coryza, rhinorrhea, or hoarseness present","tone":"pos","sets":[],"ddx":[{"id":"viral-throat","keep":true}],"mdm":"Coryza, rhinorrhea, or hoarseness was reported alongside sore throat, consistent with a viral upper-respiratory infection; these features lower the likelihood of streptococcal pharyngitis and antibiotic treatment was not indicated based on this presentation.","frag":"coryza, rhinorrhea, or hoarseness"}]}],"exam":[{"id":"throat-exam-airway","dx":"epiglottitis","q":"Airway assessment — stridor on auscultation? Drooling or pooling secretions? Tripod positioning? Respiratory distress?","answers":[{"label":"Airway patent — no stridor, no drooling, no distress","tone":"neg","sets":[],"ddx":[],"mdm":"The airway was assessed as patent; no stridor was heard, no drooling or secretion pooling was observed, and the patient was not in respiratory distress.","frag":"airway patent, no stridor, drooling, or distress"},{"label":"Stridor, drooling, tripoding, or respiratory distress","tone":"pos","sets":[],"ddx":[{"id":"epiglottitis","keep":true}],"mdm":"Stridor, drooling, tripod positioning, or respiratory distress was identified on examination; the airway was treated as immediately threatened and definitive airway resources were mobilized without delay.","frag":"stridor, drooling, tripoding, or distress"}]},{"id":"throat-exam-voice-secretions","dx":"epiglottitis","q":"Voice quality and secretion handling — muffled or hot-potato voice? Pooling secretions visible in the oropharynx?","answers":[{"label":"Voice clear, no pooling secretions","tone":"neg","sets":[],"ddx":[],"mdm":"Voice quality was normal and there was no pooling of secretions in the oropharynx; the examination did not suggest supraglottic or deep-space pathology.","frag":"voice normal, no pooling secretions"},{"label":"Muffled voice or pooling secretions","tone":"pos","sets":[],"ddx":[{"id":"epiglottitis","keep":true},{"id":"deep-space","keep":true}],"mdm":"A muffled or hot-potato voice or pooling secretions were identified on examination, consistent with significant supraglottic or parapharyngeal pathology requiring urgent airway monitoring and specialist consultation.","frag":"muffled voice or pooling secretions"}]},{"id":"throat-exam-deep-space","dx":"deep-space","q":"Trismus, floor-of-mouth swelling or induration, uvular deviation, or unilateral tonsillar bulge?","answers":[{"label":"No trismus, no floor-of-mouth swelling, no uvular deviation","tone":"neg","sets":[],"ddx":[],"mdm":"No trismus, floor-of-mouth swelling, uvular deviation, or asymmetric tonsillar bulge was identified; the examination did not support a deep-space neck infection.","frag":"no trismus, floor-of-mouth swelling, or uvular deviation"},{"label":"Trismus, floor-of-mouth swelling, or uvular deviation","tone":"pos","sets":[],"ddx":[{"id":"deep-space","keep":true}],"mdm":"Trismus, floor-of-mouth swelling or induration, uvular deviation, or a unilateral tonsillar bulge was identified on examination, raising concern for peritonsillar abscess, retropharyngeal abscess, or Ludwig angina; urgent otolaryngology consultation was initiated.","frag":"trismus, floor-of-mouth swelling, or uvular deviation"}]},{"id":"throat-exam-tonsils","dx":"strep","q":"Tonsillar exudate or tonsillar swelling on oropharyngeal inspection?","answers":[{"label":"No exudate, no significant swelling","tone":"neg","sets":[{"risk":"centor","field":0,"opt":0}],"ddx":[],"mdm":"No tonsillar exudate or significant tonsillar swelling was identified on oropharyngeal examination; this modified Centor criterion was not met.","frag":"no tonsillar exudate or swelling"},{"label":"Exudate or tonsillar swelling present","tone":"pos","sets":[{"risk":"centor","field":0,"opt":1}],"ddx":[{"id":"strep","keep":true}],"mdm":"Tonsillar exudate or marked tonsillar swelling was present on examination, meeting a modified Centor criterion and raising concern for streptococcal pharyngitis.","frag":"tonsillar exudate or swelling"}]},{"id":"throat-exam-cervical-nodes","dx":"strep","q":"Tender anterior cervical lymphadenopathy on palpation?","answers":[{"label":"No tender anterior cervical nodes","tone":"neg","sets":[{"risk":"centor","field":1,"opt":0}],"ddx":[],"mdm":"No tender anterior cervical lymphadenopathy was identified on palpation; this modified Centor criterion was not met.","frag":"no tender anterior cervical nodes"},{"label":"Tender anterior cervical nodes present","tone":"pos","sets":[{"risk":"centor","field":1,"opt":1}],"ddx":[{"id":"strep","keep":true}],"mdm":"Tender anterior cervical lymphadenopathy was present on palpation, meeting a modified Centor criterion and raising the likelihood of bacterial pharyngitis.","frag":"tender anterior cervical nodes"}]},{"id":"throat-exam-posterior-nodes","dx":"mono","q":"Posterior cervical lymphadenopathy or generalized lymphadenopathy on palpation?","answers":[{"label":"No posterior cervical or generalized lymphadenopathy","tone":"neg","sets":[],"ddx":[],"mdm":"No posterior cervical or generalized lymphadenopathy was identified; the lymph node exam did not support a mononucleosis syndrome.","frag":"no posterior cervical or generalized lymphadenopathy"},{"label":"Posterior cervical or generalized lymphadenopathy present","tone":"pos","sets":[],"ddx":[{"id":"mono","keep":true}],"mdm":"Posterior cervical or generalized lymphadenopathy was identified on examination, a characteristic feature of infectious mononucleosis; EBV serologies and CBC with differential were ordered.","frag":"posterior cervical or generalized lymphadenopathy"}]},{"id":"throat-exam-splenomegaly","dx":"mono","q":"Splenomegaly on abdominal palpation — enlarged or tender spleen? (Splenomegaly precaution: avoid vigorous palpation if mono suspected.)","answers":[{"label":"No splenomegaly detected","tone":"neg","sets":[],"ddx":[],"mdm":"No splenomegaly was identified on gentle abdominal palpation; this does not exclude mononucleosis.","frag":"no splenomegaly"},{"label":"Splenomegaly present","tone":"pos","sets":[],"ddx":[{"id":"mono","keep":true}],"mdm":"Splenomegaly was identified on examination, a finding consistent with infectious mononucleosis; the patient was counseled to avoid contact sports and abdominal trauma, and ultrasound confirmation was considered.","frag":"splenomegaly"}]}],"conclusions":["viral pharyngitis","streptococcal pharyngitis","sore throat NOS"],"specs":["ent","id"],"guide":"../learn/complaints/sore-throat.html"},{"id":"scrotal-pain","title":"Testicular / Scrotal Pain","aliases":["scrotal pain","testicular pain","testicle","torsion","testicular torsion","fournier","epididymitis","groin pain","swollen testicle"],"opening":"The patient was evaluated for acute scrotal pain. The time-critical diagnosis of testicular torsion was prioritized, a focused genitourinary examination was performed, and the diagnoses below were actively considered.","ddx":[{"id":"torsion","group":"lifethreat","label":"Testicular torsion","default":true,"tags":["torsion"],"ruleout":"Testicular torsion was considered; onset was not sudden, the testis was in normal vertical lie with intact cremasteric reflex, there was no high-riding testis or nausea, and Doppler showed normal flow where obtained, making it unlikely.","miss":4,"sex":"m"},{"id":"fournier","group":"lifethreat","label":"Fournier gangrene","default":true,"tags":["fournier"],"ruleout":"Fournier gangrene was considered; there was no pain out of proportion, crepitus, skin necrosis, perineal discoloration, or systemic toxicity, making necrotizing perineal infection unlikely.","miss":4,"sex":"m"},{"id":"hernia-strang","group":"lifethreat","label":"Incarcerated / strangulated hernia","default":false,"tags":["hernia"],"ruleout":"An incarcerated or strangulated inguinoscrotal hernia was considered; there was no irreducible or tender groin mass, no overlying skin change, and no signs of bowel obstruction, making it unlikely.","miss":4},{"id":"torsion-appendix-sp","group":"lifethreat","label":"Torsion of testicular appendage","default":false,"tags":["torsion-appendix-sp"],"ruleout":"Torsion of a testicular appendage was considered; there was no isolated upper-pole tenderness or blue-dot sign and Doppler showed preserved testicular flow where obtained, and while benign it does not threaten the testis.","miss":4,"sex":"m"},{"id":"appendix-testis","group":"common","label":"Torsion of the appendix testis","default":false,"tags":["appendix"],"ruleout":"Torsion of the appendix testis was considered as the more benign cause once testicular torsion was addressed; it presents with isolated upper-pole tenderness or a blue-dot sign and preserved testicular Doppler flow, and while it does not threaten the testis, the differential from true torsion still rests on flow, not on pain severity alone.","miss":4,"sex":"m"},{"id":"epididymitis","group":"common","label":"Epididymo-orchitis","default":false,"tags":["epididymitis"],"ruleout":"Epididymo-orchitis was considered based on a more gradual onset with urinary or infectious features, after torsion was excluded.","miss":2,"sex":"m"}],"risk":[{"id":"twist","label":"TWIST score (torsion)","tags":["torsion"],"scale":"low","line":"A TWIST score was documented to risk-stratify for testicular torsion.","cite":"Barbosa JA, et al. J Urol. 2013; Qin KR, et al. J Urol. 2022 (meta-analysis).","calc":{"fields":[{"label":"Testicular swelling","opts":[["No",0],["Yes",2]]},{"label":"Hard testis","opts":[["No",0],["Yes",2]]},{"label":"Absent cremasteric reflex","opts":[["No",0],["Yes",1]]},{"label":"Nausea / vomiting","opts":[["No",0],["Yes",1]]},{"label":"High-riding testis","opts":[["No",0],["Yes",1]]}],"bands":[[2,"low risk","low","Low (0–2): torsion unlikely — ultrasound rather than immediate exploration is reasonable."],[4,"intermediate risk","mod","Intermediate (3–4): urgent ultrasound with urology involvement."],[7,"high risk","high","High (5–7): emergent urology consult for likely torsion — do not let imaging delay exploration."]],"line":"TWIST {score}/7 ({band}); torsion risk stratification documented (low-risk sensitivity 0.98, high-risk specificity 0.98 in meta-analysis).","applies":"Boys and adolescents with acute scrotal pain where torsion is the concern. A high score supports urgent urology/exploration; a low score does not exclude torsion when the exam or history is concerning."},"short":"TWIST {band}"},{"id":"doppler-us","label":"Scrotal Doppler ultrasound","tags":["torsion"],"scale":"low","line":"A scrotal Doppler ultrasound was obtained to assess testicular blood flow when torsion was a consideration and the diagnosis was not already clear on clinical grounds.","short":"Doppler ultrasound"},{"id":"urology-sc","label":"Urologic consultation","tags":["torsion"],"scale":"low","line":"Urologic consultation was obtained without delay when torsion was suspected; definitive evaluation was not delayed for imaging in a clinically convincing case.","short":"Urology consulted"},{"id":"ua-sc","label":"Urinalysis","tags":["epididymitis"],"scale":"low","line":"A urinalysis was obtained to evaluate for an infectious (epididymitis) cause when the presentation was more gradual.","short":"Urinalysis obtained"}],"checks":[{"if":"torsion","needs":["twist","doppler-us","urology-sc"],"mode":"any","warn":"Testicular torsion is on the differential — a Doppler ultrasound and/or urologic evaluation documents the basis for the assessment, and should not be delayed in a convincing case."},{"if":"fournier","needs":["urology-sc"],"mode":"any","warn":"Fournier gangrene is on the differential — surgical/urologic involvement and the exam findings document the basis for excluding it."}],"history":[{"id":"sc-hx-onset","dx":"general","q":"Pain onset, severity, and time course — sudden and severe (often with nausea/vomiting), or gradual? How long ago did it start (torsion salvage falls sharply after ~6 hours)?","answers":[{"label":"Gradual onset","tone":"neg","sets":[{"risk":"twist","field":3,"opt":0}],"ddx":[],"mdm":"The pain was gradual in onset, which is less typical for testicular torsion.","frag":"gradual onset"},{"label":"Sudden, severe onset ± vomiting","tone":"pos","sets":[],"ddx":[{"id":"torsion","keep":true}],"mdm":"The pain was sudden and severe, often with nausea or vomiting, a presentation characteristic of testicular torsion and prompting time-critical evaluation.","frag":"sudden severe onset ± vomiting"}]},{"id":"sc-hx-torsion-risk","dx":"torsion","q":"Torsion risk — adolescent or neonatal age, prior intermittent testicular pain, an undescended testis, or a known bell-clapper deformity?","answers":[{"label":"No torsion risk features","tone":"neg","sets":[],"ddx":[],"mdm":"No torsion-specific risk features (characteristic age, prior intermittent pain, undescended testis) were identified.","frag":"no torsion risk features"},{"label":"Torsion risk features present","tone":"pos","sets":[],"ddx":[{"id":"torsion","keep":true}],"mdm":"Risk features for testicular torsion were present, raising the pretest probability and lowering the threshold for urgent evaluation.","frag":"torsion risk features"}]},{"id":"sc-hx-intermittent","dx":"torsion","q":"Prior similar episodes of sudden testicular pain that resolved on their own (intermittent torsion / detorsion)?","answers":[{"label":"No prior episodes","tone":"neg","sets":[],"ddx":[],"mdm":"No prior self-resolving episodes of testicular pain were reported.","frag":"no prior intermittent pain"},{"label":"Prior self-resolving episodes","tone":"pos","sets":[],"ddx":[{"id":"torsion","keep":true}],"mdm":"Prior episodes of sudden testicular pain that resolved spontaneously were reported, consistent with intermittent torsion and warranting urologic follow-up.","frag":"prior intermittent torsion"}]},{"id":"sc-hx-fournier","dx":"fournier","q":"Diabetes, immunocompromise, or perineal pain out of proportion to the visible findings with systemic toxicity?","answers":[{"label":"No Fournier risk / toxicity","tone":"neg","sets":[],"ddx":[],"mdm":"No diabetes, immunocompromise, or systemic toxicity to suggest a necrotizing perineal infection was identified.","frag":"no Fournier risk"},{"label":"Fournier risk / pain out of proportion","tone":"pos","sets":[],"ddx":[{"id":"fournier","keep":true}],"mdm":"Diabetes, immunocompromise, or perineal pain out of proportion with systemic toxicity was present, raising concern for Fournier gangrene.","frag":"Fournier risk / pain out of proportion"}]},{"id":"sc-hx-hernia","dx":"hernia-strang","q":"A groin or scrotal bulge that has become irreducible or painful, with nausea or vomiting?","answers":[{"label":"No hernia / reducible","tone":"neg","sets":[],"ddx":[],"mdm":"No hernia, or a known hernia that remains reducible, was reported.","frag":"no hernia / reducible"},{"label":"Irreducible or painful hernia","tone":"pos","sets":[],"ddx":[{"id":"hernia-strang","keep":true}],"mdm":"A previously reducible hernia became irreducible and painful, with obstructive symptoms, raising concern for incarceration or strangulation.","frag":"irreducible painful hernia"}]},{"id":"sc-hx-infectious","dx":"epididymitis","q":"More gradual onset with dysuria, urethral discharge, fever, or relief when the scrotum is elevated?","answers":[{"label":"No urinary / infectious features","tone":"neg","sets":[],"ddx":[],"mdm":"No dysuria, discharge, fever, or positional relief to suggest an infectious cause was reported.","frag":"no infectious features"},{"label":"Dysuria / discharge / fever","tone":"pos","sets":[],"ddx":[{"id":"epididymitis","keep":true}],"mdm":"A more gradual onset with dysuria, discharge, fever, or relief on elevation was reported, supporting epididymo-orchitis after torsion was addressed.","frag":"dysuria / discharge / fever"}]}],"exam":[{"id":"sc-exam-vitals","dx":"general","q":"Vital signs — febrile, tachycardic, or toxic-appearing (concern for Fournier gangrene or sepsis)?","answers":[{"label":"Afebrile, non-toxic","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was afebrile, not tachycardic, and non-toxic-appearing, without features concerning for Fournier gangrene or sepsis.","frag":"afebrile, non-toxic"},{"label":"Febrile / toxic-appearing","tone":"pos","sets":[],"ddx":[{"id":"fournier","keep":true}],"mdm":"The patient was febrile or toxic-appearing, prompting evaluation for a necrotizing or systemic infection.","frag":"febrile / toxic-appearing"}]},{"id":"sc-exam-lie","dx":"torsion","q":"Testicular lie and cremasteric reflex — a high-riding or transverse testis, or an absent cremasteric reflex?","answers":[{"label":"Normal lie, cremasteric present","tone":"neg","sets":[{"risk":"twist","field":2,"opt":0},{"risk":"twist","field":4,"opt":0}],"ddx":[],"mdm":"The testicular lie was normal and the cremasteric reflex present, noting that a present cremasteric reflex does not exclude torsion; when suspicion remained, Doppler ultrasound and/or urologic evaluation made the call.","frag":"normal lie; cremasteric present (not relied on to exclude torsion)"},{"label":"High-riding / transverse / absent cremasteric","tone":"pos","sets":[],"ddx":[{"id":"torsion","keep":true}],"mdm":"A high-riding or transverse testis or an absent cremasteric reflex was found, findings concerning for testicular torsion.","frag":"high-riding / absent cremasteric"}]},{"id":"sc-exam-twist-palpation","dx":"torsion","q":"Testis palpation — swollen? hard/firm consistency? (the two heaviest TWIST items)","answers":[{"label":"Not swollen, normal consistency","tone":"neg","sets":[{"risk":"twist","field":0,"opt":0},{"risk":"twist","field":1,"opt":0}],"ddx":[],"mdm":"The testis was neither swollen nor hard on palpation.","frag":"testis not swollen; normal consistency"},{"label":"Swollen, not hard","tone":"pos","sets":[{"risk":"twist","field":0,"opt":1},{"risk":"twist","field":1,"opt":0}],"ddx":[{"id":"torsion","keep":true}],"mdm":"The testis was swollen but without the hard consistency of torsion.","frag":"testicular swelling"},{"label":"Swollen AND hard","tone":"pos","sets":[{"risk":"twist","field":0,"opt":1},{"risk":"twist","field":1,"opt":1}],"ddx":[{"id":"torsion","keep":true}],"mdm":"The testis was swollen and hard: the two heaviest TWIST findings for torsion.","frag":"swollen, hard testis"}]},{"id":"sc-exam-skin","dx":"fournier","q":"Perineal and scrotal skin — crepitus, necrosis, bullae, or rapidly advancing erythema?","answers":[{"label":"Skin intact, no crepitus","tone":"neg","sets":[],"ddx":[],"mdm":"The perineal and scrotal skin was intact without crepitus, necrosis, or rapidly spreading erythema.","frag":"skin intact, no crepitus"},{"label":"Crepitus / necrosis / advancing erythema","tone":"pos","sets":[],"ddx":[{"id":"fournier","keep":true}],"mdm":"Crepitus, skin necrosis, bullae, or rapidly advancing erythema was present, raising strong concern for Fournier gangrene and prompting emergent surgical involvement.","frag":"crepitus / necrosis / advancing erythema"}]},{"id":"sc-exam-hernia","dx":"hernia-strang","q":"Groin examination — an irreducible, tender mass, or bowel sounds within the scrotum?","answers":[{"label":"No hernia / reducible","tone":"neg","sets":[],"ddx":[],"mdm":"No incarcerated hernia was found (no irreducible, tender mass and no bowel sounds within the scrotum) or a known hernia reduced readily.","frag":"no incarcerated hernia"},{"label":"Irreducible tender groin mass","tone":"pos","sets":[],"ddx":[{"id":"hernia-strang","keep":true}],"mdm":"An irreducible, tender inguinoscrotal mass was present, consistent with an incarcerated or strangulated hernia.","frag":"irreducible tender groin mass"}]},{"id":"sc-exam-prehn","dx":"epididymitis","q":"Epididymal tenderness or relief of pain with testicular elevation (Prehn sign)?","answers":[{"label":"No isolated epididymal tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"There was no isolated epididymal tenderness or positional relief to suggest epididymitis.","frag":"no epididymal tenderness"},{"label":"Epididymal tenderness / positional relief","tone":"pos","sets":[],"ddx":[{"id":"epididymitis","keep":true}],"mdm":"Epididymal tenderness with positional relief suggested epididymitis, recognizing that the Prehn sign is unreliable and was not used to exclude torsion.","frag":"epididymal tenderness with positional relief (Prehn, not used to exclude torsion)"}]},{"answers":[{"ddx":[],"frag":"no isolated upper-pole tenderness or blue-dot sign","label":"No appendage-torsion signs","mdm":"There was no isolated upper-pole tenderness or blue-dot sign and Doppler showed preserved testicular flow where obtained, making torsion of a testicular appendage unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"torsion-appendix-sp","keep":true}],"frag":"upper-pole tenderness or blue-dot sign","label":"Appendage-torsion signs present","mdm":"Isolated upper-pole tenderness or a blue-dot sign with preserved testicular flow suggested torsion of a testicular appendage, a benign process that does not threaten the testis.","sets":[],"tone":"pos"}],"dx":"torsion-appendix-sp","id":"sc-exam-torsion-appendix-sp","q":"Appendage torsion — isolated upper-pole tenderness or a blue-dot sign with preserved testicular Doppler flow?"}],"conclusions":["epididymitis","nonspecific scrotal pain (torsion excluded)"],"specs":["uro"],"guide":"../learn/complaints/testicular-torsion.html","pearls":[{"text":"Examine the genitals in any boy or young man with abdominal pain alone — torsion, including of an undescended testis, can present without scrotal symptoms at all.","dx":"torsion"},{"text":"An intact cremasteric reflex does not exclude torsion — it's reassuring but imperfect, and should never be the sole basis for ruling it out.","dx":"torsion"},{"text":"With high suspicion and onset under 6 hours, call urology and go straight to the OR — imaging is for equivocal or lower-suspicion cases and must never delay definitive detorsion.","dx":"torsion"},{"text":"Color Doppler ultrasound is highly sensitive but not perfect for torsion — a reassuring study in a high-suspicion presentation should not override the clinical decision to operate.","dx":"torsion"},{"text":"Manual detorsion is a bridge, not a substitute for surgery — use pain relief as the endpoint (skip a cord/inguinal block, which would mask that endpoint), be ready to reverse direction, and proceed to surgical fixation regardless of apparent success.","dx":"torsion"},{"text":"Auscultate the scrotum for bowel sounds when a hernia is in the differential — an incarcerated or strangulated inguinal hernia can mimic acute scrotal pain and needs urgent surgical evaluation.","dx":"hernia-strang"}]},{"id":"early-pregnancy","title":"Early-Pregnancy Bleeding / Pain","aliases":["ectopic","ectopic pregnancy","early pregnancy bleeding","first trimester bleeding","vaginal bleeding","miscarriage","pregnant pain","hCG","threatened abortion","spotting"],"opening":"The patient, of reproductive potential, was evaluated for first-trimester bleeding and/or pelvic pain. Ectopic pregnancy was treated as the can't-miss diagnosis until excluded, a pregnancy test was obtained, and the diagnoses below were actively considered.","ddx":[{"id":"ectopic","group":"lifethreat","label":"Ectopic pregnancy","default":true,"tags":["ectopic"],"ruleout":"Ectopic pregnancy was considered; the pregnancy was confirmed intrauterine on ultrasound (or hCG/ultrasound followed serially), there was no lateralizing pelvic pain, adnexal mass, or significant free fluid, and the patient was hemodynamically stable, making it unlikely.","miss":4,"sex":"f"},{"id":"hemorrhagic-shock-ep","group":"lifethreat","label":"Hemorrhagic shock (ruptured ectopic)","default":true,"tags":["shock"],"ruleout":"Hemorrhagic shock from a ruptured ectopic was considered; the patient was hemodynamically stable with normal heart rate and blood pressure, no syncope or orthostasis, a soft non-peritoneal abdomen, and no significant free fluid, making it unlikely.","miss":4,"sex":"f"},{"id":"heterotopic","group":"other","label":"Heterotopic pregnancy","default":false,"tags":["heterotopic"],"ruleout":"Heterotopic pregnancy was considered, particularly after assisted reproduction; the presence of an intrauterine pregnancy does not fully exclude a concurrent ectopic, and follow-up was arranged accordingly.","miss":1,"sex":"f"},{"id":"molar","group":"other","label":"Molar pregnancy","default":false,"tags":["molar"],"ruleout":"Molar pregnancy was considered; there was no markedly larger-than-dates uterus, hyperemesis, or disproportionately elevated hCG to suggest it.","miss":1,"sex":"f"},{"id":"miscarriage","group":"common","label":"Threatened / inevitable miscarriage","default":false,"tags":["miscarriage"],"ruleout":"Threatened or inevitable miscarriage was considered as a common cause of first-trimester bleeding once ectopic pregnancy was addressed, with precautions and follow-up provided.","miss":2}],"risk":[{"id":"hcg","label":"Quantitative hCG","tags":["ectopic"],"scale":"low","line":"A quantitative serum hCG was obtained and interpreted alongside the ultrasound and the discriminatory zone.","short":"Quantitative hCG"},{"id":"pelvic-us-ep","label":"Pelvic ultrasound","tags":["ectopic"],"scale":"low","line":"A pelvic ultrasound was obtained to assess for an intrauterine pregnancy, an adnexal mass, or free fluid.","short":"Pelvic ultrasound"},{"id":"rh","label":"Rh status / Rho(D) immune globulin","tags":["ectopic"],"scale":"low","line":"Rh status was determined and Rho(D) immune globulin was given to an Rh-negative patient with bleeding as indicated.","short":"Rh status checked"},{"id":"type-screen-ep","label":"Type & screen","tags":["shock"],"scale":"low","line":"A type and screen (with crossmatch if unstable) was obtained given the potential for significant hemorrhage.","short":"Type & screen"}],"checks":[{"if":"ectopic","needs":["hcg","pelvic-us-ep"],"mode":"any","warn":"Ectopic pregnancy is on the differential — a quantitative hCG and a pelvic ultrasound document the basis for the assessment and disposition."},{"if":"hemorrhagic-shock-ep","needs":["type-screen-ep"],"mode":"any","warn":"Ruptured ectopic with hemorrhage is on the differential — a type and screen and the hemodynamic assessment document the workup."},{"if":"miscarriage","needs":["rh"],"mode":"any","warn":"Document the Rh status — Rh-negative patients with early-pregnancy bleeding need RhoGAM."}],"history":[{"id":"ep-hx-bleeding","dx":"general","q":"Vaginal bleeding and pelvic pain — amount of bleeding, and has any tissue been passed?","answers":[{"label":"Light bleeding, no tissue","tone":"neg","sets":[],"ddx":[],"mdm":"Bleeding was light and no tissue passage was reported.","frag":"light bleeding, no tissue"},{"label":"Heavy bleeding or tissue passed","tone":"pos","sets":[],"ddx":[{"id":"miscarriage","keep":true}],"mdm":"Heavy bleeding or passage of tissue was reported, consistent with an ongoing miscarriage, while ectopic pregnancy was still actively excluded.","frag":"heavy bleeding / tissue passed"}],"sex":"f"},{"id":"ep-hx-ectopic-risk","dx":"ectopic","q":"Ectopic risk factors — prior ectopic, tubal surgery or ligation, pelvic inflammatory disease, an IUD in place, or assisted reproduction?","answers":[{"label":"No ectopic risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No risk factors for ectopic pregnancy were identified: no prior ectopic, tubal surgery or ligation, pelvic inflammatory disease, IUD in place, or assisted reproduction.","frag":"no ectopic risk factors"},{"label":"Ectopic risk factors present","tone":"pos","sets":[],"ddx":[{"id":"ectopic","keep":true}],"mdm":"Risk factors for ectopic pregnancy were present (prior ectopic, tubal surgery or ligation, pelvic inflammatory disease, an IUD in place, or assisted reproduction), raising the pretest probability and lowering the threshold for definitive evaluation.","frag":"ectopic risk factors"}]},{"id":"ep-hx-rupture","dx":"hemorrhagic-shock-ep","q":"Severe or worsening pain, shoulder-tip pain, lightheadedness, or syncope (suggesting hemoperitoneum from rupture)?","answers":[{"label":"No rupture / shock features","tone":"neg","sets":[],"ddx":[],"mdm":"No severe pain, shoulder-tip pain, lightheadedness, or syncope to suggest rupture was reported.","frag":"no rupture features"},{"label":"Shoulder-tip pain / lightheadedness / syncope","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock-ep","keep":true},{"id":"ectopic","keep":true}],"mdm":"Severe pain, shoulder-tip pain, lightheadedness, or syncope was reported, concerning for a ruptured ectopic with hemoperitoneum and requiring immediate evaluation.","frag":"shoulder-tip pain / syncope"}]},{"id":"ep-hx-dating","dx":"ectopic","q":"Last menstrual period and gestational age — is the pregnancy confirmed, and is the dating consistent with an expected intrauterine pregnancy on ultrasound?","answers":[{"label":"Dating known / consistent","tone":"neg","sets":[],"ddx":[],"mdm":"The last menstrual period and gestational age were established to interpret the hCG and ultrasound.","frag":"dating established"},{"label":"Dating uncertain","tone":"pos","sets":[],"ddx":[{"id":"ectopic","keep":true}],"mdm":"Gestational dating was uncertain, which complicates interpretation of the hCG and ultrasound and warrants close follow-up.","frag":"uncertain dating"}]},{"id":"ep-hx-art","dx":"heterotopic","q":"Was this pregnancy achieved with assisted reproduction (which raises the risk of a heterotopic pregnancy)?","answers":[{"label":"No assisted reproduction","tone":"neg","sets":[],"ddx":[],"mdm":"The pregnancy was not achieved with assisted reproduction.","frag":"no assisted reproduction"},{"label":"Assisted reproduction","tone":"pos","sets":[],"ddx":[{"id":"heterotopic","keep":true}],"mdm":"The pregnancy was achieved with assisted reproduction, raising the risk of a heterotopic pregnancy so that an intrauterine pregnancy does not exclude a concurrent ectopic.","frag":"assisted reproduction (heterotopic risk)"}]},{"id":"ep-hx-molar","dx":"molar","q":"Severe nausea and vomiting (hyperemesis), or a uterus much larger than expected for dates?","answers":[{"label":"No molar features","tone":"neg","sets":[],"ddx":[],"mdm":"No hyperemesis or larger-than-dates uterus to suggest molar pregnancy was reported.","frag":"no molar features"},{"label":"Hyperemesis / larger-than-dates","tone":"pos","sets":[],"ddx":[{"id":"molar","keep":true}],"mdm":"Hyperemesis or a larger-than-dates uterus was reported, prompting consideration of a molar pregnancy.","frag":"hyperemesis / larger-than-dates"}]}],"exam":[{"id":"ep-exam-vitals","dx":"hemorrhagic-shock-ep","q":"Vital signs — tachycardia, hypotension, or orthostatic change suggesting blood loss?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable, without tachycardia, hypotension, or orthostatic change to suggest blood loss.","frag":"hemodynamically stable"},{"label":"Tachycardia / hypotension / orthostasis","tone":"pos","sets":[],"ddx":[{"id":"hemorrhagic-shock-ep","keep":true}],"mdm":"Tachycardia, hypotension, or orthostatic change was present, concerning for significant hemorrhage from a ruptured ectopic.","frag":"tachycardia / hypotension / orthostasis"}]},{"id":"ep-exam-abdomen","dx":"ectopic","q":"Abdominal examination — peritoneal signs, rebound, or guarding?","answers":[{"label":"Soft, non-peritoneal abdomen","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen was soft without peritoneal signs, rebound, or guarding.","frag":"soft, non-peritoneal abdomen"},{"label":"Peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"ectopic","keep":true},{"id":"hemorrhagic-shock-ep","keep":true}],"mdm":"Peritoneal signs (rebound or guarding) were present on abdominal examination, concerning for intraperitoneal bleeding from a ruptured ectopic.","frag":"peritoneal signs"}]},{"id":"ep-exam-pelvic","dx":"ectopic","q":"Pelvic examination — adnexal tenderness or mass, peritoneal signs, and cervical os open vs. closed? (CMT alone is a nonspecific peritoneal sign, not an ectopic discriminator.)","answers":[{"label":"No adnexal tenderness/mass; os closed","tone":"neg","sets":[],"ddx":[],"mdm":"Pelvic examination showed no adnexal tenderness or mass and no peritoneal signs; the cervical os was closed.","frag":"no adnexal tenderness or mass; no peritoneal signs; os closed"},{"label":"Adnexal tenderness/mass or peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"ectopic","keep":true}],"mdm":"Adnexal tenderness, an adnexal mass, or peritoneal signs were present: findings concerning for ectopic pregnancy pending ultrasound localization.","frag":"adnexal tenderness, mass, or peritoneal signs"},{"label":"Open os / tissue at os","tone":"pos","sets":[],"ddx":[{"id":"miscarriage","keep":true}],"mdm":"The cervical os was open or tissue was present at the os, consistent with an inevitable or incomplete miscarriage; ectopic remained excluded only by ultrasound localization.","frag":"open cervical os or tissue at the os"}]},{"id":"ep-exam-us","dx":"ectopic","q":"Ultrasound — is an intrauterine pregnancy confirmed, and is there free fluid in the pelvis?","answers":[{"label":"IUP confirmed, no free fluid","tone":"neg","sets":[],"ddx":[],"mdm":"An intrauterine pregnancy was confirmed on ultrasound without free fluid, substantially lowering (though in assisted reproduction not eliminating) ectopic risk.","frag":"IUP confirmed, no free fluid"},{"label":"No IUP / free fluid present","tone":"pos","sets":[],"ddx":[{"id":"ectopic","keep":true},{"id":"hemorrhagic-shock-ep","keep":true}],"mdm":"No intrauterine pregnancy was seen and/or free fluid was present on ultrasound, findings concerning for an ectopic pregnancy and possible rupture.","frag":"no IUP / free fluid"}]}],"conclusions":["threatened abortion (viable IUP)","early intrauterine pregnancy, reassuring"],"specs":["obgyn"],"guide":"../learn/complaints/early-pregnancy.html","pearls":[{"text":"A single hCG value can never exclude ectopic — the discriminatory zone is a guide, not a rule. Diagnose ectopic or a failed pregnancy from ultrasound findings, not one hCG number.","dx":"ectopic"},{"text":"An intrauterine pregnancy on ultrasound does not fully exclude a coexisting ectopic — heterotopic pregnancy risk rises sharply after assisted reproduction.","dx":"heterotopic"},{"text":"In the unstable patient, resuscitate and go straight to emergent OB/surgery — don't wait on imaging to confirm what the vitals are already telling you.","dx":"hemorrhagic-shock-ep"},{"text":"Markedly elevated hCG with hyperemesis or early preeclampsia-like symptoms should raise molar pregnancy — an unusually high hCG for gestational age is the tell.","dx":"molar"},{"text":"Give RhoGAM to every Rh-negative patient with bleeding in pregnancy, and confirm the pregnancy-of-unknown-location patient (positive hCG, no IUP, stable) has OB follow-up with serial hCG and strict return precautions.","dx":"miscarriage"}]},{"id":"seizure","title":"Seizure","aliases":["seizure","convulsion","fit","status epilepticus","first seizure","epilepsy","postictal","epileptic","shaking","seizing"],"opening":"The patient was evaluated for a seizure. A history of the event and its provocations, a point-of-care glucose, and a neurologic examination were obtained, and the dangerous provocations and mimics below were actively considered.","ddx":[{"id":"status","group":"lifethreat","label":"Status epilepticus","default":true,"tags":["status"],"ruleout":"Status epilepticus was considered; the seizure self-terminated within a few minutes, there were no recurrent or ongoing convulsions and no persistently depressed consciousness, and the patient returned toward neurologic baseline, making it unlikely.","miss":4},{"id":"hypoglycemia-sz","group":"lifethreat","label":"Hypoglycemia","default":true,"tags":["hypoglycemia"],"ruleout":"Hypoglycemia was considered; an immediate point-of-care glucose was normal, making it unlikely.","miss":3},{"id":"structural-sz","group":"lifethreat","label":"Intracranial hemorrhage or mass lesion","default":true,"tags":["structural"],"ruleout":"An intracranial hemorrhage or mass lesion was considered; there was no preceding headache or head trauma, the seizure was generalized without focal onset, and the neurologic examination returned to baseline with no persistent focal deficit, making it unlikely.","miss":4},{"id":"cns-infection-sz","group":"lifethreat","label":"CNS infection (meningitis / encephalitis)","default":true,"tags":["cns"],"ruleout":"Central nervous system infection was considered; the patient was afebrile and non-immunocompromised without meningismus, rash, or altered mental status, recognizing that meningeal signs are insensitive and lumbar puncture remains the test when clinical suspicion persists.","miss":4},{"id":"eclampsia","group":"lifethreat","label":"Eclampsia / pre-eclampsia","default":false,"tags":["eclampsia"],"ruleout":"Eclampsia was considered; the patient was not pregnant or recently postpartum, there was no severe hypertension, headache, visual disturbance, edema, or proteinuria, making it unlikely.","miss":4,"sex":"f"},{"id":"tox-sz","group":"lifethreat","label":"Toxic ingestion or drug/alcohol withdrawal","default":true,"tags":["tox"],"ruleout":"A toxic or withdrawal-related cause was considered; there was no history of stimulant, sympathomimetic, or pro-convulsant exposure, no alcohol or benzodiazepine dependence or recent cessation, and no toxidrome or withdrawal signs on examination, making it unlikely.","miss":3},{"id":"metabolic-sz","group":"lifethreat","label":"Severe metabolic derangement (e.g., hyponatremia)","default":true,"tags":["metabolic"],"ruleout":"A severe metabolic derangement was considered; there was no relevant history of renal disease, polydipsia, or diuretic use, and basic electrolytes including sodium, calcium, and magnesium were within normal limits, making it unlikely.","miss":3},{"id":"trauma-sz","group":"lifethreat","label":"Traumatic brain injury / head injury","default":false,"tags":["trauma-sz"],"ruleout":"A traumatic intracranial injury was considered; there was no head trauma preceding the event, no external signs of injury, and the neurologic examination returned to baseline, making it unlikely.","miss":3},{"id":"breakthrough","group":"common","label":"Breakthrough seizure (known epilepsy)","default":false,"tags":["breakthrough"],"ruleout":"In this patient with known epilepsy, a breakthrough seizure from a missed dose, sub-therapeutic level, or other trigger was felt to be the most likely explanation after dangerous secondary causes were addressed.","miss":2},{"id":"first-unprovoked","group":"common","label":"First unprovoked seizure","default":false,"tags":["first"],"ruleout":"A first unprovoked seizure was considered; the dangerous acute symptomatic causes above were screened for, and outpatient neurology follow-up with seizure-precaution counseling was arranged.","miss":2},{"id":"provoked","group":"common","label":"Provoked / acute symptomatic seizure","default":false,"tags":["provoked"],"ruleout":"An acute symptomatic (provoked) seizure was considered, with attention to identifying and correcting the underlying provocation.","miss":2},{"id":"syncope-sz","group":"other","label":"Convulsive syncope (mimic)","default":false,"tags":["mimic"],"ruleout":"Convulsive syncope was considered as a mimic; the event description and a cardiovascular assessment were reviewed.","miss":1},{"id":"pnes","group":"other","label":"Psychogenic non-epileptic spell (mimic)","default":false,"tags":["mimic"],"ruleout":"A psychogenic non-epileptic spell was considered as a mimic only after organic and dangerous causes were addressed; this diagnosis is made with caution and appropriate follow-up.","miss":1}],"risk":[{"id":"glucose-sz","label":"Point-of-care glucose","tags":["hypoglycemia"],"scale":"low","line":"A point-of-care glucose was obtained immediately and reviewed; hypoglycemia was excluded as a cause of the seizure.","short":"POC glucose checked"},{"id":"neuroexam-sz","label":"Neuro exam / return to baseline","tags":["structural","cns"],"scale":"low","line":"A neurologic examination was performed and documented; the patient returned to neurologic baseline without a persistent focal deficit.","short":"Neuro exam documented"},{"id":"preg-sz","label":"Pregnancy test (eclampsia)","tags":["eclampsia"],"scale":"low","line":"In a patient of reproductive potential, a pregnancy test was obtained to evaluate for eclampsia as a cause of the seizure.","short":"Pregnancy test obtained"},{"id":"metabolic-labs","label":"Metabolic & toxic workup","tags":["metabolic","tox"],"scale":"low","line":"Targeted laboratory studies (sodium, calcium, magnesium, renal function, and toxicology where indicated) were obtained and reviewed for a metabolic or toxic provocation.","short":"Metabolic/tox labs"},{"id":"asm-level","label":"Antiseizure medication level / adherence","tags":["breakthrough"],"scale":"low","line":"In this patient with known epilepsy, medication adherence was assessed and an antiseizure drug level was obtained where applicable.","short":"ASM level / adherence"}],"checks":[{"if":"hypoglycemia-sz","needs":["glucose-sz"],"mode":"any","warn":"Hypoglycemia is on the differential — a point-of-care glucose documents the exclusion."},{"if":"structural-sz","needs":["neuroexam-sz"],"mode":"any","warn":"A structural cause is on the differential — a documented neuro exam / return to baseline shows the basis for the assessment."},{"if":"cns-infection-sz","needs":["neuroexam-sz"],"mode":"any","warn":"CNS infection is on the differential — a documented neuro exam (and LP if indicated) shows the basis for the assessment."},{"if":"eclampsia","needs":["preg-sz"],"mode":"any","warn":"Eclampsia is on the differential — a pregnancy test documents the basis for excluding it."},{"if":"metabolic-sz","needs":["metabolic-labs"],"mode":"any","warn":"A metabolic provocation is on the differential — targeted labs document the workup."},{"if":"breakthrough","needs":["asm-level"],"mode":"any","warn":"For a breakthrough seizure in known epilepsy, documenting anti-seizure medication adherence or level addresses the most common provoking factor."}],"history":[{"id":"sz-hx-semiology","dx":"general","q":"Event semiology — witnessed generalized convulsion with lateral tongue-biting, incontinence, and a postictal confusional period? Or features of a mimic (abrupt return to normal, situational trigger, eyes held closed, asynchronous movements)?","answers":[{"label":"Typical convulsion with postictal period","tone":"neg","sets":[],"ddx":[],"mdm":"The event was a witnessed convulsion with features typical of a true seizure (lateral tongue-biting, incontinence, and/or a postictal confusional period).","frag":"typical convulsion with postictal period"},{"label":"Features of a mimic","tone":"pos","sets":[],"ddx":[{"id":"syncope-sz","keep":true},{"id":"pnes","keep":true}],"mdm":"The event had features suggesting a mimic (abrupt recovery, situational trigger, eyes held closed, or asynchronous movements), prompting consideration of convulsive syncope or a non-epileptic spell.","frag":"features of a seizure mimic"}]},{"id":"sz-hx-duration","dx":"status","q":"Seizure duration and recurrence — a single seizure that self-terminated, or prolonged (≥ 5 minutes) or repeated seizures without recovery in between?","answers":[{"label":"Single, self-terminated < 5 min","tone":"neg","sets":[],"ddx":[],"mdm":"The seizure was single and self-terminated in under five minutes, with no prolonged or repeated activity without recovery in between, arguing against status epilepticus.","frag":"single seizure < 5 min, self-terminated"},{"label":"Prolonged ≥ 5 min or recurrent without recovery","tone":"pos","sets":[],"ddx":[{"id":"status","keep":true}],"mdm":"The seizure was prolonged (≥ 5 minutes) or recurrent without recovery of consciousness in between, meeting criteria for status epilepticus and requiring emergent treatment.","frag":"prolonged or recurrent seizure (status)"}]},{"id":"sz-hx-baseline","dx":"general","q":"Has the patient returned to their neurologic baseline (fully alert and oriented at the pre-event level)?","answers":[{"label":"Returned to baseline","tone":"neg","sets":[],"ddx":[],"mdm":"The patient returned to their neurologic baseline after a self-limited postictal period.","frag":"returned to neurologic baseline"},{"label":"Not back to baseline / persistently altered","tone":"pos","sets":[],"ddx":[{"id":"structural-sz","keep":true},{"id":"cns-infection-sz","keep":true},{"id":"status","keep":true}],"mdm":"The patient has not returned to baseline and remains altered, raising concern for nonconvulsive status, a structural lesion, or CNS infection.","frag":"not returned to baseline"}]},{"id":"sz-hx-dm","dx":"hypoglycemia-sz","q":"Hypoglycemia risk — diabetes on insulin or a sulfonylurea, missed meals, or known low glucose?","answers":[{"label":"No diabetes / hypoglycemia risk","tone":"neg","sets":[],"ddx":[],"mdm":"No diabetes, insulin or sulfonylurea use, or other hypoglycemia risk was reported.","frag":"no hypoglycemia risk"},{"label":"Insulin or sulfonylurea / hypoglycemia risk","tone":"pos","sets":[],"ddx":[{"id":"hypoglycemia-sz","keep":true}],"mdm":"The patient is on insulin or a sulfonylurea, missed meals, or had known low glucose, making hypoglycemia an important provocation to exclude.","frag":"insulin/sulfonylurea (hypoglycemia risk)"}]},{"id":"sz-hx-focal","dx":"structural-sz","q":"Focal onset (head or eye deviation, unilateral jerking) or a new focal neurologic deficit after the event?","answers":[{"label":"Generalized onset, no focal deficit","tone":"neg","sets":[],"ddx":[],"mdm":"The seizure had a generalized onset without a focal feature or a new focal neurologic deficit.","frag":"generalized onset, no focal deficit"},{"label":"Focal onset or new focal deficit","tone":"pos","sets":[],"ddx":[{"id":"structural-sz","keep":true}],"mdm":"The seizure had a focal onset or was followed by a new focal neurologic deficit, raising concern for an underlying structural lesion.","frag":"focal onset or new focal deficit"}]},{"id":"sz-hx-trauma-anticoag","dx":"structural-sz","q":"Recent head trauma, anticoagulation or antiplatelet therapy, or a known intracranial lesion or malignancy?","answers":[{"label":"None of these","tone":"neg","sets":[],"ddx":[],"mdm":"No recent head trauma, anticoagulation, or known intracranial lesion was reported.","frag":"no trauma/anticoagulation/known lesion"},{"label":"Head trauma / anticoagulation / known lesion","tone":"pos","sets":[],"ddx":[{"id":"structural-sz","keep":true}],"mdm":"Recent head trauma, anticoagulation, or a known intracranial lesion or malignancy was present, increasing concern for an intracranial hemorrhage or mass.","frag":"head trauma / anticoagulation / known lesion"}]},{"id":"sz-hx-fever","dx":"cns-infection-sz","q":"Fever, headache, neck stiffness, or an immunocompromised state?","answers":[{"label":"No fever / meningeal features","tone":"neg","sets":[],"ddx":[],"mdm":"No fever, headache, neck stiffness, or immunocompromise was reported.","frag":"no fever or meningeal features"},{"label":"Fever / headache / neck stiffness / immunocompromised","tone":"pos","sets":[],"ddx":[{"id":"cns-infection-sz","keep":true}],"mdm":"Fever, headache, neck stiffness, or immunocompromise was reported, raising concern for meningitis or encephalitis as the provocation.","frag":"fever / meningeal features / immunocompromise"}]},{"id":"sz-hx-preg","dx":"eclampsia","q":"Pregnant or within 6 weeks postpartum — with headache, visual changes, or hypertension?","answers":[{"label":"Not pregnant / not peripartum","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not pregnant or within six weeks postpartum, with no headache, visual changes, or hypertension, arguing against eclampsia.","frag":"not pregnant / peripartum"},{"label":"Pregnant or peripartum","tone":"pos","sets":[],"ddx":[{"id":"eclampsia","keep":true}],"mdm":"The patient is pregnant or within six weeks postpartum, making eclampsia a can't-miss cause and prompting assessment for headache, visual changes, and hypertension along with obstetric involvement.","frag":"pregnant / peripartum (eclampsia risk)"}]},{"id":"sz-hx-tox","dx":"tox-sz","q":"Toxic or withdrawal provocation — alcohol use with recent cessation, stimulant or sympathomimetic use, or exposure to isoniazid, bupropion, tricyclics, or other proconvulsants?","answers":[{"label":"No toxic exposure / withdrawal","tone":"neg","sets":[],"ddx":[],"mdm":"No toxic or withdrawal provocation was reported: no alcohol use with recent cessation, stimulant or sympathomimetic use, or exposure to isoniazid, bupropion, tricyclics, or other proconvulsants.","frag":"no toxic exposure or withdrawal"},{"label":"Withdrawal or toxic exposure","tone":"pos","sets":[],"ddx":[{"id":"tox-sz","keep":true}],"mdm":"Alcohol withdrawal or a proconvulsant toxic exposure was reported, identified as a likely provocation requiring targeted management.","frag":"withdrawal or toxic exposure"}]},{"id":"sz-hx-metabolic","dx":"metabolic-sz","q":"Risk for severe electrolyte derangement — polydipsia, renal failure or dialysis, recent significant illness, or known hyponatremia?","answers":[{"label":"No metabolic risk","tone":"neg","sets":[],"ddx":[],"mdm":"No risk for a severe electrolyte derangement was identified: no polydipsia, renal failure or dialysis, recent significant illness, or known hyponatremia.","frag":"no metabolic risk"},{"label":"Metabolic / electrolyte risk","tone":"pos","sets":[],"ddx":[{"id":"metabolic-sz","keep":true}],"mdm":"A risk for a severe electrolyte derangement was present (polydipsia, renal failure or dialysis, recent significant illness, or known hyponatremia), prompting targeted laboratory evaluation.","frag":"metabolic / electrolyte risk"}]},{"id":"sz-hx-epilepsy","dx":"breakthrough","q":"Known epilepsy or prior seizures — and any change such as a missed or lowered medication dose, sleep deprivation, illness, or a new interacting drug?","answers":[{"label":"No known epilepsy","tone":"neg","sets":[],"ddx":[],"mdm":"No prior seizures or known epilepsy was reported, and so no precipitating change such as a missed or lowered medication dose, sleep deprivation, illness, or a new interacting drug applied.","frag":"no known epilepsy"},{"label":"Known epilepsy — likely breakthrough","tone":"pos","sets":[],"ddx":[{"id":"breakthrough","keep":true}],"mdm":"The patient has known epilepsy and a likely breakthrough trigger (missed medication, sub-therapeutic level, sleep deprivation, or illness) was identified.","frag":"known epilepsy (breakthrough trigger)"}]},{"id":"sz-hx-firstprovoke","dx":"first-unprovoked","q":"Is this a first lifetime unprovoked seizure (no prior seizures and no acute provocation found), or is there an acute provocation?","answers":[{"label":"Provocation present / not a first seizure","tone":"neg","sets":[],"ddx":[],"mdm":"This was not a first unprovoked seizure: either prior seizures or an acute provocation was identified.","frag":"not a first unprovoked seizure"},{"label":"First unprovoked seizure","tone":"pos","sets":[],"ddx":[{"id":"first-unprovoked","keep":true},{"id":"provoked","keep":true}],"mdm":"This appears to be a first unprovoked seizure; the dangerous acute symptomatic causes were screened for and outpatient neurology follow-up with counseling was arranged.","frag":"first unprovoked seizure"}]},{"answers":[{"ddx":[],"frag":"no preceding head trauma, exam at baseline","label":"No preceding trauma","mdm":"There was no head trauma preceding the event, no external signs of injury, and the neurologic examination returned to baseline, making a traumatic intracranial injury unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"trauma-sz","keep":true}],"frag":"head trauma or post-event deficit","label":"Preceding trauma present","mdm":"Head trauma preceded the event, external signs of injury were present, or a focal deficit persisted, raising concern for traumatic intracranial injury and warranting imaging.","sets":[],"tone":"pos"}],"dx":"trauma-sz","id":"sz-hx-trauma-sz","q":"Preceding trauma — head injury before the event, external signs of trauma, or a post-event focal deficit?"}],"exam":[{"id":"sz-exam-vitals","dx":"general","q":"Vital signs — temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation within normal limits? (Hyperthermia and severe hypertension are red flags.)","answers":[{"label":"Stable / within normal limits","tone":"neg","sets":[],"ddx":[],"mdm":"Temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation were within normal limits, without hyperthermia or severe hypertension.","frag":"vitals stable"},{"label":"Hyperthermia, severe hypertension, or instability","tone":"pos","sets":[],"ddx":[{"id":"cns-infection-sz","keep":true},{"id":"eclampsia","keep":true}],"mdm":"An abnormal vital sign was present (hyperthermia, severe hypertension, or instability), prompting consideration of CNS infection, eclampsia, or an evolving dangerous process.","frag":"abnormal/red-flag vitals"}]},{"id":"sz-exam-glucose","dx":"hypoglycemia-sz","q":"Point-of-care glucose obtained immediately and within normal limits (70–180 mg/dL)?","answers":[{"label":"Glucose normal","tone":"neg","sets":[],"ddx":[],"mdm":"An immediate point-of-care glucose was within normal limits, excluding hypoglycemia.","frag":"POC glucose normal"},{"label":"Hypoglycemia on point-of-care glucose","tone":"pos","sets":[],"ddx":[{"id":"hypoglycemia-sz","keep":true}],"mdm":"The point-of-care glucose was low, identifying hypoglycemia as the cause and prompting immediate correction.","frag":"hypoglycemia on POC glucose"}]},{"id":"sz-exam-mental","dx":"general","q":"Mental status — returned to baseline and fully alert, or persistently altered / not improving (concern for nonconvulsive status or a structural or infectious cause)?","answers":[{"label":"Returned to baseline","tone":"neg","sets":[],"ddx":[],"mdm":"Mental status returned to baseline with appropriate postictal improvement.","frag":"mental status back to baseline"},{"label":"Persistently altered","tone":"pos","sets":[],"ddx":[{"id":"status","keep":true},{"id":"structural-sz","keep":true},{"id":"cns-infection-sz","keep":true}],"mdm":"Mental status remained persistently altered without expected postictal improvement, raising concern for nonconvulsive status epilepticus or a structural or infectious cause.","frag":"persistently altered mentation"}]},{"id":"sz-exam-focal","dx":"structural-sz","q":"Focal neurologic deficit on examination — persistent weakness, aphasia, or gaze deviation (beyond a transient Todd paralysis that resolves)?","answers":[{"label":"Non-focal exam / Todd paralysis resolved","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal (no persistent weakness, aphasia, or gaze deviation) or a transient Todd paralysis resolved on serial examination.","frag":"non-focal exam / Todd resolved"},{"label":"Persistent focal deficit","tone":"pos","sets":[],"ddx":[{"id":"structural-sz","keep":true}],"mdm":"A persistent focal neurologic deficit (weakness, aphasia, or gaze deviation beyond a resolving Todd paralysis) was present on examination, raising concern for an underlying structural lesion and prompting neuroimaging.","frag":"persistent focal deficit"}]},{"id":"sz-exam-trauma","dx":"structural-sz","q":"Signs of head trauma or oral injury — scalp laceration, hemotympanum, or a lateral tongue laceration?","answers":[{"label":"No significant trauma","tone":"neg","sets":[],"ddx":[],"mdm":"No signs of head trauma or oral injury were identified: no scalp laceration, hemotympanum, or lateral tongue laceration.","frag":"no significant trauma"},{"label":"Signs of head trauma","tone":"pos","sets":[],"ddx":[{"id":"structural-sz","keep":true}],"mdm":"Signs of head trauma or oral injury were present (scalp laceration, hemotympanum, or lateral tongue laceration), prompting evaluation for an intracranial injury.","frag":"signs of head trauma"}]},{"id":"sz-exam-meningismus","dx":"cns-infection-sz","q":"Meningismus — nuchal rigidity, Kernig or Brudzinski sign; fever on examination?","answers":[{"label":"No meningismus","tone":"neg","sets":[],"ddx":[],"mdm":"The neck was supple without Kernig or Brudzinski signs, noting these signs are insensitive (nuchal rigidity ~30%, Kernig/Brudzinski ~5%), so their absence was not used alone to exclude meningitis; mentation, the overall clinical picture, and the lumbar-puncture threshold carried the decision.","frag":"neck supple, no meningismus (insensitive signs, not relied on alone)"},{"label":"Meningismus / fever","tone":"pos","sets":[],"ddx":[{"id":"cns-infection-sz","keep":true}],"mdm":"Meningismus (nuchal rigidity, Kernig or Brudzinski sign) or fever was present on examination, raising concern for a central nervous system infection.","frag":"meningismus / fever"}]},{"id":"sz-exam-toxidrome","dx":"tox-sz","q":"Toxidrome or withdrawal signs — tremor, diaphoresis, tachycardia, hyperthermia, mydriasis, or autonomic instability?","answers":[{"label":"No toxidrome / withdrawal signs","tone":"neg","sets":[],"ddx":[],"mdm":"No toxidrome or withdrawal signs were identified: no tremor, diaphoresis, tachycardia, hyperthermia, mydriasis, or autonomic instability.","frag":"no toxidrome / withdrawal"},{"label":"Toxidrome / withdrawal signs","tone":"pos","sets":[],"ddx":[{"id":"tox-sz","keep":true}],"mdm":"Signs of a toxidrome or withdrawal were present (tremor, diaphoresis, tachycardia, hyperthermia, mydriasis, or autonomic instability), supporting a toxic or withdrawal-related provocation.","frag":"toxidrome / withdrawal signs"}]}],"conclusions":["known seizure disorder, returned to baseline","provoked seizure, resolved"],"specs":["neuro"],"algorithm":{"immediate":["Protect the airway, give oxygen, obtain IV access, and check a fingerstick glucose immediately.","For ongoing seizure: benzodiazepine first-line, repeated, then a second-line agent (e.g., levetiracetam, fosphenytoin, valproate); treat as status epilepticus at 5 minutes."],"criticalTests":["Fingerstick glucose and electrolytes (including sodium), calcium, magnesium","Pregnancy test in patients of reproductive potential (eclampsia)","Non-contrast head CT for first seizure, trauma, focal deficit, or persistent altered mentation","Toxicology and antiepileptic levels as indicated"],"cantMiss":[{"dx":"status","trigger":"Seizure >5 minutes or repeated seizures without recovery","test":"Clinical; EEG for nonconvulsive status","intervention":"Escalating benzodiazepines then second-line agents; anesthesia for refractory cases"},{"dx":"hypoglycemia-sz","trigger":"Low fingerstick glucose","test":"Fingerstick glucose","intervention":"IV dextrose (thiamine if malnourished)"},{"dx":"eclampsia","trigger":"Pregnant or postpartum with seizure","test":"Pregnancy test and blood pressure","intervention":"IV magnesium sulfate and urgent OB involvement"},{"dx":"structural-sz","trigger":"Focal deficit, trauma, or persistent altered mentation","test":"Non-contrast head CT","intervention":"Neurosurgery; reverse coagulopathy"},{"dx":"cns-infection-sz","trigger":"Fever with seizure or meningismus","test":"Lumbar puncture","intervention":"Early empiric antibiotics ± acyclovir"}],"disposition":"A first unprovoked seizure with full recovery and a normal workup can often be discharged with neurology follow-up and driving precautions; status, a structural cause, or incomplete recovery is admitted."},"decisionTree":{"title":"Seizure — initial approach","intro":"An original, evidence-based decision aid for seizure. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Protect & support","items":["Airway/positioning, O2, IV, glucose","Time the seizure; protect from injury"],"next":"q_status"},"q_status":{"type":"decision","q":"Ongoing seizure / status epilepticus (>5 min or recurrent without recovery)?","yes":"a_status","no":"q_reversible","cantmiss":"Treat status epilepticus now — a benzodiazepine first, then a second-line antiepileptic; don't wait."},"a_status":{"type":"action","title":"Status epilepticus pathway","items":["IV/IM benzodiazepine, repeat once","Load a second-line agent (levetiracetam, valproate, or fosphenytoin)","Check glucose/electrolytes; escalate to anesthesia for refractory status"],"tone":"danger","terminal":true},"q_reversible":{"type":"decision","q":"Reversible cause (hypoglycemia, hyponatremia, eclampsia, toxic ingestion, hypoxia)?","yes":"a_reversible","no":"q_first","pitfall":"Eclampsia (pregnant/postpartum → magnesium), hypoglycemia, and sodium derangements need cause-specific therapy, not just antiepileptics."},"a_reversible":{"type":"action","title":"Treat the cause","items":["Dextrose for hypoglycemia; magnesium for eclampsia","Correct sodium; antidotes for toxins","Oxygenate"],"tone":"danger","terminal":true},"q_first":{"type":"decision","q":"First unprovoked seizure, now resolved?","yes":"a_first","no":"a_breakthrough"},"a_first":{"type":"action","title":"Workup for a first seizure","items":["Neuroimaging and labs","Consider LP if febrile/immunocompromised","Neurology follow-up; driving/safety counseling"],"terminal":true},"a_breakthrough":{"type":"action","title":"Known epilepsy / breakthrough seizure","items":["Check antiepileptic levels, adherence, and triggers","Adjust therapy","Discharge with neurology follow-up if back to baseline"],"tone":"branch","terminal":true}}},"guide":"../learn/complaints/seizure.html"},{"id":"peds-brue","title":"Pediatric BRUE","aliases":["brue","alte","apnea infant","brief resolved unexplained event","infant event","color change infant","baby stopped breathing","apnea","turned blue","choking spell","limp"],"opening":"The infant was evaluated for a brief resolved unexplained event. The appearance and a normal examination were assessed, lower- versus higher-risk criteria were applied, and the dangerous causes below were actively considered.","ddx":[{"id":"nat-brue","group":"lifethreat","label":"Nonaccidental trauma","default":true,"tags":["nat"],"ruleout":"Nonaccidental trauma was considered; the history was consistent and developmentally plausible, and there was no bruising, oral or frenulum injury, bulging fontanelle, or retinal or skin findings, making it unlikely.","miss":3},{"id":"sepsis-brue","group":"lifethreat","label":"Sepsis / meningitis","default":true,"tags":["sepsis"],"ruleout":"Serious infection was considered; the infant was well-appearing, afebrile, and feeding normally with normal perfusion, tone, and activity and no ill contacts, making sepsis or meningitis unlikely.","miss":4},{"id":"arrhythmia-brue","group":"lifethreat","label":"Arrhythmia / congenital heart disease","default":true,"tags":["cardiac"],"ruleout":"A cardiac arrhythmia or congenital heart disease was considered; the ECG showed normal rate, intervals, and no pre-excitation or prolonged QT, and there was no murmur, gallop, hepatomegaly, or cyanosis, making it unlikely.","miss":3},{"id":"seizure-brue","group":"common","label":"Seizure","default":false,"tags":["seizure"],"ruleout":"A seizure was considered as a cause of the event; there were no focal or repetitive features and the infant returned to baseline.","miss":2},{"id":"pertussis-brue","group":"common","label":"Pertussis / RSV with apnea","default":false,"tags":["pertussis"],"ruleout":"Pertussis or an RSV-related apnea was considered, particularly with a cough or known exposure, and tested or observed as appropriate.","miss":2}],"risk":[{"id":"ecg-brue","label":"ECG reviewed","tags":["cardiac"],"scale":"low","line":"An ECG was reviewed for conduction abnormalities and a prolonged QT interval.","short":"ECG reviewed"},{"id":"appearance-brue","label":"Appearance & exam documented","tags":["sepsis","nat"],"scale":"low","line":"The infant's appearance and a complete examination, including the skin and fontanelle, were documented.","short":"Appearance/exam documented"},{"id":"criteria-brue","label":"Lower- vs higher-risk BRUE criteria","tags":["sepsis"],"scale":"low","line":"Lower- versus higher-risk BRUE criteria were applied and documented (age, gestational age, event duration, and need for CPR) to inform disposition.","short":"BRUE criteria applied"}],"checks":[{"if":"nat-brue","needs":["appearance-brue"],"mode":"any","warn":"Nonaccidental trauma is on the differential — a documented appearance and complete skin/fontanelle exam show the basis for the assessment."},{"if":"arrhythmia-brue","needs":["ecg-brue"],"mode":"any","warn":"A cardiac cause is on the differential — a documented ECG review shows the basis for the assessment."}],"history":[{"id":"brue-hx-criteria","dx":"general","q":"Lower-risk criteria — age > 60 days, born ≥ 32 weeks, a first event lasting < 1 minute, with no CPR by a trained provider?","answers":[{"label":"Meets lower-risk criteria","tone":"neg","sets":[],"ddx":[],"mdm":"The event met lower-risk BRUE criteria (age > 60 days, term/near-term, first brief event, no CPR), supporting a limited evaluation.","frag":"meets lower-risk BRUE criteria"},{"label":"Higher-risk features","tone":"pos","sets":[],"ddx":[{"id":"sepsis-brue","keep":true},{"id":"arrhythmia-brue","keep":true}],"mdm":"The event had higher-risk features (younger age, prematurity, prolonged or recurrent event, or CPR), prompting a broader evaluation and observation.","frag":"higher-risk BRUE features"}]},{"id":"brue-hx-nat","dx":"nat-brue","q":"Any inconsistency in the history, prior unexplained injuries, or bruising in a non-mobile infant?","answers":[{"label":"No NAT concern","tone":"neg","sets":[],"ddx":[],"mdm":"No history-exam discrepancy or concerning injury was identified.","frag":"no NAT concern"},{"label":"History inconsistency / injury","tone":"pos","sets":[],"ddx":[{"id":"nat-brue","keep":true}],"mdm":"An inconsistent history or a concerning injury was identified, raising concern for nonaccidental trauma.","frag":"history inconsistency / injury"}]},{"id":"brue-hx-infection","dx":"sepsis-brue","q":"Fever, poor feeding, lethargy, or ill contacts?","answers":[{"label":"No infectious features","tone":"neg","sets":[],"ddx":[],"mdm":"No fever, poor feeding, lethargy, or ill contacts were reported.","frag":"no infectious features"},{"label":"Fever / poor feeding / ill contacts","tone":"pos","sets":[],"ddx":[{"id":"sepsis-brue","keep":true},{"id":"pertussis-brue","keep":true}],"mdm":"Fever, poor feeding, lethargy, or ill contacts were reported, prompting evaluation for a serious infection.","frag":"fever / poor feeding / ill contacts"}]},{"id":"brue-hx-cardiac","dx":"arrhythmia-brue","q":"Family history of sudden death, congenital heart disease, or color change with feeding?","answers":[{"label":"No cardiac red flags","tone":"neg","sets":[],"ddx":[],"mdm":"No family history of sudden death or cardiac symptoms were reported.","frag":"no cardiac red flags"},{"label":"Family history / cardiac symptoms","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia-brue","keep":true}],"mdm":"A family history of sudden death or cardiac symptoms was reported, prompting cardiac evaluation.","frag":"family history / cardiac symptoms"}]}],"exam":[{"id":"brue-exam-appearance","dx":"sepsis-brue","q":"Appearance — well-appearing and at baseline, or ill-appearing / abnormal tone?","answers":[{"label":"Well-appearing, at baseline","tone":"neg","sets":[],"ddx":[],"mdm":"The infant was well-appearing and at baseline on examination.","frag":"well-appearing, at baseline"},{"label":"Ill-appearing / abnormal tone","tone":"pos","sets":[],"ddx":[{"id":"sepsis-brue","keep":true}],"mdm":"The infant was ill-appearing or had abnormal tone, prompting a broader and more urgent evaluation.","frag":"ill-appearing / abnormal tone"}]},{"id":"brue-exam-skin","dx":"nat-brue","q":"Skin and head — bruising, a bulging or sunken fontanelle, or signs of trauma?","answers":[{"label":"No bruising / normal fontanelle","tone":"neg","sets":[],"ddx":[],"mdm":"There was no bruising and the fontanelle was normal.","frag":"no bruising / normal fontanelle"},{"label":"Bruising / abnormal fontanelle / trauma","tone":"pos","sets":[],"ddx":[{"id":"nat-brue","keep":true}],"mdm":"Bruising, an abnormal fontanelle, or signs of trauma were present, raising concern for nonaccidental trauma.","frag":"bruising / abnormal fontanelle / trauma"}]},{"id":"brue-exam-cardioresp","dx":"arrhythmia-brue","q":"Cardiorespiratory exam — murmur, gallop, hepatomegaly, or abnormal work of breathing?","answers":[{"label":"Normal cardioresp exam","tone":"neg","sets":[],"ddx":[],"mdm":"The cardiorespiratory examination was normal, without murmur, gallop, hepatomegaly, or abnormal work of breathing.","frag":"normal cardioresp exam"},{"label":"Murmur / gallop / hepatomegaly","tone":"pos","sets":[],"ddx":[{"id":"arrhythmia-brue","keep":true}],"mdm":"A murmur, gallop, or hepatomegaly was found, prompting evaluation for congenital heart disease or heart failure.","frag":"murmur / gallop / hepatomegaly"}]}],"conclusions":["lower-risk BRUE (well-appearing)"],"specs":["peds"],"guide":"../learn/complaints/brue.html"},{"id":"peds-fever","title":"Febrile Infant / Young Child","aliases":["febrile infant","neonatal fever","baby fever","febrile child","fever infant","serious bacterial infection","pediatric fever","newborn fever","young child fever","kid fever"],"opening":"The febrile young child was evaluated with age and appearance driving the workup. The neonate (<= 28 days) gets a full evaluation and admission regardless of how well they look; the 29-60 day infant is risk-stratified with inflammatory markers; neonatal HSV is the quiet killer to cover when the story fits; and a fever that will not quit (>= 5 days) raises Kawasaki disease.","ddx":[{"id":"bacteremia","group":"lifethreat","label":"Bacteremia / sepsis","default":true,"tags":["bacteremia"],"ruleout":"Bacteremia and sepsis were considered; the child was well-appearing with normal perfusion, capillary refill, and activity, no toxic appearance or hypotension, and an age-appropriate workup including blood culture was obtained, making it unlikely.","miss":3},{"id":"meningitis-pf","group":"lifethreat","label":"Bacterial meningitis","default":true,"tags":["meningitis"],"ruleout":"Bacterial meningitis was considered; the infant was well-appearing and consolable with a soft, flat fontanelle, normal tone, and no neck stiffness or seizure, with lumbar puncture pursued per age and risk, making it unlikely.","miss":4},{"id":"hsv-pf","group":"lifethreat","label":"Neonatal HSV / myocarditis","default":false,"tags":["hsv"],"ruleout":"Neonatal HSV and myocarditis were considered; there was no maternal HSV history, vesicular rash, seizure, transaminitis, or ill or septic appearance, and no tachycardia, gallop, or respiratory distress out of proportion, making them unlikely.","miss":3},{"id":"uti-pf","group":"common","label":"Urinary tract infection","default":false,"tags":["uti"],"ruleout":"A urinary tract infection was considered as a common source; a urinalysis and urine culture were obtained as indicated.","miss":2},{"id":"viral-pf","group":"common","label":"Viral syndrome","default":false,"tags":["viral"],"ruleout":"A self-limited viral syndrome was considered after serious bacterial infection was appropriately addressed for the age and appearance.","miss":2},{"id":"kawasaki-pf","group":"other","label":"Kawasaki disease (prolonged fever)","default":false,"tags":["kawasaki-pf"],"ruleout":"Kawasaki disease was considered once fever persisted >= 5 days, looking for conjunctivitis, mucositis, rash, extremity changes, and adenopathy, given the coronary-aneurysm cost of a missed diagnosis.","miss":4}],"risk":[{"id":"age-appearance-pf","label":"Age & appearance documented","tags":["bacteremia"],"scale":"low","line":"The infant's exact age and appearance (well- versus ill-appearing) were documented, as they drive the workup and disposition.","short":"Age/appearance documented"},{"id":"workup-pf","label":"Age-appropriate sepsis workup","tags":["bacteremia","meningitis"],"scale":"low","line":"An age-appropriate workup (urinalysis and urine culture, blood culture, inflammatory markers, and lumbar puncture as indicated) was obtained.","short":"Age-appropriate workup"},{"id":"empiric-pf","label":"Empiric therapy / disposition by age","tags":["hsv"],"scale":"low","line":"Empiric antibiotics (with acyclovir in the at-risk neonate) and disposition were guided by age and appearance.","short":"Empiric therapy by age"},{"id":"markers-pf","label":"Inflammatory markers (procalcitonin/CRP/ANC)","tags":["bacteremia"],"scale":"low","line":"Inflammatory markers -- procalcitonin, CRP, and absolute neutrophil count -- were used to risk-stratify the well-appearing 8-60 day-old infant per current febrile-infant guidance.","short":"inflammatory markers risk-stratified"},{"id":"lp-pf","label":"Lumbar puncture per age/risk","tags":["meningitis-pf"],"scale":"low","line":"A lumbar puncture was performed, or its deferral explicitly justified, according to the infant's age and risk -- routine in the neonate and in any ill-appearing or high-risk infant.","short":"LP performed or deferral justified"},{"id":"hsv-cover-pf","label":"Neonatal HSV considered / covered","tags":["hsv-pf"],"scale":"low","line":"Neonatal HSV was considered and empiric acyclovir with HSV studies started when there were vesicles, seizures, maternal HSV, ill appearance, or CSF pleocytosis.","short":"HSV considered; acyclovir if indicated"}],"checks":[{"if":"bacteremia","needs":["age-appearance-pf","workup-pf"],"mode":"any","warn":"Serious bacterial infection is on the differential — the documented age, appearance, and age-appropriate workup show the basis for the assessment."},{"if":"meningitis-pf","needs":["workup-pf"],"mode":"any","warn":"Bacterial meningitis is on the differential — the documented workup (including LP as indicated) shows the basis."},{"if":"bacteremia","needs":["markers-pf"],"mode":"any","warn":"In the 8-60 day infant, well appearance alone is not enough -- procalcitonin/CRP/ANC drive risk-stratification; document the markers or the validated low-risk criteria used."},{"if":"meningitis-pf","needs":["lp-pf"],"mode":"any","warn":"An LP is part of the workup in the neonate and in any ill-appearing infant -- document the CSF result or an explicit, defensible reason it was deferred."},{"if":"hsv-pf","needs":["hsv-cover-pf"],"mode":"any","warn":"Neonatal HSV is subtle and often afebrile-mild -- when vesicles, seizures, maternal HSV, or CSF pleocytosis are present, start acyclovir empirically rather than waiting for confirmation."}],"history":[{"id":"pf-hx-age","dx":"general","q":"Age — neonate (≤ 28 days), young infant (29–60 days), or older? And the measured maximum temperature?","answers":[{"label":"Older infant / low-risk age","tone":"neg","sets":[],"ddx":[],"mdm":"The child was older than the highest-risk windows (beyond the neonatal (≤ 28 days) and young-infant (29–60 days) periods), supporting an appearance-guided evaluation.","frag":"older / low-risk age"},{"label":"Neonate or young infant (≤ 60 days)","tone":"pos","sets":[],"ddx":[{"id":"bacteremia","keep":true},{"id":"meningitis-pf","keep":true}],"mdm":"The infant was a neonate or young infant (≤ 60 days), an age group warranting a structured serious-bacterial-infection evaluation regardless of appearance.","frag":"neonate / young infant (≤ 60 days)"}]},{"id":"pf-hx-appearance","dx":"bacteremia","q":"Feeding, activity, and behavior — feeding well and consolable, or poor feeding, lethargy, or inconsolability?","answers":[{"label":"Feeding well, consolable","tone":"neg","sets":[],"ddx":[],"mdm":"The infant was feeding well and consolable, without poor feeding, lethargy, or inconsolability.","frag":"feeding well, consolable"},{"label":"Poor feeding / lethargy / inconsolable","tone":"pos","sets":[],"ddx":[{"id":"bacteremia","keep":true},{"id":"meningitis-pf","keep":true}],"mdm":"Poor feeding, lethargy, or inconsolability was reported, raising concern for a serious infection.","frag":"poor feeding / lethargy / inconsolable"}]},{"id":"pf-hx-hsv","dx":"hsv-pf","q":"In a neonate — maternal genital herpes, vesicular rash, seizures, or known perinatal HSV exposure?","answers":[{"label":"No HSV risk","tone":"neg","sets":[],"ddx":[],"mdm":"No neonatal HSV risk factors (maternal genital herpes, a vesicular rash, seizures, or known perinatal HSV exposure) were identified.","frag":"no HSV risk"},{"label":"HSV risk / vesicles / seizures","tone":"pos","sets":[],"ddx":[{"id":"hsv-pf","keep":true}],"mdm":"Neonatal HSV risk factors were present (maternal genital herpes, a vesicular rash, seizures, or known perinatal HSV exposure), prompting HSV testing and empiric acyclovir.","frag":"HSV risk / vesicles / seizures"}]},{"id":"pf-hx-uti","dx":"uti-pf","q":"Decreased urine output, foul-smelling urine, or no other source of fever found?","answers":[{"label":"No urinary features","tone":"neg","sets":[],"ddx":[],"mdm":"No urinary symptoms were reported.","frag":"no urinary features"},{"label":"Urinary features / no other source","tone":"pos","sets":[],"ddx":[{"id":"uti-pf","keep":true}],"mdm":"Urinary symptoms or a fever without another source prompted evaluation for a urinary tract infection.","frag":"urinary features / no other source"}]},{"id":"pf-hx-risk","dx":"bacteremia","q":"Risk modifiers -- prematurity, recent antibiotics, or a chronic/immunocompromising condition?","answers":[{"label":"No risk modifiers","tone":"neg","sets":[],"ddx":[],"mdm":"There are no serious-bacterial-infection risk modifiers.","frag":"no SBI risk modifiers"},{"label":"Risk modifier present","tone":"pos","sets":[{"risk":"markers-pf"}],"ddx":[{"id":"bacteremia","keep":true}],"mdm":"Prematurity, recent antibiotics, or immunocompromise raises serious-bacterial-infection risk and shifts thresholds.","frag":"SBI risk modifier present"}]},{"id":"pf-hx-immz","dx":"bacteremia","q":"Immunization status -- up to date for age (especially Hib and pneumococcal), or incomplete/unknown?","answers":[{"label":"Up to date for age","tone":"neg","sets":[],"ddx":[],"mdm":"Immunizations were up to date for age, including Hib and pneumococcal conjugate vaccine, lowering the risk of occult bacteremia from these organisms.","frag":"immunizations up to date"},{"label":"Incomplete / unknown","tone":"pos","sets":[{"risk":"markers-pf"}],"ddx":[{"id":"bacteremia","keep":true}],"mdm":"Immunizations were incomplete or unknown, raising the risk of vaccine-preventable invasive bacterial infection (Hib, S. pneumoniae) and lowering the threshold for evaluation.","frag":"immunizations incomplete / unknown"}]},{"id":"pf-hx-duration","dx":"kawasaki-pf","q":"Duration of fever -- has it persisted 5 days or more?","answers":[{"label":"Under 5 days","tone":"neg","sets":[],"ddx":[],"mdm":"The fever has lasted fewer than 5 days.","frag":"fever < 5 days"},{"label":"5 or more days","tone":"pos","sets":[],"ddx":[{"id":"kawasaki-pf","keep":true}],"mdm":"Fever persisting >= 5 days raises Kawasaki disease and prompts a search for its clinical criteria.","frag":"fever >= 5 days (Kawasaki considered)"}]}],"exam":[{"id":"pf-exam-appearance","dx":"bacteremia","q":"Appearance and perfusion — well-appearing with normal perfusion, or ill-appearing, mottled, or with delayed capillary refill?","answers":[{"label":"Well-appearing, perfusion normal","tone":"neg","sets":[],"ddx":[],"mdm":"The infant was well-appearing with normal perfusion.","frag":"well-appearing, perfusion normal"},{"label":"Ill-appearing / mottled / delayed refill","tone":"pos","sets":[],"ddx":[{"id":"bacteremia","keep":true}],"mdm":"The infant was ill-appearing, mottled, or had delayed capillary refill, concerning for sepsis.","frag":"ill-appearing / mottled / delayed refill"}]},{"id":"pf-exam-meningismus","dx":"meningitis-pf","q":"A bulging fontanelle, paradoxical irritability, or meningismus (less reliable in infants)?","answers":[{"label":"Fontanelle normal, no meningismus","tone":"neg","sets":[],"ddx":[],"mdm":"The fontanelle was normal without meningismus.","frag":"fontanelle normal, no meningismus"},{"label":"Bulging fontanelle / paradoxical irritability","tone":"pos","sets":[],"ddx":[{"id":"meningitis-pf","keep":true}],"mdm":"A bulging fontanelle or paradoxical irritability was found, raising concern for meningitis.","frag":"bulging fontanelle / paradoxical irritability"}]},{"id":"pf-exam-source","dx":"viral-pf","q":"A focal source on examination — otitis, pharyngitis, viral exanthem, or clear respiratory findings?","answers":[{"label":"No clear focal source","tone":"neg","sets":[],"ddx":[],"mdm":"No clear focal source (otitis, pharyngitis, a viral exanthem, or clear respiratory findings) was found on examination.","frag":"no clear focal source"},{"label":"Focal viral / minor source","tone":"pos","sets":[],"ddx":[{"id":"viral-pf","keep":true}],"mdm":"A focal viral or minor source (such as otitis, pharyngitis, or a viral exanthem) was identified, though serious infection was still addressed by age and appearance.","frag":"focal viral / minor source"}]},{"id":"pf-exam-rash","dx":"bacteremia","q":"Skin -- petechiae or purpura, or mucocutaneous Kawasaki features (red eyes, cracked lips, rash, extremity changes)?","answers":[{"label":"No petechiae or Kawasaki features","tone":"neg","sets":[],"ddx":[],"mdm":"There are no petechiae, purpura, or mucocutaneous Kawasaki features.","frag":"no petechiae or mucocutaneous features"},{"label":"Petechiae / Kawasaki features","tone":"pos","sets":[],"ddx":[{"id":"bacteremia","keep":true},{"id":"kawasaki-pf","keep":true}],"mdm":"Petechiae or purpura raise invasive bacterial disease such as meningococcemia, and mucocutaneous changes raise Kawasaki.","frag":"petechiae / mucocutaneous features"}]}],"conclusions":["viral syndrome (well-appearing child)","well-appearing 8-60 day infant, low-risk markers -- shared-decision disposition with reliable follow-up","neonatal fever -- full evaluation and admission regardless of appearance"],"specs":["peds","id"],"guide":"../learn/complaints/febrile-infant.html","pearls":[{"text":"Any infant ≤21 days with fever gets the full workup — blood culture, catheterized urine, and CSF — and empiric admission on antibiotics regardless of how well they look or what the inflammatory markers show.","dx":"bacteremia"},{"text":"Suspect and test for neonatal HSV in any ill-appearing, hypothermic, or seizing infant, or one with vesicles, transaminitis, CSF pleocytosis, or thrombocytopenia — vesicles are absent in many cases, so don't wait for them. Each day's delay in acyclovir increases mortality.","dx":"hsv-pf"},{"text":"For 22–60 day-olds, use validated inflammatory markers (procalcitonin >0.5, ANC, CRP ≥20, temp >38.5°C) to drive the LP decision — WBC and bands alone are no longer used for risk stratification.","dx":"meningitis-pf"},{"text":"Avoid ceftriaxone in infants ≤21 days — it displaces bilirubin and risks kernicterus; use ampicillin plus ceftazidime or gentamicin instead.","dx":"bacteremia"},{"text":"A well appearance does not override age — the 8–21 day full workup and admission applies regardless of exam, and even the 22–60 day pathway is driven by markers and CSF, not gestalt.","dx":"meningitis-pf"}]},{"id":"peds-resp","title":"Pediatric Respiratory Distress","aliases":["pediatric respiratory distress","bronchiolitis","child trouble breathing","wheezing child","croup","infant breathing","retractions","rsv","child breathing","kid wheezing"],"opening":"The child was evaluated for respiratory distress. Work of breathing, oxygenation, and feeding/hydration were assessed, and the non-bronchiolitis emergencies below were actively considered.","ddx":[{"id":"resp-failure","group":"lifethreat","label":"Impending respiratory failure / apnea","default":true,"tags":["failure"],"ruleout":"Impending respiratory failure or apnea was considered; the child was alert with normal mental status, maintained oxygen saturation on room air, and showed no severe retractions, fatigue, apnea, or grunting, making it unlikely.","miss":3},{"id":"foreign-body","group":"lifethreat","label":"Foreign-body aspiration","default":false,"tags":["fb"],"ruleout":"Foreign-body aspiration was considered; there was no sudden-onset choking or witnessed aspiration event, no stridor, and breath sounds were symmetric without focal wheeze or decreased aeration, making it unlikely.","miss":3},{"id":"anaphylaxis-p","group":"lifethreat","label":"Anaphylaxis","default":false,"tags":["anaphylaxis"],"ruleout":"Anaphylaxis was considered; there was no preceding allergen, food, or sting exposure and no urticaria, angioedema, vomiting, or hypotension, making it unlikely.","miss":4},{"id":"myocarditis-p","group":"lifethreat","label":"Myocarditis / heart failure","default":false,"tags":["cardiac"],"ruleout":"Myocarditis or heart failure was considered; there was no hepatomegaly, gallop, or persistent tachycardia out of proportion to fever or distress, and perfusion was normal, making it unlikely.","miss":3},{"id":"tension-ptx-p","group":"lifethreat","label":"Tension pneumothorax","default":false,"tags":["tension-ptx-p"],"ruleout":"Tension pneumothorax was considered; breath sounds were symmetric without tracheal deviation, hyperresonance, or hemodynamic compromise, making it unlikely.","miss":4},{"id":"bronchiolitis","group":"common","label":"Bronchiolitis / viral","default":false,"tags":["bronchiolitis"],"ruleout":"Bronchiolitis or a viral lower-respiratory illness was considered as the likely cause after the dangerous mimics above were addressed, with attention to hydration and apnea risk.","miss":2}],"risk":[{"id":"wob-pr","label":"Work of breathing & SpO₂","tags":["failure"],"scale":"low","line":"Work of breathing and oxygen saturation were assessed and documented.","short":"WOB & SpO₂ documented"},{"id":"hydration-pr","label":"Feeding & hydration","tags":["bronchiolitis"],"scale":"low","line":"Feeding and hydration status were assessed, as poor feeding is an important marker of severity in infants.","short":"Feeding/hydration assessed"},{"id":"apnea-pr","label":"Apnea risk (age, prematurity)","tags":["failure"],"scale":"low","line":"Apnea risk factors (young age, prematurity) were considered in the disposition decision.","short":"Apnea risk considered"}],"checks":[{"if":"resp-failure","needs":["wob-pr"],"mode":"any","warn":"Impending respiratory failure is on the differential — documented work of breathing and oxygenation show the basis for the assessment."},{"if":"bronchiolitis","needs":["hydration-pr","apnea-pr"],"mode":"any","warn":"Bronchiolitis is supportive care — document hydration/feeding and the apnea watch (young/preterm infants); routine bronchodilators, steroids, and chest x-rays are not indicated."}],"history":[{"id":"pr-hx-onset","dx":"foreign-body","q":"Sudden onset or a witnessed choking episode (foreign body), versus gradual onset with a viral prodrome?","answers":[{"label":"Gradual onset / viral prodrome","tone":"neg","sets":[],"ddx":[],"mdm":"The onset was gradual with a viral prodrome, more typical of bronchiolitis.","frag":"gradual onset / viral prodrome"},{"label":"Sudden onset / choking episode","tone":"pos","sets":[],"ddx":[{"id":"foreign-body","keep":true}],"mdm":"A sudden onset or witnessed choking episode was reported, raising concern for foreign-body aspiration.","frag":"sudden onset / choking episode"}]},{"id":"pr-hx-apnea","dx":"resp-failure","q":"Apnea, cyanosis, or pauses in breathing; young age (< 12 weeks) or prematurity?","answers":[{"label":"No apnea / low apnea risk","tone":"neg","sets":[],"ddx":[],"mdm":"No apnea or cyanosis and no high apnea-risk features were reported.","frag":"no apnea / low apnea risk"},{"label":"Apnea / cyanosis / young or premature","tone":"pos","sets":[],"ddx":[{"id":"resp-failure","keep":true}],"mdm":"Apnea, cyanosis, or high apnea-risk features (young age, prematurity) were reported, prompting close monitoring.","frag":"apnea / cyanosis / young or premature"}]},{"id":"pr-hx-anaphylaxis","dx":"anaphylaxis-p","q":"A preceding exposure (food, drug, sting) with hives, swelling, or vomiting?","answers":[{"label":"No anaphylaxis features","tone":"neg","sets":[],"ddx":[],"mdm":"No preceding exposure with systemic allergic symptoms was reported.","frag":"no anaphylaxis features"},{"label":"Exposure with hives / swelling","tone":"pos","sets":[],"ddx":[{"id":"anaphylaxis-p","keep":true}],"mdm":"A preceding exposure with hives, swelling, or vomiting was reported, concerning for anaphylaxis.","frag":"exposure with hives / swelling"}]},{"id":"pr-hx-feeding","dx":"bronchiolitis","q":"Reduced feeding, wet diapers, or signs of dehydration?","answers":[{"label":"Feeding and hydration adequate","tone":"neg","sets":[],"ddx":[],"mdm":"Feeding and hydration were adequate.","frag":"feeding/hydration adequate"},{"label":"Reduced feeding / dehydration","tone":"pos","sets":[],"ddx":[{"id":"bronchiolitis","keep":true},{"id":"resp-failure","keep":true}],"mdm":"Reduced feeding or signs of dehydration were reported, an important severity marker prompting closer evaluation.","frag":"reduced feeding / dehydration"}]}],"exam":[{"id":"pr-exam-wob","dx":"resp-failure","q":"Work of breathing — retractions, nasal flaring, grunting, head-bobbing, or markedly increased respiratory rate?","answers":[{"label":"Comfortable, mild work of breathing","tone":"neg","sets":[],"ddx":[],"mdm":"Work of breathing was comfortable or only mildly increased, without retractions, nasal flaring, grunting, head-bobbing, or a markedly increased respiratory rate.","frag":"comfortable, mild work of breathing"},{"label":"Marked retractions / grunting / flaring","tone":"pos","sets":[],"ddx":[{"id":"resp-failure","keep":true}],"mdm":"Marked retractions, grunting, or nasal flaring was present, concerning for impending respiratory failure.","frag":"marked retractions / grunting / flaring"}]},{"id":"pr-exam-spo2","dx":"resp-failure","q":"Oxygenation and mental status — hypoxia, cyanosis, or lethargy / poor responsiveness?","answers":[{"label":"SpO₂ adequate, alert","tone":"neg","sets":[],"ddx":[],"mdm":"Oxygen saturation was adequate and the child was alert, without hypoxia, cyanosis, lethargy, or poor responsiveness.","frag":"SpO₂ adequate, alert"},{"label":"Hypoxia / cyanosis / lethargy","tone":"pos","sets":[],"ddx":[{"id":"resp-failure","keep":true}],"mdm":"Hypoxia, cyanosis, or lethargy was present, concerning for respiratory failure and prompting escalation.","frag":"hypoxia / cyanosis / lethargy"}]},{"id":"pr-exam-auscultation","dx":"foreign-body","q":"Auscultation — focal or asymmetric breath sounds (foreign body) or a gallop/hepatomegaly (cardiac)?","answers":[{"label":"Symmetric breath sounds, no gallop","tone":"neg","sets":[],"ddx":[],"mdm":"Breath sounds were symmetric without focal or asymmetric findings to suggest a foreign body, and without a gallop or hepatomegaly to suggest a cardiac cause.","frag":"symmetric breath sounds, no gallop"},{"label":"Asymmetric sounds / gallop / hepatomegaly","tone":"pos","sets":[],"ddx":[{"id":"foreign-body","keep":true},{"id":"myocarditis-p","keep":true}],"mdm":"Asymmetric breath sounds (foreign body) or a gallop with hepatomegaly (cardiac) was found, prompting targeted evaluation.","frag":"asymmetric sounds / gallop / hepatomegaly"}]},{"answers":[{"ddx":[],"frag":"symmetric breath sounds, no tracheal deviation","label":"No tension-PTX signs","mdm":"Breath sounds were symmetric without tracheal deviation, hyperresonance, or hemodynamic compromise, making tension pneumothorax unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"tension-ptx-p","keep":true}],"frag":"asymmetric breath sounds or tracheal deviation","label":"Tension-PTX signs present","mdm":"Asymmetric breath sounds, tracheal deviation, hyperresonance, or hemodynamic compromise was present, requiring immediate decompression for tension pneumothorax.","sets":[],"tone":"pos"}],"dx":"tension-ptx-p","id":"pr-exam-tension-ptx-p","q":"Tension pneumothorax — asymmetric breath sounds, tracheal deviation, hyperresonance, or hemodynamic compromise?"}],"conclusions":["bronchiolitis (mild, well-appearing)","viral URI"],"specs":["peds","pulm"],"guide":"../learn/complaints/bronchiolitis.html"},{"id":"peds-cough","specs":["peds","pulm","id"],"title":"Pediatric Cough","aliases":["peds cough","child cough","kid cough","whooping cough","pertussis","croup","barky cough","chronic cough child","toddler cough","baby cough","post tussive vomiting","nighttime cough","persistent cough child","choking on food","cough child","infant cough","wheezing cough child"],"opening":"Most childhood coughs are viral, but the cough is also how pertussis, the inhaled foreign body, an early pneumonia, and the first presentation of asthma announce themselves — and the well-looking child between coughing fits is the trap.","ddx":[{"id":"fb-aspiration","group":"lifethreat","label":"Foreign-body aspiration","default":true,"tags":["fb-aspiration"],"ruleout":"Foreign-body aspiration was considered; there was no sudden onset while eating or playing, no witnessed choking episode, and breath sounds were symmetric without focal wheeze or stridor, making it unlikely.","miss":3},{"id":"pertussis","group":"lifethreat","label":"Pertussis (whooping cough)","default":true,"tags":["pertussis"],"ruleout":"Pertussis was considered; there were no coughing paroxysms, inspiratory whoop, or post-tussive emesis, immunizations were up to date, there were no known exposures, and young infants had no apnea or cyanosis, making it unlikely.","miss":3},{"id":"pneumonia-peds","group":"lifethreat","label":"Pneumonia","default":true,"tags":["pneumonia-peds"],"ruleout":"Pneumonia was considered; there was no high or persistent fever, normal work of breathing with maintained oxygen saturation, and lungs were clear without focal crackles, decreased breath sounds, or tachypnea, making it unlikely.","miss":3},{"id":"resp-compromise","group":"lifethreat","label":"Respiratory compromise / hypoxia","default":true,"tags":["resp-compromise"],"ruleout":"Respiratory compromise was considered; work of breathing was normal with no retractions, oxygen saturation was maintained on room air, mental status and hydration were normal, and there was no stridor at rest, making it unlikely.","miss":3},{"id":"asthma-rad","group":"common","label":"Asthma / reactive airway disease","default":false,"tags":["asthma-rad"],"ruleout":"Reactive airway disease was considered given the wheeze, nocturnal/exertional pattern, and atopic or family history, and a bronchodilator response was assessed where appropriate.","miss":2},{"id":"croup-peds","group":"common","label":"Croup (viral laryngotracheitis)","default":false,"tags":["croup-peds"],"ruleout":"Croup was considered on the barky cough and stridor; severity was graded by stridor at rest and work of breathing.","miss":2},{"id":"viral-uri-peds","group":"other","label":"Viral URI / post-viral cough","default":false,"tags":["viral-uri-peds"],"ruleout":"Self-limited viral or post-viral cough was the working diagnosis once the dangerous causes above were judged unlikely.","miss":1}],"risk":[{"id":"spo2-peds","label":"Oxygenation & work-of-breathing documented","tags":["resp-compromise","pneumonia-peds"],"scale":"low","line":"Oxygen saturation, respiratory rate, work of breathing, and mental status were documented and reassuring.","short":"SpO₂ and work of breathing documented"},{"id":"fb-eval","label":"Foreign-body evaluation (exam ± imaging)","tags":["fb-aspiration"],"scale":"low","line":"Foreign-body aspiration was evaluated by auscultation for focal/asymmetric findings and, where suspicion warranted, inspiratory/expiratory or lateral-decubitus imaging or specialist referral.","short":"foreign-body evaluation documented"},{"id":"pertussis-eval","label":"Pertussis testing & public-health / return plan","tags":["pertussis"],"scale":"low","line":"Pertussis testing was sent as indicated, and immunization status, household exposures, public-health reporting, and apnea return precautions for young infants were addressed.","short":"pertussis testing + exposure/return plan addressed"}],"checks":[{"if":"resp-compromise","needs":["spo2-peds"],"mode":"any","warn":"Document the oxygen saturation and work of breathing — a comfortable appearance is not a substitute for the number."},{"if":"fb-aspiration","needs":["fb-eval"],"mode":"any","warn":"A sudden cough in a toddler is an inhaled foreign body until the auscultation (± imaging) says otherwise — document it."},{"if":"pertussis","needs":["pertussis-eval"],"mode":"any","warn":"Paroxysms, post-tussive emesis, or infant apnea is pertussis until excluded — document testing, exposures, and the public-health/return plan."}],"history":[{"id":"pc-hx-onset","dx":"general","q":"Onset and duration — gradual with a viral prodrome, vs. sudden onset, or prolonged (> 4 weeks)?","answers":[{"label":"Gradual, acute, with viral prodrome","tone":"neg","sets":[],"ddx":[],"mdm":"The cough began gradually with a viral prodrome over an acute course, rather than abruptly or persisting beyond 4 weeks.","frag":"gradual acute onset with a viral prodrome"},{"label":"Sudden or prolonged (> 4 weeks)","tone":"pos","sets":[],"ddx":[{"id":"fb-aspiration","keep":true},{"id":"pertussis","keep":true}],"mdm":"The cough began suddenly or has persisted beyond 4 weeks, outside the gradual viral-prodrome pattern.","frag":"sudden onset or prolonged cough beyond 4 weeks"}]},{"id":"pc-hx-fb","dx":"fb-aspiration","q":"Sudden onset while eating or playing with a small object, or any witnessed or possible choking episode — even if the child seems fine now?","answers":[{"label":"No choking event","tone":"neg","sets":[],"ddx":[],"mdm":"There was no witnessed choking episode or small-object exposure.","frag":"no choking event or small-object exposure"},{"label":"Choking event / small object","tone":"pos","sets":[{"risk":"fb-eval"}],"ddx":[{"id":"fb-aspiration","keep":true}],"mdm":"A choking episode or small-object exposure was reported; an inhaled foreign body must be excluded even though the child can look well between events.","frag":"witnessed or possible choking event"}]},{"id":"pc-hx-pertussis","dx":"pertussis","q":"Coughing fits (paroxysms), an inspiratory whoop, or vomiting after coughing — and is the child under-immunized or exposed?","answers":[{"label":"No paroxysms or whoop","tone":"neg","sets":[],"ddx":[],"mdm":"There were no coughing paroxysms, inspiratory whoop, or post-tussive emesis, and no known pertussis exposure.","frag":"no paroxysms, whoop, or post-tussive emesis"},{"label":"Paroxysms / whoop / post-tussive emesis","tone":"pos","sets":[{"risk":"pertussis-eval"}],"ddx":[{"id":"pertussis","keep":true}],"mdm":"Coughing paroxysms, an inspiratory whoop, or post-tussive emesis was reported, raising pertussis; immunization status and exposures were reviewed.","frag":"paroxysms, whoop, or post-tussive emesis"}]},{"id":"pc-hx-infant","dx":"resp-compromise","q":"Young infant (< 3–6 months) or any apnea, color change, or pauses in breathing with the coughing?","answers":[{"label":"Older infant/child, no apnea","tone":"neg","sets":[],"ddx":[],"mdm":"There were no apneic or cyanotic episodes and the child is not in the highest-risk young-infant group.","frag":"no apnea, cyanosis, or high-risk young age"},{"label":"Young infant / apnea / color change","tone":"pos","sets":[{"risk":"pertussis-eval"}],"ddx":[{"id":"resp-compromise","keep":true},{"id":"pertussis","keep":true}],"mdm":"A young infant, or apnea/color change with coughing, was present: a low threshold for admission and a pertussis/RSV apnea concern.","frag":"young infant, apnea, or color change"}]},{"id":"pc-hx-fever","dx":"pneumonia-peds","q":"Fever pattern — brief low-grade, vs. high or prolonged fever, or fever that returned after improving?","answers":[{"label":"Brief, low-grade","tone":"neg","sets":[],"ddx":[],"mdm":"Fever was brief and low-grade, consistent with a viral course.","frag":"brief low-grade fever"},{"label":"High / prolonged / returned","tone":"pos","sets":[],"ddx":[{"id":"pneumonia-peds","keep":true}],"mdm":"Fever was high, prolonged, or returned after improving: a pattern that raises bacterial pneumonia.","frag":"high, prolonged, or recurrent fever"}]},{"id":"pc-hx-feeding","dx":"resp-compromise","q":"Feeding and hydration — drinking normally with wet diapers, vs. poor feeding, fewer wet diapers, or too breathless to feed?","answers":[{"label":"Feeding and hydrated well","tone":"neg","sets":[],"ddx":[],"mdm":"The child is feeding and hydrating well, drinking normally with adequate wet diapers, without poor feeding or breathlessness with feeds.","frag":"feeding well and well hydrated"},{"label":"Poor feeding / dehydration","tone":"pos","sets":[],"ddx":[{"id":"resp-compromise","keep":true}],"mdm":"Poor feeding, fewer wet diapers, or breathlessness with feeds was present and was addressed.","frag":"poor feeding or signs of dehydration"}]},{"id":"pc-hx-asthma","dx":"asthma-rad","q":"Recurrent wheeze, nighttime or exercise-triggered cough, eczema/allergies, or a family history of asthma?","answers":[{"label":"No atopic/recurrent pattern","tone":"neg","sets":[],"ddx":[],"mdm":"There is no recurrent wheeze, nocturnal/exertional pattern, or atopic/family history.","frag":"no recurrent wheeze or atopic pattern"},{"label":"Recurrent wheeze / atopy","tone":"pos","sets":[],"ddx":[{"id":"asthma-rad","keep":true}],"mdm":"A recurrent wheeze, nocturnal/exertional cough, or atopic/family history suggests reactive airway disease.","frag":"recurrent wheeze or atopic pattern"}]},{"id":"pc-hx-barky","dx":"croup-peds","q":"Barky, seal-like cough with a hoarse voice and noisy breathing?","answers":[{"label":"Not barky","tone":"neg","sets":[],"ddx":[],"mdm":"The cough is not barky and there is no hoarseness or stridulous quality.","frag":"no barky cough or hoarseness"},{"label":"Barky / hoarse","tone":"pos","sets":[],"ddx":[{"id":"croup-peds","keep":true}],"mdm":"A barky, seal-like cough with hoarseness suggests croup; severity was graded by stridor at rest.","frag":"barky cough with hoarseness"}]}],"exam":[{"id":"pc-ex-wob","dx":"resp-compromise","q":"Work of breathing & oxygenation — respiratory rate, retractions, nasal flaring, grunting, SpO₂, and mental status?","answers":[{"label":"Comfortable, normal SpO₂, alert","tone":"neg","sets":[{"risk":"spo2-peds"}],"ddx":[],"mdm":"Work of breathing was comfortable, with normal respiratory rate, no retractions, nasal flaring, or grunting, normal oxygen saturation, and an alert, interactive child.","frag":"comfortable work of breathing; normal SpO₂; alert"},{"label":"Increased WOB / hypoxia / lethargy","tone":"pos","sets":[{"risk":"spo2-peds"}],"ddx":[{"id":"resp-compromise","keep":true}],"mdm":"There was increased work of breathing (tachypnea, retractions, nasal flaring, or grunting); hypoxia, or lethargy.","frag":"increased work of breathing, hypoxia, or lethargy"}]},{"id":"pc-ex-ausc","dx":"fb-aspiration","q":"Auscultation — symmetric breath sounds, vs. focal/asymmetric findings or a unilateral wheeze (foreign body)?","answers":[{"label":"Symmetric","tone":"neg","sets":[],"ddx":[],"mdm":"Breath sounds are symmetric without focal or asymmetric findings.","frag":"symmetric breath sounds"},{"label":"Focal / asymmetric / unilateral wheeze","tone":"pos","sets":[{"risk":"fb-eval"}],"ddx":[{"id":"fb-aspiration","keep":true},{"id":"pneumonia-peds","keep":true}],"mdm":"Focal or asymmetric breath sounds, or a unilateral wheeze, were heard: a foreign body or focal consolidation.","frag":"focal, asymmetric, or unilateral findings"}]},{"id":"pc-ex-stridor","dx":"croup-peds","q":"Stridor and upper airway — none at rest (stridor only with activity/crying), vs. stridor at rest, drooling, or a toxic, tripoding child?","answers":[{"label":"No stridor at rest, non-toxic","tone":"neg","sets":[],"ddx":[],"mdm":"There is no stridor at rest and the child is non-toxic without drooling.","frag":"no stridor at rest; non-toxic appearance"},{"label":"Stridor at rest / toxic / drooling","tone":"pos","sets":[],"ddx":[{"id":"resp-compromise","keep":true},{"id":"croup-peds","keep":true}],"mdm":"Stridor at rest, drooling, or a toxic appearance is present: severe croup, or an airway emergency such as epiglottitis or retropharyngeal abscess.","frag":"stridor at rest, drooling, or toxic appearance"}]},{"id":"pc-ex-focal","dx":"pneumonia-peds","q":"Focal signs of pneumonia — focal crackles, decreased breath sounds, or hypoxia?","answers":[{"label":"No focal findings","tone":"neg","sets":[{"risk":"spo2-peds"}],"ddx":[],"mdm":"There are no focal crackles, decreased breath sounds, or hypoxia.","frag":"no focal crackles or decreased breath sounds"},{"label":"Focal findings / hypoxia","tone":"pos","sets":[{"risk":"spo2-peds"}],"ddx":[{"id":"pneumonia-peds","keep":true}],"mdm":"Focal crackles, decreased breath sounds, or hypoxia suggests pneumonia.","frag":"focal crackles, decreased breath sounds, or hypoxia"}]}],"conclusions":["viral URI / post-viral cough","croup — mild, managed and observed","reactive airway disease / asthma","community-acquired pneumonia (well-appearing) — outpatient","pediatric cough NOS (red flags excluded)"],"guide":"../learn/complaints/peds-cough.html"},{"id":"peds-vomiting","title":"Pediatric Vomiting","aliases":["pediatric vomiting","infant vomiting","bilious emesis","malrotation","volvulus","intussusception","pyloric stenosis","child vomiting","bilious","kid throwing up"],"opening":"The child was evaluated for vomiting. The character of the emesis and the abdominal and genitourinary examinations were assessed, and the time-critical surgical and metabolic causes below were actively considered.","ddx":[{"id":"volvulus","group":"lifethreat","label":"Malrotation with midgut volvulus","default":true,"tags":["volvulus"],"ruleout":"Malrotation with midgut volvulus was considered; the emesis was non-bilious, the abdomen was soft and non-distended without tenderness, and the infant was well-perfused and feeding, making it unlikely.","miss":4},{"id":"intussusception","group":"lifethreat","label":"Intussusception","default":true,"tags":["intussusception"],"ruleout":"Intussusception was considered; there were no episodes of intermittent severe colicky pain or lethargy, no currant-jelly or bloody stool, and the abdomen was soft without a palpable mass, making it unlikely.","miss":4},{"id":"ic-hernia","group":"lifethreat","label":"Incarcerated hernia","default":false,"tags":["hernia"],"ruleout":"An incarcerated hernia was considered; the inguinal and umbilical orifices were examined and were free of any tender, irreducible, or erythematous swelling, making it unlikely.","miss":4},{"id":"icp-pv","group":"lifethreat","label":"Raised intracranial pressure","default":false,"tags":["icp"],"ruleout":"Raised intracranial pressure was considered; there was no early-morning or projectile vomiting, headache, or altered mental status, and the fontanelle was soft with a normal neurologic examination and no papilledema, making it unlikely.","miss":3},{"id":"pyloric-pv","group":"lifethreat","label":"Pyloric stenosis","default":false,"tags":["pyloric-pv"],"ruleout":"Pyloric stenosis was considered; there was no progressive projectile non-bilious vomiting, the infant was feeding and gaining weight, and there was no palpable epigastric olive or visible gastric peristalsis, making it unlikely.","miss":3},{"id":"dka-pv","group":"common","label":"DKA / metabolic","default":false,"tags":["dka"],"ruleout":"Diabetic ketoacidosis and other metabolic causes were considered; a glucose was checked and the child was assessed for dehydration and tachypnea.","miss":2},{"id":"gastro-pv","group":"common","label":"Gastroenteritis","default":false,"tags":["gastro"],"ruleout":"Viral gastroenteritis was considered as the likely cause after the surgical and metabolic emergencies above were addressed, with attention to hydration.","miss":2}],"risk":[{"id":"glucose-pv","label":"Point-of-care glucose","tags":["dka"],"scale":"low","line":"A point-of-care glucose was obtained to assess for diabetic ketoacidosis and hypoglycemia.","short":"POC glucose checked"},{"id":"abd-exam-pv","label":"Abdominal & GU examination","tags":["volvulus","hernia"],"scale":"low","line":"The abdomen, hernia orifices, and genitalia were examined for distension, mass, tenderness, and an incarcerated hernia or testicular torsion.","short":"Abdomen/GU examined"},{"id":"imaging-pv","label":"Surgical imaging (if obstruction suspected)","tags":["volvulus","intussusception"],"scale":"low","line":"Imaging (upper GI series or ultrasound) and surgical involvement were pursued when a surgical obstruction was suspected.","short":"Surgical imaging"}],"checks":[{"if":"volvulus","needs":["abd-exam-pv","imaging-pv"],"mode":"any","warn":"Malrotation/volvulus is on the differential — a documented abdominal exam and prompt imaging show the basis; bilious emesis in an infant is volvulus until proven otherwise."},{"if":"dka-pv","needs":["glucose-pv"],"mode":"any","warn":"DKA is on the differential — a documented glucose shows the basis for the assessment."},{"if":"intussusception","needs":["abd-exam-pv","imaging-pv"],"mode":"any","warn":"Intussusception is on the differential — a documented abdominal exam and ultrasound (or air/contrast enema) show how it was pursued; lethargy alone can be the only presenting sign."}],"history":[{"id":"pv-hx-bilious","dx":"volvulus","q":"Is the emesis bilious (green) — especially in a young infant — or bloody?","answers":[{"label":"Non-bilious, non-bloody emesis","tone":"neg","sets":[],"ddx":[],"mdm":"The emesis was non-bilious and non-bloody.","frag":"non-bilious, non-bloody emesis"},{"label":"Bilious or bloody emesis","tone":"pos","sets":[],"ddx":[{"id":"volvulus","keep":true},{"id":"intussusception","keep":true}],"mdm":"Bilious (green) emesis, especially in a young infant, or bloody emesis was reported: bilious emesis is malrotation with volvulus until proven otherwise.","frag":"bilious or bloody emesis"}]},{"id":"pv-hx-intuss","dx":"intussusception","q":"Intermittent episodes of severe pain or drawing up the legs, marked lethargy between episodes, or bloody/currant-jelly stool?","answers":[{"label":"No intussusception pattern","tone":"neg","sets":[],"ddx":[],"mdm":"No intermittent severe pain, lethargy, or bloody stool was reported.","frag":"no intussusception pattern"},{"label":"Intermittent pain / lethargy / currant-jelly stool","tone":"pos","sets":[],"ddx":[{"id":"intussusception","keep":true}],"mdm":"Intermittent severe pain, marked lethargy, or currant-jelly stool was reported, concerning for intussusception.","frag":"intermittent pain / lethargy / currant-jelly stool"}]},{"id":"pv-hx-icp","dx":"icp-pv","q":"Persistent or projectile vomiting with headache, lethargy, a bulging fontanelle, or abnormal eye movements?","answers":[{"label":"No raised-ICP features","tone":"neg","sets":[],"ddx":[],"mdm":"No neurologic features to suggest raised intracranial pressure were reported.","frag":"no raised-ICP features"},{"label":"Headache / lethargy / projectile vomiting","tone":"pos","sets":[],"ddx":[{"id":"icp-pv","keep":true}],"mdm":"Persistent or projectile vomiting with neurologic features was reported, prompting evaluation for raised intracranial pressure.","frag":"headache / lethargy / projectile vomiting"}]},{"id":"pv-hx-dka","dx":"dka-pv","q":"Polyuria, polydipsia, weight loss, or rapid breathing (possible new-onset diabetes)?","answers":[{"label":"No DKA features","tone":"neg","sets":[],"ddx":[],"mdm":"No polyuria, polydipsia, or rapid breathing was reported.","frag":"no DKA features"},{"label":"Polyuria / polydipsia / rapid breathing","tone":"pos","sets":[],"ddx":[{"id":"dka-pv","keep":true}],"mdm":"Polyuria, polydipsia, or rapid breathing was reported, prompting a glucose check for diabetic ketoacidosis.","frag":"polyuria / polydipsia / rapid breathing"}]},{"answers":[{"ddx":[],"frag":"no projectile vomiting, feeding and gaining weight","label":"No pyloric-stenosis features","mdm":"There was no progressive projectile non-bilious vomiting, the infant was feeding and gaining weight, and there was no palpable epigastric olive or visible gastric peristalsis, making pyloric stenosis unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"pyloric-pv","keep":true}],"frag":"progressive projectile non-bilious vomiting","label":"Pyloric-stenosis features present","mdm":"Progressive projectile non-bilious vomiting with poor weight gain or a palpable epigastric olive was present, raising concern for pyloric stenosis and warranting ultrasound and electrolyte assessment.","sets":[],"tone":"pos"}],"dx":"pyloric-pv","id":"pv-hx-pyloric-pv","q":"Pyloric stenosis — progressive projectile non-bilious vomiting, poor weight gain, palpable epigastric olive, or visible gastric peristalsis (typically 2–8 weeks of age)?"}],"exam":[{"id":"pv-exam-abdomen","dx":"volvulus","q":"Abdominal examination — distension, a mass, tenderness, or peritoneal signs?","answers":[{"label":"Soft, non-distended abdomen","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen was soft and non-distended, without a mass, tenderness, or peritoneal signs.","frag":"soft, non-distended abdomen"},{"label":"Distension / mass / tenderness","tone":"pos","sets":[],"ddx":[{"id":"volvulus","keep":true},{"id":"intussusception","keep":true}],"mdm":"Abdominal distension, a mass, or tenderness was found, prompting evaluation for a surgical obstruction.","frag":"distension / mass / tenderness"}]},{"id":"pv-exam-gu","dx":"ic-hernia","q":"Hernia orifices and genitalia — an incarcerated hernia or a tender, high-riding testis (torsion)?","answers":[{"label":"Hernia orifices clear, GU normal","tone":"neg","sets":[],"ddx":[],"mdm":"The hernia orifices were clear and the genitourinary examination was normal.","frag":"hernia orifices clear, GU normal"},{"label":"Incarcerated hernia / abnormal GU","tone":"pos","sets":[],"ddx":[{"id":"ic-hernia","keep":true}],"mdm":"An incarcerated hernia or an abnormal genitourinary examination was found, prompting urgent surgical evaluation.","frag":"incarcerated hernia / abnormal GU"}]},{"id":"pv-exam-hydration","dx":"gastro-pv","q":"Hydration — dry mucous membranes, sunken eyes or fontanelle, reduced urine output, or lethargy?","answers":[{"label":"Well-hydrated","tone":"neg","sets":[],"ddx":[],"mdm":"The child was well-hydrated, with moist mucous membranes, no sunken eyes or fontanelle, normal urine output, and no lethargy.","frag":"well-hydrated"},{"label":"Signs of dehydration","tone":"pos","sets":[],"ddx":[{"id":"gastro-pv","keep":true},{"id":"dka-pv","keep":true}],"mdm":"Signs of dehydration (dry mucous membranes, sunken eyes or fontanelle, reduced urine output, or lethargy) were present, prompting rehydration and a search for the underlying cause.","frag":"signs of dehydration"}]}],"conclusions":["viral gastroenteritis (well-appearing, hydrated)"],"specs":["peds","gi"]},{"id":"peds-head","title":"Pediatric Head Injury","aliases":["peds head injury","child head injury","pediatric head trauma","kid hit head","baby fell","infant head injury","pecarn","child fell","toddler head injury","child concussion","fell off bed","nonaccidental trauma head","abusive head trauma"],"opening":"Most pediatric head injuries are minor, but PECARN exists to find the few with clinically-important TBI without irradiating the many — and the injury that doesn't fit the story should always raise abusive head trauma.","ddx":[{"id":"citbi","group":"lifethreat","label":"Clinically-important TBI (ciTBI)","default":true,"tags":["citbi"],"ruleout":"Clinically-important traumatic brain injury was considered; the PECARN predictors were negative with a normal GCS and mental status, no signs of basilar or palpable skull fracture, no severe mechanism, no persistent vomiting, and no severe headache or LOC, making it unlikely.","miss":3},{"id":"skull-fx-p","group":"lifethreat","label":"Skull fracture","default":false,"tags":["skull-fx-p","citbi"],"ruleout":"Skull fracture was considered; there was no scalp hematoma other than frontal in older children, no palpable step-off or depression, and no signs of basilar fracture such as hemotympanum, raccoon eyes, or Battle sign, making it unlikely.","miss":3},{"id":"aht","group":"lifethreat","label":"Abusive head trauma","default":false,"tags":["aht"],"ruleout":"Abusive head trauma was considered; the injury was consistent with the reported mechanism and the child's developmental stage, and there was no unexplained bruising, retinal hemorrhage, altered mental status, or bulging fontanelle, making it unlikely.","miss":4},{"id":"concussion-p","group":"common","label":"Concussion","default":false,"tags":["concussion-p"],"ruleout":"Concussion was considered as the working diagnosis once a structural injury was felt unlikely.","miss":2}],"risk":[{"id":"pecarn","label":"PECARN pediatric head-injury criteria","tags":["citbi","skull-fx-p"],"scale":"low","line":"The PECARN pediatric head-injury predictors were applied; the high-risk predictors were assessed and the imaging-versus-observation decision was documented accordingly.","cite":"Kuppermann N, et al. Lancet. 2009.","short":"PECARN {band}","calc":{"decision":true,"fields":[{"label":"Age","opts":[["≥ 2 years",0],["< 2 years",0]]},{"label":"GCS ≤ 14 or other signs of altered mental status","opts":[["No",0],["Yes",10]]},{"label":"Severe injury mechanism","opts":[["No",0],["Yes",1]]},{"label":"Signs of basilar skull fracture","opts":[["No",0],["Yes",10]],"showIf":{"field":0,"in":[0]}},{"label":"History of loss of consciousness","opts":[["No",0],["Yes",1]],"showIf":{"field":0,"in":[0]}},{"label":"History of vomiting","opts":[["No",0],["Yes",1]],"showIf":{"field":0,"in":[0]}},{"label":"Severe headache","opts":[["No",0],["Yes",1]],"showIf":{"field":0,"in":[0]}},{"label":"Palpable skull fracture","opts":[["No",0],["Yes",10]],"showIf":{"field":0,"in":[1]}},{"label":"Occipital, parietal, or temporal scalp hematoma","opts":[["No",0],["Yes",1]],"showIf":{"field":0,"in":[1]}},{"label":"Loss of consciousness ≥ 5 seconds","opts":[["No",0],["Yes",1]],"showIf":{"field":0,"in":[1]}},{"label":"Not acting normally per the parent","opts":[["No",0],["Yes",1]],"showIf":{"field":0,"in":[1]}}],"bands":[[0,"very low risk","low","No PECARN predictor: risk of clinically-important TBI is very low — CT not recommended; observe or discharge with return precautions."],[9,"intermediate risk","mod","Intermediate predictor(s) only: observation versus CT using shared decision-making — clinician experience, isolated versus multiple findings, worsening, and parental preference."],[9999,"high risk","high","High-risk predictor present: clinically-important TBI risk is elevated — head CT recommended."]],"line":"PECARN pediatric head-injury rule ({band}).","applies":"Children under 18 with blunt head trauma within 24h and GCS 14-15, with separate criteria for under-2 vs 2-and-older. Not for trivial mechanisms excluded by the study or for known coagulopathy."},"bandNotes":{"very low":"ciTBI risk <0.05% in the validation cohorts (Kuppermann 2009)"}},{"id":"obs-head-p","label":"Observation in lieu of immediate CT","tags":["citbi"],"scale":"low","line":"A period of structured observation was chosen in lieu of immediate CT, with a shared decision and a clear plan to image if the child deteriorated.","short":"structured observation documented"}],"checks":[{"if":"citbi","needs":["pecarn"],"mode":"any","warn":"Apply PECARN — document the high-risk predictors and whether CT, structured observation, or no imaging was chosen."},{"if":"aht","needs":["pecarn"],"mode":"any","warn":"If the injury doesn't fit the mechanism or the child's developmental stage, document the abusive-head-trauma consideration."}],"history":[{"id":"ph-hx-mech","dx":"citbi","q":"Mechanism — high-risk (MVC with ejection/rollover/fatality, pedestrian/cyclist without helmet, fall > 3 ft if < 2 y or > 5 ft if ≥ 2 y, high-impact object)?","answers":[{"label":"Low-risk mechanism","tone":"neg","sets":[{"risk":"pecarn"}],"ddx":[],"mdm":"The mechanism was low-risk, without high-risk features such as an MVC with ejection, rollover, or fatality, an unhelmeted pedestrian or cyclist, a fall over 3 ft if under 2 years or over 5 ft if 2 years or older, or a high-impact object.","frag":"low-risk mechanism"},{"label":"Severe mechanism","tone":"pos","sets":[{"risk":"pecarn"}],"ddx":[{"id":"citbi","keep":true}],"mdm":"A severe mechanism was reported: an MVC with ejection, rollover, or fatality, an unhelmeted pedestrian or cyclist, a fall over 3 ft if under 2 years or over 5 ft if 2 years or older, or a high-impact object.","frag":"severe injury mechanism"}]},{"id":"ph-hx-loc","dx":"citbi","q":"Loss of consciousness — and if so, ≥ 5 seconds?","answers":[{"label":"No or very brief (< 5 s)","tone":"neg","sets":[{"risk":"pecarn"}],"ddx":[],"mdm":"There was no, or only very brief (<5 second), loss of consciousness.","frag":"no or <5-second LOC"},{"label":"LOC ≥ 5 s","tone":"pos","sets":[{"risk":"pecarn"}],"ddx":[{"id":"citbi","keep":true}],"mdm":"Loss of consciousness lasted 5 seconds or longer.","frag":"LOC ≥ 5 seconds"}]},{"id":"ph-hx-behavior","dx":"citbi","q":"Is the child acting normally per the caregiver — and does the injury fit the reported mechanism and the child's developmental stage?","answers":[{"label":"Acting normally, story fits","tone":"neg","sets":[{"risk":"pecarn"}],"ddx":[],"mdm":"The child is acting normally per the caregiver and the injury is consistent with the reported mechanism and developmental stage.","frag":"acting normally per caregiver; injury consistent with mechanism"},{"label":"Not normal / story doesn't fit","tone":"pos","sets":[{"risk":"pecarn"}],"ddx":[{"id":"citbi","keep":true},{"id":"aht","keep":true}],"mdm":"The child is not acting normally per the caregiver, or the injury is inconsistent with the reported mechanism, raising both ciTBI and abusive head trauma.","frag":"not acting normally, or injury inconsistent with the reported mechanism"}]},{"id":"ph-hx-symptoms","dx":"citbi","q":"Vomiting or severe headache since the injury?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"pecarn"}],"ddx":[],"mdm":"There has been no vomiting and no severe headache.","frag":"no vomiting or severe headache"},{"label":"Vomiting / severe headache","tone":"pos","sets":[{"risk":"pecarn"}],"ddx":[{"id":"citbi","keep":true}],"mdm":"The child has had vomiting or a severe headache.","frag":"vomiting or severe headache"}]}],"exam":[{"id":"ph-ex-ams","dx":"citbi","q":"Mental status — GCS 15 / acting normally with no altered mental status (agitation, somnolence, slow responses, repetitive questioning)?","answers":[{"label":"Normal mental status","tone":"neg","sets":[{"risk":"pecarn"}],"ddx":[],"mdm":"Mental status is normal with no agitation, somnolence, or slowed responses.","frag":"normal mental status, no agitation or somnolence"},{"label":"Altered mental status","tone":"pos","sets":[{"risk":"pecarn"}],"ddx":[{"id":"citbi","keep":true}],"mdm":"The child has an altered mental status (agitation, somnolence, slow responses, or repetitive questioning); rather than a GCS of 15 and acting normally.","frag":"altered mental status"}]},{"id":"ph-ex-skull","dx":"skull-fx-p","q":"Palpable skull fracture or signs of basilar skull fracture?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"pecarn"}],"ddx":[],"mdm":"There is no palpable skull fracture and no basilar skull-fracture sign.","frag":"no palpable or basilar skull-fracture signs"},{"label":"Present","tone":"pos","sets":[{"risk":"pecarn"}],"ddx":[{"id":"skull-fx-p","keep":true},{"id":"citbi","keep":true}],"mdm":"A palpable skull fracture or basilar skull-fracture sign is present.","frag":"palpable or basilar skull-fracture signs"}]},{"id":"ph-ex-hematoma","dx":"citbi","q":"Scalp hematoma — and in a child < 2 y, is it occipital, parietal, or temporal (non-frontal)?","answers":[{"label":"None or frontal only","tone":"neg","sets":[{"risk":"pecarn"}],"ddx":[],"mdm":"There is no significant scalp hematoma, or only a frontal one, without an occipital, parietal, or temporal hematoma of concern in a child under 2.","frag":"no significant or only frontal scalp hematoma"},{"label":"Non-frontal scalp hematoma (< 2 y)","tone":"pos","sets":[{"risk":"pecarn"}],"ddx":[{"id":"citbi","keep":true}],"mdm":"There is a non-frontal (occipital, parietal, or temporal); scalp hematoma in a child under 2.","frag":"occipital, parietal, or temporal scalp hematoma in a child under 2"}]}],"conclusions":["concussion, very low ciTBI risk","minor head injury, PECARN low-risk — CT not indicated","head injury NOS (low-risk, observed)"],"specs":["peds","nsgy","trauma"],"guide":"../learn/complaints/peds-head.html"},{"id":"peds-limp","specs":["peds","ortho"],"title":"Pediatric Limp / Refusal to Bear Weight","aliases":["limp","limping child","child won't walk","refusing to walk","refusing to bear weight","toddler not walking","hip pain child","knee pain child","leg pain child","kocher","transient synovitis","toxic synovitis","septic hip","scfe","slipped capital femoral epiphysis","perthes","toddler's fracture","won't bear weight"],"opening":"A limping child is a screening problem: most have transient synovitis or a minor injury, but the job is to not miss the few that are limb- or life-threatening. Three traps recur -- septic arthritis hiding behind a 'viral' story (Kocher helps but does not exclude), the adolescent whose only complaint is knee or thigh pain when the lesion is a slipped capital femoral epiphysis at the hip, and the non-ambulatory infant with an injury whose history does not fit. Check weight-bearing, check a temperature, and image the hip when the story is off.","ddx":[{"id":"septic-arthritis-p","group":"lifethreat","label":"Septic arthritis","default":true,"tags":["septic-arthritis-p"],"ruleout":"Septic arthritis was considered; the child was afebrile, able to bear weight, and had a non-elevated WBC and inflammatory markers with low-risk Kocher criteria, and the joint was without effusion, warmth, or pain on passive range of motion, making it unlikely.","miss":4},{"id":"osteomyelitis-p","group":"lifethreat","label":"Osteomyelitis","default":false,"tags":["osteomyelitis-p"],"ruleout":"Osteomyelitis was considered; the child was afebrile with no focal bony tenderness or point pain over the metaphysis and normal inflammatory markers, making it unlikely.","miss":3},{"id":"scfe","group":"lifethreat","label":"Slipped capital femoral epiphysis (SCFE)","default":true,"tags":["scfe"],"ruleout":"Slipped capital femoral epiphysis was considered; the hip had full pain-free range without obligate external rotation on flexion, there was no referred knee or thigh pain, and frog-leg radiographs showed no slip, making it unlikely.","miss":3},{"id":"nai-limp","group":"lifethreat","label":"Non-accidental trauma / occult fracture","default":false,"tags":["nai-limp"],"ruleout":"Non-accidental trauma was considered; the history was present, consistent, and developmentally plausible, the child was ambulatory, and the injury pattern fit the mechanism without unexplained bruising or fractures, making it unlikely.","miss":4},{"id":"transient-synovitis","group":"common","label":"Transient (toxic) synovitis","default":true,"tags":["transient-synovitis"],"ruleout":"Transient synovitis was the working diagnosis only after septic arthritis was stratified as low risk, with a clear reassessment and follow-up plan.","miss":2},{"id":"toddler-fx","group":"common","label":"Toddler's fracture / minor injury","default":false,"tags":["toddler-fx"],"ruleout":"An occult toddler's fracture or minor soft-tissue injury was considered with focal examination and imaging where tenderness localized.","miss":2},{"id":"perthes","group":"other","label":"Legg-Calve-Perthes","default":false,"tags":["perthes"],"ruleout":"Legg-Calve-Perthes was noted for the 4-8 year-old with a more chronic limp and was referred for orthopedic imaging and follow-up.","miss":1},{"id":"malignancy-p","group":"other","label":"Malignancy (leukemia / bone tumor)","default":false,"tags":["malignancy-p"],"ruleout":"Malignancy was considered where there was night pain, weight loss, bruising/bleeding, or cytopenias, with a blood count and film reviewed.","miss":1}],"risk":[{"id":"kocher","label":"Kocher criteria (septic hip)","tags":["septic-arthritis-p"],"scale":"high","line":"The Kocher criteria were applied to stratify septic arthritis versus transient synovitis.","cite":"Kocher MS, et al. J Bone Joint Surg Am. 1999.","short":"Kocher {score}/4","calc":{"fields":[{"label":"Non-weight-bearing on the affected side","opts":[["No",0],["Yes",1]]},{"label":"Fever > 38.5 C (by history or measured)","opts":[["No",0],["Yes",1]]},{"label":"ESR > 40 mm/hr (or CRP clearly elevated)","opts":[["No",0],["Yes",1]]},{"label":"WBC > 12,000 /uL","opts":[["No",0],["Yes",1]]}],"bands":[[0,"very low risk","low","0 predictors: septic arthritis <1% -- transient synovitis is far more likely; reassess, treat symptomatically, and arrange follow-up with clear return precautions."],[1,"low risk","low","1 predictor (~3%): shared decision-making -- consider inflammatory markers, a period of observation, and close follow-up rather than reflex aspiration."],[2,"intermediate risk","mod","2 predictors (~40%): strongly consider arthrocentesis and involve orthopedics -- this is not a group to discharge as synovitis."],[4,"high risk","high","3-4 predictors (93-99%): treat as septic arthritis -- urgent arthrocentesis, orthopedics, and antibiotics after cultures; do not wait for imaging to act."]],"applies":"Children with an atraumatic painful hip or limp, to stratify septic arthritis vs transient synovitis. A derived probability, not a rule-out -- clinical concern overrides a low score, and it is weaker outside the hip."}},{"id":"weightbearing-doc","label":"Weight-bearing status documented","tags":["transient-synovitis"],"scale":"low","line":"Whether the child would bear weight or walk was directly observed and documented, as it drives the differential and disposition.","short":"weight-bearing status documented"},{"id":"markers-cbc","label":"Inflammatory markers + CBC checked","tags":["septic-arthritis-p"],"scale":"low","line":"Inflammatory markers (CRP/ESR) and a complete blood count were checked to stratify infection and screen for malignancy.","short":"CRP/ESR + CBC checked"},{"id":"joint-aspirate-p","label":"Arthrocentesis if not low risk","tags":["septic-arthritis-p"],"scale":"high","line":"Where septic arthritis was not low risk, arthrocentesis (cell count, Gram stain, culture) was pursued with orthopedics rather than discharging on a presumptive synovitis label.","short":"arthrocentesis pursued"},{"id":"scfe-xray","label":"Frog-leg pelvis X-ray (SCFE)","tags":["scfe"],"scale":"high","line":"A frog-leg lateral pelvis radiograph was obtained in the older child or adolescent with hip, thigh, or knee pain to exclude a slipped capital femoral epiphysis.","short":"frog-leg pelvis obtained"},{"id":"nai-screen-limp","label":"Non-accidental trauma considered","tags":["nai-limp"],"scale":"high","line":"The plausibility of the mechanism was assessed against the child's developmental stage and injury pattern, with safeguarding escalation and a skeletal survey where the history did not fit.","short":"NAI considered / history consistent"}],"checks":[{"if":"septic-arthritis-p","needs":["weightbearing-doc","markers-cbc"],"mode":"all","warn":"Document weight-bearing and the markers that feed Kocher -- 'looks like synovitis' without them is the line that gets quoted when a septic hip comes back."},{"if":"scfe","needs":["scfe-xray"],"mode":"any","warn":"Isolated knee or thigh pain in an adolescent is SCFE until a frog-leg pelvis says otherwise -- a missed slip risks avascular necrosis of the hip."},{"if":"nai-limp","needs":["nai-screen-limp"],"mode":"any","warn":"A fracture in a pre-ambulatory child, or a history that does not fit, mandates a non-accidental-trauma pathway -- not a splint and discharge."},{"if":"osteomyelitis-p","needs":["markers-cbc"],"mode":"any","warn":"Osteomyelitis is on the differential — inflammatory markers (CRP/ESR) and targeted imaging support the workup."}],"history":[{"id":"pl-hx-wb","dx":"transient-synovitis","q":"Will the child bear weight or walk at all?","answers":[{"label":"Walks, mild limp","tone":"neg","sets":[{"risk":"weightbearing-doc"}],"ddx":[],"mdm":"The child is ambulating with only a mild limp.","frag":"ambulating with mild limp"},{"label":"Refuses to bear weight","tone":"pos","sets":[{"risk":"weightbearing-doc"}],"ddx":[{"id":"septic-arthritis-p","keep":true}],"mdm":"Refusal to bear weight raises septic arthritis and significant injury and lowers the threshold for workup.","frag":"non-weight-bearing"}]},{"id":"pl-hx-fever","dx":"septic-arthritis-p","q":"Fever or systemic illness?","answers":[{"label":"Afebrile, well","tone":"neg","sets":[],"ddx":[],"mdm":"The child is afebrile and well-appearing.","frag":"afebrile and well"},{"label":"Fever / unwell","tone":"pos","sets":[{"risk":"markers-cbc"}],"ddx":[{"id":"septic-arthritis-p","keep":true},{"id":"osteomyelitis-p","keep":true}],"mdm":"Fever or systemic illness raises septic arthritis and osteomyelitis.","frag":"febrile / systemically unwell"}]},{"id":"pl-hx-age","dx":"scfe","q":"Older child / adolescent (esp. with overweight habitus) and hip, thigh, or knee pain?","answers":[{"label":"Young child, not this pattern","tone":"neg","sets":[],"ddx":[],"mdm":"The age and pattern do not fit a slipped capital femoral epiphysis.","frag":"does not fit SCFE pattern"},{"label":"Adolescent with hip/thigh/knee pain","tone":"pos","sets":[{"risk":"scfe-xray"}],"ddx":[{"id":"scfe","keep":true}],"mdm":"An adolescent with hip, thigh, or knee pain fits SCFE -- referred knee pain is a classic miss.","frag":"adolescent, SCFE pattern"}]},{"id":"pl-hx-trauma","dx":"nai-limp","q":"Mechanism -- is there a clear, plausible injury that fits the child's age and the findings?","answers":[{"label":"Clear, consistent mechanism","tone":"neg","sets":[],"ddx":[{"id":"toddler-fx","keep":true}],"mdm":"There is a clear injury mechanism consistent with the findings.","frag":"clear consistent mechanism"},{"label":"No history / inconsistent / pre-ambulatory","tone":"pos","sets":[{"risk":"nai-screen-limp"}],"ddx":[{"id":"nai-limp","keep":true}],"mdm":"An absent, inconsistent, or developmentally implausible mechanism raises non-accidental trauma.","frag":"history inconsistent / pre-ambulatory"}]},{"id":"pl-hx-viral","dx":"transient-synovitis","q":"Recent viral illness with an otherwise well child?","answers":[{"label":"No recent viral illness","tone":"neg","sets":[],"ddx":[],"mdm":"There is no antecedent viral illness.","frag":"no antecedent viral illness"},{"label":"Recent viral, well-appearing","tone":"pos","sets":[],"ddx":[{"id":"transient-synovitis","keep":true}],"mdm":"A recent viral illness in a well child supports transient synovitis -- once infection is stratified as low risk.","frag":"post-viral, well-appearing"}]},{"id":"pl-hx-redflag","dx":"malignancy-p","q":"Night pain, weight loss, bruising, or bleeding?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There are no constitutional or bleeding red flags.","frag":"no constitutional red flags"},{"label":"Present","tone":"pos","sets":[{"risk":"markers-cbc"}],"ddx":[{"id":"malignancy-p","keep":true}],"mdm":"Night pain, weight loss, or bruising/bleeding raises malignancy and warrants a blood count and film.","frag":"constitutional / bleeding red flags"}]}],"exam":[{"id":"pl-ex-gait","dx":"transient-synovitis","q":"Observed gait / weight-bearing on exam?","answers":[{"label":"Bears weight, mild antalgia","tone":"neg","sets":[],"ddx":[],"mdm":"On observation the child bears weight with a mild antalgic gait.","frag":"bears weight, mildly antalgic"},{"label":"Will not bear weight","tone":"pos","sets":[],"ddx":[{"id":"septic-arthritis-p","keep":true}],"mdm":"The child will not bear weight on examination.","frag":"refuses weight-bearing on exam"}]},{"id":"pl-ex-joint","dx":"septic-arthritis-p","q":"Hip/joint exam -- effusion, warmth, or marked pain with gentle range of motion?","answers":[{"label":"Comfortable range of motion","tone":"neg","sets":[],"ddx":[],"mdm":"The joint moves comfortably without effusion or guarding.","frag":"comfortable ROM, no effusion"},{"label":"Irritable / restricted joint","tone":"pos","sets":[{"risk":"joint-aspirate-p"}],"ddx":[{"id":"septic-arthritis-p","keep":true}],"mdm":"A hot, effused, or markedly irritable joint points to septic arthritis.","frag":"irritable, restricted joint"}]},{"id":"pl-ex-bony","dx":"toddler-fx","q":"Focal bony tenderness along the limb?","answers":[{"label":"No focal bony tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"There is no focal bony tenderness.","frag":"no focal bony tenderness"},{"label":"Focal point tenderness","tone":"pos","sets":[],"ddx":[{"id":"toddler-fx","keep":true},{"id":"osteomyelitis-p","keep":true}],"mdm":"Focal bony tenderness suggests fracture or osteomyelitis and directs imaging.","frag":"focal bony tenderness"}]},{"id":"pl-ex-skin","dx":"nai-limp","q":"Skin -- bruising in unusual sites, patterned marks, or pallor/petechiae?","answers":[{"label":"Normal skin","tone":"neg","sets":[],"ddx":[],"mdm":"The skin exam is normal without concerning bruising or pallor.","frag":"skin exam normal"},{"label":"Concerning bruising / pallor","tone":"pos","sets":[{"risk":"nai-screen-limp"}],"ddx":[{"id":"nai-limp","keep":true},{"id":"malignancy-p","keep":true}],"mdm":"Patterned or unusual bruising, or pallor/petechiae, raises non-accidental trauma or malignancy.","frag":"concerning bruising / pallor"}]},{"id":"pl-ex-frogleg","dx":"scfe","q":"Diagnostic review — hip radiographs: was a frog-leg lateral obtained and Klein's line traced? Early SCFE is commonly missed on the AP view alone.","answers":[{"label":"Frog-leg obtained — physis normal","tone":"neg","sets":[],"ddx":[],"mdm":"Frog-leg lateral views were obtained and reviewed with Klein's line traced; the physis was normal bilaterally.","frag":"frog-leg views reviewed (physis normal)"},{"label":"Widened physis / Klein's line abnormal","tone":"pos","sets":[],"ddx":[],"mdm":"The frog-leg lateral showed physeal widening or a Klein's line that failed to intersect the femoral head, consistent with SCFE: the child was made non-weight-bearing and orthopedics was consulted emergently.","frag":"SCFE on frog-leg lateral (non-weight-bearing, ortho consulted)"}]}],"conclusions":["transient synovitis -- septic arthritis stratified low risk, reassess and follow up","septic arthritis -- arthrocentesis, orthopedics, and antibiotics after cultures","slipped capital femoral epiphysis -- non-weight-bearing, orthopedics engaged","occult fracture / toddler's fracture -- immobilized with follow-up","non-accidental trauma pathway initiated with safeguarding"],"guide":"../learn/complaints/pediatric-limp.html"},{"id":"weakness","title":"Weakness / Focal Symptoms","aliases":["weakness","focal weakness","numbness","stroke","tia","facial droop","slurred speech","ascending weakness","cord compression","guillain barre","hemiparesis","tingling","paralysis","cant move"],"opening":"The patient was evaluated for weakness or focal neurologic symptoms. The pattern was characterized (focal versus symmetric or ascending), a neurologic examination and a point-of-care glucose were obtained, and the time-critical causes below were actively considered.","ddx":[{"id":"stroke","group":"lifethreat","label":"Acute ischemic stroke / TIA","default":true,"tags":["stroke"],"ruleout":"Acute ischemic stroke or TIA was considered; the deficit was non-focal without facial droop, limb weakness, dysarthria, or visual-field loss, the point-of-care glucose was normal, and the examination was symmetric, making a cerebrovascular cause unlikely.","miss":4},{"id":"cord-compression","group":"lifethreat","label":"Spinal cord compression","default":true,"tags":["cord"],"ruleout":"Spinal cord compression was considered; there was no bilateral weakness, sensory level, saddle anesthesia, or bowel or bladder dysfunction, and there were no red flags for an epidural or malignant process, making it unlikely.","miss":4},{"id":"metabolic-w","group":"lifethreat","label":"Metabolic cause (hypoglycemia, Na/K)","default":true,"tags":["metabolic"],"ruleout":"A metabolic cause was considered; the point-of-care glucose was normal and serum electrolytes including sodium, potassium, and calcium were within normal limits, making it unlikely.","miss":3},{"id":"gbs-w","group":"lifethreat","label":"Guillain-Barre syndrome","default":false,"tags":["gbs-w"],"ruleout":"Guillain-Barre syndrome was considered; there was no ascending symmetric weakness, loss of reflexes, or respiratory or bulbar involvement, with normal grip and negative inspiratory force, making it unlikely.","miss":4},{"id":"gbs","group":"common","label":"Guillain-Barré syndrome","default":false,"tags":["gbs"],"ruleout":"Guillain-Barré syndrome was considered for symmetric, ascending weakness with areflexia; respiratory function was assessed when it was a consideration.","miss":4},{"id":"neuromuscular","group":"other","label":"Neuromuscular crisis (myasthenia, botulism)","default":false,"tags":["nmj"],"ruleout":"A neuromuscular junction crisis (myasthenic crisis or botulism) was considered when bulbar or respiratory involvement was present, with attention to ventilatory status.","miss":1}],"risk":[{"id":"glucose-w","label":"Point-of-care glucose","tags":["metabolic"],"scale":"low","line":"A point-of-care glucose was obtained immediately to exclude hypoglycemia as a cause of the deficit.","short":"POC glucose checked"},{"id":"neuroexam-w","label":"Documented neuro exam (pattern, reflexes, sensory level)","tags":["stroke","cord"],"scale":"low","line":"A focused neurologic examination (pattern of weakness, reflexes, sensory level, and gait) was performed and documented.","short":"Neuro exam documented"},{"id":"lkw-stroke","label":"Last-known-well & stroke imaging","tags":["stroke"],"scale":"low","line":"The last-known-well time was established and neuroimaging (CT/CTA) was pursued when an acute focal deficit was present, to inform reperfusion decisions.","short":"LKW & CT/CTA"},{"id":"resp-w","label":"Respiratory function (NIF / FVC)","tags":["gbs","nmj"],"scale":"low","line":"Respiratory function (negative inspiratory force / forced vital capacity) was monitored when ascending or neuromuscular weakness raised concern for ventilatory failure.","short":"NIF / FVC monitored"}],"checks":[{"if":"stroke","needs":["lkw-stroke","neuroexam-w"],"mode":"any","warn":"Stroke is on the differential — the last-known-well time, a documented neuro exam, and imaging document the basis and the reperfusion window."},{"if":"cord-compression","needs":["neuroexam-w"],"mode":"any","warn":"Cord compression is on the differential — a documented neuro exam (pattern, sensory level, reflexes) shows the basis for the assessment."},{"if":"metabolic-w","needs":["glucose-w"],"mode":"any","warn":"A metabolic cause is on the differential — a point-of-care glucose documents the exclusion of hypoglycemia."},{"if":"gbs","needs":["resp-w"],"mode":"any","warn":"Guillain-Barré is on the differential — documenting respiratory function shows ventilatory status was assessed."},{"if":"neuromuscular","needs":["neuroexam-w"],"mode":"any","warn":"A neuromuscular cause (GBS, myasthenia, botulism, periodic paralysis) is on the differential — a documented neurologic exam and respiratory assessment support it."}],"history":[{"id":"w-hx-pattern","dx":"general","q":"Onset and pattern — sudden focal weakness on one side, or symmetric/ascending weakness over hours to days?","answers":[{"label":"Gradual / non-focal","tone":"neg","sets":[],"ddx":[],"mdm":"The weakness was gradual or non-focal, less typical for an acute stroke or an evolving ascending process.","frag":"gradual / non-focal weakness"},{"label":"Sudden focal — one side","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true}],"mdm":"The weakness was sudden and focal (one side), characteristic of an acute cerebrovascular event and prompting time-critical evaluation.","frag":"sudden focal one-sided weakness"},{"label":"Symmetric / ascending","tone":"pos","sets":[],"ddx":[{"id":"gbs","keep":true}],"mdm":"The weakness was symmetric and ascending over hours to days, raising concern for Guillain-Barré syndrome.","frag":"symmetric / ascending weakness"}]},{"id":"w-hx-stroke","dx":"stroke","q":"Sudden facial droop, arm or leg weakness, speech difficulty, or vision change — with a known last-well time?","answers":[{"label":"No sudden focal deficit","tone":"neg","sets":[],"ddx":[],"mdm":"No sudden focal deficit (face, arm, speech, or vision) was reported.","frag":"no sudden focal deficit"},{"label":"Sudden focal deficit, LKW known","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true}],"mdm":"A sudden focal deficit was reported with an established last-known-well time, prompting stroke-pathway evaluation.","frag":"sudden focal deficit, LKW known"}]},{"id":"w-hx-vascular","dx":"stroke","q":"Vascular risk factors — hypertension, diabetes, atrial fibrillation, prior stroke or TIA, or smoking?","answers":[{"label":"No vascular risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was assessed for vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke or TIA, and smoking), none of which were present.","frag":"no vascular risk factors"},{"label":"Vascular risk factors present","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true}],"mdm":"Vascular risk factors (such as hypertension, diabetes, atrial fibrillation, prior stroke or TIA, or smoking) were present, increasing the pretest probability of an ischemic event.","frag":"vascular risk factors"}]},{"id":"w-hx-cord","dx":"cord-compression","q":"Bilateral leg weakness, a band-like sensory level, or new urinary retention or incontinence?","answers":[{"label":"No cord-compression features","tone":"neg","sets":[],"ddx":[],"mdm":"No bilateral weakness, sensory level, or bowel/bladder change was reported.","frag":"no cord features"},{"label":"Bilateral weakness / sensory level / retention","tone":"pos","sets":[],"ddx":[{"id":"cord-compression","keep":true}],"mdm":"Bilateral weakness, a sensory level, or new bowel/bladder dysfunction was reported, concerning for spinal cord compression.","frag":"bilateral weakness / sensory level / retention"}]},{"id":"w-hx-cord-risk","dx":"cord-compression","q":"History of cancer, IV drug use, immunocompromise, or fever with focal back pain (epidural abscess or malignant compression)?","answers":[{"label":"No epidural / malignancy risk","tone":"neg","sets":[],"ddx":[],"mdm":"No cancer history, infection risk, or fever to suggest an epidural or malignant process was reported.","frag":"no epidural/malignancy risk"},{"label":"Cancer / infection risk present","tone":"pos","sets":[],"ddx":[{"id":"cord-compression","keep":true}],"mdm":"A history of cancer, injection drug use, immunocompromise, or fever with focal back pain was present, raising concern for malignant or infectious cord compression.","frag":"cancer / infection risk"}]},{"id":"w-hx-bulbar","dx":"neuromuscular","q":"Bulbar symptoms (double vision, difficulty swallowing or speaking) or shortness of breath suggesting respiratory involvement?","answers":[{"label":"No bulbar / respiratory symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No bulbar or respiratory symptoms were reported.","frag":"no bulbar / respiratory symptoms"},{"label":"Bulbar / respiratory symptoms","tone":"pos","sets":[],"ddx":[{"id":"neuromuscular","keep":true},{"id":"gbs","keep":true}],"mdm":"Bulbar symptoms or breathing difficulty were reported, raising concern for a neuromuscular crisis with impending respiratory failure.","frag":"bulbar / respiratory symptoms"}]}],"exam":[{"id":"w-exam-glucose","dx":"metabolic-w","q":"Point-of-care glucose obtained and within normal limits?","answers":[{"label":"Glucose normal","tone":"neg","sets":[],"ddx":[],"mdm":"An immediate point-of-care glucose was within normal limits, excluding hypoglycemia.","frag":"POC glucose normal"},{"label":"Hypoglycemia","tone":"pos","sets":[],"ddx":[{"id":"metabolic-w","keep":true}],"mdm":"The point-of-care glucose was low, identifying hypoglycemia as a reversible cause prompting immediate correction.","frag":"hypoglycemia on POC glucose"}]},{"id":"w-exam-focal","dx":"stroke","q":"Focal deficit on examination — facial droop, pronator drift, unilateral weakness, aphasia, or gaze deviation?","answers":[{"label":"Non-focal exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal, with no facial droop, pronator drift, unilateral weakness, aphasia, or gaze deviation.","frag":"non-focal exam"},{"label":"Focal deficit present","tone":"pos","sets":[],"ddx":[{"id":"stroke","keep":true}],"mdm":"A focal deficit (facial droop, pronator drift, unilateral weakness, aphasia, or gaze deviation) was present on examination, concerning for an acute stroke and prompting urgent imaging.","frag":"focal deficit on exam"}]},{"id":"w-exam-reflexes","dx":"gbs","q":"Reflexes and pattern — hyperreflexia with a sensory level (cord) versus areflexia with symmetric weakness (GBS)?","answers":[{"label":"Reflexes normal / symmetric","tone":"neg","sets":[],"ddx":[],"mdm":"Reflexes were normal and symmetric without a sensory level.","frag":"reflexes normal / symmetric"},{"label":"Areflexia (GBS) or hyperreflexia + level (cord)","tone":"pos","sets":[],"ddx":[{"id":"gbs","keep":true},{"id":"cord-compression","keep":true}],"mdm":"An abnormal reflex pattern was found: areflexia with symmetric weakness (Guillain-Barré) or hyperreflexia with a sensory level (cord compression).","frag":"abnormal reflex pattern"}]},{"id":"w-exam-resp","dx":"neuromuscular","q":"Respiratory effort — reduced vital capacity, weak cough, or accessory-muscle use?","answers":[{"label":"Normal respiratory effort","tone":"neg","sets":[],"ddx":[],"mdm":"Respiratory effort was normal, with no reduced vital capacity, weak cough, or accessory-muscle use.","frag":"normal respiratory effort"},{"label":"Reduced respiratory effort","tone":"pos","sets":[],"ddx":[{"id":"neuromuscular","keep":true},{"id":"gbs","keep":true}],"mdm":"Reduced respiratory effort or a weak cough was present, concerning for evolving ventilatory failure and prompting close monitoring.","frag":"reduced respiratory effort"}]},{"answers":[{"ddx":[],"frag":"no ascending weakness, reflexes intact","label":"No GBS features","mdm":"There was no ascending symmetric weakness, loss of reflexes, or respiratory or bulbar involvement, with normal grip and negative inspiratory force, making Guillain-Barre syndrome unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"gbs-w","keep":true}],"frag":"ascending weakness or areflexia","label":"GBS features present","mdm":"Ascending symmetric weakness, areflexia, or respiratory or bulbar involvement was present, raising concern for Guillain-Barre syndrome and warranting respiratory monitoring.","sets":[],"tone":"pos"}],"dx":"gbs-w","id":"w-exam-gbs-w","q":"Guillain-Barre — ascending symmetric weakness, loss of reflexes, respiratory or bulbar involvement; grip strength and negative inspiratory force?"}],"conclusions":["resolved deficit, neurologically intact at baseline","nonfocal / functional weakness"],"specs":["neuro"],"algorithm":{"immediate":["Immediate fingerstick glucose and a focused neurologic exam to separate focal from diffuse weakness; note last-known-well time.","If acute focal deficit: activate the stroke pathway and obtain emergent imaging; if ascending or bulbar/respiratory weakness, monitor respiratory function closely."],"criticalTests":["Fingerstick glucose and electrolytes (Na, K, Ca)","Non-contrast head CT ± CT angiography/perfusion for acute focal deficit","MRI of the spine when cord compression is suspected","Negative inspiratory force / vital capacity for neuromuscular weakness"],"cantMiss":[{"dx":"stroke","trigger":"Sudden focal deficit within the treatment window","test":"Non-contrast CT, CT angiography/perfusion","intervention":"Thrombolysis and/or thrombectomy per pathway; permissive blood pressure"},{"dx":"cord-compression","trigger":"Bilateral weakness, a sensory level, or bowel/bladder dysfunction","test":"Emergent spinal MRI","intervention":"High-dose steroids where indicated; emergent neurosurgery/oncology"},{"dx":"metabolic-w","trigger":"Hypoglycemia or sodium/potassium derangement","test":"Glucose and electrolytes","intervention":"Correct the derangement promptly"},{"dx":"gbs-w","trigger":"Ascending symmetric weakness with areflexia","test":"Vital capacity / negative inspiratory force; LP/MRI to support","intervention":"Respiratory monitoring; IVIG or plasma exchange"}],"disposition":"Acute focal deficits and progressive neuromuscular weakness are admitted (stroke unit or monitored bed); a resolved TIA still warrants expedited risk stratification."},"decisionTree":{"title":"Weakness — initial approach","intro":"An original, evidence-based decision aid for weakness. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Assess & triage","items":["Vitals, glucose, focused neuro exam","Distinguish focal vs generalized, central vs peripheral","Check respiratory status"],"next":"q_stroke"},"q_stroke":{"type":"decision","q":"Acute focal deficit suggesting stroke?","yes":"a_stroke","no":"q_cord","cantmiss":"Acute focal weakness is a stroke until proven otherwise — check glucose and activate the stroke pathway."},"a_stroke":{"type":"action","title":"Stroke pathway","items":["Glucose, last-known-well, NIHSS","Emergent non-contrast CT","Reperfusion evaluation"],"tone":"danger","terminal":true},"q_cord":{"type":"decision","q":"Bilateral leg weakness, a sensory level, or bladder/bowel dysfunction?","yes":"a_cord","no":"q_gbs","pitfall":"Spinal cord compression and cauda equina are time-critical — urgent MRI, and steroids/surgery for compression."},"a_cord":{"type":"action","title":"Cord compression / cauda equina","items":["Urgent spinal MRI","Steroids for malignant compression","Neurosurgery/oncology — don't wait"],"tone":"danger","terminal":true},"q_gbs":{"type":"decision","q":"Ascending weakness with areflexia (Guillain-Barré) or respiratory compromise?","yes":"a_gbs","no":"q_metab"},"a_gbs":{"type":"action","title":"Neuromuscular emergency","items":["Monitor respiratory function (vital capacity / NIF)","IVIG or plasma exchange","Watch for autonomic instability; ICU as needed"],"tone":"danger","terminal":true},"q_metab":{"type":"decision","q":"Metabolic/toxic or generalized cause (electrolytes, hypoglycemia, medications)?","yes":"a_metab","no":"a_workup"},"a_metab":{"type":"action","title":"Correct the cause","items":["Treat electrolyte/glucose derangements","Review medications/toxins","Monitor"],"terminal":true},"a_workup":{"type":"action","title":"Broaden the evaluation","items":["Labs, imaging as indicated","Consider non-neurologic mimics (deconditioning, infection)","Disposition per cause"],"terminal":true}}},"guide":"../learn/complaints/weakness.html"},{"id":"stroke-deficit","specs":["neuro"],"title":"Stroke / acute focal deficit","aliases":["stroke","cva","tia","code stroke","facial droop","slurred speech","aphasia","can't speak","weak on one side","hemiparesis","arm weakness sudden","numbness one side","be-fast","fast","last known well","thrombolysis","tpa","tenecteplase","thrombectomy","sudden vision loss","sudden vertigo","brain attack"],"opening":"Time is brain: the last-known-well time, not the arrival time, sets the thrombolysis (<=4.5h, extendable by perfusion) and thrombectomy (to 24h by imaging) windows. Three traps hide here -- hypoglycemia and post-ictal Todd's mimicking stroke, the posterior stroke that looks like benign vertigo, and treating an intracerebral bleed as ischemia. Check a glucose, get the CT, and document the clock.","ddx":[{"id":"ischemic-lvo","group":"lifethreat","label":"Ischemic stroke / large-vessel occlusion","default":true,"tags":["ischemic-lvo"],"ruleout":"Large-vessel occlusion was considered; the NIHSS was low without cortical signs such as gaze deviation, neglect, or aphasia, vessel imaging showed no proximal occlusion, and there was no disabling deficit, making it unlikely.","miss":4},{"id":"ich","group":"lifethreat","label":"Intracerebral hemorrhage","default":true,"tags":["ich"],"ruleout":"Intracerebral hemorrhage was considered; non-contrast head CT showed no acute intracranial blood, the patient was normotensive without depressed consciousness, and anticoagulation status was reviewed, making it unlikely.","miss":3},{"id":"sah-deficit","group":"lifethreat","label":"Subarachnoid hemorrhage","default":false,"tags":["sah-deficit"],"ruleout":"Subarachnoid hemorrhage was considered; there was no thunderclap or worst-ever headache, no meningismus or sudden severe presentation, and non-contrast CT showed no subarachnoid blood, making it unlikely.","miss":4},{"id":"posterior","group":"lifethreat","label":"Posterior-circulation stroke","default":true,"tags":["posterior"],"ruleout":"Posterior-circulation stroke was considered; there was no vertigo, ataxia, diplopia, dysarthria, or dysphagia, the HINTS exam was reassuring with no central pattern, and there was no truncal instability, making it unlikely.","miss":4},{"id":"hypo-mimic","group":"common","label":"Hypoglycemia / metabolic mimic","default":true,"tags":["hypo-mimic"],"ruleout":"Hypoglycemia and metabolic mimics were excluded by a point-of-care glucose and review of sodium/infection.","miss":2},{"id":"seizure-mimic","group":"common","label":"Seizure / Todd's paralysis","default":false,"tags":["seizure-mimic"],"ruleout":"A seizure with post-ictal (Todd's) deficit was considered where there was a witnessed convulsion or gradual march.","miss":2},{"id":"other-mimic","group":"other","label":"Other mimic (migraine, Bell's palsy, peripheral vertigo, functional)","default":false,"tags":["other-mimic"],"ruleout":"Benign mimics were weighed only after the dangerous causes were addressed.","miss":1}],"risk":[{"id":"nihss","label":"NIHSS (stroke severity)","tags":["ischemic-lvo"],"scale":"high","line":"An NIHSS was performed to quantify and document stroke severity.","cite":"Brott T, et al. Stroke. 1989.","short":"NIHSS {score}","calc":{"fields":[{"label":"1a · Level of consciousness","opts":[["Alert",0],["Drowsy",1],["Stuporous",2],["Coma",3]]},{"label":"1b · LOC questions (month, age)","opts":[["Both correct",0],["One correct",1],["Neither",2]]},{"label":"1c · LOC commands (eyes, grip)","opts":[["Both",0],["One",1],["Neither",2]]},{"label":"2 · Best gaze","opts":[["Normal",0],["Partial palsy",1],["Forced deviation",2]]},{"label":"3 · Visual fields","opts":[["No loss",0],["Partial hemianopia",1],["Complete hemianopia",2],["Bilateral",3]]},{"label":"4 · Facial palsy","opts":[["Normal",0],["Minor",1],["Partial",2],["Complete",3]]},{"label":"5a · Motor — left arm","opts":[["No drift",0],["Drift",1],["Some antigravity",2],["No antigravity",3],["No movement",4]]},{"label":"5b · Motor — right arm","opts":[["No drift",0],["Drift",1],["Some antigravity",2],["No antigravity",3],["No movement",4]]},{"label":"6a · Motor — left leg","opts":[["No drift",0],["Drift",1],["Some antigravity",2],["No antigravity",3],["No movement",4]]},{"label":"6b · Motor — right leg","opts":[["No drift",0],["Drift",1],["Some antigravity",2],["No antigravity",3],["No movement",4]]},{"label":"7 · Limb ataxia","opts":[["Absent",0],["One limb",1],["Two limbs",2]]},{"label":"8 · Sensory","opts":[["Normal",0],["Mild-moderate loss",1],["Severe / total",2]]},{"label":"9 · Best language","opts":[["No aphasia",0],["Mild-moderate",1],["Severe",2],["Mute / global",3]]},{"label":"10 · Dysarthria","opts":[["Normal",0],["Mild-moderate",1],["Severe",2]]},{"label":"11 · Extinction / inattention","opts":[["None",0],["Partial",1],["Complete",2]]}],"bands":[[0,"no measurable deficit","low","NIHSS 0: no measurable deficit — a normal score does not exclude stroke (posterior strokes score low); judge clinically and image if suspicion persists."],[4,"minor","low","Minor (1-4): still a thrombolysis candidate within the window — a disabling deficit, not a low score, drives the lytic decision."],[15,"moderate","mod","Moderate (5-15): NIHSS >= 6 with an anterior large-vessel occlusion is a thrombectomy candidate — activate the stroke pathway and vascular imaging now."],[20,"moderate-severe","high","Moderate-severe (16-20): high large-vessel-occlusion likelihood — emergent vascular imaging and thrombectomy evaluation."],[42,"severe","high","Severe (21-42): emergent reperfusion evaluation; weigh hemorrhage risk and goals of care."]],"applies":"Patients with a suspected acute stroke, to quantify and trend deficit severity. Posterior strokes can score low -- a low NIHSS does not exclude a disabling or treatable stroke."}},{"id":"glucose-checked","label":"Point-of-care glucose / hypoglycemia excluded","tags":["hypo-mimic"],"scale":"low","line":"A point-of-care glucose was checked and hypoglycemia excluded as a stroke mimic.","short":"glucose checked; not hypoglycemic"},{"id":"lkw-documented","label":"Last-known-well time documented","tags":["ischemic-lvo"],"scale":"low","line":"The last-known-well time was established and documented, and reperfusion eligibility (thrombolysis window, and thrombectomy window by perfusion imaging) was assessed against it.","short":"last-known-well documented"},{"id":"stroke-activated","label":"Stroke pathway activated / imaging + neurology","tags":["ischemic-lvo"],"scale":"low","line":"The acute stroke pathway was activated with emergent non-contrast CT, vascular/perfusion imaging as indicated, and neurology engaged.","short":"stroke pathway activated"},{"id":"bp-managed","label":"Blood pressure managed to the reperfusion plan","tags":["ich"],"scale":"low","line":"Blood pressure was managed to the plan -- below 185/110 before and 180/105 after thrombolysis or thrombectomy, and otherwise permissive unless >= 220/120 -- and the target was documented.","short":"BP managed to reperfusion plan"}],"checks":[{"if":"ischemic-lvo","needs":["lkw-documented","stroke-activated"],"mode":"any","warn":"Document the last-known-well time and that the stroke pathway/imaging were activated -- the clock is what plaintiff and stroke-team review both look for."},{"if":"hypo-mimic","needs":["glucose-checked"],"mode":"any","warn":"A glucose is mandatory before calling a focal deficit a stroke -- hypoglycemia is the classic reversible mimic."},{"if":"ich","needs":["bp-managed"],"mode":"any","warn":"Hemorrhage changes everything -- exclude it on CT and document the BP target before any antithrombotic."}],"history":[{"id":"st-hx-lkw","dx":"ischemic-lvo","q":"Last known well -- when was the patient definitely at baseline (not when symptoms were found)?","answers":[{"label":"Clear time, within window","tone":"neg","sets":[{"risk":"lkw-documented"}],"ddx":[],"mdm":"The last-known-well time is clearly established and within a reperfusion window.","frag":"clear last-known-well, in window"},{"label":"Unknown / wake-up / out of window","tone":"pos","sets":[{"risk":"lkw-documented"}],"ddx":[{"id":"ischemic-lvo","keep":true}],"mdm":"The onset is unwitnessed, wake-up, or beyond the standard window -- perfusion imaging determines extended reperfusion eligibility.","frag":"unwitnessed / wake-up onset"}]},{"id":"st-hx-befast","dx":"ischemic-lvo","q":"Deficit pattern -- sudden face droop, arm/leg weakness, speech change, or vision loss (BE-FAST)?","answers":[{"label":"No focal deficit","tone":"neg","sets":[],"ddx":[],"mdm":"There is no sudden focal neurologic deficit.","frag":"no focal deficit"},{"label":"Sudden focal deficit","tone":"pos","sets":[{"risk":"stroke-activated"}],"ddx":[{"id":"ischemic-lvo","keep":true}],"mdm":"A sudden focal deficit (BE-FAST positive) is present.","frag":"sudden focal deficit (BE-FAST+)"}]},{"id":"st-hx-posterior","dx":"posterior","q":"Vertigo, ataxia, diplopia, or sudden severe imbalance (posterior signs)?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There are no posterior-circulation symptoms.","frag":"no posterior symptoms"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"posterior","keep":true}],"mdm":"Vertigo, ataxia, or diplopia raises posterior-circulation stroke -- not assumed benign.","frag":"vertigo/ataxia/diplopia"}]},{"id":"st-hx-headache","dx":"sah-deficit","q":"Thunderclap or worst-ever headache with the deficit?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There is no thunderclap or worst-ever headache.","frag":"no thunderclap headache"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"sah-deficit","keep":true},{"id":"ich","keep":true}],"mdm":"A thunderclap/worst-ever headache accompanies the deficit -- hemorrhage (SAH/ICH) is prioritized.","frag":"thunderclap headache"}]},{"id":"st-hx-anticoag","dx":"ich","q":"Anticoagulant or recent thrombolytic / bleeding history?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not anticoagulated and has no recent bleeding history.","frag":"not anticoagulated"},{"label":"Anticoagulated / bleeding risk","tone":"pos","sets":[],"ddx":[{"id":"ich","keep":true}],"mdm":"Anticoagulation or bleeding history raises hemorrhage risk and bears on thrombolysis eligibility.","frag":"anticoagulated / bleeding risk"}]},{"id":"st-hx-seizure","dx":"seizure-mimic","q":"Witnessed seizure at onset, or a gradual spreading 'march' of symptoms?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There was no witnessed seizure or gradual march.","frag":"no seizure at onset"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"seizure-mimic","keep":true}],"mdm":"A witnessed seizure or gradual march raises post-ictal (Todd's) paralysis as a mimic -- though stroke is not excluded.","frag":"seizure at onset / march"}]},{"id":"st-hx-diabetes","dx":"hypo-mimic","q":"Diabetic on insulin or a sulfonylurea, or any chance of hypoglycemia?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There is no hypoglycemia risk by history.","frag":"no hypoglycemia risk"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"hypo-mimic","keep":true}],"mdm":"Diabetes on insulin/sulfonylurea makes hypoglycemia a live mimic to exclude.","frag":"hypoglycemia risk present"}]}],"exam":[{"id":"st-ex-glucose","dx":"hypo-mimic","q":"Point-of-care glucose -- normal, excluding hypoglycemia?","answers":[{"label":"Normal glucose","tone":"neg","sets":[{"risk":"glucose-checked"}],"ddx":[],"mdm":"The point-of-care glucose is normal, excluding hypoglycemia.","frag":"glucose normal"},{"label":"Low / not yet checked","tone":"pos","sets":[],"ddx":[{"id":"hypo-mimic","keep":true}],"mdm":"Glucose is low or not yet checked -- hypoglycemia must be corrected/excluded before calling a stroke.","frag":"glucose low / unchecked"}]},{"id":"st-ex-deficit","dx":"ischemic-lvo","q":"Focal neuro exam -- score the deficit on the NIHSS.","answers":[{"label":"No focal deficit on exam","tone":"neg","sets":[],"ddx":[],"mdm":"The focused neurologic exam shows no focal deficit.","frag":"no focal deficit on exam"},{"label":"Focal deficit -- NIHSS performed","tone":"pos","sets":[{"risk":"nihss"}],"ddx":[{"id":"ischemic-lvo","keep":true}],"mdm":"A focal deficit is present and quantified on the NIHSS.","frag":"focal deficit, NIHSS scored"}]},{"id":"st-ex-bp","dx":"ich","q":"Blood pressure -- and is it within the reperfusion target?","answers":[{"label":"At/within target","tone":"neg","sets":[{"risk":"bp-managed"}],"ddx":[],"mdm":"Blood pressure is within the reperfusion target.","frag":"BP within target"},{"label":"Above target","tone":"pos","sets":[],"ddx":[{"id":"ich","keep":true}],"mdm":"Blood pressure is above the reperfusion target and was managed to plan.","frag":"BP above target"}]},{"id":"st-ex-cerebellar","dx":"posterior","q":"Cerebellar / gait -- dysmetria, truncal ataxia, or unable to walk?","answers":[{"label":"Normal","tone":"neg","sets":[],"ddx":[],"mdm":"Cerebellar testing and gait are normal.","frag":"cerebellar/gait normal"},{"label":"Abnormal","tone":"pos","sets":[],"ddx":[{"id":"posterior","keep":true}],"mdm":"Cerebellar signs or gait failure point to a posterior-circulation lesion.","frag":"cerebellar/gait abnormal"}]}],"conclusions":["acute ischemic stroke -- pathway activated, reperfusion eligibility addressed","TIA -- deficit resolved, expedited workup and secondary prevention","intracerebral hemorrhage -- BP and reversal managed, neurosurgery engaged","stroke mimic (hypoglycemia corrected) -- deficit resolved","posterior-circulation stroke -- imaged and admitted"],"guide":"../learn/complaints/stroke.html","pearls":[{"text":"Exclude hypoglycemia before calling anything a stroke — a low glucose is a common and completely reversible stroke mimic.","dx":"hypo-mimic"},{"text":"NIHSS under-weights posterior-circulation findings — a low NIHSS does not exclude a dangerous posterior stroke; vertigo, diplopia, and ataxia are easily dismissed and deserve the same urgency as a hemiparesis.","dx":"posterior"},{"text":"Consider cervical artery dissection in headache or neck pain with a deficit, spontaneous or post-trauma/manipulation — a young, otherwise healthy patient is not reassuring here.","dx":"posterior"},{"text":"Early ischemic signs on non-contrast CT (hyperdense vessel, insular ribbon loss) are subtle and insensitive — a 'normal' early CT does not rule out a large ischemic stroke.","dx":"ischemic-lvo"},{"text":"Don't mislabel a stroke as conversion/psychiatric — hypoglycemia and seizure/Todd's paralysis are the mimics to rule out first, not a diagnosis of exclusion made on gestalt.","dx":"seizure-mimic"}]},{"id":"flank-pain","title":"Flank Pain","aliases":["flank pain","kidney stone","renal colic","nephrolithiasis","aaa","pyelonephritis","cva tenderness","ureteral stone","side pain","hematuria"],"opening":"The patient was evaluated for flank pain. Rather than anchoring on renal colic, the dangerous vascular and infectious causes below were actively considered alongside ureterolithiasis.","ddx":[{"id":"aaa-f","group":"lifethreat","label":"Ruptured / symptomatic AAA","default":true,"tags":["aaa"],"ruleout":"A ruptured or symptomatic abdominal aortic aneurysm was considered; the patient was hemodynamically stable without syncope, there was no pulsatile abdominal mass or tearing pain, and bedside ultrasound showed a normal-caliber aorta, making it unlikely.","miss":4},{"id":"dissection-f","group":"lifethreat","label":"Aortic dissection","default":false,"tags":["dissection"],"ruleout":"Aortic dissection was considered; the pain was neither tearing nor migratory, pulses and blood pressures were symmetric without an inter-arm differential, and there was no focal neurologic deficit or new murmur, making it unlikely.","miss":4},{"id":"renal-infarct","group":"lifethreat","label":"Renal infarction","default":false,"tags":["infarct"],"ruleout":"Renal infarction was considered; there was no atrial fibrillation or embolic source, no abrupt severe flank pain out of proportion, and no unexplained markedly elevated LDH, making it unlikely.","miss":3},{"id":"pyelo","group":"common","label":"Pyelonephritis","default":false,"tags":["pyelo"],"ruleout":"Pyelonephritis was considered based on fever, costovertebral angle tenderness, and urinary findings, and treated accordingly.","miss":2},{"id":"stone","group":"common","label":"Ureterolithiasis","default":false,"tags":["stone"],"ruleout":"Ureterolithiasis was considered as a benign cause once the dangerous vascular diagnoses above were addressed, with imaging as appropriate especially in a first presentation or older patient.","miss":2}],"risk":[{"id":"ua-f","label":"Urinalysis","tags":["pyelo","stone"],"scale":"low","line":"A urinalysis was obtained to assess for hematuria and for evidence of infection.","short":"Urinalysis obtained"},{"id":"preg-f","label":"Pregnancy test","tags":["aaa"],"scale":"low","line":"A pregnancy test was obtained in a patient of reproductive potential before imaging and to broaden the differential.","short":"Pregnancy test obtained"},{"id":"imaging-f","label":"Imaging (CT / ultrasound)","tags":["aaa","stone"],"scale":"low","line":"Imaging (CT or ultrasound) was obtained to evaluate for aneurysm, obstruction, or an alternative cause, particularly in older patients or a first presentation.","short":"Imaging obtained"}],"checks":[{"if":"aaa-f","needs":["imaging-f"],"mode":"any","warn":"A symptomatic AAA is on the differential — the exam and imaging document the basis for excluding it, particularly in an older patient with a first presentation."},{"if":"pyelo","needs":["ua-f"],"mode":"any","warn":"Pyelonephritis / infected obstructing stone is on the differential — a documented urinalysis (with temperature) shows infection was assessed; fever plus obstruction is a urologic emergency."}],"history":[{"id":"f-hx-character","dx":"general","q":"Pain character — colicky, waxing-and-waning radiating to the groin (stone), or sudden, severe, tearing, or constant?","answers":[{"label":"Colicky, radiating to groin","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was colicky and waxing-and-waning with radiation to the groin rather than sudden, severe, tearing, or constant, a pattern typical of ureterolithiasis.","frag":"colicky pain radiating to groin"},{"label":"Sudden / tearing / constant severe","tone":"pos","sets":[],"ddx":[{"id":"aaa-f","keep":true},{"id":"dissection-f","keep":true}],"mdm":"The pain was sudden, tearing, or constant and severe, a pattern that should not be attributed to a stone without excluding a vascular catastrophe.","frag":"sudden / tearing / constant severe pain"}]},{"id":"f-hx-aaa","dx":"aaa-f","q":"Age ≥ 60 with hypertension, smoking, known aneurysm, or pain with syncope or a pulsatile abdominal sensation?","answers":[{"label":"No AAA risk features","tone":"neg","sets":[],"ddx":[],"mdm":"No age or vascular risk features for an aneurysm were identified.","frag":"no AAA risk features"},{"label":"AAA risk / syncope / pulsatile sensation","tone":"pos","sets":[],"ddx":[{"id":"aaa-f","keep":true}],"mdm":"Age and vascular risk factors, a known aneurysm, or associated syncope or a pulsatile sensation were present, raising concern for a symptomatic or ruptured AAA.","frag":"AAA risk / syncope / pulsatile"}]},{"id":"f-hx-embolic","dx":"renal-infarct","q":"Atrial fibrillation, a mechanical valve, or another embolic source (for renal infarction)?","answers":[{"label":"No embolic source","tone":"neg","sets":[],"ddx":[],"mdm":"No atrial fibrillation or embolic source was identified.","frag":"no embolic source"},{"label":"Embolic source present","tone":"pos","sets":[],"ddx":[{"id":"renal-infarct","keep":true}],"mdm":"Atrial fibrillation or another embolic source was present, raising consideration of renal infarction.","frag":"embolic source (renal infarct)"}]},{"id":"f-hx-infection","dx":"pyelo","q":"Fever, chills, dysuria, urinary frequency, or known immunocompromise / pregnancy / obstruction?","answers":[{"label":"No infectious features","tone":"neg","sets":[],"ddx":[],"mdm":"No fever or urinary infectious features were reported.","frag":"no infectious features"},{"label":"Fever / dysuria / urinary symptoms","tone":"pos","sets":[],"ddx":[{"id":"pyelo","keep":true}],"mdm":"Fever, chills, or urinary symptoms were reported, supporting pyelonephritis, with attention to obstruction or immunocompromise.","frag":"fever / dysuria / urinary symptoms"}]},{"id":"f-hx-hematuria","dx":"stone","q":"Gross hematuria or a prior history of kidney stones?","answers":[{"label":"No hematuria / prior stones","tone":"neg","sets":[],"ddx":[],"mdm":"No gross hematuria or prior stone history was reported.","frag":"no hematuria / prior stones"},{"label":"Hematuria / prior stones","tone":"pos","sets":[],"ddx":[{"id":"stone","keep":true}],"mdm":"Gross hematuria or a prior stone history was reported, supporting ureterolithiasis after dangerous causes were addressed.","frag":"hematuria / prior stones"}]}],"exam":[{"id":"f-exam-vitals","dx":"aaa-f","q":"Vital signs — hypotension, tachycardia, or signs of shock?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable, without hypotension, tachycardia, or signs of shock.","frag":"hemodynamically stable"},{"label":"Hypotension / tachycardia / shock","tone":"pos","sets":[],"ddx":[{"id":"aaa-f","keep":true}],"mdm":"Hypotension, tachycardia, or signs of shock were present, concerning for a ruptured aneurysm or another catastrophe.","frag":"hypotension / tachycardia / shock"}]},{"id":"f-exam-mass","dx":"aaa-f","q":"A pulsatile abdominal mass, an abdominal bruit, or asymmetric femoral pulses?","answers":[{"label":"No pulsatile mass, pulses symmetric","tone":"neg","sets":[],"ddx":[],"mdm":"No pulsatile abdominal mass was palpated and femoral pulses were symmetric, noting palpation is only ~68% sensitive for AAA and cannot exclude one. Imaging thresholds were set by age, vascular risk factors, and the clinical picture.","frag":"no pulsatile mass, symmetric pulses (palpation is only ~68% sensitive for AAA and cannot exclude one, so imaging was driven by age and vascular risk)"},{"label":"Pulsatile mass / pulse deficit","tone":"pos","sets":[],"ddx":[{"id":"aaa-f","keep":true},{"id":"dissection-f","keep":true}],"mdm":"A pulsatile abdominal mass or a femoral pulse deficit was found, concerning for an aneurysm or dissection.","frag":"pulsatile mass / pulse deficit"}]},{"id":"f-exam-cva","dx":"pyelo","q":"Costovertebral angle tenderness, with fever on examination?","answers":[{"label":"No CVA tenderness / afebrile","tone":"neg","sets":[],"ddx":[],"mdm":"There was no costovertebral angle tenderness and the patient was afebrile.","frag":"no CVA tenderness, afebrile"},{"label":"CVA tenderness / fever","tone":"pos","sets":[],"ddx":[{"id":"pyelo","keep":true}],"mdm":"Costovertebral angle tenderness or fever was present, supporting pyelonephritis.","frag":"CVA tenderness / fever"}]}],"conclusions":["renal colic / uncomplicated kidney stone","flank pain NOS (low-risk)"],"specs":["uro"],"guide":"../learn/complaints/flank-pain.html"},{"id":"palpitations","title":"Palpitations","aliases":["palpitations","racing heart","irregular heartbeat","arrhythmia","wpw","long qt","svt","skipped beats","heart racing","fluttering","afib","pounding heart"],"opening":"The patient was evaluated for palpitations. An ECG was personally reviewed for malignant arrhythmias and high-risk features, and the dangerous causes below were actively considered.","ddx":[{"id":"vt","group":"lifethreat","label":"Ventricular tachycardia / malignant arrhythmia","default":true,"tags":["vt"],"ruleout":"A malignant ventricular arrhythmia was considered; the ECG showed no wide-complex tachycardia, ischemic change, or structural clues, and there was no exertional syncope or family history of sudden cardiac death, making it unlikely.","miss":3},{"id":"preexcitation","group":"lifethreat","label":"Pre-excitation (WPW) / long-QT","default":true,"tags":["wpw"],"ruleout":"Pre-excitation or long-QT syndrome was considered; the ECG showed no delta wave or short PR interval, the corrected QT was normal, and there was no syncope or family history of sudden death, making it unlikely.","miss":4},{"id":"acs-p","group":"lifethreat","label":"ACS / structural heart disease","default":false,"tags":["acs"],"ruleout":"An ischemic or structural cardiac cause was considered; there was no associated chest pain, dyspnea, or exertional symptom, and the ECG showed no ischemic ST or T-wave changes, making it unlikely.","miss":3},{"id":"pe-p","group":"lifethreat","label":"Pulmonary embolism","default":false,"tags":["pe"],"ruleout":"Pulmonary embolism was considered; pretest probability was low with no dyspnea, pleuritic pain, hemoptysis, leg swelling, recent immobility, surgery, or malignancy, and oxygen saturation was normal, making it unlikely.","miss":4},{"id":"electrolyte-p","group":"lifethreat","label":"Electrolyte derangement","default":false,"tags":["electrolyte-p"],"ruleout":"An electrolyte derangement was considered; there was no relevant diuretic use, vomiting, or renal disease, and serum potassium, magnesium, and calcium were within normal limits, making it unlikely.","miss":3},{"id":"metabolic-p","group":"common","label":"Electrolyte / thyroid / stimulant cause","default":false,"tags":["metabolic"],"ruleout":"A metabolic or stimulant cause (electrolyte derangement, thyrotoxicosis, caffeine or sympathomimetics) was considered and evaluated as indicated.","miss":2}],"risk":[{"id":"ecg-p","label":"ECG personally reviewed","tags":["vt","wpw"],"scale":"low","line":"The ECG was personally reviewed for rate and rhythm, a delta wave, the QT interval, and ischemic change.","short":"ECG reviewed"},{"id":"lytes-p","label":"Electrolytes & magnesium","tags":["metabolic"],"scale":"low","line":"Electrolytes including potassium and magnesium were obtained and reviewed.","short":"Electrolytes / Mg"},{"id":"tsh-p","label":"Thyroid function","tags":["metabolic"],"scale":"low","line":"Thyroid function was checked when thyrotoxicosis was a consideration.","short":"TSH checked"}],"checks":[{"if":"vt","needs":["ecg-p"],"mode":"any","warn":"A malignant arrhythmia is on the differential — a personally reviewed ECG documents the basis for the assessment."},{"if":"preexcitation","needs":["ecg-p"],"mode":"any","warn":"Pre-excitation or long-QT is on the differential — documenting the ECG review (delta wave, QT) shows the basis."},{"if":"acs-p","needs":["ecg-p"],"mode":"any","warn":"ACS can present as palpitations — a documented ECG (and troponin when indicated) shows ischemia was considered."},{"if":"metabolic-p","needs":["lytes-p","tsh-p"],"mode":"any","warn":"Metabolic causes of palpitations are common — document electrolytes and a TSH (hyperthyroidism)."}],"history":[{"id":"p-hx-syncope","dx":"vt","q":"Exertional syncope or palpitations during exertion, or a family history of sudden cardiac death before age 50?","answers":[{"label":"No exertional syncope / FH sudden death","tone":"neg","sets":[],"ddx":[],"mdm":"No exertional syncope and no family history of premature sudden death were reported.","frag":"no exertional syncope / FH sudden death"},{"label":"Exertional syncope / FH sudden death","tone":"pos","sets":[],"ddx":[{"id":"vt","keep":true},{"id":"preexcitation","keep":true}],"mdm":"Exertional syncope or a family history of sudden cardiac death was reported, a high-risk feature for a malignant arrhythmia or inherited channelopathy.","frag":"exertional syncope / FH sudden death"}]},{"id":"p-hx-structural","dx":"acs-p","q":"Known structural heart disease, prior myocardial infarction, or reduced ejection fraction?","answers":[{"label":"No structural heart disease","tone":"neg","sets":[],"ddx":[],"mdm":"No known structural heart disease was reported.","frag":"no structural heart disease"},{"label":"Structural heart disease","tone":"pos","sets":[],"ddx":[{"id":"vt","keep":true},{"id":"acs-p","keep":true}],"mdm":"Known structural heart disease or prior infarction was reported, increasing the risk that a wide-complex tachycardia is ventricular.","frag":"structural heart disease"}]},{"id":"p-hx-chestpain","dx":"acs-p","q":"Associated chest pain, dyspnea, or diaphoresis suggesting ischemia?","answers":[{"label":"No ischemic symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No associated chest pain or ischemic symptoms were reported.","frag":"no ischemic symptoms"},{"label":"Chest pain / dyspnea / diaphoresis","tone":"pos","sets":[],"ddx":[{"id":"acs-p","keep":true}],"mdm":"Associated chest pain, dyspnea, or diaphoresis was reported, prompting evaluation for an ischemic cause.","frag":"chest pain / dyspnea / diaphoresis"}]},{"id":"p-hx-pe","dx":"pe-p","q":"VTE risk — recent immobilization or surgery, prior DVT/PE, active malignancy, estrogen, or pleuritic pain/dyspnea?","answers":[{"label":"No PE risk features","tone":"neg","sets":[],"ddx":[],"mdm":"No VTE risk features were reported: no recent immobilization or surgery, prior DVT/PE, active malignancy, estrogen use, or pleuritic pain or dyspnea.","frag":"no PE risk features"},{"label":"PE risk features","tone":"pos","sets":[],"ddx":[{"id":"pe-p","keep":true}],"mdm":"VTE risk features (recent immobilization or surgery, prior DVT/PE, active malignancy, estrogen use, or pleuritic pain or dyspnea) were reported, prompting consideration of pulmonary embolism as a cause of the palpitations.","frag":"PE risk features"}]},{"id":"p-hx-stimulant","dx":"metabolic-p","q":"Caffeine, stimulants, thyroid symptoms (heat intolerance, weight loss, tremor), or recent vomiting/diarrhea (electrolyte loss)?","answers":[{"label":"No stimulant / metabolic trigger","tone":"neg","sets":[],"ddx":[],"mdm":"No stimulant use or metabolic trigger was identified.","frag":"no stimulant / metabolic trigger"},{"label":"Stimulant / thyroid / electrolyte trigger","tone":"pos","sets":[],"ddx":[{"id":"metabolic-p","keep":true}],"mdm":"A stimulant, thyroid, or electrolyte trigger was identified, supporting a metabolic contributor after dangerous causes were addressed.","frag":"stimulant / thyroid / electrolyte trigger"}]},{"answers":[{"ddx":[],"frag":"no diuretic use, vomiting, or renal disease","label":"No electrolyte risk","mdm":"There was no relevant diuretic use, vomiting, or renal disease, and serum potassium, magnesium, and calcium were within normal limits, making an electrolyte derangement unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"electrolyte-p","keep":true}],"frag":"diuretic use, vomiting, or renal disease","label":"Electrolyte risk present","mdm":"Diuretic use, vomiting, renal disease, or an abnormal electrolyte was present, raising concern for an electrolyte derangement as a cause of the palpitations.","sets":[],"tone":"pos"}],"dx":"electrolyte-p","id":"p-hx-electrolyte-p","q":"Electrolyte risk — diuretic use, vomiting, or renal disease; potassium, magnesium, and calcium status?"}],"exam":[{"id":"p-exam-vitals","dx":"vt","q":"Vital signs and rhythm — sustained tachycardia, hypotension, or hemodynamic instability?","answers":[{"label":"Stable, no sustained tachyarrhythmia","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable, without sustained tachycardia, hypotension, or hemodynamic instability.","frag":"stable, no sustained tachyarrhythmia"},{"label":"Sustained tachycardia / instability","tone":"pos","sets":[],"ddx":[{"id":"vt","keep":true}],"mdm":"A sustained tachyarrhythmia or hemodynamic instability was present, prompting immediate rhythm assessment and management.","frag":"sustained tachycardia / instability"}]},{"id":"p-exam-ecg","dx":"vt","q":"ECG — wide-complex tachycardia, a delta wave, prolonged QT, or ischemic changes?","answers":[{"label":"ECG without high-risk features","tone":"neg","sets":[],"ddx":[],"mdm":"The ECG showed no wide-complex tachycardia, delta wave, QT prolongation, or ischemic change.","frag":"ECG without high-risk features"},{"label":"Wide-complex / delta wave / long QT / ischemia","tone":"pos","sets":[],"ddx":[{"id":"vt","keep":true},{"id":"preexcitation","keep":true},{"id":"acs-p","keep":true}],"mdm":"The ECG showed a high-risk feature (wide-complex tachycardia, a delta wave, QT prolongation, or ischemic change), prompting targeted management.","frag":"high-risk ECG feature"}]}],"conclusions":["benign palpitations (no arrhythmia captured)","sinus tachycardia, resolved"],"specs":["cards"],"decisionTree":{"title":"Symptomatic arrhythmia — stable vs unstable","intro":"An original, evidence-based decision aid for a symptomatic tachy- or brady-arrhythmia in the ED. Apply local protocol (ACLS) and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Assess & monitor","items":["Monitor/defibrillator pads, IV access, 12-lead ECG, full vitals","Identify the rhythm (rate, regularity, QRS width)","Decide whether the rhythm is causing instability"],"next":"q_unstable"},"q_unstable":{"type":"decision","q":"Unstable from the rhythm? (hypotension, ischemic chest pain, acute heart failure, shock, or altered mentation)","cantmiss":"If the rhythm is driving the instability, electricity is the priority — pacing for bradycardia, synchronized cardioversion for a tachyarrhythmia.","yes":"q_brady_u","no":"q_brady_s"},"q_brady_u":{"type":"decision","q":"Is it too slow (bradyarrhythmia)?","yes":"a_brady_u","no":"a_dccv"},"a_brady_u":{"type":"action","tone":"danger","title":"Unstable bradycardia","terminal":true,"items":["Atropine first","If inadequate: transcutaneous pacing and/or a chronotrope (epinephrine or dopamine infusion)","Treat reversible causes (ischemia, drugs, hyperkalemia); urgent cardiology"]},"a_dccv":{"type":"action","tone":"danger","title":"Unstable tachycardia → synchronized cardioversion","terminal":true,"items":["Procedural sedation, then synchronized cardioversion","Pulseless VT or VF: switch to the cardiac-arrest pathway (defibrillate)","Treat reversible causes"]},"q_brady_s":{"type":"decision","q":"Stable, but too slow (bradyarrhythmia)?","yes":"a_brady_s","no":"q_wide_s"},"a_brady_s":{"type":"action","title":"Stable bradycardia","terminal":true,"items":["Identify and treat the cause (ischemia, drugs, electrolytes, hypothyroidism)","Monitor; keep atropine and pacing ready if it worsens","Cardiology for high-grade AV block"]},"q_wide_s":{"type":"decision","q":"Wide-complex tachycardia?","pitfall":"Don't assume SVT with aberrancy — treat a regular wide-complex tachycardia as VT until proven otherwise.","yes":"a_wide_s","no":"q_regular_s"},"a_wide_s":{"type":"action","tone":"danger","title":"Stable wide-complex tachycardia","terminal":true,"items":["Treat as VT until proven otherwise","Antiarrhythmic (e.g., amiodarone or procainamide)","Avoid AV-nodal blockers if irregular/uncertain (possible pre-excited AF); prepare for cardioversion; cardiology"]},"q_regular_s":{"type":"decision","q":"Regular narrow-complex (likely SVT)?","yes":"a_svt","no":"a_irregular"},"a_svt":{"type":"action","title":"Regular narrow-complex SVT","terminal":true,"items":["Vagal maneuvers first (e.g., modified Valsalva)","Adenosine if vagal maneuvers fail","Rate control (calcium-channel or beta-blocker) for persistent SVT; cardiology if recurrent"]},"a_irregular":{"type":"action","title":"Irregular narrow-complex (likely AF/flutter)","terminal":true,"items":["Follow the atrial fibrillation pathway","Rate vs rhythm control by duration and stability","Anticoagulation by stroke risk"]}}},"guide":"../learn/complaints/palpitations.html"},{"id":"leg-swelling","title":"Unilateral Leg Pain / Swelling","aliases":["leg swelling","leg pain","dvt","calf pain","limb ischemia","compartment syndrome","cellulitis","necrotizing","clot","blood clot","calf swelling","unilateral leg swelling","deep vein thrombosis"],"opening":"The patient was evaluated for unilateral leg pain or swelling. Deep vein thrombosis and the limb-threatening vascular and infectious causes below were actively considered.","ddx":[{"id":"dvt","group":"lifethreat","label":"Deep vein thrombosis","default":true,"tags":["dvt"],"ruleout":"Deep vein thrombosis was considered; the leg was without disproportionate unilateral swelling, calf tenderness along the deep veins, warmth, or pitting edema, the Wells score was low, and there were no thrombotic risk factors, making it unlikely.","miss":3},{"id":"limb-ischemia","group":"lifethreat","label":"Acute limb ischemia","default":true,"tags":["ischemia"],"ruleout":"Acute limb ischemia was considered; the limb was warm and pink with intact distal pulses, normal capillary refill, and preserved sensation and motor function, without pain, pallor, pulselessness, paresthesia, or poikilothermia, making it unlikely.","miss":3},{"id":"compartment","group":"lifethreat","label":"Compartment syndrome","default":false,"tags":["compartment"],"ruleout":"Compartment syndrome was considered, particularly after trauma or reperfusion; there was no pain out of proportion, no pain on passive stretch, the compartments were soft and compressible, and distal sensation and pulses were intact, making it unlikely.","miss":4},{"id":"nsti-leg","group":"lifethreat","label":"Necrotizing soft-tissue infection","default":false,"tags":["nsti"],"ruleout":"Necrotizing soft-tissue infection was considered; there was no pain out of proportion to exam, crepitus, bullae, skin necrosis, or rapidly advancing erythema, and the patient was non-toxic without systemic signs, making it unlikely.","miss":4},{"id":"ruptured-baker-cyst","group":"lifethreat","label":"Ruptured Baker cyst / DVT mimic","default":false,"tags":["ruptured-baker-cyst"],"ruleout":"A ruptured Baker cyst and other DVT mimics were considered; there was no popliteal fullness, sudden calf pain with crescent bruising, or ecchymosis, though these do not obviate excluding true thrombosis, making it unlikely.","miss":3},{"id":"cellulitis","group":"common","label":"Cellulitis","default":false,"tags":["cellulitis"],"ruleout":"Cellulitis was considered as a more benign infectious cause once the limb- and life-threatening diagnoses above were addressed.","miss":2}],"risk":[{"id":"wells-dvt","label":"Wells DVT score","tags":["dvt"],"scale":"low","line":"A Wells score for DVT was documented to risk-stratify the presentation and to guide d-dimer versus ultrasound.","short":"Wells DVT documented"},{"id":"us-leg","label":"Compression ultrasound","tags":["dvt"],"scale":"low","line":"A compression ultrasound was obtained to evaluate for deep vein thrombosis when pretest probability warranted.","short":"Compression ultrasound"},{"id":"pulses-leg","label":"Pulses & perfusion documented","tags":["ischemia"],"scale":"low","line":"Distal pulses and perfusion were assessed and documented to evaluate for acute limb ischemia.","short":"Pulses / perfusion documented"}],"checks":[{"if":"dvt","needs":["wells-dvt","us-leg"],"mode":"any","warn":"DVT is on the differential — a Wells score and d-dimer or ultrasound document the basis for the assessment."},{"if":"limb-ischemia","needs":["pulses-leg"],"mode":"any","warn":"Acute limb ischemia is on the differential — documented pulses and perfusion show the basis for excluding it."}],"history":[{"id":"l-hx-vte","dx":"dvt","q":"VTE risk — recent surgery or immobilization, prior DVT/PE, active malignancy, estrogen use, or a long-haul trip?","answers":[{"label":"No VTE risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No VTE risk factors (recent surgery or immobilization, prior DVT/PE, active malignancy, estrogen use, or a long-haul trip) were identified.","frag":"no VTE risk factors"},{"label":"VTE risk factors present","tone":"pos","sets":[],"ddx":[{"id":"dvt","keep":true}],"mdm":"VTE risk factors (recent surgery or immobilization, prior DVT/PE, active malignancy, estrogen use, or a long-haul trip) were present, increasing the pretest probability of deep vein thrombosis.","frag":"VTE risk factors"}]},{"id":"l-hx-ischemia","dx":"limb-ischemia","q":"Sudden onset with a cold, pale, or painful limb — or known peripheral arterial disease or atrial fibrillation?","answers":[{"label":"No acute ischemic features","tone":"neg","sets":[],"ddx":[],"mdm":"No sudden cold, pale, painful limb or embolic risk was reported.","frag":"no acute ischemic features"},{"label":"Cold / pale / painful limb, embolic risk","tone":"pos","sets":[],"ddx":[{"id":"limb-ischemia","keep":true}],"mdm":"A sudden cold, pale, or painful limb or an embolic risk was reported, concerning for acute limb ischemia.","frag":"cold / pale / painful limb"}]},{"id":"l-hx-trauma","dx":"compartment","q":"Recent trauma, fracture, crush, or a tight cast — with pain out of proportion?","answers":[{"label":"No trauma / pain out of proportion","tone":"neg","sets":[],"ddx":[],"mdm":"No recent trauma or pain out of proportion was reported.","frag":"no trauma / pain out of proportion"},{"label":"Trauma with pain out of proportion","tone":"pos","sets":[],"ddx":[{"id":"compartment","keep":true}],"mdm":"Recent trauma or a tight cast with pain out of proportion was reported, raising concern for compartment syndrome.","frag":"trauma with pain out of proportion"}]},{"id":"l-hx-nsti","dx":"nsti-leg","q":"Rapidly spreading redness, severe pain out of proportion, fever, or systemic toxicity; diabetes or immunocompromise?","answers":[{"label":"No NSTI features","tone":"neg","sets":[],"ddx":[],"mdm":"No rapidly spreading infection, disproportionate pain, or systemic toxicity was reported.","frag":"no NSTI features"},{"label":"Rapidly spreading / pain out of proportion / toxicity","tone":"pos","sets":[],"ddx":[{"id":"nsti-leg","keep":true}],"mdm":"Rapidly spreading erythema, pain out of proportion, or systemic toxicity was reported, raising concern for a necrotizing soft-tissue infection.","frag":"rapidly spreading / pain out of proportion / toxicity"}]}],"exam":[{"id":"l-exam-dvt","dx":"dvt","q":"Unilateral calf swelling, tenderness along the deep veins, or a measured calf-circumference difference?","answers":[{"label":"No DVT signs","tone":"neg","sets":[],"ddx":[],"mdm":"No unilateral calf swelling or deep-vein tenderness was found.","frag":"no DVT signs"},{"label":"Calf swelling / deep-vein tenderness","tone":"pos","sets":[],"ddx":[{"id":"dvt","keep":true}],"mdm":"Unilateral calf swelling or deep-vein tenderness was present, consistent with possible DVT and increasing the Wells score.","frag":"calf swelling / deep-vein tenderness"}]},{"id":"l-exam-perfusion","dx":"limb-ischemia","q":"Pulses and perfusion — diminished or absent pulses, pallor, coolness, or delayed capillary refill?","answers":[{"label":"Pulses intact, perfusion normal","tone":"neg","sets":[],"ddx":[],"mdm":"Distal pulses were intact and perfusion was normal, without diminished or absent pulses, pallor, coolness, or delayed capillary refill.","frag":"pulses intact, perfusion normal"},{"label":"Diminished pulses / pallor / coolness","tone":"pos","sets":[],"ddx":[{"id":"limb-ischemia","keep":true}],"mdm":"Diminished or absent pulses, pallor, or coolness was found, concerning for acute limb ischemia and prompting urgent vascular involvement.","frag":"diminished pulses / pallor / coolness"}]},{"id":"l-exam-compartment","dx":"compartment","q":"Tense compartments or pain with passive stretch of the muscle group?","answers":[{"label":"Compartments soft","tone":"neg","sets":[],"ddx":[],"mdm":"The compartments were soft without pain on passive stretch.","frag":"compartments soft"},{"label":"Tense compartments / pain with passive stretch","tone":"pos","sets":[],"ddx":[{"id":"compartment","keep":true}],"mdm":"Tense compartments or pain with passive stretch was present, concerning for compartment syndrome and prompting pressure measurement and surgical involvement.","frag":"tense compartments / pain with passive stretch"}]},{"id":"l-exam-skin","dx":"nsti-leg","q":"Skin — crepitus, bullae, skin necrosis, or rapidly advancing margins?","answers":[{"label":"No crepitus / necrosis","tone":"neg","sets":[],"ddx":[],"mdm":"The skin showed no crepitus, bullae, or necrosis and no rapidly advancing margin.","frag":"no crepitus / necrosis"},{"label":"Crepitus / bullae / necrosis","tone":"pos","sets":[],"ddx":[{"id":"nsti-leg","keep":true}],"mdm":"Crepitus, bullae, or necrosis was present, raising strong concern for a necrotizing infection and prompting emergent surgical involvement.","frag":"crepitus / bullae / necrosis"}]},{"answers":[{"ddx":[],"frag":"no popliteal fullness or crescent bruising (but a Baker cyst and a DVT can coexist, so thrombosis was still excluded)","label":"No Baker-cyst signs","mdm":"There was no popliteal fullness, sudden calf pain, or crescent ecchymosis to suggest a ruptured Baker cyst, but because a cyst and a DVT can coexist and look alike, a true thrombosis was still actively excluded rather than assumed away.","sets":[],"tone":"neg"},{"ddx":[{"id":"ruptured-baker-cyst","keep":true}],"frag":"popliteal fullness or crescent calf ecchymosis","label":"Baker-cyst signs present","mdm":"Popliteal fullness or sudden calf pain with crescent ecchymosis suggested a ruptured Baker cyst, though true thrombosis was still actively excluded.","sets":[],"tone":"pos"}],"dx":"ruptured-baker-cyst","id":"l-exam-ruptured-baker-cyst","q":"DVT mimic — popliteal fullness or sudden calf pain with crescent (ecchymotic) bruising suggesting a ruptured Baker cyst?"}],"conclusions":["musculoskeletal / superficial cause (DVT excluded)","cellulitis","chronic venous changes"],"specs":["vasc"],"guide":"../learn/complaints/leg-swelling.html"},{"id":"vision-loss","title":"Acute Vision Loss","aliases":["vision loss","blindness","crao","angle closure glaucoma","giant cell arteritis","temporal arteritis","retinal detachment","endophthalmitis","blind","blurry vision","flashes","floaters","curtain over vision","sudden blindness"],"opening":"The patient was evaluated for acute vision change or a red, painful eye. Visual acuity, intraocular pressure, the pupillary response, and the fundus were assessed, and the sight- and life-threatening causes below were actively considered.","ddx":[{"id":"crao","group":"lifethreat","label":"Central retinal artery occlusion","default":true,"tags":["crao"],"ruleout":"Central retinal artery occlusion was considered for sudden painless monocular loss; vision was preserved, there was no relative afferent pupillary defect, and fundoscopy showed no pale retina, cherry-red spot, or arterial boxcarring, making it unlikely.","miss":4},{"id":"angle-closure","group":"lifethreat","label":"Acute angle-closure glaucoma","default":false,"tags":["glaucoma"],"ruleout":"Acute angle-closure glaucoma was considered; the eye was white and non-painful without a fixed mid-dilated pupil, corneal haze, halos, headache, or nausea, and intraocular pressure was not elevated, making it unlikely.","miss":4},{"id":"gca-eye","group":"lifethreat","label":"Giant cell arteritis","default":false,"tags":["gca"],"ruleout":"Giant cell arteritis was considered in this older patient; there was no new headache, jaw claudication, scalp tenderness, temporal artery abnormality, or polymyalgia, and inflammatory markers were not elevated, making it unlikely.","miss":4},{"id":"detachment","group":"lifethreat","label":"Retinal detachment","default":false,"tags":["detachment"],"ruleout":"Retinal detachment was considered; the patient reported no flashes, new floaters, or a peripheral curtain or shadow over the visual field, visual fields were full to confrontation, and fundoscopy was unremarkable, making it unlikely.","miss":3},{"id":"stroke-vision","group":"lifethreat","label":"Stroke / occipital or retrochiasmal infarct","default":false,"tags":["stroke-vision"],"ruleout":"A central cause such as occipital stroke was considered; the deficit respected the vertical meridian as a homonymous field cut rather than monocular loss, with no other focal neurologic findings, and stroke workup was pursued when suspected.","miss":4},{"id":"endophthalmitis","group":"common","label":"Endophthalmitis","default":false,"tags":["endophthalmitis"],"ruleout":"Endophthalmitis was considered after recent intraocular surgery or injection; there was no progressive pain, hypopyon, or worsening vision to suggest it.","miss":2}],"risk":[{"id":"acuity-iop","label":"Visual acuity & intraocular pressure","tags":["crao","glaucoma"],"scale":"low","line":"Visual acuity and intraocular pressure were measured and documented as part of the focused eye examination.","short":"Acuity & IOP documented"},{"id":"esr-crp-eye","label":"ESR / CRP (if GCA suspected)","tags":["gca"],"scale":"low","line":"Inflammatory markers (ESR and CRP) were obtained when giant cell arteritis was a consideration.","short":"ESR / CRP obtained"},{"id":"ophtho","label":"Ophthalmology involvement","tags":["crao","detachment"],"scale":"low","line":"Ophthalmology was involved without delay for a time-critical, sight-threatening diagnosis.","short":"Ophthalmology involved"}],"checks":[{"if":"crao","needs":["acuity-iop","ophtho"],"mode":"any","warn":"CRAO is on the differential — documented acuity and urgent ophthalmology involvement show the basis and the time-critical pathway."},{"if":"angle-closure","needs":["acuity-iop"],"mode":"any","warn":"Angle-closure glaucoma is on the differential — a documented intraocular pressure shows the basis for the assessment."},{"if":"gca-eye","needs":["esr-crp-eye"],"mode":"any","warn":"Giant cell arteritis is on the differential — inflammatory markers document the workup."},{"if":"detachment","needs":["acuity-iop","ophtho"],"mode":"any","warn":"Retinal detachment is on the differential — document visual acuity/fields and arrange ophthalmology."}],"history":[{"id":"v-hx-onset","dx":"general","q":"Onset — sudden painless monocular vision loss, or gradual / painful change? And the time since onset?","answers":[{"label":"Gradual / non-acute change","tone":"neg","sets":[],"ddx":[],"mdm":"The change was gradual rather than a sudden painless loss.","frag":"gradual / non-acute change"},{"label":"Sudden painless monocular loss","tone":"pos","sets":[],"ddx":[{"id":"crao","keep":true}],"mdm":"Sudden painless monocular vision loss was reported, a presentation concerning for a retinal artery occlusion and time-critical.","frag":"sudden painless monocular loss"}]},{"id":"v-hx-painred","dx":"angle-closure","q":"A painful red eye with headache, nausea/vomiting, or halos around lights?","answers":[{"label":"No painful red eye","tone":"neg","sets":[],"ddx":[],"mdm":"No painful red eye, halos, or associated nausea was reported.","frag":"no painful red eye"},{"label":"Painful red eye / halos / nausea","tone":"pos","sets":[],"ddx":[{"id":"angle-closure","keep":true}],"mdm":"A painful red eye with halos, headache, or nausea was reported, concerning for acute angle-closure glaucoma.","frag":"painful red eye / halos / nausea"}]},{"id":"v-hx-gca","dx":"gca-eye","q":"Age ≥ 50 with new headache, jaw claudication, scalp tenderness, or transient visual loss?","answers":[{"label":"No GCA features","tone":"neg","sets":[],"ddx":[],"mdm":"No age or symptoms to suggest giant cell arteritis were reported.","frag":"no GCA features"},{"label":"GCA features present","tone":"pos","sets":[],"ddx":[{"id":"gca-eye","keep":true}],"mdm":"Age and features such as headache, jaw claudication, or scalp tenderness were present, raising concern for giant cell arteritis requiring urgent treatment.","frag":"GCA features"}]},{"id":"v-hx-detach","dx":"detachment","q":"Flashes of light, new floaters, or a curtain or shadow across the visual field?","answers":[{"label":"No flashes / floaters / curtain","tone":"neg","sets":[],"ddx":[],"mdm":"No flashes, floaters, or visual-field curtain were reported.","frag":"no flashes / floaters / curtain"},{"label":"Flashes / floaters / curtain","tone":"pos","sets":[],"ddx":[{"id":"detachment","keep":true}],"mdm":"Flashes, floaters, or a visual-field curtain were reported, concerning for retinal detachment.","frag":"flashes / floaters / curtain"}]},{"id":"v-hx-procedure","dx":"endophthalmitis","q":"Recent eye surgery, an intravitreal injection, or ocular trauma?","answers":[{"label":"No recent eye procedure / trauma","tone":"neg","sets":[],"ddx":[],"mdm":"No recent intraocular procedure or trauma was reported.","frag":"no recent eye procedure / trauma"},{"label":"Recent eye procedure / trauma","tone":"pos","sets":[],"ddx":[{"id":"endophthalmitis","keep":true}],"mdm":"A recent intraocular procedure or trauma was reported, raising concern for endophthalmitis.","frag":"recent eye procedure / trauma"}]}],"exam":[{"id":"v-exam-acuity","dx":"crao","q":"Visual acuity and an afferent pupillary defect — markedly reduced acuity or a relative afferent pupillary defect?","answers":[{"label":"Acuity preserved, no APD","tone":"neg","sets":[],"ddx":[],"mdm":"Visual acuity was preserved and there was no relative afferent pupillary defect.","frag":"acuity preserved, no APD"},{"label":"Reduced acuity / APD","tone":"pos","sets":[],"ddx":[{"id":"crao","keep":true},{"id":"gca-eye","keep":true}],"mdm":"Markedly reduced acuity or a relative afferent pupillary defect was found, concerning for an optic-nerve or retinal arterial process.","frag":"reduced acuity / APD"}]},{"id":"v-exam-iop","dx":"angle-closure","q":"Intraocular pressure and pupil — markedly elevated pressure with a mid-dilated, poorly reactive pupil?","answers":[{"label":"IOP normal, pupil reactive","tone":"neg","sets":[],"ddx":[],"mdm":"Intraocular pressure was normal and the pupil was reactive.","frag":"IOP normal, pupil reactive"},{"label":"High IOP / mid-dilated pupil","tone":"pos","sets":[],"ddx":[{"id":"angle-closure","keep":true}],"mdm":"A markedly elevated intraocular pressure with a mid-dilated, poorly reactive pupil was found, concerning for acute angle-closure glaucoma.","frag":"high IOP / mid-dilated pupil"}]},{"id":"v-exam-fundus","dx":"detachment","q":"Fundus examination — a pale retina with a cherry-red spot (CRAO), a detachment, or disc abnormality?","answers":[{"label":"Fundus normal","tone":"neg","sets":[],"ddx":[],"mdm":"The fundus examination was unremarkable.","frag":"fundus normal"},{"label":"Abnormal fundus (pale retina / detachment / disc)","tone":"pos","sets":[],"ddx":[{"id":"crao","keep":true},{"id":"detachment","keep":true}],"mdm":"An abnormal fundus (a pale retina with a cherry-red spot, a detachment, or a disc abnormality) was found, supporting a sight-threatening diagnosis.","frag":"abnormal fundus"}]},{"answers":[{"ddx":[],"frag":"monocular loss, no homonymous field cut","label":"Monocular pattern","mdm":"The visual loss was monocular and localized to the eye rather than a homonymous field cut, with no other focal neurologic findings, making an occipital or retrochiasmal stroke less likely.","sets":[],"tone":"neg"},{"ddx":[{"id":"stroke-vision","keep":true}],"frag":"homonymous field cut or focal deficit","label":"Homonymous / focal pattern","mdm":"The deficit was a homonymous field cut respecting the vertical meridian or other focal neurologic signs were present, raising concern for a central cause such as occipital stroke and prompting stroke workup.","sets":[],"tone":"pos"}],"dx":"stroke-vision","id":"v-exam-stroke-vision","q":"Central cause — does the deficit respect the vertical meridian as a homonymous field cut rather than monocular loss, and are there other focal neurologic findings?"}],"conclusions":["viral conjunctivitis","benign red eye"],"specs":["ophtho"],"guide":"../learn/complaints/vision-loss.html"},{"id":"rash","title":"Dangerous Rash","aliases":["rash","skin eruption","petechiae","purpura","sjs","ten","necrotizing fasciitis","toxic shock","dress","anaphylaxis rash","hives","skin rash","blistering","meningococcal"],"opening":"The patient was evaluated for a rash. The dermatologic emergencies below were actively considered, with attention to airway, hemodynamics, mucosal involvement, and skin pain.","ddx":[{"id":"anaphylaxis-r","group":"lifethreat","label":"Anaphylaxis","default":true,"tags":["anaphylaxis"],"ruleout":"Anaphylaxis was considered; the skin findings were isolated without airway swelling, stridor, wheeze, dyspnea, hypotension, or persistent gastrointestinal symptoms, and vital signs were stable, so criteria were not met.","miss":4},{"id":"sjs-ten","group":"lifethreat","label":"Stevens-Johnson syndrome / TEN","default":true,"tags":["sjsten"],"ruleout":"Stevens-Johnson syndrome / toxic epidermal necrolysis was considered; there was no mucosal involvement, skin pain or tenderness, epidermal sloughing, target lesions, or positive Nikolsky sign, and no recent high-risk culprit medication, making it unlikely.","miss":4},{"id":"meningococcemia","group":"lifethreat","label":"Meningococcemia / purpuric eruption","default":true,"tags":["purpura"],"ruleout":"Meningococcemia and purpuric eruptions were considered; the rash was fully blanching without petechiae or purpura, and the patient was afebrile and non-toxic without meningismus or hemodynamic compromise, making it unlikely.","miss":4},{"id":"nec-fasc","group":"lifethreat","label":"Necrotizing fasciitis","default":false,"tags":["nstr"],"ruleout":"Necrotizing fasciitis was considered; there was no pain out of proportion to exam, crepitus, bullae, dusky or necrotic skin, or rapidly advancing erythema, and the patient was non-toxic, making it unlikely.","miss":4},{"id":"tss","group":"common","label":"Toxic shock syndrome / DRESS","default":false,"tags":["tss"],"ruleout":"Toxic shock syndrome and DRESS were considered; there was no diffuse erythroderma with hypotension, and no fever with facial edema and eosinophilia after a culprit drug.","miss":2}],"risk":[{"id":"vitals-r","label":"Vital signs & airway documented","tags":["anaphylaxis","purpura"],"scale":"low","line":"Vital signs and airway status were assessed and documented, given the potential for anaphylaxis or sepsis.","short":"Vitals/airway documented"},{"id":"skin-exam-r","label":"Mucosa & skin examination","tags":["sjsten","nstr"],"scale":"low","line":"The mucous membranes and skin were examined for involvement, tenderness, sloughing, crepitus, and the rate of spread.","short":"Skin/mucosa examined"},{"id":"labs-r","label":"Targeted labs / cultures","tags":["tss"],"scale":"low","line":"Targeted laboratory studies and cultures were obtained when a systemic or infectious process was suspected.","short":"Labs/cultures obtained"}],"checks":[{"if":"anaphylaxis-r","needs":["vitals-r"],"mode":"any","warn":"Anaphylaxis is on the differential — documented vitals and airway status show the basis for the assessment."},{"if":"meningococcemia","needs":["vitals-r"],"mode":"any","warn":"A purpuric/septic eruption is on the differential — documented vitals show the perfusion assessment."},{"if":"nec-fasc","needs":["skin-exam-r"],"mode":"any","warn":"Necrotizing infection is on the differential — the documented skin exam shows the basis for excluding it."},{"if":"sjs-ten","needs":["skin-exam-r"],"mode":"any","warn":"SJS/TEN is on the differential — document the skin/mucosal exam (Nikolsky sign, mucosal involvement, body-surface area)."},{"if":"tss","needs":["vitals-r"],"mode":"any","warn":"Toxic shock is on the differential — document vital signs (fever, hypotension) and the source search."}],"history":[{"id":"r-hx-anaphylaxis","dx":"anaphylaxis-r","q":"New exposure (food, drug, sting) with hives plus any breathing difficulty, throat tightness, vomiting, or lightheadedness?","answers":[{"label":"No systemic / airway symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"The skin findings were not accompanied by respiratory, GI, or hemodynamic symptoms.","frag":"no systemic / airway symptoms"},{"label":"Exposure with systemic symptoms","tone":"pos","sets":[],"ddx":[{"id":"anaphylaxis-r","keep":true}],"mdm":"A new exposure with hives plus respiratory, GI, or hemodynamic symptoms was reported, meeting concern for anaphylaxis.","frag":"exposure with systemic symptoms"}]},{"id":"r-hx-sjs","dx":"sjs-ten","q":"A new medication in the preceding weeks, with painful skin, blistering, or sores in the mouth, eyes, or genitals?","answers":[{"label":"No culprit drug / mucosal symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No new culprit medication or mucosal or painful-skin symptoms were reported.","frag":"no culprit drug / mucosal symptoms"},{"label":"New drug + painful skin / mucosal sores","tone":"pos","sets":[],"ddx":[{"id":"sjs-ten","keep":true}],"mdm":"A new medication with painful skin or mucosal sores was reported, concerning for Stevens-Johnson syndrome / TEN.","frag":"new drug + painful skin / mucosal sores"}]},{"id":"r-hx-purpura","dx":"meningococcemia","q":"Fever with a rash that does not blanch, headache, neck stiffness, or rapid progression?","answers":[{"label":"No fever / non-blanching rash","tone":"neg","sets":[],"ddx":[],"mdm":"No fever or non-blanching rash was reported.","frag":"no fever / non-blanching rash"},{"label":"Fever + non-blanching rash","tone":"pos","sets":[],"ddx":[{"id":"meningococcemia","keep":true}],"mdm":"Fever with a non-blanching rash or meningeal symptoms was reported, concerning for meningococcemia.","frag":"fever + non-blanching rash"}]},{"id":"r-hx-nstr","dx":"nec-fasc","q":"Severe pain out of proportion to the skin findings, rapid spread, or diabetes/immunocompromise?","answers":[{"label":"No pain out of proportion / rapid spread","tone":"neg","sets":[],"ddx":[],"mdm":"No disproportionate pain or rapid spread was reported.","frag":"no pain out of proportion / rapid spread"},{"label":"Pain out of proportion / rapid spread","tone":"pos","sets":[],"ddx":[{"id":"nec-fasc","keep":true}],"mdm":"Pain out of proportion or rapidly spreading skin findings were reported, raising concern for a necrotizing infection.","frag":"pain out of proportion / rapid spread"}]}],"exam":[{"id":"r-exam-vitals","dx":"anaphylaxis-r","q":"Vital signs and airway — hypotension, wheeze/stridor, facial or oropharyngeal swelling?","answers":[{"label":"Stable vitals, airway patent","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable and the airway was patent, without hypotension, wheeze or stridor, or facial or oropharyngeal swelling.","frag":"stable vitals, airway patent"},{"label":"Hypotension / stridor / swelling","tone":"pos","sets":[],"ddx":[{"id":"anaphylaxis-r","keep":true}],"mdm":"Hypotension, wheeze or stridor, or facial or oropharyngeal swelling was present, requiring immediate treatment for anaphylaxis.","frag":"hypotension / stridor / swelling"}]},{"id":"r-exam-mucosa","dx":"sjs-ten","q":"Mucosal involvement, skin tenderness, sloughing, or a positive Nikolsky sign?","answers":[{"label":"No mucosal involvement / Nikolsky negative","tone":"neg","sets":[],"ddx":[],"mdm":"There was no mucosal involvement, skin tenderness, or sloughing; Nikolsky was negative.","frag":"no mucosal involvement, Nikolsky negative"},{"label":"Mucosal involvement / sloughing / Nikolsky+","tone":"pos","sets":[],"ddx":[{"id":"sjs-ten","keep":true}],"mdm":"Mucosal involvement, skin tenderness, sloughing, or a positive Nikolsky sign was present, concerning for SJS/TEN.","frag":"mucosal involvement / sloughing / Nikolsky+"}]},{"id":"r-exam-purpura","dx":"meningococcemia","q":"Non-blanching petechiae or purpura on examination (confirmed with diascopy)?","answers":[{"label":"No petechiae / purpura","tone":"neg","sets":[],"ddx":[],"mdm":"No non-blanching petechiae or purpura were found.","frag":"no petechiae / purpura"},{"label":"Non-blanching petechiae / purpura","tone":"pos","sets":[],"ddx":[{"id":"meningococcemia","keep":true}],"mdm":"Non-blanching petechiae or purpura were present on examination, concerning for meningococcemia or another serious cause.","frag":"non-blanching petechiae / purpura"}]},{"id":"r-exam-nstr","dx":"nec-fasc","q":"Skin — crepitus, bullae, necrosis, or a rapidly advancing margin?","answers":[{"label":"No crepitus / bullae / necrosis","tone":"neg","sets":[],"ddx":[],"mdm":"The skin showed no crepitus, bullae, necrosis, or rapid advance.","frag":"no crepitus / bullae / necrosis"},{"label":"Crepitus / bullae / necrosis","tone":"pos","sets":[],"ddx":[{"id":"nec-fasc","keep":true}],"mdm":"Crepitus, bullae, or necrosis was present, raising strong concern for a necrotizing infection.","frag":"crepitus / bullae / necrosis"}]}],"conclusions":["benign viral exanthem","nonspecific dermatitis","urticaria"],"specs":["derm","id"],"guide":"../learn/complaints/rash.html"},{"id":"hot-joint","title":"Acute Hot Joint","aliases":["hot joint","swollen joint","septic arthritis","gout","monoarthritis","joint pain","arthrocentesis","red joint","hot knee"],"opening":"The patient was evaluated for an acutely swollen, painful joint. Septic arthritis was treated as the can't-miss diagnosis — crystal disease does not exclude infection — and the diagnoses below were actively considered.","ddx":[{"id":"septic-arthritis","group":"lifethreat","label":"Septic arthritis","default":true,"tags":["septic"],"ruleout":"Septic arthritis was considered; the patient was afebrile with no joint effusion, warmth, or pain on micro-motion, full painless range of motion was preserved, and there were no septic risk factors, making it unlikely.","miss":4},{"id":"dgi","group":"lifethreat","label":"Disseminated gonococcal infection","default":false,"tags":["dgi"],"ruleout":"Disseminated gonococcal infection was considered; there were no migratory polyarthralgias, tenosynovitis, or pustular or vesiculopustular skin lesions, and no relevant sexual or exposure risk, making it unlikely.","miss":3},{"id":"nec-joint","group":"lifethreat","label":"Overlying necrotizing infection","default":false,"tags":["nstr"],"ruleout":"Necrotizing infection overlying the joint was considered; there was no pain out of proportion, crepitus, bullae, skin necrosis, or rapidly advancing erythema with systemic toxicity, making it unlikely.","miss":4},{"id":"crystal","group":"common","label":"Crystal arthropathy (gout / pseudogout)","default":false,"tags":["crystal"],"ruleout":"A crystal arthropathy was considered as a common cause, but only after septic arthritis was addressed, since crystals and infection can coexist.","miss":2},{"id":"reactive","group":"common","label":"Reactive / inflammatory arthritis","default":false,"tags":["reactive"],"ruleout":"A reactive or inflammatory arthritis was considered after infection was addressed, based on the history and pattern of involvement.","miss":2}],"risk":[{"id":"arthrocentesis","label":"Arthrocentesis (cell count, Gram stain, crystals)","tags":["septic"],"scale":"low","line":"Arthrocentesis was performed (or planned) with synovial cell count, Gram stain, culture, and crystal analysis to evaluate for infection before attributing the presentation to crystal disease.","short":"Arthrocentesis"},{"id":"inflammatory-j","label":"Inflammatory markers / blood cultures","tags":["septic"],"scale":"low","line":"Inflammatory markers and blood cultures were obtained when septic arthritis was a consideration.","short":"Markers / cultures"}],"checks":[{"if":"septic-arthritis","needs":["arthrocentesis"],"mode":"any","warn":"Septic arthritis is on the differential — synovial fluid analysis documents the basis for the assessment and should not be skipped because crystals are found."},{"if":"dgi","needs":["arthrocentesis"],"mode":"any","warn":"Disseminated gonococcal infection can present as a hot joint — arthrocentesis (plus genital/throat/rectal cultures) documents the workup."},{"if":"crystal","needs":["arthrocentesis"],"mode":"any","warn":"Don't assume crystal arthropathy — arthrocentesis with cell count and crystal analysis is what distinguishes gout/pseudogout from septic arthritis (they can coexist)."}],"history":[{"id":"j-hx-onset","dx":"general","q":"Onset and number of joints — a single acutely hot, swollen joint over hours to days, with fever?","answers":[{"label":"Chronic / polyarticular, no fever","tone":"neg","sets":[],"ddx":[],"mdm":"The presentation was chronic or polyarticular without fever, less typical for a single septic joint.","frag":"chronic / polyarticular, no fever"},{"label":"Acute monoarticular ± fever","tone":"pos","sets":[],"ddx":[{"id":"septic-arthritis","keep":true}],"mdm":"A single acutely hot, swollen joint developed over hours to days, with or without fever, a presentation that must be evaluated for septic arthritis.","frag":"acute monoarticular ± fever"}]},{"id":"j-hx-risk","dx":"septic-arthritis","q":"Risk factors — prosthetic joint, immunosuppression, injection drug use, recent joint procedure, or bacteremia?","answers":[{"label":"No septic risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No risk factors for joint infection were identified: no prosthetic joint, immunosuppression, injection drug use, recent joint procedure, or bacteremia.","frag":"no septic risk factors"},{"label":"Septic risk factors present","tone":"pos","sets":[],"ddx":[{"id":"septic-arthritis","keep":true}],"mdm":"Risk factors for septic arthritis (prosthetic joint, immunosuppression, injection drug use, recent procedure) were present, raising the pretest probability.","frag":"septic risk factors"}]},{"id":"j-hx-dgi","dx":"dgi","q":"Sexually active with migratory joint pains, tenosynovitis, or pustular skin lesions?","answers":[{"label":"No DGI features","tone":"neg","sets":[],"ddx":[],"mdm":"No migratory arthralgias, tenosynovitis, or pustular lesions to suggest gonococcal infection were reported.","frag":"no DGI features"},{"label":"Migratory pain / tenosynovitis / pustules","tone":"pos","sets":[],"ddx":[{"id":"dgi","keep":true}],"mdm":"Migratory arthralgias, tenosynovitis, or pustular skin lesions were reported, raising concern for disseminated gonococcal infection.","frag":"migratory pain / tenosynovitis / pustules"}]},{"id":"j-hx-crystal","dx":"crystal","q":"Prior identical attacks of gout or pseudogout in the same joint?","answers":[{"label":"No prior crystal attacks","tone":"neg","sets":[],"ddx":[],"mdm":"No prior crystal attacks were reported.","frag":"no prior crystal attacks"},{"label":"Prior gout / pseudogout","tone":"pos","sets":[],"ddx":[{"id":"crystal","keep":true}],"mdm":"Prior identical crystal attacks were reported; this supports gout or pseudogout but does not exclude a concurrent infection.","frag":"prior gout / pseudogout"}]}],"exam":[{"id":"j-exam-joint","dx":"septic-arthritis","q":"Joint examination — warmth, effusion, and pain on minimal passive (micro) motion?","answers":[{"label":"No effusion / tolerates motion","tone":"neg","sets":[],"ddx":[],"mdm":"There was no significant effusion and the joint tolerated passive motion.","frag":"no effusion / tolerates motion"},{"label":"Effusion + pain on micro-motion","tone":"pos","sets":[],"ddx":[{"id":"septic-arthritis","keep":true}],"mdm":"A warm effusion with pain on minimal passive (micro) motion was present, a finding concerning for septic arthritis.","frag":"effusion + pain on micro-motion"}]},{"id":"j-exam-fever","dx":"septic-arthritis","q":"Fever or systemic toxicity on examination?","answers":[{"label":"Afebrile, non-toxic","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was afebrile and non-toxic-appearing.","frag":"afebrile, non-toxic"},{"label":"Febrile / toxic","tone":"pos","sets":[],"ddx":[{"id":"septic-arthritis","keep":true}],"mdm":"Fever or systemic toxicity was present, increasing concern for a septic joint or bacteremia.","frag":"febrile / toxic"}]},{"id":"j-exam-skin","dx":"nec-joint","q":"Overlying skin — crepitus, bullae, necrosis, or pain out of proportion?","answers":[{"label":"Overlying skin benign","tone":"neg","sets":[],"ddx":[],"mdm":"The overlying skin was benign without crepitus, bullae, or disproportionate pain.","frag":"overlying skin benign"},{"label":"Crepitus / bullae / pain out of proportion","tone":"pos","sets":[],"ddx":[{"id":"nec-joint","keep":true}],"mdm":"Crepitus, bullae, or pain out of proportion of the overlying skin was present, concerning for a necrotizing infection.","frag":"crepitus / bullae / pain out of proportion"}]}],"conclusions":["gout / crystal arthropathy","reactive arthralgia (septic joint excluded)"],"specs":["ortho","id"],"guide":"../learn/complaints/hot-joint.html"},{"id":"neck-pain","title":"Neck Pain","aliases":["neck pain","neck stiffness","cervical","carotid dissection","vertebral dissection","meningitis neck","torticollis","stiff neck","meningitis"],"opening":"The patient was evaluated for neck pain. Beyond musculoskeletal strain, the vascular, infectious, and compressive emergencies below were actively considered.","ddx":[{"id":"meningitis-n","group":"lifethreat","label":"Meningitis","default":true,"tags":["meningitis"],"ruleout":"Meningitis was considered; the patient was afebrile and alert without nuchal rigidity, photophobia, or rash, with normal mentation, recognizing that meningeal signs are insensitive, making it unlikely.","miss":4},{"id":"dissection-n","group":"lifethreat","label":"Cervical artery dissection","default":true,"tags":["dissection"],"ruleout":"Cervical artery dissection was considered, particularly with neck pain or recent trauma; there was no thunderclap or unusual headache, partial Horner syndrome, or focal posterior-circulation deficit, and pulses were symmetric, making it unlikely.","miss":4},{"id":"epidural-n","group":"lifethreat","label":"Spinal epidural abscess","default":false,"tags":["epidural"],"ruleout":"Spinal epidural abscess was considered; the patient was afebrile without focal midline spinal tenderness, neurologic deficit, or risk factors such as injection drug use, immunocompromise, or recent bacteremia or instrumentation, making it unlikely.","miss":4},{"id":"sah-n","group":"lifethreat","label":"Subarachnoid hemorrhage","default":false,"tags":["sah"],"ruleout":"Subarachnoid hemorrhage was considered; there was no thunderclap or worst-ever headache, no maximal-at-onset pain, syncope, vomiting, neck stiffness, or neurologic deficit, making it unlikely.","miss":4},{"id":"cord-compression-n","group":"lifethreat","label":"Cervical cord / myelopathy compression","default":false,"tags":["cord-compression-n"],"ruleout":"Acute cervical cord compression was considered; there was no bilateral limb weakness, sensory level, hyperreflexia, gait disturbance, or bowel or bladder dysfunction, and motor and sensory exam were intact, making it unlikely.","miss":4},{"id":"msk-n","group":"common","label":"Musculoskeletal strain","default":false,"tags":["msk"],"ruleout":"A musculoskeletal cause was considered as the likely explanation after the dangerous vascular, infectious, and compressive diagnoses above were addressed.","miss":2}],"risk":[{"id":"neuroexam-n","label":"Documented neuro exam","tags":["dissection","epidural"],"scale":"low","line":"A focused neurologic examination was performed and documented, with attention to focal and posterior-circulation findings.","short":"Neuro exam documented"},{"id":"cta-n","label":"Vascular imaging (CTA/MRA) if dissection suspected","tags":["dissection"],"scale":"low","line":"Vascular imaging (CTA or MRA) was pursued when arterial dissection was a consideration.","short":"CTA/MRA if indicated"},{"id":"inflammatory-n","label":"Inflammatory markers (if infection suspected)","tags":["epidural"],"scale":"low","line":"Inflammatory markers were obtained when a spinal infection was a consideration.","short":"ESR/CRP if indicated"}],"checks":[{"if":"dissection-n","needs":["neuroexam-n","cta-n"],"mode":"any","warn":"Cervical artery dissection is on the differential — a documented neuro exam and vascular imaging show the basis for the assessment."},{"if":"epidural-n","needs":["neuroexam-n"],"mode":"any","warn":"Spinal epidural abscess is on the differential — a documented neuro exam and infection screen show the basis."}],"history":[{"id":"n-hx-meningitis","dx":"meningitis-n","q":"Fever, headache, photophobia, or neck stiffness; immunocompromise?","answers":[{"label":"No fever / meningeal features","tone":"neg","sets":[],"ddx":[],"mdm":"No fever or meningeal features were reported.","frag":"no fever / meningeal features"},{"label":"Fever / meningeal features","tone":"pos","sets":[],"ddx":[{"id":"meningitis-n","keep":true}],"mdm":"Fever, headache, photophobia, or neck stiffness was reported, raising concern for meningitis.","frag":"fever / meningeal features"}]},{"id":"n-hx-dissection","dx":"dissection-n","q":"Recent neck trauma or manipulation, severe headache, or stroke-like symptoms (double vision, slurred speech, limb weakness, a drooping eyelid)?","answers":[{"label":"No dissection features","tone":"neg","sets":[],"ddx":[],"mdm":"No trauma, severe headache, or focal/posterior-circulation symptoms were reported.","frag":"no dissection features"},{"label":"Trauma / headache / focal symptoms","tone":"pos","sets":[],"ddx":[{"id":"dissection-n","keep":true}],"mdm":"Recent neck trauma or manipulation, a severe headache, or stroke-like symptoms were reported, raising concern for cervical artery dissection.","frag":"trauma / headache / focal symptoms"}]},{"id":"n-hx-epidural","dx":"epidural-n","q":"Fever with focal neck pain, injection drug use, immunocompromise, recent bacteremia, or a spinal procedure?","answers":[{"label":"No epidural-abscess risk","tone":"neg","sets":[],"ddx":[],"mdm":"No infection risk or fever with focal pain to suggest a spinal abscess was reported.","frag":"no epidural-abscess risk"},{"label":"Infection risk / fever + focal pain","tone":"pos","sets":[],"ddx":[{"id":"epidural-n","keep":true}],"mdm":"Fever with focal neck pain or risk factors for spinal infection were reported, raising concern for an epidural abscess.","frag":"infection risk / fever + focal pain"}]},{"id":"n-hx-sah","dx":"sah-n","q":"A sudden, severe (thunderclap) headache accompanying the neck pain?","answers":[{"label":"No thunderclap headache","tone":"neg","sets":[],"ddx":[],"mdm":"No sudden, severe headache was reported with the neck pain.","frag":"no thunderclap headache"},{"label":"Thunderclap headache","tone":"pos","sets":[],"ddx":[{"id":"sah-n","keep":true}],"mdm":"A sudden, severe headache accompanied the neck pain, prompting consideration of subarachnoid hemorrhage.","frag":"thunderclap headache"}]}],"exam":[{"id":"n-exam-meningismus","dx":"meningitis-n","q":"Meningismus — nuchal rigidity, Kernig or Brudzinski sign; fever on examination?","answers":[{"label":"No meningismus","tone":"neg","sets":[],"ddx":[],"mdm":"The neck was supple without Kernig or Brudzinski signs, noting these signs are insensitive (nuchal rigidity ~30%, Kernig/Brudzinski ~5%), so their absence was not used alone to exclude meningitis; mentation, the overall clinical picture, and the lumbar-puncture threshold carried the decision.","frag":"neck supple, no meningismus (insensitive signs, not relied on alone)"},{"label":"Meningismus / fever","tone":"pos","sets":[],"ddx":[{"id":"meningitis-n","keep":true}],"mdm":"Meningismus (nuchal rigidity, Kernig or Brudzinski sign) or fever was present, raising concern for a central nervous system infection.","frag":"meningismus / fever"}]},{"id":"n-exam-neuro","dx":"dissection-n","q":"Focal neurologic deficit, posterior-circulation signs, or Horner syndrome (ptosis, miosis)?","answers":[{"label":"Non-focal neuro exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal without Horner findings.","frag":"non-focal neuro exam"},{"label":"Focal deficit / Horner / posterior-circ signs","tone":"pos","sets":[],"ddx":[{"id":"dissection-n","keep":true}],"mdm":"A focal deficit, Horner syndrome, or posterior-circulation signs were present, concerning for cervical artery dissection.","frag":"focal deficit / Horner / posterior-circ signs"}]},{"id":"n-exam-tenderness","dx":"epidural-n","q":"Focal midline spinal tenderness to percussion, with fever?","answers":[{"label":"No focal spinal tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"There was no focal midline spinal tenderness.","frag":"no focal spinal tenderness"},{"label":"Focal spinal tenderness / fever","tone":"pos","sets":[],"ddx":[{"id":"epidural-n","keep":true}],"mdm":"Focal midline spinal tenderness, particularly with fever, was present, raising concern for a spinal infection.","frag":"focal spinal tenderness / fever"}]},{"answers":[{"ddx":[],"frag":"no myelopathic signs, motor and sensory intact","label":"No myelopathic signs","mdm":"There was no bilateral limb weakness, sensory level, hyperreflexia, gait disturbance, or bowel or bladder dysfunction, and motor and sensory exam were intact, making acute cervical cord compression unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"cord-compression-n","keep":true}],"frag":"bilateral weakness, sensory level, or hyperreflexia","label":"Myelopathic signs present","mdm":"Bilateral limb weakness, a sensory level, hyperreflexia, gait disturbance, or bowel or bladder dysfunction was present, raising concern for acute cervical cord compression and warranting urgent MRI.","sets":[],"tone":"pos"}],"dx":"cord-compression-n","id":"n-exam-cord-compression-n","q":"Cervical myelopathy — bilateral limb weakness, a sensory level, hyperreflexia, gait disturbance, or bowel or bladder dysfunction?"}],"conclusions":["musculoskeletal neck pain","cervical strain"],"specs":["nsgy"],"guide":"../learn/complaints/neck-pain.html"},{"id":"hemoptysis","title":"Hemoptysis","aliases":["hemoptysis","coughing blood","bloody sputum","massive hemoptysis","pulmonary hemorrhage","blood in sputum","bloody cough"],"opening":"The patient was evaluated for hemoptysis. The volume and airway were assessed first, and the life-threatening causes below were actively considered.","ddx":[{"id":"massive","group":"lifethreat","label":"Massive / airway-threatening hemorrhage","default":true,"tags":["massive"],"ruleout":"Massive or airway-threatening hemorrhage was considered first; the volume expectorated was small, the airway was patent and self-protected, oxygenation was maintained, and the patient was hemodynamically stable, making it unlikely.","miss":3},{"id":"pe-h","group":"lifethreat","label":"Pulmonary embolism","default":true,"tags":["pe"],"ruleout":"Pulmonary embolism was considered; there was no pleuritic chest pain, dyspnea, tachycardia, hypoxia, or unilateral leg swelling, the PERC and Wells criteria were not met, and there were no thrombotic risk factors, making it unlikely.","miss":4},{"id":"malignancy-h","group":"lifethreat","label":"Malignancy","default":false,"tags":["malignancy"],"ruleout":"Pulmonary malignancy was considered; there was no significant smoking history, unintentional weight loss, constitutional symptoms, or prior abnormal chest imaging, and the bleeding was attributable to a benign cause, making it unlikely.","miss":3},{"id":"tb-h","group":"common","label":"Tuberculosis / infection","default":false,"tags":["tb"],"ruleout":"Tuberculosis and other pulmonary infections were considered based on risk factors and exposure, with appropriate isolation and testing when suspected.","miss":2},{"id":"dah","group":"common","label":"Diffuse alveolar hemorrhage / vasculitis","default":false,"tags":["dah"],"ruleout":"Diffuse alveolar hemorrhage or a vasculitis was considered when there were systemic features or renal involvement, and evaluated as indicated.","miss":2}],"risk":[{"id":"airway-h","label":"Airway & oxygenation documented","tags":["massive"],"scale":"low","line":"The airway, oxygenation, and estimated volume of bleeding were assessed and documented.","short":"Airway/oxygenation documented"},{"id":"imaging-h","label":"Chest imaging","tags":["malignancy","tb"],"scale":"low","line":"Chest imaging was obtained to evaluate for a source of bleeding, a mass, or infection.","short":"Chest imaging"},{"id":"pe-assess-h","label":"PE pretest assessment","tags":["pe"],"scale":"low","line":"Pretest probability for pulmonary embolism was assessed and documented, with further testing as indicated.","short":"PE assessment"}],"checks":[{"if":"massive","needs":["airway-h"],"mode":"any","warn":"Massive hemoptysis is on the differential — documented airway, oxygenation, and volume show the basis for the assessment."},{"if":"pe-h","needs":["pe-assess-h"],"mode":"any","warn":"PE can present with hemoptysis — document the pretest-probability assessment."},{"if":"malignancy-h","needs":["imaging-h"],"mode":"any","warn":"Malignancy is a leading cause of hemoptysis — document chest imaging and the follow-up/CT plan, especially in smokers."}],"history":[{"id":"h-hx-volume","dx":"massive","q":"Volume of blood — small streaks, or large-volume bleeding, recurrent large clots, or breathing difficulty?","answers":[{"label":"Small-volume / streaks","tone":"neg","sets":[],"ddx":[],"mdm":"The bleeding was small-volume or blood-streaked sputum, without large-volume bleeding, recurrent large clots, or associated breathing difficulty.","frag":"small-volume / streaks"},{"label":"Large-volume / recurrent / dyspnea","tone":"pos","sets":[],"ddx":[{"id":"massive","keep":true}],"mdm":"Large-volume or recurrent bleeding, or accompanying breathing difficulty, was reported, concerning for an airway-threatening hemorrhage.","frag":"large-volume / recurrent / dyspnea"}]},{"id":"h-hx-pe","dx":"pe-h","q":"VTE risk — recent immobilization or surgery, prior DVT/PE, active malignancy, estrogen, or pleuritic chest pain?","answers":[{"label":"No PE risk features","tone":"neg","sets":[],"ddx":[],"mdm":"No VTE risk features (recent immobilization or surgery, prior DVT/PE, active malignancy, estrogen use, or pleuritic chest pain) were reported.","frag":"no PE risk features"},{"label":"PE risk features","tone":"pos","sets":[],"ddx":[{"id":"pe-h","keep":true}],"mdm":"VTE risk features (recent immobilization or surgery, prior DVT/PE, active malignancy, estrogen use, or pleuritic chest pain) were reported, prompting consideration of pulmonary embolism.","frag":"PE risk features"}]},{"id":"h-hx-malignancy","dx":"malignancy-h","q":"Significant smoking history, unintentional weight loss, or a known or suspected malignancy?","answers":[{"label":"No malignancy risk","tone":"neg","sets":[],"ddx":[],"mdm":"No smoking history, weight loss, or known malignancy was reported.","frag":"no malignancy risk"},{"label":"Smoking / weight loss / known cancer","tone":"pos","sets":[],"ddx":[{"id":"malignancy-h","keep":true}],"mdm":"A smoking history, weight loss, or known malignancy was reported, raising concern for a neoplastic source.","frag":"smoking / weight loss / known cancer"}]},{"id":"h-hx-tb","dx":"tb-h","q":"TB exposure or risk — endemic travel, known contact, incarceration, HIV, or night sweats and fevers?","answers":[{"label":"No TB risk / exposure","tone":"neg","sets":[],"ddx":[],"mdm":"No tuberculosis risk factors or exposures (endemic travel, known contact, incarceration, HIV, or night sweats and fevers) were reported.","frag":"no TB risk / exposure"},{"label":"TB risk / exposure","tone":"pos","sets":[],"ddx":[{"id":"tb-h","keep":true}],"mdm":"Tuberculosis risk factors or exposures (endemic travel, known contact, incarceration, HIV, or night sweats and fevers) were reported, prompting appropriate testing and isolation precautions.","frag":"TB risk / exposure"}]}],"exam":[{"id":"h-exam-airway","dx":"massive","q":"Airway and oxygenation — respiratory distress, hypoxia, or an inability to clear blood from the airway?","answers":[{"label":"Airway protected, oxygenation adequate","tone":"neg","sets":[],"ddx":[],"mdm":"The airway was protected and oxygenation was adequate, without respiratory distress, hypoxia, or an inability to clear blood from the airway.","frag":"airway protected, oxygenation adequate"},{"label":"Respiratory distress / hypoxia","tone":"pos","sets":[],"ddx":[{"id":"massive","keep":true}],"mdm":"Respiratory distress, hypoxia, or difficulty clearing blood was present, concerning for an airway-threatening hemorrhage.","frag":"respiratory distress / hypoxia"}]},{"id":"h-exam-vitals","dx":"massive","q":"Hemodynamics — tachycardia or hypotension suggesting significant blood loss?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable.","frag":"hemodynamically stable"},{"label":"Tachycardia / hypotension","tone":"pos","sets":[],"ddx":[{"id":"massive","keep":true}],"mdm":"Tachycardia or hypotension was present, concerning for significant or ongoing hemorrhage.","frag":"tachycardia / hypotension"}]}],"conclusions":["minor hemoptysis from URI / bronchitis (low-risk)"],"specs":["pulm"],"guide":"../learn/complaints/hemoptysis.html"},{"id":"late-pregnancy","title":"Late-Pregnancy Pain / Bleeding","aliases":["late pregnancy","third trimester","abruption","preeclampsia","hellp","uterine rupture","preterm labor","pregnant bleeding","contractions"],"opening":"The patient, in the second half of pregnancy, was evaluated for abdominal pain and/or vaginal bleeding. The obstetric emergencies below were actively considered alongside surgical causes, with early obstetric involvement.","ddx":[{"id":"abruption","group":"lifethreat","label":"Placental abruption","default":true,"tags":["abruption"],"ruleout":"Placental abruption was considered; there was no abdominal or back pain, no vaginal bleeding, the uterus was soft and non-tender without frequent contractions, and fetal monitoring was reassuring, making it unlikely.","miss":4,"sex":"f"},{"id":"preeclampsia","group":"lifethreat","label":"Preeclampsia / HELLP","default":true,"tags":["preeclampsia"],"ruleout":"Preeclampsia and HELLP were considered; blood pressure was below severe range without headache, visual changes, right-upper-quadrant pain, or edema, and there was no proteinuria or laboratory abnormality, making it unlikely.","miss":4,"sex":"f"},{"id":"uterine-rupture","group":"lifethreat","label":"Uterine rupture","default":false,"tags":["rupture"],"ruleout":"Uterine rupture was considered, particularly with prior cesarean or uterine surgery; there was no sudden severe or tearing abdominal pain, hemodynamic instability, loss of fetal station, or abnormal fetal tracing, making it unlikely.","miss":3,"sex":"f"},{"id":"preterm-labor","group":"common","label":"Preterm labor","default":false,"tags":["preterm"],"ruleout":"Preterm labor was considered based on contractions and cervical change, with obstetric involvement for management.","miss":2},{"id":"appendicitis-ob","group":"common","label":"Appendicitis / surgical cause","default":false,"tags":["surgical"],"ruleout":"Appendicitis and other surgical causes were considered, recognizing that the presentation can be atypical in pregnancy, and evaluated with examination and imaging as appropriate.","miss":2}],"risk":[{"id":"bp-ob","label":"Blood pressure & preeclampsia labs","tags":["preeclampsia"],"scale":"low","line":"Blood pressure was measured and preeclampsia labs (including platelets, liver enzymes, and protein) were obtained when indicated.","short":"BP & preeclampsia labs"},{"id":"fetal-mon","label":"Fetal monitoring","tags":["abruption","rupture"],"scale":"low","line":"Fetal status and uterine activity were assessed with monitoring.","short":"Fetal monitoring"},{"id":"us-ob","label":"Obstetric ultrasound","tags":["abruption"],"scale":"low","line":"An obstetric ultrasound was obtained, and a digital or speculum examination was deferred until placenta previa was excluded.","short":"Obstetric ultrasound"}],"checks":[{"if":"abruption","needs":["fetal-mon","us-ob"],"mode":"any","warn":"Placental abruption is on the differential — fetal monitoring and ultrasound (with digital exam deferred until previa is excluded) document the basis."},{"if":"preeclampsia","needs":["bp-ob"],"mode":"any","warn":"Preeclampsia/HELLP is on the differential — a documented blood pressure and labs show the basis for the assessment."}],"history":[{"id":"ob-hx-bleeding","dx":"abruption","q":"Vaginal bleeding with abdominal or back pain — and is the pain constant with a hard, tender abdomen?","answers":[{"label":"No painful bleeding","tone":"neg","sets":[],"ddx":[],"mdm":"No painful vaginal bleeding was reported.","frag":"no painful bleeding"},{"label":"Painful bleeding / constant pain","tone":"pos","sets":[],"ddx":[{"id":"abruption","keep":true}],"mdm":"Painful vaginal bleeding or constant abdominal pain was reported, concerning for placental abruption.","frag":"painful bleeding / constant pain"}]},{"id":"ob-hx-preeclampsia","dx":"preeclampsia","q":"Severe headache, visual changes, right-upper-quadrant pain, or known elevated blood pressure?","answers":[{"label":"No preeclampsia symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No headache, visual change, or right-upper-quadrant pain was reported.","frag":"no preeclampsia symptoms"},{"label":"Headache / visual change / RUQ pain","tone":"pos","sets":[],"ddx":[{"id":"preeclampsia","keep":true}],"mdm":"Headache, visual changes, or right-upper-quadrant pain was reported, concerning for preeclampsia or HELLP.","frag":"headache / visual change / RUQ pain"}]},{"id":"ob-hx-rupture","dx":"uterine-rupture","q":"Prior cesarean or uterine surgery, with sudden severe pain or a change in contraction pattern?","answers":[{"label":"No prior uterine surgery / sudden change","tone":"neg","sets":[],"ddx":[],"mdm":"No prior uterine surgery or sudden severe pain was reported.","frag":"no prior uterine surgery / sudden change"},{"label":"Prior uterine surgery + sudden severe pain","tone":"pos","sets":[],"ddx":[{"id":"uterine-rupture","keep":true}],"mdm":"A prior uterine surgery with sudden severe pain or a change in contractions was reported, raising concern for uterine rupture.","frag":"prior uterine surgery + sudden severe pain"}]},{"id":"ob-hx-preterm","dx":"preterm-labor","q":"Regular contractions, leaking fluid, or pelvic pressure before term?","answers":[{"label":"No contractions / leaking fluid","tone":"neg","sets":[],"ddx":[],"mdm":"No regular contractions or leaking fluid was reported.","frag":"no contractions / leaking fluid"},{"label":"Contractions / leaking fluid","tone":"pos","sets":[],"ddx":[{"id":"preterm-labor","keep":true}],"mdm":"Regular contractions or leaking fluid was reported, prompting evaluation for preterm labor with obstetric involvement.","frag":"contractions / leaking fluid"}]}],"exam":[{"id":"ob-exam-bp","dx":"preeclampsia","q":"Blood pressure — severe-range readings (≥ 160/110)?","answers":[{"label":"Blood pressure normal range","tone":"neg","sets":[],"ddx":[],"mdm":"Blood pressure was within an acceptable range.","frag":"BP normal range"},{"label":"Severe-range blood pressure","tone":"pos","sets":[],"ddx":[{"id":"preeclampsia","keep":true}],"mdm":"Severe-range blood pressure was measured, concerning for preeclampsia with severe features and prompting treatment.","frag":"severe-range blood pressure"}]},{"id":"ob-exam-uterus","dx":"abruption","q":"Abdominal/uterine examination — a rigid, tender uterus or signs of hemodynamic compromise?","answers":[{"label":"Uterus soft, hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The uterus was soft and non-tender, without rigidity or signs of hemodynamic compromise.","frag":"uterus soft, stable"},{"label":"Rigid tender uterus / instability","tone":"pos","sets":[],"ddx":[{"id":"abruption","keep":true},{"id":"uterine-rupture","keep":true}],"mdm":"A rigid, tender uterus or hemodynamic compromise was present, concerning for abruption or uterine rupture.","frag":"rigid tender uterus / instability"}]},{"id":"ob-exam-fetal","dx":"abruption","q":"Fetal status — reassuring fetal heart tones on monitoring?","answers":[{"label":"Reassuring fetal status","tone":"neg","sets":[],"ddx":[],"mdm":"Fetal heart tones were reassuring on monitoring.","frag":"reassuring fetal status"},{"label":"Non-reassuring fetal status","tone":"pos","sets":[],"ddx":[{"id":"abruption","keep":true}],"mdm":"Non-reassuring fetal status was present on monitoring, prompting emergent obstetric involvement.","frag":"non-reassuring fetal status"}]}],"conclusions":["normal third-trimester discomfort (reassuring)","Braxton-Hicks contractions"],"specs":["obgyn"],"guide":"../learn/complaints/late-pregnancy.html"},{"id":"pelvic-pain","title":"Pelvic Pain (Female)","aliases":["pelvic pain","ovarian torsion","tubo-ovarian abscess","pid","ovarian cyst","lower abdominal pain female","lower abdominal pain","ectopic","female pelvic pain"],"opening":"The patient was evaluated for pelvic pain, and a pregnancy test anchored the workup because it splits the differential in two. A positive test makes ectopic the diagnosis to exclude -- and a heterotopic pregnancy possible after assisted reproduction; a negative test turns attention to torsion, a hemorrhagic or ruptured cyst, and PID. The time-critical traps are torsion, where normal Doppler flow does not exclude it, and a tubo-ovarian abscess; the quiet cost is an undertreated PID.","ddx":[{"id":"ectopic-pel","group":"lifethreat","label":"Ectopic pregnancy","default":true,"tags":["ectopic"],"ruleout":"Ectopic pregnancy was considered; the pregnancy test was negative, excluding it, or where positive, ultrasound confirmed an intrauterine pregnancy without free fluid or adnexal mass and the patient was hemodynamically stable, making it unlikely.","miss":4,"sex":"f"},{"id":"torsion-ov","group":"lifethreat","label":"Ovarian torsion","default":true,"tags":["torsion"],"ruleout":"Ovarian torsion was considered; there was no sudden-onset severe unilateral pain, nausea or vomiting, or palpable adnexal mass, and ultrasound showed a normal ovary with preserved Doppler flow, recognizing normal flow does not fully exclude it.","miss":4,"sex":"f"},{"id":"toa","group":"lifethreat","label":"Tubo-ovarian abscess / PID","default":false,"tags":["toa"],"ruleout":"Tubo-ovarian abscess and pelvic inflammatory disease were considered; the patient was afebrile without cervical motion, uterine, or adnexal tenderness, no adnexal mass or purulent discharge, making it unlikely.","miss":3,"sex":"f"},{"id":"ruptured-cyst","group":"common","label":"Ruptured ovarian cyst (hemoperitoneum)","default":false,"tags":["cyst"],"ruleout":"A ruptured ovarian cyst with hemoperitoneum was considered; the patient was hemodynamically stable without significant free fluid to suggest substantial bleeding.","miss":2,"sex":"f"},{"id":"appendicitis-pel","group":"common","label":"Appendicitis","default":false,"tags":["appy"],"ruleout":"Appendicitis was considered as a non-gynecologic cause and evaluated with examination, laboratory studies, and imaging as appropriate.","miss":2},{"id":"preg-loss","group":"common","label":"Pregnancy loss / threatened or septic abortion","default":false,"tags":["preg-loss"],"ruleout":"With a positive pregnancy test and bleeding, threatened, incomplete, or septic abortion was considered alongside ectopic, and a heterotopic pregnancy was kept in mind after assisted reproduction.","miss":2,"sex":"f"},{"id":"uro-pel","group":"other","label":"Urinary cause (UTI / pyelonephritis / stone)","default":false,"tags":["uro-pel"],"ruleout":"A urinary source -- cystitis, pyelonephritis, or a ureteral stone -- was considered with urinalysis and imaging where urinary symptoms or flank pain predominated.","miss":1}],"risk":[{"id":"preg-pel","label":"Pregnancy test","tags":["ectopic"],"scale":"low","line":"A pregnancy test was obtained as the first step in evaluating pelvic pain in a patient of reproductive potential.","short":"Pregnancy test obtained"},{"id":"us-pel","label":"Pelvic ultrasound with Doppler","tags":["torsion","ectopic"],"scale":"low","line":"A pelvic ultrasound with Doppler was obtained to evaluate for an adnexal mass, torsion, free fluid, and the location of pregnancy.","short":"Pelvic ultrasound"},{"id":"gyn-pel","label":"Gynecology involvement","tags":["torsion"],"scale":"low","line":"Gynecology was involved without delay when torsion or another surgical emergency was suspected.","short":"Gynecology involved"},{"id":"sti-empiric","label":"STI testing + empiric PID treatment","tags":["toa"],"scale":"low","line":"When pelvic inflammatory disease was a consideration, the threshold to test for sexually transmitted infections and begin empiric CDC-regimen treatment was kept deliberately low, given the fertility cost of undertreatment.","short":"STI testing; empiric PID treatment if indicated"},{"id":"rh-status","label":"Rh status / RhoGAM if bleeding","tags":["ectopic"],"scale":"low","line":"In a pregnant patient with bleeding, the Rh status was checked and anti-D immunoglobulin given to Rh-negative patients.","short":"Rh status checked; RhoGAM if Rh-negative"}],"checks":[{"if":"ectopic-pel","needs":["preg-pel","us-pel"],"mode":"any","warn":"Ectopic pregnancy is on the differential — a pregnancy test and pelvic ultrasound document the basis for the assessment."},{"if":"torsion-ov","needs":["us-pel","gyn-pel"],"mode":"any","warn":"Ovarian torsion is on the differential — Doppler ultrasound and gynecology involvement document the basis, recognizing normal flow does not exclude it."},{"if":"toa","needs":["sti-empiric"],"mode":"any","warn":"PID is the diagnosis you treat on suspicion -- with cervical motion or adnexal tenderness, test for STIs and treat empirically; the cost of a missed PID is infertility."},{"if":"preg-loss","needs":["rh-status"],"mode":"any","warn":"Any bleeding in pregnancy needs an Rh type -- give anti-D immunoglobulin to Rh-negative patients."}],"history":[{"id":"pel-hx-hcg-result","dx":"ectopic-pel","q":"Pregnancy status — reproductive potential and the test result (negative effectively excludes ectopic; positive is ectopic until located)?","answers":[{"label":"hCG negative","tone":"neg","sets":[{"risk":"preg-pel"}],"ddx":[],"mdm":"The pregnancy test was negative, effectively excluding ectopic pregnancy.","frag":"pregnancy test negative (ectopic effectively excluded)"},{"label":"hCG positive","tone":"pos","sets":[{"risk":"preg-pel"}],"ddx":[{"id":"ectopic-pel","keep":true}],"mdm":"The pregnancy test was positive; pelvic pain with a positive test is an ectopic pregnancy until the location is established by quantitative hCG and pelvic ultrasound."}]},{"id":"pel-hx-torsion","dx":"torsion-ov","q":"Sudden, severe, unilateral pain with nausea and vomiting, or a known ovarian cyst or mass?","answers":[{"label":"No sudden severe unilateral pain","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was not sudden, severe, and unilateral with vomiting.","frag":"no sudden severe unilateral pain"},{"label":"Sudden severe unilateral pain ± vomiting","tone":"pos","sets":[],"ddx":[{"id":"torsion-ov","keep":true}],"mdm":"Sudden, severe, unilateral pain with vomiting, or a known ovarian mass, was reported, concerning for ovarian torsion.","frag":"sudden severe unilateral pain ± vomiting"}]},{"id":"pel-hx-pid","dx":"toa","q":"Fever, vaginal discharge, or risk factors for pelvic inflammatory disease (new or multiple partners, IUD, prior PID)?","answers":[{"label":"No PID features","tone":"neg","sets":[],"ddx":[],"mdm":"No fever, discharge, or PID risk factors were reported.","frag":"no PID features"},{"label":"Fever / discharge / PID risk","tone":"pos","sets":[],"ddx":[{"id":"toa","keep":true}],"mdm":"Fever, vaginal discharge, or PID risk factors were reported, raising concern for pelvic inflammatory disease or a tubo-ovarian abscess.","frag":"fever / discharge / PID risk"}]},{"id":"pel-hx-ectopic-rf","dx":"ectopic-pel","q":"Ectopic risk factors -- prior ectopic, tubal surgery, IUD in place, or assisted reproduction?","answers":[{"label":"No ectopic risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"There are no specific ectopic risk factors.","frag":"no ectopic risk factors"},{"label":"Ectopic risk factor present","tone":"pos","sets":[],"ddx":[{"id":"ectopic-pel","keep":true}],"mdm":"Prior ectopic, tubal surgery, an IUD, or assisted reproduction raises ectopic risk, and assisted reproduction raises the heterotopic possibility even with an intrauterine pregnancy.","frag":"ectopic risk factor present"}]},{"id":"pel-hx-bleeding","dx":"preg-loss","q":"Vaginal bleeding -- and if pregnant, how heavy, with any tissue passage?","answers":[{"label":"No vaginal bleeding","tone":"neg","sets":[],"ddx":[],"mdm":"There is no vaginal bleeding.","frag":"no vaginal bleeding"},{"label":"Vaginal bleeding","tone":"pos","sets":[{"risk":"rh-status"}],"ddx":[{"id":"preg-loss","keep":true},{"id":"ectopic-pel","keep":true}],"mdm":"Vaginal bleeding with a positive pregnancy test raises threatened or incomplete abortion and ectopic, and the Rh status was addressed.","frag":"vaginal bleeding"}]},{"id":"pel-hx-urinary","dx":"uro-pel","q":"Urinary symptoms -- dysuria, frequency, or flank pain?","answers":[{"label":"No urinary symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There are no urinary symptoms.","frag":"no urinary symptoms"},{"label":"Urinary symptoms / flank pain","tone":"pos","sets":[],"ddx":[{"id":"uro-pel","keep":true}],"mdm":"Dysuria, frequency, or flank pain raises a urinary source such as cystitis, pyelonephritis, or a stone.","frag":"urinary symptoms / flank pain"}]}],"exam":[{"id":"pel-exam-vitals","dx":"ruptured-cyst","q":"Vital signs — tachycardia, hypotension, or orthostatic change suggesting hemoperitoneum?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable, without tachycardia, hypotension, or orthostatic change to suggest hemoperitoneum.","frag":"hemodynamically stable"},{"label":"Tachycardia / hypotension / orthostasis","tone":"pos","sets":[],"ddx":[{"id":"ruptured-cyst","keep":true},{"id":"ectopic-pel","keep":true}],"mdm":"Tachycardia, hypotension, or orthostatic change was present, concerning for hemoperitoneum from a ruptured cyst or ectopic.","frag":"tachycardia / hypotension / orthostasis"}]},{"id":"pel-exam-pelvic","dx":"toa","q":"Pelvic examination — cervical motion or adnexal tenderness, an adnexal mass, or fever?","answers":[{"label":"No CMT / adnexal findings","tone":"neg","sets":[],"ddx":[],"mdm":"There was no cervical motion or adnexal tenderness and no mass.","frag":"no CMT / adnexal findings"},{"label":"CMT / adnexal tenderness or mass","tone":"pos","sets":[],"ddx":[{"id":"toa","keep":true},{"id":"torsion-ov","keep":true}],"mdm":"Cervical motion or adnexal tenderness or an adnexal mass was found, supporting a gynecologic process such as PID/TOA or torsion.","frag":"CMT / adnexal tenderness or mass"}]},{"id":"pel-exam-peritoneal","dx":"appendicitis-pel","q":"Abdominal examination — focal right-lower-quadrant or peritoneal signs?","answers":[{"label":"No focal / peritoneal signs","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen was without focal or peritoneal signs.","frag":"no focal / peritoneal signs"},{"label":"RLQ / peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"appendicitis-pel","keep":true}],"mdm":"Focal right-lower-quadrant or peritoneal signs were present, prompting evaluation for appendicitis.","frag":"RLQ / peritoneal signs"}]},{"id":"pel-exam-speculum","dx":"toa","q":"Speculum -- mucopurulent discharge, products of conception at the os, or active bleeding?","answers":[{"label":"No discharge or products","tone":"neg","sets":[],"ddx":[],"mdm":"The speculum exam shows no mucopurulent discharge or products of conception.","frag":"speculum without discharge or products"},{"label":"Discharge / products / bleeding","tone":"pos","sets":[{"risk":"sti-empiric"}],"ddx":[{"id":"toa","keep":true},{"id":"preg-loss","keep":true}],"mdm":"Mucopurulent discharge supports PID, while products of conception at the os or active bleeding support an abortion in progress.","frag":"discharge / products at os / bleeding"}]}],"conclusions":["dysmenorrhea","uncomplicated ovarian cyst","nonspecific pelvic pain","pelvic inflammatory disease -- empirically treated, STI testing sent","threatened abortion -- Rh status addressed, gynecology follow-up"],"specs":["obgyn"],"guide":"../learn/complaints/pelvic-pain.html"},{"id":"alcohol","title":"Alcohol Intoxication / Withdrawal","aliases":["alcohol","intoxication","drunk","etoh","withdrawal","dts","delirium tremens","ciwa","found down","sobriety","intoxicated","ethanol","inebriated","alcohol withdrawal"],"opening":"The patient was evaluated for alcohol intoxication. Intoxication was treated as a diagnosis of exclusion: the dangerous mimics and complications below were actively considered, a point-of-care glucose was obtained, and the patient was observed with serial examinations to clinical sobriety.","ddx":[{"id":"head-injury-a","group":"lifethreat","label":"Occult head injury / intracranial hemorrhage","default":true,"tags":["head"],"ruleout":"Occult head injury or intracranial hemorrhage was considered; there was no external head trauma or scalp injury, no anticoagulation, a non-focal neurologic exam improving as expected, and no indication for CT, making it unlikely.","miss":4},{"id":"hypoglycemia-a","group":"lifethreat","label":"Hypoglycemia","default":true,"tags":["glucose"],"ruleout":"Hypoglycemia was considered, as alcohol impairs gluconeogenesis; point-of-care glucose was within normal limits, definitively excluding it as a cause of the presentation.","miss":3},{"id":"coingestion","group":"lifethreat","label":"Co-ingestion / toxic alcohols","default":true,"tags":["tox"],"ruleout":"Co-ingestion including acetaminophen, salicylates, and toxic alcohols was considered; the history disclosed no additional ingestion, the anion and osmolal gaps were normal, and directed levels were unremarkable, making it unlikely.","miss":4},{"id":"withdrawal","group":"lifethreat","label":"Alcohol withdrawal / delirium tremens","default":true,"tags":["withdrawal"],"ruleout":"Alcohol withdrawal and delirium tremens were considered; the last drink was recent without prior withdrawal seizures or DTs, and there was no tremor, diaphoresis, tachycardia, agitation, or hallucination on monitoring, making it unlikely.","miss":3},{"id":"wernicke","group":"lifethreat","label":"Wernicke encephalopathy","default":true,"tags":["wernicke"],"ruleout":"Wernicke encephalopathy was considered in this patient with chronic alcohol use; there was no confusion, ophthalmoplegia or nystagmus, or gait ataxia, and thiamine was administered, making it unlikely.","miss":4},{"id":"other-ams-a","group":"lifethreat","label":"Other AMS cause (infection, hepatic, metabolic)","default":false,"tags":["mimic"],"ruleout":"An alternative cause of altered mentation, including CNS or systemic infection, hepatic encephalopathy, or metabolic derangement, was considered; the patient was afebrile, non-icteric, without asterixis or focal deficit, and improving consistent with intoxication, making it unlikely.","miss":3},{"id":"uncomplicated","group":"common","label":"Uncomplicated intoxication","default":false,"tags":["intox"],"ruleout":"After the dangerous mimics above were addressed, uncomplicated alcohol intoxication remained the working diagnosis, managed with observation to clinical sobriety.","miss":2}],"risk":[{"id":"glucose-a","label":"Point-of-care glucose","tags":["glucose"],"scale":"low","line":"A point-of-care glucose was obtained immediately and reviewed; hypoglycemia was excluded.","short":"POC glucose checked"},{"id":"serial-a","label":"Serial exams to clinical sobriety","tags":["head","intox"],"scale":"low","line":"The patient was observed with serial neurologic and mental-status examinations, with the expectation of steady improvement; failure to improve would have prompted imaging and broader workup.","short":"Serial exams documented"},{"id":"ciwa","label":"CIWA-Ar documented","tags":["withdrawal"],"scale":"low","line":"Withdrawal severity was scored (CIWA-Ar) and trended, with symptom-triggered benzodiazepine treatment as indicated.","short":"CIWA documented"},{"id":"thiamine","label":"Thiamine given","tags":["wernicke"],"scale":"low","line":"Thiamine was administered before or with glucose in this patient with chronic alcohol use.","short":"Thiamine given"},{"id":"ct-head-a","label":"CT head (when indicated)","tags":["head"],"scale":"low","line":"CT of the head was obtained for trauma signs, anticoagulation, a focal deficit, or failure to improve as expected.","short":"CT head if indicated"},{"id":"tox-labs-a","label":"Tox labs / osmolal gap (when indicated)","tags":["tox"],"scale":"low","line":"Directed toxicology (acetaminophen, salicylate, and an anion/osmolal gap for toxic alcohols) was obtained when co-ingestion was a consideration.","short":"Tox labs / osm gap"}],"checks":[{"if":"hypoglycemia-a","needs":["glucose-a"],"mode":"any","warn":"Hypoglycemia is on the differential — a point-of-care glucose documents the exclusion."},{"if":"head-injury-a","needs":["serial-a","ct-head-a"],"mode":"any","warn":"Occult head injury is on the differential — serial exams to clinical sobriety and/or a CT head document the basis for excluding it."},{"if":"withdrawal","needs":["ciwa"],"mode":"any","warn":"Withdrawal is on the differential — a documented CIWA score and treatment response show the basis for the assessment."},{"if":"wernicke","needs":["thiamine"],"mode":"any","warn":"Wernicke is on the differential — documenting thiamine (before/with glucose) shows the prophylaxis was given."},{"if":"coingestion","needs":["tox-labs-a"],"mode":"any","warn":"Co-ingestion is on the differential — directed tox labs / an osmolal gap document the workup."}],"history":[{"id":"a-hx-trauma","dx":"head-injury-a","q":"Any fall, assault, or possible head trauma — witnessed or unwitnessed (including 'found down')? Anticoagulation or antiplatelet use?","answers":[{"label":"No trauma, not anticoagulated","tone":"neg","sets":[],"ddx":[],"mdm":"No fall, assault, or head trauma (witnessed or unwitnessed, including 'found down') was reported or suspected, and the patient is not on anticoagulation or an antiplatelet agent.","frag":"no trauma, not anticoagulated"},{"label":"Possible head trauma / found down / anticoagulated","tone":"pos","sets":[],"ddx":[{"id":"head-injury-a","keep":true}],"mdm":"Possible head trauma (including an unwitnessed fall or being found down) or anticoagulant use was present, lowering the threshold for CT and close serial examination.","frag":"possible head trauma / found down / anticoagulated"}]},{"id":"a-hx-lastdrink","dx":"withdrawal","q":"Timing of the last drink — and any prior withdrawal seizures or delirium tremens?","answers":[{"label":"Drinking recently, no withdrawal history","tone":"neg","sets":[],"ddx":[],"mdm":"The last drink was recent and there is no history of withdrawal seizures or delirium tremens.","frag":"recent drink, no withdrawal history"},{"label":"Last drink > 6–12 h ago or prior withdrawal seizures / DTs","tone":"pos","sets":[],"ddx":[{"id":"withdrawal","keep":true}],"mdm":"The last drink was many hours ago or there is a history of withdrawal seizures or delirium tremens, placing the patient at risk for significant withdrawal during the visit.","frag":"last drink hours ago / prior DTs or seizures"}]},{"id":"a-hx-coingestion","dx":"coingestion","q":"Any possibility of co-ingestion — acetaminophen, other medications, or non-beverage alcohol (methanol, ethylene glycol, isopropanol)?","answers":[{"label":"Beverage alcohol only","tone":"neg","sets":[],"ddx":[],"mdm":"Only beverage alcohol was reported, with no suggestion of acetaminophen, other medication, or non-beverage alcohol (methanol, ethylene glycol, isopropanol) co-ingestion.","frag":"beverage alcohol only"},{"label":"Possible co-ingestion / non-beverage alcohol","tone":"pos","sets":[],"ddx":[{"id":"coingestion","keep":true}],"mdm":"A co-ingestion (acetaminophen, other medication, or non-beverage alcohol (methanol, ethylene glycol, isopropanol)) was possible, prompting directed toxicology and an anion/osmolal gap.","frag":"possible co-ingestion / toxic alcohol"}]},{"id":"a-hx-diabetes","dx":"hypoglycemia-a","q":"Diabetes on insulin or a sulfonylurea, or prolonged poor intake?","answers":[{"label":"No hypoglycemia risk","tone":"neg","sets":[],"ddx":[],"mdm":"No diabetes medications or prolonged fasting raising hypoglycemia risk were reported.","frag":"no hypoglycemia risk"},{"label":"Insulin / sulfonylurea / poor intake","tone":"pos","sets":[],"ddx":[{"id":"hypoglycemia-a","keep":true}],"mdm":"Diabetes medication use or prolonged poor intake was present, making hypoglycemia an important contributor to exclude and recheck.","frag":"insulin / sulfonylurea / poor intake"}]},{"id":"a-hx-chronic","dx":"wernicke","q":"Chronic heavy daily drinking with poor nutrition (Wernicke risk), or prior alcohol-related hospitalizations?","answers":[{"label":"Episodic use, nourished","tone":"neg","sets":[],"ddx":[],"mdm":"Alcohol use is episodic and nutrition is adequate, lowering Wernicke risk.","frag":"episodic use, nourished"},{"label":"Chronic heavy use / malnourished","tone":"pos","sets":[],"ddx":[{"id":"wernicke","keep":true},{"id":"withdrawal","keep":true}],"mdm":"Chronic heavy use with poor nutrition was reported, raising the risk of Wernicke encephalopathy (thiamine indicated) and significant withdrawal.","frag":"chronic heavy use / malnourished"}]},{"id":"a-hx-baseline","dx":"other-ams-a","q":"Is this presentation typical of the patient's prior intoxications, per the patient, family, or records — or different (more confused, agitated, or somnolent than usual)?","answers":[{"label":"Typical of prior episodes","tone":"neg","sets":[],"ddx":[],"mdm":"The presentation is consistent with the patient's prior intoxication episodes, without being more confused, agitated, or somnolent than usual.","frag":"typical of prior episodes"},{"label":"Different from baseline intoxication","tone":"pos","sets":[],"ddx":[{"id":"other-ams-a","keep":true},{"id":"head-injury-a","keep":true}],"mdm":"The presentation differs from the patient's usual intoxication (more confused, agitated, or somnolent than usual), which argues against attributing it to alcohol alone and broadens the differential.","frag":"different from usual intoxication"}]}],"exam":[{"id":"a-exam-glucose","dx":"hypoglycemia-a","q":"Point-of-care glucose obtained immediately and within normal limits?","answers":[{"label":"Glucose normal","tone":"neg","sets":[],"ddx":[],"mdm":"An immediate point-of-care glucose was within normal limits.","frag":"POC glucose normal"},{"label":"Hypoglycemia","tone":"pos","sets":[],"ddx":[{"id":"hypoglycemia-a","keep":true}],"mdm":"The point-of-care glucose was low; hypoglycemia was identified and corrected (with thiamine in the chronic user).","frag":"hypoglycemia on POC glucose"}]},{"id":"a-exam-head","dx":"head-injury-a","q":"Head-to-toe trauma survey — scalp hematoma or laceration, hemotympanum, raccoon eyes, Battle sign, or facial trauma?","answers":[{"label":"No trauma signs","tone":"neg","sets":[],"ddx":[],"mdm":"A trauma survey found no scalp, skull-base, or facial signs of head injury.","frag":"no trauma signs"},{"label":"Signs of head trauma","tone":"pos","sets":[],"ddx":[{"id":"head-injury-a","keep":true}],"mdm":"Signs of head trauma were present (scalp hematoma or laceration, hemotympanum, raccoon eyes, Battle sign, or facial trauma), prompting CT and serial neurologic examination.","frag":"signs of head trauma"}]},{"id":"a-exam-focal","dx":"head-injury-a","q":"Focal neurologic deficit — pupil asymmetry, lateralizing weakness, or new focal findings at any point?","answers":[{"label":"Non-focal exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal, with symmetric pupils, no lateralizing weakness, and no new focal findings.","frag":"non-focal exam"},{"label":"Focal deficit / pupil asymmetry","tone":"pos","sets":[],"ddx":[{"id":"head-injury-a","keep":true},{"id":"other-ams-a","keep":true}],"mdm":"A focal deficit (pupil asymmetry, lateralizing weakness, or new focal findings) was present and not attributable to intoxication, prompting immediate imaging.","frag":"focal deficit / pupil asymmetry"}]},{"id":"a-exam-course","dx":"other-ams-a","q":"Serial mental status — steadily improving toward baseline over observation, or static / worsening?","answers":[{"label":"Improving toward baseline","tone":"neg","sets":[],"ddx":[],"mdm":"Mental status improved steadily toward baseline over observation, consistent with simple intoxication.","frag":"improving toward baseline"},{"label":"Static or worsening mentation","tone":"pos","sets":[],"ddx":[{"id":"other-ams-a","keep":true},{"id":"head-injury-a","keep":true}],"mdm":"Mental status failed to improve or worsened during observation (incompatible with simple intoxication), prompting imaging and a broader workup.","frag":"static or worsening mentation"}]},{"id":"a-exam-withdrawal","dx":"withdrawal","q":"Withdrawal signs — tremor, diaphoresis, tachycardia, hypertension, agitation, or hallucinations (trend the CIWA)?","answers":[{"label":"No withdrawal signs","tone":"neg","sets":[],"ddx":[],"mdm":"No tremor, autonomic hyperactivity, or agitation to suggest withdrawal was present.","frag":"no withdrawal signs"},{"label":"Tremor / autonomic signs / agitation","tone":"pos","sets":[],"ddx":[{"id":"withdrawal","keep":true}],"mdm":"Withdrawal signs were present (tremor, autonomic hyperactivity, or agitation), scored with the CIWA and treated with benzodiazepines as indicated.","frag":"tremor / autonomic signs / agitation"}]},{"id":"a-exam-wernicke","dx":"wernicke","q":"Wernicke screen — confusion out of proportion, ataxia, or ophthalmoplegia/nystagmus?","answers":[{"label":"No Wernicke triad features","tone":"neg","sets":[],"ddx":[],"mdm":"No confusion out of proportion, ataxia, or ophthalmoplegia was found.","frag":"no Wernicke features"},{"label":"Confusion / ataxia / ophthalmoplegia","tone":"pos","sets":[],"ddx":[{"id":"wernicke","keep":true}],"mdm":"Features of Wernicke encephalopathy (confusion out of proportion, ataxia, or ophthalmoplegia/nystagmus) were present, prompting immediate high-dose thiamine.","frag":"confusion / ataxia / ophthalmoplegia"}]}],"conclusions":["acute alcohol intoxication, clinically sober on reassessment","uncomplicated intoxication"],"specs":["tox"]},{"id":"gastroenteritis","title":"Vomiting / Diarrhea (Adult)","aliases":["gastroenteritis","ge","vomiting","throwing up","diarrhea","nausea","stomach bug","food poisoning","viral gi","n/v","nausea vomiting","travelers diarrhea","traveller's diarrhea","bloody diarrhea","dysentery","c diff","c. difficile","loose stools","the runs","gastro"],"opening":"The patient was evaluated for vomiting and/or diarrhea. The dangerous causes that masquerade as gastroenteritis were actively considered before attributing symptoms to a self-limited process — on the vomiting side the surgical, cardiac, metabolic, and CNS mimics, and on the diarrhea side the inflammatory and Shiga-toxin pictures, antibiotic-associated colitis, and travel- or food-related exposures that change management.","ddx":[{"id":"acs-epigastric","group":"lifethreat","label":"Acute coronary syndrome (atypical / epigastric)","default":true,"tags":["acs-epigastric"],"ruleout":"Atypical acute coronary syndrome was considered, especially in older or diabetic patients; there was no chest pressure, dyspnea, diaphoresis, or radiating pain, and the ECG showed no ischemic changes, making it unlikely.","miss":4},{"id":"dka","group":"lifethreat","label":"DKA / metabolic emergency","default":true,"tags":["dka"],"ruleout":"DKA and metabolic emergencies were considered; the patient was not polyuric or dehydrated beyond expected, glucose was normal without ketonuria, and the anion gap was not elevated, making it unlikely.","miss":3},{"id":"cns-ge","group":"lifethreat","label":"CNS cause (raised ICP, posterior stroke)","default":true,"tags":["cns-ge"],"ruleout":"A central cause of vomiting from raised intracranial pressure or posterior-circulation stroke was considered; there was no headache, vertigo, diplopia, ataxia, or focal neurologic deficit, and vomiting fit the gastrointestinal picture, making it unlikely.","miss":4},{"id":"obstruction-ge","group":"lifethreat","label":"Bowel obstruction","default":true,"tags":["obstruction-ge"],"ruleout":"Bowel obstruction was considered; vomiting was non-bilious without abdominal distension, the patient was passing flatus and stool without obstipation, and there was no hernia or prior abdominal surgery, making it unlikely.","miss":3},{"id":"surgical-abdomen","group":"lifethreat","label":"Surgical abdomen (appendicitis, ischemia)","default":true,"tags":["surgical-abdomen"],"ruleout":"A surgical abdomen including appendicitis or mesenteric ischemia was considered; the abdomen was soft and non-focal without localizing, migratory, or out-of-proportion pain, peritoneal signs, or pain preceding vomiting, making it unlikely.","miss":3},{"id":"invasive-diarrhea","group":"lifethreat","label":"Inflammatory / Shiga-toxin / C. difficile diarrhea","default":true,"tags":["invasive-diarrhea"],"ruleout":"Inflammatory diarrhea was considered; the stools were watery without blood or mucus, the patient was afebrile and non-toxic, and there was no recent antibiotic exposure suggesting C. difficile, making it unlikely.","miss":3},{"id":"aaa-ge","group":"lifethreat","label":"Ruptured / symptomatic abdominal aortic aneurysm","default":false,"tags":["aaa-ge"],"ruleout":"A symptomatic or ruptured abdominal aortic aneurysm was considered in this at-risk patient; there was no abdominal, flank, or back pain, no pulsatile mass, and the patient was hemodynamically stable with symmetric pulses, making it unlikely.","miss":4},{"id":"travelers","group":"common","label":"Travelers' / parasitic diarrhea","default":false,"tags":["travelers"],"ruleout":"Travelers' and parasitic diarrhea were considered in light of recent travel or untreated-water exposure, which changes the likely pathogens and the testing and treatment plan.","miss":2},{"id":"dehydration-ge","group":"common","label":"Dehydration / electrolyte disturbance","default":false,"tags":["dehydration-ge"],"ruleout":"Volume status and electrolyte disturbance were assessed and addressed; tolerance of oral intake was confirmed before disposition.","miss":2},{"id":"viral-ge","group":"other","label":"Viral / foodborne gastroenteritis","default":false,"tags":["viral-ge"],"ruleout":"Self-limited viral or foodborne gastroenteritis was the working diagnosis once the dangerous mimics above were judged unlikely.","miss":1},{"id":"chs","group":"common","label":"Cannabinoid hyperemesis / medication-induced","default":false,"tags":["chs"],"ruleout":"Cannabinoid hyperemesis (cyclical vomiting in a heavy cannabis user, classically relieved by hot showers) and medication drivers (GLP-1 agonists, opioids) were considered.","miss":2}],"risk":[{"id":"ecg-ge","label":"ECG obtained (at-risk)","tags":["acs-epigastric"],"scale":"low","line":"An ECG was obtained and reviewed to address the possibility of an atypical cardiac cause in an at-risk patient.","short":"ECG obtained: no ischemia"},{"id":"stool-workup","label":"Inflammatory-diarrhea workup & STEC precautions","tags":["invasive-diarrhea","travelers"],"scale":"low","line":"Given the inflammatory pattern, stool studies were sent as indicated (including Shiga-toxin/STEC and C. difficile testing), and empiric antibiotics and antimotility agents were withheld pending results because they can worsen Shiga-toxin disease.","short":"stool studies sent; empiric antibiotics/antimotility withheld pending STEC"},{"id":"po-trial","label":"Oral hydration trial tolerated","tags":["dehydration-ge"],"scale":"low","line":"An oral hydration trial was tolerated in the department, supporting safe discharge with oral rehydration.","short":"oral hydration trial tolerated"}],"checks":[{"if":"acs-epigastric","needs":["ecg-ge"],"mode":"any","warn":"Atypical ACS is on the differential — an ECG documents that a cardiac cause was considered in an at-risk patient."},{"if":"invasive-diarrhea","needs":["stool-workup"],"mode":"any","warn":"Bloody or antibiotic-associated diarrhea is on the differential — document stool studies (Shiga-toxin/STEC, C. difficile) and that empiric antibiotics and antimotility agents were withheld pending results."}],"history":[{"id":"ge-hx-course","dx":"general","q":"Duration and trajectory — acute and improving, vs. prolonged (> 7 days), escalating, or relapsing?","answers":[{"label":"Acute, improving","tone":"neg","sets":[],"ddx":[],"mdm":"The course was acute and improving at evaluation rather than prolonged beyond 7 days, escalating, or relapsing, consistent with a self-limited process.","frag":"acute, self-limited, improving course"},{"label":"Prolonged / escalating / relapsing","tone":"pos","sets":[],"ddx":[{"id":"travelers","keep":true},{"id":"invasive-diarrhea","keep":true}],"mdm":"The course is prolonged, escalating, or relapsing: beyond the expected window for simple viral gastroenteritis.","frag":"prolonged, escalating, or relapsing course"}]},{"id":"ge-hx-cardiac","dx":"acs-epigastric","q":"Chest pressure, dyspnea, diaphoresis, or an exertional component — especially if older, diabetic, or with cardiac history?","answers":[{"label":"No chest, exertional, or cardiac features","tone":"neg","sets":[],"ddx":[],"mdm":"No chest pressure, dyspnea, diaphoresis, or exertional component was reported; an atypical coronary presentation was not suggested by history.","frag":"no chest, exertional, or cardiac features"},{"label":"Cardiac features in an at-risk patient","tone":"pos","sets":[{"risk":"ecg-ge"}],"ddx":[{"id":"acs-epigastric","keep":true}],"mdm":"Chest pressure, dyspnea, diaphoresis, or an exertional component was reported in an at-risk patient; an atypical coronary presentation was actively considered and an ECG was obtained.","frag":"cardiac features in an at-risk patient"}]},{"id":"ge-hx-dka","dx":"dka","q":"Known diabetes, polyuria or polydipsia, or missed insulin / poor oral intake?","answers":[{"label":"No diabetic or metabolic red flags","tone":"neg","sets":[],"ddx":[],"mdm":"There were no diabetic or metabolic red flags by history.","frag":"no diabetic or metabolic red flags"},{"label":"Diabetic or metabolic red flags","tone":"pos","sets":[],"ddx":[{"id":"dka","keep":true}],"mdm":"Diabetes with osmotic symptoms or a missed-insulin history was reported; a metabolic emergency was screened for rather than assumed away.","frag":"diabetic or metabolic red flags"}]},{"id":"ge-hx-cns","dx":"cns-ge","q":"Headache, neck stiffness, neurologic symptoms, vertigo, or vomiting out of keeping with the GI picture (e.g. without diarrhea)?","answers":[{"label":"No neurologic features","tone":"neg","sets":[],"ddx":[],"mdm":"There were no headache, neck stiffness, vertigo, or focal neurologic features, and the vomiting fit the GI picture.","frag":"no neurologic features"},{"label":"Neurologic features or isolated vomiting","tone":"pos","sets":[],"ddx":[{"id":"cns-ge","keep":true}],"mdm":"Headache, neurologic symptoms, vertigo, or vomiting out of keeping with the GI picture was present; a central cause was considered.","frag":"neurologic features or vomiting out of keeping with the GI picture"}]},{"id":"ge-hx-obstruction","dx":"obstruction-ge","q":"Bilious or feculent vomiting, abdominal distension, obstipation, or prior abdominal surgery / hernia?","answers":[{"label":"No obstructive features","tone":"neg","sets":[],"ddx":[],"mdm":"There was no bilious or feculent vomiting, distension, or obstipation, and no relevant surgical or hernia history.","frag":"no obstructive features"},{"label":"Obstructive features present","tone":"pos","sets":[],"ddx":[{"id":"obstruction-ge","keep":true}],"mdm":"Bilious/feculent vomiting, distension, obstipation, or a relevant surgical/hernia history raised bowel obstruction.","frag":"obstructive features present"}]},{"id":"ge-hx-surgical","dx":"surgical-abdomen","q":"Pain that localizes, precedes the vomiting, is severe or constant, or seems out of proportion to the exam?","answers":[{"label":"Pain mild, diffuse, and follows vomiting","tone":"neg","sets":[],"ddx":[],"mdm":"Pain was mild and diffuse and followed the vomiting: the benign pattern rather than the surgical one.","frag":"pain mild, diffuse, and following the vomiting"},{"label":"Localized, severe, or out-of-proportion pain","tone":"pos","sets":[],"ddx":[{"id":"surgical-abdomen","keep":true}],"mdm":"Pain localized, preceded the vomiting, or was out of proportion to the exam; a surgical abdomen including mesenteric ischemia was considered.","frag":"localized, severe, or out-of-proportion pain"}]},{"id":"ge-hx-blood","dx":"invasive-diarrhea","q":"Stool character — watery, vs. bloody or mucoid (dysentery)?","answers":[{"label":"Non-bloody, watery","tone":"neg","sets":[],"ddx":[],"mdm":"Stools were watery and non-bloody, against an invasive/inflammatory process.","frag":"non-bloody, watery stools"},{"label":"Bloody / mucoid","tone":"pos","sets":[{"risk":"stool-workup"}],"ddx":[{"id":"invasive-diarrhea","keep":true}],"mdm":"Bloody or mucoid diarrhea was reported; an invasive/inflammatory cause (Shiga-toxin E. coli with its HUS risk, Shigella, Campylobacter) was considered, with stool studies and empiric antibiotics/antimotility agents withheld pending results.","frag":"bloody or mucoid diarrhea"}]},{"id":"ge-hx-abx","dx":"invasive-diarrhea","q":"Recent antibiotics, hospitalization, or chemotherapy in the past ~3 months — the C. difficile setting?","answers":[{"label":"No recent antibiotic / healthcare exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was no recent antibiotic, hospitalization, or chemotherapy exposure to suggest C. difficile.","frag":"no recent antibiotic or healthcare exposure"},{"label":"Recent antibiotics / healthcare exposure","tone":"pos","sets":[{"risk":"stool-workup"}],"ddx":[{"id":"invasive-diarrhea","keep":true}],"mdm":"Recent antibiotic, hospitalization, or chemotherapy exposure was reported; C. difficile colitis was considered and tested for as indicated.","frag":"recent antibiotic or healthcare exposure (C. difficile risk)"}]},{"id":"ge-hx-travel","dx":"travelers","q":"Recent travel to a developing region, wilderness or untreated-water exposure, or a known outbreak within the past few weeks?","answers":[{"label":"No relevant travel","tone":"neg","sets":[],"ddx":[],"mdm":"There was no relevant travel or untreated-water exposure.","frag":"no relevant travel or untreated-water exposure"},{"label":"Recent travel / untreated water","tone":"pos","sets":[{"risk":"stool-workup"}],"ddx":[{"id":"travelers","keep":true}],"mdm":"Recent travel or untreated-water exposure was reported; travelers' and parasitic causes were considered, with stool studies and treatment tailored accordingly.","frag":"recent travel or untreated-water exposure"}]},{"id":"ge-hx-food","dx":"invasive-diarrhea","q":"High-risk food exposure — undercooked meat or eggs, unpasteurized dairy, or raw seafood?","answers":[{"label":"No high-risk food exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was no undercooked, unpasteurized, or raw-seafood exposure.","frag":"no high-risk food exposure"},{"label":"High-risk food exposure","tone":"pos","sets":[],"ddx":[{"id":"invasive-diarrhea","keep":true}],"mdm":"Undercooked meat/eggs, unpasteurized dairy, or raw seafood was reported, raising specific foodborne pathogens.","frag":"high-risk food exposure (undercooked, unpasteurized, or raw seafood)"}]},{"id":"ge-hx-host","dx":"general","q":"Host factors — immunocompromise (HIV, transplant, chemotherapy, chronic steroids), advanced age, pregnancy, or inflammatory bowel disease?","answers":[{"label":"Immunocompetent, no special host factors","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was immunocompetent without host factors that broaden the differential: no immunocompromise (HIV, transplant, chemotherapy, chronic steroids), advanced age, pregnancy, or inflammatory bowel disease.","frag":"immunocompetent without special host factors"},{"label":"Immunocompromised / vulnerable host","tone":"pos","sets":[],"ddx":[{"id":"invasive-diarrhea","keep":true}],"mdm":"Immunocompromise, advanced age, pregnancy, or IBD was present, lowering the threshold for testing, admission, and a broader differential.","frag":"immunocompromised or otherwise vulnerable host"}]},{"id":"ge-hx-chs","dx":"chs","q":"Substance and medication context — heavy cannabis use (with cyclical vomiting, classically relieved by hot showers), GLP-1 agonists, or opioids?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no heavy cannabis use and no GLP-1 or opioid driver.","frag":"no cannabis, GLP-1, or opioid context"},{"label":"Heavy cannabis / GLP-1 / opioids","tone":"pos","sets":[],"ddx":[{"id":"chs","keep":true}],"mdm":"Heavy cannabis use (with a cyclical, hot-shower-relieved pattern) or a GLP-1/opioid driver is present: cannabinoid hyperemesis or a medication effect explains the picture better than infection.","frag":"heavy cannabis use or GLP-1/opioid driver"}]},{"answers":[{"ddx":[],"frag":"no abdominal/flank/back pain or pulsatile mass","label":"No AAA features","mdm":"There was no abdominal, flank, or back pain, no pulsatile mass, and the patient was hemodynamically stable with symmetric pulses, making a symptomatic or ruptured abdominal aortic aneurysm unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"aaa-ge","keep":true}],"frag":"abdominal/back pain or pulsatile mass","label":"AAA features present","mdm":"Abdominal, flank, or back pain, a pulsatile mass, or asymmetric pulses was present in an at-risk patient, raising concern for a symptomatic or ruptured abdominal aortic aneurysm and warranting immediate imaging.","sets":[],"tone":"pos"}],"dx":"aaa-ge","id":"ge-hx-aaa-ge","q":"AAA — abdominal, flank, or back pain, a pulsatile mass, or asymmetric pulses in an at-risk patient?"}],"exam":[{"id":"ge-exam-vitals","dx":"general","q":"Vital signs — fever, tachycardia, hypotension, or orthostatic changes?","answers":[{"label":"Vitals stable, no orthostasis","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable without fever, tachycardia, hypotension, or orthostatic change.","frag":"vital signs stable without orthostasis"},{"label":"Abnormal vitals or orthostasis","tone":"pos","sets":[],"ddx":[{"id":"dehydration-ge","keep":true}],"mdm":"Fever, tachycardia, hypotension, or orthostasis was present and was addressed before disposition.","frag":"abnormal vital signs or orthostasis"}]},{"id":"ge-exam-abdomen","dx":"surgical-abdomen","q":"Abdominal exam — focal tenderness, peritoneal signs, distension, or a pulsatile mass?","answers":[{"label":"Soft, nontender, no peritoneal signs","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen was soft and nontender without peritoneal signs, distension, or a pulsatile mass.","frag":"abdomen soft and nontender without peritoneal signs"},{"label":"Focal tenderness, peritoneal signs, or distension","tone":"pos","sets":[],"ddx":[{"id":"surgical-abdomen","keep":true},{"id":"obstruction-ge","keep":true}],"mdm":"Focal tenderness, peritoneal signs, or distension was present, raising a surgical cause.","frag":"focal tenderness, peritoneal signs, or distension"}]},{"id":"ge-exam-hydration","dx":"dehydration-ge","q":"Hydration status — mucous membranes, skin turgor, mentation, capillary refill, and tolerance of oral intake?","answers":[{"label":"Well hydrated, tolerating oral intake","tone":"neg","sets":[{"risk":"po-trial"}],"ddx":[],"mdm":"The patient was well hydrated (moist mucous membranes, normal skin turgor, intact mentation, and brisk capillary refill) and tolerated an oral intake trial.","frag":"well hydrated and tolerating oral intake"},{"label":"Clinical signs of dehydration","tone":"pos","sets":[],"ddx":[{"id":"dehydration-ge","keep":true}],"mdm":"There were clinical signs of dehydration (dry mucous membranes, reduced skin turgor, delayed capillary refill, or poor oral tolerance), which were addressed with rehydration and reassessment.","frag":"clinical signs of dehydration"}]}],"conclusions":["viral gastroenteritis (well-appearing, tolerating PO)","travelers' diarrhea","food poisoning / toxin-mediated GI illness","gastroenteritis with mild dehydration (corrected)","vomiting/diarrhea NOS (dangerous causes excluded)"],"specs":["gi","id"],"guide":"../learn/complaints/gastroenteritis.html"},{"id":"uti-dysuria","title":"Dysuria / UTI","aliases":["uti","dysuria","urinary tract infection","burning urination","urinary frequency","urgency","cystitis","pyelonephritis","kidney infection","bladder infection"],"opening":"The patient was evaluated for dysuria and urinary symptoms. A focused history and examination were performed, and the diagnoses that mimic or complicate a simple urinary tract infection were actively considered.","ddx":[{"id":"urosepsis","group":"lifethreat","label":"Pyelonephritis / urosepsis","default":true,"tags":[],"ruleout":"Pyelonephritis and urosepsis were considered; the patient was afebrile without rigors, flank pain, or costovertebral-angle tenderness, and was hemodynamically stable with no systemic inflammatory signs, making it unlikely.","miss":3},{"id":"obstructing-stone","group":"lifethreat","label":"Obstructing stone with infection","default":true,"tags":[],"ruleout":"An obstructed, infected collecting system was considered; there was no severe colicky flank pain radiating to the groin, no hematuria, and no concurrent fever or systemic signs to suggest an obstructing infected stone, making it unlikely.","miss":3},{"id":"preg-uti","group":"lifethreat","label":"Pregnancy (ectopic / complicated)","default":false,"tags":[],"ruleout":"Pregnancy was considered, as it broadens the differential and alters management; the pregnancy test was negative, excluding ectopic and pregnancy-related complications from the presentation.","miss":4,"sex":"f"},{"id":"sti","group":"common","label":"STI / urethritis / PID","default":true,"tags":[],"ruleout":"A sexually transmitted infection, urethritis, or pelvic inflammatory disease was considered as an alternative to cystitis based on the sexual history and examination.","miss":2},{"id":"retention","group":"other","label":"Urinary retention / outlet obstruction","default":false,"tags":[],"ruleout":"Urinary retention or outlet obstruction was considered, particularly in older men; the patient was voiding without concern for significant retention.","miss":1},{"id":"cystitis","group":"common","label":"Uncomplicated cystitis","default":false,"tags":[],"ruleout":"Uncomplicated lower urinary tract infection was considered the likely diagnosis after the complicated and alternative causes above were addressed.","miss":2}],"risk":[{"id":"ua","label":"Urinalysis obtained","tags":["cystitis","urosepsis"],"scale":"low","line":"A urinalysis was obtained and interpreted in the clinical context.","short":"UA obtained"},{"id":"preg-test-uti","label":"Pregnancy test (childbearing potential)","tags":["preg-uti"],"scale":"low","line":"A pregnancy test was obtained in a patient of childbearing potential prior to treatment.","short":"pregnancy test done"}],"checks":[{"if":"preg-uti","needs":["preg-test-uti"],"mode":"any","warn":"Pregnancy changes management — document a pregnancy test in a patient of childbearing potential."},{"if":"urosepsis","needs":["ua"],"mode":"any","warn":"Urosepsis is on the differential — document the urinalysis (pyuria) and the sepsis assessment; fever plus obstruction is a urologic emergency."},{"if":"cystitis","needs":["ua"],"mode":"any","warn":"Document the urinalysis supporting the UTI diagnosis (leukocyte esterase/nitrites/pyuria); a bag specimen is not diagnostic in young children."}],"history":[{"id":"uti-hx-luts","dx":"general","q":"Classic lower urinary tract symptoms — dysuria, frequency, urgency, suprapubic discomfort?","answers":[{"label":"Typical isolated lower urinary tract symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"The patient reported typical lower urinary tract symptoms (dysuria, frequency, and urgency) without systemic or upper-tract features.","frag":"typical isolated lower-tract symptoms"},{"label":"Atypical, systemic, or upper-tract features","tone":"pos","sets":[],"ddx":[],"mdm":"Symptoms extended beyond simple cystitis (beyond dysuria, frequency, urgency, and suprapubic discomfort) with systemic or upper-tract features, prompting evaluation for a complicated infection.","frag":"systemic or upper-tract features"}]},{"id":"uti-hx-systemic","dx":"urosepsis","q":"Fever, chills or rigors, flank or back pain, nausea or vomiting?","answers":[{"label":"No fever, rigors, or flank pain","tone":"neg","sets":[],"ddx":[],"mdm":"No fever, rigors, flank pain, or vomiting was reported; pyelonephritis or systemic infection was not suggested by history.","frag":"no fever, rigors, or flank pain"},{"label":"Fever, rigors, or flank pain","tone":"pos","sets":[],"ddx":[{"id":"urosepsis","keep":true}],"mdm":"Fever, rigors, flank pain, or vomiting was reported, raising concern for pyelonephritis or urosepsis; the patient was assessed for systemic illness and the need for cultures and broader therapy.","frag":"fever, rigors, or flank pain"}]},{"id":"uti-hx-stone","dx":"obstructing-stone","q":"Severe colicky flank pain, a history of stones, or gross hematuria?","answers":[{"label":"No colicky flank pain or stone history","tone":"neg","sets":[],"ddx":[],"mdm":"There was no severe colicky flank pain, prior stone disease, or gross hematuria to suggest an obstructing infected stone.","frag":"no colicky flank pain or stone history"},{"label":"Colicky flank pain or stone history","tone":"pos","sets":[],"ddx":[{"id":"obstructing-stone","keep":true}],"mdm":"Severe colicky flank pain, a stone history, or gross hematuria was reported; an obstructing infected stone was considered and imaging was pursued to exclude obstruction.","frag":"colicky flank pain / stone history"}]},{"id":"uti-hx-sti","dx":"sti","q":"New or multiple partners, vaginal or urethral discharge, or pelvic pain?","answers":[{"label":"No STI risk features or discharge","tone":"neg","sets":[],"ddx":[],"mdm":"No new partners, discharge, or pelvic pain was reported; a sexually transmitted infection or PID was less likely on history.","frag":"no STI risk features or discharge"},{"label":"STI risk features, discharge, or pelvic pain","tone":"pos","sets":[],"ddx":[{"id":"sti","keep":true}],"mdm":"Sexual-history risk factors, discharge, or pelvic pain was reported; urethritis, an STI, or PID was considered and appropriate testing and examination were performed.","frag":"STI risk features / discharge"}]},{"id":"uti-hx-pregnancy","dx":"preg-uti","q":"Any possibility of pregnancy, or an uncertain last menstrual period (childbearing potential)?","answers":[{"label":"Pregnancy not possible / not applicable","tone":"neg","sets":[],"ddx":[],"mdm":"Pregnancy was not possible or not applicable for this patient.","frag":"pregnancy not applicable"},{"label":"Pregnancy possible — testing obtained","tone":"pos","sets":[{"risk":"preg-test-uti"}],"ddx":[{"id":"preg-uti","keep":true}],"mdm":"Pregnancy was possible; a pregnancy test was obtained, as pregnancy alters management of urinary symptoms and broadens the differential.","frag":"pregnancy possible (tested)"}]},{"id":"uti-hx-retention","dx":"retention","q":"Difficulty voiding, weak stream, incomplete emptying, or known prostatic enlargement (older men)?","answers":[{"label":"Voiding normally, no obstructive symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was voiding normally without hesitancy, weak stream, or a sense of incomplete emptying.","frag":"voiding normally, no obstruction"},{"label":"Obstructive voiding symptoms","tone":"pos","sets":[],"ddx":[{"id":"retention","keep":true}],"mdm":"Obstructive voiding symptoms were reported; urinary retention was considered and a post-void residual was assessed.","frag":"obstructive voiding symptoms"}]}],"exam":[{"id":"uti-exam-vitals","dx":"urosepsis","q":"Vital signs — fever, tachycardia, or hypotension suggesting systemic infection?","answers":[{"label":"Vitals stable, no SIRS features","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable without fever, tachycardia, or hypotension to suggest systemic infection.","frag":"vitals stable, no SIRS features"},{"label":"Abnormal vitals / SIRS features","tone":"pos","sets":[],"ddx":[{"id":"urosepsis","keep":true}],"mdm":"Abnormal vital signs (fever, tachycardia, or hypotension); consistent with a systemic inflammatory response were identified, prompting evaluation and treatment for urosepsis.","frag":"abnormal vitals / SIRS features"}]},{"id":"uti-exam-cva","dx":"urosepsis","q":"Costovertebral angle tenderness on examination?","answers":[{"label":"No CVA tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"There was no costovertebral angle tenderness on examination.","frag":"no CVA tenderness"},{"label":"CVA tenderness present","tone":"pos","sets":[],"ddx":[{"id":"urosepsis","keep":true}],"mdm":"Costovertebral angle tenderness was present, supporting upper-tract involvement (pyelonephritis), and management was escalated accordingly.","frag":"CVA tenderness"}]},{"id":"uti-exam-abdomen","dx":"retention","q":"Abdominal / suprapubic exam — suprapubic tenderness, a distended bladder, or peritoneal signs?","answers":[{"label":"Suprapubic exam benign, no distension","tone":"neg","sets":[],"ddx":[],"mdm":"The suprapubic examination was benign without a palpably distended bladder or peritoneal signs.","frag":"suprapubic exam benign, no distension"},{"label":"Suprapubic tenderness or bladder distension","tone":"pos","sets":[],"ddx":[{"id":"retention","keep":true},{"id":"cystitis","keep":true}],"mdm":"Suprapubic tenderness or a distended bladder was identified, prompting assessment for retention or a complicated infection.","frag":"suprapubic tenderness / bladder distension"}]}],"conclusions":["uncomplicated cystitis (lower UTI)","UTI tolerating oral therapy","urethritis / STI pending testing","dysuria NOS (complicated causes excluded)"],"specs":["uro","id"],"guide":"../learn/complaints/uti-dysuria.html"},{"id":"allergic-reaction","title":"Allergic Reaction","aliases":["allergic reaction","allergy","hives","urticaria","anaphylaxis","angioedema","swelling","allergic rash","food allergy","bee sting","drug reaction","allergic"],"opening":"The patient was evaluated for an allergic reaction. A focused history and examination, with specific attention to airway, breathing, and circulation, were performed to distinguish anaphylaxis and angioedema from a limited cutaneous reaction.","ddx":[{"id":"anaphylaxis","group":"lifethreat","label":"Anaphylaxis","default":true,"tags":["airway"],"ruleout":"Anaphylaxis was actively considered; there was no airway, respiratory, cardiovascular, or persistent gastrointestinal involvement, only a limited cutaneous reaction, so criteria were not met, recognizing skin findings are not required to diagnose it.","miss":4},{"id":"angioedema","group":"lifethreat","label":"Angioedema (incl. ACE-inhibitor)","default":true,"tags":["airway"],"ruleout":"Angioedema was considered; there was no lip, tongue, facial, or laryngeal swelling, no voice change, drooling, or airway compromise, and ACE-inhibitor and hereditary causes were reviewed, making it unlikely.","miss":3},{"id":"biphasic","group":"other","label":"Biphasic reaction risk","default":false,"tags":[],"ruleout":"The risk of a biphasic reaction was considered in observation and discharge planning; the patient was counseled and given an epinephrine auto-injector prescription where indicated.","miss":1},{"id":"urticaria-dx","group":"common","label":"Localized urticaria / cutaneous reaction","default":false,"tags":[],"ruleout":"A limited cutaneous urticarial reaction without systemic involvement was considered as the diagnosis after anaphylaxis and angioedema were excluded.","miss":2}],"risk":[{"id":"airway-allergy","label":"Airway assessment documented","tags":["anaphylaxis","angioedema"],"scale":"low","line":"The airway was assessed and documented as patent, without stridor, voice change, or oropharyngeal swelling.","short":"airway patent"},{"id":"obs-allergy","label":"Observation for biphasic reaction","tags":["biphasic"],"scale":"low","line":"The patient was observed for an appropriate period for any biphasic or progressive reaction before disposition.","short":"observed, no progression"}],"checks":[{"if":"anaphylaxis","needs":["airway-allergy"],"mode":"any","warn":"Anaphylaxis is on the differential — a documented airway assessment shows the ABCs were evaluated."},{"if":"biphasic","needs":["obs-allergy"],"mode":"any","warn":"Anaphylaxis carries a biphasic-reaction risk — documenting an appropriate observation period (and an epinephrine autoinjector prescription with referral at discharge) addresses it."}],"history":[{"id":"allergy-hx-trigger","dx":"general","q":"Identifiable trigger and time course — food, drug, sting, or latex, with onset minutes to hours after exposure?","answers":[{"label":"Clear trigger, limited reaction","tone":"neg","sets":[],"ddx":[],"mdm":"An identifiable trigger (food, drug, sting, or latex) was reported with a typical onset minutes to hours after exposure, and the reaction was limited without systemic features.","frag":"clear trigger, limited reaction"},{"label":"Unclear trigger or progressive reaction","tone":"pos","sets":[],"ddx":[],"mdm":"No clear trigger among food, drug, sting, or latex was identified, or the reaction was progressive, prompting closer observation for evolving systemic involvement.","frag":"unclear trigger / progressive reaction"}]},{"id":"allergy-hx-anaphylaxis","dx":"anaphylaxis","q":"Breathing difficulty, throat tightness, wheeze, lightheadedness or syncope, or persistent vomiting / abdominal cramps?","answers":[{"label":"No respiratory, cardiovascular, or persistent GI symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No respiratory difficulty, throat tightness, lightheadedness, syncope, or persistent gastrointestinal symptoms were reported; criteria for anaphylaxis were not met by history.","frag":"no respiratory, cardiovascular, or GI involvement"},{"label":"Systemic involvement reported","tone":"pos","sets":[{"risk":"airway-allergy"}],"ddx":[{"id":"anaphylaxis","keep":true}],"mdm":"Respiratory, cardiovascular, or persistent gastrointestinal involvement was reported, meeting criteria for anaphylaxis; epinephrine was administered and the patient was monitored closely.","frag":"systemic involvement (anaphylaxis)"}]},{"id":"allergy-hx-angioedema","dx":"angioedema","q":"Lip, tongue, facial, or throat swelling, or voice change — and any ACE-inhibitor use?","answers":[{"label":"No mucosal swelling or voice change","tone":"neg","sets":[],"ddx":[],"mdm":"No lip, tongue, facial, or throat swelling and no voice change were reported; angioedema was not suggested by history.","frag":"no mucosal swelling or voice change"},{"label":"Mucosal swelling or voice change","tone":"pos","sets":[{"risk":"airway-allergy"}],"ddx":[{"id":"angioedema","keep":true}],"mdm":"Lip, tongue, facial, or throat swelling, or voice change, was reported; angioedema was considered with attention to the airway and to ACE-inhibitor and hereditary causes.","frag":"mucosal swelling / voice change"}]},{"id":"allergy-hx-biphasic","dx":"biphasic","q":"Prior severe reactions, asthma, or delayed or recurrent symptoms after initial improvement?","answers":[{"label":"No high-risk or recurrence features","tone":"neg","sets":[],"ddx":[],"mdm":"No history of severe reactions, asthma, or recurrent symptoms was reported; the risk of a significant biphasic reaction was felt to be low.","frag":"no high-risk or recurrence features"},{"label":"High-risk or recurrence features","tone":"pos","sets":[{"risk":"obs-allergy"}],"ddx":[{"id":"biphasic","keep":true}],"mdm":"A history of severe reactions, asthma, or recurrent symptoms was reported, raising the risk of a biphasic reaction; observation was extended and the patient was counseled and prescribed an epinephrine auto-injector.","frag":"high-risk / recurrence features"}]}],"exam":[{"id":"allergy-exam-airway","dx":"anaphylaxis","q":"Airway and breathing — stridor, wheeze, hoarseness, oropharyngeal or tongue swelling, or respiratory distress?","answers":[{"label":"Airway patent, lungs clear, no swelling","tone":"neg","sets":[],"ddx":[],"mdm":"The airway was patent with clear lungs, no stridor or wheeze, and no oropharyngeal or tongue swelling.","frag":"airway patent, lungs clear, no swelling"},{"label":"Stridor, wheeze, or oropharyngeal swelling","tone":"pos","sets":[],"ddx":[{"id":"anaphylaxis","keep":true},{"id":"angioedema","keep":true}],"mdm":"Stridor, wheeze, hoarseness, or oropharyngeal swelling was identified; the airway was treated as at-risk, epinephrine was given, and definitive airway resources were mobilized.","frag":"stridor, wheeze, or airway swelling"}]},{"id":"allergy-exam-circulation","dx":"anaphylaxis","q":"Circulation — hypotension, tachycardia, or signs of poor perfusion?","answers":[{"label":"Hemodynamically stable, well perfused","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable and well perfused without hypotension or tachycardia.","frag":"hemodynamically stable, well perfused"},{"label":"Hypotension or poor perfusion","tone":"pos","sets":[],"ddx":[{"id":"anaphylaxis","keep":true}],"mdm":"Hypotension, tachycardia, or poor perfusion was identified, consistent with anaphylactic shock; epinephrine and fluid resuscitation were initiated.","frag":"hypotension / poor perfusion"}]},{"id":"allergy-exam-skin","dx":"urticaria-dx","q":"Skin — urticaria, flushing, or the distribution of any angioedema?","answers":[{"label":"Limited urticaria without systemic signs","tone":"neg","sets":[],"ddx":[],"mdm":"The cutaneous findings were limited to urticaria or flushing without mucosal swelling or systemic signs, noting that skin findings are absent in roughly 10–20% of anaphylaxis, so their absence was not used to exclude it; the airway, breathing, circulation, and GI criteria carried the assessment.","frag":"limited urticaria, no systemic signs"},{"label":"Extensive involvement or angioedema","tone":"pos","sets":[],"ddx":[{"id":"urticaria-dx","keep":true},{"id":"angioedema","keep":true}],"mdm":"Extensive cutaneous involvement (widespread urticaria or flushing, or angioedema in its distribution) was identified, prompting reassessment for systemic involvement and an extended observation period.","frag":"extensive involvement / angioedema"}]}],"conclusions":["localized urticaria / allergic reaction (no systemic involvement)","allergic reaction, resolved with antihistamines","anaphylaxis treated, observed without biphasic reaction","allergic reaction NOS (anaphylaxis / angioedema excluded)"],"specs":["derm","pulm"],"guide":"../learn/complaints/anaphylaxis.html"},{"id":"extremity-injury","title":"Ankle & Knee Injury","aliases":["ankle injury","ankle sprain","twisted ankle","foot injury","knee injury","extremity injury","ottawa ankle","ottawa knee","leg injury","can't walk","rolled ankle","knee pain after fall","achilles","fracture","broken ankle","sprain","twisted knee","ankle pain","knee pain","foot pain","hurt my ankle","hurt my knee"],"opening":"Most twisted ankles and knees are sprains, but the misses that matter are the fracture the Ottawa rules would have caught, the Achilles or extensor-mechanism rupture hiding behind 'sprain', and the compartment or neurovascular emergency that can't wait for follow-up.","ddx":[{"id":"fracture","group":"lifethreat","label":"Clinically-important fracture / dislocation","default":true,"tags":["fracture"],"ruleout":"Clinically-important fracture or dislocation was considered; there was no bony tenderness over the malleoli, midfoot, or patella, no deformity, and the patient could bear weight, with Ottawa criteria not met, making it unlikely.","miss":3},{"id":"compartment","group":"lifethreat","label":"Compartment syndrome","default":false,"tags":["compartment"],"ruleout":"Compartment syndrome was considered; there was no pain out of proportion, no pain on passive stretch, the compartments were soft, and distal sensation and pulses were intact, making it unlikely.","miss":4},{"id":"neurovasc","group":"lifethreat","label":"Neurovascular compromise","default":true,"tags":["neurovasc"],"ruleout":"Neurovascular compromise was considered; distal pulses were palpable, capillary refill was brisk, and sensation and motor function were intact and symmetric below the injury, making it unlikely.","miss":3},{"id":"septic-joint-ei","group":"lifethreat","label":"Septic arthritis / joint effusion","default":false,"tags":["septic-joint-ei"],"ruleout":"Septic arthritis was considered when an effusion was present; the patient was afebrile with no atraumatic joint swelling, warmth, or pain on micro-motion, and the picture was fully explained by the injury, making it unlikely.","miss":4},{"id":"tendon-rupture","group":"common","label":"Achilles / extensor-mechanism rupture","default":false,"tags":["tendon-rupture"],"ruleout":"Achilles tendon and extensor-mechanism rupture (the classic 'sprain' mimics) were considered and examined for.","miss":2},{"id":"sprain","group":"common","label":"Ligamentous sprain","default":false,"tags":["sprain"],"ruleout":"A ligamentous sprain was considered as the working diagnosis.","miss":2},{"id":"contusion","group":"other","label":"Contusion / soft-tissue injury","default":false,"tags":["contusion"],"ruleout":"A simple contusion was considered.","miss":1}],"risk":[{"id":"ottawa-ankle","label":"Ottawa ankle & foot rules","tags":["fracture"],"scale":"low","line":"The Ottawa ankle and foot rules were applied: no malleolar or midfoot bony tenderness and the patient bore weight for four steps, so radiography was not indicated by the rule.","cite":"Stiell IG, et al. JAMA. 1993.","short":"Ottawa ankle/foot {band}","calc":{"fields":[{"label":"Bony tenderness — posterior edge/tip of lateral malleolus","opts":[["No",0],["Yes",1]]},{"label":"Bony tenderness — posterior edge/tip of medial malleolus","opts":[["No",0],["Yes",1]]},{"label":"Bony tenderness — base of the 5th metatarsal","opts":[["No",0],["Yes",1]]},{"label":"Bony tenderness — navicular","opts":[["No",0],["Yes",1]]},{"label":"Unable to bear weight 4 steps (immediately and in ED)","opts":[["No",0],["Yes",1]]}],"bands":[[0,"negative","low","No criterion present: ankle/foot radiography is not required by the rule."],[5,"positive","high","≥1 criterion present: obtain an ankle and/or foot X-ray series for the zone involved."]],"line":"Ottawa ankle & foot rule: {score} of 5 criteria present ({band}).","applies":"Adults and children >= 5y with ankle or midfoot pain after trauma, to decide whether X-rays are needed. Unreliable when the exam is limited by intoxication, distracting injury, or reduced sensation."}},{"id":"ottawa-knee","label":"Ottawa knee rule","tags":["fracture"],"scale":"low","line":"The Ottawa knee rule was applied: age under 55, no patellar or fibular-head tenderness, flexion to 90°, and able to bear weight, so radiography was not indicated by the rule.","cite":"Stiell IG, et al. JAMA. 1996.","short":"Ottawa knee {band}","calc":{"fields":[{"label":"Age ≥ 55","opts":[["No",0],["Yes",1]]},{"label":"Tenderness at the head of the fibula","opts":[["No",0],["Yes",1]]},{"label":"Isolated tenderness of the patella","opts":[["No",0],["Yes",1]]},{"label":"Unable to flex the knee to 90°","opts":[["No",0],["Yes",1]]},{"label":"Unable to bear weight 4 steps (immediately and in ED)","opts":[["No",0],["Yes",1]]}],"bands":[[0,"negative","low","No criterion present: knee radiography is not required by the rule."],[5,"positive","high","≥1 criterion present: obtain a knee X-ray series."]],"line":"Ottawa knee rule: {score} of 5 criteria present ({band}).","applies":"Adults with acute knee pain after trauma, to decide whether X-rays are needed. Use caution in young children; unreliable when the exam itself is unreliable."}},{"id":"nv-exam","label":"Neurovascular exam documented","tags":["neurovasc","compartment"],"scale":"low","line":"Distal pulses, capillary refill, and sensation were examined and intact, and the compartments were soft.","short":"neurovascular exam intact"}],"checks":[{"if":"fracture","needs":["ottawa-ankle","ottawa-knee"],"mode":"any","warn":"Fracture is on the differential — document the Ottawa criteria (or the imaging obtained) so the X-ray decision is defensible."},{"if":"neurovasc","needs":["nv-exam"],"mode":"any","warn":"Document the distal neurovascular examination — it is the line that matters most if the limb worsens after discharge."},{"if":"compartment","needs":["nv-exam"],"mode":"any","warn":"Compartment syndrome is the can't-miss in extremity injury — document the neurovascular exam and pain out of proportion; a normal pulse does not exclude it."}],"history":[{"id":"ei-hx-mech","dx":"fracture","q":"Mechanism — twisting/inversion vs. high-energy (fall from height, crush, MVC) or a pop felt at injury?","answers":[{"label":"Low-energy twist","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was a low-energy twist or inversion, without high-energy features such as a fall from height, crush, or MVC, and no pop was felt at injury.","frag":"low-energy twisting mechanism"},{"label":"High-energy / felt a pop","tone":"pos","sets":[],"ddx":[{"id":"fracture","keep":true},{"id":"tendon-rupture","keep":true}],"mdm":"The mechanism was high-energy, or the patient felt a pop at the moment of injury.","frag":"high-energy mechanism or a felt pop"}]},{"id":"ei-hx-weight","dx":"fracture","q":"Able to bear weight — four steps immediately after the injury AND now (limping counts as bearing weight)?","answers":[{"label":"Bears weight ×4 steps","tone":"neg","sets":[{"risk":"ottawa-ankle","field":4,"opt":0},{"risk":"ottawa-knee","field":4,"opt":0}],"ddx":[],"mdm":"The patient was able to take four steps both immediately after the injury and on evaluation.","frag":"able to bear weight for four steps"},{"label":"Cannot bear weight","tone":"pos","sets":[{"risk":"ottawa-ankle","field":4,"opt":1},{"risk":"ottawa-knee","field":4,"opt":1}],"ddx":[{"id":"fracture","keep":true}],"mdm":"The patient cannot take four steps, which is an Ottawa indication for radiography.","frag":"unable to bear weight for four steps"}]},{"id":"ei-hx-pain-progress","dx":"compartment","q":"Pain trajectory — controlled, or escalating out of proportion / not relieved by analgesia and elevation?","answers":[{"label":"Proportionate, controlled","tone":"neg","sets":[],"ddx":[],"mdm":"Pain is proportionate to the injury and adequately controlled.","frag":"pain proportionate to injury and controlled"},{"label":"Out of proportion / escalating","tone":"pos","sets":[],"ddx":[{"id":"compartment","keep":true}],"mdm":"Pain is out of proportion to the apparent injury or escalating despite analgesia: compartment syndrome must be excluded.","frag":"pain out of proportion or escalating despite analgesia"}]},{"id":"ei-hx-numb","dx":"neurovasc","q":"Numbness, tingling, or a cold or pale foot since the injury?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There are no sensory or perfusion complaints distal to the injury.","frag":"no numbness or perfusion symptoms"},{"label":"Numbness / cold foot","tone":"pos","sets":[],"ddx":[{"id":"neurovasc","keep":true}],"mdm":"There are sensory or perfusion complaints distal to the injury.","frag":"distal numbness or perfusion symptoms"}]},{"id":"ei-hx-anticoag","dx":"compartment","q":"On anticoagulation — raising the risk of an expanding hematoma or compartment syndrome?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not on anticoagulation.","frag":"not anticoagulated"},{"label":"Anticoagulated","tone":"pos","sets":[],"ddx":[{"id":"compartment","keep":true}],"mdm":"The patient is anticoagulated, raising the risk of an expanding hematoma and compartment syndrome.","frag":"on anticoagulation"}]}],"exam":[{"id":"ei-ex-ankle","dx":"fracture","q":"Ottawa ankle/foot points — bony tenderness at the posterior 6 cm of either malleolus, the navicular, or the base of the 5th metatarsal?","answers":[{"label":"No bony tenderness","tone":"neg","sets":[{"risk":"ottawa-ankle","field":0,"opt":0},{"risk":"ottawa-ankle","field":1,"opt":0},{"risk":"ottawa-ankle","field":2,"opt":0},{"risk":"ottawa-ankle","field":3,"opt":0}],"ddx":[],"mdm":"There is no bony tenderness at the Ottawa ankle or midfoot points.","frag":"no malleolar, navicular, or 5th-metatarsal bony tenderness"},{"label":"Bony tenderness present","tone":"pos","sets":[],"ddx":[{"id":"fracture","keep":true}],"mdm":"Bony tenderness is present at an Ottawa point: radiography is indicated by the rule.","frag":"Ottawa bony tenderness present"}]},{"id":"ei-ex-knee","dx":"fracture","q":"Ottawa knee points — age ≥ 55, patellar or fibular-head tenderness, or unable to flex to 90°?","answers":[{"label":"None apply","tone":"neg","sets":[{"risk":"ottawa-knee","field":0,"opt":0},{"risk":"ottawa-knee","field":1,"opt":0},{"risk":"ottawa-knee","field":2,"opt":0},{"risk":"ottawa-knee","field":3,"opt":0}],"ddx":[],"mdm":"No Ottawa knee criterion was met (age was under 55, there was no patellar or fibular-head tenderness, and the knee flexed to 90 degrees); so radiography was not required by the rule.","frag":"no Ottawa knee criteria met; flexion to 90°"},{"label":"≥ 1 criterion","tone":"pos","sets":[],"ddx":[{"id":"fracture","keep":true}],"mdm":"At least one Ottawa knee criterion was present (age ≥ 55, patellar or fibular-head tenderness, or inability to flex to 90°); so radiography was indicated by the rule.","frag":"Ottawa knee criterion present"}]},{"id":"ei-ex-nv","dx":"neurovasc","q":"Distal neurovascular exam — pulses, capillary refill, and sensation intact; compartments soft?","answers":[{"label":"Intact, compartments soft","tone":"neg","sets":[{"risk":"nv-exam"}],"ddx":[],"mdm":"Distal pulses, capillary refill, and sensation are intact and the compartments are soft.","frag":"distal pulses, sensation, and perfusion intact; compartments soft"},{"label":"Deficit / tense compartment","tone":"pos","sets":[],"ddx":[{"id":"neurovasc","keep":true},{"id":"compartment","keep":true}],"mdm":"The distal neurovascular exam was abnormal (a deficit in pulses, capillary refill, or sensation, or a tense compartment), requiring urgent attention.","frag":"neurovascular deficit or tense compartment"}]},{"id":"ei-ex-tendon","dx":"tendon-rupture","q":"Tendon checks — Thompson test (calf squeeze plantarflexes the foot) and active knee extension / straight-leg raise intact?","answers":[{"label":"Intact","tone":"neg","sets":[],"ddx":[],"mdm":"The Thompson test is negative and active extension is intact: no Achilles or extensor-mechanism rupture.","frag":"Thompson test negative; extensor mechanism intact"},{"label":"Abnormal","tone":"pos","sets":[],"ddx":[{"id":"tendon-rupture","keep":true}],"mdm":"The Thompson test is positive or active extension is lost: tendon rupture is suspected.","frag":"positive Thompson test or unable to actively extend"}]},{"id":"ei-ex-skin","dx":"fracture","q":"Skin — any wound near the injury or deformity suggesting an open fracture or dislocation?","answers":[{"label":"Skin intact, no deformity","tone":"neg","sets":[],"ddx":[],"mdm":"The skin was intact with no wound near the injury and no deformity to suggest an open fracture or dislocation.","frag":"skin intact without deformity"},{"label":"Open wound / deformity","tone":"pos","sets":[],"ddx":[{"id":"fracture","keep":true}],"mdm":"There is a wound over the injury or a gross deformity: open fracture or dislocation must be addressed emergently.","frag":"open wound over the injury or gross deformity"}]},{"answers":[{"ddx":[],"frag":"no atraumatic effusion, warmth, or pain on micro-motion (afebrile, but fever is absent in up to half of septic arthritis, so the joint findings carried it)","label":"No septic-joint signs","mdm":"There was no atraumatic joint effusion, warmth, or pain on micro-motion, and the picture was fully explained by the injury, making septic arthritis unlikely. The patient was afebrile, noting fever is absent in up to half of septic arthritis, so the joint findings rather than temperature carried the assessment.","sets":[],"tone":"neg"},{"ddx":[{"id":"septic-joint-ei","keep":true}],"frag":"effusion with warmth or pain on micro-motion","label":"Septic-joint signs present","mdm":"Fever, an atraumatic effusion, warmth, or pain on micro-motion was present, raising concern for septic arthritis and warranting arthrocentesis.","sets":[],"tone":"pos"}],"dx":"septic-joint-ei","id":"ei-exam-septic-joint-ei","q":"Septic arthritis — fever, an atraumatic joint effusion, warmth, or pain on micro-motion not explained by the injury?"},{"id":"ei-ex-lipohemarthrosis","dx":"fracture","q":"Diagnostic review — knee films after axial load: fat-fluid level (lipohemarthrosis) on the horizontal-beam lateral? A fat-fluid level means an intra-articular fracture (often a subtle tibial plateau) even when no fracture line is visible.","answers":[{"label":"No fat-fluid level or effusion","tone":"neg","sets":[],"ddx":[],"mdm":"The horizontal-beam lateral showed no fat-fluid level or significant effusion.","frag":"no lipohemarthrosis on knee films"},{"label":"Fat-fluid level present","tone":"pos","sets":[],"ddx":[],"mdm":"A fat-fluid level (lipohemarthrosis) was present on the lateral knee film: this indicates an intra-articular fracture even without a visible fracture line, so I treated it as an occult tibial plateau fracture with appropriate immobilization and follow-up imaging.","frag":"lipohemarthrosis (treated as occult intra-articular fracture)"}]}],"conclusions":["ankle sprain, Ottawa negative","knee sprain / strain, Ottawa negative","contusion, no fracture indicated","extremity injury NOS (low-risk)"],"specs":["ortho","trauma"],"guide":"../learn/complaints/extremity-injury.html"},{"id":"laceration","title":"Laceration & Wound","aliases":["laceration","cut","wound","hand laceration","finger cut","glass cut","knife cut","stitches","foreign body","tendon","bite","dog bite","cat bite","fight bite","puncture","high pressure injection","tetanus"],"opening":"Lacerations are routine until the one with a severed tendon, a retained shard of glass, or a violated joint is closed and sent home — wound cases are won and lost on the exploration and the distal exam, not on the sutures.","ddx":[{"id":"tendon","group":"lifethreat","label":"Tendon injury","default":true,"tags":["tendon"],"ruleout":"Tendon injury was considered; the patient had full active range of motion against resistance with normal resting tone, and exploration through the full arc of motion revealed an intact tendon without partial laceration, making injury unlikely.","miss":3},{"id":"nerve-inj","group":"lifethreat","label":"Nerve injury","default":true,"tags":["nerve-inj"],"ruleout":"Nerve injury was considered; distal sensation, including two-point discrimination where relevant, was intact prior to anesthesia and motor function distal to the wound was preserved, making it unlikely.","miss":3},{"id":"foreign-body","group":"lifethreat","label":"Retained foreign body","default":true,"tags":["foreign-body"],"ruleout":"A retained foreign body was considered; the mechanism was low-risk for retained material, the wound was explored to its base without identifiable debris, and imaging was negative or documented as not indicated, making it unlikely.","miss":3},{"id":"deep-structure","group":"lifethreat","label":"Joint / fracture / vascular involvement","default":false,"tags":["deep-structure"],"ruleout":"Deep-structure involvement was considered; there was no joint penetration on exploration, no bony tenderness, deformity, or fracture on imaging, and distal pulses, perfusion, and capillary refill were intact, making it unlikely.","miss":3},{"id":"bite-wound","group":"common","label":"Bite wound / infection-prone wound","default":false,"tags":["bite-wound"],"ruleout":"The wound's infection risk (bite, contamination, host factors) was assessed and shaped the closure and antibiotic decisions.","miss":2},{"id":"simple-lac","group":"other","label":"Simple laceration","default":false,"tags":["simple-lac"],"ruleout":"A simple laceration without deep-structure involvement was the working assessment.","miss":1}],"risk":[{"id":"explored","label":"Wound explored through range of motion","tags":["tendon","foreign-body","deep-structure"],"scale":"low","line":"The wound was anesthetized, irrigated, and explored to its base through full range of motion; no tendon involvement, foreign body, or deep-structure injury was identified.","short":"explored through ROM: base visualized"},{"id":"fb-imaging","label":"Foreign-body imaging considered","tags":["foreign-body"],"scale":"low","line":"Given the mechanism, imaging for a radiopaque foreign body was obtained or explicitly considered and documented.","short":"FB imaging addressed"},{"id":"tetanus","label":"Tetanus status addressed","tags":["bite-wound","simple-lac"],"scale":"low","line":"Tetanus immunization status was reviewed and updated as indicated.","short":"tetanus addressed"},{"id":"distal-exam","label":"Distal neurovascular / tendon exam before anesthesia","tags":["nerve-inj","tendon"],"scale":"low","line":"Distal sensory, motor, and vascular examination was performed and documented before local anesthesia.","short":"distal exam pre-anesthesia intact"}],"checks":[{"if":"tendon","needs":["explored","distal-exam"],"mode":"any","warn":"Tendon injury is on the differential — document exploration through range of motion and the pre-anesthesia function exam."},{"if":"foreign-body","needs":["explored","fb-imaging"],"mode":"any","warn":"Glass and metal mechanisms retain fragments — document exploration and whether imaging was obtained or why not."},{"if":"nerve-inj","needs":["distal-exam"],"mode":"any","warn":"A nerve injury is on the differential — document the distal sensory/motor exam (two-point discrimination) before anesthesia."},{"if":"deep-structure","needs":["explored"],"mode":"any","warn":"Deep-structure injury (tendon, joint, vessel) is on the differential — document wound exploration through full range of motion in a bloodless field."}],"history":[{"id":"lac-hx-mech","dx":"foreign-body","q":"Mechanism — glass, metal, or anything that can fragment and retain?","answers":[{"label":"Clean, non-fragmenting","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was clean and non-fragmenting, without glass, metal, or other material that could fragment and be retained.","frag":"non-fragmenting mechanism"},{"label":"Glass / metal / fragmenting","tone":"pos","sets":[{"risk":"fb-imaging"}],"ddx":[{"id":"foreign-body","keep":true}],"mdm":"The mechanism (glass/metal) carries a real retained-foreign-body risk.","frag":"glass or metal mechanism with retained-fragment risk"}]},{"id":"lac-hx-bite","dx":"bite-wound","q":"Bite or fight-bite — animal, human, or knuckle wound from a punch?","answers":[{"label":"Not a bite","tone":"neg","sets":[],"ddx":[],"mdm":"This was not a bite or fight-bite wound: not an animal or human bite, and not a knuckle wound from a punch.","frag":"not a bite wound"},{"label":"Bite / fight bite","tone":"pos","sets":[],"ddx":[{"id":"bite-wound","keep":true},{"id":"deep-structure","keep":true}],"mdm":"This was a bite or fight-bite wound (animal, human, or a knuckle wound from a punch), carrying high infection risk, and a clenched-fist injury was assumed to involve the joint until proven otherwise.","frag":"bite or fight-bite mechanism"}]},{"id":"lac-hx-injection","dx":"deep-structure","q":"High-pressure injection injury (paint, grease, hydraulic) — even with a pinhole entry?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There is no high-pressure injection mechanism.","frag":"no high-pressure injection mechanism"},{"label":"High-pressure injection","tone":"pos","sets":[],"ddx":[{"id":"deep-structure","keep":true}],"mdm":"This is a high-pressure injection injury: a surgical emergency regardless of how benign the entry wound looks.","frag":"high-pressure injection injury"}]},{"id":"lac-hx-tetanus","dx":"general","q":"Tetanus status — last booster within 5–10 years for this wound class?","answers":[{"label":"Up to date","tone":"neg","sets":[{"risk":"tetanus"}],"ddx":[],"mdm":"Tetanus immunization is current for this wound class.","frag":"tetanus up to date"},{"label":"Due / unknown","tone":"pos","sets":[{"risk":"tetanus"}],"ddx":[],"mdm":"Tetanus status is due or unknown and was updated in the ED.","frag":"tetanus due or unknown (updated)"}]},{"id":"lac-hx-host","dx":"bite-wound","q":"Host factors — diabetes, immunosuppression, asplenia, or poor follow-up access?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There were no host factors raising infection risk: no diabetes, immunosuppression, asplenia, or poor follow-up access.","frag":"no high-risk host factors"},{"label":"High-risk host","tone":"pos","sets":[],"ddx":[{"id":"bite-wound","keep":true}],"mdm":"Host factors (diabetes, immunosuppression, asplenia, or poor follow-up access); raised the infection risk and lowered the threshold for antibiotics and early recheck.","frag":"high-risk host factors for infection"}]},{"id":"lac-hx-hand","dx":"tendon","q":"Hand or wrist wound in a working hand — occupation and handedness noted?","answers":[{"label":"Not hand/wrist","tone":"neg","sets":[],"ddx":[],"mdm":"The wound does not involve the hand or wrist.","frag":"not a hand or wrist wound"},{"label":"Hand / wrist wound","tone":"pos","sets":[],"ddx":[{"id":"tendon","keep":true},{"id":"nerve-inj","keep":true}],"mdm":"The wound involves the hand or wrist, where tendon and nerve injuries are most often missed.","frag":"hand or wrist wound"}]}],"exam":[{"id":"lac-ex-explore","dx":"tendon","q":"Exploration — wound visualized to its base, through full range of motion, in a bloodless field where possible?","answers":[{"label":"Base visualized through ROM","tone":"neg","sets":[{"risk":"explored"}],"ddx":[],"mdm":"The wound was explored to its base through full range of motion; no tendon or deep-structure injury and no foreign body was seen.","frag":"wound base visualized through full range of motion"},{"label":"Base not visualized / partial injury possible","tone":"pos","sets":[],"ddx":[{"id":"tendon","keep":true},{"id":"foreign-body","keep":true}],"mdm":"The wound base could not be fully visualized: a partial tendon injury or retained foreign body cannot be excluded by this exam.","frag":"wound base not fully visualized"}]},{"id":"lac-ex-tendonfn","dx":"tendon","q":"Tendon function — full strength through range of motion against resistance (weakness or pain with resistance suggests partial laceration)?","answers":[{"label":"Full strength, painless","tone":"neg","sets":[{"risk":"distal-exam"}],"ddx":[],"mdm":"Tendon function is full-strength and painless against resistance.","frag":"full strength against resistance"},{"label":"Weak / painful against resistance","tone":"pos","sets":[],"ddx":[{"id":"tendon","keep":true}],"mdm":"Function against resistance is weak or painful: a partial tendon laceration is suspected.","frag":"weakness or pain against resistance"}]},{"id":"lac-ex-sensory","dx":"nerve-inj","q":"Sensory exam before anesthesia — two-point discrimination distal to the wound (hand) or light touch intact?","answers":[{"label":"Intact","tone":"neg","sets":[{"risk":"distal-exam"}],"ddx":[],"mdm":"Distal sensation, including two-point discrimination where relevant, was intact before anesthesia.","frag":"distal sensation intact before anesthesia"},{"label":"Diminished","tone":"pos","sets":[],"ddx":[{"id":"nerve-inj","keep":true}],"mdm":"Distal sensation is diminished: nerve injury is suspected.","frag":"diminished distal sensation"}]},{"id":"lac-ex-vasc","dx":"deep-structure","q":"Vascular — brisk capillary refill and no expanding hematoma or pulsatile bleeding?","answers":[{"label":"Perfusion intact","tone":"neg","sets":[],"ddx":[],"mdm":"Distal perfusion is intact with no pulsatile bleeding or expanding hematoma.","frag":"distal perfusion intact; no pulsatile bleeding"},{"label":"Vascular concern","tone":"pos","sets":[],"ddx":[{"id":"deep-structure","keep":true}],"mdm":"There is pulsatile bleeding, an expanding hematoma, or a distal perfusion deficit.","frag":"pulsatile bleeding or perfusion deficit"}]}],"conclusions":["simple laceration, repaired","laceration, explored — no deep injury","bite wound managed without closure","wound NOS (low-risk)"],"specs":["ortho","surg","trauma"],"guide":"../learn/complaints/laceration.html"},{"id":"suicidal-ideation","title":"Suicidal Ideation / Self-harm","aliases":["suicidal","suicide","si","self harm","self-harm","psych","psychiatric","depression","wants to die","suicidal ideation","mental health crisis","c-ssrs","safety plan","overdose attempt","cutting"],"opening":"No ED discharge is litigated harder than the patient who later completes suicide. The chart must show a structured risk assessment, a search for occult ingestion, the protective factors actually weighed, and a safety plan that is more than a phrase.","ddx":[{"id":"active-si","group":"lifethreat","label":"Active suicidality requiring higher level of care","default":true,"tags":["active-si"],"ruleout":"Active suicidality requiring inpatient care was considered; a structured risk assessment found no current intent, plan, or access to lethal means, with protective factors and future orientation present, making acute high-risk status unlikely.","miss":3},{"id":"occult-ingestion","group":"lifethreat","label":"Occult ingestion / self-harm already underway","default":true,"tags":["occult-ingestion"],"ruleout":"An ingestion already underway was considered; the patient denied any recent overdose or self-harm act, had no relevant symptoms, and acetaminophen and salicylate screening was negative or not indicated, making occult ingestion unlikely.","miss":3},{"id":"organic","group":"lifethreat","label":"Medical mimic (intoxication, hypoglycemia, delirium)","default":true,"tags":["organic"],"ruleout":"A medical mimic was considered; the patient was alert and oriented with a normal point-of-care glucose, normal vital signs and oxygen saturation, and no evidence of intoxication or delirium, making an organic cause unlikely.","miss":3},{"id":"mdd","group":"common","label":"Depressive / adjustment disorder","default":false,"tags":["mdd"],"ruleout":"A primary depressive or adjustment disorder was considered as the working diagnosis.","miss":2},{"id":"substance-mh","group":"common","label":"Substance-driven crisis","default":false,"tags":["substance-mh"],"ruleout":"A substance-driven crisis was considered, with reassessment after clinical sobriety.","miss":2}],"risk":[{"id":"cssrs","label":"Structured risk screen (C-SSRS or equivalent)","tags":["active-si"],"scale":"low","line":"A structured suicide risk assessment (Columbia protocol or equivalent) was performed and documented, covering ideation, plan, intent, means, and recent behavior.","cite":"Posner K, et al. Am J Psychiatry. 2011.","short":"structured risk screen (C-SSRS) documented"},{"id":"safety-plan","label":"Safety plan + lethal-means counseling","tags":["active-si"],"scale":"low","line":"A personalized safety plan was completed with the patient (warning signs, coping steps, contacts, and crisis resources) and lethal-means counseling (including firearm and medication access) was performed and documented.","short":"safety plan + lethal-means counseling done"},{"id":"collateral","label":"Collateral information obtained","tags":["active-si"],"scale":"low","line":"Collateral information was obtained from family, friends, or outpatient providers and weighed in the risk assessment.","short":"collateral obtained"},{"id":"apap-screen","label":"Acetaminophen / salicylate screening","tags":["occult-ingestion"],"scale":"low","line":"Acetaminophen and salicylate levels were obtained to exclude an occult ingestion, which can be clinically silent in the treatable window.","short":"APAP/salicylate screened"}],"checks":[{"if":"active-si","needs":["cssrs"],"mode":"any","warn":"Use a structured tool (C-SSRS or equivalent) — 'denies SI' without a structured assessment is the least defensible line in psychiatry."},{"if":"active-si","needs":["safety-plan","collateral"],"mode":"any","warn":"If discharge is being considered, document the safety plan, lethal-means counseling, and collateral — these are what the chart is judged on."},{"if":"occult-ingestion","needs":["apap-screen"],"mode":"any","warn":"Ask directly whether anything was already taken, and screen for acetaminophen/salicylate when the story raises any doubt — APAP is silent early."}],"history":[{"id":"si-hx-ideation","dx":"active-si","q":"Current ideation — passive thoughts vs. active ideation with plan, intent, or rehearsal?","answers":[{"label":"Passive / resolved, no plan or intent","tone":"neg","sets":[{"risk":"cssrs"}],"ddx":[],"mdm":"Ideation is passive or resolved, without plan, intent, preparatory behavior, or rehearsal.","frag":"passive or resolved ideation without plan or intent"},{"label":"Active with plan / intent","tone":"pos","sets":[{"risk":"cssrs"}],"ddx":[{"id":"active-si","keep":true}],"mdm":"There is active ideation with a plan, intent, or preparatory behavior.","frag":"active ideation with plan or intent"}]},{"id":"si-hx-attempts","dx":"active-si","q":"Prior attempts — the strongest single predictor — and recency of the last one?","answers":[{"label":"No prior attempts","tone":"neg","sets":[{"risk":"cssrs"}],"ddx":[],"mdm":"There is no history of prior suicide attempts.","frag":"no prior suicide attempts"},{"label":"Prior attempt(s)","tone":"pos","sets":[{"risk":"cssrs"}],"ddx":[{"id":"active-si","keep":true}],"mdm":"There is a history of prior attempt: the strongest predictor of future attempt.","frag":"history of prior suicide attempt"}]},{"id":"si-hx-means","dx":"active-si","q":"Access to lethal means — firearms in the home, stockpiled medications?","answers":[{"label":"No ready access","tone":"neg","sets":[],"ddx":[],"mdm":"There is no ready access to firearms or stockpiled medication, confirmed in the means discussion.","frag":"no ready access to lethal means"},{"label":"Access to lethal means","tone":"pos","sets":[],"ddx":[{"id":"active-si","keep":true}],"mdm":"There is access to lethal means; counseling on restricting access was performed and documented.","frag":"access to firearms or stockpiled medication"}]},{"id":"si-hx-taken","dx":"occult-ingestion","q":"Asked directly: did you take anything tonight — pills, alcohol, anything to hurt yourself — before coming in?","answers":[{"label":"Denies, story consistent","tone":"neg","sets":[],"ddx":[],"mdm":"The patient credibly denies taking any pills, alcohol, or other substance to self-harm before arrival, and the account is internally consistent.","frag":"denies any ingestion; account consistent"},{"label":"Possible / admitted ingestion","tone":"pos","sets":[{"risk":"apap-screen"}],"ddx":[{"id":"occult-ingestion","keep":true}],"mdm":"An ingestion of pills, alcohol, or another substance to self-harm before arrival is admitted or cannot be excluded; the patient is screened and treated as an overdose in parallel.","frag":"possible or admitted ingestion"}]},{"id":"si-hx-protective","dx":"active-si","q":"Protective factors — engaged supports, dependents, treatment alliance, future orientation, willingness to safety-plan?","answers":[{"label":"Present and credible","tone":"neg","sets":[],"ddx":[],"mdm":"Protective factors are present and credible: engaged supports, future orientation, and active engagement with safety planning.","frag":"credible protective factors (supports, future orientation, engages with safety planning)"},{"label":"Few / none","tone":"pos","sets":[],"ddx":[{"id":"active-si","keep":true}],"mdm":"Protective factors (engaged supports, dependents, treatment alliance, future orientation, and willingness to safety-plan) are few or absent, which weighs toward a higher level of care.","frag":"few or no protective factors"}]},{"id":"si-hx-substance","dx":"substance-mh","q":"Substance use now — intoxicated at assessment, or escalating use as part of the crisis?","answers":[{"label":"Sober at assessment","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is clinically sober at the time of the risk assessment.","frag":"clinically sober at assessment"},{"label":"Intoxicated / escalating use","tone":"pos","sets":[],"ddx":[{"id":"substance-mh","keep":true},{"id":"organic","keep":true}],"mdm":"The patient is intoxicated or escalating use: the definitive risk assessment was repeated at clinical sobriety.","frag":"intoxicated at assessment or escalating substance use"}]}],"exam":[{"id":"si-ex-medical","dx":"organic","q":"Medical screen — vitals, glucose, and a directed exam excluding a medical driver of the presentation?","answers":[{"label":"Unremarkable screen","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs, glucose, and the directed examination show no medical driver of the presentation.","frag":"vitals, glucose, and directed exam unremarkable"},{"label":"Abnormal screen","tone":"pos","sets":[],"ddx":[{"id":"organic","keep":true}],"mdm":"The medical screen (vitals, glucose, and a directed exam to exclude a medical driver) is abnormal, and the psychiatric presentation may be secondary.","frag":"abnormal medical screening findings"}]},{"id":"si-ex-mse","dx":"active-si","q":"Mental status — engaged and future-oriented vs. hopeless, agitated, or withdrawn at evaluation?","answers":[{"label":"Engaged, future-oriented","tone":"neg","sets":[],"ddx":[],"mdm":"On mental status examination the patient is engaged, linear, and future-oriented, without hopelessness, agitation, or withdrawal.","frag":"engaged, linear, future-oriented on mental status exam"},{"label":"Hopeless / agitated / withdrawn","tone":"pos","sets":[],"ddx":[{"id":"active-si","keep":true}],"mdm":"The mental status exam shows hopelessness, agitation, or withdrawal rather than an engaged, future-oriented affect.","frag":"hopeless, agitated, or withdrawn affect"}]},{"id":"si-ex-injury","dx":"occult-ingestion","q":"Evidence of self-harm already — cuts, ligature marks, or toxidrome signs?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There were no signs of recent self-harm (cuts or ligature marks) and no toxidrome.","frag":"no signs of self-harm or toxidrome"},{"label":"Present","tone":"pos","sets":[{"risk":"apap-screen"}],"ddx":[{"id":"occult-ingestion","keep":true}],"mdm":"There are signs of recent self-harm (cuts or ligature marks) or an evolving toxidrome.","frag":"signs of self-harm or a toxidrome"}]}],"conclusions":["low acute risk — discharged with safety plan and follow-up","risk requires psychiatric evaluation in the ED","substance-driven crisis, reassessed at sobriety"],"specs":["psych","tox"],"guide":"../learn/complaints/suicidal-ideation.html"},{"id":"overdose","title":"Overdose / Ingestion","aliases":["overdose","ingestion","od","poisoning","took pills","tylenol overdose","acetaminophen","aspirin overdose","salicylate","tca","polypharmacy ingestion","intentional ingestion","accidental ingestion","drank chemicals","toxicology"],"opening":"The ingestion in front of you is rarely the one that kills — it's the acetaminophen quietly co-ingested, the salicylate dismissed as anxiety, and the QRS that widens an hour after a reassuring triage ECG.","ddx":[{"id":"apap","group":"lifethreat","label":"Acetaminophen toxicity (often silent)","default":true,"tags":["apap"],"ruleout":"Acetaminophen toxicity was considered; a level drawn at or beyond four hours post-ingestion was below the treatment line on the Rumack-Matthew nomogram with normal transaminases, making significant toxicity unlikely.","miss":3},{"id":"salicylate","group":"lifethreat","label":"Salicylate toxicity","default":true,"tags":["salicylate"],"ruleout":"Salicylate toxicity was considered; there was no tinnitus, tachypnea, hyperthermia, or altered mentation, and the acid-base picture and salicylate level were unremarkable, making it unlikely.","miss":3},{"id":"cardiotox","group":"lifethreat","label":"Cardiotoxic ingestion (TCA / QT-prolonging)","default":true,"tags":["cardiotox"],"ruleout":"A cardiotoxic ingestion was considered; the ECG showed a narrow QRS without terminal R in aVR and a normal QTc, with stable hemodynamics, making clinically significant cardiotoxicity unlikely.","miss":3},{"id":"opioid-od","group":"lifethreat","label":"Opioid toxicity / respiratory depression","default":false,"tags":["opioid-od"],"ruleout":"Opioid toxicity was considered; the patient maintained an adequate respiratory rate, normal oxygen saturation, and normal mentation throughout an observation period spanning the agent's expected duration, making it unlikely.","miss":3},{"id":"etoh-od","group":"common","label":"Ethanol / sedative co-ingestion","default":false,"tags":["etoh-od"],"ruleout":"Ethanol or sedative co-ingestion was considered.","miss":2},{"id":"benign-ingestion","group":"other","label":"Benign / sub-toxic ingestion","default":false,"tags":["benign-ingestion"],"ruleout":"A sub-toxic ingestion was the working assessment after levels, ECG, and observation.","miss":1}],"risk":[{"id":"apap-level","label":"Timed acetaminophen level (≥ 4 h)","tags":["apap"],"scale":"low","line":"An acetaminophen level drawn at or after 4 hours from ingestion was interpreted against the Rumack-Matthew nomogram.","cite":"Rumack BH, Matthew H. Pediatrics. 1975.","short":"4-hour APAP level below treatment line"},{"id":"sal-level","label":"Salicylate level","tags":["salicylate"],"scale":"low","line":"A salicylate level was obtained and was non-toxic; symptoms and acid-base status were concordant.","short":"salicylate non-toxic"},{"id":"ecg-od","label":"ECG reviewed (QRS / QTc)","tags":["cardiotox"],"scale":"low","line":"The ECG was personally reviewed: QRS narrow, no terminal R in aVR, QTc not prolonged.","short":"ECG: QRS narrow, QTc normal"},{"id":"poison-control","label":"Poison control / toxicology consulted","tags":["apap","salicylate","cardiotox"],"scale":"low","line":"Poison control (or toxicology) was consulted and the recommendations were followed and documented.","short":"poison control consulted"},{"id":"obs-period","label":"Observation across peak toxicity","tags":["opioid-od","cardiotox"],"scale":"low","line":"The patient was observed across the expected peak toxicity of the reported agents, with serial reassessment documented.","short":"observed across expected peak"}],"checks":[{"if":"apap","needs":["apap-level"],"mode":"any","warn":"Every intentional ingestion gets a timed acetaminophen level — early toxicity is silent and the antidote window closes."},{"if":"cardiotox","needs":["ecg-od"],"mode":"any","warn":"Document the ECG review (QRS, aVR, QTc) — and repeat it; cardiotoxicity evolves after arrival."},{"if":"salicylate","needs":["sal-level"],"mode":"any","warn":"Tachypnea plus tinnitus is salicylate until a level says otherwise."},{"if":"opioid-od","needs":["obs-period"],"mode":"any","warn":"After opioid reversal, document an adequate observation period — naloxone can wear off before the opioid does."}],"history":[{"id":"od-hx-what","dx":"apap","q":"Exactly what, how much, and when — including acetaminophen-containing combinations (cold medicines, opioid combos)?","answers":[{"label":"Single agent, time known, no APAP","tone":"neg","sets":[{"risk":"apap-level"}],"ddx":[],"mdm":"A single known agent was taken at a known time, and acetaminophen-containing products were specifically asked about and denied.","frag":"single known agent at a known time; no acetaminophen-containing product"},{"label":"Unknown / multiple / APAP possible","tone":"pos","sets":[{"risk":"apap-level"}],"ddx":[{"id":"apap","keep":true}],"mdm":"The ingestion is unknown, mixed, or may contain acetaminophen: screen broadly and time the level.","frag":"unknown, multiple, or possibly acetaminophen-containing ingestion"}]},{"id":"od-hx-intent","dx":"apap","q":"Intent — intentional self-harm (link the suicide-risk assessment) vs. accidental or therapeutic error?","answers":[{"label":"Accidental / therapeutic error","tone":"neg","sets":[],"ddx":[],"mdm":"The ingestion was accidental or a therapeutic error.","frag":"accidental or therapeutic-error ingestion"},{"label":"Intentional","tone":"pos","sets":[],"ddx":[{"id":"apap","keep":true},{"id":"cardiotox","keep":true}],"mdm":"The ingestion was intentional self-harm rather than accidental or a therapeutic error: a structured suicide risk assessment is documented separately and disposition is joint medical-psychiatric.","frag":"intentional self-harm ingestion"}]},{"id":"od-hx-tinnitus","dx":"salicylate","q":"Tinnitus, hyperventilation, nausea, or diaphoresis — the salicylate constellation?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no tinnitus, hyperventilation, or diaphoresis suggesting salicylism.","frag":"no tinnitus or hyperventilation"},{"label":"Present","tone":"pos","sets":[{"risk":"sal-level"}],"ddx":[{"id":"salicylate","keep":true}],"mdm":"Tinnitus or hyperventilation is present: treat as salicylate toxicity until the level returns.","frag":"tinnitus or hyperventilation"}]},{"id":"od-hx-cardiac-meds","dx":"cardiotox","q":"Access to cardiotoxic agents — TCAs, antipsychotics, antiarrhythmics, or anything QT-prolonging in the home?","answers":[{"label":"No access reported","tone":"neg","sets":[{"risk":"ecg-od"}],"ddx":[],"mdm":"No access to cardiotoxic agents was identified: no TCAs, antipsychotics, antiarrhythmics, or other QT-prolonging medications in the home.","frag":"no access to cardiotoxic agents"},{"label":"Access / possible ingestion","tone":"pos","sets":[{"risk":"ecg-od"}],"ddx":[{"id":"cardiotox","keep":true}],"mdm":"A cardiotoxic agent (a TCA, antipsychotic, antiarrhythmic, or other QT-prolonging medication) was accessible and may have been ingested, so serial ECGs are required.","frag":"possible cardiotoxic agent ingested"}]},{"id":"od-hx-opioid","dx":"opioid-od","q":"Opioids involved — including long-acting or extended-release formulations that outlast naloxone?","answers":[{"label":"No opioids","tone":"neg","sets":[],"ddx":[],"mdm":"No opioid involvement is reported or suspected.","frag":"no opioid involvement"},{"label":"Opioids / long-acting possible","tone":"pos","sets":[{"risk":"obs-period"}],"ddx":[{"id":"opioid-od","keep":true}],"mdm":"Opioids may be involved, including long-acting formulations: observation must outlast the agent, not the naloxone.","frag":"possible opioid ingestion including long-acting formulation"}]}],"exam":[{"id":"od-ex-mental","dx":"opioid-od","q":"Mental status and airway — alert and protecting the airway, with normal respiratory rate and effort?","answers":[{"label":"Alert, protecting airway","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is alert, protecting the airway, with normal respiratory rate and effort.","frag":"alert, protecting airway, normal respirations"},{"label":"Depressed / labored","tone":"pos","sets":[],"ddx":[{"id":"opioid-od","keep":true}],"mdm":"Mental status or respiratory effort is depressed.","frag":"depressed mental status or respiratory effort"}]},{"id":"od-ex-toxidrome","dx":"cardiotox","q":"Toxidrome signs — pupils, skin (dry vs. diaphoretic), bowel sounds, clonus, temperature?","answers":[{"label":"No toxidrome","tone":"neg","sets":[],"ddx":[],"mdm":"Examination showed no toxidrome: pupils, skin moisture, bowel sounds, clonus, and temperature were unremarkable, with no anticholinergic, sympathomimetic, serotonergic, or opioid pattern.","frag":"no toxidrome on examination"},{"label":"Toxidrome present","tone":"pos","sets":[],"ddx":[{"id":"cardiotox","keep":true}],"mdm":"A toxidrome was present on examination: pupils, skin, bowel sounds, clonus, and temperature together identified the drug class.","frag":"toxidrome present on examination"}]},{"id":"od-ex-vitals","dx":"salicylate","q":"Vitals — tachypnea, tachycardia, or hyperthermia out of proportion to anxiety?","answers":[{"label":"Vitals reassuring","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were reassuring, without tachypnea, tachycardia, or hyperthermia out of proportion to anxiety.","frag":"vital signs within normal limits"},{"label":"Abnormal vitals","tone":"pos","sets":[{"risk":"sal-level"}],"ddx":[{"id":"salicylate","keep":true}],"mdm":"Tachypnea, tachycardia, or hyperthermia is present: do not attribute to anxiety before toxicity is excluded.","frag":"tachypnea, tachycardia, or hyperthermia"}]}],"conclusions":["sub-toxic ingestion, observed and medically cleared","ingestion treated, medically cleared for psychiatric evaluation","accidental ingestion, low-risk"],"specs":["tox","psych"]},{"id":"cough","title":"Cough / Possible Pneumonia","aliases":["cough","pneumonia","bronchitis","uri","chest cold","productive cough","lower respiratory infection","lung infection","curb 65","curb-65","chest congestion","tb","tuberculosis","walking pneumonia"],"opening":"Most coughs are bronchitis, but the chart has to show why this one isn't the pneumonia that bounces back septic, the PE wearing a respiratory costume, or the TB that exposed the waiting room.","ddx":[{"id":"pneumonia","group":"lifethreat","label":"Community-acquired pneumonia","default":true,"tags":["pneumonia"],"ruleout":"Pneumonia was considered; the patient was afebrile and non-hypoxic with a clear chest, no focal crackles or consolidation, and no infiltrate on chest imaging when obtained, making it unlikely.","miss":3},{"id":"pe-cough","group":"lifethreat","label":"Pulmonary embolism","default":false,"tags":["pe-cough"],"ruleout":"Pulmonary embolism was considered; there was no pleuritic chest pain, hemoptysis, or unexplained hypoxia or tachycardia, no leg swelling, and no significant VTE risk factors, making it unlikely.","miss":4},{"id":"tb","group":"lifethreat","label":"Tuberculosis","default":false,"tags":["tb"],"ruleout":"Tuberculosis was considered; there were no risk factors, exposures, or relevant travel, no chronic productive cough, hemoptysis, night sweats, or weight loss, and no apical or cavitary findings on imaging, making it unlikely.","miss":3},{"id":"ptx-cough","group":"lifethreat","label":"Pneumothorax","default":false,"tags":["ptx-cough"],"ruleout":"Pneumothorax was considered; the patient had no sudden pleuritic pain or dyspnea, breath sounds were equal bilaterally without hyperresonance, and chest imaging showed no pleural line, making it unlikely.","miss":3},{"id":"malignancy-cough","group":"common","label":"Malignancy (smoker, weight loss, hemoptysis)","default":false,"tags":["malignancy-cough"],"ruleout":"An underlying malignancy was considered in a smoker with persistent cough; outpatient evaluation was arranged.","miss":2},{"id":"bronchitis","group":"common","label":"Acute bronchitis","default":false,"tags":["bronchitis"],"ruleout":"Acute bronchitis was the working diagnosis.","miss":2},{"id":"uri-cough","group":"other","label":"URI / post-viral or postnasal cough","default":false,"tags":["uri-cough"],"ruleout":"An upper-respiratory or post-viral cough was considered.","miss":1},{"id":"aspiration-fb-c","group":"common","label":"Aspiration / airway foreign body","default":false,"tags":["aspiration-fb-c"],"ruleout":"Aspiration and an airway foreign body were considered: a choking episode while eating, or aspiration risk factors, with attention to focal findings.","miss":2}],"risk":[{"id":"curb65","label":"CURB-65 severity score","tags":["pneumonia"],"scale":"low","line":"CURB-65 was documented to ground the disposition decision for community-acquired pneumonia.","cite":"Lim WS, et al. Thorax. 2003.","calc":{"fields":[{"label":"Confusion (new)","opts":[["No",0],["Yes",1]]},{"label":"BUN > 19 mg/dL","opts":[["No",0],["Yes",1]]},{"label":"RR ≥ 30","opts":[["No",0],["Yes",1]]},{"label":"SBP < 90 or DBP ≤ 60","opts":[["No",0],["Yes",1]]},{"label":"Age ≥ 65","opts":[["No",0],["Yes",1]]}],"bands":[[1,"low risk","low","CURB-65 0–1: low severity — outpatient treatment is often appropriate."],[2,"moderate risk","mod","Score 2: consider short-stay admission or close outpatient follow-up."],[5,"high risk","high","≥3: admit; assess for ICU care at 4–5."]],"line":"CURB-65 {score}/5 ({band}); severity stratification documented and used to inform disposition.","applies":"Adults with community-acquired pneumonia, to gauge severity and site of care. It can under-call severity in young patients and ignores hypoxia and comorbidity -- pair it with oxygenation and judgment."},"short":"CURB-65 {band}","bandNotes":{"low":"30-day mortality ≈1.5% (Lim 2003)","moderate":"30-day mortality ≈9% (Lim 2003)","high":"30-day mortality ≈22% (Lim 2003)"}},{"id":"cxr","label":"Chest X-ray reviewed","tags":["pneumonia","malignancy-cough"],"scale":"low","line":"The chest radiograph was personally reviewed for infiltrate, effusion, and mass.","short":"CXR personally reviewed"},{"id":"spo2-doc","label":"Oxygenation documented (rest ± ambulation)","tags":["pneumonia","pe-cough"],"scale":"low","line":"Oxygen saturation was documented at rest, with ambulatory saturation checked before discharge where indicated.","short":"SpO₂ documented, incl. ambulatory"}],"checks":[{"if":"pneumonia","needs":["curb65","cxr"],"mode":"any","warn":"Pneumonia is on the differential — document CURB-65 (or the CXR review) so the home-versus-admit call is grounded, not gestalt."},{"if":"tb","needs":["cxr"],"mode":"any","warn":"TB is on the differential — address isolation and the chest film before the patient sits in a waiting room."},{"if":"malignancy-cough","needs":["cxr"],"mode":"any","warn":"Malignancy is on the differential for persistent cough — document chest imaging and follow-up, especially in smokers."}],"history":[{"id":"cg-hx-duration","dx":"pneumonia","q":"Duration and trajectory — days and worsening (pneumonia pattern) vs. weeks with weight loss or night sweats (think TB / malignancy)?","answers":[{"label":"Acute, days","tone":"neg","sets":[],"ddx":[],"mdm":"The cough was acute, measured in days, without the weeks of duration, weight loss, or night sweats that would suggest TB or malignancy.","frag":"acute cough measured in days"},{"label":"Weeks + constitutional symptoms","tone":"pos","sets":[],"ddx":[{"id":"tb","keep":true},{"id":"malignancy-cough","keep":true}],"mdm":"The cough was prolonged over weeks with weight loss or night sweats, adding TB and malignancy to the differential.","frag":"prolonged cough with weight loss or night sweats"}]},{"id":"cg-hx-age","dx":"pneumonia","q":"Age ≥ 65?","answers":[{"label":"Under 65","tone":"neg","sets":[{"risk":"curb65","field":4,"opt":0}],"ddx":[],"mdm":"The patient is under 65.","frag":"age under 65"},{"label":"65 or older","tone":"pos","sets":[{"risk":"curb65","field":4,"opt":1}],"ddx":[{"id":"pneumonia","keep":true}],"mdm":"The patient is 65 or older.","frag":"age ≥ 65"}]},{"id":"cg-hx-bun","dx":"pneumonia","q":"Labs, if obtained — BUN > 19 mg/dL (7 mmol/L)?","answers":[{"label":"BUN ≤ 19","tone":"neg","sets":[{"risk":"curb65","field":1,"opt":0}],"ddx":[],"mdm":"The BUN is 19 mg/dL or less.","frag":"BUN within normal range"},{"label":"BUN > 19","tone":"pos","sets":[{"risk":"curb65","field":1,"opt":1}],"ddx":[{"id":"pneumonia","keep":true}],"mdm":"The BUN exceeds 19 mg/dL.","frag":"BUN > 19 mg/dL"}]},{"id":"cg-hx-pe","dx":"pe-cough","q":"PE features — pleuritic pain, hemoptysis, unilateral leg swelling, immobilization, prior VTE, or hypoxia out of proportion?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There are no pleuritic features, hemoptysis, or VTE risk factors.","frag":"no pleuritic pain, hemoptysis, or VTE risk factors"},{"label":"PE features present","tone":"pos","sets":[],"ddx":[{"id":"pe-cough","keep":true}],"mdm":"Features compatible with pulmonary embolism (pleuritic pain, hemoptysis, unilateral leg swelling, immobilization, prior VTE, or hypoxia out of proportion) were present, prompting risk stratification rather than anchoring on infection.","frag":"pleuritic pain, hemoptysis, or VTE risk factors"}]},{"id":"cg-hx-tb-risk","dx":"tb","q":"TB risk — known exposure, prior TB, birth or travel in a high-prevalence region, incarceration, homelessness, or immunosuppression?","answers":[{"label":"No risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"There were no tuberculosis risk factors: no known exposure, prior TB, birth or travel in a high-prevalence region, incarceration, homelessness, or immunosuppression.","frag":"no tuberculosis risk factors"},{"label":"Risk factors present","tone":"pos","sets":[],"ddx":[{"id":"tb","keep":true}],"mdm":"Tuberculosis risk factors were present (such as known exposure, prior TB, birth or travel in a high-prevalence region, incarceration, homelessness, or immunosuppression) and isolation criteria were addressed.","frag":"tuberculosis risk factors present"}]},{"id":"cg-hx-smoker","dx":"malignancy-cough","q":"Smoking history with new or changed cough, hemoptysis, or weight loss in an adult > 40?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There is no smoking history with a new or changed cough pattern.","frag":"no smoking-related red flags"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"malignancy-cough","keep":true}],"mdm":"A significant smoking history with a changed cough or systemic features warrants malignancy follow-up.","frag":"smoker with changed cough, hemoptysis, or weight loss"}]},{"id":"cg-hx-ace","dx":"general","q":"On an ACE inhibitor (lisinopril and relatives) — the dry cough that outlasts every antibiotic?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not on an ACE inhibitor.","frag":"not on an ACE inhibitor"},{"label":"On an ACE inhibitor","tone":"pos","sets":[],"ddx":[],"mdm":"The patient takes an ACE inhibitor: a class-effect cough is plausible and a medication change discussion was had.","frag":"ACE-inhibitor cough plausible"}]},{"id":"cg-hx-aspiration","dx":"aspiration-fb-c","q":"A choking episode while eating, or aspiration risk (dysphagia, stroke history, intoxication)?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There was no choking episode and no aspiration risk factor.","frag":"no choking episode or aspiration risk"},{"label":"Choking episode / aspiration risk","tone":"pos","sets":[],"ddx":[{"id":"aspiration-fb-c","keep":true}],"mdm":"A choking episode or aspiration risk is present: an airway foreign body or aspiration pneumonia joins the differential.","frag":"choking episode or aspiration risk"}]}],"exam":[{"id":"cg-ex-confusion","dx":"pneumonia","q":"Mental status — alert and oriented at baseline (new confusion is a CURB-65 point and a severity sign)?","answers":[{"label":"At baseline","tone":"neg","sets":[{"risk":"curb65","field":0,"opt":0}],"ddx":[],"mdm":"The patient is alert with no new confusion.","frag":"alert, no new confusion"},{"label":"New confusion","tone":"pos","sets":[{"risk":"curb65","field":0,"opt":1}],"ddx":[{"id":"pneumonia","keep":true}],"mdm":"New confusion is present: a CURB-65 point and a marker of severe disease.","frag":"new confusion"}]},{"id":"cg-ex-rr","dx":"pneumonia","q":"Respiratory rate ≥ 30?","answers":[{"label":"RR < 30","tone":"neg","sets":[{"risk":"curb65","field":2,"opt":0}],"ddx":[],"mdm":"The respiratory rate is below 30.","frag":"respiratory rate below 30"},{"label":"RR ≥ 30","tone":"pos","sets":[{"risk":"curb65","field":2,"opt":1}],"ddx":[{"id":"pneumonia","keep":true}],"mdm":"The respiratory rate is 30 or higher.","frag":"respiratory rate ≥ 30"}]},{"id":"cg-ex-bp","dx":"pneumonia","q":"Blood pressure — SBP < 90 or DBP ≤ 60?","answers":[{"label":"Normotensive","tone":"neg","sets":[{"risk":"curb65","field":3,"opt":0}],"ddx":[],"mdm":"Blood pressure is above the CURB-65 hypotension thresholds.","frag":"normotensive"},{"label":"Hypotensive","tone":"pos","sets":[{"risk":"curb65","field":3,"opt":1}],"ddx":[{"id":"pneumonia","keep":true}],"mdm":"Blood pressure meets the CURB-65 hypotension criterion.","frag":"SBP < 90 or DBP ≤ 60"}]},{"id":"cg-ex-spo2","dx":"pneumonia","q":"Oxygenation — SpO₂ ≥ 94% at rest, and with ambulation if discharge is planned?","answers":[{"label":"≥ 94% incl. ambulation","tone":"neg","sets":[{"risk":"spo2-doc"}],"ddx":[],"mdm":"Oxygen saturation is at least 94% at rest and with ambulation.","frag":"SpO₂ ≥ 94% at rest and with ambulation"},{"label":"Hypoxic / desaturates","tone":"pos","sets":[{"risk":"spo2-doc"}],"ddx":[{"id":"pneumonia","keep":true},{"id":"pe-cough","keep":true}],"mdm":"The patient is hypoxic at rest or desaturates with ambulation.","frag":"hypoxia at rest or with ambulation"}]},{"id":"cg-ex-lungs","dx":"pneumonia","q":"Lung exam — focal crackles, egophony, or dullness vs. clear or diffusely coarse?","answers":[{"label":"Clear / non-focal","tone":"neg","sets":[],"ddx":[],"mdm":"The lung examination is clear without focal consolidation findings.","frag":"lungs clear without focal findings"},{"label":"Focal findings","tone":"pos","sets":[{"risk":"cxr"}],"ddx":[{"id":"pneumonia","keep":true}],"mdm":"Focal lung findings (crackles, egophony, or dullness); suggested consolidation.","frag":"focal crackles or signs of consolidation"}]},{"answers":[{"ddx":[],"frag":"equal breath sounds, no sudden pleuritic pain","label":"No pneumothorax signs","mdm":"There was no sudden pleuritic pain or dyspnea, breath sounds were equal bilaterally without hyperresonance, and chest imaging showed no pleural line, making pneumothorax unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"ptx-cough","keep":true}],"frag":"sudden pleuritic pain with decreased breath sounds","label":"Pneumothorax signs present","mdm":"Sudden pleuritic pain or dyspnea with asymmetric breath sounds or hyperresonance was present, raising concern for pneumothorax and warranting chest imaging.","sets":[],"tone":"pos"}],"dx":"ptx-cough","id":"cg-exam-ptx-cough","q":"Pneumothorax — sudden pleuritic pain or dyspnea, asymmetric breath sounds, or hyperresonance?"}],"conclusions":["acute bronchitis — antibiotics not indicated","community-acquired pneumonia, low-risk — outpatient treatment","viral URI / post-viral cough"],"specs":["pulm","id"],"guide":"../learn/complaints/cough.html"},{"id":"epistaxis","title":"Epistaxis","aliases":["epistaxis","nosebleed","nose bleed","bleeding nose","posterior nosebleed","nosebleed on blood thinner","recurrent nosebleed"],"opening":"An anterior nosebleed is a procedure; a posterior bleed is an airway-and-volume problem; and on anticoagulation, either one is a systemic decision — the chart should show which of the three this was.","ddx":[{"id":"posterior","group":"lifethreat","label":"Posterior epistaxis","default":true,"tags":["posterior"],"ruleout":"A posterior source was considered; bleeding was controlled with anterior pressure without persistent drainage into the oropharynx, an anterior septal source was identified, and the patient remained hemodynamically stable, making a posterior bleed unlikely.","miss":3},{"id":"coagulopathy","group":"lifethreat","label":"Coagulopathy / anticoagulant-driven bleeding","default":true,"tags":["coagulopathy"],"ruleout":"Coagulopathy was considered; the patient was not on anticoagulants or antiplatelet agents beyond expected, had no bruising or bleeding elsewhere, and coagulation studies were normal where checked, making a bleeding diathesis unlikely.","miss":3},{"id":"htn-epistaxis","group":"lifethreat","label":"Severe hypertension / hemodynamic instability","default":false,"tags":["htn-epistaxis"],"ruleout":"Hemodynamically significant blood loss and severe hypertension were considered; the patient was normotensive without tachycardia or orthostasis, and serial vitals remained stable with bleeding controlled, making instability unlikely.","miss":3},{"id":"neoplasm-nose","group":"common","label":"Neoplasm (recurrent unilateral)","default":false,"tags":["neoplasm-nose"],"ruleout":"A nasal or nasopharyngeal neoplasm was considered for recurrent unilateral bleeding and referred appropriately.","miss":2},{"id":"anterior","group":"common","label":"Anterior epistaxis (Kiesselbach)","default":false,"tags":["anterior"],"ruleout":"An anterior septal source was identified or presumed and managed locally.","miss":2}],"risk":[{"id":"anticoag-nose","label":"Anticoagulation reviewed / reversal addressed","tags":["coagulopathy"],"scale":"low","line":"The patient's anticoagulant and antiplatelet regimen was reviewed; the indication, the bleeding severity, and whether to hold or reverse were weighed and documented.","short":"anticoagulation addressed"},{"id":"source-vis","label":"Bleeding source directly visualized","tags":["anterior","posterior"],"scale":"low","line":"The nasal cavity was examined after clot evacuation and the bleeding source was directly visualized anteriorly.","short":"anterior source visualized"},{"id":"obs-tamponade","label":"Observed after hemostasis","tags":["posterior"],"scale":"low","line":"The patient was observed after hemostasis with no rebleeding, and the oropharynx was re-inspected before discharge.","short":"observed post-hemostasis, no rebleed"}],"checks":[{"if":"posterior","needs":["source-vis","obs-tamponade"],"mode":"any","warn":"Posterior bleeding is on the differential — document the source visualization and the post-hemostasis oropharynx recheck."},{"if":"coagulopathy","needs":["anticoag-nose"],"mode":"any","warn":"Document the anticoagulation decision — holding, continuing, or reversing is the consequential call in epistaxis."}],"history":[{"id":"ep-hx-anticoag","dx":"coagulopathy","q":"Anticoagulant or antiplatelet use — warfarin, DOAC, clopidogrel, or aspirin?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"The patient takes no anticoagulant or antiplatelet agent: no warfarin, DOAC, clopidogrel, or aspirin.","frag":"no anticoagulant or antiplatelet use"},{"label":"On anticoagulation","tone":"pos","sets":[{"risk":"anticoag-nose"}],"ddx":[{"id":"coagulopathy","keep":true}],"mdm":"The patient is on anticoagulant or antiplatelet therapy (warfarin, a DOAC, clopidogrel, or aspirin); the hold/reverse decision is documented.","frag":"on anticoagulant/antiplatelet therapy"}]},{"id":"ep-hx-pattern","dx":"neoplasm-nose","q":"Pattern — recurrent and unilateral from the same side, or with nasal obstruction (think neoplasm), vs. sporadic?","answers":[{"label":"Sporadic / bilateral","tone":"neg","sets":[],"ddx":[],"mdm":"The bleeding pattern is sporadic without recurrent unilateral predominance.","frag":"sporadic pattern without unilateral recurrence"},{"label":"Recurrent unilateral / obstruction","tone":"pos","sets":[],"ddx":[{"id":"neoplasm-nose","keep":true}],"mdm":"Recurrent unilateral bleeding from the same side or with new nasal obstruction was reported, a pattern warranting ENT referral to exclude neoplasm.","frag":"recurrent unilateral bleeding or new obstruction"}]},{"id":"ep-hx-bleeding-dx","dx":"coagulopathy","q":"Bleeding diathesis — easy bruising, gum bleeding, family bleeding history, liver disease, or heavy alcohol use?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There were no features of a systemic bleeding diathesis: no easy bruising, gum bleeding, family bleeding history, liver disease, or heavy alcohol use.","frag":"no bleeding-diathesis features"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"coagulopathy","keep":true}],"mdm":"Features of a bleeding diathesis (easy bruising, gum bleeding, family bleeding history, liver disease, or heavy alcohol use) were present; screening labs are indicated.","frag":"bleeding-diathesis features"}]},{"id":"ep-hx-volume","dx":"posterior","q":"Volume and duration — brisk, prolonged (> 30 min), or with lightheadedness or syncope?","answers":[{"label":"Minor, self-limited","tone":"neg","sets":[],"ddx":[],"mdm":"The bleeding was minor and self-limited: not brisk or prolonged beyond 30 minutes, and without associated lightheadedness or syncope.","frag":"minor, self-limited bleeding"},{"label":"Brisk / prolonged / presyncope","tone":"pos","sets":[],"ddx":[{"id":"posterior","keep":true}],"mdm":"The bleeding was brisk or prolonged with systemic symptoms.","frag":"brisk or prolonged bleeding with presyncope"}]}],"exam":[{"id":"ep-ex-vitals","dx":"posterior","q":"Hemodynamics — heart rate and blood pressure normal, no orthostasis?","answers":[{"label":"Stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is hemodynamically stable.","frag":"hemodynamically stable"},{"label":"Tachycardic / hypotensive","tone":"pos","sets":[],"ddx":[{"id":"posterior","keep":true}],"mdm":"There is tachycardia, hypotension, or orthostasis: treat as significant hemorrhage.","frag":"hemodynamic compromise"}]},{"id":"ep-ex-source","dx":"anterior","q":"Anterior rhinoscopy after clot evacuation — anterior septal source visualized?","answers":[{"label":"Anterior source seen","tone":"neg","sets":[{"risk":"source-vis"}],"ddx":[],"mdm":"An anterior septal source was directly visualized.","frag":"anterior septal source visualized"},{"label":"No anterior source","tone":"pos","sets":[],"ddx":[{"id":"posterior","keep":true}],"mdm":"No anterior source is seen despite adequate examination: a posterior source becomes more likely.","frag":"no anterior source identified"}]},{"id":"ep-ex-posterior","dx":"posterior","q":"Oropharynx — blood running down the posterior pharynx despite anterior pressure or packing?","answers":[{"label":"Oropharynx clear","tone":"neg","sets":[{"risk":"obs-tamponade"}],"ddx":[],"mdm":"The oropharynx is clear with no posterior trickle.","frag":"no posterior pharyngeal bleeding"},{"label":"Posterior trickle","tone":"pos","sets":[],"ddx":[{"id":"posterior","keep":true}],"mdm":"Blood continues down the posterior pharynx despite anterior control: posterior bleeding.","frag":"ongoing posterior pharyngeal bleeding"}]},{"id":"ep-ex-other-bleed","dx":"coagulopathy","q":"Other bleeding signs — petechiae, purpura, gum bleeding, or hematuria?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There were no other bleeding signs on examination: no petechiae, purpura, gum bleeding, or hematuria.","frag":"no other bleeding signs"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"coagulopathy","keep":true}],"mdm":"Bleeding signs at other sites (petechiae, purpura, gum bleeding, or hematuria) were present, suggesting a systemic process.","frag":"petechiae or other site bleeding"}]},{"answers":[{"ddx":[],"frag":"normotensive, no tachycardia or orthostasis","label":"Hemodynamically stable","mdm":"The patient was normotensive without tachycardia or orthostasis, and serial vitals remained stable with bleeding controlled, making hemodynamic instability or severe hypertension unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"htn-epistaxis","keep":true}],"frag":"hypertension, tachycardia, or ongoing bleeding","label":"Unstable / severe HTN","mdm":"Severe hypertension, tachycardia, orthostasis, or ongoing uncontrolled bleeding was present, requiring active hemodynamic management and blood-pressure control.","sets":[],"tone":"pos"}],"dx":"htn-epistaxis","id":"ep-exam-htn-epistaxis","q":"Hemodynamic status — hypertension, tachycardia, orthostasis, or ongoing uncontrolled bleeding?"}],"conclusions":["anterior epistaxis, hemostasis achieved","epistaxis controlled, anticoagulation continued with plan","epistaxis resolved, ENT follow-up arranged"],"specs":["ent","heme"],"guide":"../learn/complaints/epistaxis.html"},{"id":"hyperglycemia","title":"Hyperglycemia / DKA","aliases":["hyperglycemia","high blood sugar","dka","diabetic ketoacidosis","hhs","diabetes","sugar high","glucose high","euglycemic dka","sglt2","new diabetes","diabetic emergency"],"opening":"The glucose is a number, not a diagnosis. The chart has to show three things: that ketoacidosis was excluded (including euglycemic DKA on SGLT2 inhibitors), that the precipitant was hunted, and why this patient was safe to titrate as an outpatient.","ddx":[{"id":"dka","group":"lifethreat","label":"Diabetic ketoacidosis (incl. euglycemic)","default":true,"tags":["dka"],"ruleout":"DKA, including euglycemic DKA, was considered; the patient had no ketonemia or ketonuria, no anion-gap metabolic acidosis, and normal bicarbonate with no Kussmaul respirations, making it unlikely regardless of the glucose value.","miss":4},{"id":"hhs","group":"lifethreat","label":"Hyperosmolar hyperglycemic state","default":false,"tags":["hhs"],"ruleout":"HHS was considered; the patient was alert with normal mentation, was not significantly dehydrated, and serum osmolality was not markedly elevated, making it unlikely.","miss":3},{"id":"precipitant","group":"lifethreat","label":"Serious precipitant (infection, MI, ischemia)","default":true,"tags":["precipitant"],"ruleout":"A serious precipitant was actively sought; there were no infectious symptoms or fever, no chest pain or ischemic ECG changes, and the elevation was attributable to an identified benign cause, making an acute serious trigger unlikely.","miss":3},{"id":"new-dm","group":"common","label":"New-onset diabetes","default":false,"tags":["new-dm"],"ruleout":"New-onset diabetes was considered and connected to urgent outpatient initiation of care.","miss":2},{"id":"nonadherence","group":"other","label":"Nonadherence / simple hyperglycemia","default":false,"tags":["nonadherence"],"ruleout":"Medication gap or dietary excursion was the working explanation once DKA and a serious precipitant were excluded.","miss":1}],"risk":[{"id":"ketones-gap","label":"Ketones + anion gap checked","tags":["dka"],"scale":"low","line":"Serum ketones (or beta-hydroxybutyrate) and the anion gap were checked and did not show ketoacidosis.","short":"ketones negative, no gap"},{"id":"sglt2-check","label":"SGLT2-inhibitor use addressed","tags":["dka"],"scale":"low","line":"SGLT2-inhibitor use was specifically reviewed because euglycemic DKA can occur at near-normal glucose values.","short":"SGLT2 (euglycemic DKA) addressed"},{"id":"precip-search","label":"Precipitant search documented","tags":["precipitant"],"scale":"low","line":"A precipitant search was documented (infectious review and examination, and cardiac symptoms); rather than attributing hyperglycemia to nonadherence by default.","short":"precipitant search documented"},{"id":"ecg-hyperglyc","label":"ECG reviewed","tags":["precipitant"],"scale":"low","line":"The ECG was reviewed for silent ischemia and for the effects of potassium derangement.","short":"ECG reviewed"}],"checks":[{"if":"dka","needs":["ketones-gap"],"mode":"any","warn":"Document ketones and the gap — 'glucose improved with fluids' does not exclude DKA, and SGLT2 inhibitors make the glucose itself unreliable."},{"if":"precipitant","needs":["precip-search","ecg-hyperglyc"],"mode":"any","warn":"Hunt the precipitant — the missed diagnosis in hyperglycemia is rarely the sugar; it's the infection or the silent MI that drove it."},{"if":"hhs","needs":["ketones-gap"],"mode":"any","warn":"Hyperosmolar hyperglycemic state is on the differential — document ketones/anion gap (and osmolality) to distinguish it from DKA."}],"history":[{"id":"hg-hx-meds","dx":"nonadherence","q":"Medication history — missed insulin or oral agents, pump malfunction, or recent steroid course?","answers":[{"label":"Adherent, no changes","tone":"neg","sets":[],"ddx":[],"mdm":"The patient reported medication adherence without missed insulin or oral agents, pump malfunction, or a recent steroid course.","frag":"adherent without medication changes"},{"label":"Missed doses / pump issue / steroids","tone":"pos","sets":[],"ddx":[{"id":"nonadherence","keep":true}],"mdm":"A medication-related trigger (missed insulin or oral agents, pump malfunction, or a recent steroid course); likely contributed to the hyperglycemia.","frag":"missed doses, pump malfunction, or recent steroids"}]},{"id":"hg-hx-sglt2","dx":"dka","q":"On an SGLT2 inhibitor (empagliflozin, dapagliflozin, canagliflozin) — euglycemic DKA risk?","answers":[{"label":"No","tone":"neg","sets":[{"risk":"sglt2-check"}],"ddx":[],"mdm":"The patient is not on an SGLT2 inhibitor.","frag":"not on an SGLT2 inhibitor"},{"label":"Yes","tone":"pos","sets":[{"risk":"sglt2-check"},{"risk":"ketones-gap"}],"ddx":[{"id":"dka","keep":true}],"mdm":"The patient takes an SGLT2 inhibitor: check ketones even at modest glucose values.","frag":"on an SGLT2 inhibitor (euglycemic DKA possible)"}]},{"id":"hg-hx-symptoms","dx":"dka","q":"DKA symptoms — nausea, vomiting, abdominal pain, or rapid breathing?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"The patient denied DKA symptoms: nausea, vomiting, abdominal pain, and rapid breathing were all absent.","frag":"no nausea, vomiting, abdominal pain, or dyspnea"},{"label":"Present","tone":"pos","sets":[{"risk":"ketones-gap"}],"ddx":[{"id":"dka","keep":true}],"mdm":"Symptoms compatible with DKA (nausea, vomiting, abdominal pain, or rapid breathing) were present.","frag":"nausea, vomiting, abdominal pain, or rapid breathing"}]},{"id":"hg-hx-infection","dx":"precipitant","q":"Infectious review — fever, urinary symptoms, cough, skin or foot wounds?","answers":[{"label":"No infectious symptoms","tone":"neg","sets":[{"risk":"precip-search"}],"ddx":[],"mdm":"The infectious review was negative: no fever, urinary symptoms, cough, or skin or foot wounds.","frag":"no infectious symptoms on review"},{"label":"Infectious symptoms","tone":"pos","sets":[{"risk":"precip-search"}],"ddx":[{"id":"precipitant","keep":true}],"mdm":"Infectious symptoms (fever, urinary symptoms, cough, or a skin or foot wound) were present and represent the likely precipitant.","frag":"infectious symptoms present"}]},{"id":"hg-hx-cardiac","dx":"precipitant","q":"Cardiac symptoms — chest pressure, dyspnea, or diaphoresis (diabetics infarct silently)?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"ecg-hyperglyc"}],"ddx":[],"mdm":"The patient denied cardiac symptoms, with no chest pressure, dyspnea, or diaphoresis to suggest silent ischemia.","frag":"no cardiac symptoms"},{"label":"Present","tone":"pos","sets":[{"risk":"ecg-hyperglyc"}],"ddx":[{"id":"precipitant","keep":true}],"mdm":"Cardiac symptoms (chest pressure, dyspnea, or diaphoresis) were present, and silent ischemia may be the precipitant.","frag":"cardiac symptoms present"}]},{"id":"hg-hx-polyuria","dx":"hhs","q":"Duration — days of polyuria, polydipsia, and weight loss (HHS develops slowly; profound dehydration)?","answers":[{"label":"Short / mild course","tone":"neg","sets":[],"ddx":[],"mdm":"The course was brief without prolonged polyuria, polydipsia, or weight loss to suggest the profound dehydration of HHS.","frag":"brief course without profound osmotic symptoms"},{"label":"Days of osmotic symptoms","tone":"pos","sets":[],"ddx":[{"id":"hhs","keep":true}],"mdm":"A prolonged course of polyuria, polydipsia, and weight loss was reported, suggesting significant dehydration and possible HHS.","frag":"days of polyuria and polydipsia with weight loss"}]}],"exam":[{"id":"hg-ex-mental","dx":"hhs","q":"Mental status — alert and at baseline (obtundation tracks with osmolality)?","answers":[{"label":"Alert, baseline","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is alert and at baseline.","frag":"alert and at neurologic baseline"},{"label":"Altered","tone":"pos","sets":[],"ddx":[{"id":"hhs","keep":true},{"id":"dka","keep":true}],"mdm":"Mental status is altered: HHS or severe DKA territory.","frag":"altered mental status"}]},{"id":"hg-ex-volume","dx":"dka","q":"Volume status — mucous membranes, tachycardia, orthostasis, urine output?","answers":[{"label":"Euvolemic","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was clinically euvolemic, with moist mucous membranes, no tachycardia or orthostasis, and preserved urine output.","frag":"clinically euvolemic"},{"label":"Volume depleted","tone":"pos","sets":[],"ddx":[{"id":"dka","keep":true},{"id":"hhs","keep":true}],"mdm":"There was clinically significant volume depletion, with findings such as dry mucous membranes, tachycardia, orthostasis, or reduced urine output.","frag":"clinically volume depleted"}]},{"id":"hg-ex-kussmaul","dx":"dka","q":"Respirations — deep/rapid (Kussmaul) or fruity breath odor?","answers":[{"label":"Normal respirations","tone":"neg","sets":[],"ddx":[],"mdm":"Respirations are normal without a ketotic odor.","frag":"no Kussmaul respirations"},{"label":"Kussmaul / ketotic odor","tone":"pos","sets":[{"risk":"ketones-gap"}],"ddx":[{"id":"dka","keep":true}],"mdm":"Kussmaul respirations or a ketotic odor is present.","frag":"Kussmaul respirations or ketotic breath"}]},{"id":"hg-ex-focus","dx":"precipitant","q":"Infection focus exam — skin, feet (between the toes), insulin sites, dentition, flanks?","answers":[{"label":"No focus found","tone":"neg","sets":[{"risk":"precip-search"}],"ddx":[],"mdm":"A directed examination of the skin, feet (including between the toes), insulin sites, dentition, and flanks showed no infectious focus.","frag":"no infectious focus on directed exam"},{"label":"Focus found","tone":"pos","sets":[{"risk":"precip-search"}],"ddx":[{"id":"precipitant","keep":true}],"mdm":"An infectious focus was identified on directed examination of the skin, feet, insulin sites, dentition, or flanks.","frag":"infectious focus identified"}]}],"conclusions":["simple hyperglycemia — DKA excluded, outpatient titration","new-onset diabetes without ketoacidosis","hyperglycemia from missed doses, corrected"],"specs":["endo"],"decisionTree":{"title":"DKA / hyperglycemic emergency","intro":"An original, evidence-based decision aid for the hyperglycemic crisis. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Assess & confirm","items":["ABCs, IV access, cardiac monitor","Check glucose, a venous blood gas, electrolytes (including potassium), and ketones","ECG (ischemic precipitant and hyperkalemic changes)"],"next":"q_dka"},"q_dka":{"type":"decision","q":"DKA or HHS? (hyperglycemia with anion-gap acidosis/ketosis, or marked hyperglycemia with hyperosmolarity)","yes":"q_k","no":"a_simple"},"a_simple":{"type":"action","title":"Hyperglycemia without DKA/HHS","terminal":true,"items":["Rehydrate; adjust or resume the home regimen","Identify the precipitant; arrange follow-up and return precautions"]},"q_k":{"type":"decision","q":"Potassium known and ≥3.3 mmol/L?","cantmiss":"Check potassium BEFORE starting insulin — insulin drives K⁺ into cells and can cause life-threatening hypokalemia.","yes":"a_treat","no":"a_holdinsulin"},"a_holdinsulin":{"type":"action","tone":"danger","title":"Replace potassium first","items":["Give IV fluids and potassium","HOLD insulin until potassium is ≥3.3 mmol/L"],"next":"a_treat"},"a_treat":{"type":"action","title":"Fluids, insulin, and potassium","items":["IV isotonic fluids first","Insulin infusion","Add potassium to fluids once K⁺ <5.0–5.5 mmol/L with adequate urine output","Hourly glucose; frequent electrolytes"],"next":"q_glucose"},"q_glucose":{"type":"decision","q":"Glucose falling toward ~200–250 mg/dL while the anion gap is still open?","yes":"a_dextrose","no":"a_dispo"},"a_dextrose":{"type":"action","title":"Add dextrose, keep insulin going","items":["Add dextrose-containing fluids and continue the insulin infusion until the gap closes"],"pitfall":"Stopping insulin when glucose falls but the gap is still open lets ketoacidosis persist — add dextrose and continue insulin instead.","next":"a_dispo"},"a_dispo":{"type":"action","tone":"branch","title":"Reassess & admit","terminal":true,"items":["Track gap closure and electrolytes; transition to subcutaneous insulin only once the gap has closed","Treat the precipitant; admit (ICU/step-down for severe disease)"]}}},"guide":"../learn/complaints/hyperglycemia.html"},{"id":"hypoglycemia","specs":["endo"],"title":"Hypoglycemia / low blood sugar","aliases":["hypoglycemia","low blood sugar","low sugar","hypoglycemic","insulin reaction","sulfonylurea","glipizide","glyburide","insulin overdose","sugar low","glucose low","found down diabetic","altered diabetic","sweaty shaky","neuroglycopenia"],"opening":"Correcting the number is the easy part; the chart has to show why it happened and why it will not happen again on the drive home. Two traps dominate: a sulfonylurea low recurs for many hours, so one amp of dextrose and a discharge is a trap -- observe and consider octreotide; and hypoglycemia in someone not on a glucose-lowering drug is a red flag for sepsis, adrenal failure, or liver disease, not a nuisance to feed and street.","ddx":[{"id":"sulfonylurea","group":"lifethreat","label":"Sulfonylurea-induced (prolonged / recurrent)","default":true,"tags":["sulfonylurea"],"ruleout":"Sulfonylurea-induced hypoglycemia was considered; the patient was on no sulfonylurea, glucose remained normal after correction through a monitored observation period without recurrence, making prolonged drug-driven hypoglycemia unlikely.","miss":3},{"id":"critical-illness","group":"lifethreat","label":"Sepsis / critical-illness / organ-failure hypoglycemia","default":true,"tags":["critical-illness"],"ruleout":"Critical-illness hypoglycemia was considered; the patient was well-appearing and afebrile with normal vital signs, no signs of sepsis or hepatic failure, and a clear benign explanation for the low glucose, making serious underlying illness unlikely.","miss":3},{"id":"adrenal","group":"lifethreat","label":"Adrenal insufficiency / hypopituitarism","default":false,"tags":["adrenal"],"ruleout":"Adrenal insufficiency was considered; the hypoglycemia was explained and non-recurrent without hypotension, hyponatremia, hyperpigmentation, or steroid-use history, making it unlikely.","miss":3},{"id":"intentional","group":"lifethreat","label":"Intentional insulin / sulfonylurea overdose (self-harm)","default":false,"tags":["intentional"],"ruleout":"An intentional or factitious overdose was considered; the exposure was consistent with prescribed dosing, the patient denied self-harm intent, and the history showed no discrepancy suggesting surreptitious administration, making it unlikely.","miss":3},{"id":"insulin-excess","group":"common","label":"Insulin excess / missed meal (diabetic)","default":true,"tags":["insulin-excess"],"ruleout":"The likely mechanism -- too much insulin relative to intake or activity -- was identified, corrected, and addressed with a plan to prevent recurrence.","miss":2},{"id":"alcohol-starv","group":"common","label":"Alcohol / starvation ketotic hypoglycemia","default":false,"tags":["alcohol-starv"],"ruleout":"Alcohol use or poor caloric intake as a driver was considered, with thiamine and nutrition addressed.","miss":2},{"id":"endogenous","group":"other","label":"Endogenous hyperinsulinism / insulinoma (rare)","default":false,"tags":["endogenous"],"ruleout":"Endogenous hyperinsulinism was noted for outpatient evaluation when hypoglycemia recurred in a non-diabetic without an exogenous agent.","miss":1}],"risk":[{"id":"glucose-corrected","label":"Glucose corrected and rechecked","tags":["insulin-excess"],"scale":"low","line":"The glucose was corrected and a repeat point-of-care value confirmed sustained normoglycemia after treatment.","short":"glucose corrected and rechecked"},{"id":"agent-identified","label":"Culprit agent / cause identified","tags":["sulfonylurea"],"scale":"low","line":"The responsible agent or mechanism was identified -- insulin, a sulfonylurea, alcohol, or an organic cause -- rather than treating the number in isolation.","short":"cause/agent identified"},{"id":"sulfonylurea-obs","label":"Sulfonylurea -> extended observation","tags":["sulfonylurea"],"scale":"high","line":"For sulfonylurea exposure, an extended observation period was used because hypoglycemia recurs for many hours, and octreotide and admission were considered rather than discharging after a single correction.","short":"sulfonylurea: extended observation"},{"id":"nondiabetic-workup","label":"Non-diabetic hypoglycemia worked up","tags":["critical-illness"],"scale":"high","line":"Because hypoglycemia in a patient not on a glucose-lowering agent is abnormal, a cause was sought -- sepsis, hepatic failure, adrenal insufficiency, or occult insulin -- rather than simply feeding and discharging.","short":"non-diabetic cause sought"},{"id":"eats-before-dc","label":"Tolerating oral intake before discharge","tags":["insulin-excess"],"scale":"low","line":"Before discharge the patient was tolerating oral intake, had a meal, and had a means to eat and monitor at home with reliable follow-up.","short":"tolerating PO; safe to discharge"},{"id":"selfharm-screen","label":"Self-harm screen if intentional","tags":["intentional"],"scale":"low","line":"Where the exposure could be intentional, a self-harm screen was performed and psychiatric evaluation arranged after medical clearance.","short":"self-harm screen done"}],"checks":[{"if":"sulfonylurea","needs":["sulfonylurea-obs"],"mode":"any","warn":"A single dextrose bolus does not 'fix' a sulfonylurea low -- it recurs for hours. Observe, feed, consider octreotide, and admit rather than discharging on a transient normal value."},{"if":"critical-illness","needs":["nondiabetic-workup"],"mode":"any","warn":"Hypoglycemia without a glucose-lowering drug is a red flag, not a nuisance -- look for sepsis, hepatic failure, or adrenal insufficiency before discharge."},{"if":"insulin-excess","needs":["glucose-corrected","eats-before-dc"],"mode":"all","warn":"Document the recheck and that the patient ate -- discharging on a single corrected value without confirming sustained intake is how people bounce back obtunded."}],"history":[{"id":"hy-hx-agent","dx":"sulfonylurea","q":"Glucose-lowering agent -- insulin, a sulfonylurea (glipizide/glyburide), both, or none?","answers":[{"label":"None of these","tone":"neg","sets":[],"ddx":[{"id":"critical-illness","keep":true}],"mdm":"The patient takes no insulin or sulfonylurea.","frag":"no glucose-lowering agent"},{"label":"Sulfonylurea (+/- insulin)","tone":"pos","sets":[{"risk":"agent-identified"}],"ddx":[{"id":"sulfonylurea","keep":true}],"mdm":"A sulfonylurea is involved, so a prolonged, recurrent course is expected.","frag":"on a sulfonylurea"},{"label":"Insulin only","tone":"pos","sets":[{"risk":"agent-identified"}],"ddx":[{"id":"insulin-excess","keep":true}],"mdm":"Exogenous insulin excess is the likely mechanism.","frag":"insulin-treated"}]},{"id":"hy-hx-diabetic","dx":"critical-illness","q":"Is the patient actually diabetic, or is this hypoglycemia without any glucose-lowering drug?","answers":[{"label":"Known diabetic on therapy","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is a known diabetic on glucose-lowering therapy.","frag":"known diabetic on therapy"},{"label":"Not diabetic / no agent","tone":"pos","sets":[{"risk":"nondiabetic-workup"}],"ddx":[{"id":"critical-illness","keep":true},{"id":"adrenal","keep":true},{"id":"endogenous","keep":true}],"mdm":"Hypoglycemia without a glucose-lowering agent is abnormal and prompts a search for an organic cause.","frag":"non-diabetic hypoglycemia"}]},{"id":"hy-hx-intent","dx":"intentional","q":"Any concern for intentional or factitious overdose?","answers":[{"label":"No, clearly accidental","tone":"neg","sets":[],"ddx":[],"mdm":"The exposure appears accidental.","frag":"accidental exposure"},{"label":"Possible intentional / factitious","tone":"pos","sets":[{"risk":"selfharm-screen"}],"ddx":[{"id":"intentional","keep":true}],"mdm":"Intentional or factitious insulin/sulfonylurea use is a concern.","frag":"possible intentional overdose"}]},{"id":"hy-hx-intake","dx":"alcohol-starv","q":"Alcohol use, poor intake, or missed meals around the event?","answers":[{"label":"Eating normally, no alcohol","tone":"neg","sets":[],"ddx":[],"mdm":"Intake was normal without significant alcohol.","frag":"normal intake"},{"label":"Alcohol / poor intake","tone":"pos","sets":[],"ddx":[{"id":"alcohol-starv","keep":true}],"mdm":"Alcohol or poor caloric intake contributed; thiamine and nutrition were addressed.","frag":"alcohol / poor intake"}]},{"id":"hy-hx-infection","dx":"critical-illness","q":"Fever, infectious symptoms, or looks systemically unwell?","answers":[{"label":"Well-appearing, no infection","tone":"neg","sets":[],"ddx":[],"mdm":"There are no infectious symptoms and the patient is well-appearing.","frag":"no infectious features"},{"label":"Infectious / unwell","tone":"pos","sets":[{"risk":"nondiabetic-workup"}],"ddx":[{"id":"critical-illness","keep":true}],"mdm":"Infectious symptoms raise sepsis-related hypoglycemia.","frag":"infectious / unwell"}]},{"id":"hy-hx-severity","dx":"insulin-excess","q":"Severity -- did the patient need assistance, lose consciousness, or seize?","answers":[{"label":"Self-treated, mild","tone":"neg","sets":[],"ddx":[],"mdm":"The episode was mild and self-treated.","frag":"mild, self-treated"},{"label":"Needed help / LOC / seizure","tone":"pos","sets":[],"ddx":[{"id":"insulin-excess","keep":true}],"mdm":"A severe episode (needing assistance, loss of consciousness, or seizure) raises the bar for observation and a recurrence plan.","frag":"severe episode (assistance/LOC/seizure)"}]}],"exam":[{"id":"hy-ex-glucose","dx":"insulin-excess","q":"Glucose -- corrected and rechecked after treatment?","answers":[{"label":"Corrected, recheck normal","tone":"neg","sets":[{"risk":"glucose-corrected"}],"ddx":[],"mdm":"The glucose is corrected and the repeat value is normal.","frag":"glucose corrected, recheck normal"},{"label":"Still low / not rechecked","tone":"pos","sets":[],"ddx":[{"id":"insulin-excess","keep":true}],"mdm":"The glucose remains low or has not been rechecked -- treatment and monitoring continue.","frag":"glucose still low / unrechecked"}]},{"id":"hy-ex-mental","dx":"insulin-excess","q":"Mental status -- neuroglycopenia resolved and back to baseline?","answers":[{"label":"Alert, baseline","tone":"neg","sets":[],"ddx":[],"mdm":"Mental status returned to baseline after correction.","frag":"mental status back to baseline"},{"label":"Still altered","tone":"pos","sets":[],"ddx":[{"id":"critical-illness","keep":true},{"id":"intentional","keep":true}],"mdm":"Persistent altered mental status despite a corrected glucose demands another explanation.","frag":"persistent altered mental status"}]},{"id":"hy-ex-vitals","dx":"critical-illness","q":"Vitals -- any signs of sepsis or hemodynamic compromise?","answers":[{"label":"Stable vitals","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs are stable without signs of sepsis.","frag":"vitals stable"},{"label":"Unstable / septic-appearing","tone":"pos","sets":[{"risk":"nondiabetic-workup"}],"ddx":[{"id":"critical-illness","keep":true}],"mdm":"Abnormal vitals point to a serious underlying driver of the hypoglycemia.","frag":"septic / unstable vitals"}]},{"id":"hy-ex-po","dx":"insulin-excess","q":"Before discharge -- tolerating oral intake and able to eat at home?","answers":[{"label":"Eating, has a plan","tone":"neg","sets":[{"risk":"eats-before-dc"}],"ddx":[],"mdm":"The patient is tolerating intake with a means to eat and monitor at home.","frag":"tolerating PO, discharge plan in place"},{"label":"Not yet eating","tone":"pos","sets":[],"ddx":[{"id":"insulin-excess","keep":true}],"mdm":"The patient is not yet reliably eating -- discharge is premature.","frag":"not yet tolerating PO"}]}],"conclusions":["insulin-related hypoglycemia corrected, tolerating PO, safe discharge with a recurrence plan","sulfonylurea-induced hypoglycemia -- admitted/observed for recurrence, octreotide considered","hypoglycemia as a sign of serious illness -- admitted for the underlying cause","intentional insulin overdose -- medically cleared, psychiatric evaluation arranged"],"decisionTree":{"title":"Hypoglycemia — emergency management","intro":"An original, evidence-based decision aid for symptomatic hypoglycemia. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Confirm & treat immediately","items":["Confirm a low fingerstick glucose; protect the airway","Assess mentation and obtain IV access","Give thiamine before/with glucose if malnourished or alcohol use is suspected"],"next":"q_iv"},"q_iv":{"type":"decision","q":"IV access available?","yes":"a_iv","no":"a_noiv"},"a_iv":{"type":"action","title":"IV dextrose","items":["Give IV dextrose (titrated D10, or D50 bolus)","Recheck glucose in ~10–15 minutes and re-dose as needed"],"next":"q_recur"},"a_noiv":{"type":"action","title":"No IV — IM glucagon","items":["Give IM glucagon (less effective if glycogen-depleted or alcoholic)","Establish IV access as soon as possible","Oral carbohydrate only if fully awake and protecting the airway"],"next":"q_recur"},"q_recur":{"type":"decision","q":"Sulfonylurea or long-acting insulin involved, or recurrent/refractory hypoglycemia?","cantmiss":"Sulfonylureas and long-acting insulin cause prolonged, relapsing hypoglycemia — a single correction is not enough.","yes":"a_prolonged","no":"q_cause"},"a_prolonged":{"type":"action","tone":"danger","title":"Prolonged-agent hypoglycemia","terminal":true,"items":["Start a continuous dextrose infusion with frequent rechecks","Octreotide for sulfonylurea-induced hypoglycemia","Admit for extended observation"]},"q_cause":{"type":"decision","q":"Reversible cause resolved, eating reliably, and a safe home situation?","yes":"a_dc","no":"a_admit"},"a_dc":{"type":"action","tone":"branch","title":"Discharge with safeguards","terminal":true,"items":["Give a complex meal and confirm sustained euglycemia","Review the trigger and adjust medication doses","Return precautions and timely follow-up"]},"a_admit":{"type":"action","title":"Observe / admit","terminal":true,"items":["Continued monitoring for an unclear cause, poor intake, or unreliable follow-up"]}}},"guide":"../learn/complaints/hypoglycemia.html"},{"id":"red-eye","title":"Red Eye / Eye Pain","aliases":["red eye","eye pain","pink eye","conjunctivitis","eye redness","painful eye","contact lens pain","photophobia","glaucoma","corneal ulcer","iritis","eye infection","something in eye","chemical in eye"],"opening":"Visual acuity is the vital sign of the eye — the red eye that blinds is the angle-closure attack called a migraine, the contact-lens ulcer called pink eye, and the endophthalmitis after an injection nobody asked about.","ddx":[{"id":"acg","group":"lifethreat","label":"Acute angle-closure glaucoma","default":true,"tags":["acg"],"ruleout":"Acute angle-closure glaucoma was considered; there were no halos, headache, or vomiting, the pupil was round and reactive rather than mid-dilated and fixed, the cornea was clear, and intraocular pressure was normal, making it unlikely.","miss":4},{"id":"ulcer","group":"lifethreat","label":"Corneal ulcer / microbial keratitis","default":true,"tags":["ulcer"],"ruleout":"Microbial keratitis was considered; the patient was not a contact-lens wearer, had no corneal opacity or infiltrate, and fluorescein examination showed no epithelial defect or ulceration, making it unlikely.","miss":3},{"id":"endoph","group":"lifethreat","label":"Endophthalmitis (post-op / post-injection)","default":false,"tags":["endoph"],"ruleout":"Endophthalmitis was considered; there was no recent intraocular surgery, injection, or penetrating trauma, vision was preserved, and there was no hypopyon or vitritis, making it unlikely.","miss":3},{"id":"orbital-cell","group":"lifethreat","label":"Orbital cellulitis","default":false,"tags":["orbital-cell"],"ruleout":"Orbital cellulitis was distinguished from preseptal disease; there was no pain or restriction with eye movement, no proptosis, and visual acuity and color vision were normal, making postseptal involvement unlikely.","miss":3},{"id":"globe-rupture","group":"lifethreat","label":"Open globe / penetrating injury","default":false,"tags":["globe-rupture"],"ruleout":"Open-globe injury was considered; there was no high-risk trauma mechanism, the globe was intact with a normal anterior chamber and round pupil, and there was no Seidel sign, prolapsed uvea, or hyphema, making it unlikely.","miss":3},{"id":"iritis","group":"common","label":"Iritis / uveitis","default":false,"tags":["iritis"],"ruleout":"Iritis was considered: photophobia, perilimbal injection, and consensual photophobia were assessed.","miss":2},{"id":"conjunctivitis","group":"common","label":"Conjunctivitis","default":false,"tags":["conjunctivitis"],"ruleout":"Conjunctivitis was the working diagnosis once vision-threatening causes were excluded.","miss":2},{"id":"abrasion","group":"other","label":"Corneal abrasion / foreign body","default":false,"tags":["abrasion"],"ruleout":"Corneal abrasion or a retained foreign body (including under the lid) was assessed with fluorescein and lid eversion.","miss":1},{"id":"subconj","group":"other","label":"Subconjunctival hemorrhage","default":false,"tags":["subconj"],"ruleout":"A simple subconjunctival hemorrhage was considered.","miss":1}],"risk":[{"id":"va-doc","label":"Visual acuity documented (both eyes)","tags":["acg","ulcer","endoph","orbital-cell"],"scale":"low","line":"Visual acuity was measured and documented in both eyes: the vital sign of the eye.","short":"visual acuity documented OU"},{"id":"fluorescein","label":"Fluorescein / slit-lamp exam","tags":["ulcer","abrasion"],"scale":"low","line":"Fluorescein examination (slit lamp where available) was performed, with attention to dendrites, ulceration, and Seidel sign.","short":"fluorescein exam performed"},{"id":"iop","label":"Intraocular pressure measured","tags":["acg"],"scale":"low","line":"Intraocular pressure was measured and documented.","short":"IOP measured, normal"},{"id":"cl-counsel","label":"Contact-lens precautions given","tags":["ulcer"],"scale":"low","line":"The patient was counseled to stop contact-lens wear, the lens was removed, and antipseudomonal coverage with next-day ophthalmology follow-up was arranged as indicated.","short":"contact-lens precautions + ophtho follow-up"}],"checks":[{"if":"acg","needs":["iop","va-doc"],"mode":"any","warn":"Angle closure is on the differential — measure the pressure; a red eye with headache and vomiting is glaucoma until the IOP says otherwise."},{"if":"ulcer","needs":["fluorescein","cl-counsel"],"mode":"any","warn":"In a contact-lens wearer, document the fluorescein exam and the no-lens counseling — 'pink eye' in a lens wearer is an ulcer until proven otherwise."}],"history":[{"id":"re-hx-cl","dx":"ulcer","q":"Contact lens wear — including sleeping or swimming in lenses?","answers":[{"label":"No lens wear","tone":"neg","sets":[],"ddx":[],"mdm":"The patient does not wear contact lenses.","frag":"no contact-lens wear"},{"label":"Lens wearer","tone":"pos","sets":[{"risk":"cl-counsel"},{"risk":"fluorescein"}],"ddx":[{"id":"ulcer","keep":true}],"mdm":"The patient wears contact lenses: microbial keratitis risk; never patch, and arrange next-day ophthalmology.","frag":"contact-lens wearer"}]},{"id":"re-hx-pain","dx":"iritis","q":"Pain quality — gritty surface irritation vs. deep ache with true photophobia?","answers":[{"label":"Gritty / surface irritation","tone":"neg","sets":[],"ddx":[],"mdm":"The discomfort is surface-level without deep pain or true photophobia.","frag":"surface irritation without deep pain or photophobia"},{"label":"Deep ache + photophobia","tone":"pos","sets":[],"ddx":[{"id":"iritis","keep":true},{"id":"acg","keep":true}],"mdm":"Deep pain with photophobia points away from the conjunctiva: iritis, ulcer, or glaucoma.","frag":"deep ocular pain with photophobia"}]},{"id":"re-hx-halos","dx":"acg","q":"Halos around lights, severe unilateral headache, or nausea/vomiting with the eye symptoms?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There are no halos, severe headache, or vomiting accompanying the red eye.","frag":"no halos, headache, or vomiting"},{"label":"Present","tone":"pos","sets":[{"risk":"iop"}],"ddx":[{"id":"acg","keep":true}],"mdm":"Halos with headache or vomiting: angle closure until the pressure is measured.","frag":"halos with headache or vomiting"}]},{"id":"re-hx-surgery","dx":"endoph","q":"Recent eye surgery, intravitreal injection, or penetrating trauma?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There has been no recent eye surgery, injection, or penetrating trauma.","frag":"no recent eye surgery, injection, or trauma"},{"label":"Recent surgery / injection","tone":"pos","sets":[],"ddx":[{"id":"endoph","keep":true}],"mdm":"Recent surgery or injection: endophthalmitis requires same-day ophthalmology.","frag":"recent eye surgery or intravitreal injection"}]},{"id":"re-hx-vision","dx":"acg","q":"Vision — subjectively normal, or blurred / decreased in the affected eye?","answers":[{"label":"Vision normal","tone":"neg","sets":[{"risk":"va-doc"}],"ddx":[],"mdm":"Vision is subjectively at baseline.","frag":"vision subjectively normal"},{"label":"Blurred / decreased","tone":"pos","sets":[{"risk":"va-doc"}],"ddx":[{"id":"acg","keep":true},{"id":"ulcer","keep":true},{"id":"endoph","keep":true}],"mdm":"Vision is subjectively decreased: a vision-threatening cause must be excluded.","frag":"subjective vision loss"}]},{"id":"re-hx-chemical","dx":"ulcer","q":"Chemical exposure — splash or spray (irrigation comes before everything else)?","answers":[{"label":"No exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was no chemical exposure.","frag":"no chemical exposure"},{"label":"Chemical splash","tone":"pos","sets":[],"ddx":[{"id":"ulcer","keep":true}],"mdm":"A chemical exposure occurred: immediate irrigation to neutral pH precedes the rest of the evaluation.","frag":"chemical exposure (irrigated immediately, pH checked)"}]}],"exam":[{"id":"re-ex-va","dx":"acg","q":"Visual acuity, both eyes, with correction or pinhole — at the patient's baseline?","answers":[{"label":"Acuity at baseline OU","tone":"neg","sets":[{"risk":"va-doc"}],"ddx":[],"mdm":"Visual acuity is at baseline in both eyes.","frag":"visual acuity at baseline in both eyes"},{"label":"Decreased acuity","tone":"pos","sets":[{"risk":"va-doc"}],"ddx":[{"id":"acg","keep":true},{"id":"ulcer","keep":true},{"id":"endoph","keep":true}],"mdm":"Acuity is reduced in the affected eye.","frag":"reduced visual acuity in the affected eye"}]},{"id":"re-ex-pupil","dx":"acg","q":"Pupil — reactive and equal vs. mid-dilated and fixed, or pain in the affected eye when light hits the other (consensual photophobia)?","answers":[{"label":"Equal and reactive","tone":"neg","sets":[],"ddx":[],"mdm":"Pupils were equal and reactive, neither mid-dilated and fixed nor with consensual photophobia.","frag":"pupils equal and reactive without consensual photophobia"},{"label":"Mid-dilated fixed / consensual photophobia","tone":"pos","sets":[{"risk":"iop"}],"ddx":[{"id":"acg","keep":true},{"id":"iritis","keep":true}],"mdm":"A mid-dilated, fixed pupil suggests acute angle closure, or pain in the affected eye when light hits the other (consensual photophobia) suggests iritis.","frag":"mid-dilated fixed pupil or consensual photophobia"}]},{"id":"re-ex-fluor","dx":"ulcer","q":"Fluorescein — clean cornea vs. uptake (abrasion), dendrite (HSV), or an infiltrate/ulcer; lids everted for foreign body?","answers":[{"label":"No uptake, lids clear","tone":"neg","sets":[{"risk":"fluorescein"}],"ddx":[],"mdm":"There is no fluorescein uptake and lid eversion shows no foreign body.","frag":"no fluorescein uptake; lids everted, no foreign body"},{"label":"Uptake / dendrite / infiltrate","tone":"pos","sets":[{"risk":"fluorescein"}],"ddx":[{"id":"ulcer","keep":true},{"id":"abrasion","keep":true}],"mdm":"Fluorescein shows uptake, a dendrite, or an infiltrate.","frag":"fluorescein uptake, dendrite, or infiltrate"}]},{"id":"re-ex-orbit","dx":"orbital-cell","q":"Orbit — pain with eye movement, proptosis, or restricted motility (orbital vs. preseptal cellulitis)?","answers":[{"label":"Full painless motility","tone":"neg","sets":[],"ddx":[],"mdm":"Extraocular movements are full and painless without proptosis.","frag":"full painless extraocular movements, no proptosis"},{"label":"Painful EOM / proptosis","tone":"pos","sets":[],"ddx":[{"id":"orbital-cell","keep":true}],"mdm":"Painful eye movement or proptosis: orbital cellulitis, not preseptal.","frag":"pain with eye movement or proptosis"}]},{"answers":[{"ddx":[],"frag":"globe intact, no Seidel sign or hyphema","label":"No open-globe signs","mdm":"There was no high-risk trauma mechanism, the globe was intact with a normal anterior chamber and round pupil, and there was no Seidel sign, prolapsed uvea, or hyphema, making open-globe injury unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"globe-rupture","keep":true}],"frag":"Seidel sign, hyphema, or irregular pupil","label":"Open-globe signs present","mdm":"A high-risk mechanism, Seidel sign, prolapsed uvea, hyphema, or irregular pupil was present, raising concern for open-globe injury and warranting a shield and urgent ophthalmology.","sets":[],"tone":"pos"}],"dx":"globe-rupture","id":"re-exam-globe-rupture","q":"Open globe — high-risk trauma mechanism, a Seidel sign, prolapsed uvea, hyphema, or an irregular pupil?"}],"conclusions":["conjunctivitis — vision-threatening causes excluded","corneal abrasion, ophthalmology follow-up","subconjunctival hemorrhage, reassurance"],"specs":["ophtho"],"guide":"../learn/complaints/red-eye.html"},{"id":"uri","specs":["ent","id"],"title":"URI / Sinusitis","aliases":["uri","cold","common cold","sinus","sinusitis","sinus infection","congestion","runny nose","flu","influenza","sinus pressure","facial pressure","upper respiratory infection","head cold","post nasal drip","stuffy nose","flu like illness"],"opening":"The cold is the easiest diagnosis in medicine and the easiest to be wrong about twice: once by missing the orbital or intracranial complication brewing behind 'sinusitis', and once by prescribing the antibiotic the visit didn't need.","ddx":[{"id":"orbital-comp","group":"lifethreat","label":"Orbital / intracranial extension of sinusitis","default":true,"tags":["orbital-comp"],"ruleout":"Orbital and intracranial extension of sinusitis was considered; there were no periorbital swelling, proptosis, or pain with eye movement, vision was intact, and the neurologic examination was normal without headache or meningismus, making extension unlikely.","miss":3},{"id":"flu-highrisk","group":"common","label":"Influenza in a high-risk host","default":false,"tags":["flu-highrisk"],"ruleout":"Influenza in a high-risk host was considered; antiviral candidacy and the worsening trajectory that should trigger return were addressed.","miss":2},{"id":"bacterial-sinusitis","group":"common","label":"Acute bacterial rhinosinusitis","default":false,"tags":["bacterial-sinusitis"],"ruleout":"Bacterial rhinosinusitis was distinguished from viral disease on duration and the double-worsening pattern, not on the color of the drainage.","miss":2},{"id":"secondary-lri","group":"common","label":"Lower respiratory involvement","default":false,"tags":["secondary-lri"],"ruleout":"Lower respiratory involvement was considered: dyspnea, hypoxia, and focal lung findings were assessed.","miss":2},{"id":"viral-uri","group":"other","label":"Viral URI","default":false,"tags":["viral-uri"],"ruleout":"An uncomplicated viral upper respiratory infection was the working diagnosis.","miss":1}],"risk":[{"id":"orbital-exam","label":"Orbital exam documented","tags":["orbital-comp"],"scale":"low","line":"The periorbital tissues, extraocular movements, and vision were examined and were normal: no evidence of orbital extension.","short":"orbital exam normal"},{"id":"abx-stewardship","label":"Antibiotic decision documented","tags":["bacterial-sinusitis","viral-uri"],"scale":"low","line":"The viral nature of the illness and the rationale for withholding (or prescribing) antibiotics were discussed with the patient, with a specific plan to return or start treatment if the double-worsening pattern develops.","short":"antibiotic decision + return plan documented"}],"checks":[{"if":"orbital-comp","needs":["orbital-exam"],"mode":"any","warn":"Sinusitis complications are on the differential — document the periorbital, eye-movement, and vision exam."},{"if":"bacterial-sinusitis","needs":["abx-stewardship"],"mode":"any","warn":"Document the antibiotic decision and the double-worsening return plan — the defensible chart shows the reasoning either way."}],"history":[{"id":"uri-hx-duration","dx":"bacterial-sinusitis","q":"Duration and pattern — under 10 days and improving, or ≥ 10 days without improvement / improved-then-worsened (double worsening)?","answers":[{"label":"< 10 days, improving course","tone":"neg","sets":[],"ddx":[],"mdm":"Symptoms have lasted under 10 days with the expected improving viral course.","frag":"symptoms under 10 days with an improving course"},{"label":"≥ 10 days or double worsening","tone":"pos","sets":[],"ddx":[{"id":"bacterial-sinusitis","keep":true}],"mdm":"Symptoms have persisted ≥10 days without improvement or followed a double-worsening pattern: the criteria that actually suggest bacterial disease.","frag":"≥10 days without improvement or double-worsening pattern"}]},{"id":"uri-hx-host","dx":"flu-highrisk","q":"High-risk host — pregnant, immunocompromised, ≥ 65, significant cardiopulmonary disease, or diabetes?","answers":[{"label":"Otherwise healthy","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was assessed for high-risk host factors for complicated influenza (pregnancy, immunocompromise, age ≥ 65, significant cardiopulmonary disease, or diabetes), none of which were present.","frag":"no high-risk host factors"},{"label":"High-risk host","tone":"pos","sets":[],"ddx":[{"id":"flu-highrisk","keep":true}],"mdm":"The patient has one or more host factors that raise the risk of complicated influenza (pregnancy, immunocompromise, age ≥ 65, significant cardiopulmonary disease, or diabetes) and was therefore considered a candidate for antiviral therapy (e.g., oseltamivir), which was addressed.","frag":"high-risk host (pregnancy, immunocompromise, age, chronic disease)"}]},{"id":"uri-hx-neuro","dx":"orbital-comp","q":"Severe or worsening headache, repeated vomiting, confusion, or neck stiffness?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no severe headache, vomiting, confusion, or meningism.","frag":"no severe headache, vomiting, or confusion"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"orbital-comp","keep":true}],"mdm":"Severe headache, vomiting, or altered mentation raises intracranial extension.","frag":"severe headache, vomiting, or altered mentation"}]},{"id":"uri-hx-eye","dx":"orbital-comp","q":"Eye symptoms — periorbital swelling, pain with eye movement, double vision, or vision change?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There were no eye symptoms (no periorbital swelling, pain with eye movement, double vision, or vision change), arguing against orbital or periorbital extension.","frag":"no periorbital swelling or visual symptoms"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"orbital-comp","keep":true}],"mdm":"Periorbital swelling or pain with eye movement raises orbital involvement.","frag":"periorbital swelling or pain with eye movement"}]},{"id":"uri-hx-lower","dx":"secondary-lri","q":"Lower tract symptoms — dyspnea, pleuritic pain, or a productive cough that is worsening?","answers":[{"label":"Upper tract only","tone":"neg","sets":[],"ddx":[],"mdm":"Symptoms were confined to the upper tract, without dyspnea, pleuritic pain, or a worsening productive cough to suggest lower-tract involvement.","frag":"no dyspnea or lower respiratory symptoms"},{"label":"Lower tract symptoms","tone":"pos","sets":[],"ddx":[{"id":"secondary-lri","keep":true}],"mdm":"Lower-tract symptoms were present (dyspnea, pleuritic pain, or a worsening productive cough), prompting evaluation for possible pneumonia.","frag":"dyspnea or worsening productive cough"}]}],"exam":[{"id":"uri-ex-vitals","dx":"general","q":"Vitals — afebrile or low-grade, with normal heart rate, respiratory rate, and saturation?","answers":[{"label":"Reassuring","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were reassuring: the patient was afebrile or low-grade with a normal heart rate, respiratory rate, and oxygen saturation.","frag":"vital signs reassuring"},{"label":"Febrile / abnormal","tone":"pos","sets":[],"ddx":[],"mdm":"Fever or abnormal vital signs (an elevated heart rate, respiratory rate, or low oxygen saturation) were present and were addressed before disposition.","frag":"fever or abnormal vital signs"}]},{"id":"uri-ex-orbital","dx":"orbital-comp","q":"Orbital exam — periorbital tissues normal, extraocular movements full and painless, vision at baseline?","answers":[{"label":"Normal","tone":"neg","sets":[{"risk":"orbital-exam"}],"ddx":[],"mdm":"The periorbital examination, extraocular movements, and vision are normal.","frag":"periorbital tissues normal; EOM full and painless; vision at baseline"},{"label":"Abnormal","tone":"pos","sets":[],"ddx":[{"id":"orbital-comp","keep":true}],"mdm":"Periorbital findings, painful eye movements, or vision change: orbital cellulitis territory.","frag":"periorbital erythema/swelling, painful EOM, or vision change"}]},{"id":"uri-ex-lungs","dx":"secondary-lri","q":"Lungs — clear, without focal crackles or wheeze?","answers":[{"label":"Clear","tone":"neg","sets":[],"ddx":[],"mdm":"The lungs were clear, without focal crackles or wheeze.","frag":"lungs clear"},{"label":"Focal findings","tone":"pos","sets":[],"ddx":[{"id":"secondary-lri","keep":true}],"mdm":"Focal lung findings (crackles or wheeze) were present, prompting evaluation for pneumonia.","frag":"focal lung findings"}]},{"id":"uri-ex-face","dx":"bacterial-sinusitis","q":"Face — diffuse congestion vs. severe unilateral facial pain, swelling, or erythema over a sinus?","answers":[{"label":"Diffuse, mild","tone":"neg","sets":[],"ddx":[],"mdm":"Facial findings were the diffuse, mild congestion of a viral process, without severe unilateral facial pain, swelling, or erythema over a sinus.","frag":"diffuse mild congestion without focal facial findings"},{"label":"Severe unilateral / facial swelling","tone":"pos","sets":[],"ddx":[{"id":"bacterial-sinusitis","keep":true},{"id":"orbital-comp","keep":true}],"mdm":"Severe unilateral facial pain or overlying swelling suggests complicated bacterial disease.","frag":"severe unilateral facial pain or swelling"}]}],"conclusions":["viral URI — antibiotics not indicated","acute viral rhinosinusitis","bacterial sinusitis — outpatient treatment","influenza-like illness"],"guide":"../learn/complaints/uri.html"},{"id":"ear-pain","specs":["ent","peds"],"title":"Ear Pain / Otitis","aliases":["ear pain","earache","otitis","ear infection","otitis media","otitis externa","swimmers ear","ear discharge","ear drainage","my ear hurts","mastoiditis","ear fullness"],"opening":"Almost every earache is otitis — which is exactly why the mastoiditis behind the ear, the necrotizing otitis externa in the diabetic, and the facial-nerve involvement get missed: nobody looks past the drum.","ddx":[{"id":"mastoiditis","group":"lifethreat","label":"Mastoiditis","default":true,"tags":["mastoiditis"],"ruleout":"Mastoiditis was considered; the postauricular area was non-tender without swelling or erythema, there was no protrusion of the auricle, and the patient was non-toxic, making it unlikely.","miss":3},{"id":"malignant-oe","group":"lifethreat","label":"Necrotizing (malignant) otitis externa","default":true,"tags":["malignant-oe"],"ruleout":"Necrotizing otitis externa was considered; the patient was not immunocompromised or diabetic, had no pain out of proportion, and the canal showed no granulation tissue or exposed bone, making it unlikely.","miss":4},{"id":"facial-nerve","group":"lifethreat","label":"Facial nerve involvement / Ramsay Hunt","default":false,"tags":["facial-nerve"],"ruleout":"Facial nerve involvement, including Ramsay Hunt syndrome, was considered; facial movements were symmetric without weakness and the auricle and canal showed no vesicles, making it unlikely.","miss":3},{"id":"aom","group":"common","label":"Acute otitis media","default":false,"tags":["aom"],"ruleout":"Acute otitis media was assessed by direct visualization of the tympanic membrane.","miss":2},{"id":"oe","group":"common","label":"Otitis externa","default":false,"tags":["oe"],"ruleout":"Otitis externa was considered on canal findings and tragal tenderness.","miss":2},{"id":"referred-ear","group":"other","label":"Referred ear pain (TMJ, dental, pharynx)","default":false,"tags":["referred-ear"],"ruleout":"Referred otalgia was considered: TMJ, dentition, and oropharynx were examined when the ear itself looked normal.","miss":1}],"risk":[{"id":"tm-vis","label":"Tympanic membrane visualized","tags":["aom","mastoiditis"],"scale":"low","line":"The tympanic membrane was directly visualized and its appearance documented.","short":"TM visualized and documented"},{"id":"host-check","label":"Host factors assessed (diabetes / immunocompromise)","tags":["malignant-oe"],"scale":"low","line":"Diabetes and immunocompromise were specifically assessed, since they change the differential for ear pain.","short":"host factors assessed"}],"checks":[{"if":"mastoiditis","needs":["tm-vis"],"mode":"any","warn":"Document the TM and the postauricular exam — 'ear infection' without a visualized drum is not a diagnosis."},{"if":"malignant-oe","needs":["host-check"],"mode":"any","warn":"In a diabetic or immunocompromised patient, severe otalgia is necrotizing otitis externa until the canal is examined and the possibility is documented."},{"if":"aom","needs":["tm-vis"],"mode":"any","warn":"Document the tympanic-membrane findings (bulging, effusion, mobility) supporting acute otitis media, and the antibiotic-vs-observation decision."}],"history":[{"id":"ear-hx-host","dx":"malignant-oe","q":"Diabetes or immunocompromise — the hosts in whom otitis externa turns necrotizing?","answers":[{"label":"No","tone":"neg","sets":[{"risk":"host-check"}],"ddx":[],"mdm":"There is no diabetes or immunocompromise.","frag":"no diabetes or immunocompromise"},{"label":"Diabetic / immunocompromised","tone":"pos","sets":[{"risk":"host-check"}],"ddx":[{"id":"malignant-oe","keep":true}],"mdm":"The patient is diabetic or immunocompromised, necrotizing otitis externa must be actively excluded.","frag":"diabetic or immunocompromised host"}]},{"id":"ear-hx-severity","dx":"malignant-oe","q":"Pain severity — typical otitis discomfort, or severe, deep, night-waking pain out of proportion to findings?","answers":[{"label":"Typical discomfort","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was typical otitis discomfort, proportionate to the visible findings rather than severe, deep, or night-waking pain out of proportion.","frag":"pain proportionate to findings"},{"label":"Severe / out of proportion","tone":"pos","sets":[],"ddx":[{"id":"malignant-oe","keep":true}],"mdm":"The pain was severe, deep, and night-waking, out of proportion to the visible findings: a necrotizing process must be considered.","frag":"deep pain out of proportion to findings"}]},{"id":"ear-hx-systemic","dx":"mastoiditis","q":"Systemic features — high fever, ill appearance, or symptoms worsening despite treatment?","answers":[{"label":"Well, improving","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was well-appearing and improving, without high fever, ill appearance, or symptoms worsening despite treatment.","frag":"well-appearing without systemic features"},{"label":"Febrile / worsening on treatment","tone":"pos","sets":[],"ddx":[{"id":"mastoiditis","keep":true}],"mdm":"High fever, ill appearance, or symptoms worsening despite treatment was present, raising concern for a suppurative complication.","frag":"febrile or worsening despite treatment"}]},{"id":"ear-hx-facial","dx":"facial-nerve","q":"Facial weakness, new vertigo, or painful rash near the ear?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no facial weakness, vertigo, or periauricular rash.","frag":"no facial weakness, vertigo, or periauricular rash"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"facial-nerve","keep":true}],"mdm":"Facial weakness or periauricular vesicles: facial nerve involvement / Ramsay Hunt.","frag":"facial weakness or periauricular vesicles"}]},{"id":"ear-hx-water","dx":"oe","q":"Recent swimming, ear-canal trauma, or hearing-aid/earbud occlusion?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There are no external-canal risk factors.","frag":"no canal risk factors"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"oe","keep":true}],"mdm":"Canal risk factors are present, favoring otitis externa.","frag":"swimming or canal trauma"}]}],"exam":[{"id":"ear-ex-tm","dx":"aom","q":"Tympanic membrane — visualized: normal/translucent vs. bulging, erythematous, or perforated with discharge?","answers":[{"label":"TM normal","tone":"neg","sets":[{"risk":"tm-vis"}],"ddx":[],"mdm":"The tympanic membrane was visualized and normal and translucent, without bulging, erythema, or perforation with discharge.","frag":"tympanic membrane visualized and normal"},{"label":"Bulging / perforated","tone":"pos","sets":[{"risk":"tm-vis"}],"ddx":[{"id":"aom","keep":true}],"mdm":"The tympanic membrane is bulging or perforated.","frag":"bulging or perforated tympanic membrane"}]},{"id":"ear-ex-postauricular","dx":"mastoiditis","q":"Postauricular area — swelling, erythema, tenderness, or a protruding auricle?","answers":[{"label":"Normal","tone":"neg","sets":[],"ddx":[],"mdm":"The postauricular area showed no swelling, erythema, or tenderness, and there was no protruding auricle.","frag":"no postauricular swelling or auricular protrusion"},{"label":"Swelling / protrusion","tone":"pos","sets":[],"ddx":[{"id":"mastoiditis","keep":true}],"mdm":"Postauricular swelling or auricular protrusion: mastoiditis.","frag":"postauricular swelling or protruding auricle"}]},{"id":"ear-ex-canal","dx":"malignant-oe","q":"Canal — mild edema/debris vs. granulation tissue at the floor of the canal or severe circumferential edema?","answers":[{"label":"Mild findings","tone":"neg","sets":[],"ddx":[],"mdm":"The canal shows at most mild edema without granulation tissue.","frag":"no canal granulation tissue"},{"label":"Granulation / severe edema","tone":"pos","sets":[],"ddx":[{"id":"malignant-oe","keep":true}],"mdm":"The canal showed granulation tissue at its floor or severe circumferential edema rather than mild edema or debris: the signature of necrotizing otitis externa.","frag":"canal granulation tissue or severe edema"}]},{"id":"ear-ex-facial","dx":"facial-nerve","q":"Facial nerve — symmetric smile and eye closure; no vesicles on the auricle or in the canal?","answers":[{"label":"Symmetric, no vesicles","tone":"neg","sets":[],"ddx":[],"mdm":"Facial movements are symmetric and there are no vesicles.","frag":"facial movements symmetric; no vesicles"},{"label":"Asymmetry / vesicles","tone":"pos","sets":[],"ddx":[{"id":"facial-nerve","keep":true}],"mdm":"Facial asymmetry or vesicles are present.","frag":"facial asymmetry or auricular vesicles"}]},{"id":"ear-ex-referred","dx":"referred-ear","q":"If the ear looks normal — TMJ, dentition, and oropharynx examined for a referred source?","answers":[{"label":"Source identified / ear abnormal","tone":"neg","sets":[],"ddx":[],"mdm":"An otologic source explains the pain.","frag":"otologic source identified"},{"label":"Normal ear, source elsewhere","tone":"pos","sets":[],"ddx":[{"id":"referred-ear","keep":true}],"mdm":"The ear is normal: TMJ, dental, and pharyngeal sources were examined; persistent unexplained otalgia in an adult warrants ENT follow-up.","frag":"normal ear exam (referred source examined)"}]}],"conclusions":["acute otitis media","otitis externa","eustachian tube dysfunction","referred otalgia — outpatient workup"],"guide":"../learn/complaints/ear-pain.html"},{"id":"dental","specs":["ent","surg"],"title":"Dental & Facial Pain","aliases":["dental pain","toothache","tooth pain","dental abscess","jaw pain","facial swelling","ludwig","dry socket","tooth extraction","bleeding after extraction","tooth infection","gum swelling","face pain"],"opening":"Dental pain is a dental problem until it's an airway problem (Ludwig), a cavernous-sinus problem (midface), or a heart problem (the exertional jaw ache that was never about the tooth).","ddx":[{"id":"ludwig","group":"lifethreat","label":"Ludwig angina / submandibular space infection","default":true,"tags":["ludwig"],"ruleout":"Ludwig angina was considered; there was no floor-of-mouth swelling or induration, tongue mobility and elevation were normal, the patient handled secretions without drooling or voice change, and the airway was patent, making it unlikely.","miss":4},{"id":"deep-space","group":"lifethreat","label":"Deep-space extension (incl. cavernous sinus from midface)","default":true,"tags":["deep-space"],"ruleout":"Deep-space extension was considered; there was no trismus, dysphagia, or neck swelling, no midface or periorbital involvement, and no fever or systemic toxicity, making spread toward the cavernous sinus or fascial spaces unlikely.","miss":4},{"id":"cardiac-jaw","group":"lifethreat","label":"Cardiac ischemia presenting as jaw pain","default":false,"tags":["cardiac-jaw"],"ruleout":"An anginal equivalent was considered for the jaw pain; the pain was reproducible and clearly dental in origin, non-exertional without associated dyspnea or diaphoresis, with no cardiac risk factors and a non-ischemic ECG, making it unlikely.","miss":3},{"id":"deep-neck-airway","group":"lifethreat","label":"Retropharyngeal / parapharyngeal abscess","default":false,"tags":["deep-neck-airway"],"ruleout":"Deep neck-space abscess was considered; there was no neck stiffness, odynophagia, muffled voice, or drooling, the oropharynx was without bulging, and the airway was patent, making it unlikely.","miss":4},{"id":"post-extraction","group":"common","label":"Post-extraction bleeding / dry socket","default":false,"tags":["post-extraction"],"ruleout":"Post-extraction complications (socket bleeding (anticoagulation reviewed) and alveolar osteitis) were considered.","miss":2},{"id":"periapical","group":"common","label":"Pulpitis / periapical abscess","default":false,"tags":["periapical"],"ruleout":"A periapical source was identified or presumed, with dental follow-up arranged.","miss":2}],"risk":[{"id":"airway-dental","label":"Floor-of-mouth / airway exam documented","tags":["ludwig","deep-space"],"scale":"low","line":"The floor of the mouth was soft, the tongue mobile, voice normal, and there was no stridor, trismus, or drooling: no airway-threatening spread.","short":"floor of mouth soft; airway unthreatened"},{"id":"ecg-dental","label":"Cardiac cause addressed (exertional jaw pain)","tags":["cardiac-jaw"],"scale":"low","line":"Because the jaw pain lacked a clear dental source, a cardiac cause was considered and an ECG was obtained.","short":"cardiac cause addressed, ECG obtained"}],"checks":[{"if":"ludwig","needs":["airway-dental"],"mode":"any","warn":"Document the floor-of-mouth and airway exam — Ludwig angina is the dental complaint that kills, and it kills by airway."},{"if":"cardiac-jaw","needs":["ecg-dental"],"mode":"any","warn":"Jaw pain without a dental source in a patient with cardiac risk factors needs an ECG, and the chart needs to show it."},{"if":"deep-space","needs":["airway-dental"],"mode":"any","warn":"A deep-space neck infection is on the differential — document the airway assessment (trismus, drooling, voice, swelling) and imaging if indicated."}],"history":[{"id":"dt-hx-source","dx":"periapical","q":"Clear dental source — a specific tooth that is tender, broken, or temperature-sensitive?","answers":[{"label":"Clear dental source","tone":"neg","sets":[],"ddx":[{"id":"periapical","keep":true}],"mdm":"A specific tooth that was tender, broken, or temperature-sensitive localized the pain to a clear dental source.","frag":"clear localizable dental source"},{"label":"No clear dental source","tone":"pos","sets":[],"ddx":[{"id":"cardiac-jaw","keep":true}],"mdm":"No specific tooth was tender, broken, or temperature-sensitive, so no clear dental source localized the pain and the differential was widened beyond the teeth.","frag":"no localizable dental source"}]},{"id":"dt-hx-cardiac","dx":"cardiac-jaw","q":"Cardiac pattern — jaw ache with exertion, relieved by rest, or with diaphoresis/dyspnea, especially with cardiac risk factors?","answers":[{"label":"No exertional pattern","tone":"neg","sets":[],"ddx":[],"mdm":"There was no cardiac pattern: the jaw ache was not exertional, not relieved by rest, and not associated with diaphoresis or dyspnea.","frag":"no exertional or cardiac-associated pattern"},{"label":"Exertional / associated symptoms","tone":"pos","sets":[{"risk":"ecg-dental"}],"ddx":[{"id":"cardiac-jaw","keep":true}],"mdm":"A cardiac pattern was present (jaw ache with exertion, relief with rest, or associated diaphoresis or dyspnea) and was treated as an anginal equivalent until proven otherwise.","frag":"exertional jaw pain or cardiac-associated symptoms"}]},{"id":"dt-hx-spread","dx":"deep-space","q":"Spread symptoms — fever, trismus, difficulty swallowing, or swelling extending under the jaw or up the face?","answers":[{"label":"Localized, no spread","tone":"neg","sets":[],"ddx":[],"mdm":"There is no fever, trismus, dysphagia, or spreading swelling.","frag":"no fever, trismus, dysphagia, or spreading swelling"},{"label":"Spread symptoms","tone":"pos","sets":[],"ddx":[{"id":"deep-space","keep":true},{"id":"ludwig","keep":true}],"mdm":"Trismus, dysphagia, or spreading swelling: deep-space extension.","frag":"trismus, dysphagia, or spreading facial swelling"}]},{"id":"dt-hx-extraction","dx":"post-extraction","q":"Recent extraction — and if bleeding, is the patient anticoagulated?","answers":[{"label":"No recent extraction","tone":"neg","sets":[],"ddx":[],"mdm":"There has been no recent dental procedure.","frag":"no recent extraction"},{"label":"Recent extraction ± anticoagulation","tone":"pos","sets":[],"ddx":[{"id":"post-extraction","keep":true}],"mdm":"A recent extraction is relevant: socket bleeding and anticoagulation were addressed.","frag":"recent extraction; bleeding/anticoagulation addressed"}]},{"id":"dt-hx-midface","dx":"deep-space","q":"Midface involvement — swelling or infection of the upper teeth/midface with headache, eye symptoms, or fever (cavernous-sinus territory)?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There was no midface involvement: no upper-tooth or midface swelling or infection with headache, eye symptoms, or fever to suggest cavernous-sinus territory spread.","frag":"no midface involvement with systemic or eye symptoms"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"deep-space","keep":true}],"mdm":"Midface infection with headache or eye symptoms tracks toward the cavernous sinus.","frag":"midface infection with headache or eye symptoms"}]}],"exam":[{"id":"dt-ex-floor","dx":"ludwig","q":"Floor of mouth — soft and non-elevated, tongue freely mobile, voice normal, no drooling or stridor?","answers":[{"label":"Soft, airway unthreatened","tone":"neg","sets":[{"risk":"airway-dental"}],"ddx":[],"mdm":"The floor of the mouth is soft, the tongue mobile, and the airway unthreatened.","frag":"floor of mouth soft; tongue mobile; no stridor or drooling"},{"label":"Woody floor / elevated tongue","tone":"pos","sets":[],"ddx":[{"id":"ludwig","keep":true}],"mdm":"The floor of mouth was woody and elevated, raising concern for Ludwig angina; the airway was addressed first.","frag":"woody floor of mouth or elevated tongue"}]},{"id":"dt-ex-trismus","dx":"deep-space","q":"Trismus — mouth opens fully (three finger-breadths)?","answers":[{"label":"Full opening","tone":"neg","sets":[],"ddx":[],"mdm":"Mouth opening is full without trismus.","frag":"no trismus"},{"label":"Limited opening","tone":"pos","sets":[],"ddx":[{"id":"deep-space","keep":true}],"mdm":"Trismus is present: a deep-space process until imaged.","frag":"trismus"}]},{"id":"dt-ex-tooth","dx":"periapical","q":"Dentition — percussion-tender tooth, periapical swelling, or fluctuance limited to the gingiva?","answers":[{"label":"Localized periapical findings","tone":"neg","sets":[],"ddx":[{"id":"periapical","keep":true}],"mdm":"Findings were localized to a single periapical source: a percussion-tender tooth, periapical swelling, or fluctuance limited to the gingiva.","frag":"localized periapical findings only"},{"label":"Diffuse / extending swelling","tone":"pos","sets":[],"ddx":[{"id":"deep-space","keep":true}],"mdm":"Swelling extended beyond the gingiva and alveolar ridge rather than remaining a percussion-tender tooth or localized periapical fluctuance, indicating more than a simple periapical abscess.","frag":"swelling extending beyond the alveolar ridge"}]},{"id":"dt-ex-vitals","dx":"general","q":"Vitals — afebrile and hemodynamically normal?","answers":[{"label":"Reassuring","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs are reassuring.","frag":"vital signs reassuring"},{"label":"Febrile / tachycardic","tone":"pos","sets":[],"ddx":[],"mdm":"Fever or tachycardia accompanies the facial infection.","frag":"fever or tachycardia"}]},{"answers":[{"ddx":[],"frag":"no odynophagia, muffled voice, or drooling","label":"No deep-neck signs","mdm":"There was no neck stiffness, odynophagia, muffled voice, or drooling, the oropharynx was without bulging, and the airway was patent, making a deep neck-space abscess unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"deep-neck-airway","keep":true}],"frag":"odynophagia, muffled voice, or drooling","label":"Deep-neck signs present","mdm":"Neck stiffness, odynophagia, muffled voice, drooling, or oropharyngeal bulging was present, raising concern for a retropharyngeal or parapharyngeal abscess and warranting imaging and airway vigilance.","sets":[],"tone":"pos"}],"dx":"deep-neck-airway","id":"dt-exam-deep-neck-airway","q":"Deep neck space — neck stiffness, odynophagia, muffled voice, drooling, oropharyngeal bulging, or airway compromise?"}],"conclusions":["dental caries / periapical abscess — dental follow-up","dry socket — managed, dental follow-up","post-extraction bleeding controlled","facial pain NOS (low-risk)"],"guide":"../learn/complaints/dental.html"},{"id":"cellulitis","specs":["derm","id","surg"],"title":"Cellulitis & Abscess","aliases":["cellulitis","abscess","skin infection","boil","spider bite","red leg","wound infection","mrsa","infected cut","skin abscess","leg redness","necrotizing fasciitis","red streak","carbuncle"],"opening":"Three traps live inside 'cellulitis': the necrotizing infection that looks like cellulitis with the volume turned up, the DVT wearing red, and the bilateral 'cellulitis' that is almost always stasis dermatitis — plus the abscess that needed a blade, not a prescription.","ddx":[{"id":"necfasc","group":"lifethreat","label":"Necrotizing soft-tissue infection","default":true,"tags":["necfasc"],"ruleout":"Necrotizing soft-tissue infection was considered; there was no pain out of proportion, rapid progression, crepitus, bullae, skin necrosis, or systemic toxicity, and the patient was hemodynamically stable, making it unlikely.","miss":4},{"id":"dvt-mimic","group":"lifethreat","label":"DVT presenting as a red, swollen leg","default":false,"tags":["dvt-mimic"],"ruleout":"DVT was considered for the unilateral swollen leg; there was no calf tenderness along the deep veins, a low pretest probability, and negative D-dimer or compression ultrasound where pursued, making it unlikely.","miss":3},{"id":"septic-joint-cell","group":"lifethreat","label":"Septic joint / deep extension","default":false,"tags":["septic-joint-cell"],"ruleout":"Septic arthritis and deep extension were considered for infection overlying a joint; the patient had preserved, painless range of motion without effusion, and the erythema spared the joint line, making joint involvement unlikely.","miss":3},{"id":"abscess-cell","group":"common","label":"Drainable abscess","default":false,"tags":["abscess-cell"],"ruleout":"A drainable collection was assessed by examination (and bedside ultrasound where available); source control was addressed.","miss":2},{"id":"simple-cellulitis","group":"common","label":"Nonpurulent cellulitis","default":false,"tags":["simple-cellulitis"],"ruleout":"Nonpurulent cellulitis was the working diagnosis.","miss":2},{"id":"stasis-derm","group":"other","label":"Stasis dermatitis (the bilateral mimic)","default":false,"tags":["stasis-derm"],"ruleout":"Stasis dermatitis was considered: bilateral 'cellulitis' is stasis until proven otherwise.","miss":1}],"risk":[{"id":"necfasc-assessed","label":"Necrotizing features assessed","tags":["necfasc"],"scale":"low","line":"Necrotizing features were specifically assessed and absent: no pain out of proportion, crepitus, bullae, dusky discoloration, woody induration, or systemic toxicity, recognizing these findings are specific but insensitive, so absence reduces, not eliminates, the risk; progression instructions address the remainder.","short":"no necrotizing features on directed exam"},{"id":"margin-marked","label":"Margin marked + progression instructions","tags":["simple-cellulitis","abscess-cell"],"scale":"low","line":"The erythema border was marked and photographed/described, and the patient was instructed to return if it progresses past the line or systemic symptoms develop.","short":"margin marked; progression return plan given"},{"id":"source-control","label":"Source control addressed (I&D / no collection)","tags":["abscess-cell"],"scale":"low","line":"Source control was addressed: the collection was incised and drained (or a drainable collection was excluded by exam/ultrasound).","short":"source control addressed"},{"id":"host-cell","label":"Host factors assessed","tags":["necfasc","simple-cellulitis"],"scale":"low","line":"Host factors (diabetes, immunocompromise, vascular disease, and recent trauma or surgery) were assessed and factored into disposition.","short":"host factors assessed"}],"checks":[{"if":"necfasc","needs":["necfasc-assessed"],"mode":"any","warn":"Document the directed necrotizing-features exam — 'cellulitis, started antibiotics' without it is indefensible if the patient returns in the OR."},{"if":"abscess-cell","needs":["source-control"],"mode":"any","warn":"An abscess is treated with drainage — document the I&D or why no drainable collection exists."},{"if":"dvt-mimic","needs":["margin-marked"],"mode":"any","warn":"Unilateral red swollen leg — document why this is infection and not thrombosis (or risk-stratify for DVT)."}],"history":[{"id":"ce-hx-speed","dx":"necfasc","q":"Tempo — stable or slowly spreading over days, vs. spreading over hours?","answers":[{"label":"Slow, over days","tone":"neg","sets":[],"ddx":[],"mdm":"The erythema had progressed slowly over days rather than spreading over hours, against a necrotizing tempo.","frag":"gradual spread over days"},{"label":"Spreading over hours","tone":"pos","sets":[],"ddx":[{"id":"necfasc","keep":true}],"mdm":"The erythema spread over hours rather than days, a necrotizing tempo.","frag":"rapid spread over hours"}]},{"id":"ce-hx-pain","dx":"necfasc","q":"Pain — proportionate to the visible redness, or severe and out of proportion (or anesthesia of the skin)?","answers":[{"label":"Proportionate","tone":"neg","sets":[],"ddx":[],"mdm":"Pain is proportionate to the visible findings.","frag":"pain proportionate to visible findings"},{"label":"Out of proportion / numb skin","tone":"pos","sets":[],"ddx":[{"id":"necfasc","keep":true}],"mdm":"Pain out of proportion (or a numb patch) is necrotizing infection until excluded.","frag":"pain out of proportion or cutaneous anesthesia"}]},{"id":"ce-hx-host","dx":"necfasc","q":"Host factors — diabetes, immunocompromise, IV drug use, cirrhosis, or recent surgery/trauma at the site?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"host-cell"}],"ddx":[],"mdm":"No high-risk host factors were present: no diabetes, immunocompromise, IV drug use, cirrhosis, or recent surgery or trauma at the site.","frag":"no high-risk host factors"},{"label":"Present","tone":"pos","sets":[{"risk":"host-cell"}],"ddx":[{"id":"necfasc","keep":true}],"mdm":"High-risk host factors (diabetes, immunocompromise, IV drug use, cirrhosis, or recent surgery or trauma at the site) were present and lowered every threshold.","frag":"high-risk host factors"}]},{"id":"ce-hx-bilateral","dx":"stasis-derm","q":"Distribution — unilateral, or bilateral lower-leg redness (bilateral 'cellulitis' is usually stasis dermatitis)?","answers":[{"label":"Unilateral","tone":"neg","sets":[],"ddx":[],"mdm":"The involvement is unilateral.","frag":"unilateral involvement"},{"label":"Bilateral","tone":"pos","sets":[],"ddx":[{"id":"stasis-derm","keep":true}],"mdm":"Bilateral redness is far more often stasis dermatitis than infection: antibiotics may be the wrong treatment entirely.","frag":"bilateral lower-extremity redness"}]},{"id":"ce-hx-dvt","dx":"dvt-mimic","q":"DVT risk in a red swollen leg — immobilization, surgery, malignancy, prior VTE, or calf pain/swelling without a skin break?","answers":[{"label":"No VTE risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No VTE risk factors were present: no immobilization, surgery, malignancy, prior VTE, or calf pain or swelling without a skin break.","frag":"no VTE risk factors"},{"label":"VTE risk factors","tone":"pos","sets":[],"ddx":[{"id":"dvt-mimic","keep":true}],"mdm":"VTE risk factors (immobilization, surgery, malignancy, prior VTE, or calf pain or swelling without a skin break) were present, and DVT shares this presentation.","frag":"VTE risk factors in a red swollen leg"}]}],"exam":[{"id":"ce-ex-nec","dx":"necfasc","q":"Necrotizing features — crepitus, bullae, dusky or gray discoloration, woody induration, or ill appearance?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"necfasc-assessed"}],"ddx":[],"mdm":"There is no crepitus, bullae, dusky discoloration, woody induration, or systemic toxicity, recognizing that bullae and hypotension are specific but late and insensitive (sens ~21–25%), so their absence does not exclude early necrotizing infection; the tempo, pain trajectory, and reassessment plan address that residual risk.","frag":"no crepitus, bullae, dusky change, or systemic toxicity"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"necfasc","keep":true}],"mdm":"Necrotizing features (crepitus, bullae, dusky or gray discoloration, woody induration, or ill appearance) were present, prompting surgical consultation now, not after imaging.","frag":"necrotizing features on exam"}]},{"id":"ce-ex-fluct","dx":"abscess-cell","q":"Fluctuance — a drainable collection by palpation (or bedside ultrasound)?","answers":[{"label":"No collection","tone":"neg","sets":[{"risk":"source-control"}],"ddx":[],"mdm":"There is no fluctuance and no drainable collection.","frag":"no fluctuance or drainable collection"},{"label":"Fluctuant collection","tone":"pos","sets":[],"ddx":[{"id":"abscess-cell","keep":true}],"mdm":"A drainable collection is present: source control is the treatment.","frag":"fluctuant drainable collection"}]},{"id":"ce-ex-margin","dx":"simple-cellulitis","q":"Margin — border demarcated and marked for tracking, vs. ill-defined or advancing while observed?","answers":[{"label":"Marked","tone":"neg","sets":[{"risk":"margin-marked"}],"ddx":[],"mdm":"The border was demarcated and marked for tracking, rather than ill-defined or advancing while observed, so progression is objective rather than remembered.","frag":"erythema border marked for progression tracking"},{"label":"Ill-defined / advancing","tone":"pos","sets":[],"ddx":[{"id":"necfasc","keep":true}],"mdm":"The border is ill-defined or visibly advanced during the ED stay: a tempo that raises a deeper process.","frag":"ill-defined or advancing erythema border"}]},{"id":"ce-ex-joint","dx":"septic-joint-cell","q":"Joint involvement — infection overlying a joint: full painless range of motion?","answers":[{"label":"Full painless ROM","tone":"neg","sets":[],"ddx":[],"mdm":"The adjacent joint moves fully and painlessly.","frag":"full painless range of motion of the adjacent joint"},{"label":"Pain with ROM / overlying joint","tone":"pos","sets":[],"ddx":[{"id":"septic-joint-cell","keep":true}],"mdm":"Painful motion beneath the infection: septic arthritis must be excluded.","frag":"painful range of motion under the infection"}]}],"conclusions":["nonpurulent cellulitis — outpatient antibiotics, margin marked","abscess — incised and drained","stasis dermatitis — not infection","skin infection NOS (low-risk)"],"guide":"../learn/complaints/cellulitis.html"},{"id":"wrist-hand","specs":["ortho","trauma"],"title":"Wrist & Hand Injury","aliases":["wrist injury","wrist pain","foosh","fell on hand","hand injury","scaphoid","broken wrist","finger injury","jammed finger","boxer fracture","hand pain","punched a wall","snuffbox","hand infection","finger infection","flexor tenosynovitis","elbow","elbow injury","elbow pain","FOOSH","fell on outstretched hand","fat pad"],"opening":"The wrist X-ray lies twice: the scaphoid fracture it doesn't show for two weeks, and the perilunate dislocation it shows to everyone who actually traces the arcs. Add the Kanavel finger that looks like a minor infection, and the hand earns its own pack.","ddx":[{"id":"scaphoid","group":"lifethreat","label":"Occult scaphoid fracture","default":true,"tags":["scaphoid"],"ruleout":"Occult scaphoid fracture was considered; there was no anatomic snuffbox or scaphoid-tubercle tenderness and no pain on axial thumb loading, with normal radiographs, making fracture unlikely though immobilization and repeat imaging were arranged if suspicion persisted.","miss":3},{"id":"perilunate","group":"lifethreat","label":"Perilunate / lunate dislocation","default":true,"tags":["perilunate"],"ruleout":"Perilunate and lunate dislocation were considered; carpal alignment was preserved with intact Gilula arcs and normal radiocapitate-lunate alignment on lateral view, making dislocation unlikely.","miss":3},{"id":"flexor-teno","group":"lifethreat","label":"Flexor tenosynovitis","default":false,"tags":["flexor-teno"],"ruleout":"Flexor tenosynovitis was considered; the Kanavel signs were absent, with no fusiform swelling, no flexed resting posture, no tenderness along the flexor sheath, and no pain on passive extension, making it unlikely.","miss":3},{"id":"distal-radius","group":"common","label":"Distal radius fracture","default":false,"tags":["distal-radius"],"ruleout":"Distal radius fracture was assessed clinically and radiographically.","miss":2},{"id":"metacarpal","group":"common","label":"Metacarpal (boxer's) fracture","default":false,"tags":["metacarpal"],"ruleout":"Metacarpal fracture was assessed, with attention to rotational alignment and any bite wound over the knuckle.","miss":2},{"id":"sprain-wh","group":"other","label":"Sprain / contusion","default":false,"tags":["sprain-wh"],"ruleout":"A sprain or contusion was the working diagnosis.","miss":1}],"risk":[{"id":"snuffbox-exam","label":"Scaphoid exam documented","tags":["scaphoid"],"scale":"low","line":"The anatomic snuffbox, scaphoid tubercle, and axial thumb compression were examined and non-tender.","short":"scaphoid exam non-tender"},{"id":"spica-plan","label":"Scaphoid precautions despite negative imaging","tags":["scaphoid"],"scale":"low","line":"Because clinical suspicion can outlast a negative film, the wrist was immobilized in a thumb-spica splint with repeat examination and imaging arranged in 10–14 days; the patient understands a normal X-ray today does not exclude a scaphoid fracture.","short":"thumb-spica + repeat imaging despite negative film"},{"id":"xray-arcs","label":"X-ray reviewed incl. carpal alignment","tags":["perilunate","distal-radius"],"scale":"low","line":"The radiographs were personally reviewed, including carpal alignment (Gilula arcs) and the lunate's position on the lateral, specifically to exclude perilunate injury.","short":"films reviewed incl. Gilula arcs"},{"id":"nv-hand","label":"Neurovascular / tendon exam documented","tags":["scaphoid","distal-radius","metacarpal"],"scale":"low","line":"Median, ulnar, and radial nerve function, perfusion, and tendon function were examined and intact, with rotational alignment of the digits confirmed.","short":"hand neurovascular and tendon exam intact"}],"checks":[{"if":"scaphoid","needs":["snuffbox-exam","spica-plan"],"mode":"any","warn":"Snuffbox tenderness with a negative film still gets a thumb spica and repeat imaging — the missed scaphoid that necroses is a classic claim."},{"if":"perilunate","needs":["xray-arcs"],"mode":"any","warn":"Document that the carpal arcs were traced — perilunate dislocations are missed by readers who stop at 'no fracture'."},{"if":"flexor-teno","needs":["nv-hand"],"mode":"any","warn":"A painful finger held in flexion needs the Kanavel signs documented — flexor tenosynovitis is hours-to-OR, not days-to-clinic."}],"history":[{"id":"wh-hx-mech","dx":"scaphoid","q":"Mechanism — fall on the outstretched hand (FOOSH) or axial load through the wrist?","answers":[{"label":"Other mechanism","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was not a fall on the outstretched hand.","frag":"no FOOSH or axial-load mechanism"},{"label":"FOOSH / axial load","tone":"pos","sets":[],"ddx":[{"id":"scaphoid","keep":true},{"id":"perilunate","keep":true},{"id":"distal-radius","keep":true}],"mdm":"A FOOSH mechanism puts the scaphoid and carpus at risk.","frag":"fall on outstretched hand"}]},{"id":"wh-hx-energy","dx":"perilunate","q":"Energy — ground-level vs. high-energy (motorcycle, fall from height, sports at speed)?","answers":[{"label":"Low energy","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was low-energy and ground-level, without a high-energy mechanism such as motorcycle, fall from height, or sports at speed.","frag":"low-energy mechanism"},{"label":"High energy","tone":"pos","sets":[],"ddx":[{"id":"perilunate","keep":true}],"mdm":"A high-energy mechanism (motorcycle, fall from height, or sports at speed); raises carpal dislocation and unstable fracture risk.","frag":"high-energy mechanism"}]},{"id":"wh-hx-punch","dx":"metacarpal","q":"Punch mechanism — struck a wall or a person (any wound over the knuckle is a fight bite)?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There was no punch mechanism.","frag":"no punch mechanism"},{"label":"Punch ± knuckle wound","tone":"pos","sets":[],"ddx":[{"id":"metacarpal","keep":true}],"mdm":"A punch mechanism: check rotation, and any knuckle wound is a fight bite involving the joint until proven otherwise.","frag":"punch mechanism; knuckle wound treated as fight bite"}]},{"id":"wh-hx-infection","dx":"flexor-teno","q":"Atraumatic painful finger — swelling after a puncture, bite, or no clear event?","answers":[{"label":"Traumatic, no infection features","tone":"neg","sets":[],"ddx":[],"mdm":"There are no infectious features: no swelling after a puncture or bite, and the presentation is traumatic rather than atraumatic.","frag":"no infectious features"},{"label":"Swollen painful finger ± puncture","tone":"pos","sets":[],"ddx":[{"id":"flexor-teno","keep":true}],"mdm":"A swollen, painful finger after a puncture is present: flexor tenosynovitis is on the table.","frag":"atraumatic swollen painful finger"}]},{"id":"wh-hx-function","dx":"general","q":"Hand dominance and occupation — does this hand earn the patient's living?","answers":[{"label":"Documented","tone":"neg","sets":[],"ddx":[],"mdm":"Hand dominance and occupational demands were documented.","frag":"hand dominance and occupation documented"},{"label":"High-stakes hand","tone":"pos","sets":[],"ddx":[],"mdm":"This is a high-functional-demand hand: the threshold for specialist follow-up is lower.","frag":"dominant working hand with high functional demand"}]}],"exam":[{"id":"wh-ex-snuffbox","dx":"scaphoid","q":"Scaphoid — snuffbox tenderness, scaphoid tubercle tenderness, or pain with axial compression of the thumb?","answers":[{"label":"All non-tender","tone":"neg","sets":[{"risk":"snuffbox-exam"}],"ddx":[],"mdm":"The snuffbox and scaphoid tubercle are non-tender and axial thumb load is painless.","frag":"snuffbox and scaphoid tubercle non-tender; axial load painless"},{"label":"Tender","tone":"pos","sets":[{"risk":"spica-plan"}],"ddx":[{"id":"scaphoid","keep":true}],"mdm":"Scaphoid-area tenderness (snuffbox or scaphoid tubercle tenderness, or pain on axial compression of the thumb) was present; treat as a scaphoid fracture even if the film is negative.","frag":"snuffbox or scaphoid tenderness"}]},{"id":"wh-ex-arcs","dx":"perilunate","q":"Radiographs — carpal alignment traced (Gilula arcs, lunate position on the lateral)?","answers":[{"label":"Alignment normal","tone":"neg","sets":[{"risk":"xray-arcs"}],"ddx":[],"mdm":"Carpal alignment is normal, with the arcs traced and the lunate seated on the lateral view.","frag":"carpal alignment normal including Gilula arcs"},{"label":"Disrupted / not yet imaged","tone":"pos","sets":[],"ddx":[{"id":"perilunate","keep":true}],"mdm":"Carpal alignment is disrupted or not yet imaged.","frag":"carpal malalignment or imaging pending"}]},{"id":"wh-ex-kanavel","dx":"flexor-teno","q":"Kanavel signs — fusiform swelling, flexed posture, tenderness along the flexor sheath, pain on passive extension?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"nv-hand"}],"ddx":[],"mdm":"There are no Kanavel signs: no fusiform swelling, flexed posture, tenderness along the flexor sheath, or pain on passive extension.","frag":"no Kanavel signs"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"flexor-teno","keep":true}],"mdm":"Kanavel signs are present (fusiform swelling, flexed posture, tenderness along the flexor sheath, or pain on passive extension), indicating flexor tenosynovitis; hand surgery now.","frag":"Kanavel signs present"}]},{"id":"wh-ex-nv","dx":"general","q":"Neurovascular and tendon — median/ulnar/radial sensation, perfusion, tendon function, and digit rotation?","answers":[{"label":"Intact, no rotation","tone":"neg","sets":[{"risk":"nv-hand"}],"ddx":[],"mdm":"Neurovascular and tendon function are intact and the digits are not malrotated.","frag":"neurovascular and tendon function intact; no rotational deformity"},{"label":"Deficit / malrotation","tone":"pos","sets":[],"ddx":[{"id":"metacarpal","keep":true}],"mdm":"A neurovascular or tendon deficit (abnormal median/ulnar/radial sensation, perfusion, tendon function, or digit rotation) is present.","frag":"neurovascular deficit or rotational deformity"}]},{"id":"wh-ex-elbow-fatpad","dx":"general","q":"Elbow films (FOOSH with elbow pain) — posterior fat pad or sail sign? A visible posterior fat pad is always pathologic: treat as an occult fracture (radial head in adults, supracondylar in children) even when no fracture line is seen.","answers":[{"label":"No posterior fat pad","tone":"neg","sets":[],"ddx":[],"mdm":"The elbow radiograph showed no posterior fat pad or sail sign, and the anterior fat pad was normal.","frag":"no posterior fat pad or sail sign on elbow films"},{"label":"Posterior fat pad / sail sign","tone":"pos","sets":[],"ddx":[],"mdm":"A posterior fat pad (or elevated anterior 'sail' sign) was present on the elbow radiograph: this is always pathologic, so I treated it as an occult fracture and immobilized accordingly even without a visible fracture line.","frag":"posterior fat pad (treated as occult fracture)"}]}],"conclusions":["wrist sprain — scaphoid precautions given","distal radius fracture — splinted, ortho follow-up","boxer's fracture — splinted, rotation normal","hand contusion (low-risk)"],"guide":"../learn/complaints/wrist-hand.html"},{"id":"hip-fall","specs":["ortho","geri","trauma"],"title":"Hip Injury / Fall (Older Adult)","aliases":["hip pain after fall","fall","elderly fall","ground level fall","hip fracture","fell down","found on floor","can't walk after fall","hip injury","groin pain after fall","geriatric fall","broken hip","long lie","fall workup"],"opening":"Two questions decide the geriatric fall: did the hip break (a negative X-ray doesn't answer it), and why did they fall (a 'mechanical fall' diagnosed without asking is the syncope you missed). The long lie and the anticoagulated head strike ride along.","ddx":[{"id":"occult-hip","group":"lifethreat","label":"Hip / pelvic fracture (incl. occult)","default":true,"tags":["occult-hip"],"ruleout":"Occult hip and pelvic fracture were considered; the patient bore weight without groin or trochanteric pain, the limb was neither shortened nor externally rotated, and pelvic compression was nontender, with X-rays negative, making fracture unlikely.","miss":3},{"id":"fall-cause","group":"lifethreat","label":"Medical cause of the fall (syncope, arrhythmia)","default":true,"tags":["fall-cause"],"ruleout":"A medical cause of the fall was considered; the patient recalled the event without preceding lightheadedness, palpitations, chest pain, or loss of consciousness, with no orthostatic drop, a normal ECG, and no new infection, supporting a mechanical fall.","miss":3},{"id":"head-anticoag","group":"lifethreat","label":"Head strike on anticoagulation","default":true,"tags":["head-anticoag"],"ruleout":"Intracranial hemorrhage was considered; the patient denied any head strike, was not on anticoagulation or antiplatelet therapy, had no headache, vomiting, or loss of consciousness, and was neurologically intact at baseline GCS, making bleed unlikely.","miss":3},{"id":"rhabdo-fall","group":"lifethreat","label":"Long-lie rhabdomyolysis / dehydration","default":false,"tags":["rhabdo-fall"],"ruleout":"Rhabdomyolysis from a prolonged down-time was considered; the patient was found promptly without a long lie, had no muscle pain, swelling, or dark urine, and renal function and CK were normal, making it unlikely.","miss":3},{"id":"long-lie","group":"common","label":"Long-lie complications (rhabdo, pressure injury, hypothermia)","default":false,"tags":["long-lie"],"ruleout":"Time on the floor was established; rhabdomyolysis, pressure injury, dehydration, and hypothermia were assessed after a long lie.","miss":2},{"id":"hip-contusion","group":"other","label":"Hip contusion / soft-tissue injury","default":false,"tags":["hip-contusion"],"ruleout":"A soft-tissue injury was the working diagnosis once fracture and a medical cause were addressed.","miss":1}],"risk":[{"id":"hip-imaging","label":"Imaging reviewed; occult-fracture plan if negative","tags":["occult-hip"],"scale":"low","line":"Hip and pelvis radiographs were personally reviewed; because a plain film can miss a femoral-neck fracture, the plan included MRI/CT (or documented re-evaluation) if the patient could not bear weight or pain persisted.","short":"films reviewed; occult-fracture (MRI/CT) plan documented"},{"id":"fall-screen","label":"Why-they-fell screen (syncope, orthostatics, meds)","tags":["fall-cause"],"scale":"low","line":"A directed fall-cause screen was performed: the moments before the fall reconstructed, orthostatic vitals and ECG obtained as indicated, and the medication list reviewed for culprits.","short":"fall-cause screen done (prodrome, orthostatics, ECG, med review)"},{"id":"ambulation-test","label":"Ambulation observed before discharge","tags":["occult-hip","hip-contusion"],"scale":"low","line":"The patient was observed to ambulate safely (with their usual aid) before discharge, and a home-safety/PT referral was addressed.","short":"ambulated safely before discharge"}],"checks":[{"if":"occult-hip","needs":["hip-imaging","ambulation-test"],"mode":"any","warn":"A negative hip X-ray plus 'can't walk' is an occult fracture until MRI/CT says otherwise — document the imaging review and the weight-bearing test."},{"if":"fall-cause","needs":["fall-screen"],"mode":"any","warn":"Document why they fell — 'mechanical fall' without a syncope screen is the missed arrhythmia's favorite costume."}],"history":[{"id":"hf-hx-before","dx":"fall-cause","q":"The seconds before the fall — a clear trip/slip with memory of the whole event, or lightheadedness, palpitations, blacking out, or no memory of going down?","answers":[{"label":"Clear mechanical trip, full recall","tone":"neg","sets":[{"risk":"fall-screen"}],"ddx":[],"mdm":"The fall was a witnessed or clearly recalled mechanical trip/slip with no prodrome and no loss of consciousness.","frag":"clear mechanical mechanism with full recall"},{"label":"Prodrome / LOC / no recall","tone":"pos","sets":[{"risk":"fall-screen"}],"ddx":[{"id":"fall-cause","keep":true}],"mdm":"Rather than a clear trip or slip with memory of the whole event, there was a prodrome (lightheadedness or palpitations), blacking out, or no memory of going down, making this a syncopal or medical fall until evaluated.","frag":"prodrome, loss of consciousness, or no recall of the fall"}]},{"id":"hf-hx-head","dx":"head-anticoag","q":"Head strike — and is the patient on anticoagulation or antiplatelet therapy?","answers":[{"label":"No head strike, not anticoagulated","tone":"neg","sets":[],"ddx":[],"mdm":"There was no head strike and the patient is not anticoagulated.","frag":"no head strike; not anticoagulated"},{"label":"Head strike and/or anticoagulated","tone":"pos","sets":[],"ddx":[{"id":"head-anticoag","keep":true}],"mdm":"A head strike occurred or the patient is anticoagulated: the intracranial-bleed pathway applies.","frag":"head strike and/or anticoagulation"}]},{"id":"hf-hx-weight","dx":"occult-hip","q":"Weight-bearing since the fall — able to stand and take steps, or unable / unwilling because of hip or groin pain?","answers":[{"label":"Bearing weight","tone":"neg","sets":[],"ddx":[],"mdm":"The patient has been able to stand and take steps since the fall, without hip or groin pain limiting weight-bearing.","frag":"able to bear weight since the fall"},{"label":"Unable to bear weight","tone":"pos","sets":[],"ddx":[{"id":"occult-hip","keep":true}],"mdm":"The patient is unable or unwilling to bear weight because of hip or groin pain: a fracture, including an occult one, must be excluded.","frag":"unable to bear weight since the fall"}]},{"id":"hf-hx-floor","dx":"long-lie","q":"Time on the floor — found quickly, or down for an hour or more (the long lie)?","answers":[{"label":"Up quickly","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was found quickly and was not down on the floor for an hour or more, so a long lie was not a concern.","frag":"no prolonged time on the floor"},{"label":"Long lie (≥ 1 h)","tone":"pos","sets":[],"ddx":[{"id":"long-lie","keep":true}],"mdm":"A long lie of an hour or more occurred; rhabdomyolysis, pressure injury, dehydration, and hypothermia were assessed.","frag":"prolonged time on the floor (long lie)"}]},{"id":"hf-hx-meds","dx":"fall-cause","q":"Medication review — new or dose-changed antihypertensives, sedatives, hypoglycemics, or polypharmacy?","answers":[{"label":"No culprit medications","tone":"neg","sets":[{"risk":"fall-screen"}],"ddx":[],"mdm":"Medication review for new or dose-changed antihypertensives, sedatives, hypoglycemics, or polypharmacy identified no likely culprits.","frag":"no culprit medications on review"},{"label":"Culprit medications","tone":"pos","sets":[{"risk":"fall-screen"}],"ddx":[{"id":"fall-cause","keep":true}],"mdm":"Review identified culprit medications (new or dose-changed antihypertensives, sedatives, hypoglycemics, or polypharmacy), that likely contributed to the fall and were addressed in the plan.","frag":"culprit medications identified"}]},{"answers":[{"ddx":[],"frag":"found promptly, no long lie or dark urine","label":"No prolonged down-time","mdm":"The patient was found promptly without a long lie, had no muscle pain, swelling, or dark urine, and renal function and CK were normal, making rhabdomyolysis unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"rhabdo-fall","keep":true}],"frag":"long lie with muscle pain or dark urine","label":"Prolonged down-time","mdm":"A prolonged down-time with muscle pain, swelling, or dark urine was present, raising concern for rhabdomyolysis and warranting a CK and renal function check.","sets":[],"tone":"pos"}],"dx":"rhabdo-fall","id":"hf-hx-rhabdo-fall","q":"Down-time — a prolonged lie before discovery, muscle pain or swelling, or dark urine?"}],"exam":[{"id":"hf-ex-leg","dx":"occult-hip","q":"Leg position — shortened and externally rotated, or pain with log roll / axial load?","answers":[{"label":"Normal position, log roll painless","tone":"neg","sets":[],"ddx":[],"mdm":"The leg is not shortened or rotated and log roll and axial load are painless.","frag":"no shortening or rotation; log roll and axial load painless"},{"label":"Shortened/rotated or painful log roll","tone":"pos","sets":[],"ddx":[{"id":"occult-hip","keep":true}],"mdm":"Shortening, rotation, or a painful log roll/axial load: fracture until imaged.","frag":"shortening, rotation, or painful log roll/axial load"}]},{"id":"hf-ex-walk","dx":"occult-hip","q":"Observed ambulation — walks with usual aid at baseline, or unable / antalgic and unsafe?","answers":[{"label":"Ambulates safely","tone":"neg","sets":[{"risk":"ambulation-test"}],"ddx":[],"mdm":"The patient ambulated safely in the department with their usual aid.","frag":"ambulates safely with usual aid"},{"label":"Unable / unsafe gait","tone":"pos","sets":[],"ddx":[{"id":"occult-hip","keep":true}],"mdm":"The patient cannot ambulate safely: occult fracture and disposition must both be addressed.","frag":"unable to ambulate or unsafe gait"}]},{"id":"hf-ex-survey","dx":"head-anticoag","q":"Head-to-toe survey — scalp, c-spine, ribs, wrists, and skin over pressure points?","answers":[{"label":"Survey unremarkable","tone":"neg","sets":[],"ddx":[],"mdm":"A head-to-toe survey of the scalp, c-spine, ribs, wrists, and skin over pressure points found no additional injury.","frag":"secondary survey unremarkable"},{"label":"Additional injuries","tone":"pos","sets":[],"ddx":[{"id":"head-anticoag","keep":true}],"mdm":"The head-to-toe survey of the scalp, c-spine, ribs, wrists, and skin over pressure points revealed additional injuries, which were addressed.","frag":"additional injuries on survey"}]},{"id":"hf-ex-vitals","dx":"fall-cause","q":"Vitals and orthostatics — hypotension, bradycardia/tachycardia, fever, or orthostatic drop?","answers":[{"label":"Vitals and orthostatics normal","tone":"neg","sets":[{"risk":"fall-screen"}],"ddx":[],"mdm":"Vital signs showed no hypotension, bradycardia or tachycardia, or fever, and orthostatics where indicated were normal.","frag":"vital signs and orthostatics normal"},{"label":"Abnormal","tone":"pos","sets":[{"risk":"fall-screen"}],"ddx":[{"id":"fall-cause","keep":true}],"mdm":"Abnormal vitals (hypotension, bradycardia or tachycardia, fever, or an orthostatic drop); point to a medical driver of the fall.","frag":"abnormal vitals or orthostasis"}]}],"conclusions":["hip contusion — ambulating safely, fracture excluded","mechanical fall, injuries excluded, home with supports","fall with negative screen — PT/home-safety follow-up"],"guide":"../learn/complaints/hip-fall.html"},{"id":"shoulder-injury","specs":["ortho","trauma"],"title":"Shoulder Injury","aliases":["shoulder pain","shoulder injury","dislocated shoulder","shoulder dislocation","fell on shoulder","can't lift arm","rotator cuff","ac separation","shoulder pain after seizure","collarbone","clavicle"],"opening":"The shoulder hides its misses well: the posterior dislocation after a seizure that looks 'normal' on a single AP view, the axillary nerve injured before (or by) the reduction, and the shoulder pain that was never the shoulder — a heart or a diaphragm talking.","ddx":[{"id":"posterior-dislo","group":"lifethreat","label":"Posterior dislocation (post-seizure/shock)","default":true,"tags":["posterior-dislo"],"ruleout":"Posterior dislocation was considered; there was no antecedent seizure or electrical injury, the arm was not locked in internal rotation, external rotation and supination were preserved, and the humeral head was normally positioned on axillary view, making it unlikely.","miss":3},{"id":"dislo-fx","group":"lifethreat","label":"Dislocation / fracture-dislocation with neurovascular risk","default":true,"tags":["dislo-fx"],"ruleout":"Dislocation and fracture-dislocation were considered; the shoulder contour was normal with intact glenohumeral congruity on imaging, and distal pulses, capillary refill, and axillary-nerve sensation over the deltoid were intact, making neurovascular injury unlikely.","miss":3},{"id":"referred-shoulder","group":"lifethreat","label":"Referred pain (cardiac / diaphragmatic)","default":false,"tags":["referred-shoulder"],"ruleout":"Referred pain was considered; there was no chest pain, dyspnea, diaphoresis, or abdominal complaint, the pain reproduced fully with shoulder movement and palpation, and vital signs were normal, making cardiac or diaphragmatic referral unlikely.","miss":3},{"id":"cuff-tear","group":"common","label":"Rotator cuff tear","default":false,"tags":["cuff-tear"],"ruleout":"A rotator cuff tear was considered: particularly in patients over 40 after a dislocation or with inability to initiate abduction.","miss":2},{"id":"ac-clavicle","group":"common","label":"AC separation / clavicle fracture","default":false,"tags":["ac-clavicle"],"ruleout":"AC separation and clavicle fracture were assessed clinically and radiographically, with skin tenting and neurovascular status checked.","miss":2},{"id":"shoulder-strain","group":"other","label":"Strain / contusion","default":false,"tags":["shoulder-strain"],"ruleout":"A strain or contusion was the working diagnosis.","miss":1}],"risk":[{"id":"axillary-view","label":"Axillary / scapular-Y view obtained","tags":["posterior-dislo","dislo-fx"],"scale":"low","line":"An axillary or scapular-Y view was obtained (the AP alone can look deceptively normal in posterior dislocation) and glenohumeral alignment was confirmed.","short":"axillary/Y-view confirms alignment"},{"id":"axillary-nerve","label":"Axillary nerve + vascular exam (pre/post reduction)","tags":["dislo-fx"],"scale":"low","line":"Axillary-nerve function (deltoid patch sensation and deltoid firing) and distal pulses were examined and documented before and after reduction.","short":"axillary nerve and pulses intact pre/post"},{"id":"postreduction-films","label":"Post-reduction films + sling/follow-up plan","tags":["dislo-fx"],"scale":"low","line":"Post-reduction radiographs confirmed alignment without iatrogenic fracture; the arm was immobilized and orthopedic follow-up arranged.","short":"post-reduction films confirm; follow-up arranged"}],"checks":[{"if":"posterior-dislo","needs":["axillary-view"],"mode":"any","warn":"After a seizure or shock, a 'normal-looking' AP does not exclude posterior dislocation — document the axillary or Y view."},{"if":"dislo-fx","needs":["axillary-nerve"],"mode":"any","warn":"Document the axillary-nerve and pulse exam before AND after reduction — the nerve injured by the injury gets blamed on the reduction."}],"history":[{"id":"sh-hx-mech","dx":"posterior-dislo","q":"Mechanism — fall/sports injury, or a seizure or electrical shock preceding the pain (the posterior-dislocation mechanisms)?","answers":[{"label":"Direct trauma / fall","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was a direct fall or sports injury, rather than a seizure or electrical shock preceding the pain that would suggest posterior dislocation.","frag":"direct traumatic mechanism"},{"label":"Seizure / electric shock","tone":"pos","sets":[{"risk":"axillary-view"}],"ddx":[{"id":"posterior-dislo","keep":true}],"mdm":"The pain followed a seizure or electrical shock: posterior dislocation until the axillary view says otherwise.","frag":"post-seizure or post-shock onset"}]},{"id":"sh-hx-prior","dx":"dislo-fx","q":"Prior dislocations of this shoulder, or first-time event?","answers":[{"label":"First-time","tone":"neg","sets":[],"ddx":[],"mdm":"This is a first-time event for this shoulder.","frag":"first-time shoulder injury"},{"label":"Recurrent dislocations","tone":"pos","sets":[],"ddx":[{"id":"dislo-fx","keep":true}],"mdm":"This shoulder has dislocated before; recurrence changes the reduction and follow-up calculus.","frag":"recurrent dislocation history"}]},{"id":"sh-hx-age","dx":"cuff-tear","q":"Age over 40 — where a dislocation tears the cuff far more often?","answers":[{"label":"40 or under","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is 40 or younger.","frag":"age 40 or under"},{"label":"Over 40","tone":"pos","sets":[],"ddx":[{"id":"cuff-tear","keep":true}],"mdm":"The patient is over 40: cuff integrity needs specific attention after a dislocation.","frag":"age over 40 (cuff tear after dislocation more likely)"}]},{"id":"sh-hx-atraumatic","dx":"referred-shoulder","q":"Atraumatic onset — no injury at all, especially with exertion, diaphoresis, or abdominal symptoms?","answers":[{"label":"Clear injury","tone":"neg","sets":[],"ddx":[],"mdm":"There is a clear traumatic mechanism, without atraumatic onset, exertion, diaphoresis, or abdominal symptoms to suggest a referred source.","frag":"clear traumatic onset"},{"label":"No trauma / exertional or systemic features","tone":"pos","sets":[],"ddx":[{"id":"referred-shoulder","keep":true}],"mdm":"Atraumatic shoulder pain (with no injury at all, particularly with exertion, diaphoresis, or abdominal symptoms) was evaluated for a referred cardiac or diaphragmatic source.","frag":"atraumatic shoulder pain with exertional or systemic features"}]}],"exam":[{"id":"sh-ex-rotation","dx":"posterior-dislo","q":"Rotation — arm locked in internal rotation with mechanical block to external rotation (posterior dislocation's signature)?","answers":[{"label":"External rotation possible","tone":"neg","sets":[],"ddx":[],"mdm":"External rotation is possible without a mechanical block.","frag":"external rotation intact, no internal-rotation lock"},{"label":"Locked internal rotation","tone":"pos","sets":[{"risk":"axillary-view"}],"ddx":[{"id":"posterior-dislo","keep":true}],"mdm":"The arm is locked in internal rotation: posterior dislocation.","frag":"locked internal rotation with blocked external rotation"}]},{"id":"sh-ex-nerve","dx":"dislo-fx","q":"Axillary nerve & vessels — deltoid-patch sensation, deltoid firing, radial pulse?","answers":[{"label":"Intact","tone":"neg","sets":[{"risk":"axillary-nerve"}],"ddx":[],"mdm":"Deltoid-patch sensation, deltoid firing, and distal pulses are intact.","frag":"axillary-nerve function and pulses intact"},{"label":"Deficit","tone":"pos","sets":[{"risk":"axillary-nerve"}],"ddx":[{"id":"dislo-fx","keep":true}],"mdm":"An axillary-nerve or vascular deficit (abnormal deltoid-patch sensation, deltoid firing, or radial pulse) is present and documented before any manipulation.","frag":"axillary-nerve or vascular deficit"}]},{"id":"sh-ex-cuff","dx":"cuff-tear","q":"Cuff function (once reduced / if no dislocation) — initiates abduction and resists external rotation?","answers":[{"label":"Cuff functioning","tone":"neg","sets":[],"ddx":[],"mdm":"The cuff initiates abduction and resists external rotation.","frag":"initiates abduction; resists external rotation"},{"label":"Cannot initiate abduction / weak","tone":"pos","sets":[],"ddx":[{"id":"cuff-tear","keep":true}],"mdm":"Inability to initiate abduction or marked weakness: a cuff tear needs specific follow-up.","frag":"unable to initiate abduction or marked weakness"}]},{"id":"sh-ex-ac","dx":"ac-clavicle","q":"AC joint and clavicle — point tenderness, step-off, or skin tenting?","answers":[{"label":"No AC/clavicle findings","tone":"neg","sets":[],"ddx":[],"mdm":"There is no AC or clavicular point tenderness, step-off, or skin tenting.","frag":"no AC or clavicular tenderness, step-off, or tenting"},{"label":"Tenderness / step-off / tenting","tone":"pos","sets":[],"ddx":[{"id":"ac-clavicle","keep":true}],"mdm":"AC or clavicular findings (point tenderness, step-off, or skin tenting) are present; tenting skin needs urgent attention.","frag":"AC or clavicular tenderness, step-off, or tenting"}]}],"conclusions":["anterior dislocation — reduced, neurovascular intact, ortho follow-up","AC sprain — conservative management","shoulder strain / contusion","shoulder injury NOS (low-risk)"],"guide":"../learn/complaints/shoulder-injury.html"},{"id":"rib-chest-trauma","specs":["trauma","pulm","geri"],"title":"Rib & Chest Wall Trauma","aliases":["rib fracture","rib pain after fall","chest wall injury","broken rib","chest trauma","blunt chest injury","fell on chest","rib injury","chest pain after fall","bruised ribs","sternal fracture"],"opening":"Rib fractures are a pain problem in the young and a mortality problem in the old — and the rib is never the whole story: the pneumothorax above it, the spleen or liver below it, and the pneumonia three days after discharge are what the chart must answer for.","ddx":[{"id":"ptx-htx","group":"lifethreat","label":"Pneumothorax / hemothorax","default":true,"tags":["ptx-htx"],"ruleout":"Pneumothorax and hemothorax were considered; breath sounds were equal bilaterally, the trachea was midline, the patient was not hypoxic or tachypneic, and chest imaging showed no pleural air or fluid, making them unlikely.","miss":3},{"id":"pulm-contusion","group":"lifethreat","label":"Pulmonary contusion / flail segment","default":true,"tags":["pulm-contusion"],"ruleout":"Pulmonary contusion and flail segment were considered; there was no paradoxical chest-wall movement, oxygen saturation and work of breathing remained normal on serial assessment, and imaging showed no parenchymal opacity, making significant contusion unlikely.","miss":3},{"id":"abd-organ","group":"lifethreat","label":"Splenic / hepatic injury (lower ribs)","default":true,"tags":["abd-organ"],"ruleout":"Splenic and hepatic injury were considered; the abdomen was soft and nontender without guarding or referred shoulder pain, the patient remained hemodynamically stable, and eFAST showed no free fluid, making intra-abdominal organ injury unlikely.","miss":3},{"id":"cardiac-contusion","group":"lifethreat","label":"Sternal fracture / blunt cardiac injury","default":false,"tags":["cardiac-contusion"],"ruleout":"Blunt cardiac injury was considered; there was no sternal tenderness or high-energy frontal impact, the patient had no palpitations or chest pain, and the ECG showed normal sinus rhythm without dysrhythmia or new changes, making it unlikely.","miss":3},{"id":"aortic-injury","group":"lifethreat","label":"Traumatic aortic / great-vessel injury","default":false,"tags":["aortic-injury"],"ruleout":"Traumatic aortic injury was considered; the mechanism was not a high-energy deceleration, there was no inter-scapular pain or pulse differential, and the mediastinum was normal on imaging, making it unlikely.","miss":3},{"id":"simple-rib","group":"common","label":"Rib fracture / chest wall contusion","default":false,"tags":["simple-rib"],"ruleout":"Simple rib fracture or contusion was the working diagnosis, with analgesia and pulmonary toilet as the actual treatment.","miss":2}],"risk":[{"id":"chest-imaging","label":"Chest imaging reviewed (CXR / eFAST / CT)","tags":["ptx-htx","pulm-contusion"],"scale":"low","line":"Chest imaging was personally reviewed for pneumothorax, hemothorax, contusion, and rib-fracture pattern.","short":"chest imaging personally reviewed"},{"id":"ambulatory-sat","label":"Oxygenation incl. ambulatory saturation","tags":["pulm-contusion","simple-rib"],"scale":"low","line":"Oxygen saturation was documented at rest and with ambulation before discharge.","short":"SpO₂ documented at rest and ambulating"},{"id":"pain-spirometry","label":"Analgesia + incentive-spirometry plan","tags":["simple-rib"],"scale":"low","line":"Multimodal analgesia sufficient for deep breathing and coughing was provided, with incentive spirometry / deep-breathing instructions (the pneumonia-prevention plan); documented.","short":"analgesia adequate for deep breathing; spirometry plan given"},{"id":"geri-threshold","label":"Age-adjusted admission threshold applied","tags":["simple-rib","pulm-contusion"],"scale":"low","line":"Because rib-fracture mortality climbs with age, the admission threshold was age-adjusted (older patients with multiple fractures or borderline oxygenation were not sent home by default).","short":"age-adjusted admission threshold applied"}],"checks":[{"if":"ptx-htx","needs":["chest-imaging"],"mode":"any","warn":"Pneumothorax/hemothorax is on the differential — document the imaging review."},{"if":"abd-organ","needs":["chest-imaging"],"mode":"any","warn":"Lower-rib pain owns the spleen and liver — document the abdominal assessment, not just the chest."},{"if":"simple-rib","needs":["pain-spirometry","ambulatory-sat"],"mode":"any","warn":"The discharge treatment for rib fracture is analgesia good enough to breathe deeply — document the plan and the ambulatory saturation."}],"history":[{"id":"rc-hx-energy","dx":"ptx-htx","q":"Mechanism energy — simple fall or impact, vs. high-energy (MVC, fall from height, crush)?","answers":[{"label":"Low-energy","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was low-energy: a simple fall or impact rather than a high-energy MVC, fall from height, or crush.","frag":"low-energy mechanism"},{"label":"High-energy","tone":"pos","sets":[],"ddx":[{"id":"ptx-htx","keep":true},{"id":"abd-organ","keep":true}],"mdm":"A high-energy mechanism (MVC, fall from height, or crush); widened the injury search to the chest cavity and abdomen.","frag":"high-energy mechanism"}]},{"id":"rc-hx-dyspnea","dx":"pulm-contusion","q":"Breathing — pain-limited only, or true dyspnea / worsening breathlessness since the injury?","answers":[{"label":"Pain-limited only","tone":"neg","sets":[],"ddx":[],"mdm":"Breathing is limited by pain only, without true dyspnea.","frag":"no true dyspnea"},{"label":"True / worsening dyspnea","tone":"pos","sets":[],"ddx":[{"id":"pulm-contusion","keep":true},{"id":"ptx-htx","keep":true}],"mdm":"True or worsening dyspnea: contusion, pneumothorax, or hemothorax until imaged.","frag":"true or worsening dyspnea"}]},{"id":"rc-hx-lower","dx":"abd-organ","q":"Location — lower ribs (below the nipple line) or with abdominal / left-shoulder-tip pain?","answers":[{"label":"Upper / mid chest wall only","tone":"neg","sets":[],"ddx":[],"mdm":"Involvement is confined to the upper or mid chest wall.","frag":"upper or mid chest wall involvement only"},{"label":"Lower ribs ± abdominal pain","tone":"pos","sets":[],"ddx":[{"id":"abd-organ","keep":true}],"mdm":"Lower-rib involvement or abdominal/shoulder-tip pain: splenic or hepatic injury must be assessed.","frag":"lower-rib involvement or abdominal/shoulder-tip pain"}]},{"id":"rc-hx-age","dx":"simple-rib","q":"Age ≥ 65 or frailty — where rib fractures carry real mortality?","answers":[{"label":"Under 65, robust","tone":"neg","sets":[{"risk":"geri-threshold"}],"ddx":[],"mdm":"The patient is under 65 without frailty.","frag":"under 65 without frailty"},{"label":"≥ 65 / frail","tone":"pos","sets":[{"risk":"geri-threshold"}],"ddx":[{"id":"pulm-contusion","keep":true}],"mdm":"Age or frailty raises rib-fracture mortality: the admission threshold drops accordingly.","frag":"age ≥ 65 or frailty"}]},{"id":"rc-hx-anticoag","dx":"ptx-htx","q":"Anticoagulation — raising hemothorax and delayed-bleeding risk?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not anticoagulated.","frag":"not anticoagulated"},{"label":"Anticoagulated","tone":"pos","sets":[],"ddx":[{"id":"ptx-htx","keep":true}],"mdm":"Anticoagulation raises hemothorax and delayed bleeding risk and lowers the imaging/observation threshold.","frag":"on anticoagulation"}]},{"answers":[{"ddx":[],"frag":"low-energy mechanism, no inter-scapular pain or pulse differential","label":"No aortic-injury features","mdm":"The mechanism was not a high-energy deceleration, there was no inter-scapular pain or pulse differential, and the mediastinum was normal on imaging, making traumatic aortic injury unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"aortic-injury","keep":true}],"frag":"high-energy mechanism or pulse differential","label":"Aortic-injury features present","mdm":"A high-energy deceleration mechanism, inter-scapular pain, or a pulse or blood-pressure differential was present, raising concern for traumatic aortic injury and warranting CT angiography.","sets":[],"tone":"pos"}],"dx":"aortic-injury","id":"rc-hx-aortic-injury","q":"Aortic injury — high-energy deceleration mechanism, inter-scapular pain, or a pulse or blood-pressure differential between limbs?"}],"exam":[{"id":"rc-ex-resp","dx":"ptx-htx","q":"Respiratory exam — breath sounds symmetric, no subcutaneous emphysema, SpO₂ normal?","answers":[{"label":"Symmetric, no subQ air, SpO₂ normal","tone":"neg","sets":[{"risk":"ambulatory-sat"}],"ddx":[],"mdm":"Breath sounds are symmetric with no subcutaneous emphysema and normal oxygen saturation.","frag":"symmetric breath sounds; no subcutaneous emphysema; normal SpO₂"},{"label":"Asymmetric / subQ air / hypoxia","tone":"pos","sets":[{"risk":"chest-imaging"}],"ddx":[{"id":"ptx-htx","keep":true}],"mdm":"Asymmetric breath sounds, subcutaneous emphysema, or hypoxia were present: pneumothorax or hemothorax until imaged.","frag":"asymmetric breath sounds, subcutaneous emphysema, or hypoxia"}]},{"id":"rc-ex-flail","dx":"pulm-contusion","q":"Chest wall — focal crepitus with paradoxical movement (flail), or stable tenderness only?","answers":[{"label":"Stable, tenderness only","tone":"neg","sets":[],"ddx":[],"mdm":"The chest wall is stable with focal tenderness only.","frag":"chest wall stable without paradoxical movement"},{"label":"Flail / paradoxical movement","tone":"pos","sets":[],"ddx":[{"id":"pulm-contusion","keep":true}],"mdm":"A flail segment is present.","frag":"flail segment with paradoxical movement"}]},{"id":"rc-ex-abd","dx":"abd-organ","q":"Abdomen — LUQ/RUQ tenderness, guarding, or referred shoulder-tip pain?","answers":[{"label":"Benign abdomen","tone":"neg","sets":[],"ddx":[],"mdm":"The directed abdominal examination was benign, without LUQ or RUQ tenderness, guarding, or referred shoulder-tip pain.","frag":"abdomen benign on directed exam"},{"label":"LUQ/RUQ tenderness or guarding","tone":"pos","sets":[],"ddx":[{"id":"abd-organ","keep":true}],"mdm":"Upper-quadrant findings (LUQ or RUQ tenderness or guarding) were present, raising splenic or hepatic injury until assessed.","frag":"upper-quadrant tenderness or guarding"}]},{"id":"rc-ex-sternum","dx":"cardiac-contusion","q":"Sternum — point tenderness or deformity (and if so, ECG screened)?","answers":[{"label":"Non-tender","tone":"neg","sets":[],"ddx":[],"mdm":"The sternum was non-tender without point tenderness or deformity.","frag":"sternum non-tender"},{"label":"Sternal tenderness / deformity","tone":"pos","sets":[],"ddx":[{"id":"cardiac-contusion","keep":true}],"mdm":"Sternal tenderness or deformity: blunt cardiac injury screened with ECG (± troponin).","frag":"sternal tenderness or deformity"}]}],"conclusions":["chest wall contusion — analgesia and breathing plan","isolated rib fracture(s) — discharged with spirometry plan","rib fractures — admitted for pain control / monitoring"],"guide":"../learn/complaints/blunt-chest-trauma.html"},{"id":"elevated-bp","specs":["cards"],"title":"Elevated Blood Pressure","aliases":["high blood pressure","hypertension","elevated bp","bp high","blood pressure check","hypertensive urgency","hypertensive emergency","asymptomatic hypertension"],"opening":"The number is not the emergency — the end organ is. The visit's two jobs are a disciplined symptom screen for hypertensive emergency (and preeclampsia), and the discipline NOT to chase or acutely treat an asymptomatic number, per ACEP policy.","ddx":[{"id":"htn-emergency","group":"lifethreat","label":"Hypertensive emergency (end-organ damage)","default":true,"tags":["htn-emergency"],"ruleout":"Hypertensive emergency was considered; the patient denied chest pain, dyspnea, headache, vision change, neurologic deficit, and reduced urine output, with a normal neurologic exam and no signs of acute end-organ injury, making it unlikely.","miss":3},{"id":"preeclampsia-bp","group":"lifethreat","label":"Preeclampsia (pregnant or postpartum)","default":false,"tags":["preeclampsia-bp"],"ruleout":"Preeclampsia was considered; the patient was not pregnant or within the postpartum window, denied headache, visual disturbance, and epigastric pain, and had no peripheral edema or proteinuria, making preeclampsia inapplicable.","miss":4,"sex":"f"},{"id":"stroke-bp","group":"lifethreat","label":"Acute stroke / intracranial hemorrhage","default":false,"tags":["stroke-bp"],"ruleout":"Acute stroke or intracranial hemorrhage was considered; the patient had no headache, vision change, weakness, numbness, or speech disturbance, and the neurologic exam was nonfocal, making an acute intracranial event unlikely.","miss":4},{"id":"secondary-bp","group":"common","label":"Medication / stimulant driver","default":false,"tags":["secondary-bp"],"ruleout":"Missed antihypertensives, NSAIDs, decongestants, and stimulant use were reviewed as drivers.","miss":2},{"id":"asymp-htn","group":"other","label":"Asymptomatic elevated BP","default":false,"tags":["asymp-htn"],"ruleout":"Asymptomatic elevated blood pressure was managed with outpatient follow-up rather than acute ED lowering, consistent with ACEP policy.","miss":1}],"risk":[{"id":"endorgan-screen","label":"End-organ symptom screen documented","tags":["htn-emergency"],"scale":"low","line":"A directed end-organ screen was documented: no chest pain, dyspnea, focal weakness or speech change, vision change, severe headache, confusion, or decreased urine output.","short":"end-organ symptom screen negative"},{"id":"bp-recheck","label":"BP rechecked (proper cuff, repeat reading)","tags":["htn-emergency","asymp-htn"],"scale":"low","line":"The blood pressure was rechecked with an appropriate cuff after rest, and the repeat value was documented.","short":"BP rechecked and documented"},{"id":"htn-followup","label":"Outpatient BP plan (ACEP-consistent)","tags":["asymp-htn"],"scale":"low","line":"Consistent with ACEP policy on asymptomatic elevated blood pressure, acute ED lowering was not pursued; outpatient follow-up for ongoing management was arranged and return precautions for end-organ symptoms were given.","cite":"ACEP Clinical Policy: Asymptomatic Elevated Blood Pressure. Ann Emerg Med. 2013.","short":"outpatient plan per ACEP; end-organ return precautions given"}],"checks":[{"if":"htn-emergency","needs":["endorgan-screen","bp-recheck"],"mode":"any","warn":"Document the end-organ symptom screen and the repeat reading — the screen, not the number, is the assessment."}],"history":[{"id":"bp-hx-symptoms","dx":"htn-emergency","q":"End-organ symptoms — chest pain, shortness of breath, weakness or numbness, trouble speaking, vision change, severe headache, confusion, or decreased urination?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"endorgan-screen"}],"ddx":[],"mdm":"A directed review found no end-organ symptoms: no chest pain, shortness of breath, weakness or numbness, trouble speaking, vision change, severe headache, confusion, or decreased urination.","frag":"no end-organ symptoms on directed review"},{"label":"Present","tone":"pos","sets":[{"risk":"endorgan-screen"}],"ddx":[{"id":"htn-emergency","keep":true}],"mdm":"End-organ symptoms (such as chest pain, shortness of breath, weakness or numbness, trouble speaking, vision change, severe headache, confusion, or decreased urination) are present, so this is evaluated as a hypertensive emergency, not a number.","frag":"end-organ symptoms present"}]},{"id":"bp-hx-preg","dx":"preeclampsia-bp","q":"Pregnant, or delivered within the past 6 weeks?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not pregnant or recently postpartum.","frag":"not pregnant or postpartum"},{"label":"Pregnant / postpartum","tone":"pos","sets":[],"ddx":[{"id":"preeclampsia-bp","keep":true}],"mdm":"Pregnancy or the postpartum window changes the threshold entirely: preeclampsia was evaluated.","frag":"pregnant or within 6 weeks postpartum"}]},{"id":"bp-hx-meds","dx":"secondary-bp","q":"Missed blood-pressure medicines, or NSAIDs, decongestants, stimulants, or cocaine?","answers":[{"label":"No driver identified","tone":"neg","sets":[],"ddx":[],"mdm":"No medication gap or stimulant driver was identified.","frag":"no medication or stimulant driver"},{"label":"Driver identified","tone":"pos","sets":[],"ddx":[{"id":"secondary-bp","keep":true}],"mdm":"A medication gap or stimulant driver likely explains the reading and was addressed.","frag":"medication gap or stimulant driver"}]},{"id":"bp-hx-context","dx":"asymp-htn","q":"What prompted the check — routine reading at home or pharmacy, vs. a symptom?","answers":[{"label":"Routine / incidental reading","tone":"neg","sets":[],"ddx":[],"mdm":"The elevated reading was incidental: a routine home or pharmacy measurement rather than one prompted by a symptom.","frag":"incidental reading without symptoms"},{"label":"Checked because of a symptom","tone":"pos","sets":[],"ddx":[{"id":"htn-emergency","keep":true}],"mdm":"The pressure was checked because of a symptom rather than as a routine home or pharmacy reading: evaluate the symptom on its own merits.","frag":"checked because of a symptom"}]}],"exam":[{"id":"bp-ex-recheck","dx":"htn-emergency","q":"Repeat BP — appropriate cuff, after rest, both arms if aortic concern?","answers":[{"label":"Rechecked and documented","tone":"neg","sets":[{"risk":"bp-recheck"}],"ddx":[],"mdm":"The pressure was rechecked with appropriate technique (correctly sized cuff, after a period of rest, and in both arms where aortic pathology was a concern) and documented.","frag":"blood pressure rechecked with appropriate technique"},{"label":"Markedly elevated on recheck with symptoms","tone":"pos","sets":[{"risk":"bp-recheck"}],"ddx":[{"id":"htn-emergency","keep":true}],"mdm":"On recheck with appropriate technique (correctly sized cuff and after rest), the pressure remained markedly elevated in a symptomatic patient.","frag":"persistently and markedly elevated with symptoms"}]},{"id":"bp-ex-neuro","dx":"htn-emergency","q":"Neurologic exam — alert, non-focal, normal vision?","answers":[{"label":"Non-focal","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination is non-focal with normal vision.","frag":"neurologically intact"},{"label":"Focal deficit / encephalopathy","tone":"pos","sets":[],"ddx":[{"id":"htn-emergency","keep":true}],"mdm":"A focal deficit or encephalopathy is present on neurologic exam rather than an alert, non-focal patient with normal vision: hypertensive emergency.","frag":"focal deficit or encephalopathy"}]},{"id":"bp-ex-cardiopulm","dx":"htn-emergency","q":"Cardiopulmonary exam — clear lungs, no S3, no acute distress?","answers":[{"label":"Unremarkable","tone":"neg","sets":[],"ddx":[],"mdm":"There are no signs of acute heart failure.","frag":"no signs of acute heart failure"},{"label":"Crackles / S3 / distress","tone":"pos","sets":[],"ddx":[{"id":"htn-emergency","keep":true}],"mdm":"Cardiopulmonary findings of pulmonary edema (crackles, an S3, or acute distress) are present, indicating end-organ involvement.","frag":"signs of acute heart failure"}]},{"answers":[{"ddx":[],"frag":"no neuro symptoms, nonfocal exam","label":"No acute neuro deficit","mdm":"The patient had no headache, vision change, weakness, numbness, or speech disturbance, and the neurologic exam was nonfocal, making an acute stroke or intracranial hemorrhage unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"stroke-bp","keep":true}],"frag":"focal deficit or acute neuro symptoms","label":"Acute neuro deficit present","mdm":"A headache, vision change, weakness, numbness, speech disturbance, or focal exam finding was present, raising concern for acute stroke or intracranial hemorrhage and warranting urgent neuroimaging.","sets":[],"tone":"pos"}],"dx":"stroke-bp","id":"bp-exam-stroke-bp","q":"Acute neuro — headache, vision change, weakness, numbness, or speech disturbance; focal findings on exam?"}],"conclusions":["asymptomatic elevated BP — outpatient management arranged","elevated BP from missed doses — resumed therapy","BP recheck arranged with primary care"],"guide":"../learn/complaints/elevated-bp.html"},{"id":"constipation","specs":["gi"],"title":"Constipation","aliases":["constipation","can't poop","no bowel movement","obstipation","hard stool","blocked up","fecal impaction","not passing gas"],"opening":"Constipation is benign until it's an obstruction, a medication effect, an impaction in a frail patient, or the first announcement of a colon cancer — the history's job is the last flatus, the alarm features, and the medication list.","ddx":[{"id":"obstruction-c","group":"lifethreat","label":"Bowel obstruction","default":true,"tags":["obstruction-c"],"ruleout":"Bowel obstruction was considered; the patient continued to pass flatus, the abdomen was soft and non-distended without high-pitched or absent bowel sounds, there was no bilious vomiting, and no prior abdominal surgery or hernia, making it unlikely.","miss":3},{"id":"malignancy-c","group":"lifethreat","label":"Colorectal malignancy (alarm features)","default":false,"tags":["malignancy-c"],"ruleout":"Colorectal malignancy was considered; there was no recent change in bowel habit, rectal bleeding, unintentional weight loss, or stool-caliber change, and no anemia or family history, with outpatient screening current, making occult malignancy unlikely.","miss":3},{"id":"appendicitis-c","group":"lifethreat","label":"Appendicitis / acute abdomen","default":false,"tags":["appendicitis-c"],"ruleout":"Appendicitis and acute abdomen were considered; the abdomen was soft and nontender without focal right-lower-quadrant pain, guarding, rebound, or fever, and the patient was tolerating oral intake, making an acute surgical abdomen unlikely.","miss":3},{"id":"impaction","group":"common","label":"Fecal impaction","default":false,"tags":["impaction"],"ruleout":"Fecal impaction was assessed, including by rectal examination where indicated.","miss":2},{"id":"med-constipation","group":"common","label":"Medication-induced (opioids, anticholinergics)","default":false,"tags":["med-constipation"],"ruleout":"Opioids and anticholinergic burden were reviewed as drivers.","miss":2},{"id":"functional-c","group":"other","label":"Functional constipation","default":false,"tags":["functional-c"],"ruleout":"Functional constipation was the working diagnosis once obstruction and alarm features were addressed.","miss":1}],"risk":[{"id":"obstruction-screen","label":"Obstruction screen documented","tags":["obstruction-c"],"scale":"low","line":"An obstruction screen was documented: passing flatus, no bilious vomiting, and no peritoneal findings or significant distension.","short":"passing flatus; no obstructive features"},{"id":"rectal-exam-c","label":"Rectal examination performed","tags":["impaction","malignancy-c"],"scale":"low","line":"A rectal examination was performed, assessing for impaction, mass, and blood.","short":"rectal exam performed"}],"checks":[{"if":"obstruction-c","needs":["obstruction-screen"],"mode":"any","warn":"Document the flatus question — 'constipated' with obstipation and vomiting is an obstruction, not a laxative problem."}],"history":[{"id":"cn-hx-flatus","dx":"obstruction-c","q":"Last bowel movement AND last passage of gas — still passing flatus?","answers":[{"label":"Passing flatus","tone":"neg","sets":[{"risk":"obstruction-screen"}],"ddx":[],"mdm":"The patient continues to pass flatus.","frag":"still passing flatus"},{"label":"Obstipation (no gas)","tone":"pos","sets":[],"ddx":[{"id":"obstruction-c","keep":true}],"mdm":"Neither stool nor gas is passing: obstruction until excluded.","frag":"obstipation (no flatus)"}]},{"id":"cn-hx-vomit","dx":"obstruction-c","q":"Vomiting — especially bilious — or increasing distension?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no vomiting or progressive distension.","frag":"no vomiting or distension"},{"label":"Vomiting / distension","tone":"pos","sets":[],"ddx":[{"id":"obstruction-c","keep":true}],"mdm":"Vomiting or progressive distension accompanies the constipation.","frag":"vomiting or progressive distension"}]},{"id":"cn-hx-alarm","dx":"malignancy-c","q":"Alarm features — new change in bowel habit in an adult > 50, blood in stool, weight loss, or narrowing stools?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There were no malignancy alarm features: no new change in bowel habit in an adult over 50, blood in stool, weight loss, or narrowing stools.","frag":"no malignancy alarm features"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"malignancy-c","keep":true}],"mdm":"Alarm features (a new change in bowel habit in an adult over 50, blood in stool, weight loss, or narrowing stools) were present, and colorectal evaluation was arranged.","frag":"malignancy alarm features"}]},{"id":"cn-hx-meds","dx":"med-constipation","q":"Opioids, anticholinergics, iron, or calcium-channel blockers?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"No constipating medications were identified.","frag":"no constipating medications"},{"label":"Constipating medications","tone":"pos","sets":[],"ddx":[{"id":"med-constipation","keep":true}],"mdm":"Constipating medications are in use and were addressed in the plan.","frag":"constipating medications in use"}]},{"id":"cn-hx-surg","dx":"obstruction-c","q":"Prior abdominal surgery or known hernia?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There is no adhesion-forming surgical history or known hernia.","frag":"no surgical or hernia history"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"obstruction-c","keep":true}],"mdm":"A surgical or hernia history raises mechanical obstruction.","frag":"prior abdominal surgery or hernia"}]}],"exam":[{"id":"cn-ex-abd","dx":"obstruction-c","q":"Abdomen — distension, tympany, focal tenderness, or peritoneal signs?","answers":[{"label":"Soft, non-distended","tone":"neg","sets":[{"risk":"obstruction-screen"}],"ddx":[],"mdm":"The abdomen was soft and non-distended, without tympany, focal tenderness, or peritoneal signs.","frag":"abdomen soft, non-distended, non-peritoneal"},{"label":"Distended / tender / peritoneal","tone":"pos","sets":[],"ddx":[{"id":"obstruction-c","keep":true}],"mdm":"Distension or peritoneal findings are present.","frag":"distension, focal tenderness, or peritoneal signs"}]},{"id":"cn-ex-rectal","dx":"impaction","q":"Rectal exam (when indicated) — impaction, mass, or blood?","answers":[{"label":"No impaction, mass, or blood","tone":"neg","sets":[{"risk":"rectal-exam-c"}],"ddx":[],"mdm":"The rectal examination shows no impaction, mass, or blood.","frag":"rectal exam without impaction, mass, or blood"},{"label":"Impaction / mass / blood","tone":"pos","sets":[{"risk":"rectal-exam-c"}],"ddx":[{"id":"impaction","keep":true},{"id":"malignancy-c","keep":true}],"mdm":"The rectal examination found impaction, a mass, or blood.","frag":"impaction, mass, or blood on rectal exam"}]},{"id":"cn-ex-hernia","dx":"obstruction-c","q":"Hernia orifices checked — any incarcerated hernia?","answers":[{"label":"No incarcerated hernia","tone":"neg","sets":[],"ddx":[],"mdm":"The hernia orifices are clear.","frag":"hernia orifices clear"},{"label":"Incarcerated hernia","tone":"pos","sets":[],"ddx":[{"id":"obstruction-c","keep":true}],"mdm":"An incarcerated hernia was found: the obstruction's cause.","frag":"incarcerated hernia found"}]},{"answers":[{"ddx":[],"frag":"soft nontender abdomen, no focal RLQ pain, guarding, or fever (early or atypical appendicitis can lack these, so re-exam and return precautions rather than the exam alone)","label":"No acute-abdomen signs","mdm":"The abdomen was soft and nontender without focal right-lower-quadrant pain, guarding, rebound, or fever, and the patient tolerated oral intake, lowering concern for appendicitis. Because early or atypical appendicitis can lack these findings, re-examination and strict return precautions were used rather than the exam alone to exclude it.","sets":[],"tone":"neg"},{"ddx":[{"id":"appendicitis-c","keep":true}],"frag":"focal RLQ pain with guarding or rebound","label":"Acute-abdomen signs present","mdm":"Focal right-lower-quadrant pain, guarding, rebound, fever, or inability to tolerate oral intake was present, raising concern for appendicitis or an acute surgical abdomen and warranting imaging and surgical evaluation.","sets":[],"tone":"pos"}],"dx":"appendicitis-c","id":"cn-exam-appendicitis-c","q":"Acute abdomen — focal right-lower-quadrant pain, guarding, rebound, fever, or inability to tolerate oral intake?"}],"conclusions":["functional constipation — bowel regimen and follow-up","medication-induced constipation — regimen adjusted","fecal impaction — disimpacted, regimen started"],"guide":"../learn/complaints/constipation.html"},{"id":"hematuria","specs":["uro"],"title":"Hematuria","aliases":["blood in urine","hematuria","red urine","bloody urine","peeing blood","clots in urine","gross hematuria"],"opening":"Two traps own this complaint: clot retention that closes the bladder outlet, and the painless gross hematuria that is bladder cancer until urology says otherwise — and being on a blood thinner explains neither.","ddx":[{"id":"clot-retention","group":"lifethreat","label":"Clot retention / obstruction","default":true,"tags":["clot-retention"],"ruleout":"Clot retention and obstruction were considered; the patient was voiding freely without visible clots, had no suprapubic distension or pain, and a post-void bladder scan showed minimal residual, making retention unlikely.","miss":3},{"id":"gu-malignancy","group":"lifethreat","label":"GU malignancy (painless gross hematuria)","default":true,"tags":["gu-malignancy"],"ruleout":"GU malignancy was considered; the hematuria was associated with infection or trauma rather than painless gross bleeding, there was no smoking history, weight loss, or flank mass, and urology follow-up was arranged for any unexplained hematuria.","miss":3},{"id":"stone-infxn","group":"common","label":"Stone / urinary infection","default":false,"tags":["stone-infxn"],"ruleout":"Stone disease and infection were assessed on pain pattern, urinary symptoms, and urinalysis.","miss":2},{"id":"gu-trauma","group":"common","label":"GU trauma","default":false,"tags":["gu-trauma"],"ruleout":"A traumatic source was considered where there was a mechanism.","miss":2},{"id":"benign-hematuria","group":"other","label":"Benign / exercise-induced / menstrual contamination","default":false,"tags":["benign-hematuria"],"ruleout":"Benign explanations were considered only after the dangerous ones.","miss":1}],"risk":[{"id":"voiding-confirmed","label":"Voiding confirmed / retention excluded","tags":["clot-retention"],"scale":"low","line":"The patient voided freely without clot obstruction, and there was no suprapubic distension.","short":"voiding freely; no retention"},{"id":"uro-referral","label":"Urology referral for gross hematuria documented","tags":["gu-malignancy"],"scale":"low","line":"Urologic follow-up for cystoscopy and upper-tract imaging was arranged for gross hematuria, explicitly noting that anticoagulation does not obviate the malignancy workup.","short":"urology workup arranged (anticoagulation does not excuse it)"}],"checks":[{"if":"gu-malignancy","needs":["uro-referral"],"mode":"any","warn":"Painless gross hematuria gets a urology referral in writing — 'on warfarin' is not a diagnosis."},{"if":"clot-retention","needs":["voiding-confirmed"],"mode":"any","warn":"Document that the patient can void — clot retention is the same-night return visit."}],"history":[{"id":"hu-hx-visible","dx":"gu-malignancy","q":"Visible blood or clots — and is it painful or painless?","answers":[{"label":"Painful / with urinary symptoms","tone":"neg","sets":[],"ddx":[{"id":"stone-infxn","keep":true}],"mdm":"The hematuria is painful or accompanied by urinary symptoms, pointing toward stone or infection.","frag":"painful hematuria with urinary symptoms"},{"label":"Painless gross hematuria","tone":"pos","sets":[{"risk":"uro-referral"}],"ddx":[{"id":"gu-malignancy","keep":true}],"mdm":"Painless gross hematuria: a malignancy presentation until urology completes the workup.","frag":"painless gross hematuria"}]},{"id":"hu-hx-void","dx":"clot-retention","q":"Passing clots, straining, or trouble emptying the bladder?","answers":[{"label":"Voiding freely","tone":"neg","sets":[{"risk":"voiding-confirmed"}],"ddx":[],"mdm":"The patient is voiding freely without significant clots.","frag":"voiding freely without clots"},{"label":"Clots / difficulty voiding","tone":"pos","sets":[],"ddx":[{"id":"clot-retention","keep":true}],"mdm":"Clots or voiding difficulty: retention risk.","frag":"clots or difficulty voiding"}]},{"id":"hu-hx-anticoag","dx":"gu-malignancy","q":"Anticoagulant or antiplatelet use — noting it does NOT explain hematuria?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not anticoagulated.","frag":"not anticoagulated"},{"label":"Anticoagulated","tone":"pos","sets":[{"risk":"uro-referral"}],"ddx":[{"id":"gu-malignancy","keep":true}],"mdm":"The patient is anticoagulated; the bleeding source still requires full evaluation.","frag":"anticoagulated (workup still required)"}]},{"id":"hu-hx-risk","dx":"gu-malignancy","q":"Bladder-cancer risk — smoking, age > 50, occupational dye/chemical exposure, or prior pelvic radiation?","answers":[{"label":"No risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"There are no urothelial cancer risk factors: no smoking, age over 50, occupational dye/chemical exposure, or prior pelvic radiation.","frag":"no urothelial risk factors"},{"label":"Risk factors present","tone":"pos","sets":[],"ddx":[{"id":"gu-malignancy","keep":true}],"mdm":"Bladder-cancer risk factors (smoking, age over 50, occupational dye/chemical exposure, or prior pelvic radiation); strengthen the malignancy concern.","frag":"urothelial cancer risk factors"}]},{"id":"hu-hx-flank","dx":"stone-infxn","q":"Colicky flank pain radiating to the groin, fever, or dysuria?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no stone- or infection-pattern history.","frag":"no colic, fever, or dysuria"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"stone-infxn","keep":true}],"mdm":"A stone or infection pattern is present.","frag":"colicky pain, fever, or dysuria"}]}],"exam":[{"id":"hu-ex-bladder","dx":"clot-retention","q":"Suprapubic exam — distended, tender bladder?","answers":[{"label":"Not distended","tone":"neg","sets":[{"risk":"voiding-confirmed"}],"ddx":[],"mdm":"There is no suprapubic distension.","frag":"no suprapubic distension"},{"label":"Distended bladder","tone":"pos","sets":[],"ddx":[{"id":"clot-retention","keep":true}],"mdm":"The bladder is palpably distended: retention.","frag":"palpably distended bladder"}]},{"id":"hu-ex-vitals","dx":"stone-infxn","q":"Vitals — fever or hemodynamic change?","answers":[{"label":"Normal","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs are normal.","frag":"vital signs normal"},{"label":"Fever / abnormal","tone":"pos","sets":[],"ddx":[{"id":"stone-infxn","keep":true}],"mdm":"Fever or hemodynamic change accompanies the hematuria.","frag":"fever or abnormal vitals"}]},{"id":"hu-ex-flank","dx":"stone-infxn","q":"Flank — costovertebral angle tenderness?","answers":[{"label":"Non-tender","tone":"neg","sets":[],"ddx":[],"mdm":"There is no costovertebral angle tenderness.","frag":"no CVA tenderness"},{"label":"CVA tenderness","tone":"pos","sets":[],"ddx":[{"id":"stone-infxn","keep":true}],"mdm":"Costovertebral angle tenderness is present.","frag":"CVA tenderness"}]}],"conclusions":["gross hematuria — voiding freely, urology workup arranged","hematuria with UTI — treated, recheck arranged","stone-associated hematuria"],"guide":"../learn/complaints/hematuria.html"},{"id":"foley-problem","specs":["uro"],"title":"Foley / catheter problem","aliases":["foley","catheter","urinary catheter","blocked catheter","clogged foley","catheter not draining","foley not draining","catheter won't drain","blood in catheter","clot in catheter","clots in foley","catheter leaking","bypassing catheter","catheter fell out","catheter won't come out","balloon won't deflate","suprapubic catheter","spinal cord blocked catheter"],"opening":"A catheter that 'just needs changing' hides four ways to die: a blocked catheter in a spinal-cord-injury patient one autonomic-dysreflexia crisis from a stroke, clot retention behind gross hematuria, an obstructed-and-infected system that is urosepsis, and the fresh-post-op or traumatized urethra you must never force a catheter into. Restore drainage, then ask why it blocked.","ddx":[{"id":"autonomic-dysreflexia","group":"lifethreat","label":"Autonomic dysreflexia (SCI ≥ T6 + blocked catheter)","default":true,"tags":["autonomic-dysreflexia"],"ruleout":"Autonomic dysreflexia was considered; the patient had no spinal-cord injury at or above T6, blood pressure was at baseline without a pounding headache, flushing, or sweating above the lesion, and the bladder drained promptly, making it unlikely.","miss":3},{"id":"obstruction-retention","group":"lifethreat","label":"Catheter obstruction / urinary retention","default":true,"tags":["obstruction-retention"],"ruleout":"Catheter obstruction and retention were considered; the catheter irrigated and drained freely, urine output was adequate, there was no suprapubic distension or discomfort, and a post-drainage bladder scan was low, making obstruction unlikely.","miss":3},{"id":"clot-retention","group":"lifethreat","label":"Gross hematuria with clot retention","default":true,"tags":["clot-retention"],"ruleout":"Gross hematuria with clot retention was considered; the urine was clear to lightly blood-tinged without clots, the catheter drained freely, and there was no suprapubic distension, so continuous bladder irrigation was not required.","miss":3},{"id":"cauti-urosepsis","group":"lifethreat","label":"Obstructed / infected system → urosepsis","default":true,"tags":["cauti-urosepsis"],"ruleout":"An obstructed, infected system progressing to urosepsis was considered; the patient was afebrile and hemodynamically stable without rigors, flank pain, or altered mentation, the catheter drained freely, and there were no systemic signs of sepsis, making urosepsis unlikely.","miss":3},{"id":"urethral-trauma","group":"common","label":"Urethral trauma / false passage / post-op anastomosis","default":false,"tags":["urethral-trauma"],"ruleout":"Recent urologic surgery and traumatic or failed catheterization were screened for: no catheter was forced, and urology was involved before further instrumentation.","miss":2},{"id":"balloon-mechanical","group":"other","label":"Non-deflating balloon / mechanical catheter issue","default":false,"tags":["balloon-mechanical"],"ruleout":"A mechanical problem (a retained, non-deflating balloon or a catheter that would not exchange) was considered rather than forcing removal.","miss":1}],"risk":[{"id":"drainage-restored","label":"Drainage restored / patency confirmed","tags":["obstruction-retention"],"scale":"low","line":"Catheter patency was restored: the catheter was irrigated or exchanged, drained urine freely, and the bladder was decompressed.","short":"drainage restored, bladder decompressed"},{"id":"ad-managed","label":"Dysreflexia trigger relieved / BP controlled","tags":["autonomic-dysreflexia"],"scale":"low","line":"The blocked catheter was relieved as the autonomic-dysreflexia trigger, the patient was sat upright with constrictions loosened, and blood pressure was monitored and treated until it settled.","short":"AD trigger relieved, BP controlled"},{"id":"cbi-started","label":"Clots evacuated / three-way CBI","tags":["clot-retention"],"scale":"low","line":"Clots were manually evacuated and a large-bore three-way catheter with continuous bladder irrigation to gravity was started, titrated until the effluent ran clear.","short":"clots evacuated, 3-way CBI to clear"},{"id":"source-control","label":"Source control / cultures + antibiotics","tags":["cauti-urosepsis"],"scale":"low","line":"For the obstructed, infected system the catheter was exchanged for source control with the bladder decompressed, cultures were drawn, and empiric antibiotics were started.","short":"catheter exchanged, cultures + antibiotics"},{"id":"uro-consult","label":"Urology involved — no forced reinsertion","tags":["urethral-trauma"],"scale":"low","line":"Because of recent urologic surgery or traumatic/failed catheterization, blind reinsertion was abandoned and urology was involved before any further attempt.","short":"urology consulted; catheter not forced"}],"checks":[{"if":"autonomic-dysreflexia","needs":["ad-managed"],"mode":"any","warn":"SCI at or above T6 with a blocked catheter is a hypertensive emergency — relieve the trigger and document the BP response, even if vitals looked fine on arrival."},{"if":"obstruction-retention","needs":["drainage-restored"],"mode":"any","warn":"Document that drainage was actually restored — a catheter that still will not drain is the same-night bounce-back."},{"if":"clot-retention","needs":["cbi-started"],"mode":"any","warn":"Gross hematuria with clots needs clot evacuation and a three-way catheter, not a fresh small Foley that re-clots."},{"if":"cauti-urosepsis","needs":["source-control"],"mode":"any","warn":"Obstructed plus infected is urosepsis — exchange the catheter for source control and start antibiotics; do not just unblock and discharge."},{"if":"urethral-trauma","needs":["uro-consult"],"mode":"any","warn":"Recent prostatectomy/TURP/urethral repair or blood at the meatus: stop forcing the catheter and call urology before you create a false passage."}],"history":[{"id":"fc-hx-problem","dx":"obstruction-retention","q":"What is the catheter doing — draining, not draining, leaking around it (bypassing), or has it fallen out?","answers":[{"label":"Draining clear urine adequately","tone":"neg","sets":[],"ddx":[],"mdm":"The catheter was draining clear urine adequately, without failure to drain, leaking around it, or dislodgement.","frag":"catheter draining adequately"},{"label":"Not draining / bypassing / dislodged","tone":"pos","sets":[],"ddx":[{"id":"obstruction-retention","keep":true}],"mdm":"The catheter was not draining, was bypassing, or had become dislodged: drainage must be restored.","frag":"catheter not draining / bypassing"}]},{"id":"fc-hx-duration","dx":"obstruction-retention","q":"How long has it not drained, and is there suprapubic pain or fullness?","answers":[{"label":"Brief, no pain or fullness","tone":"neg","sets":[],"ddx":[],"mdm":"The interruption was brief without suprapubic pain or distension.","frag":"brief, no distension"},{"label":"Prolonged / painful distension","tone":"pos","sets":[],"ddx":[{"id":"obstruction-retention","keep":true}],"mdm":"Drainage has been obstructed long enough to cause painful distension, with post-obstructive renal injury a concern.","frag":"prolonged painful distension"}]},{"id":"fc-hx-ad","dx":"autonomic-dysreflexia","q":"Spinal cord injury at or above T6 — and any pounding headache, flushing, sweating, or sense of a blood-pressure spike?","answers":[{"label":"No SCI / no dysreflexia symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There was no spinal cord injury at or above T6 and no dysreflexia symptoms: no pounding headache, flushing, sweating, or sense of a blood-pressure spike.","frag":"no SCI, no dysreflexia symptoms"},{"label":"SCI ≥ T6 with dysreflexia symptoms","tone":"pos","sets":[{"risk":"ad-managed"}],"ddx":[{"id":"autonomic-dysreflexia","keep":true}],"mdm":"A patient with spinal cord injury at or above T6 had dysreflexia symptoms (pounding headache, flushing, sweating, or a sense of a blood-pressure spike) with the blocked catheter the likely trigger, a hypertensive emergency until the bladder is drained and the pressure settles.","frag":"SCI ≥ T6 with dysreflexia symptoms"}]},{"id":"fc-hx-blood","dx":"clot-retention","q":"Blood in the catheter — gross hematuria or clots obstructing flow?","answers":[{"label":"No significant blood or clots","tone":"neg","sets":[],"ddx":[],"mdm":"There is no significant hematuria or clot burden.","frag":"no significant clots"},{"label":"Gross hematuria / clots","tone":"pos","sets":[{"risk":"cbi-started"}],"ddx":[{"id":"clot-retention","keep":true}],"mdm":"Gross hematuria with clots is obstructing the catheter, raising clot-retention risk.","frag":"gross hematuria with clots"}]},{"id":"fc-hx-infection","dx":"cauti-urosepsis","q":"Fever, chills or rigors, or feeling systemically unwell?","answers":[{"label":"Afebrile, systemically well","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is afebrile and systemically well.","frag":"afebrile, well-appearing"},{"label":"Fever / rigors / unwell","tone":"pos","sets":[{"risk":"source-control"}],"ddx":[{"id":"cauti-urosepsis","keep":true}],"mdm":"Fever or systemic illness with an obstructed catheter points to an obstructed, infected system requiring source control.","frag":"febrile / systemically unwell"}]},{"id":"fc-hx-context","dx":"urethral-trauma","q":"Why the catheter, and any recent urologic surgery (prostatectomy, TURP, urethral repair) or traumatic / self-removal with the balloon up?","answers":[{"label":"Chronic stable indwelling; no recent surgery or trauma","tone":"neg","sets":[],"ddx":[],"mdm":"This is a chronic indwelling catheter with no recent urologic surgery or traumatic removal.","frag":"chronic catheter, no recent surgery/trauma"},{"label":"Recent GU surgery or traumatic removal","tone":"pos","sets":[{"risk":"uro-consult"}],"ddx":[{"id":"urethral-trauma","keep":true}],"mdm":"Recent urologic surgery or a traumatic removal makes blind reinsertion hazardous to the urethra or a fresh anastomosis: urology was involved before instrumentation.","frag":"recent GU surgery / traumatic removal"}]},{"id":"fc-hx-anticoag","dx":"clot-retention","q":"Anticoagulant or antiplatelet use?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is not anticoagulated.","frag":"not anticoagulated"},{"label":"Anticoagulated / antiplatelet","tone":"pos","sets":[],"ddx":[{"id":"clot-retention","keep":true}],"mdm":"Anticoagulation increases the clot burden and bleeding, though it does not by itself explain catheter hematuria.","frag":"anticoagulated"}]},{"id":"fc-hx-balloon","dx":"balloon-mechanical","q":"Trouble removing the catheter — balloon will not deflate or it is stuck?","answers":[{"label":"Exchanges / removes normally","tone":"neg","sets":[],"ddx":[],"mdm":"The catheter exchanges and removes normally.","frag":"catheter exchanges normally"},{"label":"Balloon won't deflate / catheter stuck","tone":"pos","sets":[],"ddx":[{"id":"balloon-mechanical","keep":true}],"mdm":"A non-deflating balloon or stuck catheter is a mechanical problem to solve deliberately, not by traction.","frag":"non-deflating balloon / stuck catheter"}]}],"exam":[{"id":"fc-ex-vitals","dx":"cauti-urosepsis","q":"Vitals — fever, tachycardia, or hypotension (sepsis)?","answers":[{"label":"Normal","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were normal, without fever, tachycardia, or hypotension to suggest sepsis.","frag":"vital signs normal"},{"label":"Fever / septic physiology","tone":"pos","sets":[{"risk":"source-control"}],"ddx":[{"id":"cauti-urosepsis","keep":true}],"mdm":"Fever, tachycardia, or hypotension was present, indicating septic physiology accompanying the catheter problem.","frag":"fever / septic physiology"}]},{"id":"fc-ex-bp","dx":"autonomic-dysreflexia","q":"Blood pressure — severe hypertension, with bradycardia or sweating/flushing above the lesion?","answers":[{"label":"Blood pressure at baseline","tone":"neg","sets":[],"ddx":[],"mdm":"Blood pressure was at the patient's baseline, without severe hypertension, bradycardia, or sweating/flushing above the lesion.","frag":"BP at baseline"},{"label":"Severe HTN / dysreflexia pattern","tone":"pos","sets":[{"risk":"ad-managed"}],"ddx":[{"id":"autonomic-dysreflexia","keep":true}],"mdm":"Severe hypertension with a dysreflexia pattern is present: relieve the trigger and treat the pressure.","frag":"severe HTN, dysreflexia pattern"}]},{"id":"fc-ex-bladder","dx":"obstruction-retention","q":"Suprapubic exam / bladder scan — distended bladder?","answers":[{"label":"Decompressed / not distended","tone":"neg","sets":[{"risk":"drainage-restored"}],"ddx":[],"mdm":"The bladder is decompressed without suprapubic distension.","frag":"bladder decompressed"},{"label":"Palpably distended bladder","tone":"pos","sets":[],"ddx":[{"id":"obstruction-retention","keep":true}],"mdm":"The bladder is palpably distended: the catheter is not draining.","frag":"distended bladder"}]},{"id":"fc-ex-patency","dx":"obstruction-retention","q":"Patency test — does the catheter flush and drain after irrigation or exchange?","answers":[{"label":"Flushes and drains freely","tone":"neg","sets":[{"risk":"drainage-restored"}],"ddx":[],"mdm":"After irrigation or exchange the catheter flushes and drains freely.","frag":"flushes and drains freely"},{"label":"Will not flush or drain","tone":"pos","sets":[],"ddx":[{"id":"obstruction-retention","keep":true}],"mdm":"The catheter will not flush or drain and was exchanged.","frag":"will not flush or drain"}]},{"id":"fc-ex-meatus","dx":"urethral-trauma","q":"Meatus / genitalia — blood at the meatus, a false passage, or a trapped foreskin (paraphimosis)?","answers":[{"label":"Normal; no blood at the meatus","tone":"neg","sets":[],"ddx":[],"mdm":"The meatus and genitalia are normal with no blood at the meatus.","frag":"no blood at the meatus"},{"label":"Blood at meatus / trauma / paraphimosis","tone":"pos","sets":[{"risk":"uro-consult"}],"ddx":[{"id":"urethral-trauma","keep":true}],"mdm":"Blood at the meatus or local trauma signals urethral injury: no catheter was forced and urology was involved.","frag":"blood at meatus / urethral trauma"}]}],"conclusions":["blocked catheter exchanged — drainage restored, discharged with urology follow-up","clot retention — three-way catheter with CBI, admitted","catheter-associated UTI with obstruction — decompressed, cultures and antibiotics, admitted","autonomic dysreflexia from a blocked catheter — trigger relieved, BP controlled","failed / traumatic catheterization — urology managing, no forced attempts"],"guide":"../learn/complaints/foley-problem.html"},{"id":"urinary-retention","specs":["uro"],"title":"Acute Urinary Retention","aliases":["urinary retention","acute urinary retention","aur","can't pee","unable to urinate","cannot void","not passing urine","bladder full","distended bladder","obstructive uropathy","post-void residual","trial without catheter","twoc","no urine output"],"opening":"Decompressing the bladder is the relief; the documentation has to show three things were not missed. The clock-stopper is cauda equina -- retention with back pain, saddle numbness, or bilateral leg symptoms is a neurosurgical emergency, not a Foley and discharge. The second is obstructive kidney injury when both sides are blocked, with post-obstructive diuresis to anticipate after decompression. The third is naming the actual cause -- outlet obstruction, a new anticholinergic or opioid, infection, or clot -- rather than draining and streeting without a plan.","ddx":[{"id":"cauda-equina-r","group":"lifethreat","label":"Cauda equina / cord compression","default":true,"tags":["cauda-equina-r"],"ruleout":"Cauda equina syndrome was considered; the patient had no back pain, saddle sensation was intact, anal tone and bilateral lower-limb strength and reflexes were normal, and there was no other neurologic deficit, making cord or cauda compression unlikely.","miss":4},{"id":"obstructive-aki-r","group":"lifethreat","label":"Bilateral obstruction / obstructive AKI","default":true,"tags":["obstructive-aki-r"],"ruleout":"Bilateral obstruction with obstructive AKI was considered; renal function was normal after decompression, urine output resumed appropriately without post-obstructive diuresis, and there was no hydronephrosis, making obstructive injury unlikely.","miss":3},{"id":"bph-outlet","group":"common","label":"Outlet obstruction (BPH / stricture)","default":true,"tags":["bph-outlet"],"ruleout":"Outlet obstruction from prostatic enlargement or stricture was identified as the likely mechanism, with a catheter or trial-without-catheter plan and urology follow-up.","miss":2},{"id":"med-retention","group":"common","label":"Medication-induced retention","default":false,"tags":["med-retention"],"ruleout":"A precipitating medication -- anticholinergic, opioid, antihistamine, or sympathomimetic -- was reviewed and addressed.","miss":2},{"id":"uti-prostatitis-r","group":"common","label":"UTI / prostatitis","default":false,"tags":["uti-prostatitis-r"],"ruleout":"Infection (cystitis or prostatitis) as a precipitant was considered with urinalysis and a prostate exam where appropriate.","miss":2},{"id":"clot-retention","group":"other","label":"Clot retention (gross hematuria)","default":false,"tags":["clot-retention"],"ruleout":"Clot retention from gross hematuria was considered, with a large-bore or three-way catheter and irrigation as needed.","miss":1},{"id":"neurogenic-bladder","group":"other","label":"Neurogenic bladder","default":false,"tags":["neurogenic-bladder"],"ruleout":"A neurogenic cause (diabetic cystopathy, multiple sclerosis, recent neuraxial anesthesia, or post-operative) was considered when no obstructive or pharmacologic cause fit.","miss":1}],"risk":[{"id":"bladder-scan","label":"Retention confirmed (bladder scan / residual)","tags":["bph-outlet"],"scale":"low","line":"Retention was confirmed objectively by bladder ultrasound or by the catheterized residual volume rather than by symptoms alone.","short":"retention confirmed; residual recorded"},{"id":"cauda-exam-r","label":"Cauda equina screen (saddle, tone, legs)","tags":["cauda-equina-r"],"scale":"high","line":"A cauda equina screen was documented -- perineal/saddle sensation, anal sphincter tone, and bilateral lower-limb strength and reflexes -- with urgent MRI and neurosurgery when any feature was abnormal or back pain was present.","short":"cauda equina screen documented"},{"id":"renal-function-r","label":"Renal function checked (obstructive AKI)","tags":["obstructive-aki-r"],"scale":"low","line":"Renal function was checked to detect obstructive kidney injury, and post-obstructive diuresis was anticipated and monitored after decompression.","short":"renal function checked; diuresis watched"},{"id":"cause-sought-r","label":"Precipitant / cause identified","tags":["med-retention"],"scale":"low","line":"The cause of the retention was identified -- outlet obstruction, a culprit medication, infection, or clot -- rather than decompressing without an explanation.","short":"cause identified"},{"id":"twoc-plan","label":"Catheter / trial-without-catheter + urology follow-up","tags":["bph-outlet"],"scale":"low","line":"A clear disposition was set -- indwelling catheter with leg bag and teaching or a planned trial without catheter -- with urology follow-up and return precautions.","short":"catheter/TWOC plan + urology follow-up"}],"checks":[{"if":"cauda-equina-r","needs":["cauda-exam-r"],"mode":"any","warn":"Retention with back pain, saddle numbness, or bilateral leg symptoms is cauda equina until an MRI says otherwise -- document the saddle/tone/leg exam and escalate; this is the line that gets quoted in a missed-cauda-equina suit."},{"if":"obstructive-aki-r","needs":["renal-function-r"],"mode":"any","warn":"Bilateral obstruction injures the kidneys -- check a creatinine and anticipate post-obstructive diuresis after the bladder is decompressed."},{"if":"bph-outlet","needs":["bladder-scan","twoc-plan"],"mode":"all","warn":"Confirm the retention objectively and set a catheter/trial-without-catheter plan with urology follow-up -- 'drained and discharged' without a residual volume or a plan is an incomplete chart."},{"if":"med-retention","needs":["cause-sought-r"],"mode":"any","warn":"A medication cause of retention is common — document that the medication list (anticholinergics, opioids, sympathomimetics) was reviewed as the cause."}],"history":[{"id":"ur-hx-cauda","dx":"cauda-equina-r","q":"Back pain, saddle (perineal) numbness, bilateral leg weakness, or new bowel incontinence?","answers":[{"label":"None of these","tone":"neg","sets":[],"ddx":[],"mdm":"There are no neurologic red flags for cauda equina.","frag":"no cauda equina red flags"},{"label":"Any red flag present","tone":"pos","sets":[{"risk":"cauda-exam-r"}],"ddx":[{"id":"cauda-equina-r","keep":true}],"mdm":"Back pain, saddle numbness, bilateral leg symptoms, or bowel incontinence makes cauda equina the priority.","frag":"cauda equina red flag present"}]},{"id":"ur-hx-bph","dx":"bph-outlet","q":"Prior prostate/outlet symptoms -- weak stream, hesitancy, nocturia, or prior retention?","answers":[{"label":"No outlet symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There are no preceding outlet-obstruction symptoms.","frag":"no prior outlet symptoms"},{"label":"Outlet symptoms / prior retention","tone":"pos","sets":[],"ddx":[{"id":"bph-outlet","keep":true}],"mdm":"A history of outlet symptoms or prior retention supports prostatic or stricture-related obstruction.","frag":"outlet symptoms / prior retention"}],"sex":"m"},{"id":"ur-hx-meds","dx":"med-retention","q":"New medications -- anticholinergic, opioid, antihistamine, or decongestant?","answers":[{"label":"No new medications","tone":"neg","sets":[],"ddx":[],"mdm":"There are no new precipitating medications.","frag":"no new precipitating medications"},{"label":"New culprit medication","tone":"pos","sets":[{"risk":"cause-sought-r"}],"ddx":[{"id":"med-retention","keep":true}],"mdm":"A new anticholinergic, opioid, antihistamine, or sympathomimetic likely precipitated the retention.","frag":"precipitating medication"}]},{"id":"ur-hx-infection","dx":"uti-prostatitis-r","q":"Dysuria, fever, or perineal/prostate pain?","answers":[{"label":"No infectious symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There are no symptoms of urinary or prostate infection.","frag":"no infectious symptoms"},{"label":"Dysuria / fever / prostate pain","tone":"pos","sets":[],"ddx":[{"id":"uti-prostatitis-r","keep":true}],"mdm":"Dysuria, fever, or prostate pain raises UTI or prostatitis as a precipitant.","frag":"infectious precipitant"}]},{"id":"ur-hx-hematuria","dx":"clot-retention","q":"Gross hematuria or passing clots?","answers":[{"label":"No gross blood","tone":"neg","sets":[],"ddx":[],"mdm":"There is no gross hematuria or clot.","frag":"no gross hematuria"},{"label":"Gross blood / clots","tone":"pos","sets":[],"ddx":[{"id":"clot-retention","keep":true}],"mdm":"Gross hematuria with clots can cause clot retention needing a large-bore or three-way catheter and irrigation.","frag":"gross hematuria / clots"}]},{"id":"ur-hx-neuro","dx":"neurogenic-bladder","q":"Diabetes, multiple sclerosis, recent spinal anesthesia, or post-operative state?","answers":[{"label":"No neurogenic risk","tone":"neg","sets":[],"ddx":[],"mdm":"There is no clear neurogenic predisposition.","frag":"no neurogenic risk factors"},{"label":"Neurogenic risk present","tone":"pos","sets":[],"ddx":[{"id":"neurogenic-bladder","keep":true}],"mdm":"A neurogenic contributor (diabetic cystopathy, MS, neuraxial anesthesia, or post-op) is plausible.","frag":"neurogenic risk present"}]}],"exam":[{"id":"ur-ex-scan","dx":"bph-outlet","q":"Bladder scan / palpable distension -- is retention objectively confirmed?","answers":[{"label":"Confirmed, residual recorded","tone":"neg","sets":[{"risk":"bladder-scan"}],"ddx":[],"mdm":"Retention is confirmed by bladder scan or catheterized residual, which was recorded.","frag":"retention confirmed, residual recorded"},{"label":"Not yet confirmed","tone":"pos","sets":[],"ddx":[{"id":"bph-outlet","keep":true}],"mdm":"Retention has not yet been objectively confirmed -- a bladder scan or catheter residual is needed.","frag":"retention not yet confirmed"}]},{"id":"ur-ex-cauda","dx":"cauda-equina-r","q":"Neuro exam -- saddle sensation, anal tone, and lower-limb strength?","answers":[{"label":"Normal saddle/tone/legs","tone":"neg","sets":[{"risk":"cauda-exam-r"}],"ddx":[],"mdm":"Perineal sensation, anal tone, and lower-limb function are normal.","frag":"saddle sensation, tone, and legs normal"},{"label":"Any deficit","tone":"pos","sets":[{"risk":"cauda-exam-r"}],"ddx":[{"id":"cauda-equina-r","keep":true}],"mdm":"A deficit in saddle sensation, anal tone, or the legs mandates urgent MRI and neurosurgery.","frag":"neuro deficit -> urgent MRI"}]},{"id":"ur-ex-renal","dx":"obstructive-aki-r","q":"Renal function and decompression volume -- any concern for obstructive injury or large drainage?","answers":[{"label":"Normal function, modest volume","tone":"neg","sets":[{"risk":"renal-function-r"}],"ddx":[],"mdm":"Renal function is normal and the drained volume was modest.","frag":"renal function normal, modest residual"},{"label":"Raised creatinine / large volume","tone":"pos","sets":[{"risk":"renal-function-r"}],"ddx":[{"id":"obstructive-aki-r","keep":true}],"mdm":"An elevated creatinine or a large drained volume signals obstructive injury -- monitor for post-obstructive diuresis.","frag":"obstructive AKI / large residual"}]},{"id":"ur-ex-prostate","dx":"bph-outlet","q":"Rectal/prostate exam -- enlarged prostate, or tenderness suggesting prostatitis?","answers":[{"label":"Enlarged, non-tender","tone":"neg","sets":[],"ddx":[],"mdm":"The prostate is enlarged and non-tender, consistent with outlet obstruction.","frag":"prostate enlarged, non-tender"},{"label":"Tender / boggy prostate","tone":"pos","sets":[],"ddx":[{"id":"uti-prostatitis-r","keep":true}],"mdm":"A tender, boggy prostate suggests prostatitis as the precipitant.","frag":"tender prostate (prostatitis)"}],"sex":"m"}],"conclusions":["acute retention from outlet obstruction -- decompressed, residual recorded, urology follow-up","retention with red flags -- cauda equina excluded by exam and MRI","obstructive AKI -- decompressed, renal function and post-obstructive diuresis monitored","medication-induced retention -- offending agent stopped, voiding trial planned","clot retention -- three-way catheter and irrigation, urology engaged"],"guide":"../learn/complaints/urinary-retention.html"},{"id":"vaginal-bleeding","specs":["obgyn","heme"],"title":"Vaginal Bleeding (Not Pregnant)","aliases":["vaginal bleeding","heavy period","abnormal uterine bleeding","aub","menorrhagia","postmenopausal bleeding","bleeding between periods","heavy menstrual bleeding"],"opening":"Three questions carry this visit: is she actually not pregnant (test, not history), is the bleeding hemodynamically real (pads per hour, syncope), and is she postmenopausal — where any bleeding is cancer until proven otherwise.","ddx":[{"id":"hd-bleeding","group":"lifethreat","label":"Hemodynamically significant bleeding","default":true,"tags":["hd-bleeding"],"ruleout":"Hemodynamically significant bleeding was considered; the patient was soaking fewer than one pad per hour without large clots, denied syncope or lightheadedness, and had normal vital signs without orthostatic change and a stable hemoglobin, making it unlikely.","miss":3},{"id":"unrecognized-preg","group":"lifethreat","label":"Unrecognized pregnancy / ectopic","default":true,"tags":["unrecognized-preg"],"ruleout":"Unrecognized pregnancy and ectopic were considered; a urine or serum hCG was negative, and there was no abdominal pain, syncope, or hemodynamic instability, excluding pregnancy as the cause of the bleeding.","miss":4,"sex":"f"},{"id":"pmb","group":"lifethreat","label":"Postmenopausal bleeding (malignancy until excluded)","default":false,"tags":["pmb"],"ruleout":"Postmenopausal bleeding as endometrial malignancy was considered; the patient was premenopausal with a clear benign source, or where postmenopausal, gynecologic evaluation and endometrial assessment were arranged, so cancer was not left unexcluded.","miss":3},{"id":"coagulopathy-vb","group":"lifethreat","label":"Coagulopathy / bleeding disorder","default":false,"tags":["coagulopathy-vb"],"ruleout":"An underlying coagulopathy was considered; the patient had no easy bruising, mucosal bleeding, or family bleeding history, was not on anticoagulants, and had normal platelets and coagulation studies, making a bleeding disorder unlikely.","miss":3},{"id":"coag-bleeding","group":"common","label":"Anticoagulant / bleeding disorder","default":false,"tags":["coag-bleeding"],"ruleout":"Anticoagulation and a bleeding diathesis (including von Willebrand in heavy menses since menarche) were reviewed.","miss":2},{"id":"structural-aub","group":"common","label":"Structural cause (fibroids, polyp)","default":false,"tags":["structural-aub"],"ruleout":"Structural causes were considered with outpatient gynecologic evaluation.","miss":2},{"id":"ovulatory-aub","group":"other","label":"Anovulatory / ovulatory AUB","default":false,"tags":["ovulatory-aub"],"ruleout":"Hormonal/anovulatory bleeding was the working diagnosis once the dangerous causes were addressed.","miss":1}],"risk":[{"id":"preg-test-vb","label":"Pregnancy test documented","tags":["unrecognized-preg"],"scale":"low","line":"A pregnancy test was obtained and documented: negative testing excludes pregnancy-related bleeding; positive testing changes the entire pathway.","short":"pregnancy test documented"},{"id":"hemodynamics-vb","label":"Hemodynamics ± orthostatics documented","tags":["hd-bleeding"],"scale":"low","line":"Vital signs (with orthostatics where indicated) and a hemoglobin were documented against the reported bleeding volume.","short":"hemodynamics and hemoglobin documented"},{"id":"gyn-followup-vb","label":"Gynecology follow-up arranged","tags":["pmb","structural-aub"],"scale":"low","line":"Gynecologic follow-up was arranged: urgently for postmenopausal bleeding, which requires endometrial evaluation.","short":"gynecology follow-up arranged"}],"checks":[{"if":"unrecognized-preg","needs":["preg-test-vb"],"mode":"any","warn":"Document the pregnancy TEST — history alone has ended careers here."},{"if":"pmb","needs":["gyn-followup-vb"],"mode":"any","warn":"Postmenopausal bleeding needs documented gynecology follow-up — it is endometrial cancer until proven otherwise."}],"history":[{"id":"vb-hx-preg","dx":"unrecognized-preg","q":"Pregnancy test result — the first branch point, regardless of reported history?","answers":[{"label":"hCG negative","tone":"neg","sets":[{"risk":"preg-test-vb"}],"ddx":[],"mdm":"The pregnancy test is negative, excluding pregnancy-related bleeding.","frag":"pregnancy test negative"},{"label":"hCG positive","tone":"pos","sets":[{"risk":"preg-test-vb"}],"ddx":[{"id":"unrecognized-preg","keep":true}],"mdm":"The pregnancy test was positive: this visit is now a pregnancy-bleeding evaluation (ectopic until located), and the early-pregnancy pathway applies.","frag":""}]},{"id":"vb-hx-volume","dx":"hd-bleeding","q":"Bleeding volume — pads or tampons per hour, clots larger than a quarter, or flooding?","answers":[{"label":"Manageable volume","tone":"neg","sets":[],"ddx":[],"mdm":"The bleeding volume is manageable without flooding or large clots.","frag":"bleeding volume manageable"},{"label":"≥ 1 pad/hour / flooding / large clots","tone":"pos","sets":[],"ddx":[{"id":"hd-bleeding","keep":true}],"mdm":"Bleeding at a pad or tampon per hour, with clots larger than a quarter or flooding, is hemodynamically significant until proven otherwise.","frag":"heavy bleeding (pad per hour or flooding)"}]},{"id":"vb-hx-syncope","dx":"hd-bleeding","q":"Lightheadedness, syncope, or exertional fatigue with the bleeding?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There are no presyncopal or anemic symptoms.","frag":"no presyncopal symptoms"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"hd-bleeding","keep":true}],"mdm":"Presyncope or syncope accompanies the bleeding.","frag":"presyncope or syncope with bleeding"}]},{"id":"vb-hx-menopause","dx":"pmb","q":"Menopausal status — has bleeding returned after 12 months without periods?","answers":[{"label":"Premenopausal","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is premenopausal.","frag":"premenopausal"},{"label":"Postmenopausal bleeding","tone":"pos","sets":[{"risk":"gyn-followup-vb"}],"ddx":[{"id":"pmb","keep":true}],"mdm":"Bleeding after menopause: endometrial cancer until excluded.","frag":"postmenopausal bleeding"}]},{"id":"vb-hx-coag","dx":"coag-bleeding","q":"Anticoagulants, or a lifelong heavy-bleeding pattern (heavy menses since menarche, easy bruising, family history)?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"There is no anticoagulant use or bleeding-diathesis pattern.","frag":"no anticoagulants or bleeding-diathesis history"},{"label":"Yes","tone":"pos","sets":[],"ddx":[{"id":"coag-bleeding","keep":true}],"mdm":"Anticoagulation or a lifelong bleeding pattern (think von Willebrand) is present.","frag":"anticoagulation or bleeding-diathesis pattern"}],"sex":"f"},{"answers":[{"ddx":[],"frag":"no easy bruising, mucosal bleeding, or anticoagulant use","label":"No coagulopathy features","mdm":"The patient had no easy bruising, mucosal bleeding, or family bleeding history, was not on anticoagulants, and had normal platelets and coagulation studies, making an underlying coagulopathy unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"coagulopathy-vb","keep":true}],"frag":"easy bruising, mucosal bleeding, or anticoagulant use","label":"Coagulopathy features present","mdm":"Easy bruising, mucosal bleeding, a family bleeding history, or anticoagulant use was present, raising concern for an underlying coagulopathy and warranting platelet and coagulation studies.","sets":[],"tone":"pos"}],"dx":"coagulopathy-vb","id":"vb-hx-coagulopathy-vb","q":"Bleeding disorder — easy bruising, mucosal bleeding, a family bleeding history, or anticoagulant use?"}],"exam":[{"id":"vb-ex-vitals","dx":"hd-bleeding","q":"Vitals ± orthostatics — tachycardia, hypotension, or orthostatic change?","answers":[{"label":"Stable","tone":"neg","sets":[{"risk":"hemodynamics-vb"}],"ddx":[],"mdm":"The patient is hemodynamically stable, without tachycardia, hypotension, or orthostatic change.","frag":"hemodynamically stable"},{"label":"Unstable / orthostatic","tone":"pos","sets":[{"risk":"hemodynamics-vb"}],"ddx":[{"id":"hd-bleeding","keep":true}],"mdm":"Hemodynamic or orthostatic compromise (tachycardia, hypotension, or orthostatic change) is present.","frag":"hemodynamic or orthostatic compromise"}]},{"id":"vb-ex-source","dx":"structural-aub","q":"Examination — bleeding confirmed uterine (not a laceration, urethral, or rectal source)?","answers":[{"label":"Uterine source confirmed","tone":"neg","sets":[],"ddx":[],"mdm":"Examination confirms a uterine source, not a laceration, urethral, or rectal source.","frag":"uterine source confirmed on examination"},{"label":"Other source / laceration","tone":"pos","sets":[],"ddx":[],"mdm":"A non-uterine source (a laceration, urethral, or rectal source) was identified and managed directly.","frag":"non-uterine source identified"}],"sex":"f"},{"id":"vb-ex-pallor","dx":"hd-bleeding","q":"Signs of anemia — pallor, tachycardia at rest?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There are no clinical signs of significant anemia.","frag":"no clinical anemia signs"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"hd-bleeding","keep":true}],"mdm":"Clinical signs of anemia are present.","frag":"clinical signs of anemia"}]}],"conclusions":["anovulatory AUB — hemodynamically stable, gyn follow-up","heavy menstrual bleeding — stabilized, treatment started","postmenopausal bleeding — urgent gynecology referral"],"guide":"../learn/complaints/vaginal-bleeding.html"},{"id":"bites-stings","specs":["id","derm"],"title":"Bite, Sting & Tick Exposure","aliases":["dog bite","cat bite","animal bite","bee sting","wasp sting","tick bite","tick","spider bite actual","bat exposure","human bite","snake bite","insect sting","lyme"],"opening":"The bite itself is rarely the problem. Rabies risk lives in the species question (and any bat in the bedroom), anaphylaxis in the minutes after the sting, Lyme in the attachment clock, and the cat's tooth in the joint it punctured.","ddx":[{"id":"rabies-risk","group":"lifethreat","label":"Rabies-risk exposure","default":true,"tags":["rabies-risk"],"ruleout":"Rabies-risk exposure was considered; the bite was from a healthy, provoked, observable domestic animal with no high-risk wildlife or bat contact, and the patient had no unexplained bat-proximity exposure, making rabies transmission unlikely.","miss":3},{"id":"anaphylaxis-sting","group":"lifethreat","label":"Anaphylaxis (sting)","default":true,"tags":["anaphylaxis-sting"],"ruleout":"Anaphylaxis was considered; after the sting there was no airway swelling, wheeze, hypotension, urticaria beyond the site, or GI symptoms over an observation window, with stable vital signs, making systemic allergic reaction unlikely.","miss":4},{"id":"deep-bite","group":"lifethreat","label":"Deep structure / joint involvement (cat, fight bite)","default":false,"tags":["deep-bite"],"ruleout":"Deep-structure and joint involvement were considered; there was no wound overlying a joint or tendon sheath, no cat or clenched-fist mechanism, full range of motion without pain on tendon loading, and no signs of deep infection, making it unlikely.","miss":3},{"id":"necsoft-bite","group":"lifethreat","label":"Necrotizing soft-tissue infection","default":false,"tags":["necsoft-bite"],"ruleout":"Necrotizing soft-tissue infection was considered; there was no pain out of proportion, rapidly spreading erythema, crepitus, bullae, or systemic toxicity, and the wound appeared locally contained, making it unlikely.","miss":4},{"id":"tick-disease","group":"common","label":"Tick-borne disease risk","default":false,"tags":["tick-disease"],"ruleout":"Tick attachment duration, engorgement, regional disease, and the prophylaxis decision were documented, with rash-and-fever return precautions.","miss":2},{"id":"local-reaction","group":"other","label":"Local reaction / simple wound","default":false,"tags":["local-reaction"],"ruleout":"A local reaction or simple wound was the working diagnosis.","miss":1}],"risk":[{"id":"rabies-pep","label":"Rabies PEP decision documented","tags":["rabies-risk"],"scale":"low","line":"The rabies post-exposure prophylaxis decision was documented per public-health guidance: species, exposure type, animal observation availability, and the disposition of the PEP decision.","cite":"CDC ACIP rabies post-exposure prophylaxis recommendations.","short":"rabies PEP decision documented"},{"id":"tetanus-bs","label":"Tetanus addressed","tags":["deep-bite","local-reaction"],"scale":"low","line":"Tetanus status was reviewed and updated for this wound class.","short":"tetanus addressed"},{"id":"tick-prophylaxis","label":"Tick prophylaxis decision documented","tags":["tick-disease"],"scale":"low","line":"The single-dose doxycycline prophylaxis decision was made and documented against attachment time, engorgement, and local Lyme prevalence, with erythema-migrans and fever return precautions.","short":"tick prophylaxis decision + return precautions"}],"checks":[{"if":"rabies-risk","needs":["rabies-pep"],"mode":"any","warn":"Document the rabies decision explicitly — rabies is uniformly fatal and the PEP window is the whole case."},{"if":"deep-bite","needs":["tetanus-bs"],"mode":"any","warn":"Cat punctures and fight bites reach deeper than they look — document the exploration, the joint, and the tetanus."},{"if":"tick-disease","needs":["tick-prophylaxis"],"mode":"any","warn":"Tick-borne illness is on the differential — document the exposure and the prophylaxis or empiric-treatment decision (e.g., doxycycline) and the rash/serology plan."}],"history":[{"id":"bs-hx-species","dx":"rabies-risk","q":"What bit or stung — and if an animal: species, provoked or not, and is it available for observation?","answers":[{"label":"Known, observable domestic animal","tone":"neg","sets":[],"ddx":[],"mdm":"The animal was a known domestic species, unprovoked status notwithstanding, and available for observation, lowering the rabies post-exposure prophylaxis concern.","frag":"known domestic animal available for observation"},{"label":"Wild / stray / unobservable animal","tone":"pos","sets":[{"risk":"rabies-pep"}],"ddx":[{"id":"rabies-risk","keep":true}],"mdm":"The animal was wild, stray, or otherwise unavailable for observation, making the rabies post-exposure prophylaxis decision the central issue.","frag":"wild, stray, or unobservable animal"}]},{"id":"bs-hx-bat","dx":"rabies-risk","q":"Any bat contact — including waking to find a bat in the room, even without a known bite?","answers":[{"label":"No bat exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was no bat exposure.","frag":"no bat exposure"},{"label":"Bat exposure","tone":"pos","sets":[{"risk":"rabies-pep"}],"ddx":[{"id":"rabies-risk","keep":true}],"mdm":"Bat exposure occurred: PEP is indicated even without a visible bite in sleep/incapacity scenarios.","frag":"bat exposure (bite not required)"}]},{"id":"bs-hx-systemic","dx":"anaphylaxis-sting","q":"After the sting — hives beyond the site, throat tightness, wheeze, vomiting, or lightheadedness?","answers":[{"label":"Local only","tone":"neg","sets":[],"ddx":[],"mdm":"The reaction was local only, without systemic features such as hives beyond the site, throat tightness, wheeze, vomiting, or lightheadedness.","frag":"local reaction only"},{"label":"Systemic features","tone":"pos","sets":[],"ddx":[{"id":"anaphylaxis-sting","keep":true}],"mdm":"Systemic features after the sting (hives beyond the site, throat tightness, wheeze, vomiting, or lightheadedness) were present, triggering the anaphylaxis pathway with epinephrine first.","frag":"systemic allergic features after the sting"}]},{"id":"bs-hx-tick","dx":"tick-disease","q":"Tick — how long attached, engorged, and from a Lyme-endemic area?","answers":[{"label":"Brief attachment, not engorged","tone":"neg","sets":[{"risk":"tick-prophylaxis"}],"ddx":[],"mdm":"Attachment was brief and the tick not engorged: prophylaxis generally not indicated.","frag":"brief tick attachment, not engorged"},{"label":"≥ 36 h / engorged / endemic","tone":"pos","sets":[{"risk":"tick-prophylaxis"}],"ddx":[{"id":"tick-disease","keep":true}],"mdm":"The tick was attached at least 36 hours or engorged and acquired in a Lyme-endemic area; the prophylaxis criteria were applied.","frag":"prolonged or engorged tick attachment in an endemic area"}]},{"id":"bs-hx-location","dx":"deep-bite","q":"Bite location — hand, over a joint, cat puncture, or a knuckle wound from a punch?","answers":[{"label":"Low-risk location","tone":"neg","sets":[],"ddx":[],"mdm":"The wound was at a low-risk site, not involving the hand, a joint, a cat puncture, or a knuckle from a punch.","frag":"bite at a low-risk site"},{"label":"Hand / joint / cat puncture / fight bite","tone":"pos","sets":[{"risk":"tetanus-bs"}],"ddx":[{"id":"deep-bite","keep":true}],"mdm":"The bite was at a high-risk site (the hand, over a joint, a cat puncture, or a knuckle wound from a punch (fight bite)), raising concern for deep-structure involvement and aggressive infection.","frag":"high-risk bite site (hand, joint, cat puncture)"}]}],"exam":[{"id":"bs-ex-airway","dx":"anaphylaxis-sting","q":"Airway and breathing — voice change, tongue/lip swelling, stridor, or wheeze?","answers":[{"label":"Clear","tone":"neg","sets":[],"ddx":[],"mdm":"Airway and breathing were unremarkable, without voice change, tongue or lip swelling, stridor, or wheeze.","frag":"airway and breathing unremarkable"},{"label":"Involved","tone":"pos","sets":[],"ddx":[{"id":"anaphylaxis-sting","keep":true}],"mdm":"Airway or breathing involvement (voice change, tongue or lip swelling, stridor, or wheeze) was present, prompting epinephrine now.","frag":"airway or breathing involvement"}]},{"id":"bs-ex-wound","dx":"deep-bite","q":"Wound — depth, joint proximity, and range of motion over the bite?","answers":[{"label":"Superficial, joint clear","tone":"neg","sets":[],"ddx":[],"mdm":"The wound was superficial, not in proximity to a joint, with painless range of motion over the bite.","frag":"superficial wound away from joint; painless ROM"},{"label":"Deep / over joint / painful ROM","tone":"pos","sets":[],"ddx":[{"id":"deep-bite","keep":true}],"mdm":"Depth or painful motion over a joint: assume inoculation of the deep structures.","frag":"deep wound or painful motion over a joint"}]},{"id":"bs-ex-rash","dx":"tick-disease","q":"Skin — expanding erythema (erythema migrans) or petechial rash with fever?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no expanding erythema or petechial rash.","frag":"no erythema migrans or petechiae"},{"label":"EM / petechiae + fever","tone":"pos","sets":[],"ddx":[{"id":"tick-disease","keep":true}],"mdm":"An expanding or petechial rash with fever: treat the tick-borne disease, not the bite.","frag":"erythema migrans or febrile petechial rash"}]},{"answers":[{"ddx":[],"frag":"no pain out of proportion, crepitus, or bullae","label":"No necrotizing features","mdm":"There was no pain out of proportion, rapidly spreading erythema, crepitus, bullae, or systemic toxicity, and the wound appeared locally contained, making a necrotizing soft-tissue infection unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"necsoft-bite","keep":true}],"frag":"pain out of proportion, crepitus, or bullae","label":"Necrotizing features present","mdm":"Pain out of proportion, rapidly spreading erythema, crepitus, bullae, or systemic toxicity was present, raising concern for a necrotizing soft-tissue infection and warranting emergent surgical consultation.","sets":[],"tone":"pos"}],"dx":"necsoft-bite","id":"bs-exam-necsoft-bite","q":"Necrotizing infection — pain out of proportion, rapidly spreading erythema, crepitus, bullae, or systemic toxicity?"}],"conclusions":["dog bite — irrigated, low infection risk, rabies addressed","sting with local reaction only","tick removed — prophylaxis decision documented"],"guide":"../learn/complaints/mammalian-bites.html"},{"id":"foreign-body","specs":["ent","gi","peds"],"title":"Swallowed / Aspirated Foreign Body","aliases":["swallowed object","foreign body","button battery","swallowed battery","swallowed magnet","choking","food stuck","fishbone","swallowed coin","something stuck in throat","aspirated"],"opening":"One question changes everything: WHAT was swallowed. A coin can wait; an esophageal button battery burns through in hours; stacked magnets staple bowel together; and the choking toddler who 'seems fine now' may be quietly ventilating around an airway foreign body.","ddx":[{"id":"battery","group":"lifethreat","label":"Button battery (esophageal = emergency)","default":true,"tags":["battery"],"ruleout":"Button-battery ingestion was considered; the object was not a battery by history and caregiver identification, imaging showed no double-rim or halo sign, and there was no drooling, dysphagia, or chest pain, making an esophageal battery unlikely.","miss":4},{"id":"magnets","group":"lifethreat","label":"Multiple magnets","default":true,"tags":["magnets"],"ruleout":"Multiple-magnet ingestion was considered; only a single inert object was involved by history and imaging, with no second magnetic foreign body, making cross-bowel attraction, necrosis, and fistula formation unlikely.","miss":3},{"id":"airway-fb","group":"lifethreat","label":"Airway foreign body","default":true,"tags":["airway-fb"],"ruleout":"Airway foreign body was considered; there was no witnessed choking episode, no stridor, drooling, voice change, or focal wheeze, breath sounds were symmetric, and oxygenation was normal, making airway obstruction unlikely.","miss":3},{"id":"esoph-impaction","group":"common","label":"Esophageal impaction","default":false,"tags":["esoph-impaction"],"ruleout":"Esophageal impaction was assessed: drooling, inability to swallow secretions, and the recurrent-food-impaction history that suggests eosinophilic esophagitis.","miss":2},{"id":"passed-fb","group":"other","label":"Inert object likely to pass","default":false,"tags":["passed-fb"],"ruleout":"An inert, low-risk object expected to pass was the working assessment.","miss":1}],"risk":[{"id":"fb-localization","label":"Object identified + localized on imaging","tags":["battery","magnets","esoph-impaction"],"scale":"low","line":"The object was identified by history and localized radiographically where indicated: esophageal versus gastric position decides the urgency.","short":"object identified and localized"},{"id":"emergent-pathway","label":"Emergent removal pathway activated (battery/magnets)","tags":["battery","magnets"],"scale":"low","line":"For an esophageal button battery or multiple magnets, the emergent endoscopy pathway was activated without delay.","short":"emergent endoscopy pathway activated"},{"id":"secretions-tolerated","label":"Handling secretions / tolerating PO","tags":["esoph-impaction","airway-fb"],"scale":"low","line":"The patient handled secretions and tolerated oral intake before disposition.","short":"handling secretions; tolerating PO"}],"checks":[{"if":"battery","needs":["fb-localization"],"mode":"any","warn":"Ask 'could it be a button battery?' by name and localize it NOW — esophageal batteries injure in hours."},{"if":"airway-fb","needs":["secretions-tolerated"],"mode":"any","warn":"A choking episode with a quiet interval does not clear the airway — document the exam and the disposition logic."},{"if":"magnets","needs":["emergent-pathway"],"mode":"any","warn":"Multiple magnets are a surgical emergency — document localization and the emergent removal pathway (bowel necrosis/perforation/fistula risk)."},{"if":"esoph-impaction","needs":["secretions-tolerated"],"mode":"any","warn":"An esophageal impaction in a patient who can't handle secretions needs emergent removal — document the secretion/airway status."}],"history":[{"id":"fb-hx-object","dx":"battery","q":"Exactly what was swallowed — could it be a button battery, more than one magnet, or something sharp?","answers":[{"label":"Inert, blunt, single object","tone":"neg","sets":[{"risk":"fb-localization"}],"ddx":[],"mdm":"The object was a single, inert, blunt item: not a button battery, multiple magnets, or anything sharp.","frag":"single inert blunt object"},{"label":"Battery / magnets / sharp","tone":"pos","sets":[{"risk":"fb-localization"},{"risk":"emergent-pathway"}],"ddx":[{"id":"battery","keep":true},{"id":"magnets","keep":true}],"mdm":"The object was a button battery, more than one magnet, or something sharp; the high-risk pathway applies.","frag":"button battery, multiple magnets, or sharp object"}]},{"id":"fb-hx-choke","dx":"airway-fb","q":"A choking, gagging, or coughing fit at the time — even if it settled?","answers":[{"label":"No choking episode","tone":"neg","sets":[],"ddx":[],"mdm":"There was no choking or coughing episode.","frag":"no choking episode"},{"label":"Choking episode","tone":"pos","sets":[],"ddx":[{"id":"airway-fb","keep":true}],"mdm":"A choking episode occurred: airway foreign body until examined (and imaged where indicated).","frag":"witnessed choking episode"}]},{"id":"fb-hx-drool","dx":"esoph-impaction","q":"Drooling, spitting out saliva, or unable to swallow liquids since?","answers":[{"label":"Swallowing normally","tone":"neg","sets":[{"risk":"secretions-tolerated"}],"ddx":[],"mdm":"The patient swallows secretions and liquids normally.","frag":"swallowing secretions and liquids"},{"label":"Drooling / can't swallow","tone":"pos","sets":[],"ddx":[{"id":"esoph-impaction","keep":true}],"mdm":"Inability to handle secretions: esophageal obstruction needing urgent intervention.","frag":"unable to handle secretions"}]},{"id":"fb-hx-prior","dx":"esoph-impaction","q":"Prior food impactions or trouble swallowing (the eosinophilic-esophagitis pattern)?","answers":[{"label":"First event","tone":"neg","sets":[],"ddx":[],"mdm":"There is no prior impaction or dysphagia history.","frag":"no prior impaction history"},{"label":"Recurrent impactions","tone":"pos","sets":[],"ddx":[{"id":"esoph-impaction","keep":true}],"mdm":"Recurrent impactions: arrange GI follow-up for the underlying esophagopathy.","frag":"recurrent food impactions"}]}],"exam":[{"id":"fb-ex-airway","dx":"airway-fb","q":"Airway — stridor, voice change, drooling, or respiratory distress?","answers":[{"label":"Airway unremarkable","tone":"neg","sets":[{"risk":"secretions-tolerated"}],"ddx":[],"mdm":"There is no stridor, voice change, drooling, or distress.","frag":"no stridor, voice change, or distress"},{"label":"Stridor / voice change","tone":"pos","sets":[],"ddx":[{"id":"airway-fb","keep":true}],"mdm":"Stridor or voice change: airway involvement.","frag":"stridor or voice change"}]},{"id":"fb-ex-lungs","dx":"airway-fb","q":"Lungs — symmetric air entry, or unilateral wheeze / decreased sounds?","answers":[{"label":"Symmetric","tone":"neg","sets":[],"ddx":[],"mdm":"Air entry is symmetric.","frag":"symmetric air entry"},{"label":"Unilateral findings","tone":"pos","sets":[],"ddx":[{"id":"airway-fb","keep":true}],"mdm":"Unilateral findings: a bronchial foreign body.","frag":"unilateral wheeze or decreased air entry"}]},{"id":"fb-ex-neck","dx":"esoph-impaction","q":"Neck and chest — subcutaneous crepitus or severe pain (perforation)?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no crepitus or sign of perforation.","frag":"no crepitus or perforation signs"},{"label":"Crepitus / severe pain","tone":"pos","sets":[],"ddx":[{"id":"esoph-impaction","keep":true}],"mdm":"Crepitus or disproportionate pain: perforation until excluded.","frag":"crepitus or perforation-pattern pain"}]}],"conclusions":["inert object — expectant management with return precautions","food impaction resolved — GI follow-up arranged","object localized — endoscopy arranged"],"guide":"../learn/complaints/foreign-body.html"},{"id":"burns","specs":["derm","surg","trauma"],"title":"Burns","aliases":["burn","scald","thermal burn","chemical burn","electrical burn","sunburn severe","hot water burn","grease burn","house fire","smoke inhalation"],"opening":"The skin is the visible problem; the killers are upstream — the airway burned in an enclosed space, the current that crossed the heart, the chemical still burning during the history, and the immersion pattern on a child that no story explains.","ddx":[{"id":"inhalation","group":"lifethreat","label":"Inhalation injury / airway burn","default":true,"tags":["inhalation"],"ruleout":"Inhalation injury was considered; there was no enclosed-space exposure, the patient had no hoarseness, stridor, singed nasal hair, carbonaceous sputum, or oropharyngeal soot, and oxygenation was normal, making airway injury unlikely.","miss":3},{"id":"electrical","group":"lifethreat","label":"Electrical injury (cardiac, deep tissue)","default":false,"tags":["electrical"],"ruleout":"Electrical injury was considered; the mechanism was thermal rather than electrical, there were no entry or exit wounds, the ECG showed normal sinus rhythm, and there was no disproportionate deep-tissue pain, making electrical injury unlikely.","miss":3},{"id":"chemical-burn","group":"lifethreat","label":"Chemical burn (ongoing injury)","default":false,"tags":["chemical-burn"],"ruleout":"Chemical burn was considered; the mechanism was thermal rather than chemical with no caustic or acid exposure, there was no ongoing tissue contact, and copious irrigation was not required, making continued chemical injury unlikely.","miss":3},{"id":"nat-burn","group":"lifethreat","label":"Nonaccidental burn (pattern / immersion)","default":false,"tags":["nat-burn"],"ruleout":"Nonaccidental burn was considered; the burn pattern was consistent with the reported mechanism and the child's developmental stage, there were no immersion stocking-glove lines or patterned contact marks, and the history was consistent, making abuse unlikely.","miss":3},{"id":"cohgb-burn","group":"lifethreat","label":"Carbon monoxide / cyanide toxicity","default":false,"tags":["cohgb-burn"],"ruleout":"Carbon monoxide and cyanide toxicity were considered; there was no enclosed-space fire exposure, the patient had no headache, confusion, or syncope, and oxygenation and carboxyhemoglobin were normal, making occult poisoning unlikely.","miss":4},{"id":"simple-burn","group":"common","label":"Partial-thickness thermal burn","default":false,"tags":["simple-burn"],"ruleout":"A partial-thickness thermal burn was the working diagnosis, with TBSA, depth, and referral criteria applied.","miss":2}],"risk":[{"id":"tbsa-doc","label":"TBSA + depth documented","tags":["simple-burn","inhalation"],"scale":"low","line":"Burn extent (TBSA by an accepted method) and depth were estimated and documented.","short":"TBSA and depth documented"},{"id":"aba-criteria","label":"Burn-center referral criteria reviewed","tags":["simple-burn","electrical","chemical-burn"],"scale":"low","line":"The burn-center referral criteria were reviewed against this burn: extent, depth, special locations (face, hands, feet, genitalia, major joints), electrical and chemical mechanisms, and inhalation injury.","cite":"American Burn Association burn-center referral criteria.","short":"ABA referral criteria reviewed"},{"id":"irrigation-burn","label":"Chemical irrigation performed","tags":["chemical-burn"],"scale":"low","line":"Copious irrigation was started immediately and continued until symptom improvement (and pH neutrality for eye involvement).","short":"copious irrigation performed"}],"checks":[{"if":"inhalation","needs":["tbsa-doc"],"mode":"any","warn":"Document the airway assessment and the burn size — the inhalation airway closes on its own schedule."},{"if":"simple-burn","needs":["aba-criteria"],"mode":"any","warn":"Run the burn through the referral criteria and document it — hands, face, feet, genitalia, and joints are referral burns regardless of size."},{"if":"chemical-burn","needs":["irrigation-burn"],"mode":"any","warn":"A chemical burn is treated by immediate, prolonged irrigation — document the irrigation and the agent; for the eye, irrigate to a neutral pH."}],"history":[{"id":"bu-hx-enclosed","dx":"inhalation","q":"Enclosed space or smoke — fire indoors, smoke exposure, or loss of consciousness at the scene?","answers":[{"label":"Open air, no smoke","tone":"neg","sets":[],"ddx":[],"mdm":"There was no enclosed-space or significant smoke exposure: no fire indoors, smoke exposure, or loss of consciousness at the scene.","frag":"no enclosed-space or smoke exposure"},{"label":"Enclosed space / smoke / LOC","tone":"pos","sets":[],"ddx":[{"id":"inhalation","keep":true}],"mdm":"There was fire indoors, smoke exposure, or loss of consciousness at the scene: inhalation injury and CO/cyanide exposure were assessed.","frag":"enclosed-space or smoke exposure"}]},{"id":"bu-hx-mech","dx":"electrical","q":"Mechanism — thermal scald/flame, vs. electrical (what voltage?) or chemical (what agent — irrigate first)?","answers":[{"label":"Thermal","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was thermal (scald or flame) rather than electrical or chemical.","frag":"thermal mechanism"},{"label":"Electrical / chemical","tone":"pos","sets":[{"risk":"irrigation-burn"}],"ddx":[{"id":"electrical","keep":true},{"id":"chemical-burn","keep":true}],"mdm":"An electrical or chemical mechanism: different injury physics and a different workup.","frag":"electrical or chemical mechanism"}]},{"id":"bu-hx-voice","dx":"inhalation","q":"Voice or breathing change — hoarseness, cough, or sooty sputum since the exposure?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There is no hoarseness, cough, or sooty sputum.","frag":"no hoarseness or respiratory symptoms"},{"label":"Hoarseness / sooty sputum","tone":"pos","sets":[],"ddx":[{"id":"inhalation","keep":true}],"mdm":"Hoarseness, cough, or sooty sputum since the exposure was reported: airway involvement is declared.","frag":"hoarseness or carbonaceous sputum"}]},{"id":"bu-hx-story","dx":"nat-burn","q":"In a child — does the story fit the pattern, the timing, and what the child can developmentally do?","answers":[{"label":"Story fits","tone":"neg","sets":[],"ddx":[],"mdm":"The reported mechanism is consistent with the burn pattern and developmental stage.","frag":"mechanism consistent with the burn pattern"},{"label":"Story doesn't fit / immersion pattern","tone":"pos","sets":[],"ddx":[{"id":"nat-burn","keep":true}],"mdm":"The pattern does not fit the story: nonaccidental injury was evaluated and reported as required.","frag":"burn pattern inconsistent with the story"}]},{"id":"bu-hx-tetanus","dx":"simple-burn","q":"Tetanus status current?","answers":[{"label":"Up to date","tone":"neg","sets":[],"ddx":[],"mdm":"Tetanus is current.","frag":"tetanus up to date"},{"label":"Due / unknown","tone":"pos","sets":[],"ddx":[],"mdm":"Tetanus was due and updated.","frag":"tetanus updated"}]},{"answers":[{"ddx":[],"frag":"no enclosed-space exposure, no headache or confusion","label":"No inhalation-toxicity features","mdm":"There was no enclosed-space fire exposure, the patient had no headache, confusion, or syncope, and oxygenation and carboxyhemoglobin were normal, making carbon monoxide or cyanide toxicity unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"cohgb-burn","keep":true}],"frag":"enclosed-space exposure with headache or confusion","label":"Inhalation-toxicity features present","mdm":"Enclosed-space fire exposure with headache, confusion, or syncope was present, raising concern for carbon monoxide or cyanide toxicity and warranting a carboxyhemoglobin level and lactate.","sets":[],"tone":"pos"}],"dx":"cohgb-burn","id":"bu-hx-cohgb-burn","q":"Inhalation toxicity — enclosed-space fire exposure, headache, confusion, or syncope; carboxyhemoglobin status?"}],"exam":[{"id":"bu-ex-airway","dx":"inhalation","q":"Airway — singed nasal hairs, oropharyngeal soot or edema, stridor?","answers":[{"label":"Clear","tone":"neg","sets":[{"risk":"tbsa-doc"}],"ddx":[],"mdm":"There were no signs of airway involvement: no singed nasal hairs, oropharyngeal soot or edema, or stridor.","frag":"no airway burn signs"},{"label":"Soot / edema / stridor","tone":"pos","sets":[],"ddx":[{"id":"inhalation","keep":true}],"mdm":"Airway burn signs (singed nasal hairs, oropharyngeal soot or edema, or stridor) are present; secure early, not late.","frag":"oropharyngeal soot, edema, or stridor"}]},{"id":"bu-ex-extent","dx":"simple-burn","q":"Extent and depth — TBSA estimated; any full-thickness or special-location burns (face, hands, feet, genitalia, joints)?","answers":[{"label":"Small, partial, low-risk location","tone":"neg","sets":[{"risk":"tbsa-doc"},{"risk":"aba-criteria"}],"ddx":[],"mdm":"The burn was small and partial-thickness, away from special locations (face, hands, feet, genitalia, or joints).","frag":"small partial-thickness burn at a low-risk site"},{"label":"Large / deep / special location","tone":"pos","sets":[{"risk":"tbsa-doc"},{"risk":"aba-criteria"}],"ddx":[{"id":"simple-burn","keep":true}],"mdm":"TBSA, full-thickness depth, or a special-location burn (face, hands, feet, genitalia, or joints) met referral criteria.","frag":"large, deep, or special-location burn"}]},{"id":"bu-ex-circ","dx":"electrical","q":"Circumferential burns or distal perfusion change?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"No circumferential involvement; perfusion is intact.","frag":"no circumferential involvement; distal perfusion intact"},{"label":"Circumferential / perfusion change","tone":"pos","sets":[],"ddx":[{"id":"electrical","keep":true}],"mdm":"Circumferential involvement or perfusion change: escharotomy-level urgency.","frag":"circumferential burn or perfusion compromise"}]}],"conclusions":["partial-thickness burn — dressed, referral criteria not met","burn meeting referral criteria — burn center contacted","chemical burn — irrigated, symptoms resolved"],"guide":"../learn/complaints/burns.html"},{"id":"anxiety-panic","specs":["psych","cards"],"title":"Anxiety / Panic Attack","aliases":["panic attack","anxiety","anxiety attack","panic","hyperventilating","feeling of doom","nervous breakdown","stress reaction"],"opening":"Panic is a diagnosis of exclusion wearing the same clothes as ACS, PE, arrhythmia, hypoglycemia, hyperthyroidism, and stimulant toxicity. The chart must show the mimics were screened — 'anxiety' written first is how the PE gets discharged.","ddx":[{"id":"cardiac-mimic","group":"lifethreat","label":"Cardiac mimic (ACS, arrhythmia)","default":true,"tags":["cardiac-mimic"],"ruleout":"A cardiac cause was considered; there was no exertional chest pain, abrupt sustained palpitations, or syncope, the patient had no cardiac risk factors, and the ECG was normal without ischemic changes or dysrhythmia, making ACS or arrhythmia unlikely.","miss":3},{"id":"pe-mimic","group":"lifethreat","label":"Pulmonary embolism mimic","default":true,"tags":["pe-mimic"],"ruleout":"Pulmonary embolism was considered; there was no pleuritic chest pain, hemoptysis, or unilateral leg swelling, oxygen saturation was normal, tachycardia resolved with reassurance, and VTE risk factors were absent with a low pretest probability, making PE unlikely.","miss":4},{"id":"metabolic-mimic","group":"lifethreat","label":"Hypoglycemia / metabolic mimic","default":false,"tags":["metabolic-mimic"],"ruleout":"Hypoglycemia and metabolic mimics were considered; the point-of-care glucose was normal, the patient was not on insulin or sulfonylureas, and there were no signs of thyrotoxicosis or toxidrome, making a metabolic driver unlikely.","miss":3},{"id":"tox-thyroid","group":"common","label":"Stimulant / withdrawal / hyperthyroid","default":false,"tags":["tox-thyroid"],"ruleout":"Stimulants, caffeine, medication effects, withdrawal states, and hyperthyroid features were reviewed.","miss":2},{"id":"panic-dx","group":"common","label":"Panic attack / anxiety disorder","default":false,"tags":["panic-dx"],"ruleout":"Panic was diagnosed on the pattern (prior identical episodes, recognizable triggers, and resolution); after the mimics were screened.","miss":2}],"risk":[{"id":"mimic-screen","label":"Dangerous-mimic screen documented (incl. ECG as indicated)","tags":["cardiac-mimic","pe-mimic"],"scale":"low","line":"The dangerous mimics were screened and documented: cardiac features, PE features, vital-sign normalization, and an ECG where age or features warranted.","short":"mimic screen documented; vitals normalized"},{"id":"si-screen-anx","label":"Suicide-risk screen documented","tags":["panic-dx"],"scale":"low","line":"A brief suicide-risk screen was performed and documented.","short":"suicide-risk screen done"}],"checks":[{"if":"cardiac-mimic","needs":["mimic-screen"],"mode":"any","warn":"Document the mimic screen — 'anxiety' is only defensible as a diagnosis of exclusion."}],"history":[{"id":"ax-hx-prior","dx":"panic-dx","q":"Identical prior episodes — has this exact feeling happened before, with a known pattern?","answers":[{"label":"Recurrent identical episodes","tone":"neg","sets":[],"ddx":[{"id":"panic-dx","keep":true}],"mdm":"This is a recurrent, identical episode in a known pattern.","frag":"recurrent identical episodes with a known pattern"},{"label":"First or different episode","tone":"pos","sets":[],"ddx":[{"id":"cardiac-mimic","keep":true},{"id":"pe-mimic","keep":true}],"mdm":"A first or different episode: the mimics carry more weight.","frag":"first or atypical episode"}]},{"id":"ax-hx-cardiac","dx":"cardiac-mimic","q":"Cardiac features — exertional onset, true chest pressure, syncope, or known heart disease?","answers":[{"label":"None","tone":"neg","sets":[{"risk":"mimic-screen"}],"ddx":[],"mdm":"There were no cardiac features: no exertional onset, true chest pressure, syncope, or known heart disease.","frag":"no exertional or cardiac features"},{"label":"Present","tone":"pos","sets":[{"risk":"mimic-screen"}],"ddx":[{"id":"cardiac-mimic","keep":true}],"mdm":"Cardiac features (exertional onset, true chest pressure, syncope, or known heart disease) are present; evaluate as chest pain, not anxiety.","frag":"exertional or cardiac features"}]},{"id":"ax-hx-pe","dx":"pe-mimic","q":"PE features — pleuritic pain, breathlessness out of proportion, leg swelling, immobilization, estrogen, or prior clots?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There were no PE features or risk factors: no pleuritic pain, breathlessness out of proportion, leg swelling, immobilization, estrogen use, or prior clots.","frag":"no PE features or risk factors"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"pe-mimic","keep":true}],"mdm":"PE features or risk factors (pleuritic pain, breathlessness out of proportion, leg swelling, immobilization, estrogen use, or prior clots) are present; risk-stratify before the anxiety label.","frag":"PE features or risk factors"}]},{"id":"ax-hx-substances","dx":"tox-thyroid","q":"Stimulants, heavy caffeine, decongestants, new medications, or stopping alcohol/benzodiazepines?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"No stimulant, medication, or withdrawal driver was identified.","frag":"no stimulant or withdrawal driver"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"tox-thyroid","keep":true}],"mdm":"A stimulant or withdrawal driver is present.","frag":"stimulant or withdrawal driver"}]},{"id":"ax-hx-si","dx":"panic-dx","q":"Brief safety screen — any thoughts of self-harm with this?","answers":[{"label":"No self-harm thoughts","tone":"neg","sets":[{"risk":"si-screen-anx"}],"ddx":[],"mdm":"A brief screen found no self-harm ideation.","frag":"no self-harm ideation on screen"},{"label":"Self-harm thoughts","tone":"pos","sets":[{"risk":"si-screen-anx"}],"ddx":[],"mdm":"Self-harm ideation is present: the suicide-risk pathway applies.","frag":"self-harm ideation present"}]}],"exam":[{"id":"ax-ex-vitals","dx":"pe-mimic","q":"Vitals over time — does the tachycardia settle as the episode resolves, and is SpO₂ normal?","answers":[{"label":"Normalize with calming","tone":"neg","sets":[{"risk":"mimic-screen"}],"ddx":[],"mdm":"Vital signs normalized as the episode settled, with normal oxygen saturation.","frag":"vital signs normalized as symptoms settled; SpO₂ normal"},{"label":"Persistent tachycardia / hypoxia","tone":"pos","sets":[],"ddx":[{"id":"pe-mimic","keep":true},{"id":"cardiac-mimic","keep":true}],"mdm":"Tachycardia that doesn't settle, or any hypoxia, is not panic until proven otherwise.","frag":"persistent tachycardia or hypoxia"}]},{"id":"ax-ex-thyroid","dx":"tox-thyroid","q":"Tremor, heat intolerance signs, thyromegaly, or persistent resting tachycardia?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"There are no hyperthyroid signs.","frag":"no hyperthyroid signs"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"tox-thyroid","keep":true}],"mdm":"Hyperthyroid features are present: check the TSH.","frag":"hyperthyroid features"}]},{"id":"ax-ex-glucose","dx":"metabolic-mimic","q":"Glucose checked when the picture includes diaphoresis, confusion, or diabetes medications?","answers":[{"label":"Normal / not indicated","tone":"neg","sets":[],"ddx":[],"mdm":"Glucose was normal (or not indicated by the picture).","frag":"glucose normal or not indicated"},{"label":"Hypoglycemia","tone":"pos","sets":[],"ddx":[{"id":"metabolic-mimic","keep":true}],"mdm":"Hypoglycemia was found: the 'panic' was a sugar.","frag":"hypoglycemia found"}]}],"conclusions":["panic attack — dangerous mimics screened and excluded","anxiety episode, recurrent pattern — outpatient resources given","anxiety symptoms NOS (mimics screened)"],"guide":"../learn/complaints/anxiety-panic.html"},{"id":"agitation","specs":["psych","tox","neuro"],"title":"Agitation / Acute Psychosis","aliases":["agitated patient","psychosis","acting bizarre","combative","hallucinations","paranoid","behavioral emergency","altered behavior","excited delirium","new psychosis"],"opening":"Agitation is a vital sign abnormality until proven psychiatric: the glucose, the temperature, the oxygen, the head, and the drug deck all come before the psych label — and new psychosis after 40 is medical until a real workup says otherwise.","ddx":[{"id":"medical-agitation","group":"lifethreat","label":"Medical cause (hypoglycemia, hypoxia, CNS, infection)","default":true,"tags":["medical-agitation"],"ruleout":"A medical cause of agitation was considered; bedside glucose was normal, oxygen saturation and temperature were normal, there was no head trauma, focal deficit, or signs of infection, and no offending medications, making a reversible medical driver unlikely.","miss":3},{"id":"tox-agitation","group":"lifethreat","label":"Intoxication / withdrawal","default":true,"tags":["tox-agitation"],"ruleout":"Intoxication and withdrawal were considered; collateral and exam showed no stimulant toxidrome, no tremor, diaphoresis, tachycardia, or hallucinations of alcohol/benzodiazepine withdrawal, and no signs of acute ingestion, making a toxic cause unlikely.","miss":3},{"id":"hyperthermia-risk","group":"lifethreat","label":"Severe agitation with hyperthermia (life threat)","default":false,"tags":["hyperthermia-risk"],"ruleout":"Severe agitation with hyperthermia was considered; core temperature was normal with no rigidity, diaphoresis, or autonomic instability, and the patient was not hyperthermic from prolonged struggle, making this lethal complication unlikely.","miss":3},{"id":"ich-agitation-add","group":"lifethreat","label":"Intracranial hemorrhage / CNS catastrophe","default":false,"tags":["ich-agitation-add"],"ruleout":"An intracranial catastrophe was considered; there was no headache, focal neurologic deficit, anisocoria, or history of head trauma, and the exam was nonfocal once calmed, making it unlikely.","miss":4},{"id":"primary-psych","group":"common","label":"Primary psychiatric decompensation","default":false,"tags":["primary-psych"],"ruleout":"Primary psychiatric illness was diagnosed against baseline (by collateral) once medical and toxic drivers were screened.","miss":2}],"risk":[{"id":"medical-screen-ag","label":"Glucose, vitals (incl. temp), neuro screen documented","tags":["medical-agitation","hyperthermia-risk"],"scale":"low","line":"The non-negotiables were documented: glucose, full vital signs including temperature, oxygenation, and a screening neurologic examination.","short":"glucose, temp, SpO₂, neuro screen documented"},{"id":"deescalation","label":"Verbal de-escalation attempted first","tags":["primary-psych","tox-agitation"],"scale":"low","line":"Verbal de-escalation was attempted before pharmacologic or physical measures, consistent with Project BETA, and the least-restrictive effective approach was used and documented.","cite":"Project BETA. West J Emerg Med. 2012.","short":"verbal de-escalation first (Project BETA)"},{"id":"collateral-ag","label":"Collateral / baseline established","tags":["primary-psych","medical-agitation"],"scale":"low","line":"Collateral history established the patient's baseline, the tempo of change, and substance/medication context.","short":"collateral and baseline obtained"}],"checks":[{"if":"medical-agitation","needs":["medical-screen-ag"],"mode":"any","warn":"Glucose and temperature before the psych label — the agitated hypoglycemic in restraints is a sentinel event."},{"if":"primary-psych","needs":["collateral-ag"],"mode":"any","warn":"Document the collateral and baseline — 'psychiatric history' is not an explanation for a change from baseline."},{"if":"tox-agitation","needs":["medical-screen-ag"],"mode":"any","warn":"A toxic or withdrawal cause of agitation is on the differential — document the medical screen (vitals, glucose, temperature, toxic exposures)."},{"if":"hyperthermia-risk","needs":["medical-screen-ag"],"mode":"any","warn":"Hyperthermia / excited delirium is the lethal can't-miss — document the temperature and medical screen, and avoid prolonged struggle/restraint without adequate sedation and monitoring."}],"history":[{"id":"ag-hx-baseline","dx":"medical-agitation","q":"Baseline and tempo (from collateral) — chronic pattern, or an abrupt change from baseline?","answers":[{"label":"Known pattern at baseline","tone":"neg","sets":[{"risk":"collateral-ag"}],"ddx":[],"mdm":"Collateral confirms this matches the known psychiatric pattern.","frag":"consistent with known psychiatric baseline"},{"label":"Abrupt change / no psych history","tone":"pos","sets":[{"risk":"collateral-ag"}],"ddx":[{"id":"medical-agitation","keep":true}],"mdm":"An abrupt change from baseline: medical until a real workup says otherwise.","frag":"abrupt change from baseline"}]},{"id":"ag-hx-age","dx":"medical-agitation","q":"First-ever psychosis in a patient over 40?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"mdm":"This is not a first psychotic presentation in an older adult.","frag":"not a first presentation over 40"},{"label":"New psychosis > 40","tone":"pos","sets":[],"ddx":[{"id":"medical-agitation","keep":true}],"mdm":"First psychosis after 40: organic disease leads the differential.","frag":"first psychosis after age 40"}]},{"id":"ag-hx-substances","dx":"tox-agitation","q":"Substances — stimulant use, or stopping alcohol/benzodiazepines in the past days?","answers":[{"label":"None reported / collateral negative","tone":"neg","sets":[],"ddx":[],"mdm":"No substance use or withdrawal context was identified.","frag":"no substance or withdrawal context"},{"label":"Stimulants / withdrawal window","tone":"pos","sets":[],"ddx":[{"id":"tox-agitation","keep":true}],"mdm":"Stimulant use or a withdrawal window is present.","frag":"stimulant use or withdrawal window"}]},{"id":"ag-hx-medchange","dx":"medical-agitation","q":"Medication changes — new medications, dose changes, or stopped psychiatric medications?","answers":[{"label":"No changes","tone":"neg","sets":[],"ddx":[],"mdm":"There were no recent medication changes: no new medications, dose changes, or stopped psychiatric medications.","frag":"no recent medication changes"},{"label":"Recent changes","tone":"pos","sets":[],"ddx":[{"id":"medical-agitation","keep":true},{"id":"primary-psych","keep":true}],"mdm":"Recent medication changes (a new medication, dose change, or stopped psychiatric medication); may drive the presentation.","frag":"recent medication changes"}]},{"id":"ag-hx-safety","dx":"primary-psych","q":"Safety — thoughts or threats of harming self or others, or command hallucinations?","answers":[{"label":"None elicited","tone":"neg","sets":[],"ddx":[],"mdm":"No thoughts or threats of harming self or others and no command hallucinations were elicited.","frag":"no harm ideation or commands elicited"},{"label":"Present","tone":"pos","sets":[],"ddx":[{"id":"primary-psych","keep":true}],"mdm":"Thoughts or threats of harming self or others, or command hallucinations, are present: the safety pathway applies.","frag":"harm ideation or command hallucinations"}]}],"exam":[{"id":"ag-ex-vitals","dx":"medical-agitation","q":"The non-negotiables — glucose, temperature, SpO₂, heart rate?","answers":[{"label":"All documented and normal","tone":"neg","sets":[{"risk":"medical-screen-ag"}],"ddx":[],"mdm":"Glucose, temperature, oxygenation, and heart rate are documented and normal.","frag":"glucose, temperature, SpO₂, and heart rate documented and normal"},{"label":"Abnormal","tone":"pos","sets":[{"risk":"medical-screen-ag"}],"ddx":[{"id":"medical-agitation","keep":true},{"id":"hyperthermia-risk","keep":true}],"mdm":"A non-negotiable vital sign (glucose, temperature, SpO₂, or heart rate) is abnormal; the agitation has a medical driver until corrected.","frag":"abnormal glucose, temperature, SpO₂, or heart rate"}]},{"id":"ag-ex-neuro","dx":"medical-agitation","q":"Neuro screen — pupils, focal deficit, head trauma signs, neck stiffness?","answers":[{"label":"Non-focal, no trauma signs","tone":"neg","sets":[],"ddx":[],"mdm":"The screening neurologic examination is non-focal, with normal pupils, no focal deficit, no head trauma signs, and no neck stiffness.","frag":"non-focal screening neuro exam without trauma signs"},{"label":"Focal / trauma / meningism","tone":"pos","sets":[],"ddx":[{"id":"medical-agitation","keep":true}],"mdm":"Abnormal pupils, a focal deficit, head trauma signs, or neck stiffness are present: image and treat as medical.","frag":"focal deficit, trauma signs, or meningism"}]},{"id":"ag-ex-toxidrome","dx":"tox-agitation","q":"Toxidrome — diaphoresis with mydriasis (sympathomimetic), dry hot skin (anticholinergic), tremor (withdrawal)?","answers":[{"label":"No toxidrome","tone":"neg","sets":[],"ddx":[],"mdm":"No toxidrome is identified: no diaphoresis with mydriasis (sympathomimetic), dry hot skin (anticholinergic), or tremor (withdrawal).","frag":"no toxidrome identified"},{"label":"Toxidrome present","tone":"pos","sets":[],"ddx":[{"id":"tox-agitation","keep":true}],"mdm":"A toxidrome is present (diaphoresis with mydriasis (sympathomimetic), dry hot skin (anticholinergic), or tremor (withdrawal)), identifying the class and the treatment.","frag":"toxidrome present"}]},{"answers":[{"ddx":[],"frag":"no focal deficit or anisocoria, nonfocal once calmed","label":"No intracranial signs","mdm":"There was no headache, focal neurologic deficit, anisocoria, or history of head trauma, and the exam was nonfocal once calmed, making an intracranial catastrophe unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"ich-agitation-add","keep":true}],"frag":"focal deficit, anisocoria, or head trauma","label":"Intracranial signs present","mdm":"A headache, focal deficit, anisocoria, or head trauma was present, raising concern for an intracranial catastrophe and warranting urgent neuroimaging.","sets":[],"tone":"pos"}],"dx":"ich-agitation-add","id":"ag-exam-ich-agitation-add","q":"Intracranial cause — headache, focal neurologic deficit, anisocoria, or head trauma; focal findings once calmed?"}],"conclusions":["primary psychiatric decompensation — medically screened, psych evaluation","stimulant intoxication — observed to resolution","agitation resolved — medical screen negative"],"guide":"../learn/complaints/agitation.html"},{"id":"asthma-copd","title":"Asthma / COPD Exacerbation","aliases":["asthma","copd","wheeze","wheezing","reactive airways","bronchospasm","sob","short of breath"],"opening":"Acute dyspnea and wheeze in known or suspected obstructive airway disease — gauge severity and exclude the dangerous mimics.","ddx":[{"id":"resp-failure-ac","group":"lifethreat","label":"Impending respiratory failure","default":true,"tags":["airway"],"ruleout":"Impending respiratory failure was considered; the patient was alert, speaking in full sentences, moving air well without a silent chest or accessory muscle use, was not tiring, and maintained normal oxygenation and ventilation, making it unlikely.","miss":3},{"id":"cardiac-ac","group":"lifethreat","label":"Cardiac “wheeze” / acute heart failure","default":true,"tags":[],"ruleout":"A cardiac cause of wheeze (acute heart failure) was considered; there was no orthopnea, paroxysmal nocturnal dyspnea, leg edema, elevated JVP, or basal crackles, and the picture fit obstructive airway disease, making it unlikely.","miss":3},{"id":"pe-ac","group":"lifethreat","label":"Pulmonary embolism","default":true,"tags":[],"ruleout":"Pulmonary embolism was considered; there was no pleuritic chest pain, hemoptysis, unilateral leg swelling, or immobilization/malignancy risk, the presentation matched the patient's usual exacerbation, and pretest probability was low, making it unlikely.","miss":4},{"id":"ptx-ac","group":"lifethreat","label":"Pneumothorax","default":true,"tags":[],"ruleout":"Pneumothorax was considered; there was no sudden pleuritic pain, breath sounds were symmetric without hyperresonance or tracheal deviation, and chest expansion was equal, making it unlikely.","miss":3},{"id":"anaphylaxis-ac","group":"lifethreat","label":"Anaphylaxis","default":false,"tags":[],"ruleout":"Anaphylaxis was considered; there was no antigen exposure, no urticaria, angioedema, or stridor, no hypotension, and no GI symptoms, making it unlikely.","miss":4},{"id":"pna-ac-add","group":"lifethreat","label":"Pneumonia","default":false,"tags":["pna-ac-add"],"ruleout":"Pneumonia as a trigger or mimic was considered; there was no fever, productive cough, focal crackles, or consolidation, making it unlikely.","miss":3},{"id":"exac","group":"common","label":"Asthma / COPD exacerbation","default":true,"tags":[],"ruleout":"The presentation was most consistent with an exacerbation of obstructive airway disease and was treated with bronchodilators and corticosteroids.","miss":2}],"risk":[{"id":"sev-ac","label":"Severity (work of breathing / mental status)","tags":[],"scale":"low","line":"Exacerbation severity was assessed using work of breathing, ability to speak, mental status, and air movement."},{"id":"spo2-ac","label":"Oxygenation / SpO₂","tags":[],"scale":"low","line":"Oxygen saturation was measured and supplemental oxygen titrated to target."},{"id":"peak-ac","label":"Peak flow vs personal best","tags":[],"scale":"low","line":"Peak expiratory flow was measured against the patient's baseline where applicable."},{"id":"abg-ac","label":"Blood gas if severe / fatiguing","tags":[],"scale":"low","line":"A blood gas was obtained when severity or fatigue raised concern for hypercapnic respiratory failure."},{"id":"response-ac","label":"Response to therapy reassessed","tags":[],"scale":"low","line":"Response to bronchodilator and corticosteroid therapy was reassessed before disposition."}],"history":[{"id":"ac-hx-severity","dx":"general","q":"Able to speak in full sentences and comfortable, or one-word answers, accessory-muscle use, or drowsiness?","answers":[{"label":"Full sentences, comfortable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient spoke in full sentences and was comfortable, arguing against severe airflow limitation.","frag":"speaks full sentences"},{"label":"One-word answers / accessory use / drowsy","tone":"pos","sets":[{"risk":"sev-ac"}],"ddx":[{"id":"resp-failure-ac","keep":true}],"mdm":"The patient could only speak in short phrases or had accessory-muscle use or drowsiness, indicating a severe exacerbation with risk of respiratory failure.","frag":"severe work of breathing"}]},{"id":"ac-hx-trigger","dx":"exac","q":"An identifiable trigger for this exacerbation (viral URI, allergen, smoke, missed controller medication)?","answers":[{"label":"No clear trigger","tone":"neg","sets":[],"ddx":[],"mdm":"No clear exacerbation trigger was identified.","frag":"no trigger"},{"label":"Trigger identified","tone":"pos","sets":[],"ddx":[],"mdm":"An exacerbation trigger was identified and addressed as part of the plan.","frag":"trigger present"}]},{"id":"ac-hx-cardiac","dx":"cardiac-ac","q":"Orthopnea, paroxysmal nocturnal dyspnea, leg swelling, or known heart failure suggesting a cardiac cause?","answers":[{"label":"No cardiac features","tone":"neg","sets":[],"ddx":[],"mdm":"There were no orthopnea, PND, edema, or heart-failure history to suggest a cardiac cause of the wheeze.","frag":"no cardiac features"},{"label":"Cardiac features present","tone":"pos","sets":[],"ddx":[{"id":"cardiac-ac","keep":true}],"mdm":"Orthopnea, edema, or a heart-failure history was present, prompting evaluation for a cardiac contribution.","frag":"cardiac features"}]},{"id":"ac-hx-pe","dx":"pe-ac","q":"Pleuritic chest pain, hemoptysis, or VTE risk out of proportion to the usual exacerbation?","answers":[{"label":"No PE features","tone":"neg","sets":[],"ddx":[],"mdm":"There were no pleuritic pain, hemoptysis, or disproportionate VTE risk to suggest pulmonary embolism.","frag":"no PE features"},{"label":"PE features present","tone":"pos","sets":[],"ddx":[{"id":"pe-ac","keep":true}],"mdm":"Features atypical for the usual exacerbation raised concern for pulmonary embolism, which was evaluated.","frag":"PE features"}]},{"answers":[{"ddx":[],"frag":"no antigen exposure, urticaria, or angioedema","label":"No anaphylaxis features","mdm":"There was no antigen exposure, no urticaria, angioedema, or stridor, no hypotension, and no GI symptoms, making anaphylaxis unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"anaphylaxis-ac","keep":true}],"frag":"antigen exposure with urticaria or angioedema","label":"Anaphylaxis features present","mdm":"Antigen exposure with urticaria, angioedema, stridor, hypotension, or GI symptoms was present, raising concern for anaphylaxis and warranting epinephrine.","sets":[],"tone":"pos"}],"dx":"anaphylaxis-ac","id":"ac-hx-anaphylaxis-ac","q":"Anaphylaxis — antigen exposure, urticaria, angioedema, stridor, hypotension, or GI symptoms?"}],"exam":[{"id":"ac-exam-air","dx":"general","q":"Air movement and work of breathing — good air entry with scattered wheeze, or poor air movement / silent chest / tripod positioning?","answers":[{"label":"Good air entry","tone":"neg","sets":[],"ddx":[],"mdm":"There was good air movement with scattered wheeze and no distress.","frag":"good air entry"},{"label":"Poor air movement / silent chest","tone":"pos","sets":[],"ddx":[{"id":"resp-failure-ac","keep":true}],"mdm":"Poor air movement or a silent chest with increased work of breathing was present, an ominous sign prompting escalation.","frag":"poor air movement"}]},{"id":"ac-exam-spo2","dx":"general","q":"SpO₂ ≥ 92% on room air with a respiratory rate that is not rising?","answers":[{"label":"SpO₂ ≥ 92%, stable RR","tone":"neg","sets":[],"ddx":[],"mdm":"Oxygen saturation was adequate with a stable respiratory rate.","frag":"SpO₂ adequate"},{"label":"Hypoxemia / rising RR","tone":"pos","sets":[{"risk":"spo2-ac"}],"ddx":[],"mdm":"Hypoxemia or a rising respiratory rate was present and oxygen was titrated with close monitoring.","frag":"hypoxemia"}]},{"id":"ac-exam-ptx","dx":"ptx-ac","q":"Symmetric breath sounds without subcutaneous emphysema or tracheal deviation?","answers":[{"label":"Symmetric breath sounds","tone":"neg","sets":[],"ddx":[],"mdm":"Breath sounds were symmetric without signs of pneumothorax.","frag":"symmetric breath sounds"},{"label":"Asymmetric / subcutaneous emphysema","tone":"pos","sets":[],"ddx":[{"id":"ptx-ac","keep":true}],"mdm":"Asymmetric breath sounds or subcutaneous emphysema raised concern for pneumothorax and imaging was obtained.","frag":"asymmetric breath sounds"}]},{"answers":[{"ddx":[],"frag":"afebrile, no focal crackles or consolidation","label":"No pneumonia signs","mdm":"There was no fever, productive cough, focal crackles, or consolidation, making pneumonia as a trigger or mimic unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"pna-ac-add","keep":true}],"frag":"fever with focal crackles or consolidation","label":"Pneumonia signs present","mdm":"Fever, productive cough, focal crackles, or consolidation was present, raising concern for pneumonia as a trigger or mimic and warranting chest imaging.","sets":[],"tone":"pos"}],"dx":"pna-ac-add","id":"ac-exam-pna-ac-add","q":"Pneumonia trigger — fever, productive cough, focal crackles, or consolidation?"}],"conclusions":["asthma exacerbation","COPD exacerbation","reactive airways / bronchospasm"],"specs":["pulm"],"checks":[{"if":"resp-failure-ac","needs":["sev-ac","abg-ac"],"mode":"any","warn":"Impending respiratory failure is the can't-miss — document severity and gas exchange (ABG/capnography; a rising or 'normalizing' CO2 in a tiring patient is ominous), and consider an NIV trial before intubation."},{"if":"exac","needs":["response-ac"],"mode":"any","warn":"Document the response to initial therapy — it drives disposition and the decision to escalate to NIV."}],"algorithm":{"immediate":["SpO₂, work-of-breathing assessment, and early continuous bronchodilators with steroids; consider ipratropium and magnesium for severe exacerbation.","For impending failure (silent chest, exhaustion, altered mentation): start NIV and prepare for intubation while continuing maximal medical therapy."],"criticalTests":["SpO₂ and clinical severity; venous/arterial blood gas if failing","Chest X-ray when pneumothorax, pneumonia, or an alternative diagnosis is suspected","ECG and bedside ultrasound to separate cardiac from pulmonary causes"],"cantMiss":[{"dx":"resp-failure-ac","trigger":"Silent chest, exhaustion, rising CO₂, or altered mentation","test":"Clinical plus blood gas","intervention":"NIV early; intubation with a ventilator strategy allowing prolonged expiration"},{"dx":"ptx-ac","trigger":"Sudden worsening with unilateral findings","test":"Lung ultrasound or chest X-ray","intervention":"Decompression/chest tube for tension or large pneumothorax"},{"dx":"anaphylaxis-ac","trigger":"Exposure with urticaria, angioedema, or hypotension","test":"Clinical","intervention":"Intramuscular epinephrine"},{"dx":"cardiac-ac","trigger":"Orthopnea, crackles, elevated JVP","test":"ECG, BNP, lung ultrasound","intervention":"NIV, nitrates, diuresis"},{"dx":"pe-ac","trigger":"Wheeze with pleuritic pain or hypoxia out of proportion","test":"Pretest probability then CTPA","intervention":"Anticoagulation"}],"disposition":"Discharge after sustained response with a steroid course and inhaler plan; admit for hypoxia, persistent work of breathing, or a high-risk exacerbation, and to ICU for NIV or impending failure."},"decisionTree":{"title":"Asthma / COPD exacerbation — management","intro":"An original, evidence-based decision aid for obstructive exacerbations. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Assess severity & start therapy","items":["SpO2, work of breathing, ability to speak","Oxygen to target","Start inhaled bronchodilators"],"next":"q_failure"},"q_failure":{"type":"decision","q":"Impending respiratory failure (silent chest, exhaustion, altered mentation, rising CO2)?","yes":"a_failure","no":"q_mimic","cantmiss":"A silent chest, exhaustion, or drowsiness signals impending failure — prepare NIV/intubation now."},"a_failure":{"type":"action","title":"Support ventilation","items":["NIV (especially COPD) or intubation with a lung-protective, low-rate strategy","Continuous bronchodilators; IV/IM steroids","Consider magnesium and epinephrine"],"tone":"danger","terminal":true},"q_mimic":{"type":"decision","q":"Alternative cause likely (anaphylaxis, pneumothorax, PE, cardiac/pulmonary edema)?","yes":"a_mimic","no":"q_severe","pitfall":"Not all that wheezes is asthma — consider anaphylaxis, pneumothorax, PE, and cardiac asthma."},"a_mimic":{"type":"action","title":"Target the mimic","items":["IM epinephrine for anaphylaxis","Decompress a pneumothorax","PE / ACS / pulmonary-edema pathways as indicated"],"tone":"danger","terminal":true},"q_severe":{"type":"decision","q":"Severe exacerbation not responding to initial therapy?","yes":"a_severe","no":"a_mild"},"a_severe":{"type":"action","title":"Escalate exacerbation therapy","items":["Continuous/frequent bronchodilators; systemic steroids; magnesium","Consider NIV","Reassess frequently; admit"],"terminal":true},"a_mild":{"type":"action","title":"Mild–moderate, improving","items":["Bronchodilators and systemic steroids","Observe response","Discharge with steroids, an action plan, and follow-up"],"tone":"branch","terminal":true}}},"guide":"../learn/complaints/asthma-copd.html","pearls":[{"text":"A normal or rising CO2 in a working, tiring asthma/COPD patient is not reassuring — it signals fatigue and impending respiratory failure, not improvement.","dx":"resp-failure-ac"},{"text":"A silent chest is a pre-arrest sign, not a mild-disease sign — the absence of wheeze in a severely dyspneic patient means too little air is moving to wheeze.","dx":"resp-failure-ac"},{"text":"In an intubated asthma/COPD patient with sudden hypotension, think DOPE (Displacement, Obstruction, Pneumothorax, Equipment) — disconnect and manually bag while ruling out tension pneumothorax from breath-stacking/auto-PEEP.","dx":"ptx-ac"},{"text":"Reassess after every round of therapy — the response to treatment, not the initial severity, drives the disposition and the decision to escalate to NIV or intubation.","dx":"resp-failure-ac"},{"text":"Give systemic corticosteroids early in asthma exacerbations — delayed steroids are a common, avoidable driver of relapse and prolonged course.","dx":"exac"},{"text":"Don't anchor on 'asthma/COPD exacerbation' — acute heart failure (cardiac 'asthma'), PE, anaphylaxis, and pneumonia are the mimics that get missed when wheeze triggers premature closure.","dx":"cardiac-ac"}]},{"id":"heart-failure","title":"Acute Heart Failure","aliases":["chf","heart failure","adhf","pulmonary edema","volume overload","fluid overload","dyspnea on exertion","orthopnea"],"opening":"Dyspnea with congestion — confirm decompensated heart failure while excluding the ischemic, embolic, and infectious causes that drive or mimic it.","ddx":[{"id":"acs-hf","group":"lifethreat","label":"ACS precipitant","default":true,"tags":["acs"],"ruleout":"An ischemic precipitant was considered; there was no ongoing chest pain or anginal equivalent, the ECG showed no ischemic changes, and troponin was not in a rising ischemic pattern, making ACS-driven decompensation unlikely.","miss":3},{"id":"arrhythmia-hf","group":"lifethreat","label":"Arrhythmia precipitant","default":true,"tags":[],"ruleout":"A precipitating arrhythmia was considered; the rhythm on ECG and monitor was sinus without new atrial fibrillation, sustained tachy- or bradyarrhythmia, making an arrhythmic trigger unlikely.","miss":3},{"id":"pe-hf","group":"lifethreat","label":"Pulmonary embolism","default":true,"tags":[],"ruleout":"Pulmonary embolism was considered; there was no pleuritic pain, hemoptysis, or unilateral leg swelling, no immobilization or malignancy risk, and the picture was one of bilateral congestion with low pretest probability, making it unlikely.","miss":4},{"id":"pna-hf","group":"lifethreat","label":"Pneumonia / sepsis","default":true,"tags":[],"ruleout":"Pneumonia or sepsis as a precipitant was considered; there was no fever, cough, focal consolidation, leukocytosis, or septic physiology, and findings reflected congestion rather than infection, making it unlikely.","miss":3},{"id":"tamponade-hf-add","group":"lifethreat","label":"Pericardial tamponade","default":false,"tags":["tamponade-hf-add"],"ruleout":"Pericardial tamponade was considered; there was no hypotension, muffled heart sounds, pulsus paradoxus, or distended neck veins with clear lungs, making it unlikely.","miss":4},{"id":"adhf","group":"common","label":"Acute decompensated heart failure","default":true,"tags":[],"ruleout":"The presentation was most consistent with acute decompensated heart failure and was treated with preload/afterload reduction and diuresis as appropriate.","miss":2}],"risk":[{"id":"ecg-hf","label":"ECG (ischemia / arrhythmia)","tags":["acs"],"scale":"low","line":"An ECG was reviewed for ischemia and arrhythmia as precipitants."},{"id":"trop-hf","label":"Troponin","tags":["acs"],"scale":"low","line":"A troponin was obtained to evaluate for an ischemic precipitant."},{"id":"bnp-hf","label":"Natriuretic peptide (BNP/NT-proBNP)","tags":[],"scale":"low","line":"A natriuretic peptide was interpreted in clinical context to support the diagnosis of heart failure."},{"id":"cxr-hf","label":"Chest imaging","tags":[],"scale":"low","line":"Chest imaging was reviewed for congestion and to evaluate alternative causes of dyspnea."},{"id":"o2-hf","label":"Oxygenation / respiratory support","tags":[],"scale":"low","line":"Oxygenation was assessed and respiratory support (including non-invasive ventilation) considered for respiratory distress."}],"history":[{"id":"hf-hx-congestion","dx":"general","q":"Orthopnea, paroxysmal nocturnal dyspnea, and increasing leg swelling or weight?","answers":[{"label":"No congestive symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There were no orthopnea, PND, or rising edema/weight reported.","frag":"no congestion"},{"label":"Congestive symptoms present","tone":"pos","sets":[],"ddx":[],"mdm":"Orthopnea, PND, and increasing edema or weight were reported, consistent with volume overload.","frag":"congestion present"}]},{"id":"hf-hx-ischemia","dx":"acs-hf","q":"Chest pain, pressure, or an anginal equivalent suggesting an ischemic precipitant?","answers":[{"label":"No ischemic symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There were no ischemic symptoms to suggest ACS as the precipitant.","frag":"no ischemic symptoms"},{"label":"Ischemic symptoms present","tone":"pos","sets":[{"risk":"ecg-hf"},{"risk":"trop-hf"}],"ddx":[{"id":"acs-hf","keep":true}],"mdm":"Ischemic symptoms were present, prompting evaluation for ACS driving the decompensation.","frag":"ischemic symptoms"}]},{"id":"hf-hx-precipitant","dx":"adhf","q":"An identifiable precipitant (dietary indiscretion, medication nonadherence, missed dialysis, infection)?","answers":[{"label":"No clear precipitant","tone":"neg","sets":[],"ddx":[],"mdm":"No clear decompensation precipitant was identified.","frag":"no precipitant"},{"label":"Precipitant identified","tone":"pos","sets":[],"ddx":[],"mdm":"A decompensation precipitant was identified and addressed.","frag":"precipitant present"}]},{"id":"hf-hx-palpitations","dx":"arrhythmia-hf","q":"Palpitations or an irregular pulse suggesting a precipitating arrhythmia?","answers":[{"label":"No palpitations","tone":"neg","sets":[],"ddx":[],"mdm":"There were no palpitations or irregularity to suggest a precipitating arrhythmia.","frag":"no palpitations"},{"label":"Palpitations / irregular","tone":"pos","sets":[{"risk":"ecg-hf"}],"ddx":[{"id":"arrhythmia-hf","keep":true}],"mdm":"Palpitations or an irregular rhythm were noted, prompting rhythm evaluation.","frag":"palpitations"}]},{"answers":[{"ddx":[],"frag":"no pleuritic pain, hemoptysis, or unilateral leg swelling","label":"No PE features","mdm":"There was no pleuritic pain, hemoptysis, or unilateral leg swelling, no immobilization or malignancy risk, and the picture was one of bilateral congestion with low pretest probability, making pulmonary embolism unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"pe-hf","keep":true}],"frag":"pleuritic pain, hemoptysis, or unilateral leg swelling","label":"PE features present","mdm":"Pleuritic pain, hemoptysis, unilateral leg swelling, immobilization, or malignancy was present, raising pretest probability for pulmonary embolism and warranting a formal risk assessment.","sets":[],"tone":"pos"}],"dx":"pe-hf","id":"hf-hx-pe-hf","q":"Pulmonary embolism — pleuritic pain, hemoptysis, unilateral leg swelling, recent immobilization, or malignancy?"}],"exam":[{"id":"hf-exam-vitals","dx":"general","q":"Vital signs — oxygenating adequately and not in respiratory distress?","answers":[{"label":"Stable, no distress","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable and the patient was not in respiratory distress.","frag":"stable vitals"},{"label":"Hypoxic / distressed","tone":"pos","sets":[{"risk":"o2-hf"}],"ddx":[{"id":"adhf","keep":true}],"mdm":"Hypoxia or respiratory distress was present and oxygen/ventilatory support was provided.","frag":"respiratory distress"}]},{"id":"hf-exam-congestion","dx":"adhf","q":"Examination of congestion — crackles, elevated JVP, or peripheral edema?","answers":[{"label":"No congestive findings","tone":"neg","sets":[],"ddx":[],"mdm":"There were no congestive findings on examination: no crackles, no elevated JVP, and no significant peripheral edema.","frag":"no congestive findings"},{"label":"Congestive findings present","tone":"pos","sets":[],"ddx":[{"id":"adhf","keep":true}],"mdm":"Crackles, elevated JVP, or peripheral edema were present, supporting volume overload.","frag":"congestive findings"}]},{"id":"hf-exam-perfusion","dx":"general","q":"Perfusion — warm and well-perfused, or cool/hypotensive suggesting cardiogenic shock?","answers":[{"label":"Warm, well-perfused","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was warm and well-perfused without signs of shock.","frag":"well-perfused"},{"label":"Cool / hypotensive","tone":"pos","sets":[],"ddx":[],"mdm":"Cool extremities or hypotension raised concern for cardiogenic shock, prompting escalation.","frag":"poor perfusion"}]},{"answers":[{"ddx":[],"frag":"no cough, focal consolidation, or septic physiology (afebrile, but elderly pneumonia is frequently afebrile, so imaging and the picture carried the decision)","label":"No infection signs","mdm":"There was no cough, focal consolidation, leukocytosis, or septic physiology, and findings reflected congestion rather than infection, making pneumonia unlikely. The patient was afebrile, noting elderly patients with pneumonia are frequently afebrile, so chest imaging and the overall picture rather than temperature carried the decision.","sets":[],"tone":"neg"},{"ddx":[{"id":"pna-hf","keep":true}],"frag":"fever with consolidation or septic physiology","label":"Infection signs present","mdm":"Fever, cough, focal consolidation, leukocytosis, or septic physiology was present, raising concern for pneumonia or sepsis as a precipitant and warranting a source workup.","sets":[],"tone":"pos"}],"dx":"pna-hf","id":"hf-exam-pna-hf","q":"Infectious precipitant — fever, cough, focal consolidation, leukocytosis, or septic physiology?"},{"answers":[{"ddx":[],"frag":"no Beck triad or pulsus paradoxus (insensitive signs, so echocardiography carried persistent suspicion for tamponade)","label":"No tamponade signs","mdm":"There was no hypotension, muffled heart sounds, pulsus paradoxus, or distended neck veins with clear lungs. Because the full Beck triad is present in only a minority of tamponade and pulsus paradoxus may be absent, echocardiography rather than the examination was relied on when suspicion persisted.","sets":[],"tone":"neg"},{"ddx":[{"id":"tamponade-hf-add","keep":true}],"frag":"hypotension with muffled sounds or pulsus paradoxus","label":"Tamponade signs present","mdm":"Hypotension, muffled heart sounds, pulsus paradoxus, or distended neck veins with clear lungs was present, raising concern for pericardial tamponade and warranting urgent echocardiography.","sets":[],"tone":"pos"}],"dx":"tamponade-hf-add","id":"hf-exam-tamponade-hf-add","q":"Tamponade — hypotension, muffled heart sounds, pulsus paradoxus, or distended neck veins with clear lungs?"}],"conclusions":["acute decompensated heart failure","hypertensive pulmonary edema","volume overload"],"specs":["cards","pulm"],"checks":[{"if":"acs-hf","needs":["ecg-hf","trop-hf"],"mode":"any","warn":"ACS is a common precipitant of acute heart failure — a documented ECG and troponin show it was assessed as the trigger."},{"if":"arrhythmia-hf","needs":["ecg-hf"],"mode":"any","warn":"A precipitating arrhythmia is on the differential — documenting the ECG (rhythm) shows it was evaluated."}],"algorithm":{"immediate":["Pulse oximetry, ECG, and IV access; identify and treat the precipitant.","For respiratory distress with hypertension (flash pulmonary edema): NIV and IV nitrates; for hypotension/cardiogenic shock, consider inotropes/pressors and early cardiology."],"criticalTests":["ECG and troponin to detect an ischemic precipitant","Chest X-ray and BNP; bedside lung/cardiac ultrasound","Electrolytes and renal function"],"cantMiss":[{"dx":"acs-hf","trigger":"Chest pain or ischemic ECG changes","test":"ECG and serial troponin","intervention":"ACS pathway; cardiology for revascularization"},{"dx":"arrhythmia-hf","trigger":"Tachy- or brady-dysrhythmia on the monitor","test":"ECG and telemetry","intervention":"Rate/rhythm control or pacing as appropriate"},{"dx":"pe-hf","trigger":"Pleuritic pain, hypoxia, or unilateral leg swelling","test":"Pretest probability then CTPA","intervention":"Anticoagulation"},{"dx":"tamponade-hf-add","trigger":"Hypotension, muffled sounds, distended neck veins","test":"Bedside echocardiography","intervention":"Pericardiocentesis"},{"dx":"pna-hf","trigger":"Fever, consolidation, septic physiology","test":"Lactate, cultures, chest imaging","intervention":"Early antibiotics and resuscitation"}],"disposition":"Most acute decompensations are admitted; a mild, well-responding exacerbation with a clear trigger may be considered for observation, while cardiogenic shock needs ICU-level care."},"decisionTree":{"title":"Acute heart failure — management","intro":"An original, evidence-based decision aid for acute decompensated heart failure. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Assess & support","items":["SpO2, BP, work of breathing; ECG","Sit upright; oxygen/NIV for distress","IV access"],"next":"q_unstable"},"q_unstable":{"type":"decision","q":"Cardiogenic shock or severe respiratory distress?","yes":"a_shock","no":"q_precip","cantmiss":"Cardiogenic shock (hypotension + hypoperfusion) and impending respiratory failure need immediate support — NIV, and consider inotropes/vasopressors and ICU."},"a_shock":{"type":"action","title":"Stabilize pump & ventilation","items":["NIV or intubation","Inotropes/vasopressors for shock; cautious preload management","Treat the precipitant; cardiology/ICU; consider mechanical support"],"tone":"danger","terminal":true},"q_precip":{"type":"decision","q":"Acute precipitant present (ACS, arrhythmia, PE, severe hypertension, infection)?","yes":"a_precip","no":"q_wet","pitfall":"Find the trigger — ACS, new arrhythmia, PE, and hypertensive emergency drive decompensation and change therapy."},"a_precip":{"type":"action","title":"Treat the precipitant","items":["ACS pathway; rate/rhythm control","PE management","Aggressive afterload reduction for hypertensive flash pulmonary edema"],"tone":"danger","terminal":true},"q_wet":{"type":"decision","q":"Volume overloaded / hypertensive (warm-and-wet)?","yes":"a_wet","no":"a_eval"},"a_wet":{"type":"action","title":"Decongest","items":["IV loop diuretics","Nitrates and NIV for hypertensive pulmonary edema","Monitor response and renal function"],"terminal":true},"a_eval":{"type":"action","title":"Reassess phenotype & disposition","items":["Echo and labs (natriuretic peptides)","Tailor therapy","Admit per severity; heart-failure follow-up"],"terminal":true}}},"guide":"../learn/complaints/heart-failure.html","pearls":[{"text":"Distinguish the phenotype before treating: hypertensive/flash pulmonary edema (SCAPE) needs vasodilation, not diuresis — these patients are often not volume-overloaded, and over-diuresis just injures the kidneys.","dx":"adhf"},{"text":"Get an ECG and troponin in essentially everyone with acute heart failure — ACS is a can't-miss precipitant even without chest pain.","dx":"acs-hf"},{"text":"A clear chest x-ray does not exclude acute decompensated heart failure — lung and cardiac POCUS (B-lines, reduced function, effusion) catches what a early or subtle film misses.","dx":"adhf"},{"text":"Start non-invasive ventilation (CPAP/BiPAP) early for respiratory distress — it reduces the need for intubation and should not be delayed while other therapies are titrated.","dx":"pna-hf"},{"text":"Cardiogenic shock (cold and wet) needs inotropes and a reversible-cause hunt, not diuretics alone — and inotropes can harm the preserved-EF, volume-overloaded patient, so match the drug to the phenotype.","dx":"acs-hf"}]},{"id":"atrial-fibrillation","title":"Atrial Fibrillation / RVR","aliases":["afib","a-fib","atrial fibrillation","atrial flutter","rvr","rapid ventricular response","irregular heartbeat","palpitations"],"opening":"An irregularly irregular tachycardia — stabilize if unstable, find and treat the trigger, control rate or rhythm, and document stroke risk.","ddx":[{"id":"unstable-af","group":"lifethreat","label":"Unstable AF (needs cardioversion)","default":true,"tags":[],"ruleout":"Hemodynamic instability from the arrhythmia was considered; the patient was normotensive, with no ischemic chest pain, pulmonary edema, or altered mentation, making emergent cardioversion unnecessary and instability unlikely.","miss":3},{"id":"preexcited-af","group":"lifethreat","label":"Pre-excited AF (WPW)","default":true,"tags":[],"ruleout":"Pre-excited atrial fibrillation was considered; the QRS was narrow and the rhythm was not an irregular very rapid wide-complex tachycardia, with no known WPW, making pre-excitation unlikely and AV-nodal agents appropriate.","miss":4},{"id":"acs-af","group":"lifethreat","label":"ACS","default":true,"tags":["acs"],"ruleout":"An ischemic trigger or consequence was considered; there was no chest pain, the ECG showed no ischemic changes beyond rate, and troponin was not in a rising ischemic pattern, making ACS unlikely.","miss":3},{"id":"pe-af","group":"lifethreat","label":"Pulmonary embolism","default":true,"tags":[],"ruleout":"Pulmonary embolism as a precipitant of new AF was considered; there was no pleuritic pain, hemoptysis, hypoxia, or unilateral leg swelling, and pretest probability was low, making it unlikely.","miss":4},{"id":"sepsis-af","group":"lifethreat","label":"Sepsis / thyrotoxicosis trigger","default":true,"tags":[],"ruleout":"A systemic trigger was considered; there was no fever or infectious source, no signs of thyrotoxicosis, no significant alcohol intake, and electrolytes were unremarkable, making a systemic precipitant unlikely.","miss":3},{"id":"af-stable","group":"common","label":"Atrial fibrillation / flutter (stable)","default":true,"tags":[],"ruleout":"The presentation was stable atrial fibrillation/flutter; rate or rhythm control and anticoagulation risk were addressed.","miss":2}],"risk":[{"id":"ecg-af","label":"ECG (confirm rhythm / pre-excitation / ischemia)","tags":["acs"],"scale":"low","line":"An ECG was reviewed to confirm the rhythm and to assess for pre-excitation and ischemia."},{"id":"trop-af","label":"Troponin","tags":["acs"],"scale":"low","line":"A troponin was obtained when an ischemic trigger or demand ischemia was a concern."},{"id":"trigger-af","label":"Trigger workup (sepsis/thyroid/lytes)","tags":[],"scale":"low","line":"A workup for reversible triggers (infection, thyroid, electrolytes) was pursued as indicated."},{"id":"rate-af","label":"Rate vs rhythm control","tags":[],"scale":"low","line":"A rate- versus rhythm-control strategy was selected based on stability, symptoms, and onset."},{"id":"chadsvasc","label":"CHA₂DS₂-VASc (stroke risk)","tags":[],"scale":"low","line":"Stroke risk was documented to inform anticoagulation.","cite":"Lip GYH, Nieuwlaat R, Pisters R, et al. Chest. 2010;137(2):263–72.","calc":{"fields":[{"label":"CHF / LV dysfunction","opts":[["No",0],["Yes",1]]},{"label":"Hypertension","opts":[["No",0],["Yes",1]]},{"label":"Age","opts":[["< 65",0],["65–74",1],["≥ 75",2]]},{"label":"Diabetes","opts":[["No",0],["Yes",1]]},{"label":"Prior stroke / TIA / thromboembolism","opts":[["No",0],["Yes",2]]},{"label":"Vascular disease (MI, PAD, aortic plaque)","opts":[["No",0],["Yes",1]]},{"label":"Sex","opts":[["Male",0],["Female",1]]}],"bands":[[0,"low (0)","","Score 0 (male) / 1 (female, sex point only): low annual stroke risk; oral anticoagulation generally not indicated."],[1,"intermediate (1)","","Score 1 (male): intermediate risk; oral anticoagulation may be considered with shared decision-making."],[9,"elevated (≥ 2)","","Score ≥ 2: elevated stroke risk; oral anticoagulation is generally recommended absent contraindication."]],"line":"CHA₂DS₂-VASc {score} ({band}); stroke risk documented to guide anticoagulation.","applies":"Non-valvular atrial fibrillation or flutter, to estimate annual thromboembolic stroke risk and guide anticoagulation. Not a rate/rhythm tool and not for valvular AF."},"short":"CHA₂DS₂-VASc {score}"}],"history":[{"id":"af-hx-stability","dx":"general","q":"Chest pain, severe shortness of breath, lightheadedness, or near-syncope with the rapid rate?","answers":[{"label":"No instability symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There were no symptoms of hemodynamic instability with the rapid rate.","frag":"no instability"},{"label":"Instability symptoms present","tone":"pos","sets":[{"risk":"ecg-af"}],"ddx":[{"id":"unstable-af","keep":true}],"mdm":"Ischemic chest pain, dyspnea, or presyncope accompanied the rapid rate, prompting assessment for unstable AF.","frag":"instability symptoms"}]},{"id":"af-hx-onset","dx":"af-stable","q":"Clear onset under 48 hours, or unknown / ≥ 48 hours (which changes cardioversion and anticoagulation decisions)?","answers":[{"label":"Clear onset < 48 h","tone":"neg","sets":[],"ddx":[],"mdm":"The arrhythmia had a clear onset under 48 hours, informing cardioversion and anticoagulation decisions.","frag":"onset < 48 h"},{"label":"Unknown / ≥ 48 h","tone":"pos","sets":[],"ddx":[],"mdm":"Onset was unknown or ≥ 48 hours, raising thromboembolic risk with cardioversion and shaping the strategy.","frag":"onset ≥ 48 h or unknown"}]},{"id":"af-hx-trigger","dx":"sepsis-af","q":"Fever, symptoms of infection, weight loss/tremor, or other trigger for new AF?","answers":[{"label":"No systemic trigger","tone":"neg","sets":[],"ddx":[],"mdm":"There were no features of sepsis, thyrotoxicosis, or other systemic trigger.","frag":"no systemic trigger"},{"label":"Systemic trigger present","tone":"pos","sets":[{"risk":"trigger-af"}],"ddx":[{"id":"sepsis-af","keep":true}],"mdm":"Features of a systemic trigger were present and evaluated as a driver of the arrhythmia.","frag":"systemic trigger"}]},{"id":"af-hx-anticoag","dx":"af-stable","q":"Already on anticoagulation, and any bleeding or stroke history relevant to anticoagulation decisions?","answers":[{"label":"Anticoagulation status documented","tone":"neg","sets":[],"ddx":[],"mdm":"Current anticoagulation status and relevant bleeding/stroke history were documented.","frag":"anticoag status documented"},{"label":"Not anticoagulated / high stroke risk","tone":"pos","sets":[{"risk":"chadsvasc"}],"ddx":[],"mdm":"The patient was not anticoagulated with risk factors present, and stroke prevention was addressed.","frag":"anticoag gap"}]},{"answers":[{"ddx":[],"frag":"no pleuritic pain, hypoxia, or unilateral leg swelling","label":"No PE features","mdm":"There was no pleuritic pain, hemoptysis, hypoxia, or unilateral leg swelling, and pretest probability was low, making pulmonary embolism as a precipitant of new AF unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"pe-af","keep":true}],"frag":"pleuritic pain, hypoxia, or unilateral leg swelling","label":"PE features present","mdm":"Pleuritic pain, hemoptysis, hypoxia, or unilateral leg swelling was present, raising concern for pulmonary embolism as a precipitant of new atrial fibrillation and warranting a risk assessment.","sets":[],"tone":"pos"}],"dx":"pe-af","id":"af-hx-pe-af","q":"PE precipitating new AF — pleuritic pain, hemoptysis, hypoxia, or unilateral leg swelling?"}],"exam":[{"id":"af-exam-vitals","dx":"general","q":"Vital signs and perfusion — hemodynamically stable, or hypotensive / poorly perfused?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable with adequate perfusion despite the rapid rate.","frag":"hemodynamically stable"},{"label":"Unstable / poorly perfused","tone":"pos","sets":[],"ddx":[{"id":"unstable-af","keep":true}],"mdm":"Hypotension or poor perfusion accompanied the arrhythmia, prompting consideration of cardioversion.","frag":"unstable"}]},{"id":"af-exam-ecg","dx":"general","q":"ECG/monitor — irregularly irregular narrow-complex rhythm, or a wide irregular very rapid rhythm raising pre-excitation?","answers":[{"label":"Narrow-complex AF/flutter","tone":"neg","sets":[],"ddx":[],"mdm":"The rhythm was an irregular narrow-complex atrial fibrillation/flutter.","frag":"narrow-complex AF"},{"label":"Wide irregular / very rapid","tone":"pos","sets":[{"risk":"ecg-af"}],"ddx":[{"id":"preexcited-af","keep":true}],"mdm":"A wide, irregular, very rapid rhythm raised concern for pre-excited AF, in which AV-nodal blockers are avoided.","frag":"wide irregular rhythm"}]},{"id":"af-exam-failure","dx":"acs-af","q":"Signs of ischemia or heart failure from the rate — chest findings, congestion?","answers":[{"label":"No ischemia/failure signs","tone":"neg","sets":[],"ddx":[],"mdm":"There were no examination signs of ischemia or rate-related heart failure.","frag":"no ischemia/failure"},{"label":"Ischemia / congestion present","tone":"pos","sets":[],"ddx":[{"id":"acs-af","keep":true}],"mdm":"Signs of ischemia or congestion were present, prompting evaluation and prompt rate/rhythm control.","frag":"ischemia/congestion"}]}],"conclusions":["atrial fibrillation with RVR","atrial flutter","rate-controlled atrial fibrillation"],"specs":["cards"],"checks":[{"if":"acs-af","needs":["ecg-af","trop-af"],"mode":"any","warn":"ACS can precipitate AF — a documented ECG and troponin show ischemia was assessed as a trigger."},{"if":"sepsis-af","needs":["trigger-af"],"mode":"any","warn":"AF is often a symptom of another emergency — document the search for a precipitant (sepsis, PE, thyroid, hypoxia, bleed); treat the cause, not just the rate."},{"if":"pe-af","needs":["trigger-af"],"mode":"any","warn":"New AF can be the first sign of PE — document that a precipitant was sought."},{"if":"preexcited-af","needs":["ecg-af"],"mode":"any","warn":"Examine the ECG for pre-excitation (WPW) — irregular, wide, rapid AF — because AV-nodal blocking agents can be dangerous in pre-excited AF."},{"if":"af-stable","needs":["chadsvasc"],"mode":"any","warn":"Document the CHA2DS2-VASc stroke-risk assessment and the anticoagulation decision."}],"decisionTree":{"title":"Rapid atrial fibrillation — initial approach","intro":"An original, evidence-based decision aid for new or rapid AF in the ED. Work top-down; answer each branch to reveal the next step. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Stabilize & assess","items":["Attach cardiac monitor/defibrillator and continuous pulse oximetry","Oxygen and airway support only if hypoxic or in distress","Two large-bore IVs; obtain a 12-lead ECG","Assess perfusion and screen for a precipitating cause"],"next":"q_unstable"},"q_unstable":{"type":"decision","q":"Hemodynamically unstable? (hypotension, ischemic chest pain, acute pulmonary edema, shock, or altered mentation)","yes":"q_other","no":"s_wpw"},"q_other":{"type":"decision","q":"Could another process be driving the instability rather than the AF itself? (sepsis, hemorrhage/anemia, PE, cardiogenic shock — a fast rate can be compensatory). Use bedside ultrasound.","cantmiss":"A rapid rate may be compensating for shock from another cause. Cardioverting a compensatory tachycardia can remove that compensation and worsen hypotension.","yes":"a_cause","no":"q_wpw"},"a_cause":{"type":"action","tone":"branch","title":"Treat the underlying cause first","terminal":true,"items":["Direct resuscitation at the primary problem (e.g., antibiotics + fluids for sepsis, transfusion for hemorrhage, the PE pathway)","Rate often improves as the driver is corrected","Anticipate decompensation; admit and escalate care"]},"q_wpw":{"type":"decision","q":"Pre-excited AF / accessory pathway suspected? (irregular wide-complex tachycardia, extremely rapid rate, known WPW or a delta wave on a prior ECG)","pitfall":"Avoid AV-nodal blockers (adenosine, diltiazem, verapamil, beta-blockers, digoxin) in pre-excited AF — they can accelerate conduction down the accessory pathway and precipitate ventricular fibrillation.","yes":"a_wpw","no":"a_dccv"},"a_wpw":{"type":"action","tone":"danger","title":"Pre-excited AF — avoid AV-nodal blockade","terminal":true,"items":["Unstable: immediate synchronized cardioversion with sedation","Stable: consider an antiarrhythmic that does not block the AV node (e.g., procainamide)","Do NOT give adenosine, calcium-channel blockers, beta-blockers, or digoxin","Involve cardiology/electrophysiology"]},"a_dccv":{"type":"action","tone":"danger","title":"Instability from the AF → synchronized cardioversion","items":["Synchronized DC cardioversion with procedural sedation","Optimize pad placement and energy; treat hypoxia, acidosis, and electrolyte deficits","Reassess rhythm and perfusion after each attempt"],"next":"q_success"},"q_success":{"type":"decision","q":"Converted to a perfusing rhythm with improved hemodynamics?","yes":"a_post","no":"a_refractory"},"a_post":{"type":"action","tone":"branch","title":"Post-conversion care","terminal":true,"items":["Identify and treat precipitants (ischemia, sepsis, PE, thyroid, electrolytes)","Start anticoagulation per stroke risk and shared decision-making","Admit or observe on monitor"]},"a_refractory":{"type":"action","tone":"danger","title":"Refractory instability — optimize & escalate","terminal":true,"items":["Repeat synchronized cardioversion (increase energy, reposition pads, correct hypoxia/acidosis/electrolytes)","Consider an IV antiarrhythmic (e.g., amiodarone) or rate control if cardioversion fails","Vasopressor support as needed","Urgent cardiology consultation"]},"s_wpw":{"type":"decision","q":"Stable, but pre-excitation / WPW suspected? (irregular wide-complex, very rapid, known WPW or delta wave)","pitfall":"Even in a stable patient, treat pre-excited AF without AV-nodal blockers.","yes":"a_wpw","no":"s_rate"},"s_rate":{"type":"action","title":"Stable AF with rapid ventricular response","terminal":true,"items":["Rate control with a beta-blocker or a non-dihydropyridine calcium-channel blocker","If decompensated heart failure or reduced EF: avoid these — consider amiodarone or digoxin","Determine onset/duration and stroke risk before any elective rhythm control","Start anticoagulation per a validated stroke-risk estimate (e.g., CHA₂DS₂-VASc) and shared decision-making","Treat reversible precipitants; arrange follow-up"],"cantmiss":"AF that has been present ≥48 hours (or of unknown duration) carries cardioversion stroke risk — do not electively cardiovert without addressing anticoagulation/TEE."}}},"guide":"../learn/complaints/atrial-fibrillation.html"},{"id":"hyperkalemia","title":"Hyperkalemia","aliases":["hyperkalemia","high potassium","elevated potassium","high k","potassium"],"opening":"An elevated potassium is an electrocardiographic emergency before it is a number — assess the ECG, protect the myocardium, and shift and remove potassium.","ddx":[{"id":"ecg-hyperk","group":"lifethreat","label":"ECG changes / arrhythmia","default":true,"tags":[],"ruleout":"Cardiac toxicity from hyperkalemia was considered; the ECG showed no peaked T waves, PR prolongation, QRS widening, or sine-wave pattern, and the rhythm was stable, making immediate membrane-stabilizing emergency unlikely.","miss":3},{"id":"aki-hyperk","group":"lifethreat","label":"AKI / ESRD","default":true,"tags":[],"ruleout":"Renal failure as the cause was considered; the patient was making urine, renal function was at or near baseline, and there was no missed dialysis, making a renal driver of hyperkalemia unlikely.","miss":3},{"id":"med-hyperk","group":"common","label":"Medication effect","default":true,"tags":[],"ruleout":"Contributing medications (ACE inhibitors/ARBs, potassium-sparing diuretics, NSAIDs, supplements) were reviewed and held as appropriate.","miss":2},{"id":"pseudo-hyperk","group":"common","label":"Pseudohyperkalemia","default":true,"tags":[],"ruleout":"Pseudohyperkalemia from hemolysis or a difficult draw was considered, and the value was confirmed when the clinical picture and ECG did not fit.","miss":4},{"id":"cellshift-hyperk","group":"other","label":"Transcellular shift","default":false,"tags":[],"ruleout":"A transcellular shift (acidosis, DKA, rhabdomyolysis, tumor lysis) was considered as a contributor.","miss":1}],"risk":[{"id":"ecg-k","label":"ECG for potassium effect","tags":[],"scale":"low","line":"An ECG was reviewed for hyperkalemic changes and repeated after treatment."},{"id":"stabilize-k","label":"Membrane stabilization (calcium)","tags":[],"scale":"low","line":"Calcium was given to stabilize the myocardium when ECG changes were present."},{"id":"shift-k","label":"Shift therapy (insulin/dextrose, β-agonist)","tags":[],"scale":"low","line":"Potassium-shifting therapy was given and glucose monitored."},{"id":"remove-k","label":"Removal (diuresis / dialysis / binder)","tags":[],"scale":"low","line":"A potassium-removal strategy (diuresis, dialysis, or a binder) was selected based on renal function and severity."},{"id":"repeat-k","label":"Confirm / recheck potassium","tags":[],"scale":"low","line":"The potassium was confirmed or rechecked, and pseudohyperkalemia excluded when the picture did not fit."}],"history":[{"id":"hk-hx-symptoms","dx":"general","q":"Palpitations, muscle weakness, or syncope — or is this an incidental lab finding?","answers":[{"label":"Asymptomatic / incidental","tone":"neg","sets":[],"ddx":[],"mdm":"The hyperkalemia was an incidental finding without palpitations, weakness, or syncope.","frag":"asymptomatic"},{"label":"Symptomatic","tone":"pos","sets":[{"risk":"ecg-k"}],"ddx":[{"id":"ecg-hyperk","keep":true}],"mdm":"Palpitations, weakness, or syncope were present, raising concern for cardiac toxicity.","frag":"symptomatic"}]},{"id":"hk-hx-renal","dx":"aki-hyperk","q":"Known kidney disease, dialysis, or reduced urine output?","answers":[{"label":"No renal disease","tone":"neg","sets":[],"ddx":[],"mdm":"There was no known kidney disease or oliguria.","frag":"no renal disease"},{"label":"Renal disease / oliguria","tone":"pos","sets":[],"ddx":[{"id":"aki-hyperk","keep":true}],"mdm":"Kidney disease, missed dialysis, or oliguria was present as a likely cause.","frag":"renal disease"}]},{"id":"hk-hx-meds","dx":"med-hyperk","q":"On an ACE inhibitor/ARB, potassium-sparing diuretic, NSAID, or potassium supplement?","answers":[{"label":"No contributing meds","tone":"neg","sets":[],"ddx":[],"mdm":"No potassium-retaining medications were identified.","frag":"no contributing meds"},{"label":"Contributing medication","tone":"pos","sets":[],"ddx":[{"id":"med-hyperk","keep":true}],"mdm":"A potassium-retaining medication was identified and held.","frag":"contributing med"}]}],"exam":[{"id":"hk-exam-ecg","dx":"general","q":"ECG — normal, or peaked T waves, widened QRS, or a sine-wave pattern?","answers":[{"label":"ECG without K changes","tone":"neg","sets":[],"ddx":[],"mdm":"The ECG showed no hyperkalemic changes: no peaked T waves, QRS widening, or sine-wave pattern.","frag":"ECG normal"},{"label":"Hyperkalemic ECG changes","tone":"pos","sets":[{"risk":"ecg-k"},{"risk":"stabilize-k"}],"ddx":[{"id":"ecg-hyperk","keep":true}],"mdm":"Peaked T waves, QRS widening, or a sine-wave pattern was present, prompting immediate calcium and treatment.","frag":"hyperkalemic ECG"}]},{"id":"hk-exam-strength","dx":"general","q":"Neuromuscular exam — normal strength, or ascending weakness?","answers":[{"label":"Normal strength","tone":"neg","sets":[],"ddx":[],"mdm":"Strength was normal without neuromuscular signs of hyperkalemia.","frag":"normal strength"},{"label":"Weakness present","tone":"pos","sets":[],"ddx":[],"mdm":"Muscle weakness was present, consistent with significant hyperkalemia.","frag":"weakness"}]}],"conclusions":["hyperkalemia with ECG changes","hyperkalemia (no ECG changes)","pseudohyperkalemia"],"specs":["endo"],"checks":[{"if":"ecg-hyperk","needs":["ecg-k","stabilize-k"],"mode":"any","warn":"Severe hyperkalemia is on the differential — document the ECG and, with ECG changes or a critical level, myocardial stabilization with calcium. A normal ECG does not exclude dangerous hyperkalemia."},{"if":"aki-hyperk","needs":["shift-k","remove-k"],"mode":"any","warn":"Document the treatment course — shifting potassium intracellularly (insulin/glucose, albuterol) and eliminating it (diuresis or dialysis); dialysis for refractory or anuric patients."},{"if":"pseudo-hyperk","needs":["repeat-k"],"mode":"any","warn":"Consider pseudohyperkalemia (hemolyzed sample) — document a repeat/confirmatory potassium before attributing an ECG-discordant result to true hyperkalemia."}],"decisionTree":{"title":"Hyperkalemia — emergency management","intro":"An original, evidence-based decision aid for acute hyperkalemia. Work the branches; apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Confirm & get an ECG now","items":["Place on a cardiac monitor; obtain IV access","Get a 12-lead ECG immediately","If the value is isolated and unexpected, consider a hemolyzed/spurious sample and recheck — but never delay treatment when the patient is at risk"],"next":"q_ecg"},"q_ecg":{"type":"decision","q":"ECG changes of hyperkalemia? (peaked T waves, widened QRS, flattened/absent P waves, sine wave)","cantmiss":"A normal ECG does NOT exclude dangerous hyperkalemia — treat by the level and its trajectory, not the ECG alone.","yes":"a_membrane","no":"q_level"},"a_membrane":{"type":"action","tone":"danger","title":"Stabilize the myocardium","items":["IV calcium (gluconate, or chloride via central access) right away","Repeat if ECG changes persist","Calcium protects the heart but does not lower potassium — move straight to shifting and elimination"],"next":"a_shift"},"q_level":{"type":"decision","q":"Potassium meaningfully elevated or rapidly rising (e.g., ≥6.0 mmol/L)?","yes":"a_shift","no":"a_monitor"},"a_shift":{"type":"action","title":"Shift potassium into cells","items":["IV insulin with glucose (monitor for — and pre-empt — hypoglycemia)","High-dose nebulized beta-agonist (albuterol)","Sodium bicarbonate only if a significant metabolic acidosis is present"],"next":"a_eliminate"},"a_eliminate":{"type":"action","title":"Remove potassium from the body","items":["Stop potassium-raising drugs and treat the underlying cause","Loop diuretic if the patient makes urine; a potassium binder for the gut","Urgent dialysis for severe, refractory, or dialysis-dependent patients"],"pitfall":"Shifting only buys time — potassium rebounds unless you eliminate it. Arrange definitive removal (and call nephrology) early.","next":"a_dispo"},"a_dispo":{"type":"action","tone":"branch","title":"Reassess & admit","terminal":true,"items":["Recheck potassium and the ECG after treatment","Continue cardiac monitoring","Admit for significant or refractory hyperkalemia; involve nephrology/dialysis as needed"]},"a_monitor":{"type":"action","title":"Mild, no ECG changes","terminal":true,"items":["Treat the cause; review medications and diet","Recheck potassium and arrange timely follow-up","Give clear return precautions"]}}},"guide":"../learn/complaints/hyperkalemia.html"},{"id":"acute-kidney-injury","title":"Acute Kidney Injury","aliases":["aki","acute kidney injury","acute renal failure","elevated creatinine","renal failure","rising creatinine"],"opening":"A rising creatinine or falling urine output — find the reversible cause (obstruction, hypovolemia), screen for the dangerous complications, and protect the kidneys.","ddx":[{"id":"hyperk-aki","group":"lifethreat","label":"Hyperkalemia / metabolic complication","default":true,"tags":[],"ruleout":"Life-threatening metabolic complications were considered; potassium was not critically elevated, there was no severe acidosis, and the ECG showed no hyperkalemic changes, making an immediate metabolic emergency unlikely.","miss":4},{"id":"obstruction-aki","group":"lifethreat","label":"Obstructive (post-renal) AKI","default":true,"tags":[],"ruleout":"Obstructive (post-renal) AKI was considered; there was no suprapubic distension, the post-void residual was low, and there were no obstructive urinary symptoms or hydronephrosis, making a reversible obstructive cause unlikely.","miss":3},{"id":"prerenal-aki","group":"common","label":"Pre-renal / hypovolemic AKI","default":true,"tags":[],"ruleout":"A pre-renal cause from hypovolemia or poor perfusion was considered; volume status was assessed and a fluid challenge given when appropriate.","miss":2},{"id":"intrinsic-aki","group":"common","label":"Intrinsic AKI (ATN / nephrotoxins)","default":true,"tags":[],"ruleout":"An intrinsic cause (ATN, nephrotoxins, contrast, rhabdomyolysis) was considered and offending agents were reviewed.","miss":2},{"id":"emergent-dialysis-aki","group":"other","label":"Emergent dialysis indication","default":false,"tags":[],"ruleout":"An emergent dialysis indication (refractory hyperkalemia, acidosis, volume overload, uremia, certain toxins) was considered.","miss":1}],"risk":[{"id":"k-ecg-aki","label":"Potassium + ECG","tags":[],"scale":"low","line":"Potassium was checked and an ECG reviewed for hyperkalemic changes."},{"id":"bladder-aki","label":"Bladder scan / post-void residual","tags":[],"scale":"low","line":"A bladder scan or post-void residual was obtained to exclude obstruction."},{"id":"us-aki","label":"Renal ultrasound","tags":[],"scale":"low","line":"A renal ultrasound was considered to evaluate for obstruction or chronicity."},{"id":"volume-aki","label":"Volume assessment / fluid challenge","tags":[],"scale":"low","line":"Volume status was assessed and a fluid challenge given for a suspected pre-renal cause."},{"id":"nephrotox-aki","label":"Hold nephrotoxins / dose-adjust","tags":[],"scale":"low","line":"Nephrotoxic agents were held and renally-cleared medications dose-adjusted."}],"history":[{"id":"aki-hx-urine","dx":"general","q":"Urine output over the last day — making normal amounts, or markedly reduced/none?","answers":[{"label":"Adequate urine output","tone":"neg","sets":[],"ddx":[],"mdm":"Urine output was reportedly adequate.","frag":"urine output adequate"},{"label":"Oliguria / anuria","tone":"pos","sets":[{"risk":"bladder-aki"}],"ddx":[{"id":"obstruction-aki","keep":true}],"mdm":"Markedly reduced or absent urine output was reported, prompting evaluation for obstruction and severe AKI.","frag":"oliguria"}]},{"id":"aki-hx-volume","dx":"prerenal-aki","q":"Poor intake, vomiting/diarrhea, or bleeding suggesting hypovolemia?","answers":[{"label":"No volume loss","tone":"neg","sets":[],"ddx":[],"mdm":"There were no symptoms of volume depletion.","frag":"no volume loss"},{"label":"Volume loss present","tone":"pos","sets":[{"risk":"volume-aki"}],"ddx":[{"id":"prerenal-aki","keep":true}],"mdm":"Volume loss or poor intake was present, supporting a pre-renal cause.","frag":"volume loss"}]},{"id":"aki-hx-obstruction","dx":"obstruction-aki","q":"Lower urinary tract symptoms, known prostate disease, or a single/transplant kidney?","answers":[{"label":"No obstructive features","tone":"neg","sets":[],"ddx":[],"mdm":"There were no features suggesting urinary obstruction.","frag":"no obstructive features"},{"label":"Obstructive features","tone":"pos","sets":[{"risk":"bladder-aki"}],"ddx":[{"id":"obstruction-aki","keep":true}],"mdm":"Obstructive urinary features were present, prompting bladder assessment and imaging.","frag":"obstructive features"}]},{"id":"aki-hx-nephrotox","dx":"intrinsic-aki","q":"Recent NSAIDs, contrast, new medications, or muscle injury (rhabdomyolysis)?","answers":[{"label":"No nephrotoxic exposure","tone":"neg","sets":[],"ddx":[],"mdm":"No recent nephrotoxic exposure or muscle injury was identified.","frag":"no nephrotoxin"},{"label":"Nephrotoxic exposure","tone":"pos","sets":[{"risk":"nephrotox-aki"}],"ddx":[{"id":"intrinsic-aki","keep":true}],"mdm":"A nephrotoxic exposure or muscle injury was identified as a likely intrinsic cause.","frag":"nephrotoxin"}]}],"exam":[{"id":"aki-exam-volume","dx":"general","q":"Volume status — euvolemic, or dry (hypovolemic) vs overloaded?","answers":[{"label":"Euvolemic","tone":"neg","sets":[],"ddx":[],"mdm":"The patient appeared euvolemic on examination.","frag":"euvolemic"},{"label":"Hypovolemic or overloaded","tone":"pos","sets":[],"ddx":[],"mdm":"Examination suggested hypovolemia or volume overload, guiding fluid management.","frag":"abnormal volume status"}]},{"id":"aki-exam-bladder","dx":"obstruction-aki","q":"Suprapubic fullness or a palpable distended bladder?","answers":[{"label":"No bladder distension","tone":"neg","sets":[],"ddx":[],"mdm":"There was no suprapubic fullness or bladder distension.","frag":"no distension"},{"label":"Distended bladder","tone":"pos","sets":[{"risk":"bladder-aki"}],"ddx":[{"id":"obstruction-aki","keep":true}],"mdm":"A distended bladder was found, prompting catheter decompression for obstruction.","frag":"distended bladder"}]},{"answers":[{"ddx":[],"frag":"potassium not critical, ECG without hyperkalemic changes","label":"No metabolic emergency","mdm":"Potassium was not critically elevated, there was no severe acidosis, and the ECG showed no hyperkalemic changes, making an immediate metabolic emergency unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"hyperk-aki","keep":true}],"frag":"critical hyperkalemia or hyperkalemic ECG changes","label":"Metabolic emergency present","mdm":"Critically elevated potassium, severe acidosis, or hyperkalemic ECG changes were present, requiring emergent membrane stabilization and potassium-lowering measures.","sets":[],"tone":"pos"}],"dx":"hyperk-aki","id":"aki-exam-hyperk-aki","q":"Metabolic emergency — critically elevated potassium, severe acidosis, or hyperkalemic ECG changes?"}],"conclusions":["pre-renal AKI","obstructive (post-renal) AKI","intrinsic AKI / ATN"],"specs":["uro"],"guide":"../learn/complaints/acute-kidney-injury.html"},{"id":"anemia","title":"Symptomatic Anemia","aliases":["anemia","low hemoglobin","low hgb","low blood count","pale","fatigue anemia"],"opening":"A low hemoglobin with symptoms — decide how acute and how dangerous, find the source of loss or destruction, and set a transfusion plan.","ddx":[{"id":"hemorrhage-an","group":"lifethreat","label":"Acute hemorrhage","default":true,"tags":[],"ruleout":"Acute hemorrhage was considered; vital signs were stable without tachycardia or hypotension, there was no melena, hematemesis, hematochezia, vaginal, or traumatic bleeding, and the abdomen was benign, making active blood loss unlikely.","miss":3},{"id":"hemolysis-an","group":"lifethreat","label":"Hemolysis","default":true,"tags":[],"ruleout":"Hemolysis was considered; there was no jaundice, dark urine, or splenomegaly, LDH and bilirubin were not elevated, haptoglobin was preserved, and the smear showed no schistocytes, making active hemolysis unlikely.","miss":3},{"id":"malignancy-an","group":"common","label":"Malignancy / marrow failure","default":true,"tags":[],"ruleout":"An underlying malignancy or marrow process was considered, particularly with pancytopenia or constitutional symptoms, and follow-up arranged.","miss":2},{"id":"nutritional-an","group":"common","label":"Nutritional / chronic anemia","default":true,"tags":[],"ruleout":"A chronic or nutritional anemia (iron, B12/folate, chronic disease) was considered when the presentation was indolent.","miss":2}],"risk":[{"id":"hemodynamics-an","label":"Hemodynamic assessment","tags":[],"scale":"low","line":"Hemodynamic stability was assessed to gauge the acuity and danger of the anemia."},{"id":"typescreen-an","label":"Type & screen / crossmatch","tags":[],"scale":"low","line":"A type-and-screen (or crossmatch) was sent in case transfusion was required."},{"id":"source-an","label":"Source evaluation (GI / occult / gyn)","tags":[],"scale":"low","line":"The likely source of blood loss was evaluated, including a rectal exam and gynecologic history as appropriate."},{"id":"hemolysis-labs-an","label":"Hemolysis labs + smear","tags":[],"scale":"low","line":"Hemolysis labs and a peripheral smear were reviewed when hemolysis was suspected."},{"id":"transfusion-an","label":"Transfusion threshold / plan","tags":[],"scale":"low","line":"A transfusion threshold and plan were set based on hemodynamics, symptoms, and comorbidity."}],"history":[{"id":"an-hx-acuity","dx":"general","q":"Onset of symptoms — sudden over hours/days, or gradual over weeks?","answers":[{"label":"Gradual / chronic","tone":"neg","sets":[],"ddx":[],"mdm":"Symptoms were gradual over weeks, more consistent with a chronic anemia.","frag":"gradual onset"},{"label":"Acute","tone":"pos","sets":[{"risk":"hemodynamics-an"}],"ddx":[{"id":"hemorrhage-an","keep":true}],"mdm":"Symptoms developed acutely, raising concern for active blood loss or hemolysis.","frag":"acute onset"}]},{"id":"an-hx-bleeding","dx":"hemorrhage-an","q":"Visible bleeding — melena, hematochezia, hematemesis, heavy menses, or recent trauma/surgery?","answers":[{"label":"No overt bleeding","tone":"neg","sets":[],"ddx":[],"mdm":"No overt source of bleeding was reported: no melena, hematochezia, hematemesis, heavy menses, or recent trauma or surgery.","frag":"no overt bleeding"},{"label":"Overt bleeding","tone":"pos","sets":[{"risk":"typescreen-an"},{"risk":"source-an"}],"ddx":[{"id":"hemorrhage-an","keep":true}],"mdm":"An overt source of blood loss (melena, hematochezia, hematemesis, heavy menses, or recent trauma/surgery) was reported, prompting source control and transfusion readiness.","frag":"overt bleeding"}]},{"id":"an-hx-hemolysis","dx":"hemolysis-an","q":"Dark urine, jaundice, or a known hemolytic condition?","answers":[{"label":"No hemolytic features","tone":"neg","sets":[],"ddx":[],"mdm":"There were no features suggesting hemolysis.","frag":"no hemolytic features"},{"label":"Hemolytic features","tone":"pos","sets":[{"risk":"hemolysis-labs-an"}],"ddx":[{"id":"hemolysis-an","keep":true}],"mdm":"Dark urine, jaundice, or a hemolytic history was present, prompting hemolysis evaluation.","frag":"hemolytic features"}]},{"id":"an-hx-symptoms","dx":"general","q":"Symptoms of anemia — exertional dyspnea, chest pain, lightheadedness, or syncope?","answers":[{"label":"Minimal symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"Symptoms of anemia were minimal at rest, without exertional dyspnea, chest pain, lightheadedness, or syncope.","frag":"minimal symptoms"},{"label":"Significant symptoms","tone":"pos","sets":[{"risk":"transfusion-an"}],"ddx":[],"mdm":"Exertional dyspnea, chest pain, or presyncope indicated poor tolerance and informed transfusion.","frag":"significant symptoms"}]}],"exam":[{"id":"an-exam-vitals","dx":"general","q":"Vital signs — hemodynamically stable without tachycardia or orthostasis?","answers":[{"label":"Stable, no orthostasis","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable without tachycardia or orthostasis.","frag":"stable vitals"},{"label":"Tachycardic / orthostatic / hypotensive","tone":"pos","sets":[{"risk":"hemodynamics-an"}],"ddx":[{"id":"hemorrhage-an","keep":true}],"mdm":"Tachycardia, orthostasis, or hypotension was present, indicating significant or acute blood loss.","frag":"unstable vitals"}]},{"id":"an-exam-source","dx":"hemorrhage-an","q":"Rectal/abdominal exam and skin — melena on exam, abdominal findings, or pallor/petechiae?","answers":[{"label":"No source findings","tone":"neg","sets":[],"ddx":[],"mdm":"Examination revealed no bleeding source or signs of marrow failure: no melena, abdominal findings, or pallor/petechiae.","frag":"no source findings"},{"label":"Source findings present","tone":"pos","sets":[{"risk":"source-an"}],"ddx":[{"id":"hemorrhage-an","keep":true}],"mdm":"Examination revealed melena, abdominal findings, or pallor/petechiae directing the workup.","frag":"source findings"}]}],"conclusions":["acute blood-loss anemia","chronic / nutritional anemia","anemia of uncertain cause (workup arranged)"],"specs":["heme"],"guide":"../learn/complaints/anemia.html"},{"id":"sickle-cell","title":"Sickle Cell Pain Crisis","aliases":["sickle cell","vaso-occlusive crisis","voc","pain crisis","sickle","acute chest syndrome"],"opening":"A vaso-occlusive pain crisis deserves prompt analgesia — while actively excluding acute chest syndrome, infection, stroke, and the other sickle emergencies a simple crisis can hide.","ddx":[{"id":"acs-sickle","group":"lifethreat","label":"Acute chest syndrome","default":true,"tags":[],"ruleout":"Acute chest syndrome was considered; the patient was afebrile, normoxic, without chest pain, cough, or tachypnea, and the chest film showed no new infiltrate, making it unlikely though monitoring continued given its capacity to evolve.","miss":3},{"id":"sepsis-sickle","group":"lifethreat","label":"Sepsis (functional asplenia)","default":true,"tags":[],"ruleout":"Serious infection in a functionally asplenic patient was considered; the patient was afebrile and hemodynamically stable with no localizing source of infection, making sepsis from encapsulated organisms unlikely.","miss":3},{"id":"stroke-sickle","group":"lifethreat","label":"Stroke","default":true,"tags":[],"ruleout":"Stroke was considered given elevated cerebrovascular risk; there was no headache, weakness, facial droop, aphasia, or visual or sensory deficit and the neurologic exam was nonfocal, making it unlikely.","miss":4},{"id":"sequestration-sickle","group":"lifethreat","label":"Sequestration / aplastic crisis","default":true,"tags":[],"ruleout":"Sequestration and aplastic crisis were considered; hemoglobin was at the patient's baseline, there was no left-upper-quadrant pain or splenic enlargement, and reticulocytes were preserved, making these unlikely.","miss":3},{"id":"voc","group":"common","label":"Vaso-occlusive pain crisis","default":true,"tags":[],"ruleout":"The presentation was most consistent with an uncomplicated vaso-occlusive crisis and prompt analgesia and hydration were provided.","miss":2}],"risk":[{"id":"o2-cxr-sickle","label":"SpO₂ + chest film (ACS)","tags":[],"scale":"low","line":"Oxygen saturation and a chest film were assessed to evaluate for acute chest syndrome."},{"id":"fever-sickle","label":"Fever workup / empiric antibiotics","tags":[],"scale":"low","line":"Fever was worked up and empiric antibiotics were given when indicated given functional asplenia."},{"id":"analgesia-sickle","label":"Timely analgesia + hydration","tags":[],"scale":"low","line":"Timely, adequate analgesia and hydration were provided per the patient's individualized plan where available."},{"id":"hgb-sickle","label":"Hemoglobin vs baseline / reticulocytes","tags":[],"scale":"low","line":"Hemoglobin was compared to baseline with reticulocytes to detect sequestration or aplastic crisis."}],"history":[{"id":"sc-hx-chest","dx":"general","q":"Chest pain, cough, shortness of breath, or fever suggesting acute chest syndrome?","answers":[{"label":"No chest/respiratory symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There were no chest, respiratory, or febrile symptoms to suggest acute chest syndrome.","frag":"no chest symptoms"},{"label":"Chest / respiratory symptoms","tone":"pos","sets":[{"risk":"o2-cxr-sickle"}],"ddx":[{"id":"acs-sickle","keep":true}],"mdm":"Chest pain, dyspnea, cough, or fever was present, prompting evaluation for acute chest syndrome.","frag":"chest symptoms"}]},{"id":"sc-hx-fever","dx":"sepsis-sickle","q":"Fever or rigors?","answers":[{"label":"No fever","tone":"neg","sets":[],"ddx":[],"mdm":"There was no fever or rigors reported.","frag":"no fever"},{"label":"Fever present","tone":"pos","sets":[{"risk":"fever-sickle"}],"ddx":[{"id":"sepsis-sickle","keep":true}],"mdm":"Fever was present and, given functional asplenia, was worked up with empiric antibiotics as indicated.","frag":"fever"}]},{"id":"sc-hx-neuro","dx":"stroke-sickle","q":"Any weakness, speech difficulty, facial droop, or severe headache?","answers":[{"label":"No neurologic symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There were no neurologic symptoms to suggest stroke.","frag":"no neuro symptoms"},{"label":"Neurologic symptoms","tone":"pos","sets":[],"ddx":[{"id":"stroke-sickle","keep":true}],"mdm":"Neurologic symptoms were present, prompting urgent stroke evaluation.","frag":"neuro symptoms"}]},{"id":"sc-hx-pattern","dx":"voc","q":"Is this pain typical of the patient's usual crises in location and character?","answers":[{"label":"Typical crisis pain","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was typical of the patient's usual vaso-occlusive crises.","frag":"typical crisis"},{"label":"Atypical pain","tone":"pos","sets":[],"ddx":[],"mdm":"The pain was atypical for the patient's usual crises, broadening the evaluation.","frag":"atypical pain"}]}],"exam":[{"id":"sc-exam-resp","dx":"general","q":"Respiratory exam and SpO₂ — clear and well-oxygenated, or hypoxic / focal findings?","answers":[{"label":"Clear, well-oxygenated","tone":"neg","sets":[],"ddx":[],"mdm":"The chest was clear and oxygenation adequate.","frag":"chest clear"},{"label":"Hypoxic / focal findings","tone":"pos","sets":[{"risk":"o2-cxr-sickle"}],"ddx":[{"id":"acs-sickle","keep":true}],"mdm":"Hypoxia or focal chest findings were present, prompting a chest film for acute chest syndrome.","frag":"abnormal chest"}]},{"id":"sc-exam-spleen","dx":"sequestration-sickle","q":"Abdominal exam — spleen size and tenderness?","answers":[{"label":"No splenic enlargement","tone":"neg","sets":[],"ddx":[],"mdm":"There was no rapid splenic enlargement or marked tenderness.","frag":"no splenomegaly"},{"label":"Enlarging / tender spleen","tone":"pos","sets":[{"risk":"hgb-sickle"}],"ddx":[{"id":"sequestration-sickle","keep":true}],"mdm":"An enlarging or tender spleen raised concern for sequestration, with hemoglobin checked against baseline.","frag":"splenic enlargement"}]}],"conclusions":["uncomplicated vaso-occlusive crisis","vaso-occlusive crisis with acute chest syndrome","vaso-occlusive crisis with fever (infection workup)"],"specs":["heme"],"checks":[{"if":"acs-sickle","needs":["o2-cxr-sickle"],"mode":"any","warn":"Acute chest syndrome is the leading can't-miss in sickle cell — documenting oxygenation and a chest x-ray shows it was assessed."},{"if":"sepsis-sickle","needs":["fever-sickle"],"mode":"any","warn":"Functional asplenia makes fever an emergency — documenting the fever/sepsis workup (cultures and prompt antibiotics) is essential."},{"if":"sequestration-sickle","needs":["hgb-sickle"],"mode":"any","warn":"Splenic sequestration and aplastic crisis drop the hemoglobin — documenting hemoglobin (and reticulocyte count) shows they were considered."},{"if":"voc","needs":["analgesia-sickle"],"mode":"any","warn":"Vaso-occlusive crisis is real, severe pain — documenting timely, adequate analgesia counters under-treatment and anchoring on drug-seeking."}],"guide":"../learn/complaints/sickle-cell.html"},{"id":"heat-illness","title":"Heat Illness / Hyperthermia","aliases":["heat stroke","heat exhaustion","hyperthermia","heat illness","overheating","heat injury"],"opening":"Distinguish heat exhaustion from life-threatening heat stroke (hyperthermia with CNS dysfunction), begin rapid cooling, and exclude the dangerous mimics.","ddx":[{"id":"heatstroke","group":"lifethreat","label":"Heat stroke","default":true,"tags":[],"ruleout":"Heat stroke was considered; core temperature was not markedly elevated and the patient was alert and oriented without ataxia, seizure, or other CNS dysfunction, and there was no evidence of end-organ injury, making it unlikely.","miss":4},{"id":"mimics-heat","group":"lifethreat","label":"Toxidrome / NMS / serotonin / thyroid storm","default":true,"tags":[],"ruleout":"Hyperthermic mimics were considered; the medication and exposure history revealed no sympathomimetic, anticholinergic, neuroleptic, or serotonergic agents, and there was no rigidity, clonus, or thyrotoxic features, making NMS, serotonin syndrome, toxidrome, or thyroid storm unlikely.","miss":4},{"id":"sepsis-heat","group":"lifethreat","label":"Sepsis / CNS infection","default":true,"tags":[],"ruleout":"Infection as a cause of fever with altered mentation was considered; there was no localizing infectious source, no meningismus, and hemodynamics were stable without septic physiology, making sepsis or CNS infection unlikely.","miss":3},{"id":"exhaustion-heat","group":"common","label":"Heat exhaustion","default":true,"tags":[],"ruleout":"Heat exhaustion (heat stress with normal mentation) was considered and treated with rest, cooling, and rehydration.","miss":2}],"risk":[{"id":"temp-heat","label":"Core temperature","tags":[],"scale":"low","line":"A core (rectal) temperature was measured and trended during cooling."},{"id":"cool-heat","label":"Rapid active cooling","tags":[],"scale":"low","line":"Rapid active cooling was initiated for suspected heat stroke and continued to target."},{"id":"organ-heat","label":"End-organ assessment (renal/hepatic/coag/CK)","tags":[],"scale":"low","line":"End-organ function (renal, hepatic, coagulation, creatine kinase) was assessed for heat-stroke injury."},{"id":"glucose-mental-heat","label":"Glucose + mental status","tags":[],"scale":"low","line":"Glucose and mental status were checked as part of the altered-mentation evaluation."}],"history":[{"id":"hi-hx-exposure","dx":"general","q":"A clear heat-exposure or exertional context (hot environment, exertion, vulnerable patient, limiting medications)?","answers":[{"label":"Heat exposure context","tone":"neg","sets":[],"ddx":[],"mdm":"There was a clear heat-exposure or exertional context for the presentation.","frag":"heat exposure"},{"label":"No clear exposure","tone":"pos","sets":[],"ddx":[{"id":"mimics-heat","keep":true},{"id":"sepsis-heat","keep":true}],"mdm":"There was no clear heat exposure, broadening the differential for hyperthermia.","frag":"no clear exposure"}]},{"id":"hi-hx-mental","dx":"general","q":"Mental status — normal, or confusion, agitation, or decreased responsiveness?","answers":[{"label":"Normal mentation","tone":"neg","sets":[],"ddx":[],"mdm":"Mentation was normal, without confusion, agitation, or decreased responsiveness, consistent with heat exhaustion rather than heat stroke.","frag":"normal mentation"},{"label":"Altered mentation","tone":"pos","sets":[{"risk":"temp-heat"},{"risk":"cool-heat"}],"ddx":[{"id":"heatstroke","keep":true}],"mdm":"Altered mentation (confusion, agitation, or decreased responsiveness) with hyperthermia indicated heat stroke, and rapid cooling was started.","frag":"altered mentation"}]},{"id":"hi-hx-meds","dx":"mimics-heat","q":"Stimulants, anticholinergics, antipsychotics, or serotonergic agents in the history?","answers":[{"label":"No relevant agents","tone":"neg","sets":[],"ddx":[],"mdm":"No medications or substances suggesting a hyperthermic toxidrome were identified.","frag":"no relevant agents"},{"label":"Relevant agents present","tone":"pos","sets":[],"ddx":[{"id":"mimics-heat","keep":true}],"mdm":"Agents associated with hyperthermic syndromes were present and considered.","frag":"relevant agents"}]}],"exam":[{"id":"hi-exam-temp","dx":"general","q":"Core temperature — mildly elevated, or markedly elevated (e.g., > 40°C)?","answers":[{"label":"Mildly elevated","tone":"neg","sets":[],"ddx":[],"mdm":"The core temperature was only mildly elevated, not markedly elevated (e.g., > 40°C).","frag":"temp mildly elevated"},{"label":"Markedly elevated","tone":"pos","sets":[{"risk":"temp-heat"},{"risk":"cool-heat"}],"ddx":[{"id":"heatstroke","keep":true}],"mdm":"A markedly elevated core temperature (e.g., > 40°C) was documented and aggressive cooling pursued.","frag":"temp markedly elevated"}]},{"id":"hi-exam-cns","dx":"general","q":"Neurologic exam — normal, or ataxia, confusion, seizures, or coma?","answers":[{"label":"Normal neuro exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was normal, without ataxia, confusion, seizures, or coma.","frag":"neuro normal"},{"label":"CNS dysfunction","tone":"pos","sets":[{"risk":"organ-heat"}],"ddx":[{"id":"heatstroke","keep":true}],"mdm":"CNS dysfunction (ataxia, confusion, seizures, or coma) with hyperthermia confirmed heat stroke and prompted rapid cooling and organ assessment.","frag":"CNS dysfunction"}]}],"conclusions":["heat exhaustion","heat stroke","hyperthermia of uncertain cause (workup)"],"specs":["endo"],"checks":[{"if":"heatstroke","needs":["temp-heat","cool-heat"],"mode":"any","warn":"Heat stroke is a true emergency — document a core (rectal) temperature and that rapid cooling was initiated immediately."}],"guide":"../learn/complaints/heat-illness.html"},{"id":"hypothermia","title":"Hypothermia / Cold Exposure","aliases":["hypothermia","cold exposure","frostbite","cold injury","low temperature","exposure"],"opening":"A low core temperature — handle the heart gently, rewarm by severity, and look for the illness or exposure that caused it.","ddx":[{"id":"arrhythmia-hypo","group":"lifethreat","label":"Severe hypothermia / arrhythmia","default":true,"tags":[],"ruleout":"Severe hypothermia with arrhythmia risk was considered; the core temperature was only mildly reduced, the rhythm on monitor was stable without Osborn waves or ventricular ectopy, making a life-threatening dysrhythmia unlikely while gentle handling and rewarming continued.","miss":3},{"id":"sepsis-hypo","group":"lifethreat","label":"Sepsis","default":true,"tags":[],"ruleout":"Sepsis presenting as hypothermia was considered; there was no infectious source, perfusion and mentation were intact, and there was no septic physiology, making occult sepsis unlikely.","miss":3},{"id":"endo-hypo","group":"lifethreat","label":"Endocrine (hypothyroid / adrenal / hypoglycemia)","default":true,"tags":[],"ruleout":"An endocrine cause was considered; bedside glucose was normal, there was no myxedematous appearance or known hypothyroidism, and no features of adrenal insufficiency, making an endocrine driver of hypothermia unlikely.","miss":3},{"id":"tox-hypo","group":"common","label":"Toxic / environmental exposure","default":true,"tags":[],"ruleout":"Alcohol, sedatives, or environmental exposure contributing to hypothermia were considered from the history.","miss":2}],"risk":[{"id":"temp-hypo","label":"Core temperature","tags":[],"scale":"low","line":"A low-reading core (rectal/esophageal) temperature was measured and trended."},{"id":"ecg-hypo","label":"ECG / continuous monitoring","tags":[],"scale":"low","line":"An ECG and continuous monitoring were used, with gentle handling to avoid precipitating arrhythmia."},{"id":"rewarm-hypo","label":"Rewarming by severity","tags":[],"scale":"low","line":"A rewarming strategy (passive, active external, or active internal) was selected by severity."},{"id":"glucose-hypo","label":"Glucose + cause workup","tags":[],"scale":"low","line":"Glucose was checked and an underlying cause (sepsis, endocrine, toxic) sought."}],"history":[{"id":"hypo-hx-exposure","dx":"general","q":"A clear cold-exposure context (environmental, immersion, found down, intoxication)?","answers":[{"label":"Clear exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was a clear cold-exposure context for the hypothermia.","frag":"cold exposure"},{"label":"No clear exposure","tone":"pos","sets":[],"ddx":[{"id":"sepsis-hypo","keep":true},{"id":"endo-hypo","keep":true}],"mdm":"There was no clear environmental exposure, prompting a search for a medical cause.","frag":"no clear exposure"}]},{"id":"hypo-hx-mental","dx":"general","q":"Mental status and shivering — alert and shivering, or drowsy/confused with shivering lost?","answers":[{"label":"Alert, shivering","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was alert and still shivering, consistent with milder hypothermia.","frag":"alert, shivering"},{"label":"Drowsy / shivering lost","tone":"pos","sets":[{"risk":"ecg-hypo"},{"risk":"rewarm-hypo"}],"ddx":[{"id":"arrhythmia-hypo","keep":true}],"mdm":"Decreased responsiveness with loss of shivering indicated more severe hypothermia requiring active rewarming and gentle handling.","frag":"depressed mentation"}]},{"id":"hypo-hx-cause","dx":"sepsis-hypo","q":"Features of infection, hypothyroidism, or substance use as an underlying cause?","answers":[{"label":"No underlying illness","tone":"neg","sets":[],"ddx":[],"mdm":"No infectious, endocrine, or toxic cause was apparent.","frag":"no underlying illness"},{"label":"Underlying cause suspected","tone":"pos","sets":[{"risk":"glucose-hypo"}],"ddx":[{"id":"sepsis-hypo","keep":true},{"id":"endo-hypo","keep":true}],"mdm":"Features of an underlying illness or exposure were present and evaluated.","frag":"underlying cause"}]}],"exam":[{"id":"hypo-exam-temp","dx":"general","q":"Core temperature — mild (32–35°C), or moderate-to-severe (< 32°C)?","answers":[{"label":"Mild hypothermia","tone":"neg","sets":[],"ddx":[],"mdm":"A mild core-temperature reduction was documented.","frag":"mild hypothermia"},{"label":"Moderate-to-severe","tone":"pos","sets":[{"risk":"temp-hypo"},{"risk":"rewarm-hypo"}],"ddx":[{"id":"arrhythmia-hypo","keep":true}],"mdm":"A moderate-to-severe core temperature was documented, prompting active rewarming and cardiac caution.","frag":"severe hypothermia"}]},{"id":"hypo-exam-cardiac","dx":"general","q":"Cardiac — stable perfusing rhythm, or bradycardia/instability (handle gently)?","answers":[{"label":"Stable rhythm","tone":"neg","sets":[],"ddx":[],"mdm":"A stable perfusing rhythm was present.","frag":"stable rhythm"},{"label":"Bradycardia / instability","tone":"pos","sets":[{"risk":"ecg-hypo"}],"ddx":[{"id":"arrhythmia-hypo","keep":true}],"mdm":"Bradycardia or instability was present; the patient was handled gently with monitoring during rewarming.","frag":"unstable rhythm"}]}],"conclusions":["mild hypothermia","moderate-to-severe hypothermia","hypothermia secondary to underlying illness"],"specs":["endo"],"checks":[{"if":"arrhythmia-hypo","needs":["temp-hypo","ecg-hypo","rewarm-hypo"],"mode":"any","warn":"Hypothermia causes an irritable myocardium and bradyarrhythmias — document a true core (low-reading rectal/esophageal) temperature, the ECG, and the rewarming method; handle gently and continue resuscitation until rewarmed."}],"guide":"../learn/complaints/hypothermia.html"},{"id":"eye-trauma","title":"Eye Trauma / Chemical Exposure","aliases":["eye injury","eye trauma","chemical eye","ocular trauma","globe rupture","foreign body eye","eye burn"],"opening":"For chemical exposure, irrigate before anything else — then protect a possibly ruptured globe, check vision, and exclude the sight-threatening injuries.","ddx":[{"id":"chemical-eye","group":"lifethreat","label":"Chemical burn","default":true,"tags":[],"ruleout":"Chemical ocular burn was considered; there was no caustic or chemical exposure by history, the conjunctiva was not blanched or limbal-ischemic, and ocular pH was neutral, making a chemical injury requiring continued irrigation unlikely.","miss":3},{"id":"globe-rupture","group":"lifethreat","label":"Open globe / globe rupture","default":true,"tags":[],"ruleout":"Open globe was considered; there was no full-thickness laceration, no peaked or teardrop pupil, no extruded uveal tissue, hyphema, or Seidel sign, and intraocular contents appeared intact, making globe rupture unlikely.","miss":3},{"id":"retrobulbar","group":"lifethreat","label":"Retrobulbar hematoma / orbital compartment","default":true,"tags":[],"ruleout":"Retrobulbar hematoma with orbital compartment syndrome was considered; there was no proptosis, the eye was soft with normal intraocular pressure, vision was preserved, and there was no relative afferent pupillary defect, making emergent canthotomy unnecessary.","miss":3},{"id":"retinal-eye","group":"lifethreat","label":"Retinal detachment","default":true,"tags":[],"ruleout":"Retinal detachment was considered; there were no new flashes, floaters, or a visual-field curtain, and visual acuity was preserved, making it unlikely.","miss":3},{"id":"hyphema","group":"common","label":"Hyphema","default":true,"tags":[],"ruleout":"Hyphema was considered and the anterior chamber examined for layered blood, with intraocular pressure and ophthalmology involvement as indicated.","miss":2},{"id":"orbital-fx","group":"common","label":"Orbital fracture","default":true,"tags":[],"ruleout":"An orbital (blowout) fracture was considered with the mechanism, and entrapment and globe injury assessed.","miss":2},{"id":"corneal-eye","group":"common","label":"Corneal abrasion / foreign body","default":true,"tags":[],"ruleout":"A corneal abrasion or superficial foreign body was considered once the dangerous injuries were excluded.","miss":2}],"risk":[{"id":"acuity-eye","label":"Visual acuity (each eye)","tags":[],"scale":"low","line":"Visual acuity was documented for each eye as the vital sign of the eye."},{"id":"ph-eye","label":"pH + irrigation (chemical)","tags":[],"scale":"low","line":"For chemical exposure, immediate irrigation was performed and pH checked and rechecked to neutral."},{"id":"seidel-eye","label":"Slit-lamp / Seidel test","tags":[],"scale":"low","line":"A slit-lamp examination with a Seidel test was performed to evaluate for globe disruption, hyphema, or foreign body when open globe was not evident."},{"id":"iop-eye","label":"Intraocular pressure (if no globe rupture)","tags":[],"scale":"low","line":"Intraocular pressure was measured only when open globe was not suspected."},{"id":"ct-eye","label":"CT orbits","tags":[],"scale":"low","line":"CT of the orbits was obtained for suspected fracture, occult open globe, or retrobulbar hematoma (avoiding pressure on the eye)."}],"history":[{"id":"et-hx-chemical","dx":"general","q":"Chemical splash or exposure to the eye?","answers":[{"label":"No chemical exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was no chemical exposure to the eye.","frag":"no chemical exposure"},{"label":"Chemical exposure","tone":"pos","sets":[{"risk":"ph-eye"}],"ddx":[{"id":"chemical-eye","keep":true}],"mdm":"A chemical exposure occurred, and immediate copious irrigation was begun before further assessment.","frag":"chemical exposure"}]},{"id":"et-hx-mechanism","dx":"general","q":"Mechanism — low-energy (e.g., fingernail), or high-energy/high-risk (hammering metal, projectile, blunt globe impact)?","answers":[{"label":"Low-energy mechanism","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was low-energy rather than high-risk (such as hammering metal, a projectile, or blunt globe impact), lowering the risk of open globe or intraocular foreign body.","frag":"low-energy mechanism"},{"label":"High-risk mechanism","tone":"pos","sets":[{"risk":"ct-eye"}],"ddx":[{"id":"globe-rupture","keep":true}],"mdm":"A high-risk mechanism (high-velocity metal, projectile, or significant blunt force) raised concern for open globe or an intraocular foreign body.","frag":"high-risk mechanism"}]},{"id":"et-hx-vision","dx":"general","q":"Vision — unchanged, or decreased, with flashes, floaters, or a curtain over the field?","answers":[{"label":"Vision unchanged","tone":"neg","sets":[],"ddx":[],"mdm":"Vision was subjectively unchanged.","frag":"vision unchanged"},{"label":"Vision changed","tone":"pos","sets":[{"risk":"acuity-eye"}],"ddx":[{"id":"retinal-eye","keep":true},{"id":"retrobulbar","keep":true}],"mdm":"Decreased vision or flashes/floaters/a field curtain were reported, raising concern for a sight-threatening injury.","frag":"vision changed"}]}],"exam":[{"id":"et-exam-acuity","dx":"general","q":"Visual acuity — at baseline in the affected eye, or reduced?","answers":[{"label":"Acuity at baseline","tone":"neg","sets":[],"ddx":[],"mdm":"Visual acuity was at baseline in the affected eye.","frag":"acuity baseline"},{"label":"Acuity reduced","tone":"pos","sets":[{"risk":"acuity-eye"}],"ddx":[{"id":"globe-rupture","keep":true},{"id":"retrobulbar","keep":true}],"mdm":"Visual acuity was reduced, prompting urgent evaluation for a sight-threatening cause.","frag":"acuity reduced"}]},{"id":"et-exam-globe","dx":"general","q":"Globe — intact and formed, or signs of rupture (peaked pupil, extruded contents, positive Seidel, marked subconjunctival hemorrhage)?","answers":[{"label":"Globe intact","tone":"neg","sets":[],"ddx":[],"mdm":"The globe appeared intact without signs of rupture.","frag":"globe intact"},{"label":"Signs of rupture","tone":"pos","sets":[{"risk":"ct-eye"}],"ddx":[{"id":"globe-rupture","keep":true}],"mdm":"Signs of globe rupture (a peaked pupil, extruded contents, positive Seidel, or marked subconjunctival hemorrhage) were present; the eye was shielded and ophthalmology engaged urgently without further manipulation.","frag":"globe rupture signs"}]},{"id":"et-exam-chamber","dx":"hyphema","q":"Anterior chamber — clear, or layered blood (hyphema)?","answers":[{"label":"Clear anterior chamber","tone":"neg","sets":[],"ddx":[],"mdm":"The anterior chamber was clear without hyphema.","frag":"no hyphema"},{"label":"Hyphema present","tone":"pos","sets":[],"ddx":[{"id":"hyphema","keep":true}],"mdm":"Layered blood (hyphema) was present, prompting pressure assessment and ophthalmology involvement.","frag":"hyphema"}]}],"conclusions":["corneal abrasion / foreign body","chemical eye injury (irrigated)","suspected open globe (shielded, ophthalmology engaged)"],"specs":["ophtho","trauma"],"checks":[{"if":"chemical-eye","needs":["ph-eye"],"mode":"any","warn":"A chemical eye burn is treated before anything else — document immediate copious irrigation and that the pH was rechecked toward neutral."},{"if":"globe-rupture","needs":["acuity-eye","seidel-eye"],"mode":"any","warn":"Open globe is sight-threatening — document visual acuity and the exam for rupture (Seidel test / teardrop pupil); shield the eye and avoid any pressure."}]},{"id":"fever-travel","title":"Fever in the Returning Traveler","aliases":["returning traveler","travel fever","post-travel fever","tropical fever","fever after travel","malaria","imported fever","febrile traveler"],"opening":"Fever after international travel: exclude malaria first (a true emergency), screen for viral hemorrhagic fever before drawing routine labs, and let the itinerary, incubation window, and exposures narrow the rest of the differential. Use the interactive region map to see what's endemic where they traveled.","guide":"travel-fever.html","ddx":[{"id":"malaria","group":"lifethreat","label":"Malaria","default":true,"tags":[],"ruleout":"Malaria was considered and pursued as any fever after travel to an endemic area is malaria until excluded; thick and thin smears and a rapid antigen test were negative, making malaria unlikely.","miss":3},{"id":"vhf","group":"lifethreat","label":"Viral hemorrhagic fever","default":true,"tags":[],"ruleout":"Viral hemorrhagic fever was considered; the itinerary included no compatible outbreak exposure within 21 days and there was no bleeding, bruising, or shock, making VHF unlikely while standard precautions continued.","miss":3},{"id":"meningo","group":"lifethreat","label":"Meningococcal disease / bacterial meningitis","default":true,"tags":[],"ruleout":"Meningococcal disease and bacterial meningitis were considered; there was no neck stiffness, no petechial or purpuric rash, no photophobia, and mentation was normal, making invasive meningococcal disease unlikely.","miss":4},{"id":"sepsis-tr","group":"lifethreat","label":"Sepsis / bacteremia","default":true,"tags":[],"ruleout":"Sepsis and bacteremia were considered; vital signs were stable with intact perfusion and no end-organ dysfunction, and there was no septic physiology, making it unlikely while cultures were obtained.","miss":3},{"id":"typhoid-tr-add","group":"lifethreat","label":"Enteric (typhoid) fever","default":false,"tags":["typhoid-tr-add"],"ruleout":"Enteric (typhoid) fever was considered; there was no sustained stepwise fever with relative bradycardia, abdominal pain, or rose spots, and blood cultures were obtained, making it less likely.","miss":3},{"id":"dengue","group":"common","label":"Dengue / arboviral fever","default":false,"tags":[],"ruleout":"Dengue and other arboviral infections (chikungunya, Zika) were considered from the itinerary, incubation window, and examination.","miss":2},{"id":"enteric","group":"common","label":"Enteric fever (typhoid)","default":false,"tags":[],"ruleout":"Enteric fever was considered, especially after travel to South Asia; blood cultures were obtained when the presentation was compatible.","miss":2},{"id":"zoonoses","group":"common","label":"Rickettsiosis / leptospirosis","default":false,"tags":[],"ruleout":"Rickettsial disease and leptospirosis were considered from exposure history (tick or mite bite with eschar, freshwater contact); empiric doxycycline was considered where the picture fit.","miss":2},{"id":"resp-tr","group":"common","label":"Respiratory viral illness","default":false,"tags":[],"ruleout":"A respiratory viral illness (influenza, COVID-19) (the most common cause of post-travel fever overall) was considered and tested for as indicated.","miss":2},{"id":"gi-tr","group":"common","label":"Enteric infection / viral hepatitis","default":false,"tags":[],"ruleout":"Travel-associated gastrointestinal infection and viral hepatitis A/E were considered from the exposure and examination, with hepatic function checked when jaundice was present.","miss":2}],"risk":[{"id":"malaria-test","label":"Malaria thick & thin films + rapid antigen test","tags":[],"scale":"low","line":"Thick and thin blood films and a malaria rapid antigen test were obtained, with repeat smears planned if initially negative and suspicion persisted.","cite":"CDC Yellow Book 2024"},{"id":"vhf-screen","label":"VHF risk screen + isolation if indicated","tags":[],"scale":"low","line":"A viral hemorrhagic fever risk screen (outbreak area and exposure within 21 days) was performed; isolation and public-health notification were arranged if criteria were met before routine phlebotomy."},{"id":"bcx","label":"Blood cultures","tags":[],"scale":"low","line":"Blood cultures were drawn to evaluate for enteric fever, bacteremia, and sepsis."},{"id":"cbc-diff","label":"CBC with differential","tags":[],"scale":"low","line":"A complete blood count with differential was reviewed for thrombocytopenia, leukopenia, and eosinophilia."},{"id":"lft","label":"Hepatic + renal function","tags":[],"scale":"low","line":"Hepatic and renal function were assessed given jaundice / organ-dysfunction considerations."},{"id":"prophylaxis","label":"Malaria prophylaxis + vaccination history","tags":[],"scale":"low","line":"Malaria chemoprophylaxis adherence and pre-travel vaccination history were documented."},{"id":"sepsis-bundle","label":"Sepsis screen / lactate","tags":[],"scale":"low","line":"A sepsis screen with lactate was performed and resuscitation initiated for septic physiology."},{"id":"lp","label":"Lumbar puncture considered","tags":[],"scale":"low","line":"Lumbar puncture was considered for meningismus or altered mentation, with empiric antibiotics given without waiting for the procedure."},{"id":"ph-notify","label":"Public health / ID notification","tags":[],"scale":"low","line":"Public health and infectious diseases were notified where a reportable or high-consequence pathogen was suspected."}],"checks":[{"if":"malaria","needs":["malaria-test"]},{"if":"vhf","needs":["vhf-screen"]},{"if":"meningo","needs":["bcx"]},{"if":"sepsis-tr","needs":["bcx"]},{"if":"enteric","needs":["bcx"]},{"if":"dengue","needs":["cbc-diff"],"mode":"any","warn":"Dengue is on the differential — a CBC with differential (thrombocytopenia, rising hematocrit) and the warning signs identify severe dengue."}],"history":[{"id":"ft-hx-area","dx":"general","q":"Travel to a malaria-endemic area (Sub-Saharan Africa, South/Southeast Asia, Oceania, the Amazon)?","answers":[{"label":"No malaria-endemic exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was no travel to a malaria-endemic area on the itinerary.","frag":"no malaria-endemic travel"},{"label":"Malaria-endemic exposure","tone":"pos","sets":[{"risk":"malaria-test"},{"risk":"prophylaxis"}],"ddx":[{"id":"malaria","keep":true}],"mdm":"Travel included a malaria-endemic area, so malaria was treated as the priority diagnosis until excluded.","frag":"malaria-endemic travel"}]},{"id":"ft-hx-prophylaxis","dx":"malaria","q":"Malaria chemoprophylaxis taken and adherent?","answers":[{"label":"Adherent chemoprophylaxis","tone":"neg","sets":[],"ddx":[],"mdm":"Appropriate malaria chemoprophylaxis was taken with good adherence.","frag":"prophylaxis adherent"},{"label":"No / incomplete prophylaxis","tone":"pos","sets":[{"risk":"malaria-test"}],"ddx":[{"id":"malaria","keep":true}],"mdm":"Malaria chemoprophylaxis was absent or incomplete, raising malaria risk.","frag":"no prophylaxis"}]},{"id":"ft-hx-incubation","dx":"general","q":"Symptom onset within 21 days of return (the acute window)?","answers":[{"label":"Onset more than 21 days after return","tone":"neg","sets":[],"ddx":[],"mdm":"Symptom onset was more than 21 days after return, making viral hemorrhagic fever and dengue far less likely.","frag":"onset >21 days"},{"label":"Onset within 21 days","tone":"pos","sets":[{"risk":"vhf-screen"}],"ddx":[{"id":"vhf","keep":true},{"id":"dengue","keep":true}],"mdm":"Symptom onset was within 21 days of return, keeping acute infections including VHF and dengue in play.","frag":"onset <21 days"}]},{"id":"ft-hx-vhf","dx":"vhf","q":"Travel to a VHF outbreak area with compatible exposure (sick contacts, body fluids, rodents, ticks) within 21 days?","answers":[{"label":"No VHF outbreak exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was no exposure in a viral-hemorrhagic-fever outbreak area, so routine evaluation proceeded with standard precautions.","frag":"no VHF exposure"},{"label":"Possible VHF exposure","tone":"pos","sets":[{"risk":"vhf-screen"},{"risk":"ph-notify"}],"ddx":[{"id":"vhf","keep":true}],"mdm":"A possible viral-hemorrhagic-fever exposure was identified; isolation and public-health notification were arranged before routine phlebotomy.","frag":"possible VHF exposure"}]},{"id":"ft-hx-exposures","dx":"general","q":"Specific exposures elicited (freshwater swimming, animal or insect bites, untreated food/water, sexual contact, mass gathering)?","answers":[{"label":"No high-risk exposures","tone":"neg","sets":[],"ddx":[],"mdm":"No high-risk environmental, vector, food/water, or sexual exposures were elicited.","frag":"no high-risk exposures"},{"label":"Specific exposure(s) present","tone":"pos","sets":[{"risk":"cbc-diff"}],"ddx":[{"id":"zoonoses","keep":true}],"mdm":"Specific exposures were elicited and used to focus the zoonotic and enteric differential.","frag":"exposures present"}]},{"id":"ft-hx-vaccines","dx":"general","q":"Pre-travel vaccinations current (typhoid, hepatitis A/B, meningococcal, yellow fever)?","answers":[{"label":"Vaccinations current","tone":"neg","sets":[],"ddx":[],"mdm":"Pre-travel vaccinations were current.","frag":"vaccines current"},{"label":"Unvaccinated / incomplete","tone":"pos","sets":[],"ddx":[{"id":"enteric","keep":true},{"id":"meningo","keep":true}],"mdm":"Pre-travel vaccinations were incomplete, broadening the differential to vaccine-preventable infections.","frag":"vaccines incomplete"}]},{"answers":[{"ddx":[],"frag":"no stepwise fever, abdominal pain, or rose spots","label":"No typhoid features","mdm":"There was no sustained stepwise fever with relative bradycardia, abdominal pain, or rose spots, and blood cultures were obtained, making enteric (typhoid) fever less likely.","sets":[],"tone":"neg"},{"ddx":[{"id":"typhoid-tr-add","keep":true}],"frag":"stepwise fever with abdominal pain or rose spots","label":"Typhoid features present","mdm":"A sustained stepwise fever with relative bradycardia, abdominal pain, or rose spots was present, raising concern for enteric (typhoid) fever and warranting blood cultures and empiric coverage.","sets":[],"tone":"pos"}],"dx":"typhoid-tr-add","id":"ft-hx-typhoid-tr-add","q":"Enteric fever — sustained stepwise fever with relative bradycardia, abdominal pain, or rose spots?"}],"exam":[{"id":"ft-ex-vitals","dx":"general","q":"Vital signs — stable, or septic physiology (hypotension, marked tachycardia/tachypnea)?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable without features of septic physiology.","frag":"vitals stable"},{"label":"Septic physiology","tone":"pos","sets":[{"risk":"sepsis-bundle"},{"risk":"bcx"}],"ddx":[{"id":"sepsis-tr","keep":true}],"mdm":"Septic physiology (hypotension, marked tachycardia, or tachypnea) was present, prompting a sepsis screen, cultures, and resuscitation.","frag":"septic physiology"}]},{"id":"ft-ex-skin","dx":"general","q":"Skin — no rash, or rash, petechiae, or an eschar?","answers":[{"label":"No rash or eschar","tone":"neg","sets":[],"ddx":[],"mdm":"There was no rash, petechiae, or eschar.","frag":"skin normal"},{"label":"Rash / petechiae / eschar","tone":"pos","sets":[{"risk":"cbc-diff"}],"ddx":[{"id":"dengue","keep":true},{"id":"zoonoses","keep":true},{"id":"meningo","keep":true}],"mdm":"A rash, petechiae, or eschar was present and used to focus the differential.","frag":"rash/eschar"}]},{"id":"ft-ex-neuro","dx":"general","q":"Neurologic exam — normal, or meningismus or altered mentation?","answers":[{"label":"Normal neurologic exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was normal without meningismus.","frag":"neuro normal"},{"label":"Meningismus / altered mentation","tone":"pos","sets":[{"risk":"lp"},{"risk":"bcx"}],"ddx":[{"id":"meningo","keep":true},{"id":"malaria","keep":true}],"mdm":"Meningismus or altered mentation was present; empiric antibiotics were given and lumbar puncture arranged, with cerebral malaria also considered.","frag":"meningismus/altered"}]},{"id":"ft-ex-liver","dx":"general","q":"Abdomen / skin — no jaundice or organomegaly, or jaundice or hepatosplenomegaly?","answers":[{"label":"No jaundice or organomegaly","tone":"neg","sets":[],"ddx":[],"mdm":"There was no jaundice or hepatosplenomegaly.","frag":"no jaundice/HSM"},{"label":"Jaundice / hepatosplenomegaly","tone":"pos","sets":[{"risk":"lft"}],"ddx":[{"id":"malaria","keep":true},{"id":"enteric","keep":true}],"mdm":"Jaundice or hepatosplenomegaly was present, prompting hepatic-function testing and keeping malaria and enteric fever in view.","frag":"jaundice/HSM"}]}],"conclusions":["malaria (smear / RDT pending)","dengue / arboviral fever","enteric fever (typhoid)","undifferentiated travel-associated fever (workup)"],"specs":["id"]},{"id":"acute-cholecystitis","title":"Acute Cholecystitis / Biliary Colic","kind":"diagnosis","aliases":["cholecystitis","biliary colic","gallstones","gallbladder attack","ruq pain","cholelithiasis","gallbladder","murphy sign","cholangitis","gallstone pancreatitis"],"opening":"The patient was evaluated for right-upper-quadrant or epigastric pain consistent with biliary colic or acute cholecystitis. The dangerous biliary mimics and complications below — most importantly ascending cholangitis, gallstone pancreatitis, and an inferior cardiac event masquerading as biliary pain — were actively considered and addressed.","ddx":[{"id":"cholangitis","group":"lifethreat","label":"Ascending cholangitis","default":true,"tags":["cholangitis"],"ruleout":"Ascending cholangitis was considered; the patient was afebrile without jaundice or confusion, hemodynamically stable, and liver enzymes and bilirubin showed no obstructive pattern, making biliary obstruction with infection unlikely.","miss":3},{"id":"gallstone-pancreatitis","group":"lifethreat","label":"Gallstone pancreatitis","default":true,"tags":["gallstone-pancreatitis"],"ruleout":"Gallstone pancreatitis was considered; lipase was normal and the pain was not epigastric or band-like radiating to the back, making it unlikely.","miss":3},{"id":"perforation","group":"lifethreat","label":"Gangrenous / perforated cholecystitis","default":true,"tags":["perforation"],"ruleout":"Gangrenous or perforated cholecystitis was considered; there was no high fever, marked leukocytosis, or diffuse peritoneal signs, and the exam was localized without rigidity, making an advanced or complicated infection unlikely.","miss":4},{"id":"choledocholithiasis","group":"common","label":"Choledocholithiasis","default":false,"tags":["choledocholithiasis"],"ruleout":"Choledocholithiasis was considered given the risk of progression to cholangitis or pancreatitis; liver function tests and bilirubin were reviewed and the bile duct caliber was assessed on ultrasound.","miss":2},{"id":"pud","group":"common","label":"Peptic ulcer disease","default":false,"tags":["pud"],"ruleout":"Peptic ulcer disease was considered as an epigastric mimic; the relationship of pain to meals and any history of NSAID use or prior ulcer was reviewed, and perforation was excluded by the absence of peritoneal signs.","miss":2},{"id":"acalculous","group":"other","label":"Acalculous cholecystitis","default":false,"tags":["acalculous"],"ruleout":"Acalculous cholecystitis was considered in the critically ill, fasting, or immunocompromised patient, in whom gallbladder inflammation can occur without stones and the presentation may be subtle.","miss":1},{"id":"acs","group":"lifethreat","label":"Inferior MI / ACS","default":false,"tags":["acs"],"ruleout":"An inferior MI or ACS presenting as epigastric/right-upper-quadrant pain was considered; there was no exertional or radiating chest pain, the ECG showed no inferior ischemic changes, and troponin was not elevated, making it unlikely.","miss":3},{"id":"aaa-chole-add","group":"lifethreat","label":"Ruptured/symptomatic abdominal aortic aneurysm","default":false,"tags":["aaa-chole-add"],"ruleout":"A symptomatic or ruptured abdominal aortic aneurysm was considered; there was no tearing flank/back pain, no pulsatile abdominal mass, equal femoral pulses, and stable hemodynamics, making it unlikely.","miss":4}],"risk":[{"id":"ruq-us","label":"RUQ ultrasound","tags":["cholangitis","choledocholithiasis","perforation","acalculous"],"scale":"low","line":"A right-upper-quadrant ultrasound was obtained to assess for gallstones, gallbladder wall thickening, pericholecystic fluid, a sonographic Murphy sign, and bile duct dilation.","short":"RUQ ultrasound"},{"id":"lfts","label":"LFTs / bilirubin","tags":["cholangitis","choledocholithiasis"],"scale":"low","line":"Liver function tests and bilirubin were obtained to evaluate for biliary obstruction suggesting choledocholithiasis or cholangitis.","short":"LFTs / bilirubin"},{"id":"lipase","label":"Lipase","tags":["gallstone-pancreatitis"],"scale":"low","line":"A lipase was obtained to evaluate for gallstone pancreatitis as a complication of stone passage.","short":"Lipase"},{"id":"wbc-fever","label":"WBC / fever assessment","tags":["cholangitis","perforation"],"scale":"low","line":"The temperature and white-cell count were assessed for systemic infection suggesting cholangitis or a complicated, gangrenous cholecystitis.","short":"WBC / fever"},{"id":"murphy","label":"Murphy sign","tags":["perforation","acalculous"],"scale":"low","line":"A Murphy sign was elicited on examination and the abdomen was assessed for localized versus diffuse peritoneal findings.","short":"Murphy sign"},{"id":"ecg-trop","label":"ECG / troponin","tags":["acs"],"scale":"low","line":"An ECG and troponin were obtained when the pain was epigastric or the patient carried cardiac risk to exclude an inferior coronary event.","short":"ECG / troponin"}],"checks":[{"if":"cholangitis","needs":["lfts","wbc-fever"],"mode":"any","warn":"Ascending cholangitis is on the differential — documenting LFTs/bilirubin and the fever/WBC assessment supports recognition of biliary sepsis (Charcot/Reynolds)."},{"if":"gallstone-pancreatitis","needs":["lipase"],"mode":"any","warn":"Gallstone pancreatitis is on the differential — documenting a lipase supports the assessment for this complication."},{"if":"perforation","needs":["ruq-us","murphy"],"mode":"any","warn":"Gangrenous or perforated cholecystitis is on the differential — documenting the ultrasound and abdominal exam supports detection of a complicated infection."},{"if":"acs","needs":["ecg-trop"],"mode":"any","warn":"An inferior MI can masquerade as biliary pain — documenting an ECG and troponin supports calling this biliary rather than cardiac."}],"history":[{"id":"ch-hx-pain","dx":"general","q":"Character and timing of the pain — post-prandial right-upper-quadrant or epigastric pain, and is it now constant rather than colicky?","answers":[{"label":"Brief, self-limited colic","tone":"neg","sets":[],"ddx":[],"mdm":"The post-prandial right-upper-quadrant or epigastric pain was brief, colicky, and self-limited rather than now constant, consistent with uncomplicated biliary colic that had resolved.","frag":"self-limited biliary colic"},{"label":"Constant pain > 6 hours","tone":"pos","sets":[],"ddx":[{"id":"perforation","keep":true}],"mdm":"The post-prandial right-upper-quadrant or epigastric pain was now constant rather than colicky and prolonged beyond six hours, consistent with established acute cholecystitis rather than simple colic.","frag":"constant prolonged pain"}]},{"id":"ch-hx-fever","dx":"cholangitis","q":"Fevers, chills, or yellowing of the eyes or skin (suggesting biliary obstruction with infection)?","answers":[{"label":"No fever or jaundice","tone":"neg","sets":[],"ddx":[],"mdm":"No fevers, rigors, or jaundice to suggest ascending cholangitis were reported.","frag":"no fever or jaundice"},{"label":"Fever / chills / jaundice","tone":"pos","sets":[],"ddx":[{"id":"cholangitis","keep":true},{"id":"choledocholithiasis","keep":true}],"mdm":"Fever, rigors, or jaundice was reported, raising concern for biliary obstruction with ascending cholangitis.","frag":"fever / chills / jaundice"}]},{"id":"ch-hx-radiation","dx":"gallstone-pancreatitis","q":"Has the pain shifted to the epigastrium with band-like radiation to the back, or are there persistent vomiting and inability to tolerate fluids?","answers":[{"label":"No epigastric / back radiation","tone":"neg","sets":[],"ddx":[],"mdm":"No epigastric pain radiating to the back to suggest gallstone pancreatitis was reported.","frag":"no epigastric / back radiation"},{"label":"Epigastric pain to the back","tone":"pos","sets":[],"ddx":[{"id":"gallstone-pancreatitis","keep":true}],"mdm":"Epigastric pain radiating to the back with persistent vomiting was reported, raising concern for gallstone pancreatitis.","frag":"epigastric pain to the back"}]},{"id":"ch-hx-pud","dx":"pud","q":"History of peptic ulcer disease, reflux, or regular NSAID use, with pain related to meals?","answers":[{"label":"No ulcer / NSAID history","tone":"neg","sets":[],"ddx":[],"mdm":"No history of peptic ulcer disease or NSAID use to suggest an ulcer was reported.","frag":"no ulcer / NSAID history"},{"label":"Ulcer history / NSAID use","tone":"pos","sets":[],"ddx":[{"id":"pud","keep":true}],"mdm":"A history of peptic ulcer disease or regular NSAID use was reported, keeping ulcer disease on the differential as an epigastric mimic.","frag":"ulcer history / NSAID use"}]},{"id":"ch-hx-cardiac","dx":"acs","q":"Any associated chest pressure, dyspnea, diaphoresis, or cardiac risk factors with epigastric pain?","answers":[{"label":"No cardiac features","tone":"neg","sets":[],"ddx":[],"mdm":"No chest pressure, dyspnea, or diaphoresis and no significant cardiac risk to suggest an inferior coronary event.","frag":"no cardiac features"},{"label":"Cardiac features / risk","tone":"pos","sets":[],"ddx":[{"id":"acs","keep":true}],"mdm":"Associated cardiac symptoms or risk factors were present, prompting evaluation for an inferior MI presenting as epigastric pain.","frag":"cardiac features / risk"}]}],"exam":[{"id":"ch-exam-murphy","dx":"perforation","q":"Abdominal examination — focal RUQ tenderness with a Murphy sign, or diffuse peritoneal signs?","answers":[{"label":"Focal RUQ tenderness only","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen showed focal right-upper-quadrant tenderness without diffuse peritoneal signs.","frag":"focal RUQ tenderness"},{"label":"Diffuse peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"perforation","keep":true}],"mdm":"Diffuse peritoneal signs were present, concerning for gangrenous or perforated cholecystitis.","frag":"diffuse peritoneal signs"}]},{"id":"ch-exam-vitals","dx":"cholangitis","q":"Vital signs — fever, tachycardia, hypotension, or altered mental status suggesting biliary sepsis?","answers":[{"label":"Afebrile, hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was afebrile, hemodynamically stable, and without tachycardia, hypotension, or altered mental status to suggest biliary sepsis.","frag":"afebrile, stable"},{"label":"Fever / hypotension / confusion","tone":"pos","sets":[],"ddx":[{"id":"cholangitis","keep":true}],"mdm":"Fever, hypotension, or confusion was present, concerning for ascending cholangitis with the Reynolds pentad.","frag":"fever / hypotension / confusion"}]},{"id":"ch-exam-us","dx":"choledocholithiasis","q":"Ultrasound findings — gallstones with wall thickening or pericholecystic fluid, and is the common bile duct dilated?","answers":[{"label":"Stones, non-dilated duct","tone":"neg","sets":[],"ddx":[],"mdm":"Ultrasound showed gallstones with a non-dilated common bile duct and no wall thickening or pericholecystic fluid, without sonographic evidence of obstruction.","frag":"stones, non-dilated duct"},{"label":"Dilated CBD / obstruction","tone":"pos","sets":[],"ddx":[{"id":"choledocholithiasis","keep":true},{"id":"cholangitis","keep":true}],"mdm":"Ultrasound showed common bile duct dilation, with gallstones and wall thickening or pericholecystic fluid, concerning for choledocholithiasis with risk of cholangitis.","frag":"dilated CBD"}]},{"answers":[{"ddx":[],"frag":"no tearing pain or pulsatile mass, femoral pulses equal (palpation is only ~68% sensitive for AAA and cannot exclude one, so imaging thresholds were set by risk)","label":"No AAA features","mdm":"There was no tearing flank or back pain, femoral pulses were equal, and hemodynamics were stable; no pulsatile abdominal mass was palpated, noting palpation is only ~68% sensitive for AAA and cannot exclude one. Imaging thresholds were set by risk factors and the clinical picture.","sets":[],"tone":"neg"},{"ddx":[{"id":"aaa-chole-add","keep":true}],"frag":"tearing back pain or pulsatile mass","label":"AAA features present","mdm":"Tearing flank or back pain, a pulsatile abdominal mass, or asymmetric femoral pulses was present, raising concern for a symptomatic or ruptured abdominal aortic aneurysm and warranting immediate imaging.","sets":[],"tone":"pos"}],"dx":"aaa-chole-add","id":"ch-exam-aaa-chole-add","q":"AAA — tearing flank or back pain, a pulsatile abdominal mass, or asymmetric femoral pulses?"}],"conclusions":["acute uncomplicated cholecystitis","biliary colic, resolved, tolerating PO","symptomatic cholelithiasis pending outpatient cholecystectomy"],"specs":["surg","gi"]},{"id":"acute-pancreatitis","title":"Acute Pancreatitis","kind":"diagnosis","aliases":["pancreatitis","epigastric pain","lipase","gallstone pancreatitis","alcoholic pancreatitis","necrotizing pancreatitis","pancreas inflammation","hypertriglyceridemia","amylase","bisap"],"opening":"The patient was evaluated for epigastric pain radiating to the back consistent with acute pancreatitis. The diagnosis was confirmed against criteria, an etiology was actively sought, severity was assessed, and the dangerous mimics and complications below — perforated viscus, mesenteric ischemia, ruptured aneurysm, and necrotizing pancreatitis with organ failure — were considered.","ddx":[{"id":"perforated-viscus","group":"lifethreat","label":"Perforated viscus","default":true,"tags":["perforated-viscus"],"ruleout":"Perforated viscus was considered; the abdomen was soft without rigidity, guarding, or rebound, the pain was not sudden-onset diffuse peritonitis, and there was no free air on imaging, making it unlikely.","miss":4},{"id":"mesenteric-ischemia","group":"lifethreat","label":"Mesenteric ischemia","default":true,"tags":["mesenteric-ischemia"],"ruleout":"Mesenteric ischemia was considered; the pain was not out of proportion to exam, there was no atrial fibrillation or vascular risk-driven sudden onset, no bloody stool, and the lactate was not elevated, making it unlikely.","miss":4},{"id":"necrosis-organ-failure","group":"lifethreat","label":"Necrotizing pancreatitis / organ failure","default":true,"tags":["necrosis-organ-failure"],"ruleout":"Necrotizing pancreatitis with organ failure was considered; the patient was hemodynamically stable without hypoxia, oliguria, or altered mentation, severity scoring was reassuring, and there were no peritoneal signs to suggest necrosis.","miss":4},{"id":"aaa","group":"lifethreat","label":"Ruptured abdominal aortic aneurysm","default":false,"tags":["aaa"],"ruleout":"Ruptured abdominal aortic aneurysm was considered; there was no pulsatile expansile abdominal mass, no tearing back or flank pain, the patient was hemodynamically stable with symmetric femoral pulses, making it unlikely.","miss":4},{"id":"inferior-mi-pancr","group":"lifethreat","label":"Inferior myocardial infarction","default":false,"tags":["inferior-mi-pancr"],"ruleout":"Inferior myocardial infarction was considered as a mimic of epigastric pain; there was no exertional or pressure-type chest discomfort, diaphoresis, or radiation, and the ECG showed no ischemic changes, making it unlikely.","miss":4},{"id":"gallstone-etiology","group":"common","label":"Gallstone etiology","default":false,"tags":["gallstone-etiology"],"ruleout":"A gallstone etiology was sought because it changes management; a right-upper-quadrant ultrasound and liver function tests were obtained to assess for stones and biliary obstruction.","miss":2},{"id":"metabolic-etiology","group":"common","label":"Alcohol / hypertriglyceridemia etiology","default":false,"tags":["metabolic-etiology"],"ruleout":"An alcohol-related or hypertriglyceridemic etiology was sought through the history and a triglyceride level, since identifying the cause directs treatment and prevention.","miss":2},{"id":"hypocalcemia","group":"other","label":"Hypocalcemia","default":false,"tags":["hypocalcemia"],"ruleout":"Hypocalcemia was considered as a metabolic complication and marker of severity; a calcium level was obtained as part of the laboratory evaluation.","miss":1}],"risk":[{"id":"lipase-test","label":"Lipase","tags":["necrosis-organ-failure"],"scale":"low","line":"A lipase was obtained to support the diagnosis of pancreatitis, recognizing the degree of elevation does not predict severity.","short":"Lipase"},{"id":"ruq-us-pan","label":"RUQ ultrasound","tags":["gallstone-etiology"],"scale":"low","line":"A right-upper-quadrant ultrasound was obtained to evaluate for gallstones as the etiology and for biliary obstruction.","short":"RUQ ultrasound"},{"id":"trig-calcium","label":"Triglycerides / calcium","tags":["metabolic-etiology","hypocalcemia"],"scale":"low","line":"Triglycerides and calcium were checked to identify a metabolic etiology and to detect hypocalcemia as a severity marker.","short":"Triglycerides / calcium"},{"id":"severity","label":"Severity assessment","tags":["necrosis-organ-failure"],"scale":"low","line":"A structured severity assessment incorporating mental status, systemic inflammatory response, age, fluid status, and end-organ markers was performed to risk-stratify and guide disposition.","short":"Severity score"},{"id":"ct-necrosis","label":"Contrast CT (when indicated)","tags":["necrosis-organ-failure","perforated-viscus","mesenteric-ischemia","aaa"],"scale":"low","line":"A contrast-enhanced CT was reserved for diagnostic uncertainty, clinical deterioration, or suspected necrosis, and also evaluates for perforation, ischemia, and aneurysm.","short":"Contrast CT"},{"id":"lactate-pan","label":"Lactate","tags":["mesenteric-ischemia"],"scale":"low","line":"A lactate was obtained to assess for hypoperfusion and to help evaluate for mesenteric ischemia as a mimic.","short":"Lactate"}],"checks":[{"if":"necrosis-organ-failure","needs":["severity"],"mode":"any","warn":"Necrotizing pancreatitis with organ failure is on the differential — documenting a structured severity assessment supports risk stratification and disposition."},{"if":"gallstone-etiology","needs":["ruq-us-pan"],"mode":"any","warn":"A gallstone etiology is on the differential — documenting an RUQ ultrasound avoids anchoring on lipase without seeking the cause."},{"if":"mesenteric-ischemia","needs":["lactate-pan","ct-necrosis"],"mode":"any","warn":"Mesenteric ischemia is on the differential — documenting a lactate and/or CT supports excluding this mimic."},{"if":"perforated-viscus","needs":["ct-necrosis"],"mode":"any","warn":"A perforated viscus can elevate lipase — documenting CT imaging supports excluding free air as the cause."}],"history":[{"id":"pa-hx-etiology","dx":"metabolic-etiology","q":"Alcohol use and history — recent heavy alcohol intake or known hypertriglyceridemia?","answers":[{"label":"No alcohol / lipid risk","tone":"neg","sets":[],"ddx":[],"mdm":"No recent heavy alcohol use or known lipid disorder was identified.","frag":"no alcohol / lipid risk"},{"label":"Heavy alcohol / high triglycerides","tone":"pos","sets":[],"ddx":[{"id":"metabolic-etiology","keep":true}],"mdm":"Recent heavy alcohol use or hypertriglyceridemia was reported, supporting a metabolic etiology for the pancreatitis.","frag":"alcohol / high triglycerides"}]},{"id":"pa-hx-gallstones","dx":"gallstone-etiology","q":"Any history of gallstones, prior biliary colic, or jaundice with this episode?","answers":[{"label":"No gallstone history","tone":"neg","sets":[],"ddx":[],"mdm":"No history of gallstones or biliary symptoms was reported.","frag":"no gallstone history"},{"label":"Gallstone history / jaundice","tone":"pos","sets":[],"ddx":[{"id":"gallstone-etiology","keep":true}],"mdm":"A history of gallstones or associated jaundice was reported, supporting a gallstone etiology.","frag":"gallstone history / jaundice"}]},{"id":"pa-hx-disproportion","dx":"mesenteric-ischemia","q":"Is the pain out of proportion to the exam, or are there vascular risk factors such as atrial fibrillation or known vascular disease?","answers":[{"label":"Pain proportionate, no vascular risk","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was proportionate to the examination and no major vascular risk factors were present.","frag":"no ischemia features"},{"label":"Pain out of proportion / vascular risk","tone":"pos","sets":[],"ddx":[{"id":"mesenteric-ischemia","keep":true}],"mdm":"Pain out of proportion to exam or significant vascular risk was present, prompting evaluation for mesenteric ischemia.","frag":"pain out of proportion / vascular risk"}]},{"id":"pa-hx-aaa","dx":"aaa","q":"Older age, known aneurysm, or tearing back/flank pain with the abdominal pain?","answers":[{"label":"No aneurysm risk","tone":"neg","sets":[],"ddx":[],"mdm":"No known aneurysm, tearing back pain, or high aneurysm risk was identified.","frag":"no aneurysm risk"},{"label":"Aneurysm risk / tearing pain","tone":"pos","sets":[],"ddx":[{"id":"aaa","keep":true}],"mdm":"Aneurysm risk factors or tearing back pain were present, prompting consideration of a ruptured abdominal aortic aneurysm.","frag":"aneurysm risk / tearing pain"}]},{"id":"pa-hx-severity","dx":"necrosis-organ-failure","q":"Persistent vomiting, decreased urine output, breathlessness, or confusion suggesting progression to organ dysfunction?","answers":[{"label":"No organ-dysfunction features","tone":"neg","sets":[],"ddx":[],"mdm":"No features of end-organ dysfunction were reported.","frag":"no organ-dysfunction features"},{"label":"Organ-dysfunction features","tone":"pos","sets":[],"ddx":[{"id":"necrosis-organ-failure","keep":true}],"mdm":"Features suggesting organ dysfunction were reported, raising concern for severe or necrotizing pancreatitis.","frag":"organ-dysfunction features"}]}],"exam":[{"id":"pa-exam-abdomen","dx":"perforated-viscus","q":"Abdominal examination — focal epigastric tenderness, or rigid/diffuse peritoneal signs?","answers":[{"label":"Epigastric tenderness only","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen showed epigastric tenderness without rigidity or diffuse peritoneal signs.","frag":"epigastric tenderness only"},{"label":"Rigid / peritoneal abdomen","tone":"pos","sets":[],"ddx":[{"id":"perforated-viscus","keep":true}],"mdm":"A rigid abdomen with diffuse peritoneal signs was present, concerning for a perforated viscus.","frag":"rigid / peritoneal abdomen"}]},{"id":"pa-exam-vitals","dx":"necrosis-organ-failure","q":"Vital signs and perfusion — tachycardia, hypotension, hypoxia, or systemic inflammatory response?","answers":[{"label":"Stable, no SIRS","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable, without tachycardia, hypotension, hypoxia, or a significant systemic inflammatory response.","frag":"stable, no SIRS"},{"label":"SIRS / hypotension / hypoxia","tone":"pos","sets":[],"ddx":[{"id":"necrosis-organ-failure","keep":true}],"mdm":"A systemic inflammatory response with hypotension or hypoxia was present, concerning for severe pancreatitis.","frag":"SIRS / hypotension / hypoxia"}]},{"id":"pa-exam-pulse","dx":"aaa","q":"Examination for a pulsatile abdominal mass or unequal femoral pulses?","answers":[{"label":"No pulsatile mass","tone":"neg","sets":[],"ddx":[],"mdm":"No pulsatile abdominal mass or pulse deficit was appreciated, noting palpation is only ~68% sensitive for AAA and cannot exclude one. Imaging thresholds were set by risk factors and the clinical picture.","frag":"no pulsatile mass or pulse deficit (palpation is only ~68% sensitive for AAA and cannot exclude one)"},{"label":"Pulsatile mass / pulse deficit","tone":"pos","sets":[],"ddx":[{"id":"aaa","keep":true}],"mdm":"A pulsatile abdominal mass or pulse deficit was appreciated, prompting evaluation for an abdominal aortic aneurysm.","frag":"pulsatile mass / pulse deficit"}]},{"answers":[{"ddx":[],"frag":"no exertional chest pain or ischemic ECG changes","label":"No cardiac-mimic features","mdm":"There was no exertional or pressure-type chest discomfort, diaphoresis, or radiation, and the ECG showed no ischemic changes, making inferior myocardial infarction unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"inferior-mi-pancr","keep":true}],"frag":"exertional chest discomfort or ischemic ECG changes","label":"Cardiac-mimic features present","mdm":"Exertional or pressure-type chest discomfort, diaphoresis, radiation, or ischemic ECG changes were present, raising concern for inferior myocardial infarction and warranting troponin and cardiology involvement.","sets":[],"tone":"pos"}],"dx":"inferior-mi-pancr","id":"pa-exam-inferior-mi-pancr","q":"Cardiac mimic — exertional or pressure-type chest discomfort, diaphoresis, radiation, or ischemic ECG changes?"}],"conclusions":["acute pancreatitis, mild, low-risk severity","gallstone pancreatitis pending biliary evaluation","alcohol-related acute pancreatitis"],"specs":["gi","surg"]},{"id":"diverticulitis","title":"Acute Diverticulitis","kind":"diagnosis","aliases":["diverticulitis","llq pain","left lower quadrant pain","diverticular disease","colonic abscess","diverticular abscess","perforated diverticulitis","diverticulosis","colon infection","interval colonoscopy"],"opening":"The patient was evaluated for left-lower-quadrant pain consistent with acute diverticulitis. The diagnosis was confirmed by imaging and the dangerous complications and mimics below — abscess or perforation, an underlying colon cancer, and gynecologic or vascular emergencies — were actively considered, with interval colonoscopy arranged where appropriate.","ddx":[{"id":"abscess-perforation","group":"lifethreat","label":"Abscess / perforation","default":true,"tags":["abscess-perforation"],"ruleout":"Abscess or perforation was considered; the abdomen lacked diffuse peritonitis, rigidity, or rebound, the patient was not septic-appearing, and imaging showed no drainable collection or free air, making it unlikely.","miss":4},{"id":"colon-cancer","group":"lifethreat","label":"Underlying colon cancer","default":true,"tags":["colon-cancer"],"ruleout":"Underlying colorectal malignancy was considered; there was no unintentional weight loss, iron-deficiency anemia, change in stool caliber, or rectal bleeding, and interval colonoscopy was arranged after resolution to exclude a masquerading cancer.","miss":3},{"id":"appendicitis-dv","group":"common","label":"Appendicitis (incl. right-sided)","default":false,"tags":["appendicitis-dv"],"ruleout":"Appendicitis was considered, particularly with right-sided or atypical pain, and was assessed on CT and by the location and migration of the pain.","miss":2},{"id":"gyn-pathology","group":"lifethreat","label":"Ovarian / gynecologic pathology","default":false,"tags":["gyn-pathology"],"ruleout":"Ovarian torsion or other gynecologic pathology was considered; the pregnancy test was negative, there was no sudden severe unilateral adnexal pain or palpable adnexal mass, and the pain localized to the colon rather than the pelvis.","miss":3,"sex":"f"},{"id":"ibd","group":"common","label":"Inflammatory bowel disease","default":false,"tags":["ibd"],"ruleout":"Inflammatory bowel disease was considered as a cause of left-sided pain with diarrhea or bleeding, and the history and inflammatory markers were reviewed with outpatient evaluation arranged.","miss":2},{"id":"aaa-dv","group":"lifethreat","label":"Abdominal aortic aneurysm","default":false,"tags":["aaa-dv"],"ruleout":"Ruptured abdominal aortic aneurysm was considered; there was no pulsatile expansile abdominal mass or tearing back pain, the patient was hemodynamically stable with symmetric femoral pulses, making it unlikely.","miss":4}],"risk":[{"id":"ct-ap","label":"CT abdomen/pelvis with contrast","tags":["abscess-perforation","colon-cancer","appendicitis-dv","aaa-dv"],"scale":"low","line":"A CT of the abdomen and pelvis with contrast was obtained to confirm diverticulitis and to evaluate for abscess, perforation, an obstructing mass, appendicitis, and aneurysm.","short":"CT abd/pelvis"},{"id":"wbc-crp","label":"WBC / CRP","tags":["abscess-perforation","ibd"],"scale":"low","line":"A white-cell count and inflammatory markers were obtained to gauge the severity of inflammation and support the assessment.","short":"WBC / CRP"},{"id":"preg-test-dv","label":"Pregnancy test","tags":["gyn-pathology"],"scale":"low","line":"A pregnancy test was obtained in patients of reproductive potential before imaging and to address gynecologic causes.","short":"Pregnancy test"},{"id":"colonoscopy","label":"Interval colonoscopy arranged","tags":["colon-cancer"],"scale":"low","line":"Interval colonoscopy after resolution was arranged to exclude an underlying colorectal malignancy.","short":"Interval colonoscopy"},{"id":"abd-exam-dv","label":"Abdominal exam","tags":["abscess-perforation"],"scale":"low","line":"The abdomen was examined for localized versus diffuse peritoneal signs to detect a complicated, perforated course.","short":"Abdominal exam"}],"checks":[{"if":"abscess-perforation","needs":["ct-ap","abd-exam-dv"],"mode":"any","warn":"Abscess or perforation is on the differential — documenting the CT and abdominal exam supports detection of a drainable or surgical complication."},{"if":"colon-cancer","needs":["colonoscopy"],"mode":"any","warn":"An underlying cancer can masquerade as diverticulitis — documenting arranged interval colonoscopy supports the plan to exclude malignancy."},{"if":"gyn-pathology","needs":["preg-test-dv"],"mode":"any","warn":"Gynecologic pathology is on the differential — documenting a pregnancy test supports the workup in patients of reproductive potential."}],"history":[{"id":"dv-hx-pain","dx":"general","q":"Character and location of pain — left-lower-quadrant pain with change in bowel habit, and any prior diverticulitis?","answers":[{"label":"Typical LLQ pain, prior episodes","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was typical left-lower-quadrant pain consistent with diverticulitis, similar to prior episodes.","frag":"typical LLQ pain"},{"label":"Atypical / right-sided pain","tone":"pos","sets":[],"ddx":[{"id":"appendicitis-dv","keep":true}],"mdm":"The pain was atypical or right-sided, broadening the differential to include appendicitis and other causes.","frag":"atypical / right-sided pain"}]},{"id":"dv-hx-systemic","dx":"abscess-perforation","q":"High fevers, rigors, or worsening diffuse abdominal pain suggesting abscess or perforation?","answers":[{"label":"No high fever / diffuse pain","tone":"neg","sets":[],"ddx":[],"mdm":"No high fevers or diffuse worsening pain to suggest a complicated course were reported.","frag":"no complicated features"},{"label":"High fever / diffuse pain","tone":"pos","sets":[],"ddx":[{"id":"abscess-perforation","keep":true}],"mdm":"High fevers or diffuse worsening pain were reported, raising concern for an abscess or perforation.","frag":"high fever / diffuse pain"}]},{"id":"dv-hx-cancer","dx":"colon-cancer","q":"Unintentional weight loss, rectal bleeding, change in stool caliber, or no recent colonoscopy?","answers":[{"label":"No red-flag features","tone":"neg","sets":[],"ddx":[],"mdm":"No weight loss, rectal bleeding, or change in stool caliber to suggest malignancy were reported.","frag":"no cancer red flags"},{"label":"Weight loss / bleeding / caliber change","tone":"pos","sets":[],"ddx":[{"id":"colon-cancer","keep":true}],"mdm":"Weight loss, rectal bleeding, or change in stool caliber was reported, raising concern for an underlying malignancy and reinforcing the need for interval colonoscopy.","frag":"weight loss / bleeding / caliber change"}]},{"id":"dv-hx-gyn","dx":"gyn-pathology","q":"In patients of reproductive potential — missed menses, vaginal bleeding, or sudden severe pelvic pain?","answers":[{"label":"No gynecologic features","tone":"neg","sets":[],"ddx":[],"mdm":"No missed menses, vaginal bleeding, or sudden pelvic pain to suggest a gynecologic cause were reported.","frag":"no gynecologic features"},{"label":"Gynecologic features","tone":"pos","sets":[],"ddx":[{"id":"gyn-pathology","keep":true}],"mdm":"Gynecologic features (missed menses, vaginal bleeding, or sudden severe pelvic pain) were reported, prompting a pregnancy test and consideration of ovarian or adnexal pathology.","frag":"gynecologic features"}]},{"id":"dv-hx-immuno","dx":"ibd","q":"Chronic diarrhea, blood or mucus in the stool, or young age suggesting inflammatory bowel disease?","answers":[{"label":"No IBD features","tone":"neg","sets":[],"ddx":[],"mdm":"No chronic diarrhea or bloody stools to suggest inflammatory bowel disease were reported.","frag":"no IBD features"},{"label":"Chronic diarrhea / bloody stool","tone":"pos","sets":[],"ddx":[{"id":"ibd","keep":true}],"mdm":"Chronic diarrhea or bloody stools were reported, keeping inflammatory bowel disease on the differential with outpatient evaluation arranged.","frag":"chronic diarrhea / bloody stool"}]}],"exam":[{"id":"dv-exam-abdomen","dx":"abscess-perforation","q":"Abdominal examination — localized LLQ tenderness, or diffuse peritoneal signs?","answers":[{"label":"Localized LLQ tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen showed localized left-lower-quadrant tenderness without diffuse peritoneal signs.","frag":"localized LLQ tenderness"},{"label":"Diffuse peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"abscess-perforation","keep":true}],"mdm":"Diffuse peritoneal signs were present, concerning for perforation or a complicated abscess.","frag":"diffuse peritoneal signs"}]},{"id":"dv-exam-vitals","dx":"abscess-perforation","q":"Vital signs — fever, tachycardia, or hypotension suggesting systemic involvement?","answers":[{"label":"Afebrile, stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was afebrile and hemodynamically stable, without tachycardia or hypotension to suggest systemic involvement.","frag":"afebrile, stable"},{"label":"Fever / tachycardia / hypotension","tone":"pos","sets":[],"ddx":[{"id":"abscess-perforation","keep":true}],"mdm":"Fever, tachycardia, or hypotension was present, concerning for a complicated, septic course.","frag":"fever / tachycardia / hypotension"}]},{"id":"dv-exam-ct","dx":"colon-cancer","q":"CT findings — uncomplicated diverticulitis, or a mass, abscess, or free air?","answers":[{"label":"Uncomplicated inflammation","tone":"neg","sets":[],"ddx":[],"mdm":"CT showed uncomplicated sigmoid inflammation without abscess, free air, or a mass.","frag":"uncomplicated diverticulitis on CT"},{"label":"Mass / abscess / free air","tone":"pos","sets":[],"ddx":[{"id":"colon-cancer","keep":true},{"id":"abscess-perforation","keep":true}],"mdm":"CT showed a mass, abscess, or free air, raising concern for a complicated course or an underlying malignancy.","frag":"mass / abscess / free air on CT"}]},{"answers":[{"ddx":[],"frag":"no pulsatile mass or tearing back pain, pulses symmetric (palpation is only ~68% sensitive for AAA and cannot exclude one)","label":"No AAA features","mdm":"There was no tearing back pain and the patient was hemodynamically stable with symmetric femoral pulses; no pulsatile expansile mass was palpated, noting palpation is only ~68% sensitive for AAA and cannot exclude one. Imaging thresholds were set by risk factors and the clinical picture.","sets":[],"tone":"neg"},{"ddx":[{"id":"aaa-dv","keep":true}],"frag":"pulsatile expansile mass or tearing back pain","label":"AAA features present","mdm":"A pulsatile expansile abdominal mass, tearing back pain, or asymmetric femoral pulses was present, raising concern for a ruptured abdominal aortic aneurysm and warranting immediate imaging.","sets":[],"tone":"pos"}],"dx":"aaa-dv","id":"dv-exam-aaa-dv","q":"AAA — a pulsatile expansile abdominal mass, tearing back pain, or asymmetric femoral pulses?"}],"conclusions":["acute uncomplicated diverticulitis, tolerating PO","acute diverticulitis for outpatient management with interval colonoscopy","complicated diverticulitis requiring admission"],"specs":["surg","gi"]},{"id":"small-bowel-obstruction","title":"Small-Bowel Obstruction","kind":"diagnosis","aliases":["sbo","small bowel obstruction","bowel obstruction","obstruction","ileus","incarcerated hernia","adhesions","closed loop","strangulation","abdominal distension"],"opening":"The patient was evaluated for crampy abdominal pain, distension, and vomiting consistent with a small-bowel obstruction. The diagnosis was confirmed by imaging and the dangerous complications and mimics below — strangulation or ischemia, an incarcerated hernia, perforation, and a large-bowel process — were actively considered, with surgical involvement as indicated.","ddx":[{"id":"strangulation","group":"lifethreat","label":"Strangulation / closed-loop ischemia","default":true,"tags":["strangulation"],"ruleout":"Strangulation or closed-loop ischemia was considered; there was no pain out of proportion, fever, tachycardia, or peritoneal signs, the lactate was normal, and imaging showed no closed loop or compromised bowel, making it unlikely.","miss":4},{"id":"incarcerated-hernia","group":"lifethreat","label":"Incarcerated hernia","default":true,"tags":["incarcerated-hernia"],"ruleout":"Incarcerated hernia was considered; examination of the groin, umbilicus, and surgical scars revealed no tender or irreducible bulge, and imaging showed no hernia as the transition point, making it unlikely.","miss":4},{"id":"perforation-sbo","group":"lifethreat","label":"Perforation","default":true,"tags":["perforation-sbo"],"ruleout":"Perforation was considered; the abdomen lacked rigidity, rebound, or diffuse peritonitis, the patient was hemodynamically stable, and imaging showed no free intraperitoneal air, making it unlikely.","miss":4},{"id":"large-bowel-obstruction-sbo","group":"lifethreat","label":"Large-bowel obstruction / volvulus","default":false,"tags":["large-bowel-obstruction-sbo"],"ruleout":"Large-bowel obstruction or volvulus was considered; imaging localized the transition point to the small bowel without colonic dilation or a coffee-bean sigmoid loop, and there was no marked abdominal distension with obstipation suggesting a distal cause.","miss":4},{"id":"lbo-volvulus","group":"common","label":"Large-bowel obstruction / volvulus","default":false,"tags":["lbo-volvulus"],"ruleout":"A large-bowel obstruction or volvulus was considered as an alternative pattern; the transition point and colonic caliber were reviewed on CT to localize the level of obstruction.","miss":4},{"id":"ileus","group":"common","label":"Ileus","default":false,"tags":["ileus"],"ruleout":"An ileus was considered as a mimic, distinguished from mechanical obstruction by the absence of a discrete transition point on imaging and the clinical context of recent surgery, electrolyte derangement, or medications.","miss":2},{"id":"malignancy-sbo","group":"other","label":"Obstructing malignancy","default":false,"tags":["malignancy-sbo"],"ruleout":"An obstructing malignancy was considered as the underlying cause, particularly without prior surgery or hernia, and CT was reviewed for a mass at the transition point with appropriate follow-up arranged.","miss":1}],"risk":[{"id":"ct-ap-sbo","label":"CT abdomen/pelvis","tags":["strangulation","lbo-volvulus","ileus","malignancy-sbo","perforation-sbo"],"scale":"low","line":"A CT of the abdomen and pelvis was obtained to confirm obstruction, identify the transition point and cause, and assess for closed-loop configuration, ischemia, or free air.","short":"CT abd/pelvis"},{"id":"lactate-sbo","label":"Lactate","tags":["strangulation"],"scale":"low","line":"A lactate was obtained to help detect bowel ischemia from strangulation or a closed-loop obstruction.","short":"Lactate"},{"id":"hernia-exam","label":"Hernia / scar exam","tags":["incarcerated-hernia"],"scale":"low","line":"The groin, umbilicus, and prior surgical scars were examined for an incarcerated hernia as the obstructing lesion.","short":"Hernia / scar exam"},{"id":"electrolytes-sbo","label":"Electrolytes","tags":["ileus"],"scale":"low","line":"Electrolytes were checked to assess for derangements that cause or worsen ileus and to guide resuscitation.","short":"Electrolytes"},{"id":"surg-consult","label":"Surgical consult","tags":["strangulation","incarcerated-hernia","perforation-sbo"],"scale":"low","line":"Surgical consultation was obtained for evidence of strangulation, incarceration, perforation, or a high-grade or failing obstruction.","short":"Surgical consult"},{"id":"abd-exam-sbo","label":"Abdominal exam","tags":["strangulation","perforation-sbo"],"scale":"low","line":"The abdomen was examined for distension, pain out of proportion, and peritoneal signs suggesting ischemia or perforation.","short":"Abdominal exam"}],"checks":[{"if":"strangulation","needs":["lactate-sbo","ct-ap-sbo","surg-consult"],"mode":"any","warn":"Closed-loop or strangulating obstruction is on the differential — documenting a lactate, the CT, and surgical involvement supports detection of ischemic bowel and pain out of proportion."},{"if":"incarcerated-hernia","needs":["hernia-exam"],"mode":"any","warn":"An incarcerated hernia is on the differential — documenting a hernia and scar exam supports the search for the obstructing lesion."},{"if":"ileus","needs":["ct-ap-sbo","electrolytes-sbo"],"mode":"any","warn":"Ileus can be mistaken for SBO — documenting the CT transition point and electrolytes supports distinguishing mechanical obstruction from ileus."},{"if":"perforation-sbo","needs":["abd-exam-sbo","ct-ap-sbo"],"mode":"any","warn":"Perforation is on the differential — documenting the abdominal exam and CT supports detection of free air and peritonitis."}],"history":[{"id":"sbo-hx-surgery","dx":"general","q":"Prior abdominal surgery, known hernia, or prior obstruction (the common causes)?","answers":[{"label":"Prior surgery / known adhesions","tone":"neg","sets":[],"ddx":[],"mdm":"A history of prior abdominal surgery or adhesions consistent with the usual cause of obstruction was reported.","frag":"prior surgery / adhesions"},{"label":"No prior surgery or hernia","tone":"pos","sets":[],"ddx":[{"id":"malignancy-sbo","keep":true}],"mdm":"No prior surgery or known hernia was reported, broadening consideration to an obstructing malignancy or other structural cause.","frag":"no prior surgery or hernia"}]},{"id":"sbo-hx-pain","dx":"strangulation","q":"Has the pain changed from crampy and intermittent to constant and severe, or out of proportion to the exam?","answers":[{"label":"Crampy, intermittent pain","tone":"neg","sets":[],"ddx":[],"mdm":"The pain remained crampy and intermittent without progression to constant severe pain.","frag":"crampy intermittent pain"},{"label":"Constant / out-of-proportion pain","tone":"pos","sets":[],"ddx":[{"id":"strangulation","keep":true}],"mdm":"The pain became constant, severe, or out of proportion to the exam, concerning for strangulation or ischemia.","frag":"constant / out-of-proportion pain"}]},{"id":"sbo-hx-hernia","dx":"incarcerated-hernia","q":"A new or enlarging, painful, or irreducible bulge in the groin or at a prior scar?","answers":[{"label":"No bulge reported","tone":"neg","sets":[],"ddx":[],"mdm":"No painful or irreducible bulge was reported.","frag":"no bulge reported"},{"label":"Painful / irreducible bulge","tone":"pos","sets":[],"ddx":[{"id":"incarcerated-hernia","keep":true}],"mdm":"A painful or irreducible bulge was reported, concerning for an incarcerated hernia as the obstructing lesion.","frag":"painful / irreducible bulge"}]},{"id":"sbo-hx-passage","dx":"ileus","q":"Is the patient still passing flatus or stool, and is there a recent surgery, medication, or metabolic cause to suggest ileus rather than mechanical obstruction?","answers":[{"label":"Obstipation, mechanical picture","tone":"neg","sets":[],"ddx":[],"mdm":"The patient reported obstipation with a clinical picture consistent with mechanical obstruction.","frag":"obstipation, mechanical picture"},{"label":"Ileus context present","tone":"pos","sets":[],"ddx":[{"id":"ileus","keep":true}],"mdm":"A recent surgery, medication, or metabolic context suggesting ileus was present, prompting distinction from mechanical obstruction.","frag":"ileus context"}]}],"exam":[{"id":"sbo-exam-abdomen","dx":"strangulation","q":"Abdominal examination — distension with tenderness only, or peritoneal signs and pain out of proportion?","answers":[{"label":"Distended but soft","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen was distended but soft without peritoneal signs.","frag":"distended but soft"},{"label":"Peritoneal signs / disproportion","tone":"pos","sets":[],"ddx":[{"id":"strangulation","keep":true},{"id":"perforation-sbo","keep":true}],"mdm":"Peritoneal signs or pain out of proportion were present, concerning for strangulation or perforation.","frag":"peritoneal signs / disproportion"}]},{"id":"sbo-exam-hernia","dx":"incarcerated-hernia","q":"Examination of the groin, umbilicus, and scars — a reducible defect, or a tender irreducible hernia?","answers":[{"label":"No incarcerated hernia","tone":"neg","sets":[],"ddx":[],"mdm":"Examination of the hernia sites and scars showed no tender or irreducible hernia.","frag":"no incarcerated hernia"},{"label":"Tender / irreducible hernia","tone":"pos","sets":[],"ddx":[{"id":"incarcerated-hernia","keep":true}],"mdm":"A tender, irreducible hernia was found on examination, identifying the likely obstructing and strangulating lesion.","frag":"tender / irreducible hernia"}]},{"id":"sbo-exam-ct","dx":"lbo-volvulus","q":"CT findings — a small-bowel transition point, or features of a large-bowel obstruction, volvulus, or closed loop?","answers":[{"label":"SBO transition, viable bowel","tone":"neg","sets":[],"ddx":[],"mdm":"CT showed a small-bowel transition point with viable-appearing bowel and no closed loop.","frag":"SBO transition, viable bowel"},{"label":"LBO / volvulus / closed loop","tone":"pos","sets":[],"ddx":[{"id":"lbo-volvulus","keep":true},{"id":"strangulation","keep":true}],"mdm":"CT showed a large-bowel obstruction, volvulus, or closed-loop configuration, changing the urgency and management.","frag":"LBO / volvulus / closed loop"}]}],"conclusions":["small-bowel obstruction, likely adhesive, no signs of strangulation","partial small-bowel obstruction for conservative management","high-grade small-bowel obstruction requiring surgical evaluation"],"specs":["surg","gi"]},{"id":"appendicitis","title":"Acute Appendicitis","kind":"diagnosis","aliases":["appendicitis","appendix","rlq pain","right lower quadrant pain","appendiceal","ruptured appendix","mcburney","perforated appendix","belly pain","appy"],"opening":"The patient was evaluated for right-lower-quadrant pain consistent with acute appendicitis. Clinical scoring and imaging were used to assess the likelihood, a pregnancy test was obtained where applicable, and the dangerous complications and mimics below — perforation or abscess, ectopic pregnancy, ovarian torsion, and atypical presentations — were actively considered.","ddx":[{"id":"perforation-app","group":"lifethreat","label":"Perforation / abscess","default":true,"tags":["perforation-app"],"ruleout":"Perforation or abscess was considered; symptoms were of short duration without prolonged fever, the patient was not toxic-appearing, the abdomen showed localized rather than diffuse peritonitis, and imaging showed no walled-off collection.","miss":4},{"id":"ectopic-app","group":"lifethreat","label":"Ectopic pregnancy","default":true,"tags":["ectopic-app"],"ruleout":"Ectopic pregnancy was considered; the pregnancy test was negative, excluding it as a cause of the lower abdominal pain in this patient of reproductive potential.","miss":4,"sex":"f"},{"id":"torsion-app","group":"lifethreat","label":"Ovarian torsion","default":false,"tags":["torsion-app"],"ruleout":"Ovarian torsion was considered; there was no sudden severe unilateral pelvic pain with nausea, no palpable adnexal mass, and pelvic ultrasound with Doppler showed preserved ovarian flow, making it unlikely.","miss":4,"sex":"f"},{"id":"testicular-torsion-app","group":"lifethreat","label":"Testicular torsion","default":false,"tags":["testicular-torsion-app"],"ruleout":"Testicular torsion was considered in the male patient with lower abdominal pain; the testes were non-tender and normally positioned with intact cremasteric reflexes and no scrotal swelling, making it unlikely.","miss":4,"sex":"m"},{"id":"mesenteric-adenitis","group":"common","label":"Mesenteric adenitis","default":false,"tags":["mesenteric-adenitis"],"ruleout":"Mesenteric adenitis was considered, particularly in younger patients with a recent viral illness, as a self-limited mimic distinguished on imaging from appendicitis.","miss":4},{"id":"crohn-ileitis","group":"common","label":"Crohn / terminal ileitis","default":false,"tags":["crohn-ileitis"],"ruleout":"Crohn disease or terminal ileitis was considered as a cause of right-lower-quadrant pain with diarrhea or weight loss and was assessed on imaging and history.","miss":2},{"id":"ureteral-colic","group":"other","label":"Ureteral colic","default":false,"tags":["ureteral-colic"],"ruleout":"Ureteral colic was considered as a mimic with flank-to-groin pain and hematuria and was assessed by urinalysis and imaging as needed.","miss":1}],"risk":[{"id":"preg-test-app","label":"Pregnancy test","tags":["ectopic-app"],"scale":"low","line":"A pregnancy test was obtained in patients of reproductive potential to exclude ectopic pregnancy and guide the choice of imaging.","short":"Pregnancy test"},{"id":"imaging-app","label":"CT or ultrasound","tags":["perforation-app","torsion-app","mesenteric-adenitis","crohn-ileitis"],"scale":"low","line":"Imaging was obtained (ultrasound first in younger or pregnant patients and CT when needed); to confirm appendicitis and assess for perforation, abscess, or an alternative cause.","short":"CT / ultrasound"},{"id":"wbc-app","label":"WBC / inflammatory markers","tags":["perforation-app"],"scale":"low","line":"A white-cell count and inflammatory markers were obtained to support the assessment and gauge the likelihood and severity.","short":"WBC"},{"id":"scoring-app","label":"Clinical scoring","tags":["perforation-app"],"scale":"low","line":"A clinical scoring approach combining migration of pain, right-lower-quadrant tenderness, anorexia, fever, and white count was applied to risk-stratify and guide imaging.","short":"Clinical score"},{"id":"ua-app","label":"Urinalysis","tags":["ureteral-colic"],"scale":"low","line":"A urinalysis was obtained to assess for hematuria suggesting ureteral colic and for a urinary source of pain.","short":"Urinalysis"},{"id":"pelvic-doppler","label":"Pelvic ultrasound w/ Doppler","tags":["torsion-app","ectopic-app"],"scale":"low","line":"A pelvic ultrasound with Doppler was obtained in patients of reproductive potential to assess for torsion and adnexal pathology.","short":"Pelvic US Doppler"}],"checks":[{"if":"ectopic-app","needs":["preg-test-app"],"mode":"any","warn":"Ectopic pregnancy is on the differential — documenting a pregnancy test prevents the classic omission in right-lower-quadrant pain."},{"if":"perforation-app","needs":["imaging-app","scoring-app"],"mode":"any","warn":"Perforation or abscess is on the differential — documenting imaging and clinical scoring guards against anchoring early before complications develop."},{"if":"torsion-app","needs":["pelvic-doppler"],"mode":"any","warn":"Ovarian torsion can mimic appendicitis — documenting a pelvic ultrasound with Doppler supports the assessment in women."},{"if":"ureteral-colic","needs":["ua-app"],"mode":"any","warn":"Ureteral colic is on the differential — documenting a urinalysis supports consideration of a urinary cause."}],"history":[{"id":"app-hx-migration","dx":"general","q":"Pattern of pain — periumbilical pain that migrated to the right lower quadrant with anorexia?","answers":[{"label":"Classic migration / anorexia","tone":"neg","sets":[],"ddx":[],"mdm":"The history showed classic periumbilical pain migrating to the right lower quadrant with anorexia, consistent with appendicitis.","frag":"classic migration / anorexia"},{"label":"Atypical / non-migratory pain","tone":"pos","sets":[],"ddx":[{"id":"perforation-app","keep":true}],"mdm":"The pain pattern was atypical or non-migratory, lowering the reliability of the clinical picture and warranting imaging, with attention to retrocecal or pregnant presentations.","frag":"atypical / non-migratory pain"}]},{"id":"app-hx-duration","dx":"perforation-app","q":"Duration of symptoms beyond a couple of days, or transient relief followed by worsening diffuse pain (suggesting perforation)?","answers":[{"label":"Short duration, localized","tone":"neg","sets":[],"ddx":[],"mdm":"Symptoms were of short duration and remained localized without features of perforation.","frag":"short duration, localized"},{"label":"Prolonged / relief then worse","tone":"pos","sets":[],"ddx":[{"id":"perforation-app","keep":true}],"mdm":"Prolonged symptoms or transient relief followed by worsening diffuse pain were reported, concerning for perforation.","frag":"prolonged / relief then worse"}]},{"id":"app-hx-gyn","dx":"ectopic-app","q":"In patients of reproductive potential — missed or late menses, vaginal bleeding, or risk factors for ectopic pregnancy?","answers":[{"label":"No pregnancy / gyn features","tone":"neg","sets":[],"ddx":[],"mdm":"No missed menses, vaginal bleeding, or ectopic risk factors were reported.","frag":"no gyn features"},{"label":"Missed menses / ectopic risk","tone":"pos","sets":[],"ddx":[{"id":"ectopic-app","keep":true}],"mdm":"Missed menses or ectopic risk factors were reported, prompting a pregnancy test and pelvic evaluation.","frag":"missed menses / ectopic risk"}]},{"id":"app-hx-torsion","dx":"torsion-app","q":"Sudden, severe, intermittent pelvic pain with nausea suggesting ovarian torsion?","answers":[{"label":"No torsion features","tone":"neg","sets":[],"ddx":[],"mdm":"No sudden severe intermittent pelvic pain to suggest ovarian torsion was reported.","frag":"no torsion features"},{"label":"Sudden severe pelvic pain","tone":"pos","sets":[],"ddx":[{"id":"torsion-app","keep":true}],"mdm":"Sudden, severe, intermittent pelvic pain with nausea was reported, prompting evaluation for ovarian torsion.","frag":"sudden severe pelvic pain"}]},{"id":"app-hx-gi","dx":"crohn-ileitis","q":"Chronic diarrhea, weight loss, or prior gastrointestinal disease suggesting Crohn or terminal ileitis?","answers":[{"label":"No chronic GI features","tone":"neg","sets":[],"ddx":[],"mdm":"No chronic diarrhea or weight loss to suggest inflammatory bowel disease was reported.","frag":"no chronic GI features"},{"label":"Chronic diarrhea / weight loss","tone":"pos","sets":[],"ddx":[{"id":"crohn-ileitis","keep":true}],"mdm":"Chronic diarrhea or weight loss was reported, keeping Crohn disease or terminal ileitis on the differential.","frag":"chronic diarrhea / weight loss"}]}],"exam":[{"id":"app-exam-rlq","dx":"perforation-app","q":"Abdominal examination — focal RLQ tenderness at McBurney point, or diffuse peritoneal signs?","answers":[{"label":"Focal RLQ tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen showed focal right-lower-quadrant tenderness without diffuse peritoneal signs.","frag":"focal RLQ tenderness"},{"label":"Diffuse peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"perforation-app","keep":true}],"mdm":"Diffuse peritoneal signs were present, concerning for a perforated appendix.","frag":"diffuse peritoneal signs"}]},{"id":"app-exam-vitals","dx":"perforation-app","q":"Vital signs — fever and tachycardia suggesting a complicated or perforated course?","answers":[{"label":"Afebrile, stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was afebrile and hemodynamically stable.","frag":"afebrile, stable"},{"label":"Fever / tachycardia","tone":"pos","sets":[],"ddx":[{"id":"perforation-app","keep":true}],"mdm":"Fever and tachycardia were present, raising concern for a complicated or perforated appendicitis.","frag":"fever / tachycardia"}]},{"id":"app-exam-imaging","dx":"ectopic-app","q":"Imaging — an inflamed appendix confirmed, or pelvic findings such as an adnexal mass or free fluid?","answers":[{"label":"Inflamed appendix, no pelvic findings","tone":"neg","sets":[],"ddx":[],"mdm":"Imaging confirmed an inflamed appendix without concerning pelvic findings.","frag":"appendicitis confirmed on imaging"},{"label":"Adnexal mass / free fluid","tone":"pos","sets":[],"ddx":[{"id":"ectopic-app","keep":true},{"id":"torsion-app","keep":true}],"mdm":"Imaging showed an adnexal mass or free fluid, prompting evaluation for ectopic pregnancy or ovarian torsion.","frag":"adnexal mass / free fluid"}]},{"answers":[{"ddx":[],"frag":"testes non-tender with an intact cremasteric reflex (a present cremasteric does not exclude torsion, so Doppler and urology carried any persistent suspicion)","label":"No torsion signs","mdm":"The testes were non-tender and normally positioned with intact cremasteric reflexes and no scrotal swelling. Because a present cremasteric reflex does not exclude torsion, persistent suspicion was addressed with Doppler ultrasound and urologic evaluation rather than the reflex alone.","sets":[],"tone":"neg"},{"ddx":[{"id":"testicular-torsion-app","keep":true}],"frag":"scrotal pain with high-riding testis or absent cremasteric reflex","label":"Torsion signs present","mdm":"Scrotal pain or swelling, a high-riding or transverse testis, or an absent cremasteric reflex was present, raising concern for testicular torsion and warranting emergent Doppler and urology.","sets":[],"tone":"pos"}],"dx":"testicular-torsion-app","id":"app-exam-testicular-torsion-app","q":"Testicular torsion — scrotal pain or swelling, a high-riding or transverse testis, or an absent cremasteric reflex (male patient)?"}],"conclusions":["acute uncomplicated appendicitis","acute appendicitis with concern for perforation","right-lower-quadrant pain, appendicitis excluded by imaging"],"specs":["surg","gi"]},{"id":"hyperemesis-gravidarum","title":"Hyperemesis Gravidarum","kind":"diagnosis","aliases":["hyperemesis","hyperemesis gravidarum","hg","severe morning sickness","pregnancy vomiting","nausea and vomiting of pregnancy","nvp","intractable vomiting pregnancy","dehydration pregnancy","ketosis pregnancy","puqe"],"opening":"A pregnant patient with persistent nausea and vomiting was evaluated for hyperemesis gravidarum. Rather than anchoring on routine morning sickness, dangerous mimics and complications — molar or multiple gestation, diabetic ketoacidosis, thyrotoxicosis, Wernicke encephalopathy, non-obstetric causes of vomiting, and severe dehydration with electrolyte derangement — were actively considered.","ddx":[{"id":"dka","group":"lifethreat","label":"Diabetic ketoacidosis","default":true,"tags":["dka"],"ruleout":"Diabetic ketoacidosis was considered given it can occur euglycemically in pregnancy; the glucose was not markedly elevated, there was no anion-gap metabolic acidosis, and serum or urine ketones were not significant, making it unlikely.","miss":4},{"id":"wernicke","group":"lifethreat","label":"Wernicke encephalopathy (thiamine deficiency)","default":true,"tags":["wernicke"],"ruleout":"Wernicke encephalopathy was considered given prolonged vomiting; there was no confusion, ophthalmoplegia or nystagmus, or gait ataxia, and thiamine was administered before any dextrose-containing fluids, making it unlikely.","miss":4},{"id":"molar-multiple","group":"lifethreat","label":"Molar or multiple gestation","default":true,"tags":["molar-multiple"],"ruleout":"Molar or multiple gestation was considered; pelvic ultrasound confirmed a singleton intrauterine pregnancy with no molar features or snowstorm appearance and hCG was congruent with gestational age, making it unlikely.","miss":3},{"id":"thyrotoxicosis","group":"other","label":"hCG-mediated thyrotoxicosis","default":false,"tags":["thyrotoxicosis"],"ruleout":"Gestational hCG-mediated thyrotoxicosis was considered as a contributor to vomiting; there were no clinical features of thyroid storm, and thyroid studies were obtained where indicated.","miss":1},{"id":"surgical-abdomen","group":"lifethreat","label":"Appendicitis / cholecystitis / pancreatitis / obstruction","default":false,"tags":["surgical-abdomen"],"ruleout":"A non-obstetric surgical cause such as appendicitis, cholecystitis, pancreatitis, or obstruction was considered; there was no localized or progressive abdominal pain, peritoneal sign, fever, or abnormal bowel pattern, making it unlikely.","miss":3},{"id":"pyelo-uti","group":"common","label":"Pyelonephritis / UTI","default":false,"tags":["pyelo-uti"],"ruleout":"Urinary tract infection or pyelonephritis as a precipitant of vomiting was considered; urinalysis was reviewed and there were no flank pain, fevers, or pyuria to suggest it.","miss":2},{"id":"dehydration-lytes","group":"common","label":"Severe dehydration / electrolyte derangement","default":true,"tags":["dehydration-lytes"],"ruleout":"Severe dehydration with ketosis and electrolyte derangement, particularly hypokalemia, was assessed with electrolytes, renal function, and urine ketones, and corrected with rehydration as needed.","miss":2}],"risk":[{"id":"hcg-quant","label":"Pregnancy test / quantitative hCG","tags":["molar-multiple"],"scale":"low","line":"A quantitative hCG was obtained and interpreted in the context of dating and the ultrasound to flag a disproportionately elevated value.","short":"Quantitative hCG"},{"id":"pelvic-us-hg","label":"Pelvic ultrasound","tags":["molar-multiple"],"scale":"low","line":"A pelvic ultrasound confirmed a viable intrauterine pregnancy, established the number of gestations, and excluded a molar pregnancy.","short":"Pelvic ultrasound"},{"id":"ua-ketones","label":"Urinalysis (ketones, infection)","tags":["dehydration-lytes","pyelo-uti"],"scale":"low","line":"A urinalysis was reviewed for ketones reflecting starvation, and for pyuria or nitrites suggesting a urinary source.","short":"Urinalysis"},{"id":"lytes-renal","label":"Electrolytes / renal function / glucose","tags":["dehydration-lytes","dka"],"scale":"low","line":"Electrolytes, renal function, glucose, and an anion gap were obtained to detect hypokalemia, a contraction picture, and ketoacidosis.","short":"Electrolytes / glucose"},{"id":"thyroid-studies","label":"Thyroid studies (if indicated)","tags":["thyrotoxicosis"],"scale":"low","line":"Thyroid studies were obtained where clinically indicated to assess for hCG-mediated thyrotoxicosis.","short":"Thyroid studies"},{"id":"thiamine-first","label":"Thiamine before dextrose","tags":["wernicke"],"scale":"low","line":"Thiamine was administered before or with dextrose-containing fluids to prevent precipitating Wernicke encephalopathy.","short":"Thiamine first"},{"id":"severity-orthostatics","label":"Severity / weight / orthostatics","tags":["dehydration-lytes"],"scale":"low","line":"Symptom severity, weight change, and orthostatic vital signs were documented to gauge the degree of dehydration.","short":"Severity / orthostatics"}],"checks":[{"if":"dka","needs":["lytes-renal"],"mode":"any","warn":"DKA can present at near-normal glucose in pregnancy — a glucose, anion gap, and ketones document that it was excluded."},{"if":"wernicke","needs":["thiamine-first"],"mode":"any","warn":"Giving dextrose before thiamine in a chronically vomiting patient can precipitate Wernicke encephalopathy — document thiamine first."},{"if":"molar-multiple","needs":["hcg-quant","pelvic-us-hg"],"mode":"any","warn":"Don't anchor on morning sickness — a quantitative hCG and ultrasound document exclusion of a molar or multiple gestation."},{"if":"dehydration-lytes","needs":["lytes-renal","ua-ketones"],"mode":"any","warn":"Undertreated dehydration with hypokalemia and ketosis is the main morbidity — document the electrolytes and ketone status."},{"if":"surgical-abdomen","needs":["severity-orthostatics"],"mode":"any","warn":"A non-obstetric cause of vomiting can hide behind a pregnancy diagnosis — reassess if pain localizes or the course is atypical."}],"history":[{"id":"hg-hx-pattern","dx":"general","q":"Nausea and vomiting — timing of onset, frequency, ability to keep fluids down, and any weight loss?","answers":[{"label":"Typical first-trimester pattern, tolerating some intake","tone":"neg","sets":[],"ddx":[],"mdm":"Nausea and vomiting followed a typical early first-trimester pattern in timing and frequency, with some oral intake tolerated and no significant weight loss.","frag":"typical NVP pattern, some intake"},{"label":"Intractable vomiting, unable to tolerate intake / weight loss","tone":"pos","sets":[],"ddx":[{"id":"dehydration-lytes","keep":true}],"mdm":"Vomiting was intractable with inability to tolerate oral intake and weight loss, consistent with hyperemesis and significant dehydration.","frag":"intractable vomiting / weight loss"},{"label":"Onset after first trimester or with new abdominal pain","tone":"pos","sets":[],"ddx":[{"id":"surgical-abdomen","keep":true}],"mdm":"Vomiting began later than the first trimester or was accompanied by new abdominal pain, prompting evaluation for a non-obstetric or surgical cause.","frag":"late onset / abdominal pain"}]},{"id":"hg-hx-molar","dx":"molar-multiple","q":"Known multiple gestation, prior molar pregnancy, or an hCG/uterine size larger than expected for dates?","answers":[{"label":"Singleton, dating consistent","tone":"neg","sets":[],"ddx":[],"mdm":"The pregnancy was a singleton with size and hCG consistent with dates, with no features to suggest a molar or multiple gestation.","frag":"singleton, consistent dating"},{"label":"Multiples, prior mole, or larger-than-dates","tone":"pos","sets":[],"ddx":[{"id":"molar-multiple","keep":true}],"mdm":"A multiple gestation, prior molar pregnancy, or larger-than-dates uterus and hCG were noted, raising concern for a molar or multiple gestation driving the symptoms.","frag":"multiples / mole / larger-than-dates"}],"sex":"f"},{"id":"hg-hx-diabetes","dx":"dka","q":"History of diabetes (including gestational), polyuria, or any abdominal pain with deep breathing suggesting ketoacidosis?","answers":[{"label":"No diabetes or ketoacidosis features","tone":"neg","sets":[],"ddx":[],"mdm":"There was no history of diabetes and no polyuria or features to suggest evolving ketoacidosis.","frag":"no diabetes / DKA features"},{"label":"Diabetes or features concerning for DKA","tone":"pos","sets":[],"ddx":[{"id":"dka","keep":true}],"mdm":"A history of diabetes or symptoms concerning for ketoacidosis were present, prompting assessment of glucose, an anion gap, and ketones, recognizing that pregnant patients can develop DKA at lower glucose levels.","frag":"diabetes / DKA concern"}]},{"id":"hg-hx-thiamine","dx":"wernicke","q":"Duration of poor intake — prolonged vomiting with little nutrition, or any confusion, vision changes, or unsteadiness?","answers":[{"label":"Short duration, no neuro symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"The duration of reduced intake was short, without prolonged vomiting with little nutrition and without confusion, vision changes, or unsteadiness to suggest thiamine deficiency.","frag":"short duration, no neuro Sx"},{"label":"Prolonged poor intake or neuro symptoms","tone":"pos","sets":[],"ddx":[{"id":"wernicke","keep":true}],"mdm":"Prolonged poor intake or neurologic symptoms were reported, raising concern for thiamine deficiency, so thiamine was given before any dextrose to prevent Wernicke encephalopathy.","frag":"prolonged poor intake / neuro Sx"}]},{"id":"hg-hx-thyroid","dx":"thyrotoxicosis","q":"Palpitations, heat intolerance, tremor, or known thyroid disease suggesting a thyrotoxic contribution?","answers":[{"label":"No hyperthyroid symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"There were no palpitations, heat intolerance, tremor, or thyroid history to suggest a thyrotoxic contribution.","frag":"no hyperthyroid Sx"},{"label":"Hyperthyroid symptoms present","tone":"pos","sets":[],"ddx":[{"id":"thyrotoxicosis","keep":true}],"mdm":"Symptoms suggestive of hyperthyroidism were present, prompting thyroid studies to evaluate for hCG-mediated thyrotoxicosis.","frag":"hyperthyroid symptoms"}]},{"id":"hg-hx-urinary","dx":"pyelo-uti","q":"Urinary symptoms, flank pain, or fevers that could point to a urinary tract infection precipitating vomiting?","answers":[{"label":"No urinary symptoms or fever","tone":"neg","sets":[],"ddx":[],"mdm":"There were no dysuria, flank pain, or fevers to suggest a urinary source for the vomiting.","frag":"no urinary Sx / fever"},{"label":"Dysuria, flank pain, or fever","tone":"pos","sets":[],"ddx":[{"id":"pyelo-uti","keep":true}],"mdm":"Urinary symptoms, flank pain, or fever were reported, prompting evaluation for a urinary tract infection or pyelonephritis as a precipitant.","frag":"dysuria / flank pain / fever"}]}],"exam":[{"id":"hg-exam-volume","dx":"dehydration-lytes","q":"Volume status — tachycardia, orthostatic change, dry mucous membranes, or reduced urine output?","answers":[{"label":"Euvolemic, stable vitals","tone":"neg","sets":[],"ddx":[],"mdm":"The patient appeared euvolemic with stable vital signs, no tachycardia or orthostatic change, moist mucous membranes, and preserved urine output.","frag":"euvolemic, stable vitals"},{"label":"Dehydrated / tachycardic / orthostatic","tone":"pos","sets":[],"ddx":[{"id":"dehydration-lytes","keep":true}],"mdm":"Signs of dehydration with tachycardia or orthostatic change were present, prompting rehydration and electrolyte correction.","frag":"dehydrated / orthostatic"}]},{"id":"hg-exam-abdomen","dx":"surgical-abdomen","q":"Abdominal exam — focal or right-sided tenderness, Murphy sign, peritoneal signs, or distension?","answers":[{"label":"Soft, non-focal abdomen","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen was soft and non-focal without peritoneal signs or features of a surgical abdomen.","frag":"soft, non-focal abdomen"},{"label":"Focal tenderness / peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"surgical-abdomen","keep":true}],"mdm":"Focal tenderness or peritoneal signs were present, concerning for a non-obstetric surgical cause such as appendicitis, cholecystitis, pancreatitis, or obstruction.","frag":"focal tenderness / peritoneal signs"}]},{"id":"hg-exam-neuro","dx":"wernicke","q":"Neurologic exam — confusion, nystagmus or ophthalmoplegia, or ataxia suggesting Wernicke?","answers":[{"label":"Neurologically intact","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was intact without confusion, eye-movement abnormality, or ataxia.","frag":"neuro intact"},{"label":"Confusion / ophthalmoplegia / ataxia","tone":"pos","sets":[],"ddx":[{"id":"wernicke","keep":true}],"mdm":"Confusion, an eye-movement abnormality, or ataxia was present, concerning for Wernicke encephalopathy and warranting urgent thiamine repletion.","frag":"confusion / ophthalmoplegia / ataxia"}]},{"id":"hg-exam-thyroid","dx":"thyrotoxicosis","q":"Exam for thyrotoxicosis — resting tachycardia, tremor, warm moist skin, or goiter?","answers":[{"label":"No thyrotoxic findings","tone":"neg","sets":[],"ddx":[],"mdm":"There were no resting tachycardia, tremor, or goiter to suggest thyrotoxicosis.","frag":"no thyrotoxic findings"},{"label":"Tremor / tachycardia / goiter","tone":"pos","sets":[],"ddx":[{"id":"thyrotoxicosis","keep":true}],"mdm":"Findings such as tremor, persistent tachycardia, or a goiter were present, prompting thyroid studies for hCG-mediated thyrotoxicosis.","frag":"tremor / tachycardia / goiter"}]}],"conclusions":["hyperemesis gravidarum with dehydration","hyperemesis gravidarum, improved after rehydration","nausea and vomiting of pregnancy"],"specs":["obgyn"]},{"id":"pelvic-inflammatory-disease","title":"Pelvic Inflammatory Disease","kind":"diagnosis","aliases":["pid","pelvic inflammatory disease","salpingitis","endometritis","tubo-ovarian abscess","toa","cervicitis","pelvic infection","lower abdominal pain female","cervical motion tenderness","std pelvic pain"],"opening":"A patient with lower abdominal or pelvic pain was evaluated for pelvic inflammatory disease. Because PID is a clinical diagnosis with dangerous mimics and complications, ectopic pregnancy, tubo-ovarian abscess, appendicitis, ovarian torsion, and a urinary source were actively considered, and a pregnancy test was obtained.","ddx":[{"id":"ectopic-pid","group":"lifethreat","label":"Ectopic pregnancy","default":true,"tags":["ectopic-pid"],"ruleout":"Ectopic pregnancy was considered; the pregnancy test was negative, excluding it as a cause of the pelvic pain in this patient of reproductive potential.","miss":4,"sex":"f"},{"id":"toa","group":"lifethreat","label":"Tubo-ovarian abscess","default":true,"tags":["toa"],"ruleout":"Tubo-ovarian abscess was considered; there was no palpable adnexal mass, the patient was not toxic or persistently febrile, and pelvic ultrasound showed no complex adnexal collection, making it unlikely.","miss":3,"sex":"f"},{"id":"appendicitis-pid","group":"lifethreat","label":"Appendicitis","default":false,"tags":["appendicitis-pid"],"ruleout":"Appendicitis was considered; the pain was bilateral rather than right-lower-quadrant or migratory, there was no anorexia or focal McBurney tenderness, and imaging where obtained was reassuring, making it unlikely.","miss":3},{"id":"torsion-pid","group":"lifethreat","label":"Ovarian torsion","default":false,"tags":["torsion-pid"],"ruleout":"Ovarian torsion was considered; there was no sudden severe unilateral pain, no palpable adnexal mass, and pelvic ultrasound with Doppler showed preserved bilateral ovarian flow, making it unlikely.","miss":4,"sex":"f"},{"id":"fitz-hugh-curtis","group":"other","label":"Fitz-Hugh-Curtis perihepatitis","default":false,"tags":["fitz-hugh-curtis"],"ruleout":"Fitz-Hugh-Curtis perihepatitis was considered when right-upper-quadrant pain accompanied pelvic symptoms, recognizing it as a complication of PID rather than a primary hepatobiliary process.","miss":1},{"id":"uti-pid","group":"common","label":"UTI / pyelonephritis","default":false,"tags":["uti-pid"],"ruleout":"A urinary tract infection or pyelonephritis was considered; urinalysis was reviewed and there were no convincing urinary symptoms or flank findings to account for the presentation.","miss":2}],"risk":[{"id":"preg-test-pid","label":"Pregnancy test","tags":["ectopic-pid"],"scale":"low","line":"A pregnancy test was obtained in every patient of reproductive potential to exclude an ectopic pregnancy before attributing symptoms to PID.","short":"Pregnancy test"},{"id":"pelvic-exam-pid","label":"Pelvic examination","tags":["toa","ectopic-pid"],"scale":"low","line":"A pelvic examination was performed to assess for cervical motion, uterine, and adnexal tenderness, and for an adnexal mass.","short":"Pelvic exam"},{"id":"pelvic-us-pid","label":"Pelvic ultrasound","tags":["toa","torsion-pid"],"scale":"low","line":"A pelvic ultrasound was obtained to evaluate for a tubo-ovarian abscess, an adnexal mass, or findings suggesting torsion.","short":"Pelvic ultrasound"},{"id":"gc-ct-naat","label":"GC / chlamydia NAAT","tags":["ectopic-pid"],"scale":"low","line":"Gonorrhea and chlamydia testing was sent, recognizing that empiric treatment is started without waiting for results.","short":"GC/CT NAAT"},{"id":"ua-pid","label":"Urinalysis","tags":["uti-pid"],"scale":"low","line":"A urinalysis was reviewed to assess for a urinary source as an alternative explanation.","short":"Urinalysis"},{"id":"sexual-hx-followup","label":"Sexual history / partner therapy / follow-up","tags":["ectopic-pid"],"scale":"low","line":"A sexual history was taken and partner treatment plus follow-up were arranged as part of management.","short":"Sexual Hx / follow-up"}],"checks":[{"if":"ectopic-pid","needs":["preg-test-pid"],"mode":"any","warn":"Never diagnose PID without a pregnancy test — ectopic pregnancy is the can't-miss mimic of pelvic pain."},{"if":"toa","needs":["pelvic-us-pid","pelvic-exam-pid"],"mode":"any","warn":"A tubo-ovarian abscess needs imaging — it changes management toward drainage or admission rather than outpatient antibiotics."},{"if":"torsion-pid","needs":["pelvic-us-pid"],"mode":"any","warn":"Severe unilateral pain or an adnexal mass raises torsion — document the Doppler ultrasound assessment."},{"if":"ectopic-pid","needs":["gc-ct-naat","sexual-hx-followup"],"mode":"any","warn":"Document partner treatment and follow-up — undertreated PID and untreated partners drive recurrence and infertility."}],"history":[{"id":"pid-hx-pain","dx":"general","q":"Pelvic pain — onset, laterality, abnormal discharge, and relationship to menses?","answers":[{"label":"Gradual bilateral lower pelvic pain with discharge","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was gradual and bilateral with abnormal discharge, a pattern consistent with pelvic inflammatory disease.","frag":"bilateral pelvic pain with discharge"},{"label":"Sudden severe unilateral pain","tone":"pos","sets":[],"ddx":[{"id":"torsion-pid","keep":true}],"mdm":"The pain was sudden and severely unilateral, prompting consideration of ovarian torsion in addition to PID.","frag":"sudden unilateral pain"}],"sex":"f"},{"id":"pid-hx-pregnancy","dx":"ectopic-pid","q":"Could the patient be pregnant — last menstrual period, missed menses, or any vaginal bleeding?","answers":[{"label":"Recent normal menses / negative pregnancy test","tone":"neg","sets":[],"ddx":[],"mdm":"A recent normal menstrual period or a negative pregnancy test, without missed menses or vaginal bleeding, made ectopic pregnancy unlikely.","frag":"negative pregnancy test"},{"label":"Missed menses or possible pregnancy","tone":"pos","sets":[],"ddx":[{"id":"ectopic-pid","keep":true}],"mdm":"Missed menses or possible pregnancy was reported, mandating a pregnancy test and, if positive, ultrasound localization to exclude an ectopic.","frag":"possible pregnancy"}]},{"id":"pid-hx-systemic","dx":"toa","q":"Fevers, chills, or feeling systemically unwell suggesting a more severe infection such as an abscess?","answers":[{"label":"No fevers, well-appearing","tone":"neg","sets":[],"ddx":[],"mdm":"There were no fevers or systemic features to suggest a tubo-ovarian abscess or severe infection.","frag":"no fevers, well-appearing"},{"label":"High fevers / systemically unwell","tone":"pos","sets":[],"ddx":[{"id":"toa","keep":true}],"mdm":"High fevers or systemic illness were present, raising concern for a tubo-ovarian abscess and prompting imaging.","frag":"fevers / systemically unwell"}]},{"id":"pid-hx-ruq","dx":"fitz-hugh-curtis","q":"Right-upper-quadrant or pleuritic pain accompanying the pelvic symptoms?","answers":[{"label":"No right-upper-quadrant pain","tone":"neg","sets":[],"ddx":[],"mdm":"There was no right-upper-quadrant or pleuritic pain to suggest perihepatitis.","frag":"no RUQ pain"},{"label":"Right-upper-quadrant / pleuritic pain","tone":"pos","sets":[],"ddx":[{"id":"fitz-hugh-curtis","keep":true}],"mdm":"Right-upper-quadrant or pleuritic pain accompanied the pelvic symptoms, consistent with Fitz-Hugh-Curtis perihepatitis as a complication of PID.","frag":"RUQ / pleuritic pain"}]},{"id":"pid-hx-sexual","dx":"ectopic-pid","q":"Sexual history — new or multiple partners, prior sexually transmitted infections, or prior PID?","answers":[{"label":"No high-risk sexual history","tone":"neg","sets":[],"ddx":[],"mdm":"The sexual history revealed no high-risk features (no new or multiple partners, prior sexually transmitted infections, or prior PID); though empiric treatment and follow-up were still addressed.","frag":"low-risk sexual Hx"},{"label":"New/multiple partners or prior STI/PID","tone":"pos","sets":[],"ddx":[{"id":"ectopic-pid","keep":true}],"mdm":"New or multiple partners, or prior sexually transmitted infection or PID, raised the pretest probability of PID and the importance of partner treatment and follow-up.","frag":"high-risk sexual Hx"}]}],"exam":[{"id":"pid-exam-pelvic","dx":"ectopic-pid","q":"Pelvic examination — cervical motion, uterine, or adnexal tenderness, and any adnexal mass?","answers":[{"label":"No cervical motion / adnexal tenderness or mass","tone":"neg","sets":[],"ddx":[],"mdm":"The pelvic examination showed no cervical motion, uterine, or adnexal tenderness and no adnexal mass.","frag":"no CMT / adnexal tenderness"},{"label":"Cervical motion / adnexal tenderness","tone":"pos","sets":[],"ddx":[{"id":"ectopic-pid","keep":true}],"mdm":"Cervical motion, uterine, or adnexal tenderness was present, supporting a clinical diagnosis of PID while ectopic was still excluded by pregnancy testing.","frag":"CMT / adnexal tenderness"},{"label":"Adnexal mass / fullness","tone":"pos","sets":[],"ddx":[{"id":"toa","keep":true}],"mdm":"An adnexal mass or fullness was palpated, raising concern for a tubo-ovarian abscess and prompting ultrasound.","frag":"adnexal mass / fullness"}]},{"id":"pid-exam-abdomen","dx":"appendicitis-pid","q":"Abdominal exam — right-lower-quadrant tenderness, rebound, or peritoneal signs?","answers":[{"label":"No focal RLQ or peritoneal signs","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen had no focal right-lower-quadrant tenderness or peritoneal signs to suggest appendicitis.","frag":"no RLQ / peritoneal signs"},{"label":"RLQ tenderness / peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"appendicitis-pid","keep":true}],"mdm":"Right-lower-quadrant tenderness or peritoneal signs were present, prompting evaluation for appendicitis as a mimic.","frag":"RLQ / peritoneal signs"}]},{"id":"pid-exam-vitals","dx":"toa","q":"Vital signs — fever, tachycardia, or hypotension suggesting severe or complicated infection?","answers":[{"label":"Afebrile, hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was afebrile and hemodynamically stable, without tachycardia or hypotension to suggest a severe or complicated infection.","frag":"afebrile, stable"},{"label":"Fever / tachycardia / hypotension","tone":"pos","sets":[],"ddx":[{"id":"toa","keep":true}],"mdm":"Fever, tachycardia, or hypotension was present, concerning for a complicated infection such as a tubo-ovarian abscess and prompting imaging and admission consideration.","frag":"fever / tachycardia / hypotension"}]}],"conclusions":["pelvic inflammatory disease, started on empiric therapy","clinical pelvic inflammatory disease","pelvic inflammatory disease with outpatient follow-up arranged"],"specs":["obgyn"]},{"id":"ectopic-pregnancy","title":"Ectopic Pregnancy","kind":"diagnosis","aliases":["ectopic","ectopic pregnancy","tubal pregnancy","ruptured ectopic","heterotopic pregnancy","pregnancy of unknown location","pul","adnexal mass pregnancy","hemoperitoneum","positive pregnancy test pain","rh status"],"opening":"A pregnant patient with pelvic pain and/or bleeding was evaluated for ectopic pregnancy, which was treated as the working diagnosis until an intrauterine pregnancy was confirmed. Rupture with hemoperitoneum, heterotopic pregnancy, miscarriage, torsion, and other adnexal processes were actively considered, with quantitative hCG, ultrasound, and Rh status addressed.","ddx":[{"id":"ruptured-ectopic","group":"lifethreat","label":"Ruptured ectopic with hemorrhagic shock","default":true,"tags":["ruptured-ectopic"],"ruleout":"Ruptured ectopic with hemoperitoneum was considered; the patient was hemodynamically stable without tachycardia or hypotension, there were no peritoneal signs, shoulder-tip pain, or free fluid on ultrasound, though type and screen was sent.","miss":4,"sex":"f"},{"id":"ectopic-core","group":"lifethreat","label":"Ectopic pregnancy (unruptured)","default":true,"tags":["ectopic-core"],"ruleout":"Ectopic pregnancy was the working diagnosis; transvaginal ultrasound and quantitative hCG were used to evaluate for an intrauterine pregnancy versus adnexal mass, and ectopic precautions with close follow-up were arranged.","miss":4,"sex":"f"},{"id":"heterotopic-ep","group":"lifethreat","label":"Heterotopic pregnancy","default":false,"tags":["heterotopic-ep"],"ruleout":"Heterotopic pregnancy was considered, particularly after assisted reproduction; the adnexa showed no mass and there was no free fluid, recognizing an intrauterine pregnancy does not fully exclude a concurrent ectopic, making it unlikely.","miss":3,"sex":"f"},{"id":"miscarriage-ep","group":"common","label":"Miscarriage","default":false,"tags":["miscarriage-ep"],"ruleout":"Miscarriage was considered as a common cause of first-trimester bleeding once ectopic was addressed, with Rh status checked and follow-up provided.","miss":2},{"id":"torsion-ep","group":"lifethreat","label":"Ovarian torsion","default":false,"tags":["torsion-ep"],"ruleout":"Ovarian torsion was considered; there was no sudden severe unilateral pain or palpable adnexal mass, and pelvic ultrasound with Doppler showed preserved ovarian flow, making it unlikely.","miss":4,"sex":"f"},{"id":"cyst-appendicitis","group":"other","label":"Ruptured ovarian cyst / appendicitis","default":false,"tags":["cyst-appendicitis"],"ruleout":"A ruptured ovarian cyst or appendicitis was considered as an alternative source of pelvic pain; the history, examination, and imaging did not clearly point to one.","miss":1,"sex":"f"}],"risk":[{"id":"hcg-ep","label":"Quantitative hCG","tags":["ectopic-core"],"scale":"low","line":"A quantitative serum hCG was obtained and interpreted alongside ultrasound and dating, avoiding reliance on the discriminatory zone alone.","short":"Quantitative hCG"},{"id":"tvus-ep","label":"Transvaginal ultrasound","tags":["ectopic-core","torsion-ep"],"scale":"low","line":"A transvaginal pelvic ultrasound was obtained to assess for an intrauterine pregnancy, an adnexal mass, free fluid, and ovarian flow.","short":"Transvaginal US"},{"id":"rh-ep","label":"Rh status / Rho(D) immune globulin","tags":["miscarriage-ep"],"scale":"low","line":"Rh status was determined and Rho(D) immune globulin was given to an Rh-negative patient with bleeding as indicated.","short":"Rh / RhoGAM"},{"id":"type-screen-ep2","label":"Type & screen","tags":["ruptured-ectopic"],"scale":"low","line":"A type and screen, with crossmatch if unstable, was obtained given the potential for significant hemorrhage.","short":"Type & screen"},{"id":"hemo-assess","label":"Hemodynamic / orthostatic assessment","tags":["ruptured-ectopic"],"scale":"low","line":"Hemodynamic and orthostatic status was assessed and serial vitals were followed to detect occult bleeding.","short":"Hemodynamic assessment"},{"id":"serial-followup","label":"Serial hCG / follow-up plan","tags":["ectopic-core"],"scale":"low","line":"For a pregnancy of unknown location, a serial hCG trend and explicit return precautions with obstetric follow-up were arranged.","short":"Serial hCG / follow-up"}],"checks":[{"if":"ectopic-core","needs":["hcg-ep","tvus-ep"],"mode":"any","warn":"A quantitative hCG and transvaginal ultrasound document the basis for the assessment — don't rely on the discriminatory zone to exclude ectopic."},{"if":"ruptured-ectopic","needs":["type-screen-ep2","hemo-assess"],"mode":"any","warn":"Shoulder-tip pain or free fluid suggests rupture — a type and screen and serial hemodynamic assessment document readiness for hemorrhage."},{"if":"heterotopic-ep","needs":["tvus-ep"],"mode":"any","warn":"After assisted reproduction an intrauterine pregnancy does not exclude a concurrent ectopic — document assessment of the adnexa and free fluid."},{"if":"miscarriage-ep","needs":["rh-ep"],"mode":"any","warn":"Document Rh status — Rh-negative patients with bleeding need Rho(D) immune globulin."}],"history":[{"id":"ep2-hx-symptoms","dx":"general","q":"Pelvic pain and bleeding — character, severity, and presence of a known intrauterine pregnancy?","answers":[{"label":"Confirmed IUP, mild symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"An intrauterine pregnancy had been confirmed and the pelvic pain and bleeding were mild, substantially lowering ectopic risk.","frag":"confirmed IUP, mild symptoms"},{"label":"No confirmed IUP, positive test with pain/bleeding","tone":"pos","sets":[],"ddx":[{"id":"ectopic-core","keep":true}],"mdm":"A positive pregnancy test with pelvic pain or bleeding and no confirmed intrauterine pregnancy kept ectopic pregnancy as the working diagnosis.","frag":"positive test, no confirmed IUP"}],"sex":"f"},{"id":"ep2-hx-rupture","dx":"ruptured-ectopic","q":"Severe or worsening pain, shoulder-tip pain, lightheadedness, or syncope suggesting rupture?","answers":[{"label":"No rupture / shock features","tone":"neg","sets":[],"ddx":[],"mdm":"There was no severe pain, shoulder-tip pain, lightheadedness, or syncope to suggest rupture.","frag":"no rupture features"},{"label":"Shoulder-tip pain / lightheadedness / syncope","tone":"pos","sets":[],"ddx":[{"id":"ruptured-ectopic","keep":true},{"id":"ectopic-core","keep":true}],"mdm":"Shoulder-tip pain, lightheadedness, or syncope was reported, concerning for a ruptured ectopic with hemoperitoneum and requiring immediate evaluation.","frag":"shoulder-tip pain / syncope"}]},{"id":"ep2-hx-risk","dx":"ectopic-core","q":"Ectopic risk factors — prior ectopic, tubal surgery or ligation, PID, or an IUD in place?","answers":[{"label":"No ectopic risk factors","tone":"neg","sets":[],"ddx":[],"mdm":"No risk factors for ectopic pregnancy were identified: no prior ectopic, tubal surgery or ligation, PID, or IUD in place.","frag":"no ectopic risk factors"},{"label":"Ectopic risk factors present","tone":"pos","sets":[],"ddx":[{"id":"ectopic-core","keep":true}],"mdm":"Risk factors for ectopic pregnancy (prior ectopic, tubal surgery or ligation, PID, or an IUD in place) were present, raising the pretest probability and lowering the threshold for definitive evaluation.","frag":"ectopic risk factors"}]},{"id":"ep2-hx-art","dx":"heterotopic-ep","q":"Was this pregnancy achieved with assisted reproduction, raising the risk of a heterotopic pregnancy?","answers":[{"label":"No assisted reproduction","tone":"neg","sets":[],"ddx":[],"mdm":"The pregnancy was not achieved with assisted reproduction.","frag":"no assisted reproduction"},{"label":"Assisted reproduction","tone":"pos","sets":[],"ddx":[{"id":"heterotopic-ep","keep":true}],"mdm":"The pregnancy was achieved with assisted reproduction, raising heterotopic risk so that an intrauterine pregnancy does not exclude a concurrent ectopic.","frag":"assisted reproduction (heterotopic risk)"}]},{"id":"ep2-hx-rh","dx":"miscarriage-ep","q":"Is the Rh blood type known, and has the patient had vaginal bleeding requiring Rh consideration?","answers":[{"label":"Rh-positive or no significant bleeding","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was Rh-positive or had no significant bleeding requiring Rho(D) immune globulin.","frag":"Rh-positive / no significant bleeding"},{"label":"Rh-negative with bleeding","tone":"pos","sets":[],"ddx":[{"id":"miscarriage-ep","keep":true}],"mdm":"The patient was Rh-negative with bleeding, so Rho(D) immune globulin was indicated.","frag":"Rh-negative with bleeding"}],"sex":"f"}],"exam":[{"id":"ep2-exam-vitals","dx":"ruptured-ectopic","q":"Vital signs — tachycardia, hypotension, or orthostatic change suggesting blood loss?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable, without tachycardia, hypotension, or orthostatic change to suggest blood loss.","frag":"hemodynamically stable"},{"label":"Tachycardia / hypotension / orthostasis","tone":"pos","sets":[],"ddx":[{"id":"ruptured-ectopic","keep":true}],"mdm":"Tachycardia, hypotension, or orthostatic change was present, concerning for significant hemorrhage from a ruptured ectopic.","frag":"tachycardia / hypotension / orthostasis"}]},{"id":"ep2-exam-abdomen","dx":"ectopic-core","q":"Abdominal and pelvic exam — peritoneal signs, adnexal tenderness, or an adnexal mass?","answers":[{"label":"Soft abdomen, no adnexal findings","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen was soft without peritoneal signs and there were no adnexal tenderness or mass.","frag":"soft abdomen, no adnexal findings"},{"label":"Peritoneal signs / adnexal tenderness or mass","tone":"pos","sets":[],"ddx":[{"id":"ectopic-core","keep":true},{"id":"ruptured-ectopic","keep":true}],"mdm":"Peritoneal signs, adnexal tenderness, or an adnexal mass were present, concerning for ectopic pregnancy and possible rupture.","frag":"peritoneal signs / adnexal findings"}]},{"id":"ep2-exam-us","dx":"ectopic-core","q":"Ultrasound — is an intrauterine pregnancy confirmed, and is there an adnexal mass or free fluid?","answers":[{"label":"IUP confirmed, no free fluid","tone":"neg","sets":[],"ddx":[],"mdm":"An intrauterine pregnancy was confirmed without free fluid, substantially lowering ectopic risk though not eliminating heterotopic risk after assisted reproduction.","frag":"IUP confirmed, no free fluid"},{"label":"No IUP / adnexal mass / free fluid","tone":"pos","sets":[],"ddx":[{"id":"ectopic-core","keep":true},{"id":"ruptured-ectopic","keep":true}],"mdm":"No intrauterine pregnancy was seen, or an adnexal mass or free fluid was present, findings concerning for an ectopic pregnancy and possible rupture.","frag":"no IUP / adnexal mass / free fluid"}]},{"id":"ep2-exam-adnexa","dx":"torsion-ep","q":"Is there severe unilateral adnexal tenderness or an enlarged tender ovary suggesting torsion?","answers":[{"label":"No focal adnexal torsion findings","tone":"neg","sets":[],"ddx":[],"mdm":"There was no severe unilateral adnexal tenderness or enlarged tender ovary to suggest torsion.","frag":"no torsion findings"},{"label":"Severe unilateral adnexal tenderness","tone":"pos","sets":[],"ddx":[{"id":"torsion-ep","keep":true}],"mdm":"Severe unilateral adnexal tenderness or an enlarged tender ovary was present, prompting Doppler assessment for ovarian torsion.","frag":"severe unilateral adnexal tenderness"}]}],"conclusions":["ectopic pregnancy","pregnancy of unknown location, ectopic precautions given","ectopic pregnancy, obstetrics consulted"],"specs":["obgyn"],"pearls":[{"text":"A single hCG value cannot exclude ectopic — the discriminatory zone is a guide, not a rule, and an empty uterus above the zone still needs definitive imaging or follow-up, not reassurance.","dx":"ectopic-core"},{"text":"In the hemodynamically unstable patient with a positive pregnancy test, go to the OR — don't wait on ultrasound or a repeat hCG to confirm what the vitals already show.","dx":"ruptured-ectopic"},{"text":"An intrauterine pregnancy on ultrasound does not fully exclude a coexisting ectopic — heterotopic pregnancy risk rises sharply after assisted reproduction and should stay on the differential in that population.","dx":"heterotopic-ep"},{"text":"Adnexal torsion can occur in an ectopic or enlarged corpus luteal cyst — sudden onset, severe unilateral pain with a tender adnexal mass warrants pelvic ultrasound with Doppler, not just a pregnancy-focused workup.","dx":"torsion-ep"},{"text":"Methotrexate eligibility (hemodynamically stable, no fetal cardiac activity, hCG below the treatment threshold, reliable follow-up) is an OB/GYN decision — don't discharge on medical management without their sign-off and a clear follow-up plan.","dx":"ectopic-core"}]},{"id":"priapism","title":"Priapism","kind":"diagnosis","aliases":["priapism","prolonged erection","ischemic priapism","low flow priapism","high flow priapism","non-ischemic priapism","stuttering priapism","painful erection","penile erection emergency","cavernosal aspirate"],"opening":"A patient with a prolonged penile erection was evaluated for priapism. Because ischemic (low-flow) priapism is a time-critical emergency, it was distinguished from non-ischemic (high-flow) priapism, and contributors such as sickle cell disease, offending medications or drugs, recurrent (stuttering) disease, and malignant infiltration were actively considered.","ddx":[{"id":"ischemic-priapism","group":"lifethreat","label":"Ischemic (low-flow) priapism","default":true,"tags":["ischemic-priapism"],"ruleout":"Ischemic low-flow priapism was considered; the erection was not rigid and painful with prolonged duration, the corpora were not tense, and cavernosal blood gas did not show the hypoxic acidotic pattern, favoring non-ischemic priapism.","miss":3,"sex":"m"},{"id":"nonischemic-priapism","group":"other","label":"Non-ischemic (high-flow) priapism","default":false,"tags":["nonischemic-priapism"],"ruleout":"Non-ischemic high-flow priapism, typically post-traumatic and non-painful, was considered and distinguished by a non-hypoxic cavernosal blood gas and Doppler ultrasound, recognizing it is not an emergency requiring immediate aspiration.","miss":1,"sex":"m"},{"id":"stuttering-priapism","group":"other","label":"Stuttering (recurrent) priapism","default":false,"tags":["stuttering-priapism"],"ruleout":"A stuttering recurrent pattern was considered, as repeated self-limited ischemic episodes warrant a preventive plan and urologic follow-up beyond the acute visit.","miss":1,"sex":"m"},{"id":"sickle-cell-priapism","group":"lifethreat","label":"Sickle cell disease / hemoglobinopathy","default":false,"tags":["sickle-cell-priapism"],"ruleout":"Underlying hemoglobinopathy such as sickle cell disease was considered as a trigger; there was no personal or family history of sickle cell disease and screening labs and CBC were unremarkable, making it unlikely.","miss":3},{"id":"drug-induced-priapism","group":"common","label":"Medication / drug-induced priapism","default":false,"tags":["drug-induced-priapism"],"ruleout":"Medication or drug-induced priapism (from intracavernosal agents, PDE5 inhibitors, certain antipsychotics or antidepressants, or cocaine) was considered and the offending agent identified by history.","miss":2,"sex":"m"},{"id":"malignancy-priapism","group":"other","label":"Malignancy / penile infiltration","default":false,"tags":["malignancy-priapism"],"ruleout":"Malignant infiltration of the corpora as a rare cause was considered when the presentation was atypical or there were features suggesting an underlying tumor.","miss":1,"sex":"m"}],"risk":[{"id":"cavernosal-bg","label":"Cavernosal blood gas","tags":["ischemic-priapism","nonischemic-priapism"],"scale":"low","line":"A corporal aspirate blood gas was obtained to distinguish ischemic priapism, with dark hypoxic acidotic blood, from non-ischemic high-flow priapism.","short":"Cavernosal blood gas"},{"id":"duration-priapism","label":"Duration of erection","tags":["ischemic-priapism"],"scale":"low","line":"The duration of the erection was documented, recognizing that prolonged ischemia drives irreversible fibrosis and erectile dysfunction.","short":"Erection duration"},{"id":"sickle-screen","label":"Sickle cell screen / CBC","tags":["sickle-cell-priapism"],"scale":"low","line":"A sickle cell screen and CBC were obtained to identify a hemoglobinopathy trigger, particularly in at-risk patients.","short":"Sickle screen / CBC"},{"id":"doppler-us","label":"Penile Doppler ultrasound","tags":["nonischemic-priapism"],"scale":"low","line":"A penile Doppler ultrasound was used where needed to assess cavernosal flow and support the ischemic versus non-ischemic distinction.","short":"Doppler US"},{"id":"agent-history","label":"Offending agent history","tags":["drug-induced-priapism"],"scale":"low","line":"A focused history of intracavernosal agents, PDE5 inhibitors, psychiatric medications, and recreational drugs was taken to identify a precipitant.","short":"Agent history"},{"id":"urology-consult","label":"Urology consultation","tags":["ischemic-priapism"],"scale":"low","line":"Urology was consulted promptly for ischemic priapism given the time-critical need for aspiration, irrigation, and possible operative management.","short":"Urology consult"}],"checks":[{"if":"ischemic-priapism","needs":["cavernosal-bg","duration-priapism"],"mode":"any","warn":"Ischemic priapism is time-critical — a cavernosal blood gas confirms it and the documented duration drives urgency before fibrosis sets in."},{"if":"nonischemic-priapism","needs":["cavernosal-bg","doppler-us"],"mode":"any","warn":"Don't treat high-flow priapism as an emergency aspiration case — the blood gas and Doppler distinguish it from ischemic priapism."},{"if":"ischemic-priapism","needs":["urology-consult"],"mode":"any","warn":"Delay causes irreversible fibrosis and erectile dysfunction — document prompt urologic involvement for ischemic priapism."},{"if":"sickle-cell-priapism","needs":["sickle-screen"],"mode":"any","warn":"A hemoglobinopathy trigger is easily missed — document the sickle cell screen, especially in at-risk patients."},{"if":"stuttering-priapism","needs":["duration-priapism"],"mode":"any","warn":"A recurrent stuttering pattern needs a preventive plan — document the episodic history and urologic follow-up."}],"history":[{"id":"pri-hx-onset","dx":"general","q":"Erection — duration, presence of pain, and any preceding genital or perineal trauma?","answers":[{"label":"Brief, painless, post-traumatic erection","tone":"neg","sets":[],"ddx":[{"id":"nonischemic-priapism","keep":true}],"mdm":"The erection was relatively painless and followed perineal or genital trauma, a pattern more consistent with non-ischemic high-flow priapism.","frag":"painless, post-traumatic"},{"label":"Prolonged painful erection","tone":"pos","sets":[],"ddx":[{"id":"ischemic-priapism","keep":true}],"mdm":"The erection was prolonged and painful, the hallmark of ischemic low-flow priapism requiring urgent evaluation and intervention.","frag":"prolonged painful erection"}]},{"id":"pri-hx-sickle","dx":"sickle-cell-priapism","q":"Known sickle cell disease or trait, or a family history of hemoglobinopathy?","answers":[{"label":"No hemoglobinopathy history","tone":"neg","sets":[],"ddx":[],"mdm":"There was no personal or family history of sickle cell disease or other hemoglobinopathy.","frag":"no hemoglobinopathy Hx"},{"label":"Sickle cell disease / trait","tone":"pos","sets":[],"ddx":[{"id":"sickle-cell-priapism","keep":true}],"mdm":"A history of sickle cell disease or trait was present, identifying a likely trigger for ischemic priapism and prompting disease-directed care.","frag":"sickle cell disease / trait"}]},{"id":"pri-hx-agents","dx":"drug-induced-priapism","q":"Medications or drugs — intracavernosal injections, PDE5 inhibitors, antipsychotics or antidepressants, or cocaine?","answers":[{"label":"No offending agents","tone":"neg","sets":[],"ddx":[],"mdm":"No offending agents known to cause priapism (intracavernosal injections, PDE5 inhibitors, antipsychotics or antidepressants, or cocaine) were identified.","frag":"no offending agents"},{"label":"Offending agent identified","tone":"pos","sets":[],"ddx":[{"id":"drug-induced-priapism","keep":true}],"mdm":"An offending agent such as an intracavernosal drug, PDE5 inhibitor, psychiatric medication, or cocaine was identified as a likely precipitant.","frag":"offending agent identified"}]},{"id":"pri-hx-recurrent","dx":"stuttering-priapism","q":"Prior episodes — recurrent self-limited erections suggesting a stuttering pattern?","answers":[{"label":"First isolated episode","tone":"neg","sets":[],"ddx":[],"mdm":"This was a first isolated episode without a prior recurrent pattern.","frag":"first isolated episode"},{"label":"Recurrent self-limited episodes","tone":"pos","sets":[],"ddx":[{"id":"stuttering-priapism","keep":true}],"mdm":"Recurrent self-limited episodes were reported, consistent with stuttering priapism and warranting a preventive plan and urologic follow-up.","frag":"recurrent episodes"}]},{"id":"pri-hx-systemic","dx":"malignancy-priapism","q":"Constitutional symptoms, weight loss, or known malignancy that could infiltrate the corpora?","answers":[{"label":"No malignancy features","tone":"neg","sets":[],"ddx":[],"mdm":"There were no constitutional symptoms or known malignancy to suggest infiltration of the corpora.","frag":"no malignancy features"},{"label":"Constitutional symptoms / known malignancy","tone":"pos","sets":[],"ddx":[{"id":"malignancy-priapism","keep":true}],"mdm":"Constitutional symptoms or a known malignancy raised the rare possibility of malignant infiltration of the corpora.","frag":"constitutional Sx / malignancy"}]}],"exam":[{"id":"pri-exam-corpora","dx":"ischemic-priapism","q":"Penile exam — are the corpora cavernosa rigid and tender with a soft glans, typical of ischemic priapism?","answers":[{"label":"Partially rigid, non-tender corpora","tone":"neg","sets":[],"ddx":[{"id":"nonischemic-priapism","keep":true}],"mdm":"The corpora were only partially rigid and non-tender, a pattern more consistent with non-ischemic high-flow priapism.","frag":"partially rigid, non-tender"},{"label":"Fully rigid, tender corpora","tone":"pos","sets":[],"ddx":[{"id":"ischemic-priapism","keep":true}],"mdm":"The corpora cavernosa were fully rigid and tender with a soft glans, the classic finding of ischemic priapism.","frag":"fully rigid, tender corpora"}]},{"id":"pri-exam-bloodgas","dx":"ischemic-priapism","q":"Cavernosal aspirate — is the blood dark and hypoxic (ischemic) or bright and well-oxygenated (non-ischemic)?","answers":[{"label":"Bright, well-oxygenated aspirate","tone":"neg","sets":[],"ddx":[{"id":"nonischemic-priapism","keep":true}],"mdm":"The cavernosal aspirate was bright and well-oxygenated, supporting non-ischemic high-flow priapism rather than an ischemic emergency.","frag":"bright, oxygenated aspirate"},{"label":"Dark, hypoxic/acidotic aspirate","tone":"pos","sets":[],"ddx":[{"id":"ischemic-priapism","keep":true}],"mdm":"The cavernosal aspirate was dark and hypoxic with acidosis, confirming ischemic priapism and the need for urgent intervention.","frag":"dark, hypoxic aspirate"}]},{"id":"pri-exam-trauma","dx":"nonischemic-priapism","q":"Perineal or genital exam — signs of trauma such as a perineal hematoma or straddle injury?","answers":[{"label":"No trauma findings","tone":"neg","sets":[],"ddx":[],"mdm":"There were no perineal or genital signs of trauma.","frag":"no trauma findings"},{"label":"Perineal trauma / hematoma","tone":"pos","sets":[],"ddx":[{"id":"nonischemic-priapism","keep":true}],"mdm":"Perineal trauma or a hematoma was noted, supporting a non-ischemic high-flow mechanism from a cavernosal arterial fistula.","frag":"perineal trauma / hematoma"}]}],"conclusions":["ischemic (low-flow) priapism","non-ischemic (high-flow) priapism","priapism, urology consulted"],"specs":["uro"]},{"id":"pyelonephritis","title":"Acute Pyelonephritis","kind":"diagnosis","aliases":["pyelo","kidney infection","upper uti","acute pyelonephritis","renal infection","complicated uti","flank pain fever","ascending uti","febrile uti"],"opening":"The patient was evaluated for acute pyelonephritis presenting with flank pain, fever, and urinary symptoms. Urosepsis and an obstructing infected stone were treated as the can't-miss processes, and the mimics and complications below were actively considered.","ddx":[{"id":"urosepsis","group":"lifethreat","label":"Urosepsis / septic shock","default":true,"tags":["urosepsis"],"ruleout":"Urosepsis with septic shock was considered; the patient was afebrile to mildly febrile, normotensive, and well-perfused without tachycardia or altered mentation, and the lactate was normal, making it unlikely.","miss":3},{"id":"obstructing-stone","group":"lifethreat","label":"Obstructing infected stone / pyonephrosis","default":true,"tags":["obstructing-stone"],"ruleout":"Obstructing infected stone with pyonephrosis was considered; there was no severe colicky flank pain or history of stones, the patient was improving with therapy, and imaging where obtained showed no hydronephrosis or obstruction, making it unlikely.","miss":3},{"id":"renal-abscess-pyelo","group":"lifethreat","label":"Renal or perinephric abscess","default":false,"tags":["renal-abscess-pyelo"],"ruleout":"Renal or perinephric abscess was considered, particularly with persistent fever despite appropriate antibiotics; the patient defervesced and improved clinically, and imaging where obtained showed no fluid collection, making it unlikely.","miss":3},{"id":"renal-abscess","group":"other","label":"Perinephric / renal abscess","default":false,"tags":["renal-abscess"],"ruleout":"A perinephric or renal abscess was considered, particularly with persistent fever or failure to improve, and cross-sectional imaging was used to evaluate for a drainable collection.","miss":1},{"id":"emphysematous","group":"other","label":"Emphysematous pyelonephritis","default":false,"tags":["emphysematous"],"ruleout":"Emphysematous pyelonephritis, a necrotizing gas-forming infection seen chiefly in diabetics, was considered; imaging was used to exclude gas within the renal parenchyma in the high-risk or toxic patient.","miss":1},{"id":"pyelo-pregnancy","group":"other","label":"Pyelonephritis in pregnancy","default":false,"tags":["pyelo-pregnancy"],"ruleout":"Pyelonephritis in pregnancy was considered given its association with preterm labor and sepsis; a pregnancy test was obtained and a pregnant patient was managed with admission as indicated.","miss":1,"sex":"f"},{"id":"appendicitis-pid","group":"common","label":"Appendicitis / PID (mimic)","default":false,"tags":["appendicitis-pid"],"ruleout":"Appendicitis and pelvic inflammatory disease were considered as mimics of flank or abdominal pain with pyuria; the abdominal and pelvic examination and pyelonephritis-consistent features were used to distinguish them.","miss":2,"sex":"f"}],"risk":[{"id":"ua-culture","label":"Urinalysis & culture","tags":["obstructing-stone","appendicitis-pid"],"scale":"low","line":"A urinalysis with microscopy and a urine culture were obtained to confirm pyuria and bacteriuria and to guide directed therapy.","short":"UA & culture"},{"id":"preg-test","label":"Pregnancy test","tags":["pyelo-pregnancy"],"scale":"low","line":"A pregnancy test was obtained in patients of reproductive potential, as pregnancy alters disposition and antibiotic selection.","short":"Pregnancy test"},{"id":"lactate-cx","label":"Lactate & blood cultures","tags":["urosepsis"],"scale":"low","line":"A lactate and blood cultures were obtained when sepsis was suspected, and resuscitation was initiated accordingly.","short":"Lactate / blood cx"},{"id":"renal-fn","label":"Renal function","tags":["urosepsis","obstructing-stone"],"scale":"low","line":"Renal function and electrolytes were checked to assess for acute kidney injury and to guide dosing and disposition.","short":"Renal function"},{"id":"ct-us","label":"CT or ultrasound","tags":["obstructing-stone","renal-abscess","emphysematous"],"scale":"low","line":"CT or ultrasound was obtained to exclude obstruction, abscess, or emphysematous changes in high-risk patients or those failing to improve.","short":"CT / US imaging"}],"checks":[{"if":"urosepsis","needs":["lactate-cx"],"mode":"any","warn":"Urosepsis is on the differential — a lactate and blood cultures with timely resuscitation document recognition and treatment of sepsis."},{"if":"obstructing-stone","needs":["ct-us"],"mode":"any","warn":"An obstructing infected stone is a decompression emergency — imaging documents whether obstruction is present and warrants urgent urologic drainage."},{"if":"pyelo-pregnancy","needs":["preg-test"],"mode":"any","warn":"Document the pregnancy test — pyelonephritis in pregnancy carries preterm-labor and sepsis risk and generally warrants admission."}],"history":[{"id":"pyelo-hx-symptoms","dx":"general","q":"Urinary symptoms — dysuria, frequency, flank pain, fever and chills, nausea and vomiting?","answers":[{"label":"Lower urinary symptoms only, no systemic features","tone":"neg","sets":[],"ddx":[],"mdm":"Symptoms were limited to lower urinary tract complaints such as dysuria and frequency, without flank pain or systemic features such as fever and chills or nausea and vomiting.","frag":"lower UTI symptoms only"},{"label":"Flank pain with fever and chills","tone":"pos","sets":[],"ddx":[],"mdm":"Flank pain with fever and chills was reported, consistent with upper urinary tract infection.","frag":"flank pain, fever, chills"}]},{"id":"pyelo-hx-sepsis","dx":"urosepsis","q":"Systemic toxicity — rigors, confusion, lightheadedness, or poor oral intake suggesting sepsis?","answers":[{"label":"No features of sepsis","tone":"neg","sets":[],"ddx":[],"mdm":"No rigors, confusion, or hemodynamic symptoms to suggest sepsis were reported.","frag":"no sepsis features"},{"label":"Rigors / confusion / lightheadedness","tone":"pos","sets":[],"ddx":[{"id":"urosepsis","keep":true}],"mdm":"Rigors, confusion, or lightheadedness was reported, raising concern for urosepsis and prompting septic workup and resuscitation.","frag":"rigors / confusion"}]},{"id":"pyelo-hx-stone","dx":"obstructing-stone","q":"History of kidney stones, a single or transplanted kidney, or severe colicky pain suggesting obstruction?","answers":[{"label":"No stone history or obstruction features","tone":"neg","sets":[],"ddx":[],"mdm":"No stone history or colicky pain to suggest an obstructing calculus was reported.","frag":"no stone / obstruction features"},{"label":"Stone history / colicky pain","tone":"pos","sets":[],"ddx":[{"id":"obstructing-stone","keep":true}],"mdm":"A stone history or colicky pain was reported, raising concern for an obstructing infected stone requiring imaging and possible decompression.","frag":"stone history / colicky pain"}]},{"id":"pyelo-hx-pregnancy","dx":"pyelo-pregnancy","q":"Is the patient pregnant or possibly pregnant?","answers":[{"label":"Not pregnant","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was not pregnant.","frag":"not pregnant"},{"label":"Pregnant / possibly pregnant","tone":"pos","sets":[],"ddx":[{"id":"pyelo-pregnancy","keep":true}],"mdm":"The patient was pregnant or possibly pregnant, warranting a pregnancy test and a lower threshold for admission given preterm-labor risk.","frag":"pregnant / possibly pregnant"}]},{"id":"pyelo-hx-host","dx":"emphysematous","q":"Diabetes, immunosuppression, or recent failure to improve on antibiotics?","answers":[{"label":"Immunocompetent, no complicating host factors","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was immunocompetent without complicating host factors.","frag":"no host risk factors"},{"label":"Diabetes / immunosuppression / non-improving","tone":"pos","sets":[],"ddx":[{"id":"emphysematous","keep":true},{"id":"renal-abscess","keep":true}],"mdm":"Diabetes, immunosuppression, or failure to improve was reported, raising concern for emphysematous pyelonephritis or abscess and prompting imaging.","frag":"diabetes / immunosuppressed"}]},{"answers":[{"ddx":[],"frag":"defervesced and improving, no persistent fever","label":"Clinical improvement","mdm":"The patient defervesced and improved clinically, and imaging where obtained showed no fluid collection, making a renal or perinephric abscess unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"renal-abscess-pyelo","keep":true}],"frag":"persistent fever despite appropriate antibiotics","label":"Persistent fever / no improvement","mdm":"Persistent fever despite appropriate antibiotics or failure to improve clinically was present, raising concern for a renal or perinephric abscess and warranting cross-sectional imaging.","sets":[],"tone":"pos"}],"dx":"renal-abscess-pyelo","id":"pyelo-hx-renal-abscess-pyelo","q":"Abscess — persistent fever despite appropriate antibiotics or failure to improve clinically?"}],"exam":[{"id":"pyelo-exam-vitals","dx":"urosepsis","q":"Vital signs — fever, tachycardia, hypotension, or altered mental status?","answers":[{"label":"Hemodynamically stable, normal mentation","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable with normal mentation, without fever, tachycardia, hypotension, or altered mental status.","frag":"stable vitals"},{"label":"Hypotension / tachycardia / altered mentation","tone":"pos","sets":[],"ddx":[{"id":"urosepsis","keep":true}],"mdm":"Hypotension, tachycardia, or altered mentation was present, concerning for urosepsis and prompting resuscitation.","frag":"hypotension / tachycardia"}]},{"id":"pyelo-exam-cva","dx":"obstructing-stone","q":"Costovertebral angle tenderness and flank examination?","answers":[{"label":"CVA tenderness without obstruction concern","tone":"neg","sets":[],"ddx":[],"mdm":"Costovertebral angle tenderness was present consistent with pyelonephritis, without features suggesting obstruction.","frag":"CVA tenderness"},{"label":"Severe unilateral CVA tenderness / toxic","tone":"pos","sets":[],"ddx":[{"id":"obstructing-stone","keep":true}],"mdm":"Severe unilateral CVA tenderness in a toxic patient was present, raising concern for an obstructed infected system.","frag":"severe CVA tenderness, toxic"}]},{"id":"pyelo-exam-abdomen","dx":"appendicitis-pid","q":"Abdominal and pelvic examination — focal RLQ tenderness, peritoneal signs, or cervical motion / adnexal tenderness?","answers":[{"label":"No focal abdominal or pelvic findings","tone":"neg","sets":[],"ddx":[],"mdm":"The abdomen and pelvic examination showed no focal tenderness or peritoneal signs to suggest an alternative source.","frag":"no focal abdominal/pelvic findings"},{"label":"RLQ or pelvic tenderness","tone":"pos","sets":[],"ddx":[{"id":"appendicitis-pid","keep":true}],"mdm":"Focal right lower quadrant or pelvic tenderness (with peritoneal signs or cervical motion / adnexal tenderness) was present, prompting consideration of appendicitis or PID as a mimic.","frag":"RLQ / pelvic tenderness"}]}],"conclusions":["acute uncomplicated pyelonephritis","complicated pyelonephritis","pyelonephritis, admit"],"specs":["id","uro"]},{"id":"infectious-mononucleosis","title":"Infectious Mononucleosis","kind":"diagnosis","aliases":["mono","mononucleosis","glandular fever","ebv","epstein-barr","kissing disease","heterophile positive","atypical lymphocytosis","mono pharyngitis"],"opening":"The patient was evaluated for infectious mononucleosis presenting with sore throat, fever, and lymphadenopathy. Splenic rupture and airway compromise were treated as the can't-miss complications, acute HIV was considered, and the mimics and complications below were actively addressed.","ddx":[{"id":"splenic-rupture","group":"lifethreat","label":"Splenic rupture","default":true,"tags":["splenic-rupture"],"ruleout":"Splenic rupture was considered; there was no left-upper-quadrant or shoulder-tip pain, no abdominal tenderness or hemodynamic instability, and the patient was counseled to avoid contact sports and strenuous activity for several weeks.","miss":3},{"id":"airway-compromise","group":"lifethreat","label":"Airway compromise (tonsillar hypertrophy)","default":true,"tags":["airway-compromise"],"ruleout":"Airway compromise from tonsillar hypertrophy was considered; the patient had no stridor, drooling, muffled voice, or respiratory distress and was protecting the airway with adequate oral intake, making it unlikely.","miss":3},{"id":"acute-hiv","group":"other","label":"Acute HIV seroconversion","default":false,"tags":["acute-hiv"],"ruleout":"Acute HIV seroconversion was considered as a mononucleosis-like syndrome; risk was assessed and HIV testing was offered because it is treatable and contagious.","miss":1},{"id":"strep-pharyngitis","group":"common","label":"Streptococcal pharyngitis","default":false,"tags":["strep-pharyngitis"],"ruleout":"Streptococcal pharyngitis was considered and tested for; aminopenicillins were avoided in suspected mononucleosis because of the characteristic rash.","miss":2},{"id":"peritonsillar-abscess","group":"other","label":"Peritonsillar abscess","default":false,"tags":["peritonsillar-abscess"],"ruleout":"A peritonsillar abscess was considered with asymmetric swelling, trismus, or uvular deviation, and the oropharynx was examined for a drainable collection.","miss":4},{"id":"mono-hepatitis","group":"other","label":"EBV hepatitis","default":false,"tags":["mono-hepatitis"],"ruleout":"EBV hepatitis was considered as a complication; liver function was checked when right upper quadrant tenderness, jaundice, or marked malaise was present.","miss":1},{"id":"mono-cytopenia","group":"other","label":"Hemolytic anemia / thrombocytopenia","default":false,"tags":["mono-cytopenia"],"ruleout":"Autoimmune hemolytic anemia and thrombocytopenia were considered as hematologic complications; a CBC with smear was reviewed for cytopenias and atypical lymphocytes.","miss":1}],"risk":[{"id":"mono-serology","label":"Heterophile / EBV serology","tags":["acute-hiv","strep-pharyngitis"],"scale":"low","line":"A heterophile (monospot) test and, when indicated, EBV-specific serology were obtained to support the diagnosis.","short":"Heterophile / EBV"},{"id":"cbc-smear","label":"CBC with smear","tags":["mono-cytopenia"],"scale":"low","line":"A CBC with peripheral smear was reviewed for atypical lymphocytosis and for hemolytic anemia or thrombocytopenia.","short":"CBC / smear"},{"id":"strep-test","label":"Strep testing","tags":["strep-pharyngitis"],"scale":"low","line":"Rapid streptococcal testing or culture was obtained to evaluate for concurrent or alternative streptococcal pharyngitis.","short":"Strep test"},{"id":"lfts","label":"Liver function tests","tags":["mono-hepatitis"],"scale":"low","line":"Liver function tests were obtained when hepatic involvement was suspected.","short":"LFTs"},{"id":"hiv-test","label":"HIV testing","tags":["acute-hiv"],"scale":"low","line":"HIV testing (including RNA when acute seroconversion is suspected) was offered given the mononucleosis-like presentation.","short":"HIV testing"}],"checks":[{"if":"acute-hiv","needs":["hiv-test","mono-serology"],"mode":"any","warn":"Acute HIV mimics mononucleosis — document HIV testing because the heterophile test does not exclude acute retroviral syndrome."},{"if":"splenic-rupture","needs":["cbc-smear"],"mode":"any","warn":"Splenic rupture risk persists for weeks — document counseling to avoid contact sports and strenuous activity."},{"if":"mono-hepatitis","needs":["lfts"],"mode":"any","warn":"EBV hepatitis is common — check liver function when hepatic symptoms are present."}],"history":[{"id":"mono-hx-symptoms","dx":"general","q":"Sore throat, fever, fatigue, and posterior cervical lymphadenopathy?","answers":[{"label":"Localized sore throat, no systemic syndrome","tone":"neg","sets":[],"ddx":[],"mdm":"Symptoms were a localized sore throat without the systemic features of mononucleosis.","frag":"localized sore throat"},{"label":"Sore throat, fever, fatigue, adenopathy","tone":"pos","sets":[],"ddx":[],"mdm":"Sore throat, prolonged fatigue, fever, and lymphadenopathy were reported, consistent with infectious mononucleosis.","frag":"mono syndrome"}]},{"id":"mono-hx-airway","dx":"airway-compromise","q":"Difficulty breathing, noisy breathing, trouble swallowing secretions, or muffled voice?","answers":[{"label":"No airway symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No dyspnea, stridor, drooling, or muffled voice was reported.","frag":"no airway symptoms"},{"label":"Stridor / drooling / muffled voice","tone":"pos","sets":[],"ddx":[{"id":"airway-compromise","keep":true}],"mdm":"Noisy breathing, difficulty handling secretions, or a muffled voice was reported, concerning for airway compromise from tonsillar hypertrophy.","frag":"stridor / drooling"}]},{"id":"mono-hx-spleen","dx":"splenic-rupture","q":"Left upper quadrant or left shoulder pain, recent abdominal trauma, or participation in contact sports?","answers":[{"label":"No LUQ pain or high-risk activity","tone":"neg","sets":[],"ddx":[],"mdm":"No left upper quadrant or shoulder pain and no high-risk activity were reported.","frag":"no splenic symptoms"},{"label":"LUQ / left shoulder pain","tone":"pos","sets":[],"ddx":[{"id":"splenic-rupture","keep":true}],"mdm":"Left upper quadrant or left shoulder pain was reported, concerning for splenic involvement or rupture and prompting evaluation.","frag":"LUQ / left shoulder pain"}]},{"id":"mono-hx-hiv","dx":"acute-hiv","q":"Recent high-risk exposures — new sexual partners, unprotected sex, or injection drug use?","answers":[{"label":"No HIV risk exposures","tone":"neg","sets":[],"ddx":[],"mdm":"No high-risk exposures for HIV (new sexual partners, unprotected sex, or injection drug use) were reported.","frag":"no HIV risk"},{"label":"High-risk exposures present","tone":"pos","sets":[],"ddx":[{"id":"acute-hiv","keep":true}],"mdm":"High-risk exposures (new sexual partners, unprotected sex, or injection drug use) were reported, prompting consideration of acute HIV seroconversion and HIV testing.","frag":"HIV risk exposures"}]},{"id":"mono-hx-abx","dx":"strep-pharyngitis","q":"Recent antibiotic use, particularly amoxicillin or ampicillin, and any new rash?","answers":[{"label":"No recent aminopenicillin use","tone":"neg","sets":[],"ddx":[],"mdm":"No recent aminopenicillin exposure was reported.","frag":"no aminopenicillin use"},{"label":"Aminopenicillin given / new rash","tone":"pos","sets":[],"ddx":[{"id":"strep-pharyngitis","keep":true}],"mdm":"Recent amoxicillin or ampicillin exposure or a new rash was reported, consistent with the characteristic mononucleosis rash and reinforcing avoidance of aminopenicillins.","frag":"aminopenicillin rash"}]}],"exam":[{"id":"mono-exam-airway","dx":"airway-compromise","q":"Oropharyngeal and airway examination — tonsillar size, exudate, stridor, or respiratory distress?","answers":[{"label":"Patent airway, no distress","tone":"neg","sets":[],"ddx":[],"mdm":"The airway was patent without stridor or distress despite tonsillar enlargement.","frag":"patent airway"},{"label":"Obstructing tonsils / stridor","tone":"pos","sets":[],"ddx":[{"id":"airway-compromise","keep":true}],"mdm":"Markedly enlarged kissing tonsils with exudate and stridor or respiratory distress were present, concerning for airway compromise.","frag":"obstructing tonsils / stridor"}]},{"id":"mono-exam-spleen","dx":"splenic-rupture","q":"Abdominal examination — splenomegaly, left upper quadrant tenderness, or peritoneal signs?","answers":[{"label":"No splenomegaly or peritoneal signs","tone":"neg","sets":[],"ddx":[],"mdm":"No palpable splenomegaly, LUQ tenderness, or peritoneal signs were present.","frag":"no splenic findings"},{"label":"Splenomegaly / LUQ tenderness / peritoneal signs","tone":"pos","sets":[],"ddx":[{"id":"splenic-rupture","keep":true}],"mdm":"Splenomegaly, LUQ tenderness, or peritoneal signs were present, concerning for splenic involvement or rupture.","frag":"splenomegaly / peritoneal signs"}]},{"id":"mono-exam-throat","dx":"peritonsillar-abscess","q":"Pharyngeal examination — symmetric exudative tonsillitis versus asymmetric swelling, uvular deviation, or trismus?","answers":[{"label":"Symmetric tonsillar findings","tone":"neg","sets":[],"ddx":[],"mdm":"The tonsils were symmetrically enlarged without deviation or trismus.","frag":"symmetric tonsils"},{"label":"Asymmetric swelling / uvular deviation / trismus","tone":"pos","sets":[],"ddx":[{"id":"peritonsillar-abscess","keep":true}],"mdm":"Asymmetric swelling, uvular deviation, or trismus was present, concerning for a peritonsillar abscess.","frag":"asymmetric swelling / trismus"}]},{"id":"mono-exam-liver","dx":"mono-hepatitis","q":"Right upper quadrant tenderness, hepatomegaly, or scleral icterus?","answers":[{"label":"No hepatic findings","tone":"neg","sets":[],"ddx":[],"mdm":"No RUQ tenderness, hepatomegaly, or icterus was present.","frag":"no hepatic findings"},{"label":"RUQ tenderness / jaundice","tone":"pos","sets":[],"ddx":[{"id":"mono-hepatitis","keep":true}],"mdm":"Right upper quadrant tenderness or jaundice was present, prompting evaluation for EBV hepatitis.","frag":"RUQ tenderness / jaundice"}]}],"conclusions":["infectious mononucleosis (ebv)","mononucleosis with hepatitis","mononucleosis, splenic precautions given"],"specs":["id"]},{"id":"herpes-zoster","title":"Herpes Zoster (Shingles)","kind":"diagnosis","aliases":["shingles","zoster","herpes zoster","hz","reactivated varicella","dermatomal rash","zoster ophthalmicus","ramsay hunt","postherpetic neuralgia"],"opening":"The patient was evaluated for herpes zoster presenting with a painful dermatomal rash. Ophthalmic involvement and disseminated zoster were treated as the can't-miss processes, and the mimics and complications below were actively considered.","ddx":[{"id":"zoster-ophthalmicus","group":"lifethreat","label":"Herpes zoster ophthalmicus","default":true,"tags":["zoster-ophthalmicus"],"ruleout":"Herpes zoster ophthalmicus was considered; there was no Hutchinson sign or nasociliary involvement, no eye pain, redness, or visual change, and slit-lamp examination showed no corneal dendrites or uveitis, making it unlikely.","miss":3},{"id":"disseminated-zoster","group":"lifethreat","label":"Disseminated zoster (immunocompromised)","default":true,"tags":["disseminated-zoster"],"ruleout":"Disseminated zoster was considered; the patient was immunocompetent, the eruption remained confined to a single dermatome without crossing the midline, and there were no systemic or visceral features, making it unlikely.","miss":3},{"id":"ramsay-hunt","group":"other","label":"Ramsay Hunt syndrome","default":false,"tags":["ramsay-hunt"],"ruleout":"Ramsay Hunt syndrome was considered with ear pain, vesicles in the ear canal, and facial palsy; the facial nerve and ear were examined because early therapy improves recovery.","miss":1},{"id":"zoster-cns","group":"other","label":"Zoster encephalitis / myelitis","default":false,"tags":["zoster-cns"],"ruleout":"CNS involvement (encephalitis or myelitis) was considered with headache, altered mentation, or focal neurologic deficits, prompting neurologic assessment and further evaluation.","miss":4},{"id":"bacterial-superinfection","group":"common","label":"Bacterial superinfection","default":false,"tags":["bacterial-superinfection"],"ruleout":"Bacterial superinfection of the eruption was considered with spreading erythema, warmth, or purulence beyond the dermatome.","miss":2},{"id":"pre-eruptive-mimic","group":"common","label":"Pre-eruptive pain mimicking visceral emergency","default":false,"tags":["pre-eruptive-mimic"],"ruleout":"Pre-eruptive zoster pain can mimic a visceral emergency such as acute coronary syndrome, cholecystitis, or renal colic depending on dermatome; these were considered before attributing pain to zoster.","miss":2}],"risk":[{"id":"derm-exam","label":"Dermatomal distribution exam","tags":["pre-eruptive-mimic","bacterial-superinfection"],"scale":"low","line":"The rash was characterized as a unilateral dermatomal vesicular eruption that does not cross the midline.","short":"Dermatomal exam"},{"id":"eye-exam","label":"Eye exam / Hutchinson sign","tags":["zoster-ophthalmicus"],"scale":"low","line":"The nasociliary (Hutchinson) sign and a slit-lamp / fluorescein eye examination were performed when the first trigeminal division was involved.","short":"Eye exam / Hutchinson"},{"id":"immune-status","label":"Immune status assessment","tags":["disseminated-zoster"],"scale":"low","line":"Immune status was assessed (HIV, malignancy, immunosuppressive therapy) because immunocompromise raises the risk of dissemination.","short":"Immune status"},{"id":"facial-ear-exam","label":"Facial nerve & ear exam","tags":["ramsay-hunt"],"scale":"low","line":"The facial nerve, external ear, and canal were examined for vesicles and palsy to evaluate for Ramsay Hunt syndrome.","short":"Facial / ear exam"},{"id":"neuro-assessment","label":"CNS / dissemination assessment","tags":["zoster-cns","disseminated-zoster"],"scale":"low","line":"A neurologic assessment and evaluation for dissemination were performed when systemic or CNS symptoms were present.","short":"CNS / dissemination"}],"checks":[{"if":"zoster-ophthalmicus","needs":["eye-exam"],"mode":"any","warn":"Zoster ophthalmicus threatens vision — document the Hutchinson sign and eye exam, and involve ophthalmology when the eye is at risk."},{"if":"disseminated-zoster","needs":["immune-status","neuro-assessment"],"mode":"any","warn":"Disseminated zoster in the immunocompromised is dangerous — document immune status and assess for cross-dermatomal or visceral spread."},{"if":"ramsay-hunt","needs":["facial-ear-exam"],"mode":"any","warn":"Ramsay Hunt is easily missed — examine the ear and facial nerve, as early therapy improves outcomes."}],"history":[{"id":"hz-hx-rash","dx":"general","q":"Painful rash — burning or tingling pain followed by a unilateral band-like vesicular eruption?","answers":[{"label":"Bilateral or non-dermatomal rash","tone":"neg","sets":[],"ddx":[],"mdm":"The eruption was not in a unilateral dermatomal pattern, prompting reconsideration of the diagnosis.","frag":"non-dermatomal rash"},{"label":"Unilateral dermatomal painful vesicles","tone":"pos","sets":[],"ddx":[],"mdm":"A painful unilateral dermatomal vesicular eruption preceded by burning pain was reported, consistent with herpes zoster.","frag":"dermatomal vesicular rash"}]},{"id":"hz-hx-eye","dx":"zoster-ophthalmicus","q":"Forehead, eyelid, or nose-tip involvement, eye pain, redness, or vision change?","answers":[{"label":"No facial or ocular involvement","tone":"neg","sets":[],"ddx":[],"mdm":"There was no forehead, nasal, or ocular involvement and no visual symptoms.","frag":"no ocular involvement"},{"label":"Forehead/nose-tip lesions or eye symptoms","tone":"pos","sets":[],"ddx":[{"id":"zoster-ophthalmicus","keep":true}],"mdm":"Lesions on the forehead or nose tip or ocular symptoms were reported, concerning for zoster ophthalmicus and prompting eye examination.","frag":"ophthalmic involvement"}]},{"id":"hz-hx-immune","dx":"disseminated-zoster","q":"Immunocompromise — HIV, active malignancy, transplant, or immunosuppressive medications?","answers":[{"label":"Immunocompetent","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was immunocompetent, without HIV, active malignancy, transplant, or immunosuppressive medications, and so without dissemination risk factors.","frag":"immunocompetent"},{"label":"Immunocompromised","tone":"pos","sets":[],"ddx":[{"id":"disseminated-zoster","keep":true}],"mdm":"The patient was immunocompromised (by HIV, active malignancy, transplant, or immunosuppressive medications), raising the risk of disseminated zoster and lowering the threshold for systemic therapy and isolation.","frag":"immunocompromised"}]},{"id":"hz-hx-ear","dx":"ramsay-hunt","q":"Ear pain, hearing change, vertigo, or facial weakness?","answers":[{"label":"No ear or facial nerve symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No ear pain, hearing change, vertigo, or facial weakness was reported.","frag":"no ear/facial symptoms"},{"label":"Ear pain / facial weakness / vertigo","tone":"pos","sets":[],"ddx":[{"id":"ramsay-hunt","keep":true}],"mdm":"Ear pain, facial weakness, or vertigo was reported, concerning for Ramsay Hunt syndrome.","frag":"ear pain / facial weakness"}]},{"id":"hz-hx-cns","dx":"zoster-cns","q":"Severe headache, confusion, neck stiffness, or new limb weakness?","answers":[{"label":"No CNS symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No headache, confusion, neck stiffness, or weakness to suggest CNS involvement was reported.","frag":"no CNS symptoms"},{"label":"Headache / confusion / focal deficit","tone":"pos","sets":[],"ddx":[{"id":"zoster-cns","keep":true}],"mdm":"Headache, confusion, or a focal deficit was reported, prompting evaluation for zoster encephalitis or myelitis.","frag":"CNS symptoms"}]}],"exam":[{"id":"hz-exam-distribution","dx":"pre-eruptive-mimic","q":"Skin examination — is the eruption a unilateral dermatomal pattern, or is pain present without a rash?","answers":[{"label":"Clear unilateral dermatomal eruption","tone":"neg","sets":[],"ddx":[],"mdm":"A clear unilateral dermatomal vesicular eruption was present, supporting zoster.","frag":"dermatomal eruption present"},{"label":"Pain without rash (pre-eruptive)","tone":"pos","sets":[],"ddx":[{"id":"pre-eruptive-mimic","keep":true}],"mdm":"Dermatomal pain was present without a rash, so visceral mimics appropriate to the dermatome were considered before attributing pain to zoster.","frag":"pre-eruptive pain, no rash"}]},{"id":"hz-exam-eye","dx":"zoster-ophthalmicus","q":"Eye examination — Hutchinson sign, conjunctival injection, corneal fluorescein uptake, or visual acuity change?","answers":[{"label":"Normal eye exam","tone":"neg","sets":[],"ddx":[],"mdm":"The eye examination was normal with no Hutchinson sign or corneal uptake.","frag":"normal eye exam"},{"label":"Hutchinson sign / corneal uptake / decreased acuity","tone":"pos","sets":[],"ddx":[{"id":"zoster-ophthalmicus","keep":true}],"mdm":"A Hutchinson sign, corneal fluorescein uptake, or decreased acuity was present, concerning for sight-threatening zoster ophthalmicus.","frag":"Hutchinson / corneal involvement"}]},{"id":"hz-exam-spread","dx":"disseminated-zoster","q":"Are vesicles confined to one dermatome, or are there scattered lesions crossing dermatomes?","answers":[{"label":"Confined to a single dermatome","tone":"neg","sets":[],"ddx":[],"mdm":"Vesicles were confined to a single dermatome without dissemination.","frag":"single dermatome"},{"label":"Lesions crossing dermatomes","tone":"pos","sets":[],"ddx":[{"id":"disseminated-zoster","keep":true}],"mdm":"Vesicles crossing dermatomes or scattered lesions were present, concerning for disseminated zoster.","frag":"cross-dermatomal spread"}]},{"id":"hz-exam-superinfect","dx":"bacterial-superinfection","q":"Surrounding skin — spreading erythema, warmth, fluctuance, or purulent drainage?","answers":[{"label":"No superinfection","tone":"neg","sets":[],"ddx":[],"mdm":"There was no spreading erythema, warmth, or purulence to suggest superinfection.","frag":"no superinfection"},{"label":"Spreading erythema / purulence","tone":"pos","sets":[],"ddx":[{"id":"bacterial-superinfection","keep":true}],"mdm":"Spreading erythema, warmth, or purulence beyond the dermatome was present, concerning for bacterial superinfection.","frag":"spreading erythema / purulence"}]}],"conclusions":["herpes zoster, uncomplicated","herpes zoster ophthalmicus","disseminated herpes zoster"],"specs":["id","derm"]},{"id":"lyme-disease","title":"Early Lyme Disease","kind":"diagnosis","aliases":["lyme","lyme disease","borreliosis","erythema migrans","tick bite illness","bullseye rash","borrelia","early lyme","em rash","neuroborreliosis"],"opening":"The patient was evaluated for early Lyme disease after possible tick exposure with erythema migrans or a viral-like illness. Lyme carditis with high-grade heart block and neuroborreliosis were treated as the can't-miss complications, and the mimics and complications below were actively considered.","ddx":[{"id":"lyme-carditis","group":"lifethreat","label":"Lyme carditis / high-grade AV block","default":true,"tags":["lyme-carditis"],"ruleout":"Lyme carditis with high-grade AV block was considered; there was no syncope, palpitations, dyspnea, or bradycardia, and the ECG showed a normal PR interval without conduction delay, making it unlikely.","miss":3},{"id":"neuroborreliosis","group":"lifethreat","label":"Lyme meningitis / neuroborreliosis","default":true,"tags":["neuroborreliosis"],"ruleout":"Neuroborreliosis was considered; there was no meningismus, facial or other cranial neuropathy, or radicular pain, and the neurologic and cranial nerve examination was normal, making it unlikely.","miss":4},{"id":"early-disseminated","group":"other","label":"Early disseminated (multiple EM)","default":false,"tags":["early-disseminated"],"ruleout":"Early disseminated disease with multiple erythema migrans lesions was considered, indicating spirochetemia and the need for systemic rather than localized treatment.","miss":1},{"id":"coinfection","group":"other","label":"Co-infection (anaplasmosis / babesiosis)","default":false,"tags":["coinfection"],"ruleout":"Tick-borne co-infection with anaplasmosis or babesiosis was considered, particularly with high fever or cytopenias, and a CBC with smear was reviewed.","miss":1},{"id":"cellulitis-mimic","group":"common","label":"Cellulitis (mimic of single EM)","default":false,"tags":["cellulitis-mimic"],"ruleout":"Cellulitis was considered as a mimic of a single erythema migrans lesion; the time course, central clearing, lack of warmth or pain, and tick exposure were used to distinguish them.","miss":2},{"id":"septic-arthritis-mimic","group":"common","label":"Septic arthritis (mimic of Lyme arthritis)","default":false,"tags":["septic-arthritis-mimic"],"ruleout":"Septic arthritis was considered as a mimic of Lyme arthritis in a hot, swollen joint; arthrocentesis was considered to exclude a bacterial joint infection.","miss":4}],"risk":[{"id":"exposure-hx","label":"Tick exposure / endemic area","tags":["early-disseminated","coinfection"],"scale":"low","line":"Tick exposure, outdoor activity, and residence or travel in an endemic area were documented to establish pretest probability.","short":"Tick / endemic exposure"},{"id":"em-exam","label":"Erythema migrans exam","tags":["cellulitis-mimic","early-disseminated"],"scale":"low","line":"The skin was examined for one or more expanding erythema migrans lesions with central clearing.","short":"EM exam"},{"id":"ecg-pr","label":"ECG (PR interval)","tags":["lyme-carditis"],"scale":"low","line":"An ECG with attention to the PR interval and conduction was obtained when cardiac symptoms were present to evaluate for Lyme carditis.","short":"ECG / PR"},{"id":"neuro-cn-exam","label":"Neuro & cranial nerve exam","tags":["neuroborreliosis"],"scale":"low","line":"A neurologic and cranial nerve examination, including for facial palsy and meningismus, was performed.","short":"Neuro / CN exam"},{"id":"serology-caveat","label":"Two-tier serology (caveats)","tags":["early-disseminated","neuroborreliosis"],"scale":"low","line":"Two-tier serology was interpreted with the caveat that it is frequently negative in early disease, so a treatment decision was based on clinical findings.","short":"Serology caveats"},{"id":"cbc-coinfection","label":"CBC / smear for co-infection","tags":["coinfection"],"scale":"low","line":"A CBC with peripheral smear was reviewed for cytopenias or parasitemia suggesting anaplasmosis or babesiosis.","short":"CBC / smear"}],"checks":[{"if":"lyme-carditis","needs":["ecg-pr"],"mode":"any","warn":"Lyme carditis can cause rapidly progressive heart block — obtain an ECG and check the PR interval whenever cardiac symptoms are present."},{"if":"neuroborreliosis","needs":["neuro-cn-exam"],"mode":"any","warn":"Neuroborreliosis is easily missed — examine for facial palsy and meningismus, as early serology is often negative."},{"if":"early-disseminated","needs":["serology-caveat","em-exam"],"mode":"any","warn":"Early serology is frequently negative — treat based on erythema migrans and exposure rather than waiting on antibody results."}],"history":[{"id":"lyme-hx-exposure","dx":"general","q":"Tick exposure — known tick bite, outdoor activity, or residence or travel in an endemic area?","answers":[{"label":"No tick exposure or endemic risk","tone":"neg","sets":[],"ddx":[],"mdm":"No tick exposure was identified: no known tick bite, outdoor activity, or residence or travel in an endemic area.","frag":"no tick exposure"},{"label":"Tick bite / endemic exposure","tone":"pos","sets":[],"ddx":[],"mdm":"A tick exposure was reported (a known tick bite, outdoor activity, or residence or travel in an endemic area), raising the pretest probability of Lyme disease.","frag":"tick / endemic exposure"}]},{"id":"lyme-hx-cardiac","dx":"lyme-carditis","q":"Palpitations, lightheadedness, syncope, or exertional dyspnea?","answers":[{"label":"No cardiac symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No palpitations, lightheadedness, syncope, or dyspnea was reported.","frag":"no cardiac symptoms"},{"label":"Palpitations / syncope / dyspnea","tone":"pos","sets":[],"ddx":[{"id":"lyme-carditis","keep":true}],"mdm":"Palpitations, lightheadedness, or syncope was reported, concerning for Lyme carditis and prompting an ECG.","frag":"palpitations / syncope"}]},{"id":"lyme-hx-neuro","dx":"neuroborreliosis","q":"Headache, neck stiffness, facial droop, or radiating limb pain?","answers":[{"label":"No neurologic symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No headache, neck stiffness, facial droop, or radicular pain was reported.","frag":"no neuro symptoms"},{"label":"Facial droop / meningismus / radicular pain","tone":"pos","sets":[],"ddx":[{"id":"neuroborreliosis","keep":true}],"mdm":"Facial droop, headache with neck stiffness, or radicular pain was reported, concerning for neuroborreliosis.","frag":"facial droop / meningismus"}]},{"id":"lyme-hx-multiple","dx":"early-disseminated","q":"More than one expanding rash, or systemic symptoms such as fever, myalgias, and migratory arthralgias?","answers":[{"label":"Single localized lesion only","tone":"neg","sets":[],"ddx":[],"mdm":"Findings were limited to a single localized lesion without dissemination.","frag":"single lesion"},{"label":"Multiple lesions / systemic symptoms","tone":"pos","sets":[],"ddx":[{"id":"early-disseminated","keep":true}],"mdm":"Multiple lesions or systemic symptoms were reported, consistent with early disseminated disease.","frag":"multiple lesions / systemic"}]},{"id":"lyme-hx-coinfection","dx":"coinfection","q":"High persistent fever, severe headache, or pronounced fatigue out of proportion to the rash?","answers":[{"label":"No features of co-infection","tone":"neg","sets":[],"ddx":[],"mdm":"No high fever or features suggesting a tick-borne co-infection were reported.","frag":"no co-infection features"},{"label":"High fever / severe systemic illness","tone":"pos","sets":[],"ddx":[{"id":"coinfection","keep":true}],"mdm":"High fever or pronounced systemic illness was reported, prompting consideration of anaplasmosis or babesiosis co-infection.","frag":"co-infection features"}]}],"exam":[{"id":"lyme-exam-skin","dx":"cellulitis-mimic","q":"Skin examination — expanding erythema migrans with central clearing versus a warm, tender, purulent area?","answers":[{"label":"Erythema migrans pattern","tone":"neg","sets":[],"ddx":[],"mdm":"An expanding erythematous lesion with central clearing consistent with erythema migrans was present.","frag":"erythema migrans"},{"label":"Warm, tender, purulent area","tone":"pos","sets":[],"ddx":[{"id":"cellulitis-mimic","keep":true}],"mdm":"A warm, tender, or purulent area was present, raising concern for cellulitis as a mimic.","frag":"warm tender area"}]},{"id":"lyme-exam-cardiac","dx":"lyme-carditis","q":"Cardiac examination and ECG — bradycardia, irregular rhythm, or PR prolongation / heart block?","answers":[{"label":"Normal rate, rhythm, and conduction","tone":"neg","sets":[],"ddx":[],"mdm":"The cardiac examination and ECG showed a normal rate, rhythm, and conduction, without bradycardia, irregular rhythm, or PR prolongation/heart block.","frag":"normal cardiac exam/ECG"},{"label":"Bradycardia / AV block","tone":"pos","sets":[],"ddx":[{"id":"lyme-carditis","keep":true}],"mdm":"Bradycardia, an irregular rhythm, or PR prolongation / AV block was present, concerning for Lyme carditis.","frag":"bradycardia / AV block"}]},{"id":"lyme-exam-neuro","dx":"neuroborreliosis","q":"Neurologic and cranial nerve examination — facial palsy, meningismus, or focal deficits?","answers":[{"label":"Normal neurologic exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic and cranial nerve examination was normal, without facial palsy, meningismus, or focal deficits.","frag":"normal neuro exam"},{"label":"Facial palsy / meningismus / focal deficit","tone":"pos","sets":[],"ddx":[{"id":"neuroborreliosis","keep":true}],"mdm":"A facial palsy, meningismus, or focal deficit was present, concerning for neuroborreliosis.","frag":"facial palsy / meningismus"}]},{"id":"lyme-exam-joint","dx":"septic-arthritis-mimic","q":"Joint examination — a hot, swollen, exquisitely painful joint with inability to bear weight?","answers":[{"label":"No acute monoarthritis","tone":"neg","sets":[],"ddx":[],"mdm":"No hot, swollen, exquisitely painful joint was present.","frag":"no acute monoarthritis"},{"label":"Hot, swollen, painful joint","tone":"pos","sets":[],"ddx":[{"id":"septic-arthritis-mimic","keep":true}],"mdm":"A hot, swollen, exquisitely painful joint was present, prompting consideration of septic arthritis as a mimic and arthrocentesis.","frag":"hot swollen joint"}]}],"conclusions":["early localized lyme disease (erythema migrans)","early disseminated lyme disease","lyme disease, carditis ruled out"],"specs":["id"]},{"id":"bells-palsy","kind":"diagnosis","title":"Bell's Palsy","aliases":["bell palsy","facial palsy","facial droop","facial nerve palsy","seventh nerve palsy","peripheral facial weakness","facial paralysis","idiopathic facial paralysis","cranial nerve vii palsy","one-sided facial weakness"],"opening":"The patient was evaluated for acute unilateral facial weakness consistent with a peripheral (Bell's) palsy. A central cause with forehead sparing and other dangerous mimics and complications were actively considered.","ddx":[{"id":"central-facial","group":"lifethreat","label":"Central facial weakness (stroke)","default":true,"tags":["central-facial"],"ruleout":"Central facial weakness from stroke was considered; the weakness involved the forehead consistent with a peripheral lesion, there were no additional focal neurologic deficits, and the onset was subacute, making a central cause unlikely.","miss":4},{"id":"brainstem-mass","group":"lifethreat","label":"Brainstem / posterior fossa lesion","default":false,"tags":["brainstem-mass"],"ruleout":"Brainstem or posterior fossa lesion was considered; there were no other cranial nerve deficits, ataxia, long-tract signs, or progressive course, with the isolated peripheral facial palsy making a structural intracranial lesion unlikely.","miss":3},{"id":"ramsay-hunt","group":"common","label":"Ramsay Hunt (zoster oticus)","default":true,"tags":["ramsay-hunt"],"ruleout":"Ramsay Hunt syndrome was considered; the ear, canal, and palate were examined for vesicles and the patient was asked about severe ear pain and hearing change, as this alters treatment and prognosis.","miss":2},{"id":"lyme-facial","group":"common","label":"Lyme disease facial palsy","default":false,"tags":["lyme-facial"],"ruleout":"Lyme-associated facial palsy was considered given tick exposure, endemic-area travel, or bilateral involvement, with serologic testing and antibiotic therapy arranged where indicated.","miss":2},{"id":"otitis-mastoid","group":"other","label":"Otitis media / mastoiditis / cholesteatoma","default":false,"tags":["otitis-mastoid"],"ruleout":"A complicated middle-ear or mastoid process such as otitis media, mastoiditis, or cholesteatoma was considered as a cause of facial nerve involvement; the ear examination did not show an effusion, postauricular swelling, or other concerning findings.","miss":1},{"id":"exposure-keratopathy","group":"other","label":"Exposure keratopathy (eye complication)","default":true,"tags":["exposure-keratopathy"],"ruleout":"Incomplete eye closure with resulting exposure keratopathy was addressed as a key complication; corneal protection with lubrication and taping was discussed to prevent corneal injury.","miss":1}],"risk":[{"id":"forehead-test","label":"Forehead movement","tags":["central-facial"],"scale":"low","line":"Forehead movement was specifically tested, as sparing of the forehead points to a central lesion and weakness of the forehead supports a peripheral palsy.","short":"Forehead tested"},{"id":"full-neuro","label":"Full neuro exam","tags":["central-facial","brainstem-mass"],"scale":"low","line":"A full neurologic examination was performed to detect other deficits such as limb weakness, ataxia, dysarthria, or additional cranial nerve findings.","short":"Full neuro exam"},{"id":"ear-vesicle-exam","label":"Ear / vesicle exam","tags":["ramsay-hunt","otitis-mastoid"],"scale":"low","line":"The ear, canal, and oropharynx were examined for vesicles, effusion, or mastoid findings to evaluate for Ramsay Hunt and a complicated otologic cause.","short":"Ear exam"},{"id":"lyme-eval","label":"Lyme / tick exposure","tags":["lyme-facial"],"scale":"low","line":"Tick exposure and endemic-area risk were assessed and Lyme serology was sent where indicated, especially for bilateral palsy.","short":"Lyme exposure"},{"id":"hb-grade","label":"House-Brackmann grade","tags":["central-facial"],"scale":"low","line":"The severity of the facial weakness was graded using a standard facial-function scale to document baseline and track recovery.","short":"Severity graded"},{"id":"corneal-protect","label":"Corneal protection","tags":["exposure-keratopathy"],"scale":"low","line":"Eye closure and corneal protection were assessed and lubrication with eye protection was arranged to prevent exposure keratopathy.","short":"Eye protection"}],"checks":[{"if":"central-facial","needs":["forehead-test","full-neuro"],"mode":"any","warn":"Document forehead movement and a full neuro exam - forehead sparing or other deficits mean stroke workup, not Bell's palsy."},{"if":"ramsay-hunt","needs":["ear-vesicle-exam"],"mode":"any","warn":"Examine the ear and palate for vesicles - missed Ramsay Hunt has a worse prognosis and different treatment."},{"if":"exposure-keratopathy","needs":["corneal-protect"],"mode":"any","warn":"Address eye protection - incomplete closure risks corneal injury without lubrication and taping."},{"if":"lyme-facial","needs":["lyme-eval"],"mode":"any","warn":"Ask about tick exposure and consider Lyme, especially with bilateral facial palsy."}],"history":[{"id":"bp-hx-onset","dx":"central-facial","q":"Onset and other neurologic symptoms - sudden weakness with limb numbness, slurred speech, vision change, or vertigo?","answers":[{"label":"Isolated facial weakness, no other deficits","tone":"neg","sets":[],"ddx":[],"mdm":"Onset was that of isolated facial weakness without limb, speech, vision, or balance symptoms.","frag":"isolated facial weakness"},{"label":"Other neurologic symptoms present","tone":"pos","sets":[],"ddx":[{"id":"central-facial","keep":true},{"id":"brainstem-mass","keep":true}],"mdm":"Additional neurologic symptoms such as limb weakness, slurred speech, vision change, or vertigo were reported, raising concern for a central cause.","frag":"other neuro symptoms"}]},{"id":"bp-hx-ear","dx":"ramsay-hunt","q":"Severe ear pain, ear rash or blisters, hearing change, or vertigo (suggesting zoster oticus)?","answers":[{"label":"No ear pain, rash, or hearing change","tone":"neg","sets":[],"ddx":[],"mdm":"No severe ear pain, ear rash, hearing change, or vertigo to suggest Ramsay Hunt was reported.","frag":"no ear symptoms"},{"label":"Ear pain / rash / hearing change","tone":"pos","sets":[],"ddx":[{"id":"ramsay-hunt","keep":true}],"mdm":"Severe ear pain, an ear rash, or hearing change was reported, raising concern for Ramsay Hunt syndrome.","frag":"ear pain / rash"}]},{"id":"bp-hx-tick","dx":"lyme-facial","q":"Tick exposure, recent rash, or residence in or travel to a Lyme-endemic area?","answers":[{"label":"No tick exposure or endemic risk","tone":"neg","sets":[],"ddx":[],"mdm":"No tick exposure, rash, or endemic-area risk for Lyme disease was reported.","frag":"no tick exposure"},{"label":"Tick exposure / endemic area","tone":"pos","sets":[],"ddx":[{"id":"lyme-facial","keep":true}],"mdm":"Tick exposure, a recent rash, or endemic-area risk was reported, prompting consideration of Lyme-associated facial palsy.","frag":"tick exposure / endemic"}]},{"id":"bp-hx-bilateral","dx":"lyme-facial","q":"Is the weakness one-sided, or are both sides of the face involved (a red flag)?","answers":[{"label":"Unilateral weakness","tone":"neg","sets":[],"ddx":[],"mdm":"The weakness was unilateral, consistent with a typical Bell's palsy presentation.","frag":"unilateral"},{"label":"Bilateral facial weakness","tone":"pos","sets":[],"ddx":[{"id":"lyme-facial","keep":true}],"mdm":"Bilateral facial weakness was reported, a red flag prompting evaluation for Lyme disease and other systemic causes.","frag":"bilateral palsy"}]},{"id":"bp-hx-eye","dx":"exposure-keratopathy","q":"Can the patient close the affected eye, and is there eye irritation, redness, or dryness?","answers":[{"label":"Eye closes, no irritation","tone":"neg","sets":[],"ddx":[],"mdm":"The patient could close the affected eye without significant irritation or dryness.","frag":"eye closes"},{"label":"Incomplete closure / eye irritation","tone":"pos","sets":[],"ddx":[{"id":"exposure-keratopathy","keep":true}],"mdm":"The patient could not fully close the eye or reported irritation, raising the risk of exposure keratopathy and the need for corneal protection.","frag":"incomplete closure"}]}],"exam":[{"id":"bp-exam-forehead","dx":"central-facial","q":"Forehead and facial movement - is the forehead involved (peripheral) or spared (central)?","answers":[{"label":"Forehead involved (peripheral pattern)","tone":"neg","sets":[],"ddx":[],"mdm":"The forehead was involved on the weak side, consistent with a peripheral facial nerve palsy.","frag":"forehead involved"},{"label":"Forehead spared (central pattern)","tone":"pos","sets":[],"ddx":[{"id":"central-facial","keep":true}],"mdm":"The forehead was spared on the weak side, a central pattern that warrants stroke evaluation rather than a diagnosis of Bell's palsy.","frag":"forehead spared"}]},{"id":"bp-exam-neuro","dx":"brainstem-mass","q":"Neurologic examination - limb strength, coordination, gait, speech, and other cranial nerves?","answers":[{"label":"Non-focal aside from facial nerve","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal apart from the facial weakness, with no limb, cerebellar, or other cranial nerve findings.","frag":"non-focal exam"},{"label":"Additional deficits / cranial nerves","tone":"pos","sets":[],"ddx":[{"id":"brainstem-mass","keep":true},{"id":"central-facial","keep":true}],"mdm":"Additional neurologic deficits or other cranial nerve findings were present, concerning for a brainstem or posterior fossa lesion.","frag":"additional deficits"}]},{"id":"bp-exam-ear","dx":"ramsay-hunt","q":"Ear and oropharynx examination - vesicles in the canal or on the palate, effusion, or postauricular swelling?","answers":[{"label":"No vesicles, effusion, or mastoid findings","tone":"neg","sets":[],"ddx":[],"mdm":"The ear, canal, and palate showed no vesicles, no effusion, and no postauricular swelling.","frag":"ear exam normal"},{"label":"Vesicles present","tone":"pos","sets":[],"ddx":[{"id":"ramsay-hunt","keep":true}],"mdm":"Vesicles were seen in the ear canal or on the palate, consistent with Ramsay Hunt syndrome.","frag":"vesicles present"},{"label":"Effusion / mastoid findings","tone":"pos","sets":[],"ddx":[{"id":"otitis-mastoid","keep":true}],"mdm":"A middle-ear effusion or postauricular swelling was present, raising concern for a complicated otologic cause.","frag":"effusion / mastoid"}]},{"id":"bp-exam-eye","dx":"exposure-keratopathy","q":"Eye examination - completeness of closure, Bell's phenomenon, and corneal appearance?","answers":[{"label":"Complete closure, cornea clear","tone":"neg","sets":[],"ddx":[],"mdm":"Eye closure was complete and the cornea appeared clear without signs of exposure.","frag":"closure complete"},{"label":"Incomplete closure / corneal exposure","tone":"pos","sets":[],"ddx":[{"id":"exposure-keratopathy","keep":true}],"mdm":"Eye closure was incomplete with corneal exposure, requiring lubrication and protection to prevent keratopathy.","frag":"incomplete closure"}]}],"conclusions":["bell's palsy (peripheral cn vii palsy)","peripheral facial palsy, forehead involved"],"specs":["neuro"]},{"id":"guillain-barre","kind":"diagnosis","title":"Guillain-Barré Syndrome","aliases":["gbs","guillain barre","ascending paralysis","ascending weakness","aidp","acute inflammatory demyelinating polyneuropathy","areflexic weakness","miller fisher","acute polyneuropathy","symmetric ascending weakness"],"opening":"The patient was evaluated for acute ascending weakness suggestive of Guillain-Barré syndrome. Impending respiratory failure, autonomic instability, and dangerous mimics such as cord compression were actively assessed.","ddx":[{"id":"resp-failure","group":"lifethreat","label":"Respiratory failure (diaphragm weakness)","default":true,"tags":["resp-failure"],"ruleout":"Neuromuscular respiratory failure was considered; the patient had no dyspnea, paradoxical abdominal breathing, weak cough, or single-breath count limitation, with preserved vital capacity and negative inspiratory force on serial bedside testing, making impending failure unlikely.","miss":3},{"id":"autonomic-instability","group":"lifethreat","label":"Autonomic instability / arrhythmia","default":true,"tags":["autonomic-instability"],"ruleout":"Autonomic instability was considered; there were no labile blood pressures, no resting tachycardia or unexplained bradycardia, no arrhythmia on continuous cardiac monitoring, and no urinary retention or ileus, making dangerous dysautonomia unlikely.","miss":3},{"id":"cord-compression","group":"lifethreat","label":"Cord compression / transverse myelitis","default":true,"tags":["cord-compression"],"ruleout":"Cord compression or transverse myelitis was considered; there was no discrete sensory level, no back pain, and no bowel or bladder dysfunction, with weakness ascending and areflexic rather than spastic, making a compressive cord lesion unlikely.","miss":4},{"id":"botulism","group":"common","label":"Botulism","default":false,"tags":["botulism"],"ruleout":"Botulism was considered, particularly with a descending pattern, prominent bulbar findings, or pupillary involvement, which would distinguish it from the typical ascending pattern.","miss":2},{"id":"tick-paralysis","group":"other","label":"Tick paralysis","default":false,"tags":["tick-paralysis"],"ruleout":"Tick paralysis was considered given exposure history; a thorough skin and scalp search for an attached tick was performed as removal can be curative.","miss":1},{"id":"myasthenia","group":"common","label":"Myasthenia gravis","default":false,"tags":["myasthenia"],"ruleout":"Myasthenia gravis was considered given fatigable weakness with ocular or bulbar predominance and preserved reflexes, distinguishing it from areflexic ascending weakness.","miss":2},{"id":"hypokalemia","group":"other","label":"Hypokalemia / electrolyte cause","default":false,"tags":["hypokalemia"],"ruleout":"An electrolyte cause such as hypokalemia was considered as a reversible mimic of acute weakness and assessed with laboratory testing.","miss":1}],"risk":[{"id":"resp-function","label":"Serial respiratory function","tags":["resp-failure"],"scale":"low","line":"Bedside respiratory function such as vital capacity, negative inspiratory force, or single-breath count was measured serially to detect impending neuromuscular respiratory failure.","short":"Serial FVC/NIF"},{"id":"cardiac-monitor","label":"Cardiac monitoring","tags":["autonomic-instability"],"scale":"low","line":"Continuous cardiac monitoring and serial blood pressure assessment were used to detect autonomic instability and arrhythmia.","short":"Cardiac monitor"},{"id":"reflex-exam","label":"Reflex exam","tags":["resp-failure","myasthenia"],"scale":"low","line":"Deep tendon reflexes were examined, with areflexia or hyporeflexia supporting Guillain-Barré syndrome.","short":"Reflexes checked"},{"id":"sensory-level","label":"Sensory level exam","tags":["cord-compression"],"scale":"low","line":"The sensory examination was assessed for a discrete spinal sensory level and bowel or bladder dysfunction to evaluate for a cord process.","short":"Sensory level"},{"id":"lp-eval","label":"Lumbar puncture","tags":["resp-failure"],"scale":"low","line":"A lumbar puncture was arranged to look for albuminocytologic dissociation supporting the diagnosis.","short":"LP arranged"},{"id":"electrolytes","label":"Electrolytes","tags":["hypokalemia"],"scale":"low","line":"Electrolytes including potassium were checked to exclude a reversible metabolic cause of weakness.","short":"Electrolytes"},{"id":"neuro-consult","label":"Neurology consult","tags":["resp-failure"],"scale":"low","line":"Neurology was consulted to confirm the diagnosis and guide disposition and treatment.","short":"Neuro consult"}],"checks":[{"if":"resp-failure","needs":["resp-function","neuro-consult"],"mode":"any","warn":"Measure serial respiratory function - do not rely on SpO2 or ABG, which drop late; impending failure can be missed."},{"if":"autonomic-instability","needs":["cardiac-monitor"],"mode":"any","warn":"Place on cardiac monitoring - dysautonomia can cause life-threatening blood pressure swings and arrhythmias."},{"if":"cord-compression","needs":["sensory-level"],"mode":"any","warn":"Check for a sensory level and bowel/bladder dysfunction - cord compression is a treatable mimic that must not be missed."},{"if":"hypokalemia","needs":["electrolytes"],"mode":"any","warn":"Check electrolytes - hypokalemia is a reversible mimic of acute weakness."}],"history":[{"id":"gbs-hx-pattern","dx":"general","q":"Pattern of weakness - is it symmetric and ascending from the legs upward over days?","answers":[{"label":"Symmetric, ascending over days","tone":"neg","sets":[],"ddx":[],"mdm":"The weakness was symmetric and ascending over days, a pattern typical of Guillain-Barré syndrome.","frag":"ascending, symmetric"},{"label":"Descending or bulbar onset","tone":"pos","sets":[],"ddx":[{"id":"botulism","keep":true}],"mdm":"The weakness began with descending or bulbar features, prompting consideration of botulism rather than a typical ascending pattern.","frag":"descending / bulbar"}]},{"id":"gbs-hx-resp","dx":"resp-failure","q":"Breathing difficulty - shortness of breath when lying flat, trouble taking a deep breath, or a weak cough?","answers":[{"label":"No breathing difficulty","tone":"neg","sets":[],"ddx":[],"mdm":"No shortness of breath, orthopnea, or weak cough to suggest respiratory muscle involvement was reported.","frag":"no breathing difficulty"},{"label":"Dyspnea / weak cough / orthopnea","tone":"pos","sets":[],"ddx":[{"id":"resp-failure","keep":true}],"mdm":"Shortness of breath, orthopnea, or a weak cough was reported, concerning for diaphragmatic weakness and impending respiratory failure.","frag":"dyspnea / weak cough"}]},{"id":"gbs-hx-cord","dx":"cord-compression","q":"Back pain, a sensory level on the trunk, or new bowel or bladder dysfunction?","answers":[{"label":"No back pain, level, or sphincter symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No back pain, truncal sensory level, or bowel or bladder dysfunction was reported.","frag":"no cord symptoms"},{"label":"Sensory level / sphincter dysfunction","tone":"pos","sets":[],"ddx":[{"id":"cord-compression","keep":true}],"mdm":"Back pain, a truncal sensory level, or bowel or bladder dysfunction was reported, raising concern for a cord process such as compression or transverse myelitis.","frag":"sensory level / sphincter"}]},{"id":"gbs-hx-tick","dx":"tick-paralysis","q":"Recent tick exposure or time spent in wooded or grassy areas?","answers":[{"label":"No tick exposure","tone":"neg","sets":[],"ddx":[],"mdm":"No tick exposure or relevant outdoor exposure was reported.","frag":"no tick exposure"},{"label":"Tick exposure","tone":"pos","sets":[],"ddx":[{"id":"tick-paralysis","keep":true}],"mdm":"Tick exposure was reported, prompting consideration of tick paralysis and a careful search for an attached tick.","frag":"tick exposure"}]},{"id":"gbs-hx-fatigable","dx":"myasthenia","q":"Fatigable weakness, double vision, droopy eyelids, or worsening through the day?","answers":[{"label":"No fatigable or ocular features","tone":"neg","sets":[],"ddx":[],"mdm":"No fatigable weakness, diplopia, or ptosis to suggest myasthenia gravis was reported.","frag":"no fatigable weakness"},{"label":"Fatigable / ocular weakness","tone":"pos","sets":[],"ddx":[{"id":"myasthenia","keep":true}],"mdm":"Fatigable weakness with ocular or bulbar features was reported, raising consideration of myasthenia gravis.","frag":"fatigable / ocular"}]}],"exam":[{"id":"gbs-exam-reflexes","dx":"general","q":"Deep tendon reflexes - are they reduced or absent?","answers":[{"label":"Hyporeflexic / areflexic","tone":"neg","sets":[],"ddx":[],"mdm":"Deep tendon reflexes were reduced or absent, supporting Guillain-Barré syndrome.","frag":"areflexic"},{"label":"Brisk / hyperreflexic","tone":"pos","sets":[],"ddx":[{"id":"cord-compression","keep":true}],"mdm":"Reflexes were brisk or hyperreflexic, a finding inconsistent with Guillain-Barré and concerning for a central or cord process.","frag":"hyperreflexic"}]},{"id":"gbs-exam-resp","dx":"resp-failure","q":"Respiratory assessment - single-breath count, accessory muscle use, and bedside vital capacity?","answers":[{"label":"Adequate respiratory function","tone":"neg","sets":[],"ddx":[],"mdm":"Bedside respiratory function was adequate without accessory muscle use or a reduced single-breath count.","frag":"adequate respiratory function"},{"label":"Reduced respiratory function","tone":"pos","sets":[],"ddx":[{"id":"resp-failure","keep":true}],"mdm":"Bedside respiratory function was reduced with a low single-breath count or accessory muscle use, concerning for impending respiratory failure.","frag":"reduced respiratory function"}]},{"id":"gbs-exam-autonomic","dx":"autonomic-instability","q":"Vital signs and rhythm - labile blood pressure, fluctuating heart rate, or arrhythmia?","answers":[{"label":"Stable vitals and rhythm","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs and cardiac rhythm were stable without lability or arrhythmia.","frag":"stable vitals"},{"label":"Labile BP / arrhythmia","tone":"pos","sets":[],"ddx":[{"id":"autonomic-instability","keep":true}],"mdm":"Blood pressure lability or an arrhythmia was present, concerning for autonomic instability.","frag":"labile BP / arrhythmia"}]},{"id":"gbs-exam-sensory","dx":"cord-compression","q":"Sensory examination - is there a discrete spinal sensory level?","answers":[{"label":"No discrete sensory level","tone":"neg","sets":[],"ddx":[],"mdm":"The sensory examination showed no discrete spinal level. Because a sensory level is insensitive for cord pathology, its absence was not used alone to exclude a cord process; the reflex pattern, bowel and bladder function, and the imaging threshold carried the distinction.","frag":"no discrete sensory level (insensitive for cord pathology, so reflexes, bowel and bladder function, and the imaging threshold carried the distinction)"},{"label":"Discrete sensory level","tone":"pos","sets":[],"ddx":[{"id":"cord-compression","keep":true}],"mdm":"A discrete spinal sensory level was found, concerning for cord compression or transverse myelitis and prompting urgent imaging.","frag":"sensory level present"}]}],"conclusions":["guillain-barré syndrome (ascending areflexic weakness)","acute polyneuropathy, gbs suspected"],"specs":["neuro"]},{"id":"temporal-arteritis","kind":"diagnosis","title":"Giant Cell (Temporal) Arteritis","aliases":["gca","temporal arteritis","giant cell arteritis","cranial arteritis","horton arteritis","temporal headache elderly","jaw claudication","aion","ischemic optic neuropathy","large vessel vasculitis"],"opening":"The patient, over 50 with a new headache, was evaluated for giant cell (temporal) arteritis. Irreversible vision loss and other vascular complications were treated as the can't-miss threats, with prompt steroid treatment considered ahead of biopsy.","ddx":[{"id":"vision-loss","group":"lifethreat","label":"Vision loss / ischemic optic neuropathy","default":true,"tags":["vision-loss"],"ruleout":"Ischemic optic neuropathy was considered; the patient reported no transient or permanent visual loss, no amaurosis fugax or diplopia, with normal acuity, fields, color vision, and no afferent pupillary defect or pallid disc edema on fundoscopy, making impending vision loss unlikely.","miss":3},{"id":"stroke-vbi","group":"lifethreat","label":"Stroke / vertebrobasilar involvement","default":true,"tags":["stroke-vbi"],"ruleout":"Stroke from vertebrobasilar or cranial artery involvement was considered; there were no new focal deficits, no diplopia, dysarthria, vertigo, or ataxia, and the neurologic exam was non-focal, making cerebrovascular involvement unlikely.","miss":4},{"id":"aortic-large-vessel","group":"other","label":"Aortic aneurysm / large-vessel involvement","default":false,"tags":["aortic-large-vessel"],"ruleout":"Large-vessel involvement including aortic aneurysm or arm claudication was considered, with examination of pulses and blood pressures and follow-up imaging arranged as indicated.","miss":4},{"id":"pmr","group":"common","label":"Polymyalgia rheumatica association","default":false,"tags":["pmr"],"ruleout":"An association with polymyalgia rheumatica was considered given shoulder and hip girdle stiffness, which frequently coexists with giant cell arteritis.","miss":2},{"id":"secondary-headache","group":"common","label":"Other secondary headache","default":false,"tags":["secondary-headache"],"ruleout":"Other secondary causes of a new headache in an older patient were considered, and red-flag features were assessed to determine whether further imaging was warranted.","miss":2},{"id":"jaw-claudication","group":"other","label":"Jaw claudication (ischemic feature)","default":true,"tags":["jaw-claudication"],"ruleout":"Jaw claudication, a relatively specific ischemic feature, was specifically sought as it raises the likelihood of giant cell arteritis and the threat to vision.","miss":1}],"risk":[{"id":"esr-crp","label":"ESR and CRP","tags":["vision-loss","pmr"],"scale":"low","line":"Both ESR and CRP were obtained, as a normal ESR alone does not exclude giant cell arteritis and CRP adds sensitivity.","short":"ESR + CRP"},{"id":"temporal-exam","label":"Temporal artery exam","tags":["jaw-claudication"],"scale":"low","line":"The temporal arteries were examined for tenderness, beading, thickening, or a diminished pulse.","short":"Temporal artery exam"},{"id":"visual-exam","label":"Visual acuity / fundoscopy","tags":["vision-loss"],"scale":"low","line":"Visual acuity and fundoscopy were assessed to detect ischemic optic neuropathy or other ocular ischemia.","short":"Vision / fundoscopy"},{"id":"steroid-decision","label":"Prompt steroid decision","tags":["vision-loss"],"scale":"low","line":"A decision on prompt high-dose steroid treatment was made when GCA was suspected, started without delaying for biopsy to protect vision.","short":"Steroids early"},{"id":"biopsy-arrange","label":"Temporal artery biopsy","tags":["jaw-claudication"],"scale":"low","line":"Temporal artery biopsy was arranged to confirm the diagnosis, recognizing that steroids should not be delayed pending it.","short":"Biopsy arranged"},{"id":"pulse-bp-exam","label":"Pulses / blood pressures","tags":["aortic-large-vessel","stroke-vbi"],"scale":"low","line":"Peripheral pulses and bilateral blood pressures were assessed to detect large-vessel involvement.","short":"Pulses / BPs"}],"checks":[{"if":"vision-loss","needs":["esr-crp","visual-exam","steroid-decision"],"mode":"any","warn":"Do not delay steroids for biopsy and do not anchor on a normal ESR - vision loss is irreversible and the other eye is at risk."},{"if":"jaw-claudication","needs":["temporal-exam","biopsy-arrange"],"mode":"any","warn":"Seek jaw claudication and temporal artery findings, and arrange biopsy without delaying treatment."},{"if":"aortic-large-vessel","needs":["pulse-bp-exam"],"mode":"any","warn":"Check pulses and bilateral blood pressures - large-vessel and aortic involvement can be missed."},{"if":"stroke-vbi","needs":["pulse-bp-exam"],"mode":"any","warn":"New focal deficits or diplopia warrant urgent neurovascular evaluation for vertebrobasilar involvement."}],"history":[{"id":"gca-hx-headache","dx":"secondary-headache","q":"New headache after age 50 - location, scalp tenderness, and whether it differs from prior headaches?","answers":[{"label":"New temporal headache with scalp tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"A new temporal headache with scalp tenderness in an older patient was reported, fitting the pattern of giant cell arteritis.","frag":"new temporal headache"},{"label":"Different pattern / other red flags","tone":"pos","sets":[],"ddx":[{"id":"secondary-headache","keep":true}],"mdm":"The headache had a different pattern or other red-flag features, prompting consideration of another secondary cause and possible imaging.","frag":"other headache red flags"}]},{"id":"gca-hx-vision","dx":"vision-loss","q":"Any visual symptoms - transient or persistent vision loss, double vision, or shadow over the eye?","answers":[{"label":"No visual symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No transient or persistent vision loss, diplopia, or visual obscuration was reported.","frag":"no visual symptoms"},{"label":"Vision loss / amaurosis / diplopia","tone":"pos","sets":[],"ddx":[{"id":"vision-loss","keep":true}],"mdm":"Transient or persistent vision loss, a visual shadow, or diplopia was reported, an ophthalmic emergency requiring immediate steroids to protect both eyes.","frag":"vision loss / amaurosis"}]},{"id":"gca-hx-jaw","dx":"jaw-claudication","q":"Jaw pain or fatigue with chewing (jaw claudication) or tongue pain?","answers":[{"label":"No jaw claudication","tone":"neg","sets":[],"ddx":[],"mdm":"No jaw pain or fatigue with chewing to suggest jaw claudication was reported.","frag":"no jaw claudication"},{"label":"Jaw claudication present","tone":"pos","sets":[],"ddx":[{"id":"jaw-claudication","keep":true},{"id":"vision-loss","keep":true}],"mdm":"Jaw pain or fatigue with chewing was reported, a relatively specific ischemic feature raising the likelihood of giant cell arteritis.","frag":"jaw claudication"}]},{"id":"gca-hx-pmr","dx":"pmr","q":"Shoulder or hip girdle pain and morning stiffness (suggesting polymyalgia rheumatica)?","answers":[{"label":"No girdle stiffness","tone":"neg","sets":[],"ddx":[],"mdm":"No shoulder or hip girdle pain or morning stiffness to suggest polymyalgia rheumatica was reported.","frag":"no girdle stiffness"},{"label":"Girdle pain / morning stiffness","tone":"pos","sets":[],"ddx":[{"id":"pmr","keep":true}],"mdm":"Shoulder or hip girdle pain with morning stiffness was reported, consistent with associated polymyalgia rheumatica.","frag":"girdle stiffness"}]},{"id":"gca-hx-neuro","dx":"stroke-vbi","q":"Focal neurologic symptoms - weakness, slurred speech, vertigo, or new double vision?","answers":[{"label":"No focal neuro symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No focal weakness, speech change, vertigo, or diplopia to suggest cerebrovascular involvement was reported.","frag":"no focal neuro symptoms"},{"label":"Focal deficits / vertigo / diplopia","tone":"pos","sets":[],"ddx":[{"id":"stroke-vbi","keep":true}],"mdm":"Focal deficits, vertigo, or diplopia were reported, concerning for stroke or vertebrobasilar involvement.","frag":"focal deficits"}]}],"exam":[{"id":"gca-exam-temporal","dx":"jaw-claudication","q":"Temporal artery examination - tenderness, thickening, beading, or reduced pulse?","answers":[{"label":"Temporal arteries normal","tone":"neg","sets":[],"ddx":[],"mdm":"The temporal arteries were non-tender with a normal pulse and no beading or thickening.","frag":"temporal arteries normal"},{"label":"Tender / beaded / pulseless artery","tone":"pos","sets":[],"ddx":[{"id":"jaw-claudication","keep":true}],"mdm":"The temporal artery was tender, thickened, beaded, or had a reduced pulse, supporting giant cell arteritis.","frag":"abnormal temporal artery"}]},{"id":"gca-exam-vision","dx":"vision-loss","q":"Visual examination - acuity, pupils, and fundoscopy for optic disc pallor or edema?","answers":[{"label":"Normal acuity and fundoscopy","tone":"neg","sets":[],"ddx":[],"mdm":"Visual acuity, pupils, and fundoscopy were normal without signs of optic nerve ischemia.","frag":"vision exam normal"},{"label":"Reduced acuity / disc edema / APD","tone":"pos","sets":[],"ddx":[{"id":"vision-loss","keep":true}],"mdm":"Reduced acuity, an afferent pupillary defect, or optic disc edema or pallor was found, indicating ischemic optic neuropathy and an emergency for both eyes.","frag":"ischemic optic findings"}]},{"id":"gca-exam-pulses","dx":"aortic-large-vessel","q":"Vascular examination - peripheral pulses, bilateral blood pressures, and bruits?","answers":[{"label":"Symmetric pulses and pressures","tone":"neg","sets":[],"ddx":[],"mdm":"Peripheral pulses were symmetric with equal bilateral blood pressures and no bruits.","frag":"symmetric pulses"},{"label":"Asymmetric pulses / pressures / bruit","tone":"pos","sets":[],"ddx":[{"id":"aortic-large-vessel","keep":true}],"mdm":"Asymmetric pulses, a blood pressure differential, or a bruit was found, concerning for large-vessel involvement.","frag":"asymmetric pulses / bruit"}]},{"id":"gca-exam-neuro","dx":"stroke-vbi","q":"Neurologic examination - focal deficits, cranial nerve findings, or cerebellar signs?","answers":[{"label":"Non-focal neuro exam","tone":"neg","sets":[],"ddx":[],"mdm":"The neurologic examination was non-focal without cranial nerve or cerebellar findings.","frag":"non-focal neuro exam"},{"label":"Focal / cranial nerve / cerebellar signs","tone":"pos","sets":[],"ddx":[{"id":"stroke-vbi","keep":true}],"mdm":"Focal, cranial nerve, or cerebellar findings were present, concerning for vertebrobasilar or cerebral involvement.","frag":"focal neuro findings"}]}],"conclusions":["giant cell (temporal) arteritis, treat empirically","suspected temporal arteritis pending biopsy"],"specs":["neuro","ophtho"]},{"id":"acute-pericarditis","title":"Acute Pericarditis","kind":"diagnosis","aliases":["pericarditis","acute pericarditis","myopericarditis","pericardial effusion","pericardial friction rub","pleuritic chest pain","positional chest pain","viral pericarditis","post-viral chest pain","pericardial inflammation"],"opening":"The patient was evaluated for chest pain with features suggesting acute pericarditis, with attention to its electrocardiographic and positional characteristics. Acute coronary syndrome was treated as the can't-miss mimic, and tamponade, myopericarditis, pulmonary embolism, and aortic dissection were actively considered.","ddx":[{"id":"acs-mi","group":"lifethreat","label":"Acute coronary syndrome / STEMI","default":true,"tags":["acs-mi"],"ruleout":"Acute coronary syndrome, including STEMI, was considered; the ECG showed diffuse concave ST elevation with PR depression rather than a regional infarct pattern, there were no reciprocal changes, the pain was positional and pleuritic rather than exertional, and serial troponin and clinical course were not consistent with infarction, making ischemia unlikely.","miss":4},{"id":"tamponade","group":"lifethreat","label":"Cardiac tamponade / large effusion","default":true,"tags":["tamponade"],"ruleout":"Cardiac tamponade was considered; the patient was normotensive without jugular venous distension, had normal heart sounds and no pulsus paradoxus, and bedside echocardiography showed no significant effusion or diastolic chamber collapse, making tamponade unlikely.","miss":4},{"id":"myopericarditis","group":"lifethreat","label":"Myopericarditis","default":true,"tags":["myopericarditis"],"ruleout":"Myopericarditis was considered; there was no dyspnea, palpitations, or heart-failure symptoms, the troponin was not elevated, and there were no arrhythmias or regional wall-motion abnormality, making significant myocardial involvement unlikely.","miss":3},{"id":"pe","group":"lifethreat","label":"Pulmonary embolism","default":false,"tags":["pe"],"ruleout":"Pulmonary embolism was considered; the patient had no dyspnea, hypoxia, tachycardia, leg swelling, or thromboembolic risk factors, and a low pretest probability with negative D-dimer made PE unlikely.","miss":4},{"id":"dissection","group":"lifethreat","label":"Aortic dissection","default":false,"tags":["dissection"],"ruleout":"Aortic dissection was considered; there was no tearing or migratory pain, no pulse deficit or inter-arm blood-pressure differential, no new aortic regurgitation murmur, and no mediastinal widening, making dissection unlikely.","miss":4},{"id":"esoph-rupture-peri","group":"lifethreat","label":"Esophageal rupture (Boerhaave)","default":false,"tags":["esoph-rupture-peri"],"ruleout":"Esophageal rupture was considered; there was no preceding forceful vomiting or retching, no subcutaneous emphysema or Hamman crunch, and no pneumomediastinum or pleural effusion on imaging, making Boerhaave syndrome unlikely.","miss":4},{"id":"pneumonia-pleuritis","group":"common","label":"Pneumonia / pleuritis","default":false,"tags":["pneumonia-pleuritis"],"ruleout":"Pneumonia or pleuritis was considered as a common cause of pleuritic chest pain; the chest radiograph and examination were reviewed for a focal infiltrate or pleural process.","miss":2}],"risk":[{"id":"ecg-peri","label":"ECG","tags":["acs-mi","myopericarditis"],"scale":"low","line":"An ECG was obtained and examined for diffuse ST elevation with PR depression typical of pericarditis versus a regional ST-elevation pattern with reciprocal changes suggesting infarction.","short":"ECG"},{"id":"trop-peri","label":"Troponin","tags":["acs-mi","myopericarditis"],"scale":"low","line":"A troponin was obtained to evaluate for myocardial injury, which would suggest myopericarditis or an ischemic process.","short":"Troponin"},{"id":"echo-peri","label":"Bedside echo","tags":["tamponade"],"scale":"low","line":"A bedside echocardiogram was performed to assess for a pericardial effusion and for signs of tamponade physiology.","short":"Bedside echo"},{"id":"cxr-peri","label":"Chest x-ray","tags":["pneumonia-pleuritis","pe"],"scale":"low","line":"A chest radiograph was reviewed for an enlarged cardiac silhouette, a pulmonary infiltrate, or a pleural process.","short":"Chest x-ray"},{"id":"hemo-peri","label":"Hemodynamic assessment","tags":["tamponade"],"scale":"low","line":"The hemodynamic status was assessed for hypotension, pulsus paradoxus, and jugular venous distension as markers of tamponade.","short":"Hemodynamics"},{"id":"ctpa-peri","label":"PE workup","tags":["pe"],"scale":"low","line":"When pulmonary embolism was a concern, a D-dimer or CT pulmonary angiography was pursued according to the pretest probability.","short":"PE workup"}],"checks":[{"if":"acs-mi","needs":["ecg-peri","trop-peri"],"mode":"any","warn":"Acute coronary syndrome is on the differential — the ECG and troponin document the distinction between an ischemic pattern and pericarditis so a STEMI is not mislabeled."},{"if":"tamponade","needs":["echo-peri","hemo-peri"],"mode":"any","warn":"Tamponade is on the differential — the bedside echo and hemodynamic assessment document that a large effusion with tamponade physiology was evaluated."},{"if":"myopericarditis","needs":["trop-peri"],"mode":"any","warn":"Myopericarditis is on the differential — a troponin documents whether there is myocardial involvement requiring admission."}],"history":[{"id":"peri-hx-character","dx":"general","q":"Character of the chest pain — is it sharp and pleuritic, worse lying flat and better sitting forward?","answers":[{"label":"Positional / pleuritic pain","tone":"pos","sets":[],"ddx":[{"id":"pneumonia-pleuritis","keep":true}],"mdm":"The pain was sharp and pleuritic, worse when supine and relieved by sitting forward, a pattern characteristic of pericarditis.","frag":"positional, pleuritic pain"},{"label":"Pressure / exertional pain","tone":"pos","sets":[],"ddx":[{"id":"acs-mi","keep":true}],"mdm":"The pain was described as pressure or was exertional, a pattern that raised concern for an ischemic etiology.","frag":"pressure / exertional pain"},{"label":"Pain not positional or pleuritic","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was neither clearly positional nor pleuritic.","frag":"pain not positional/pleuritic"}]},{"id":"peri-hx-prodrome","dx":"myopericarditis","q":"Recent viral prodrome, fever, or symptoms of myocardial involvement such as exertional dyspnea or palpitations?","answers":[{"label":"Viral prodrome only","tone":"neg","sets":[],"ddx":[],"mdm":"A recent viral prodrome was reported without features of myocardial involvement.","frag":"viral prodrome only"},{"label":"Dyspnea / palpitations with prodrome","tone":"pos","sets":[],"ddx":[{"id":"myopericarditis","keep":true}],"mdm":"Exertional dyspnea or palpitations accompanied the prodrome, raising concern for myocardial involvement (myopericarditis).","frag":"dyspnea/palpitations with prodrome"}]},{"id":"peri-hx-ischemic-risk","dx":"acs-mi","q":"Cardiac risk factors and prior coronary disease — does the patient have features that raise the probability of an ischemic cause?","answers":[{"label":"No significant cardiac risk","tone":"neg","sets":[],"ddx":[],"mdm":"No significant cardiac risk factors or prior coronary disease were identified.","frag":"no significant cardiac risk"},{"label":"Cardiac risk factors / prior CAD","tone":"pos","sets":[],"ddx":[{"id":"acs-mi","keep":true}],"mdm":"Cardiac risk factors or known coronary disease were present, lowering the threshold to exclude an ischemic cause before attributing the pain to pericarditis.","frag":"cardiac risk / prior CAD"}]},{"id":"peri-hx-dyspnea","dx":"pe","q":"Sudden dyspnea, hemoptysis, recent immobilization, or leg swelling suggesting pulmonary embolism?","answers":[{"label":"No PE risk features","tone":"neg","sets":[],"ddx":[],"mdm":"No sudden dyspnea, hemoptysis, immobilization, or leg swelling to suggest pulmonary embolism was reported.","frag":"no PE features"},{"label":"PE risk features present","tone":"pos","sets":[],"ddx":[{"id":"pe","keep":true}],"mdm":"Features suggesting pulmonary embolism, such as sudden dyspnea, hemoptysis, immobilization, or leg swelling, were reported.","frag":"PE risk features"}]},{"id":"peri-hx-severe","dx":"dissection","q":"Abrupt, severe, or tearing pain radiating to the back, raising concern for aortic dissection?","answers":[{"label":"No tearing / back pain","tone":"neg","sets":[],"ddx":[],"mdm":"The pain was not abrupt, tearing, or radiating to the back in a manner suggesting dissection.","frag":"no tearing/back pain"},{"label":"Tearing pain to the back","tone":"pos","sets":[],"ddx":[{"id":"dissection","keep":true}],"mdm":"Abrupt, severe, or tearing pain radiating to the back was reported, prompting consideration of aortic dissection.","frag":"tearing pain to back"}]}],"exam":[{"id":"peri-ex-rub","dx":"general","q":"Cardiac auscultation — is a pericardial friction rub present?","answers":[{"label":"No friction rub","tone":"neg","sets":[],"ddx":[],"mdm":"No pericardial friction rub was auscultated, though its absence does not exclude pericarditis.","frag":"no friction rub"},{"label":"Friction rub present","tone":"pos","sets":[],"ddx":[{"id":"myopericarditis","keep":true}],"mdm":"A pericardial friction rub was auscultated, supporting pericardial inflammation.","frag":"friction rub present"}]},{"id":"peri-ex-tamponade","dx":"tamponade","q":"Signs of tamponade — hypotension, jugular venous distension, muffled heart sounds, or pulsus paradoxus?","answers":[{"label":"No tamponade signs","tone":"neg","sets":[],"ddx":[],"mdm":"There were no signs of tamponade such as hypotension, jugular venous distension, muffled heart sounds, or pulsus paradoxus.","frag":"no tamponade signs"},{"label":"Tamponade physiology","tone":"pos","sets":[],"ddx":[{"id":"tamponade","keep":true}],"mdm":"Findings of hypotension, jugular venous distension, muffled heart sounds, or pulsus paradoxus were present, concerning for tamponade.","frag":"tamponade physiology"}]},{"id":"peri-ex-lungs","dx":"pneumonia-pleuritis","q":"Pulmonary examination — focal crackles, decreased breath sounds, or a pleural rub?","answers":[{"label":"Clear lungs","tone":"neg","sets":[],"ddx":[],"mdm":"The lungs were clear without focal findings or a pleural rub.","frag":"clear lungs"},{"label":"Focal lung findings","tone":"pos","sets":[],"ddx":[{"id":"pneumonia-pleuritis","keep":true}],"mdm":"Focal crackles, decreased breath sounds, or a pleural rub were present, suggesting a pulmonary or pleural process.","frag":"focal lung findings"}]},{"id":"peri-ex-perfusion","dx":"acs-mi","q":"Perfusion and distress — is the patient diaphoretic, ill-appearing, or showing signs of poor perfusion?","answers":[{"label":"Well-appearing, well-perfused","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was well-appearing and well-perfused, without diaphoresis, ill appearance, or signs of poor perfusion.","frag":"well-appearing"},{"label":"Diaphoretic / ill-appearing","tone":"pos","sets":[],"ddx":[{"id":"acs-mi","keep":true}],"mdm":"The patient was diaphoretic or ill-appearing, findings that heightened concern for an acute ischemic event.","frag":"diaphoretic / ill-appearing"}]},{"answers":[{"ddx":[],"frag":"no preceding retching, subcutaneous emphysema, or Hamman crunch","label":"No Boerhaave features","mdm":"There was no preceding forceful vomiting or retching, no subcutaneous emphysema or Hamman crunch, and no pneumomediastinum or pleural effusion on imaging, making esophageal rupture (Boerhaave syndrome) unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"esoph-rupture-peri","keep":true}],"frag":"retching with subcutaneous emphysema or Hamman crunch","label":"Boerhaave features present","mdm":"Preceding forceful vomiting or retching with subcutaneous emphysema or a Hamman crunch was present, raising concern for esophageal rupture (Boerhaave syndrome) and warranting contrast imaging.","sets":[],"tone":"pos"}],"dx":"esoph-rupture-peri","id":"peri-exam-esoph-rupture-peri","q":"Esophageal rupture — preceding forceful vomiting or retching, subcutaneous emphysema, or a Hamman crunch?"}],"conclusions":["acute pericarditis, low risk","presumed viral pericarditis","pericarditis, myocardial involvement excluded"],"specs":["cards"]},{"id":"spontaneous-pneumothorax","title":"Spontaneous Pneumothorax","kind":"diagnosis","aliases":["pneumothorax","spontaneous pneumothorax","collapsed lung","ptx","tension pneumothorax","primary spontaneous pneumothorax","secondary spontaneous pneumothorax","pleural air","sudden pleuritic chest pain","hemopneumothorax"],"opening":"The patient was evaluated for sudden pleuritic chest pain and dyspnea concerning for a spontaneous pneumothorax. Tension physiology was treated as the immediate can't-miss complication, and a secondary cause, hemopneumothorax, and cardiac or embolic mimics were actively considered.","ddx":[{"id":"tension-ptx","group":"lifethreat","label":"Tension pneumothorax","default":true,"tags":["tension-ptx"],"ruleout":"Tension pneumothorax was considered; the patient was hemodynamically stable with no hypotension, no tracheal deviation, no distended neck veins, and present bilateral breath sounds, making tension physiology requiring immediate decompression unlikely.","miss":4},{"id":"hemopneumothorax","group":"lifethreat","label":"Hemopneumothorax","default":false,"tags":["hemopneumothorax"],"ruleout":"Hemopneumothorax was considered; the patient was hemodynamically stable without tachycardia or hypotension, hemoglobin was stable, and imaging showed no pleural air-fluid level or layering effusion, making concurrent intrapleural bleeding unlikely.","miss":3},{"id":"secondary-ptx","group":"common","label":"Secondary pneumothorax (underlying lung disease)","default":true,"tags":["secondary-ptx"],"ruleout":"A secondary spontaneous pneumothorax from underlying lung disease such as COPD or emphysema was considered, as it carries higher risk and a lower threshold for intervention than a primary pneumothorax.","miss":2},{"id":"acs-ptx","group":"lifethreat","label":"Acute coronary syndrome","default":false,"tags":["acs-ptx"],"ruleout":"Acute coronary syndrome was considered; the pain was pleuritic and reproducible rather than exertional, with no diaphoresis or radiation, a non-ischemic ECG, and negative troponin, making a cardiac cause unlikely.","miss":4},{"id":"pe-ptx","group":"lifethreat","label":"Pulmonary embolism","default":false,"tags":["pe-ptx"],"ruleout":"Pulmonary embolism was considered; the patient had no leg swelling or thromboembolic risk factors, was not hypoxic or tachycardic out of proportion, and had a low pretest probability with negative D-dimer, making PE unlikely.","miss":4},{"id":"recurrence-ptx","group":"other","label":"Recurrence","default":false,"tags":["recurrence-ptx"],"ruleout":"The risk of recurrence was considered, particularly with prior pneumothorax or persistent underlying lung disease, and factored into disposition and follow-up planning.","miss":1}],"risk":[{"id":"cxr-ptx","label":"Chest x-ray","tags":["secondary-ptx","hemopneumothorax"],"scale":"low","line":"An upright chest radiograph was obtained to confirm and size the pneumothorax, recognizing that a supine film can under-represent or miss anterior pleural air.","short":"Chest x-ray"},{"id":"lus-ptx","label":"Lung ultrasound","tags":["secondary-ptx","tension-ptx"],"scale":"low","line":"Bedside lung ultrasound was used to evaluate for absence of lung sliding and a lung point, which are sensitive findings for pneumothorax including on a supine patient.","short":"Lung ultrasound"},{"id":"tension-assess","label":"Tension assessment","tags":["tension-ptx"],"scale":"low","line":"The patient was assessed clinically for tension physiology (hypotension, tracheal deviation, distended neck veins, and absent breath sounds) with readiness for immediate needle or finger decompression.","short":"Tension assessment"},{"id":"spo2-ptx","label":"Pulse oximetry","tags":["secondary-ptx","pe-ptx"],"scale":"low","line":"Pulse oximetry and the respiratory status were monitored to gauge the degree of physiologic compromise.","short":"Pulse oximetry"},{"id":"ecg-ptx","label":"ECG","tags":["acs-ptx"],"scale":"low","line":"An ECG was obtained when there was concern for a cardiac cause of the chest pain.","short":"ECG"},{"id":"size-ptx","label":"Size estimation","tags":["secondary-ptx"],"scale":"low","line":"The size of the pneumothorax was estimated to guide the choice between observation, aspiration, and tube thoracostomy.","short":"Size estimation"}],"checks":[{"if":"tension-ptx","needs":["tension-assess"],"mode":"any","warn":"Tension pneumothorax is on the differential — document the clinical tension assessment, since tension physiology requires immediate decompression and must not wait for imaging."},{"if":"secondary-ptx","needs":["cxr-ptx","lus-ptx"],"mode":"any","warn":"Pneumothorax is on the differential — a chest radiograph or lung ultrasound documents confirmation and sizing, noting that a supine film may miss it."},{"if":"acs-ptx","needs":["ecg-ptx"],"mode":"any","warn":"A cardiac mimic is on the differential — an ECG documents that an ischemic cause of the chest pain was considered."}],"history":[{"id":"ptx-hx-onset","dx":"general","q":"Onset — sudden pleuritic chest pain and shortness of breath, often at rest?","answers":[{"label":"Sudden pleuritic pain and dyspnea","tone":"pos","sets":[],"ddx":[{"id":"secondary-ptx","keep":true}],"mdm":"The patient reported sudden-onset pleuritic chest pain with dyspnea, a presentation consistent with a spontaneous pneumothorax.","frag":"sudden pleuritic pain and dyspnea"},{"label":"Gradual or atypical onset","tone":"neg","sets":[],"ddx":[],"mdm":"The onset was gradual or atypical rather than the abrupt pleuritic presentation typical of pneumothorax.","frag":"gradual/atypical onset"}]},{"id":"ptx-hx-lungdz","dx":"secondary-ptx","q":"Underlying lung disease — COPD, emphysema, asthma, prior pneumothorax, or smoking history?","answers":[{"label":"No underlying lung disease","tone":"neg","sets":[],"ddx":[],"mdm":"No underlying lung disease (COPD, emphysema, asthma, prior pneumothorax, or smoking history) was reported, favoring a primary spontaneous pneumothorax.","frag":"no underlying lung disease"},{"label":"Underlying lung disease present","tone":"pos","sets":[],"ddx":[{"id":"secondary-ptx","keep":true}],"mdm":"Underlying lung disease such as COPD or emphysema was present, indicating a secondary pneumothorax with higher risk and a lower threshold for intervention.","frag":"underlying lung disease"}]},{"id":"ptx-hx-prior","dx":"recurrence-ptx","q":"Prior pneumothorax on the same or opposite side?","answers":[{"label":"No prior pneumothorax","tone":"neg","sets":[],"ddx":[],"mdm":"No prior pneumothorax was reported.","frag":"no prior pneumothorax"},{"label":"Prior pneumothorax","tone":"pos","sets":[],"ddx":[{"id":"recurrence-ptx","keep":true}],"mdm":"A prior pneumothorax was reported, raising concern for recurrence and informing disposition and follow-up.","frag":"prior pneumothorax"}]},{"id":"ptx-hx-cardiac","dx":"acs-ptx","q":"Features suggesting a cardiac cause — pressure-like or exertional pain, radiation, or cardiac risk factors?","answers":[{"label":"No cardiac features","tone":"neg","sets":[],"ddx":[],"mdm":"No features suggesting an ischemic cardiac cause (pressure-like or exertional pain, radiation, or cardiac risk factors) were reported.","frag":"no cardiac features"},{"label":"Cardiac features present","tone":"pos","sets":[],"ddx":[{"id":"acs-ptx","keep":true}],"mdm":"Features such as pressure-like or exertional pain or cardiac risk factors were present, prompting evaluation for acute coronary syndrome.","frag":"cardiac features"}]},{"id":"ptx-hx-pe","dx":"pe-ptx","q":"Risk for pulmonary embolism — recent immobilization, surgery, malignancy, hemoptysis, or leg swelling?","answers":[{"label":"No PE risk features","tone":"neg","sets":[],"ddx":[],"mdm":"No risk features for pulmonary embolism (recent immobilization, surgery, malignancy, hemoptysis, or leg swelling) were reported.","frag":"no PE risk features"},{"label":"PE risk features present","tone":"pos","sets":[],"ddx":[{"id":"pe-ptx","keep":true}],"mdm":"Risk features for pulmonary embolism such as immobilization, malignancy, or leg swelling were present.","frag":"PE risk features"}]}],"exam":[{"id":"ptx-ex-tension","dx":"tension-ptx","q":"Tension signs — hypotension, tracheal deviation, distended neck veins, and absent breath sounds?","answers":[{"label":"No tension physiology","tone":"neg","sets":[],"ddx":[],"mdm":"There was no hypotension, tracheal deviation, distended neck veins, or absent breath sounds to indicate tension physiology.","frag":"no tension physiology"},{"label":"Tension physiology present","tone":"pos","sets":[],"ddx":[{"id":"tension-ptx","keep":true}],"mdm":"Findings of hypotension, tracheal deviation, distended neck veins, or absent breath sounds were present, indicating tension physiology requiring immediate decompression.","frag":"tension physiology"}]},{"id":"ptx-ex-breath","dx":"secondary-ptx","q":"Lung examination — decreased breath sounds or hyperresonance on the affected side?","answers":[{"label":"Symmetric breath sounds","tone":"neg","sets":[],"ddx":[],"mdm":"Breath sounds were symmetric without focal hyperresonance.","frag":"symmetric breath sounds"},{"label":"Decreased breath sounds / hyperresonance","tone":"pos","sets":[],"ddx":[{"id":"secondary-ptx","keep":true}],"mdm":"Breath sounds were decreased with hyperresonance on the affected side, consistent with a pneumothorax.","frag":"decreased breath sounds / hyperresonance"}]},{"id":"ptx-ex-perfusion","dx":"hemopneumothorax","q":"Hemodynamics and oxygenation — is the patient hypotensive, tachycardic, or hypoxic suggesting bleeding or major compromise?","answers":[{"label":"Stable and well-oxygenated","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable and well-oxygenated, without hypotension, tachycardia, or hypoxia to suggest bleeding or major compromise.","frag":"stable and oxygenated"},{"label":"Unstable / hypoxic","tone":"pos","sets":[],"ddx":[{"id":"hemopneumothorax","keep":true},{"id":"tension-ptx","keep":true}],"mdm":"The patient was hypotensive, tachycardic, or hypoxic, raising concern for hemopneumothorax or tension physiology.","frag":"unstable / hypoxic"}]},{"id":"ptx-ex-us","dx":"secondary-ptx","q":"Bedside lung ultrasound — is lung sliding present, and is a lung point identified?","answers":[{"label":"Lung sliding present","tone":"neg","sets":[],"ddx":[],"mdm":"Lung sliding was present on ultrasound, arguing against a pneumothorax at the interrogated site.","frag":"lung sliding present"},{"label":"Absent sliding / lung point","tone":"pos","sets":[],"ddx":[{"id":"secondary-ptx","keep":true}],"mdm":"Lung sliding was absent with a lung point identified on ultrasound, supporting a pneumothorax.","frag":"absent sliding / lung point"}]}],"conclusions":["primary spontaneous pneumothorax","secondary spontaneous pneumothorax","small pneumothorax, stable for observation"],"specs":["pulm"]},{"id":"thyroid-storm","title":"Thyroid Storm / Thyrotoxicosis","kind":"diagnosis","aliases":["thyroid storm","thyrotoxicosis","thyrotoxic crisis","hyperthyroidism","graves disease","thyroid crisis","apathetic thyrotoxicosis","thyrotoxic atrial fibrillation","decompensated hyperthyroidism","hyperthyroid emergency"],"opening":"The patient was evaluated for thyrotoxicosis with attention to whether decompensated thyroid storm was present. The distinction from uncompensated thyrotoxicosis was made clinically, a precipitant was sought, and sepsis, DKA, sympathomimetic toxicity, agitated delirium, and cardiac complications were actively considered.","ddx":[{"id":"thyroid-storm-dx","group":"lifethreat","label":"Thyroid storm (decompensated)","default":true,"tags":["thyroid-storm-dx"],"ruleout":"Thyroid storm was considered; the patient was afebrile, alert without agitation or delirium, had no heart failure or arrhythmia and no nausea, vomiting, diarrhea, or jaundice, with a low Burch-Wartofsky score indicating thyrotoxicosis without decompensation.","miss":4},{"id":"cardiac-thy","group":"lifethreat","label":"High-output failure / arrhythmia","default":true,"tags":["cardiac-thy"],"ruleout":"A cardiac complication was considered; the patient had no palpitations, the rhythm was sinus without atrial fibrillation or rapid ventricular response on ECG, and there were no signs of high-output failure such as dyspnea, edema, or pulmonary congestion, making cardiac decompensation unlikely.","miss":3},{"id":"sepsis-thy","group":"lifethreat","label":"Sepsis (precipitant & mimic)","default":true,"tags":["sepsis-thy"],"ruleout":"Sepsis was considered as both precipitant and mimic; there was no localizing infectious source, no leukocytosis with left shift, and the patient was not hypotensive or hypoperfused, making an infectious precipitant unlikely.","miss":3},{"id":"dka-thy","group":"lifethreat","label":"Diabetic ketoacidosis","default":false,"tags":["dka-thy"],"ruleout":"Diabetic ketoacidosis was considered; the glucose was normal, there was no anion-gap metabolic acidosis or ketonemia, and the patient had no polyuria, polydipsia, or Kussmaul respirations, making DKA unlikely.","miss":4},{"id":"sympathomimetic-tox-thy","group":"lifethreat","label":"Sympathomimetic / drug toxicity","default":false,"tags":["sympathomimetic-tox-thy"],"ruleout":"Sympathomimetic toxicity was considered; there was no history of stimulant, anticholinergic, or serotonergic drug use, pupils were normal, and there were no clonus or rigidity, making a toxidrome mimicking thyroid storm unlikely.","miss":3},{"id":"sympathomimetic-thy","group":"other","label":"Sympathomimetic toxicity","default":false,"tags":["sympathomimetic-thy"],"ruleout":"Sympathomimetic or stimulant toxicity was considered as a mimic of the adrenergic, hyperthermic presentation; the history of exposures and the clinical pattern were reviewed.","miss":1},{"id":"delirium-thy","group":"other","label":"Agitated delirium","default":false,"tags":["delirium-thy"],"ruleout":"Agitated delirium from another cause was considered, with caution not to anchor on agitation and miss an underlying thyrotoxic or infectious driver.","miss":1}],"risk":[{"id":"tft-thy","label":"Thyroid function tests","tags":["thyroid-storm-dx"],"scale":"low","line":"TSH, free T4, and T3 were obtained to confirm thyrotoxicosis, though treatment of suspected storm was not delayed for the results.","short":"Thyroid function tests"},{"id":"precip-thy","label":"Precipitant search","tags":["thyroid-storm-dx","sepsis-thy"],"scale":"low","line":"A precipitant was actively sought: infection, myocardial ischemia, DKA, recent iodine or contrast load, trauma, or abrupt antithyroid noncompliance.","short":"Precipitant search"},{"id":"ecg-thy","label":"ECG","tags":["cardiac-thy"],"scale":"low","line":"An ECG was obtained to evaluate for atrial fibrillation, rapid ventricular rates, or ischemia.","short":"ECG"},{"id":"temp-ms-thy","label":"Temperature & mental status","tags":["thyroid-storm-dx"],"scale":"low","line":"Temperature and mental status were assessed, as hyperthermia and altered cognition are key features distinguishing storm from uncompensated thyrotoxicosis.","short":"Temp & mental status"},{"id":"glucose-thy","label":"Glucose","tags":["dka-thy"],"scale":"low","line":"A glucose was checked to evaluate for hyperglycemia and DKA as a precipitant or mimic.","short":"Glucose"},{"id":"score-thy","label":"Severity scoring","tags":["thyroid-storm-dx"],"scale":"low","line":"A generic thyrotoxicosis severity-scoring approach was applied, integrating temperature, central nervous system effects, gastrointestinal-hepatic dysfunction, and cardiovascular findings to gauge the likelihood of storm.","short":"Severity scoring"}],"checks":[{"if":"thyroid-storm-dx","needs":["tft-thy","temp-ms-thy","score-thy"],"mode":"any","warn":"Thyroid storm is on the differential — document the thyroid studies, the temperature and mental status, and the severity assessment that separate storm from uncompensated thyrotoxicosis."},{"if":"cardiac-thy","needs":["ecg-thy"],"mode":"any","warn":"A cardiac complication is on the differential — an ECG documents evaluation for atrial fibrillation or high-output failure."},{"if":"sepsis-thy","needs":["precip-thy"],"mode":"any","warn":"Sepsis as a precipitant is on the differential — document the search for an infectious source so the trigger is not missed."},{"if":"dka-thy","needs":["glucose-thy"],"mode":"any","warn":"DKA is on the differential — a glucose documents that hyperglycemic crisis was considered as a precipitant or mimic."}],"history":[{"id":"thy-hx-known","dx":"general","q":"Known hyperthyroidism or Graves disease, and recent antithyroid medication noncompliance?","answers":[{"label":"No known thyroid disease","tone":"neg","sets":[],"ddx":[],"mdm":"No known hyperthyroidism or medication noncompliance was reported.","frag":"no known thyroid disease"},{"label":"Known hyperthyroid / stopped meds","tone":"pos","sets":[],"ddx":[{"id":"thyroid-storm-dx","keep":true}],"mdm":"Known hyperthyroidism with recent antithyroid noncompliance was reported, a common precipitant of thyroid storm.","frag":"known hyperthyroid / stopped meds"}]},{"id":"thy-hx-precip","dx":"sepsis-thy","q":"Recent precipitant — infection, surgery, trauma, iodinated contrast, or other acute illness?","answers":[{"label":"No identified precipitant","tone":"neg","sets":[],"ddx":[],"mdm":"No clear precipitant such as infection, surgery, or recent contrast was identified.","frag":"no identified precipitant"},{"label":"Infectious or other precipitant","tone":"pos","sets":[],"ddx":[{"id":"sepsis-thy","keep":true},{"id":"thyroid-storm-dx","keep":true}],"mdm":"A recent precipitant (infection, surgery, trauma, iodinated contrast, or other acute illness) was identified, supporting decompensation toward thyroid storm.","frag":"precipitant identified"}]},{"id":"thy-hx-cardiac","dx":"cardiac-thy","q":"Palpitations, irregular heartbeat, chest pain, or dyspnea suggesting a cardiac complication?","answers":[{"label":"No cardiac symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No palpitations, irregular heartbeat, chest pain, or dyspnea were reported.","frag":"no cardiac symptoms"},{"label":"Palpitations / dyspnea","tone":"pos","sets":[],"ddx":[{"id":"cardiac-thy","keep":true}],"mdm":"Palpitations, an irregular heartbeat, or dyspnea were reported, raising concern for a cardiac complication such as atrial fibrillation or high-output failure.","frag":"palpitations / dyspnea"}]},{"id":"thy-hx-tox","dx":"sympathomimetic-thy","q":"Stimulant or sympathomimetic exposure — cocaine, amphetamines, or relevant medications?","answers":[{"label":"No sympathomimetic exposure","tone":"neg","sets":[],"ddx":[],"mdm":"No stimulant or sympathomimetic exposure (cocaine, amphetamines, or relevant medications) was reported.","frag":"no sympathomimetic exposure"},{"label":"Sympathomimetic exposure","tone":"pos","sets":[],"ddx":[{"id":"sympathomimetic-thy","keep":true}],"mdm":"A stimulant or sympathomimetic exposure (cocaine, amphetamines, or a relevant medication) was reported, raising a toxicologic mimic of the adrenergic presentation.","frag":"sympathomimetic exposure"}]},{"id":"thy-hx-elderly","dx":"delirium-thy","q":"In an older patient, are symptoms subtle — apathy, weight loss, or new atrial fibrillation rather than overt agitation (apathetic thyrotoxicosis)?","answers":[{"label":"Typical hyperadrenergic picture","tone":"neg","sets":[],"ddx":[],"mdm":"The presentation was a typical hyperadrenergic picture rather than the subtle apathy, weight loss, or new atrial fibrillation of apathetic thyrotoxicosis.","frag":"typical hyperadrenergic picture"},{"label":"Apathetic / subtle presentation","tone":"pos","sets":[],"ddx":[{"id":"delirium-thy","keep":true},{"id":"thyroid-storm-dx","keep":true}],"mdm":"The presentation was subtle with apathy, weight loss, or new atrial fibrillation, consistent with apathetic thyrotoxicosis in an older patient that can be easily overlooked.","frag":"apathetic / subtle presentation"}]},{"answers":[{"ddx":[],"frag":"no stimulant use, pupils normal, no clonus","label":"No toxidrome features","mdm":"There was no history of stimulant, anticholinergic, or serotonergic drug use, pupils were normal, and there were no clonus or rigidity, making a sympathomimetic toxidrome mimicking thyroid storm unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"sympathomimetic-tox-thy","keep":true}],"frag":"stimulant use with mydriasis, clonus, or rigidity","label":"Toxidrome features present","mdm":"Stimulant, anticholinergic, or serotonergic drug use with mydriasis, clonus, or rigidity was present, raising concern for a sympathomimetic toxidrome mimicking thyroid storm.","sets":[],"tone":"pos"}],"dx":"sympathomimetic-tox-thy","id":"thy-hx-sympathomimetic-tox-thy","q":"Toxidrome — stimulant, anticholinergic, or serotonergic drug use; mydriasis, clonus, or rigidity?"}],"exam":[{"id":"thy-ex-vitals","dx":"thyroid-storm-dx","q":"Vital signs — fever, marked tachycardia out of proportion, and hypertension?","answers":[{"label":"Afebrile, proportionate vitals","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was afebrile without marked tachycardia out of proportion or hypertension.","frag":"afebrile, proportionate vitals"},{"label":"Fever / disproportionate tachycardia","tone":"pos","sets":[],"ddx":[{"id":"thyroid-storm-dx","keep":true}],"mdm":"Fever with marked tachycardia out of proportion was present, a hallmark of decompensation toward thyroid storm.","frag":"fever / disproportionate tachycardia"}]},{"id":"thy-ex-ms","dx":"delirium-thy","q":"Mental status — agitation, confusion, or decreased consciousness?","answers":[{"label":"Normal mental status","tone":"neg","sets":[],"ddx":[],"mdm":"Mental status was normal, without agitation, confusion, or decreased consciousness.","frag":"normal mental status"},{"label":"Agitation / confusion","tone":"pos","sets":[],"ddx":[{"id":"thyroid-storm-dx","keep":true},{"id":"delirium-thy","keep":true}],"mdm":"Agitation, confusion, or a decreased level of consciousness was present, a central nervous system feature of thyroid storm that should not be anchored on as isolated delirium.","frag":"agitation / confusion"}]},{"id":"thy-ex-cardiac","dx":"cardiac-thy","q":"Cardiovascular exam — irregularly irregular rhythm or signs of heart failure?","answers":[{"label":"Regular rhythm, no failure","tone":"neg","sets":[],"ddx":[],"mdm":"The rhythm was regular without signs of heart failure.","frag":"regular rhythm, no failure"},{"label":"Irregular rhythm / failure signs","tone":"pos","sets":[],"ddx":[{"id":"cardiac-thy","keep":true}],"mdm":"An irregularly irregular rhythm or signs of heart failure were present, consistent with a cardiac complication of thyrotoxicosis.","frag":"irregular rhythm / failure signs"}]},{"id":"thy-ex-thyroid","dx":"thyroid-storm-dx","q":"Thyroid and eye findings — goiter, tremor, warm moist skin, or ophthalmopathy?","answers":[{"label":"No hyperthyroid findings","tone":"neg","sets":[],"ddx":[],"mdm":"No goiter, tremor, or ophthalmopathy was identified.","frag":"no hyperthyroid findings"},{"label":"Goiter / tremor / ophthalmopathy","tone":"pos","sets":[],"ddx":[{"id":"thyroid-storm-dx","keep":true}],"mdm":"A goiter, tremor, warm moist skin, or ophthalmopathy was present, supporting underlying thyrotoxicosis.","frag":"goiter / tremor / ophthalmopathy"}]},{"answers":[{"ddx":[],"frag":"glucose normal, no acidosis or ketonemia","label":"No DKA features","mdm":"The glucose was normal, there was no anion-gap metabolic acidosis or ketonemia, and the patient had no polyuria, polydipsia, or Kussmaul respirations, making diabetic ketoacidosis unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"dka-thy","keep":true}],"frag":"hyperglycemia with anion-gap acidosis or ketonemia","label":"DKA features present","mdm":"Hyperglycemia with an anion-gap metabolic acidosis, ketonemia, or Kussmaul respirations was present, raising concern for diabetic ketoacidosis and warranting prompt metabolic correction.","sets":[],"tone":"pos"}],"dx":"dka-thy","id":"thy-exam-dka-thy","q":"DKA — hyperglycemia, an anion-gap metabolic acidosis or ketonemia, polyuria or polydipsia, or Kussmaul respirations?"}],"conclusions":["thyroid storm, treatment initiated","uncompensated thyrotoxicosis","thyrotoxic atrial fibrillation"],"specs":["endo"]},{"id":"adrenal-crisis","title":"Adrenal Crisis","kind":"diagnosis","aliases":["adrenal crisis","addisonian crisis","acute adrenal insufficiency","adrenal insufficiency","addisons disease","steroid withdrawal","cortisol deficiency","secondary adrenal insufficiency","refractory shock","hypoadrenal crisis"],"opening":"The patient was evaluated for possible adrenal crisis as a cause of shock and electrolyte derangement. Empiric stress-dose steroids were considered without awaiting a cortisol level, and septic shock, electrolyte and glucose abnormalities, the precipitating illness, and other shock etiologies were actively considered.","ddx":[{"id":"refractory-shock","group":"lifethreat","label":"Refractory hypotensive shock","default":true,"tags":["refractory-shock"],"ruleout":"Refractory adrenal-crisis shock was considered; the patient's blood pressure responded appropriately to fluids without need for escalating vasopressors, perfusion was restored, and the hemodynamics were proportionate to the identified cause, making occult adrenal crisis unlikely.","miss":3},{"id":"septic-shock","group":"lifethreat","label":"Septic shock (precipitant & mimic)","default":true,"tags":["septic-shock"],"ruleout":"Septic shock was considered as precipitant and mimic; there was no fever, leukocytosis, or localizing infectious source, lactate was normal, and the patient was not persistently hypoperfused, making a septic driver unlikely.","miss":3},{"id":"electrolyte-derange","group":"lifethreat","label":"Hyponatremia / hyperkalemia / hypoglycemia","default":true,"tags":["electrolyte-derange"],"ruleout":"The characteristic electrolyte derangements were considered; serum sodium, potassium, and glucose were within normal limits without hyponatremia, hyperkalemia, or hypoglycemia, making the metabolic signature of adrenal crisis unlikely.","miss":4},{"id":"precip-illness","group":"common","label":"Precipitating illness","default":true,"tags":["precip-illness"],"ruleout":"The precipitating stressor (infection, gastrointestinal illness, trauma, surgery, or abrupt steroid withdrawal in a chronic-steroid or known adrenal-insufficiency patient) was identified and treated.","miss":2},{"id":"other-shock","group":"lifethreat","label":"Alternative shock etiology","default":false,"tags":["other-shock"],"ruleout":"Alternative shock etiologies were considered; there was no chest pain, dyspnea, or pump failure to suggest cardiogenic shock, no bleeding source or anemia for hemorrhage, and no urticaria or exposure for anaphylaxis, making these causes unlikely.","miss":3}],"risk":[{"id":"lytes-adr","label":"Electrolytes","tags":["electrolyte-derange"],"scale":"low","line":"Serum electrolytes were obtained to evaluate for hyponatremia and hyperkalemia characteristic of adrenal insufficiency.","short":"Electrolytes"},{"id":"glucose-adr","label":"Glucose","tags":["electrolyte-derange"],"scale":"low","line":"A glucose was checked for hypoglycemia, which is common in adrenal crisis and requires prompt correction.","short":"Glucose"},{"id":"cortisol-adr","label":"Cortisol level","tags":["refractory-shock"],"scale":"low","line":"A random or stimulated cortisol level was drawn when feasible, but treatment with stress-dose steroids was not delayed for the result.","short":"Cortisol level"},{"id":"steroid-resp","label":"Steroid + fluid response","tags":["refractory-shock"],"scale":"low","line":"The hemodynamic response to empiric stress-dose steroids and fluid resuscitation was assessed, as improvement supports the diagnosis.","short":"Steroid + fluid response"},{"id":"infx-adr","label":"Infection workup","tags":["septic-shock","precip-illness"],"scale":"low","line":"An infection workup was performed to identify a precipitating or concurrent source of sepsis.","short":"Infection workup"},{"id":"hx-ai-adr","label":"Adrenal/steroid history","tags":["precip-illness"],"scale":"low","line":"The history was reviewed for known adrenal insufficiency, chronic steroid use, or recent steroid withdrawal that would predispose to crisis under stress.","short":"Adrenal/steroid history"}],"checks":[{"if":"refractory-shock","needs":["steroid-resp","cortisol-adr"],"mode":"any","warn":"Adrenal crisis is on the differential — document that empiric steroids were given and the response assessed, and that treatment was not delayed awaiting the cortisol level."},{"if":"electrolyte-derange","needs":["lytes-adr","glucose-adr"],"mode":"any","warn":"The adrenal-crisis derangements are on the differential — electrolytes and glucose document evaluation for hyperkalemia and hypoglycemia as immediate threats."},{"if":"septic-shock","needs":["infx-adr"],"mode":"any","warn":"Sepsis as a precipitant or mimic is on the differential — an infection workup documents that a source was sought."},{"if":"precip-illness","needs":["hx-ai-adr"],"mode":"any","warn":"A precipitating illness is on the differential — document the adrenal and steroid history so crisis is not missed in a known or steroid-dependent patient."}],"history":[{"id":"adr-hx-known","dx":"precip-illness","q":"Known adrenal insufficiency, chronic steroid use, or recently stopped steroids?","answers":[{"label":"No adrenal/steroid history","tone":"neg","sets":[],"ddx":[],"mdm":"No known adrenal insufficiency, chronic steroid use, or recent steroid withdrawal was reported.","frag":"no adrenal/steroid history"},{"label":"Known AI / chronic or stopped steroids","tone":"pos","sets":[],"ddx":[{"id":"precip-illness","keep":true},{"id":"refractory-shock","keep":true}],"mdm":"Known adrenal insufficiency, chronic steroid use, or recent steroid withdrawal was reported, predisposing to adrenal crisis under physiologic stress.","frag":"known AI / steroid use"}]},{"id":"adr-hx-precip","dx":"precip-illness","q":"Precipitating stressor — recent infection, vomiting or diarrhea, trauma, or surgery?","answers":[{"label":"No clear precipitant","tone":"neg","sets":[],"ddx":[],"mdm":"No clear precipitating stressor was identified: no recent infection, vomiting or diarrhea, trauma, or surgery.","frag":"no clear precipitant"},{"label":"Precipitant present","tone":"pos","sets":[],"ddx":[{"id":"precip-illness","keep":true}],"mdm":"A precipitating stressor such as infection, gastrointestinal illness, trauma, or surgery was identified.","frag":"precipitant present"}]},{"id":"adr-hx-infx","dx":"septic-shock","q":"Symptoms of infection — fever, cough, dysuria, or localizing complaints?","answers":[{"label":"No infectious symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No infectious symptoms were reported: no fever, cough, dysuria, or other localizing complaints.","frag":"no infectious symptoms"},{"label":"Infectious symptoms present","tone":"pos","sets":[],"ddx":[{"id":"septic-shock","keep":true},{"id":"precip-illness","keep":true}],"mdm":"Infectious symptoms (fever, cough, dysuria, or other localizing complaints) were reported, raising sepsis as a precipitant and a mimic of the hypotensive presentation.","frag":"infectious symptoms"}]},{"id":"adr-hx-constitutional","dx":"refractory-shock","q":"Preceding fatigue, weight loss, nausea, anorexia, or salt craving suggesting chronic adrenal insufficiency?","answers":[{"label":"No constitutional features","tone":"neg","sets":[],"ddx":[],"mdm":"No preceding fatigue, weight loss, anorexia, or salt craving was reported.","frag":"no constitutional features"},{"label":"Constitutional features present","tone":"pos","sets":[],"ddx":[{"id":"refractory-shock","keep":true}],"mdm":"Preceding fatigue, weight loss, anorexia, or salt craving was reported, suggesting underlying chronic adrenal insufficiency.","frag":"constitutional features"}]},{"id":"adr-hx-othershock","dx":"other-shock","q":"Features pointing to an alternative shock cause — chest pain, bleeding, or allergic exposure?","answers":[{"label":"No alternative shock features","tone":"neg","sets":[],"ddx":[],"mdm":"No features pointing to an alternative shock cause (chest pain, bleeding, or allergic exposure) were reported.","frag":"no alternative shock features"},{"label":"Alternative shock features","tone":"pos","sets":[],"ddx":[{"id":"other-shock","keep":true}],"mdm":"Features suggesting an alternative shock etiology (chest pain, bleeding, or allergic exposure) were reported, with care not to anchor and miss concurrent adrenal insufficiency.","frag":"alternative shock features"}]}],"exam":[{"id":"adr-ex-vitals","dx":"refractory-shock","q":"Hemodynamics — hypotension, especially out of proportion or refractory to fluids?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was hemodynamically stable without disproportionate or refractory hypotension.","frag":"hemodynamically stable"},{"label":"Refractory hypotension","tone":"pos","sets":[],"ddx":[{"id":"refractory-shock","keep":true}],"mdm":"Hypotension out of proportion or refractory to fluids was present, a hallmark concern for adrenal crisis.","frag":"refractory hypotension"}]},{"id":"adr-ex-source","dx":"septic-shock","q":"Examination for an infectious source — fever and focal findings such as a lung, abdominal, skin, or urinary source?","answers":[{"label":"No infectious source on exam","tone":"neg","sets":[],"ddx":[],"mdm":"No fever and no focal infectious source (lung, abdominal, skin, or urinary) was identified on examination.","frag":"no infectious source"},{"label":"Focal infectious source","tone":"pos","sets":[],"ddx":[{"id":"septic-shock","keep":true}],"mdm":"A focal infectious source (lung, abdominal, skin, or urinary) was identified on examination, supporting sepsis as a precipitant or mimic.","frag":"focal infectious source"}]},{"id":"adr-ex-skin","dx":"refractory-shock","q":"Skin findings — hyperpigmentation or vitiligo suggesting chronic primary adrenal insufficiency?","answers":[{"label":"No suggestive skin findings","tone":"neg","sets":[],"ddx":[],"mdm":"No hyperpigmentation or vitiligo was identified.","frag":"no suggestive skin findings"},{"label":"Hyperpigmentation / vitiligo","tone":"pos","sets":[],"ddx":[{"id":"refractory-shock","keep":true}],"mdm":"Hyperpigmentation or vitiligo was present, suggesting chronic primary adrenal insufficiency.","frag":"hyperpigmentation / vitiligo"}]},{"id":"adr-ex-mental","dx":"electrolyte-derange","q":"Mental status and volume — altered consciousness or signs of dehydration consistent with electrolyte derangement?","answers":[{"label":"Normal mentation and volume","tone":"neg","sets":[],"ddx":[],"mdm":"Mentation was normal without signs of significant volume depletion.","frag":"normal mentation and volume"},{"label":"Altered / volume-depleted","tone":"pos","sets":[],"ddx":[{"id":"electrolyte-derange","keep":true}],"mdm":"Altered mentation or signs of volume depletion were present, consistent with the electrolyte and glucose derangements of adrenal crisis.","frag":"altered / volume-depleted"}]}],"conclusions":["adrenal crisis, empiric steroids given","acute adrenal insufficiency","suspected adrenal crisis precipitated by acute illness"],"specs":["endo"]},{"id":"peritonsillar-abscess","title":"Peritonsillar Abscess","kind":"diagnosis","aliases":["pta","peritonsillar abscess","quinsy","tonsillar abscess","deep neck infection","sore throat","trismus","muffled voice","hot potato voice","uvular deviation","peritonsillar cellulitis","throat abscess"],"opening":"The patient was evaluated for a suspected peritonsillar abscess. Airway compromise and deep-space neck extension were treated as the can't-miss problems, and the mimics and complications below were actively considered.","ddx":[{"id":"airway-compromise","group":"lifethreat","label":"Airway compromise","default":true,"tags":["airway-compromise"],"ruleout":"Airway compromise was considered; the patient had no stridor, drooling, or difficulty managing secretions, voice was clear, oxygenation was normal, and the airway was patent and protected, making impending obstruction unlikely.","miss":3},{"id":"deep-space-abscess","group":"lifethreat","label":"Retropharyngeal / parapharyngeal abscess","default":true,"tags":["deep-space-abscess"],"ruleout":"Retropharyngeal or parapharyngeal extension was considered; there was no neck stiffness or pain on neck extension, no lateral neck swelling or torticollis, and no imaging evidence of deep-space spread, making deep-neck extension unlikely.","miss":4},{"id":"epiglottitis","group":"lifethreat","label":"Epiglottitis / supraglottitis","default":false,"tags":["epiglottitis"],"ruleout":"Epiglottitis was considered; the patient was non-toxic without tripoding, had no muffled stridor or drooling out of proportion to the throat findings, and oropharyngeal exam localized the process to the tonsillar region, making supraglottitis unlikely.","miss":4},{"id":"lemierre","group":"lifethreat","label":"Lemierre syndrome","default":false,"tags":["lemierre"],"ruleout":"Lemierre syndrome was considered; there was no unilateral neck pain or swelling along the sternocleidomastoid, no rigors or persistent fever, and no respiratory symptoms or septic pulmonary picture, making internal jugular thrombophlebitis unlikely.","miss":3},{"id":"epiglottitis-pta-add","group":"lifethreat","label":"Ludwig angina","default":false,"tags":["epiglottitis-pta-add"],"ruleout":"Ludwig angina was considered; there was no bilateral submandibular swelling or floor-of-mouth induration, no tongue elevation or protrusion, and no trismus with airway threat, making this deep-neck cellulitis unlikely.","miss":4},{"id":"severe-tonsillitis","group":"common","label":"Tonsillitis / peritonsillar cellulitis","default":false,"tags":["severe-tonsillitis"],"ruleout":"Severe tonsillitis or peritonsillar cellulitis without a drainable collection was considered as a common cause once a discrete abscess was excluded by exam, ultrasound, or CT.","miss":4},{"id":"mono-airway","group":"common","label":"Infectious mononucleosis with airway threat","default":false,"tags":["mono-airway"],"ruleout":"Infectious mononucleosis with marked tonsillar hypertrophy threatening the airway was considered, particularly in adolescents and young adults with posterior cervical adenopathy and fatigue.","miss":2}],"risk":[{"id":"airway-assess","label":"Airway assessment","tags":["airway-compromise","epiglottitis"],"scale":"low","line":"The airway was assessed for stridor, drooling, secretion handling, and voice change, with airway support readied if threatened.","short":"Airway assessment"},{"id":"intraoral-exam","label":"Intraoral exam / ultrasound","tags":["severe-tonsillitis","deep-space-abscess"],"scale":"low","line":"The oropharynx was inspected for uvular deviation and a fluctuant bulge, and bedside ultrasound was used to distinguish a drainable abscess from cellulitis.","short":"Intraoral exam / US"},{"id":"ct-neck","label":"CT neck with contrast","tags":["deep-space-abscess","lemierre"],"scale":"low","line":"Contrast-enhanced CT of the neck was obtained when deep-space extension or septic thrombophlebitis was a concern.","short":"CT neck w/ contrast"},{"id":"vitals-sepsis","label":"Vitals / sepsis screen","tags":["airway-compromise","lemierre"],"scale":"low","line":"Vital signs were reviewed and a sepsis screen considered given the potential for systemic spread.","short":"Vitals / sepsis"},{"id":"ent-consult","label":"ENT consultation","tags":["deep-space-abscess","airway-compromise"],"scale":"low","line":"ENT was consulted for drainage and airway management as indicated.","short":"ENT consult"}],"checks":[{"if":"airway-compromise","needs":["airway-assess"],"mode":"any","warn":"Assess the airway first — trismus, drooling, and a muffled voice can herald a threatened airway before anchoring on drainage."},{"if":"deep-space-abscess","needs":["ct-neck","intraoral-exam"],"mode":"any","warn":"Deep-space extension is easy to miss — imaging documents whether the infection has spread beyond the peritonsillar space."},{"if":"lemierre","needs":["ct-neck"],"mode":"any","warn":"Lemierre syndrome hides behind a 'just a sore throat' — unilateral neck pain with sepsis warrants contrast neck imaging."}],"history":[{"id":"pta-hx-onset","dx":"general","q":"Sore throat course — how many days, unilateral worsening, and any change in voice?","answers":[{"label":"Mild, improving sore throat","tone":"neg","sets":[],"ddx":[],"mdm":"The sore throat was mild and improving without unilateral worsening or voice change.","frag":"mild, improving sore throat"},{"label":"Worsening unilateral pain / muffled voice","tone":"pos","sets":[],"ddx":[{"id":"severe-tonsillitis","keep":true}],"mdm":"There was worsening unilateral throat pain with a muffled 'hot potato' voice, consistent with a peritonsillar process.","frag":"unilateral pain / muffled voice"}]},{"id":"pta-hx-airway","dx":"airway-compromise","q":"Any difficulty breathing, drooling, or inability to handle secretions?","answers":[{"label":"Breathing comfortably, handling secretions","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was breathing comfortably and handling secretions without drooling.","frag":"no airway distress"},{"label":"Drooling / difficulty breathing","tone":"pos","sets":[],"ddx":[{"id":"airway-compromise","keep":true},{"id":"epiglottitis","keep":true}],"mdm":"Drooling or difficulty breathing was reported, concerning for a threatened airway requiring immediate attention.","frag":"drooling / breathing difficulty"}]},{"id":"pta-hx-trismus","dx":"deep-space-abscess","q":"Trismus, neck pain/stiffness, or pain on neck movement suggesting deep-space spread?","answers":[{"label":"No trismus or neck pain","tone":"neg","sets":[],"ddx":[],"mdm":"There was no significant trismus, neck stiffness, or pain on neck movement.","frag":"no trismus / neck pain"},{"label":"Trismus / neck pain on movement","tone":"pos","sets":[],"ddx":[{"id":"deep-space-abscess","keep":true}],"mdm":"Trismus or neck pain on movement was present, raising concern for deep-space extension.","frag":"trismus / neck pain"}]},{"id":"pta-hx-lemierre","dx":"lemierre","q":"Rigors, unilateral neck swelling, or worsening systemic illness after a sore throat?","answers":[{"label":"No rigors or neck swelling","tone":"neg","sets":[],"ddx":[],"mdm":"There were no rigors, unilateral neck swelling, or systemic deterioration to suggest Lemierre syndrome.","frag":"no Lemierre features"},{"label":"Rigors / unilateral neck swelling","tone":"pos","sets":[],"ddx":[{"id":"lemierre","keep":true}],"mdm":"Rigors or unilateral neck swelling after a sore throat was reported, prompting consideration of Lemierre syndrome.","frag":"rigors / neck swelling"}]},{"id":"pta-hx-mono","dx":"mono-airway","q":"Prolonged fatigue, malaise, or a known mono exposure in an adolescent or young adult?","answers":[{"label":"No mono features","tone":"neg","sets":[],"ddx":[],"mdm":"No prolonged fatigue, malaise, or mono exposure was reported.","frag":"no mono features"},{"label":"Fatigue / mono exposure","tone":"pos","sets":[],"ddx":[{"id":"mono-airway","keep":true}],"mdm":"Prolonged fatigue or a mono exposure was reported, raising consideration of mononucleosis with tonsillar hypertrophy.","frag":"mono features"}]}],"exam":[{"id":"pta-exam-oropharynx","dx":"severe-tonsillitis","q":"Oropharyngeal exam — uvular deviation, peritonsillar bulge, or just symmetric tonsillar inflammation?","answers":[{"label":"Symmetric tonsils, no bulge","tone":"neg","sets":[],"ddx":[],"mdm":"The oropharynx showed symmetric tonsillar inflammation without a peritonsillar bulge or uvular deviation.","frag":"symmetric tonsils, no bulge"},{"label":"Uvular deviation / peritonsillar bulge","tone":"pos","sets":[],"ddx":[{"id":"severe-tonsillitis","keep":true}],"mdm":"A peritonsillar bulge with uvular deviation was seen, consistent with a peritonsillar abscess.","frag":"uvular deviation / bulge"},{"label":"Inflamed tonsils without discrete bulge","tone":"pos","sets":[],"ddx":[{"id":"severe-tonsillitis","keep":true}],"mdm":"There was marked, symmetric tonsillar inflammation without uvular deviation or a discrete peritonsillar bulge, favoring peritonsillar cellulitis over a drainable abscess.","frag":"inflamed, no discrete bulge"}]},{"id":"pta-exam-airway","dx":"airway-compromise","q":"Airway exam — stridor, tripoding, or pooling of secretions?","answers":[{"label":"No stridor, airway patent","tone":"neg","sets":[],"ddx":[],"mdm":"There was no stridor or pooling of secretions; the airway appeared patent and protected.","frag":"airway patent"},{"label":"Stridor / pooled secretions","tone":"pos","sets":[],"ddx":[{"id":"airway-compromise","keep":true},{"id":"epiglottitis","keep":true}],"mdm":"Stridor or pooled secretions were noted, concerning for a compromised airway.","frag":"stridor / pooled secretions"}]},{"id":"pta-exam-vitals","dx":"lemierre","q":"Vital signs — fever and any signs of systemic toxicity or sepsis?","answers":[{"label":"Afebrile, no toxicity","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was nontoxic with stable vital signs.","frag":"nontoxic, stable vitals"},{"label":"Febrile / toxic-appearing","tone":"pos","sets":[],"ddx":[{"id":"lemierre","keep":true},{"id":"airway-compromise","keep":true}],"mdm":"Fever or a toxic appearance was present, raising concern for systemic spread and prompting a sepsis evaluation.","frag":"febrile / toxic"}]},{"answers":[{"ddx":[],"frag":"no submandibular swelling or floor-of-mouth induration","label":"No Ludwig-angina signs","mdm":"There was no bilateral submandibular swelling or floor-of-mouth induration, no tongue elevation or protrusion, and no trismus with airway threat, making Ludwig angina unlikely.","sets":[],"tone":"neg"},{"ddx":[{"id":"epiglottitis-pta-add","keep":true}],"frag":"submandibular swelling with floor-of-mouth induration","label":"Ludwig-angina signs present","mdm":"Bilateral submandibular swelling, floor-of-mouth induration, tongue elevation, or trismus with airway threat was present, raising concern for Ludwig angina and warranting airway management and surgical consultation.","sets":[],"tone":"pos"}],"dx":"epiglottitis-pta-add","id":"pta-exam-epiglottitis-pta-add","q":"Ludwig angina — bilateral submandibular swelling, floor-of-mouth induration, tongue elevation, or trismus with airway threat?"}],"conclusions":["peritonsillar abscess","peritonsillar cellulitis without drainable abscess"],"specs":["ent"]},{"id":"orbital-cellulitis","title":"Orbital vs Preseptal Cellulitis","kind":"diagnosis","aliases":["orbital cellulitis","postseptal cellulitis","preseptal cellulitis","periorbital cellulitis","eyelid swelling","proptosis","painful eye movement","subperiosteal abscess","cavernous sinus thrombosis","eye infection","ophthalmoplegia"],"opening":"The patient was evaluated for periorbital swelling and erythema, with the central question of preseptal versus orbital (postseptal) cellulitis. Vision-threatening orbital involvement and its intracranial complications were treated as the can't-miss diagnoses.","ddx":[{"id":"orbital-postseptal","group":"lifethreat","label":"Orbital (postseptal) cellulitis","default":true,"tags":["orbital-postseptal"],"ruleout":"Orbital (postseptal) cellulitis was considered; there was no pain or restriction on extraocular movement, no proptosis, diplopia, or chemosis, and visual acuity and color vision were intact, localizing the process to the preseptal compartment.","miss":3},{"id":"orbital-abscess","group":"lifethreat","label":"Subperiosteal / orbital abscess","default":true,"tags":["orbital-abscess"],"ruleout":"A subperiosteal or orbital abscess was considered; there was no gaze restriction, globe displacement, or progressive proptosis, and orbital signs were absent, making a drainable collection unlikely.","miss":3},{"id":"cavernous-thrombosis","group":"lifethreat","label":"Cavernous sinus thrombosis","default":false,"tags":["cavernous-thrombosis"],"ruleout":"Cavernous sinus thrombosis was considered; the findings were unilateral without bilateral eye involvement, there were no multiple cranial neuropathies or sensory loss in the trigeminal distribution, and there was no rapid progression or severe headache, making it unlikely.","miss":3},{"id":"intracranial-extension","group":"lifethreat","label":"Intracranial extension / meningitis","default":false,"tags":["intracranial-extension"],"ruleout":"Intracranial extension or meningitis was considered; the patient was alert without meningismus, headache, photophobia, or focal neurologic deficit, making spread beyond the orbit unlikely.","miss":4},{"id":"preseptal","group":"common","label":"Preseptal cellulitis","default":false,"tags":["preseptal"],"ruleout":"Preseptal cellulitis was considered as the more common, anterior process once orbital signs were absent: normal acuity, full painless extraocular movements, and no proptosis.","miss":2},{"id":"allergic-edema","group":"common","label":"Allergic / contact periorbital edema","default":false,"tags":["allergic-edema"],"ruleout":"Allergic or contact periorbital edema was considered as a noninfectious mimic, with a typically bilateral, pruritic, nontender swelling without fever or pain on eye movement.","miss":2}],"risk":[{"id":"visual-acuity","label":"Visual acuity","tags":["orbital-postseptal","orbital-abscess"],"scale":"low","line":"Visual acuity was documented in each eye as a key discriminator of orbital involvement.","short":"Visual acuity"},{"id":"eom-pain","label":"EOM & pain on movement","tags":["orbital-postseptal"],"scale":"low","line":"Extraocular movements were tested for restriction, diplopia, and pain on movement, which point to postseptal disease.","short":"EOM / pain on movement"},{"id":"pupil-rapd","label":"Pupillary exam (RAPD)","tags":["orbital-postseptal","orbital-abscess"],"scale":"low","line":"The pupillary exam was performed to detect a relative afferent pupillary defect signaling optic nerve compromise.","short":"Pupils / RAPD"},{"id":"ct-orbits","label":"Contrast CT orbits/sinuses","tags":["orbital-abscess","cavernous-thrombosis"],"scale":"low","line":"Contrast CT of the orbits and sinuses was obtained to evaluate for abscess, sinus source, and posterior extension.","short":"CT orbits/sinuses"},{"id":"fever-wbc","label":"Fever / WBC","tags":["orbital-postseptal","intracranial-extension"],"scale":"low","line":"Fever and inflammatory markers were assessed to gauge severity and systemic involvement.","short":"Fever / WBC"},{"id":"ophtho-consult","label":"Ophthalmology / ENT consult","tags":["orbital-postseptal","orbital-abscess"],"scale":"low","line":"Ophthalmology and ENT were consulted for orbital involvement and sinus source management.","short":"Ophtho / ENT consult"}],"checks":[{"if":"orbital-postseptal","needs":["visual-acuity","eom-pain","pupil-rapd"],"mode":"any","warn":"Do not label postseptal disease 'preseptal' — acuity, painful/restricted EOM, and the pupillary exam document the distinction."},{"if":"orbital-abscess","needs":["ct-orbits"],"mode":"any","warn":"A subperiosteal or orbital abscess is found on imaging — contrast CT of the orbits and sinuses documents whether a collection is present."},{"if":"cavernous-thrombosis","needs":["ct-orbits"],"mode":"any","warn":"Cavernous sinus thrombosis is catastrophic — bilateral or multi-nerve findings warrant dedicated contrast venous imaging."}],"history":[{"id":"orb-hx-onset","dx":"preseptal","q":"Course — onset and progression of eyelid swelling, and any preceding sinus infection or trauma?","answers":[{"label":"Localized lid swelling, improving","tone":"neg","sets":[],"ddx":[],"mdm":"The eyelid swelling was localized and stable to improving, without rapid progression or a preceding sinus infection or trauma to suggest a deep source.","frag":"localized lid swelling"},{"label":"Rapid progression / sinusitis source","tone":"pos","sets":[],"ddx":[{"id":"preseptal","keep":true},{"id":"orbital-postseptal","keep":true}],"mdm":"Rapidly progressive eyelid swelling with a preceding sinus infection was reported, raising concern for orbital extension from a sinus source.","frag":"rapid / sinus source"}]},{"id":"orb-hx-vision","dx":"orbital-postseptal","q":"Any change in vision, double vision, or pain with eye movement?","answers":[{"label":"Vision normal, painless movement","tone":"neg","sets":[],"ddx":[],"mdm":"Vision was reported as normal with painless eye movements.","frag":"vision normal, painless EOM"},{"label":"Vision change / diplopia / painful movement","tone":"pos","sets":[],"ddx":[{"id":"orbital-postseptal","keep":true}],"mdm":"Decreased vision, diplopia, or pain on eye movement was reported, pointing toward orbital (postseptal) cellulitis.","frag":"vision change / painful EOM"}]},{"id":"orb-hx-cst","dx":"cavernous-thrombosis","q":"Rapidly worsening course, severe headache, or symptoms involving both eyes?","answers":[{"label":"Unilateral, no severe headache","tone":"neg","sets":[],"ddx":[],"mdm":"Findings were unilateral without severe headache or rapid bilateral progression.","frag":"unilateral, no red flags"},{"label":"Bilateral / severe headache","tone":"pos","sets":[],"ddx":[{"id":"cavernous-thrombosis","keep":true},{"id":"intracranial-extension","keep":true}],"mdm":"Bilateral involvement or a severe headache was reported, raising concern for cavernous sinus thrombosis.","frag":"bilateral / severe headache"}]},{"id":"orb-hx-neuro","dx":"intracranial-extension","q":"Neck stiffness, confusion, or other neurologic symptoms suggesting intracranial spread?","answers":[{"label":"No neuro symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No neck stiffness, confusion, or focal neurologic symptoms were reported.","frag":"no neuro symptoms"},{"label":"Neck stiffness / confusion","tone":"pos","sets":[],"ddx":[{"id":"intracranial-extension","keep":true}],"mdm":"Neck stiffness or confusion was reported, raising concern for intracranial extension or meningitis.","frag":"meningismus / confusion"}]},{"id":"orb-hx-allergy","dx":"allergic-edema","q":"Itching, a known allergen or insect exposure, or bilateral nontender swelling?","answers":[{"label":"No allergic features","tone":"neg","sets":[],"ddx":[],"mdm":"No itching, allergen exposure, or bilateral nontender swelling was reported.","frag":"no allergic features"},{"label":"Itchy / bilateral / allergen exposure","tone":"pos","sets":[],"ddx":[{"id":"allergic-edema","keep":true}],"mdm":"Pruritic, bilateral, or allergen-associated swelling was reported, suggesting an allergic or contact periorbital edema mimic.","frag":"itchy / allergic edema"}]}],"exam":[{"id":"orb-exam-eom","dx":"orbital-postseptal","q":"Extraocular movements — full and painless, or restricted/painful?","answers":[{"label":"Full, painless EOM","tone":"neg","sets":[],"ddx":[],"mdm":"Extraocular movements were full and painless.","frag":"full, painless EOM"},{"label":"Restricted / painful EOM","tone":"pos","sets":[],"ddx":[{"id":"orbital-postseptal","keep":true}],"mdm":"Extraocular movements were restricted or painful, a key sign of orbital (postseptal) cellulitis.","frag":"restricted / painful EOM"}]},{"id":"orb-exam-proptosis","dx":"orbital-abscess","q":"Proptosis or chemosis on inspection?","answers":[{"label":"No proptosis or chemosis","tone":"neg","sets":[],"ddx":[],"mdm":"There was no proptosis or chemosis.","frag":"no proptosis / chemosis"},{"label":"Proptosis / chemosis","tone":"pos","sets":[],"ddx":[{"id":"orbital-abscess","keep":true},{"id":"orbital-postseptal","keep":true}],"mdm":"Proptosis or chemosis was present, concerning for orbital involvement and possible abscess.","frag":"proptosis / chemosis"}]},{"id":"orb-exam-pupil","dx":"orbital-postseptal","q":"Pupillary exam and acuity — any RAPD or decreased visual acuity?","answers":[{"label":"Normal pupils and acuity","tone":"neg","sets":[],"ddx":[],"mdm":"Pupils were normal without an afferent defect and visual acuity was preserved.","frag":"normal pupils / acuity"},{"label":"RAPD / decreased acuity","tone":"pos","sets":[],"ddx":[{"id":"orbital-postseptal","keep":true},{"id":"orbital-abscess","keep":true}],"mdm":"A relative afferent pupillary defect or decreased acuity was found, indicating optic nerve compromise from orbital disease.","frag":"RAPD / decreased acuity"}]}],"conclusions":["preseptal cellulitis","orbital (postseptal) cellulitis"],"specs":["ophtho","ent"]},{"id":"carbon-monoxide-poisoning","title":"Carbon Monoxide Poisoning","kind":"diagnosis","aliases":["carbon monoxide","co poisoning","carboxyhemoglobin","cohb","smoke inhalation","furnace exposure","generator exposure","occult co","co toxicity","fire victim","exhaust exposure"],"opening":"The patient was evaluated for possible carbon monoxide poisoning, recognizing that pulse oximetry is falsely reassuring. End-organ toxicity, co-existing cyanide toxicity in fire victims, and the anchoring mimics below were actively considered.","ddx":[{"id":"co-endorgan","group":"lifethreat","label":"Severe CO toxicity (cardiac/neuro injury)","default":true,"tags":["co-endorgan"],"ruleout":"Severe CO toxicity with end-organ injury was considered; the patient was neurologically intact without syncope, confusion, or focal deficit, had no chest pain with a normal ECG and negative troponin, and the carboxyhemoglobin level was not in the severe range, making cardiac or neurologic injury unlikely.","miss":3},{"id":"cyanide-toxicity","group":"lifethreat","label":"Concomitant cyanide toxicity (smoke)","default":false,"tags":["cyanide-toxicity"],"ruleout":"Concomitant cyanide toxicity was considered; the patient had no enclosed-space fire or smoke exposure, was hemodynamically stable without coma, and the lactate was normal without a persistent anion-gap metabolic acidosis, making cyanide poisoning unlikely.","miss":3},{"id":"occult-exposure","group":"lifethreat","label":"Occult / whole-household exposure","default":false,"tags":["occult-exposure"],"ruleout":"An occult whole-household exposure was considered; no cohabitants or pets were symptomatic, symptoms were not clearly tied to time spent in the home, and no faulty combustion source was identified, making an ongoing environmental exposure unlikely.","miss":3},{"id":"meningitis-co-add","group":"lifethreat","label":"CNS infection (meningitis/encephalitis)","default":false,"tags":["meningitis-co-add"],"ruleout":"A central nervous system infection was considered as a cause of headache and altered mentation; the patient was afebrile without meningismus, photophobia, or focal deficit, and symptoms correlated with environmental exposure rather than infection, making meningitis unlikely.","miss":4},{"id":"delayed-neuro","group":"other","label":"Delayed neurologic sequelae","default":false,"tags":["delayed-neuro"],"ruleout":"Delayed neurologic sequelae were considered; the patient was counseled on cognitive and movement symptoms that can appear days to weeks later, with follow-up arranged and hyperbaric criteria assessed.","miss":1},{"id":"viral-mimic","group":"common","label":"Viral illness / gastroenteritis (anchoring mimic)","default":false,"tags":["viral-mimic"],"ruleout":"A viral illness or gastroenteritis was the anchoring mimic explicitly guarded against; nonspecific headache, nausea, and malaise prompted an exposure history rather than premature closure on a viral diagnosis.","miss":2},{"id":"migraine-mimic","group":"common","label":"Primary headache / migraine (mimic)","default":false,"tags":["migraine-mimic"],"ruleout":"A primary headache or migraine was considered as a mimic, recognizing that a normal pulse oximetry reading does not exclude CO poisoning.","miss":2}],"risk":[{"id":"cohb-level","label":"Carboxyhemoglobin (co-oximetry)","tags":["co-endorgan","occult-exposure"],"scale":"low","line":"A carboxyhemoglobin level was obtained by co-oximetry rather than relying on pulse oximetry, which reads falsely normal.","short":"CO-oximetry COHb"},{"id":"exposure-hx","label":"Source / co-exposed contacts","tags":["occult-exposure","viral-mimic"],"scale":"low","line":"The exposure source and whether cohabitants, coworkers, or pets are affected were documented to identify occult exposure.","short":"Source / contacts"},{"id":"ecg-trop","label":"ECG / troponin","tags":["co-endorgan"],"scale":"low","line":"An ECG and troponin were obtained to evaluate for myocardial ischemia from impaired oxygen delivery.","short":"ECG / troponin"},{"id":"neuro-exam-co","label":"Neuro / mental status","tags":["co-endorgan","delayed-neuro"],"scale":"low","line":"A neurologic and mental-status exam was performed to detect acute injury and establish a baseline for delayed sequelae.","short":"Neuro / mental status"},{"id":"lactate-co","label":"Lactate","tags":["cyanide-toxicity"],"scale":"low","line":"A lactate was checked, with a markedly elevated level in a fire victim raising concern for concomitant cyanide toxicity.","short":"Lactate"},{"id":"o2-hbo","label":"High-flow O2 / HBO criteria","tags":["co-endorgan","delayed-neuro"],"scale":"low","line":"High-flow oxygen was applied and hyperbaric oxygen criteria were assessed based on symptoms, level, and risk factors.","short":"High-flow O2 / HBO"}],"checks":[{"if":"co-endorgan","needs":["cohb-level","ecg-trop","neuro-exam-co"],"mode":"any","warn":"Trust co-oximetry, not the pulse ox — the COHb level with ECG/troponin and the neuro exam document end-organ assessment."},{"if":"cyanide-toxicity","needs":["lactate-co"],"mode":"any","warn":"Smoke means cyanide too — a high lactate with persistent acidosis in a fire victim should trigger cyanide consideration."},{"if":"occult-exposure","needs":["exposure-hx"],"mode":"any","warn":"Don't send the patient back into the source — document whether housemates and pets are affected before discharge."}],"history":[{"id":"co-hx-source","dx":"occult-exposure","q":"Exposure — furnace, generator, fire, or vehicle exhaust, and does anyone else at home have symptoms?","answers":[{"label":"No identifiable source / others well","tone":"neg","sets":[],"ddx":[],"mdm":"No combustion source (furnace, generator, fire, or vehicle exhaust) was identified and cohabitants were asymptomatic.","frag":"no source / others well"},{"label":"Source identified / others affected","tone":"pos","sets":[],"ddx":[{"id":"occult-exposure","keep":true},{"id":"co-endorgan","keep":true}],"mdm":"A combustion source (furnace, generator, fire, or vehicle exhaust) was identified, or cohabitants or pets were also symptomatic, indicating a likely occult household exposure.","frag":"source / others affected"}]},{"id":"co-hx-symptoms","dx":"viral-mimic","q":"Symptoms — headache, nausea, dizziness, or malaise that improve when away from home?","answers":[{"label":"Symptoms persist / clearly viral","tone":"neg","sets":[],"ddx":[],"mdm":"Symptoms (headache, nausea, dizziness, or malaise); persisted regardless of location with a clear viral context rather than improving away from home, though exposure was still screened.","frag":"persistent / viral context"},{"label":"Symptoms improve away from home","tone":"pos","sets":[],"ddx":[{"id":"viral-mimic","keep":true},{"id":"occult-exposure","keep":true}],"mdm":"Symptoms (headache, nausea, dizziness, or malaise), that improve when away from home were reported, a pattern pointing to environmental CO rather than a viral illness.","frag":"better away from home"}]},{"id":"co-hx-fire","dx":"cyanide-toxicity","q":"Enclosed-space fire or smoke inhalation (raising concern for concomitant cyanide)?","answers":[{"label":"No fire / smoke exposure","tone":"neg","sets":[],"ddx":[],"mdm":"There was no enclosed-space fire or smoke inhalation to raise cyanide concern.","frag":"no fire/smoke"},{"label":"Enclosed-space fire / smoke","tone":"pos","sets":[],"ddx":[{"id":"cyanide-toxicity","keep":true},{"id":"co-endorgan","keep":true}],"mdm":"Enclosed-space fire or smoke inhalation was reported, raising concern for concomitant cyanide toxicity.","frag":"fire / smoke inhalation"}]},{"id":"co-hx-cardiac","dx":"co-endorgan","q":"Chest pain, palpitations, syncope, or confusion suggesting end-organ effects?","answers":[{"label":"No cardiac/neuro symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"No chest pain, syncope, or confusion was reported.","frag":"no end-organ symptoms"},{"label":"Chest pain / syncope / confusion","tone":"pos","sets":[],"ddx":[{"id":"co-endorgan","keep":true}],"mdm":"Chest pain, syncope, or confusion was reported, concerning for cardiac or neurologic end-organ effects.","frag":"chest pain / syncope / confusion"}]},{"id":"co-hx-pregnancy","dx":"delayed-neuro","q":"Loss of consciousness, pregnancy, or extremes of age that lower the threshold for hyperbaric therapy and raise sequelae risk?","answers":[{"label":"No high-risk features","tone":"neg","sets":[],"ddx":[],"mdm":"No syncope, pregnancy, or age-related high-risk features were identified.","frag":"no high-risk features"},{"label":"LOC / pregnant / high-risk","tone":"pos","sets":[],"ddx":[{"id":"delayed-neuro","keep":true},{"id":"co-endorgan","keep":true}],"mdm":"A loss of consciousness, pregnancy, or other high-risk feature was identified, raising sequelae risk and informing hyperbaric assessment.","frag":"LOC / pregnant / high-risk"}]}],"exam":[{"id":"co-exam-mental","dx":"co-endorgan","q":"Mental status and neuro exam — alert and oriented, or altered/focal findings?","answers":[{"label":"Alert, nonfocal exam","tone":"neg","sets":[],"ddx":[],"mdm":"The patient was alert and oriented with a nonfocal neurologic exam.","frag":"alert, nonfocal"},{"label":"Altered / focal findings","tone":"pos","sets":[],"ddx":[{"id":"co-endorgan","keep":true},{"id":"delayed-neuro","keep":true}],"mdm":"Altered mental status or focal neurologic findings were present, concerning for CO-related neurologic injury.","frag":"altered / focal"}]},{"id":"co-exam-vitals","dx":"co-endorgan","q":"Vitals and cardiac exam — tachycardia, hypotension, or signs of cardiac compromise (note SpO2 may read falsely normal)?","answers":[{"label":"Stable, normal pulse ox noted unreliable","tone":"neg","sets":[],"ddx":[],"mdm":"Vital signs were stable, without tachycardia, hypotension, or signs of cardiac compromise; the normal pulse oximetry was explicitly noted to be unreliable in CO exposure.","frag":"stable, pulse ox unreliable"},{"label":"Tachycardia / hypotension","tone":"pos","sets":[],"ddx":[{"id":"co-endorgan","keep":true}],"mdm":"Tachycardia or hypotension was present, concerning for cardiovascular compromise from impaired oxygen delivery.","frag":"tachycardia / hypotension"}]},{"id":"co-exam-skin","dx":"cyanide-toxicity","q":"General exam in a fire victim — soot, facial burns, or signs of significant inhalation injury?","answers":[{"label":"No inhalation injury signs","tone":"neg","sets":[],"ddx":[],"mdm":"There were no soot deposits, facial burns, or other signs of significant inhalation injury.","frag":"no inhalation injury"},{"label":"Soot / facial burns","tone":"pos","sets":[],"ddx":[{"id":"cyanide-toxicity","keep":true},{"id":"co-endorgan","keep":true}],"mdm":"Soot or facial burns suggesting inhalation injury were noted, supporting concern for concomitant cyanide toxicity.","frag":"soot / facial burns"}]},{"answers":[{"ddx":[],"frag":"afebrile, no meningismus or photophobia (insensitive signs, so the LP threshold stayed low if the exposure explanation faltered)","label":"No CNS-infection signs","mdm":"The patient was afebrile without meningismus, photophobia, or focal deficit, and symptoms correlated with environmental exposure rather than infection. Because fever and meningeal signs are insensitive for meningitis, their absence was not relied on alone, and the lumbar-puncture threshold remained low if the exposure explanation faltered.","sets":[],"tone":"neg"},{"ddx":[{"id":"meningitis-co-add","keep":true}],"frag":"fever with meningismus or photophobia","label":"CNS-infection signs present","mdm":"Fever, meningismus, photophobia, or a focal deficit was present, raising concern for a central nervous system infection and warranting prompt evaluation including lumbar puncture.","sets":[],"tone":"pos"}],"dx":"meningitis-co-add","id":"co-exam-meningitis-co-add","q":"CNS infection — fever, meningismus, photophobia, or a focal deficit (versus an environmental-exposure pattern)?"}],"conclusions":["acute carbon monoxide poisoning","carbon monoxide exposure, mild","smoke inhalation with carbon monoxide exposure"],"specs":["tox"]},{"id":"croup","title":"Croup (Laryngotracheobronchitis)","kind":"diagnosis","aliases":["croup","laryngotracheobronchitis","barky cough","stridor","seal-like cough","viral croup","spasmodic croup","inspiratory stridor","hoarse cough","child stridor","ltb"],"opening":"A child was evaluated for a barky cough and stridor consistent with croup. The dangerous airway mimics below and the possibility of impending respiratory failure were actively considered, and care was taken not to agitate the child.","ddx":[{"id":"epiglottitis-c","group":"lifethreat","label":"Epiglottitis","default":true,"tags":["epiglottitis-c"],"ruleout":"Epiglottitis was considered; the child was non-toxic without drooling or tripoding, had a typical barky cough rather than a muffled voice, and was vaccinated against Haemophilus influenzae type b, making supraglottic infection unlikely.","miss":4},{"id":"bacterial-tracheitis","group":"lifethreat","label":"Bacterial tracheitis","default":false,"tags":["bacterial-tracheitis"],"ruleout":"Bacterial tracheitis was considered; the child was non-toxic without high fever, responded appropriately to nebulized epinephrine and steroids, and had no rapid clinical deterioration or copious purulent secretions, making bacterial airway infection unlikely.","miss":3},{"id":"foreign-body","group":"lifethreat","label":"Foreign-body aspiration","default":true,"tags":["foreign-body"],"ruleout":"Foreign-body aspiration was considered; there was no sudden-onset choking episode, no witnessed aspiration, and no focal or unilateral decreased breath sounds or wheeze, making an aspirated foreign body unlikely.","miss":3},{"id":"retropharyngeal-c","group":"lifethreat","label":"Retropharyngeal abscess","default":false,"tags":["retropharyngeal-c"],"ruleout":"Retropharyngeal abscess was considered; the child had no neck stiffness, no refusal to extend the neck, no muffled voice or drooling, and was able to swallow, making a deep-space neck infection unlikely.","miss":4},{"id":"anaphylaxis-c","group":"lifethreat","label":"Anaphylaxis / angioedema","default":false,"tags":["anaphylaxis-c"],"ruleout":"Anaphylaxis or angioedema was considered; there was no urticaria, lip or facial swelling, or known allergen exposure, no gastrointestinal or cardiovascular involvement, and the onset was gradual with viral prodrome, making an allergic airway process unlikely.","miss":4},{"id":"severe-croup","group":"common","label":"Severe croup / impending failure","default":false,"tags":["severe-croup"],"ruleout":"Severe croup with impending respiratory failure was considered; stridor at rest, marked retractions, fatigue, or altered alertness would signal the need for escalation.","miss":2}],"risk":[{"id":"stridor-rest","label":"Stridor at rest vs agitation","tags":["severe-croup","epiglottitis-c"],"scale":"low","line":"Whether stridor was present at rest versus only with agitation was documented as a marker of severity.","short":"Stridor at rest?"},{"id":"wob","label":"Work of breathing","tags":["severe-croup","foreign-body"],"scale":"low","line":"Work of breathing was assessed for retractions, nasal flaring, and air entry.","short":"Work of breathing"},{"id":"toxic-drool","label":"Toxic appearance / drooling","tags":["epiglottitis-c","bacterial-tracheitis"],"scale":"low","line":"The child was assessed for a toxic appearance and drooling that would point away from simple croup.","short":"Toxic / drooling"},{"id":"sat-o2","label":"Oxygen saturation","tags":["severe-croup"],"scale":"low","line":"Oxygen saturation was checked while keeping the child calm.","short":"O2 saturation"},{"id":"treatment-response","label":"Response to therapy","tags":["bacterial-tracheitis","severe-croup"],"scale":"low","line":"Response to cool/humidified air and standard croup therapy was observed, with poor response prompting reconsideration of the diagnosis.","short":"Response to therapy"},{"id":"keep-calm","label":"Avoid agitating the child","tags":["epiglottitis-c","severe-croup"],"scale":"low","line":"Examination was performed with the child kept calm on a caregiver's lap to avoid precipitating airway obstruction.","short":"Keep child calm"}],"checks":[{"if":"epiglottitis-c","needs":["toxic-drool","keep-calm"],"mode":"any","warn":"Epiglottitis hides behind 'croup' — a toxic, drooling child must not be agitated and needs urgent airway planning."},{"if":"severe-croup","needs":["stridor-rest","wob"],"mode":"any","warn":"Stridor at rest with fatigue signals impending failure — document the severity rather than assuming mild croup."},{"if":"bacterial-tracheitis","needs":["treatment-response"],"mode":"any","warn":"A toxic child who fails croup therapy may have bacterial tracheitis — reassess rather than re-dosing."}],"history":[{"id":"croup-hx-onset","dx":"general","q":"Onset — gradual barky cough with a recent cold, or sudden onset?","answers":[{"label":"Gradual barky cough with URI","tone":"neg","sets":[],"ddx":[],"mdm":"There was a gradual barky cough following a viral upper respiratory illness, typical of croup.","frag":"gradual barky cough, URI"},{"label":"Sudden onset / choking event","tone":"pos","sets":[],"ddx":[{"id":"foreign-body","keep":true}],"mdm":"A sudden onset or witnessed choking event was reported, raising concern for foreign-body aspiration.","frag":"sudden onset / choking"}]},{"id":"croup-hx-toxic","dx":"epiglottitis-c","q":"High fever, drooling, refusal to swallow, or a rapidly ill-appearing child?","answers":[{"label":"Low-grade fever, drinking","tone":"neg","sets":[],"ddx":[],"mdm":"The child had a low-grade fever and was drinking without drooling.","frag":"low-grade fever, drinking"},{"label":"High fever / drooling / toxic","tone":"pos","sets":[],"ddx":[{"id":"epiglottitis-c","keep":true},{"id":"bacterial-tracheitis","keep":true}],"mdm":"High fever, drooling, or a toxic appearance was reported, raising concern for epiglottitis or bacterial tracheitis.","frag":"high fever / drooling"}]},{"id":"croup-hx-neck","dx":"retropharyngeal-c","q":"Neck stiffness, refusal to move the neck, or a muffled voice?","answers":[{"label":"Neck moves freely","tone":"neg","sets":[],"ddx":[],"mdm":"The child moved the neck freely without stiffness or a muffled voice.","frag":"neck moves freely"},{"label":"Neck stiffness / muffled voice","tone":"pos","sets":[],"ddx":[{"id":"retropharyngeal-c","keep":true}],"mdm":"Neck stiffness or a muffled voice was reported, raising concern for a retropharyngeal abscess.","frag":"neck stiffness / muffled voice"}]},{"id":"croup-hx-allergy","dx":"anaphylaxis-c","q":"Hives, lip or facial swelling, or a known allergen exposure with rapid onset?","answers":[{"label":"No allergic features","tone":"neg","sets":[],"ddx":[],"mdm":"No hives, facial swelling, or allergen exposure was reported.","frag":"no allergic features"},{"label":"Hives / facial swelling / exposure","tone":"pos","sets":[],"ddx":[{"id":"anaphylaxis-c","keep":true}],"mdm":"Hives, facial or lip swelling, or an allergen exposure was reported, raising concern for anaphylaxis or angioedema.","frag":"hives / swelling / exposure"}]},{"id":"croup-hx-severity","dx":"severe-croup","q":"Stridor at rest, tiring with breathing, or lethargy?","answers":[{"label":"Stridor only with crying","tone":"neg","sets":[],"ddx":[],"mdm":"Stridor was present only with crying or agitation and the child was active.","frag":"stridor only with agitation"},{"label":"Stridor at rest / tiring","tone":"pos","sets":[],"ddx":[{"id":"severe-croup","keep":true}],"mdm":"Stridor at rest or signs of tiring were reported, concerning for severe croup with impending respiratory failure.","frag":"stridor at rest / tiring"}]}],"exam":[{"id":"croup-exam-appearance","dx":"epiglottitis-c","q":"General appearance — comfortable child, or toxic, tripoding, or drooling?","answers":[{"label":"Nontoxic, comfortable","tone":"neg","sets":[],"ddx":[],"mdm":"The child was nontoxic and comfortable in the caregiver's arms.","frag":"nontoxic, comfortable"},{"label":"Toxic / tripoding / drooling","tone":"pos","sets":[],"ddx":[{"id":"epiglottitis-c","keep":true},{"id":"bacterial-tracheitis","keep":true}],"mdm":"The child appeared toxic, was tripoding, or was drooling: findings concerning for epiglottitis or bacterial tracheitis.","frag":"toxic / tripoding / drooling"}]},{"id":"croup-exam-wob","dx":"severe-croup","q":"Work of breathing — stridor at rest, retractions, or fatigue?","answers":[{"label":"No stridor at rest, good air entry","tone":"neg","sets":[],"ddx":[],"mdm":"There was no stridor at rest, with good air entry and minimal retractions.","frag":"no rest stridor, good air entry"},{"label":"Rest stridor / retractions / fatigue","tone":"pos","sets":[],"ddx":[{"id":"severe-croup","keep":true}],"mdm":"Stridor at rest, marked retractions, or fatigue was present, concerning for severe croup with impending failure.","frag":"rest stridor / retractions"}]},{"id":"croup-exam-auscult","dx":"foreign-body","q":"Chest auscultation — symmetric breath sounds, or unilateral wheeze/decreased air entry?","answers":[{"label":"Symmetric breath sounds","tone":"neg","sets":[],"ddx":[],"mdm":"Breath sounds were symmetric without focal wheeze or decreased air entry.","frag":"symmetric breath sounds"},{"label":"Unilateral wheeze / decreased entry","tone":"pos","sets":[],"ddx":[{"id":"foreign-body","keep":true}],"mdm":"Unilateral wheeze or decreased air entry was noted, raising concern for an aspirated foreign body.","frag":"unilateral wheeze / decreased entry"}]}],"conclusions":["viral croup (laryngotracheobronchitis), mild","moderate croup","severe croup"],"specs":["peds","ent"]},{"id":"kawasaki-disease","title":"Kawasaki Disease","kind":"diagnosis","aliases":["kawasaki","kawasaki disease","mucocutaneous lymph node syndrome","incomplete kawasaki","atypical kawasaki","coronary aneurysm","prolonged fever child","strawberry tongue","mis-c","kawasaki shock"],"opening":"A child with prolonged fever was evaluated for Kawasaki disease. Coronary artery involvement was treated as the reason to diagnose and treat, incomplete disease in infants was specifically considered, and the mimics and complications below were assessed.","ddx":[{"id":"coronary-aneurysm","group":"lifethreat","label":"Coronary artery aneurysm","default":true,"tags":["coronary-aneurysm"],"ruleout":"Coronary artery aneurysm was considered; inflammatory markers and baseline echocardiography showed no coronary dilation or aneurysm, and timely IVIG was directed at preventing coronary involvement, making established aneurysm unlikely.","miss":3},{"id":"incomplete-kd","group":"lifethreat","label":"Incomplete / atypical Kawasaki","default":true,"tags":["incomplete-kd"],"ruleout":"Incomplete or atypical Kawasaki disease was specifically considered, particularly in this infant; fever duration, supplemental laboratory criteria, and echocardiography were assessed, and the supportive-lab threshold prompting treatment was not met.","miss":4},{"id":"kd-shock","group":"lifethreat","label":"Kawasaki shock / myocarditis","default":false,"tags":["kd-shock"],"ruleout":"Kawasaki disease shock syndrome and myocarditis were considered; the child was well-perfused and normotensive without tachycardia out of proportion, gallop, or signs of cardiac dysfunction, making shock physiology and myocarditis unlikely.","miss":4},{"id":"toxic-shock-kd","group":"lifethreat","label":"Toxic shock syndrome","default":false,"tags":["toxic-shock-kd"],"ruleout":"Toxic shock syndrome was considered; there was no diffuse macular erythroderma, no hypotension, and no identifiable toxin-producing focus such as a wound or retained tampon, making a toxin-mediated illness unlikely.","miss":3},{"id":"viral-exanthem-kd","group":"common","label":"Measles / scarlet fever / viral exanthem","default":false,"tags":["viral-exanthem-kd"],"ruleout":"Measles, scarlet fever, and viral exanthems were considered as common mimics; vaccination history, exposures, and the rash pattern were weighed against Kawasaki criteria.","miss":2},{"id":"sjs-drug-kd","group":"other","label":"Stevens-Johnson / drug reaction / MIS-C","default":false,"tags":["sjs-drug-kd"],"ruleout":"Stevens-Johnson syndrome, a drug reaction, and MIS-C were considered; mucosal involvement with skin sloughing, a culprit medication, or a preceding COVID exposure would shift the evaluation.","miss":4}],"risk":[{"id":"fever-days","label":"Fever duration","tags":["coronary-aneurysm","incomplete-kd"],"scale":"low","line":"The number of days of fever was counted, as five or more days is central to the diagnosis.","short":"Fever days"},{"id":"clinical-criteria","label":"Clinical criteria","tags":["coronary-aneurysm","viral-exanthem-kd"],"scale":"low","line":"The classic features (conjunctivitis, mucosal/lip changes, rash, extremity changes, and cervical lymphadenopathy) were documented.","short":"KD criteria"},{"id":"inflammatory-markers","label":"ESR / CRP","tags":["incomplete-kd","coronary-aneurysm"],"scale":"low","line":"Inflammatory markers (ESR and CRP) were obtained to support incomplete-disease evaluation.","short":"ESR / CRP"},{"id":"cbc-platelets","label":"CBC / platelets","tags":["incomplete-kd","kd-shock"],"scale":"low","line":"A CBC was obtained, noting anemia, leukocytosis, and the platelet trend that supports the diagnosis.","short":"CBC / platelets"},{"id":"echo-kd","label":"Echocardiogram","tags":["coronary-aneurysm","kd-shock"],"scale":"low","line":"An echocardiogram was arranged to assess the coronary arteries and cardiac function.","short":"Echocardiogram"},{"id":"exclude-mimics","label":"Exclude mimics","tags":["viral-exanthem-kd","toxic-shock-kd"],"scale":"low","line":"Mimics such as measles, scarlet fever, toxic shock, and drug reactions were assessed and excluded.","short":"Exclude mimics"}],"checks":[{"if":"coronary-aneurysm","needs":["echo-kd","fever-days","clinical-criteria"],"mode":"any","warn":"Coronary involvement is the whole point — count the fever days, document the criteria, and arrange echocardiography."},{"if":"incomplete-kd","needs":["inflammatory-markers","cbc-platelets"],"mode":"any","warn":"Incomplete Kawasaki in infants is easy to miss — prolonged fever with elevated inflammatory markers should trigger an echo even without full criteria."},{"if":"kd-shock","needs":["echo-kd"],"mode":"any","warn":"Kawasaki shock and myocarditis present as a sick, poorly perfused child — do not mistake it for sepsis alone."}],"history":[{"id":"kd-hx-fever","dx":"coronary-aneurysm","q":"Fever — how many days has it lasted and has it been persistent?","answers":[{"label":"Fever under 5 days","tone":"neg","sets":[],"ddx":[],"mdm":"Fever had been present for fewer than five days, prompting close follow-up if it persists.","frag":"fever <5 days"},{"label":"Fever 5 or more days","tone":"pos","sets":[],"ddx":[{"id":"coronary-aneurysm","keep":true},{"id":"incomplete-kd","keep":true}],"mdm":"Fever had persisted for five or more days, meeting the duration central to Kawasaki disease.","frag":"fever ≥5 days"}]},{"id":"kd-hx-criteria","dx":"viral-exanthem-kd","q":"Rash, red eyes, lip/mouth changes, or hand/foot swelling along with the fever?","answers":[{"label":"Few or no classic features","tone":"neg","sets":[],"ddx":[],"mdm":"Few of the classic mucocutaneous features were present, keeping viral exanthems in consideration.","frag":"few classic features"},{"label":"Multiple classic features","tone":"pos","sets":[],"ddx":[{"id":"viral-exanthem-kd","keep":true},{"id":"coronary-aneurysm","keep":true}],"mdm":"Multiple classic features (rash, conjunctivitis, mucosal changes, or extremity changes) were present, supporting Kawasaki disease.","frag":"multiple KD features"}]},{"id":"kd-hx-infant","dx":"incomplete-kd","q":"Is the child an infant with prolonged fever but incomplete features?","answers":[{"label":"Older child / full features","tone":"neg","sets":[],"ddx":[],"mdm":"The child was older or had more complete features, lowering concern for missed incomplete disease.","frag":"older / fuller features"},{"label":"Infant with incomplete features","tone":"pos","sets":[],"ddx":[{"id":"incomplete-kd","keep":true},{"id":"coronary-aneurysm","keep":true}],"mdm":"The patient was an infant with prolonged fever and incomplete features, a high-risk presentation warranting an echo and labs.","frag":"infant, incomplete"}]},{"id":"kd-hx-shock","dx":"kd-shock","q":"Lethargy, poor feeding, or signs of poor perfusion?","answers":[{"label":"Active, perfusing well","tone":"neg","sets":[],"ddx":[],"mdm":"The child was active and feeding with no signs of poor perfusion.","frag":"active, well-perfused"},{"label":"Lethargy / poor perfusion","tone":"pos","sets":[],"ddx":[{"id":"kd-shock","keep":true},{"id":"toxic-shock-kd","keep":true}],"mdm":"Lethargy or poor perfusion was reported, raising concern for Kawasaki shock syndrome or myocarditis.","frag":"lethargy / poor perfusion"}]},{"id":"kd-hx-mimic","dx":"sjs-drug-kd","q":"New medication, mucosal blistering/sloughing, or a recent COVID exposure?","answers":[{"label":"No drug exposure / sloughing","tone":"neg","sets":[],"ddx":[],"mdm":"No culprit medication, mucosal sloughing, or relevant COVID exposure was reported.","frag":"no drug / sloughing"},{"label":"New drug / sloughing / COVID","tone":"pos","sets":[],"ddx":[{"id":"sjs-drug-kd","keep":true}],"mdm":"A new medication, mucosal sloughing, or a recent COVID exposure was reported, prompting consideration of SJS, a drug reaction, or MIS-C.","frag":"drug / sloughing / COVID"}]}],"exam":[{"id":"kd-exam-mucocut","dx":"coronary-aneurysm","q":"Mucocutaneous exam — conjunctival injection, strawberry tongue/cracked lips, rash, or extremity changes?","answers":[{"label":"No mucocutaneous findings","tone":"neg","sets":[],"ddx":[],"mdm":"There were no conjunctival, mucosal, rash, or extremity findings on exam.","frag":"no mucocutaneous findings"},{"label":"Mucocutaneous findings present","tone":"pos","sets":[],"ddx":[{"id":"coronary-aneurysm","keep":true},{"id":"viral-exanthem-kd","keep":true}],"mdm":"Conjunctival injection, mucosal changes, rash, or extremity changes were present, supporting Kawasaki disease.","frag":"mucocutaneous findings present"}]},{"id":"kd-exam-nodes","dx":"viral-exanthem-kd","q":"Cervical lymphadenopathy — a unilateral node greater than 1.5 cm?","answers":[{"label":"No significant adenopathy","tone":"neg","sets":[],"ddx":[],"mdm":"No significant cervical lymphadenopathy was found.","frag":"no adenopathy"},{"label":"Unilateral cervical node","tone":"pos","sets":[],"ddx":[{"id":"viral-exanthem-kd","keep":true},{"id":"coronary-aneurysm","keep":true}],"mdm":"A unilateral cervical node was present, one of the classic Kawasaki criteria.","frag":"cervical node"}]},{"id":"kd-exam-perfusion","dx":"kd-shock","q":"Cardiovascular exam — tachycardia out of proportion, hypotension, or poor perfusion?","answers":[{"label":"Stable, well-perfused","tone":"neg","sets":[],"ddx":[],"mdm":"The child was hemodynamically stable and well perfused, without tachycardia out of proportion, hypotension, or poor perfusion.","frag":"stable, well-perfused"},{"label":"Hypotension / poor perfusion","tone":"pos","sets":[],"ddx":[{"id":"kd-shock","keep":true},{"id":"toxic-shock-kd","keep":true}],"mdm":"Hypotension or poor perfusion was present, concerning for Kawasaki shock syndrome, myocarditis, or toxic shock.","frag":"hypotension / poor perfusion"}]}],"conclusions":["kawasaki disease","incomplete kawasaki disease","prolonged febrile illness, kawasaki disease considered"],"specs":["peds"]},{"id":"anaphylaxis","kind":"diagnosis","title":"Anaphylaxis","specs":["pulm","derm"],"guide":"../learn/complaints/anaphylaxis.html","aliases":["anaphylaxis","anaphylactic","allergic reaction","severe allergic reaction","angioedema","allergic-reaction"],"opening":"The patient was evaluated for a severe allergic reaction. Anaphylaxis is a clinical, time-critical diagnosis: the priority is prompt intramuscular epinephrine and airway protection, with the dangerous mimics and a biphasic course actively considered.","ddx":[{"id":"airway-ana","group":"lifethreat","label":"Airway angioedema / impending obstruction","default":true,"tags":[],"ruleout":"Impending airway obstruction was considered; there was no stridor, voice change, tongue or oropharyngeal swelling, or drooling, and the airway was patent, making it unlikely.","miss":3},{"id":"shock-ana","group":"lifethreat","label":"Distributive (anaphylactic) shock","default":true,"tags":[],"ruleout":"Anaphylactic shock was considered; the patient was normotensive without tachycardia or hypoperfusion and responded to initial therapy, making distributive shock unlikely.","miss":3},{"id":"bradykinin-ana","group":"lifethreat","label":"Bradykinin angioedema (ACE-inhibitor / hereditary)","default":false,"tags":[],"ruleout":"Bradykinin-mediated angioedema was considered; there was no isolated angioedema without urticaria, no ACE-inhibitor use, and no personal or family history of recurrent angioedema, making it unlikely.","miss":3},{"id":"biphasic-ana","group":"common","label":"Biphasic reaction","default":true,"tags":[],"ruleout":"A biphasic reaction was anticipated; the presentation was not severe and did not require repeat epinephrine, and the patient was observed to sustained resolution.","miss":2},{"id":"asthma-ana","group":"common","label":"Asthma / bronchospasm mimic","default":false,"tags":[],"ruleout":"An isolated asthma exacerbation was considered; bronchospasm occurred in the context of an allergen exposure with other systems involved, supporting anaphylaxis rather than asthma alone.","miss":2},{"id":"mimic-ana","group":"other","label":"Mimic (vasovagal, scombroid, panic)","default":false,"tags":[],"ruleout":"Mimics such as vasovagal syncope, scombroid, and panic were considered and did not fit the multi-system, allergen-associated picture.","miss":1}],"risk":[{"id":"epi-ana","label":"IM epinephrine given promptly","tags":[],"scale":"low","line":"Intramuscular epinephrine was given promptly as first-line therapy and repeated as needed."},{"id":"airway-assess-ana","label":"Airway assessed / protected","tags":[],"scale":"low","line":"The airway was assessed for angioedema and stridor, and a plan for early definitive airway management was in place."},{"id":"criteria-ana","label":"Anaphylaxis criteria documented","tags":[],"scale":"low","line":"The clinical criteria for anaphylaxis (acute onset with multi-system involvement, or hypotension/airway compromise after a likely allergen) were documented."},{"id":"obs-ana","label":"Observation for biphasic reaction","tags":[],"scale":"low","line":"The patient was observed for a biphasic reaction for an appropriate period based on severity and response."},{"id":"dc-ana","label":"Auto-injector + action plan at discharge","tags":[],"scale":"low","line":"At discharge the patient received epinephrine auto-injectors with training, an allergen-avoidance and written action plan, and allergy follow-up."}],"history":[{"id":"ana-hx-trigger","dx":"general","q":"Exposure to a likely allergen (food, sting, drug, contrast) with rapid onset of symptoms?","answers":[{"label":"No clear trigger / gradual","tone":"neg","sets":[],"ddx":[],"frag":"no clear allergen exposure","mdm":"There was no clear allergen exposure with rapid onset, which is atypical for anaphylaxis and prompted consideration of mimics."},{"label":"Yes — allergen then rapid onset","tone":"pos","sets":[{"risk":"criteria-ana"}],"ddx":[],"frag":"allergen exposure with rapid multi-system onset","mdm":"A likely allergen exposure was followed by rapid-onset symptoms, supporting the clinical diagnosis of anaphylaxis."}]},{"id":"ana-hx-airway","dx":"airway-ana","q":"Throat tightness, voice change, difficulty swallowing, or tongue/lip swelling?","answers":[{"label":"No airway symptoms","tone":"neg","sets":[],"ddx":[],"frag":"no throat tightness, voice change, or tongue swelling","mdm":"There was no throat tightness, voice change, difficulty swallowing, or tongue swelling, making airway angioedema less likely."},{"label":"Yes — airway symptoms","tone":"pos","sets":[{"risk":"airway-assess-ana"}],"ddx":[{"id":"airway-ana","keep":true}],"frag":"throat tightness / voice change / tongue swelling","mdm":"Throat tightness, voice change, or tongue swelling was present, raising concern for airway angioedema and prompting preparation for early definitive airway management."}]},{"id":"ana-hx-bradykinin","dx":"bradykinin-ana","q":"Isolated swelling without hives, on an ACE inhibitor, or a personal/family history of recurrent angioedema?","answers":[{"label":"No","tone":"neg","sets":[],"ddx":[],"frag":"no ACE-inhibitor use or recurrent angioedema history","mdm":"There was no isolated angioedema without urticaria, ACE-inhibitor use, or personal/family history of recurrent angioedema, making bradykinin-mediated angioedema unlikely."},{"label":"Yes — suggests bradykinin angioedema","tone":"pos","sets":[],"ddx":[{"id":"bradykinin-ana","keep":true}],"frag":"isolated angioedema with ACE-inhibitor use or family history","mdm":"Isolated angioedema with ACE-inhibitor use or a family history was present, raising concern for bradykinin-mediated angioedema, which does not respond to epinephrine and requires specific therapy and airway vigilance."}]},{"id":"ana-hx-prior","dx":"general","q":"Prior severe allergic reactions or known high-risk allergy (and current beta-blocker use)?","answers":[{"label":"No prior severe reaction","tone":"neg","sets":[],"ddx":[],"frag":"no prior severe reaction or beta-blocker use","mdm":"There was no prior severe allergic reaction or beta-blocker use that would complicate management."},{"label":"Yes — prior reaction / beta-blocker","tone":"pos","sets":[],"ddx":[],"frag":"prior severe reaction or beta-blocker use","mdm":"A prior severe reaction or beta-blocker use was noted; beta-blockade can blunt the epinephrine response and may warrant glucagon if refractory."}]}],"exam":[{"id":"ana-exam-skin","dx":"general","q":"Urticaria, flushing, or angioedema on exam?","answers":[{"label":"No skin/mucosal findings","tone":"neg","sets":[],"ddx":[],"frag":"no urticaria or angioedema","mdm":"There was no urticaria, flushing, or angioedema on examination."},{"label":"Yes — urticaria / angioedema","tone":"pos","sets":[{"risk":"criteria-ana"}],"ddx":[],"frag":"urticaria / flushing / angioedema","mdm":"Urticaria, flushing, or angioedema was present, consistent with an acute allergic reaction."}]},{"id":"ana-exam-resp","dx":"airway-ana","q":"Stridor, wheeze, or respiratory distress?","answers":[{"label":"No respiratory findings","tone":"neg","sets":[],"ddx":[],"frag":"no stridor or wheeze","mdm":"There was no stridor, wheeze, or respiratory distress on examination."},{"label":"Yes — stridor / wheeze","tone":"pos","sets":[{"risk":"airway-assess-ana"}],"ddx":[{"id":"airway-ana","keep":true}],"frag":"stridor / wheeze / distress","mdm":"Stridor, wheeze, or respiratory distress was present, indicating respiratory involvement and the need for prompt epinephrine and airway readiness."}]},{"id":"ana-exam-perfusion","dx":"shock-ana","q":"Hypotension or signs of hypoperfusion?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"frag":"normotensive, well-perfused","mdm":"The patient was normotensive and well-perfused, making anaphylactic shock unlikely."},{"label":"Yes — hypotension / hypoperfusion","tone":"pos","sets":[{"risk":"epi-ana"}],"ddx":[{"id":"shock-ana","keep":true}],"frag":"hypotension / hypoperfusion","mdm":"Hypotension or hypoperfusion was present, indicating anaphylactic shock and requiring epinephrine, supine positioning, and aggressive IV fluids."}]}],"conclusions":["anaphylaxis, treated with epinephrine and observed","allergic reaction without anaphylaxis","anaphylaxis resolved after epinephrine, discharged with an auto-injector and action plan"],"checks":[{"if":"biphasic-ana","needs":["obs-ana"],"mode":"any","warn":"A biphasic reaction is on the differential — document an appropriate observation period and the discharge action plan."},{"if":"airway-ana","needs":["airway-assess-ana"],"mode":"any","warn":"Airway angioedema is a concern — document the airway assessment and the plan for early definitive airway management."}],"decisionTree":{"title":"Anaphylaxis — recognition & management","intro":"An original, evidence-based decision aid for severe allergic reactions. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Recognize & remove the trigger","items":["Suspect anaphylaxis: acute onset with two or more systems involved (skin/mucosa, respiratory, cardiovascular, GI), or hypotension/airway compromise after a likely allergen","Stop/remove the trigger; call for help; monitor, oxygen, IV access"],"next":"q_anaphylaxis"},"q_anaphylaxis":{"type":"decision","q":"Does it meet anaphylaxis criteria (multi-system, or airway/hypotension after a likely allergen)?","yes":"a_epi","no":"q_bradykinin"},"a_epi":{"type":"action","tone":"danger","title":"IM epinephrine now","items":["Intramuscular epinephrine into the anterolateral thigh; repeat every 5–15 minutes as needed","Position supine with legs raised (sitting if in respiratory distress); high-flow oxygen","Adjuncts only after epinephrine: IV fluids, antihistamines, bronchodilators, steroids"],"cantmiss":"Epinephrine is first-line and time-critical. Antihistamines and steroids are adjuncts — they do not treat airway swelling or shock and must not delay epinephrine.","next":"q_response"},"q_response":{"type":"decision","q":"Improved after epinephrine?","yes":"q_biphasic","no":"a_refractory"},"a_refractory":{"type":"action","tone":"danger","title":"Refractory anaphylaxis","terminal":true,"items":["Repeat IM epinephrine or start an IV epinephrine infusion","Aggressive IV crystalloid for shock","Glucagon if the patient is on a beta-blocker and refractory","Prepare for early definitive airway — angioedema can make intubation difficult; ICU admission"]},"q_biphasic":{"type":"decision","q":"Severe reaction, or required more than one epinephrine dose, or prior biphasic reaction?","pitfall":"Even after full resolution, a biphasic reaction can occur hours later — observe appropriately and never discharge without an epinephrine auto-injector and action plan.","yes":"a_obs","no":"a_dc"},"a_obs":{"type":"action","tone":"branch","title":"Extended observation / admit","terminal":true,"items":["Observe for a longer period to sustained resolution","Admit severe or refractory cases","Discharge later with auto-injectors, an action plan, and allergy referral"]},"a_dc":{"type":"action","tone":"branch","title":"Observe, then discharge with safeguards","terminal":true,"items":["Observe for an appropriate period and confirm resolution","Prescribe two epinephrine auto-injectors with training","Allergen-avoidance counseling, a written action plan, and allergy follow-up"]},"q_bradykinin":{"type":"decision","q":"Isolated angioedema without urticaria — on an ACE inhibitor or with a family history?","cantmiss":"Bradykinin-mediated angioedema (ACE-inhibitor or hereditary) does NOT respond to epinephrine, antihistamines, or steroids — prioritize the airway and specific therapy.","yes":"a_bradykinin","no":"a_mild"},"a_bradykinin":{"type":"action","tone":"danger","title":"Bradykinin-mediated angioedema","terminal":true,"items":["Protect the airway — early specialist involvement; intubation can be difficult","Stop the ACE inhibitor","Specific therapy for hereditary angioedema (e.g., C1-esterase inhibitor or icatibant) where indicated"]},"a_mild":{"type":"action","title":"Mild allergic reaction (not anaphylaxis)","terminal":true,"items":["Antihistamine; observe for progression","Counsel to return or use epinephrine if it evolves into anaphylaxis","Identify and avoid the trigger"]}}}},{"id":"stroke","kind":"diagnosis","title":"Acute stroke","specs":["neuro"],"guide":"../learn/complaints/stroke.html","aliases":["stroke","acute stroke","cva","cerebrovascular accident","brain attack","facial droop","slurred speech","hemiparesis","code stroke"],"opening":"The patient was evaluated for an acute neurologic deficit concerning for stroke. This is a time-critical pathway: establish last-known-well, check glucose, image early to separate ischemic from hemorrhagic, and determine reperfusion eligibility while actively considering stroke mimics.","ddx":[{"id":"ich-stroke","group":"lifethreat","label":"Intracranial hemorrhage","default":true,"tags":[],"ruleout":"Intracranial hemorrhage was considered; non-contrast CT showed no acute blood, and there was no severe headache, rapid decline, or coagulopathy mandating reversal, making it unlikely.","miss":4},{"id":"ischemic-stroke","group":"lifethreat","label":"Acute ischemic stroke","default":true,"tags":[],"ruleout":"Acute ischemic stroke was considered; the deficit was transient or resolved with a benign alternative explanation, the exam was non-focal, and imaging did not show acute ischemia, making an acute infarct unlikely.","miss":4},{"id":"lvo-stroke","group":"lifethreat","label":"Large-vessel occlusion","default":false,"tags":[],"ruleout":"A large-vessel occlusion was considered; there was no cortical sign (gaze deviation, aphasia, neglect) or high deficit burden, and vessel imaging where obtained showed no occlusion, making LVO unlikely.","miss":3},{"id":"posterior-stroke","group":"lifethreat","label":"Posterior-circulation stroke","default":false,"tags":[],"ruleout":"A posterior-circulation stroke was considered; there was no acute vestibular syndrome with dangerous HINTS findings, diplopia, dysarthria, or ataxia, making it unlikely.","miss":4},{"id":"sah-stroke","group":"lifethreat","label":"Subarachnoid hemorrhage","default":false,"tags":[],"ruleout":"Subarachnoid hemorrhage was considered; there was no thunderclap or maximal-at-onset headache, and CT (with LP/CTA where indicated) was non-diagnostic, making it unlikely.","miss":4},{"id":"mimic-stroke","group":"common","label":"Stroke mimic (hypoglycemia, seizure, migraine, Bell palsy)","default":true,"tags":[],"ruleout":"Stroke mimics were considered; glucose was normal, there was no seizure with a Todd paralysis, migrainous aura, or peripheral facial palsy pattern, supporting a true cerebrovascular event when present.","miss":4}],"risk":[{"id":"glucose-stroke","label":"Fingerstick glucose checked","tags":[],"scale":"low","line":"A fingerstick glucose was checked immediately to exclude hypoglycemia as a mimic."},{"id":"lkw-stroke","label":"Last-known-well established","tags":[],"scale":"low","line":"The last-known-well time was established to determine reperfusion eligibility."},{"id":"nihss-stroke","label":"NIHSS / deficit severity documented","tags":[],"scale":"low","line":"The neurologic deficit was quantified (e.g., NIHSS) and documented."},{"id":"ct-stroke","label":"Non-contrast CT (± CTA/CTP)","tags":[],"scale":"low","line":"Emergent non-contrast head CT was obtained (with vessel/perfusion imaging where indicated) to separate ischemic from hemorrhagic stroke."},{"id":"bp-stroke","label":"Blood-pressure management per pathway","tags":[],"scale":"low","line":"Blood pressure was managed according to the stroke pathway and the reperfusion plan."}],"history":[{"id":"str-hx-lkw","dx":"ischemic-stroke","q":"Exact last-known-well time and how symptoms began (sudden vs gradual)?","answers":[{"label":"Well-defined, outside window / gradual","tone":"neg","sets":[],"ddx":[],"frag":"clear onset, outside the reperfusion window","mdm":"The onset was well defined and outside the reperfusion window or gradual, which informs eligibility and broadens the differential."},{"label":"Sudden, within window","tone":"pos","sets":[{"risk":"lkw-stroke"}],"ddx":[{"id":"ischemic-stroke","keep":true}],"frag":"sudden onset within the reperfusion window","mdm":"Symptoms began suddenly with a last-known-well time within the reperfusion window, making time-critical reperfusion evaluation a priority."}]},{"id":"str-hx-anticoag","dx":"ich-stroke","q":"Anticoagulant use, bleeding tendency, or severe headache/rapid decline?","answers":[{"label":"No anticoagulation / no headache","tone":"neg","sets":[],"ddx":[],"frag":"no anticoagulation or severe headache","mdm":"There was no anticoagulant use, bleeding tendency, or severe headache/rapid decline to suggest hemorrhage."},{"label":"Yes — anticoagulated / severe headache","tone":"pos","sets":[{"risk":"ct-stroke"}],"ddx":[{"id":"ich-stroke","keep":true}],"frag":"anticoagulation or severe headache","mdm":"Anticoagulant use or a severe headache with decline was present, raising concern for intracranial hemorrhage and the need for urgent imaging and reversal."}]},{"id":"str-hx-mimic","dx":"mimic-stroke","q":"Features of a mimic — preceding seizure, migraine with aura, or a clearly peripheral facial palsy?","answers":[{"label":"No mimic features","tone":"neg","sets":[],"ddx":[],"frag":"no seizure, aura, or peripheral facial pattern","mdm":"There were no features of a mimic such as a preceding seizure, migrainous aura, or a peripheral facial-palsy pattern, supporting a true cerebrovascular event."},{"label":"Yes — mimic features","tone":"pos","sets":[],"ddx":[{"id":"mimic-stroke","keep":true}],"frag":"seizure / aura / peripheral facial pattern","mdm":"Features suggesting a mimic (a preceding seizure with Todd paralysis, migraine with aura, or a clearly peripheral facial palsy) were present and were weighed against a cerebrovascular cause."}]}],"exam":[{"id":"str-exam-focal","dx":"ischemic-stroke","q":"Focal deficit on exam (face/arm/leg weakness, sensory loss, dysarthria)?","answers":[{"label":"Non-focal exam","tone":"neg","sets":[],"ddx":[],"frag":"non-focal neuro exam","mdm":"The neurologic examination was non-focal, making an acute territorial stroke less likely."},{"label":"Yes — focal deficit","tone":"pos","sets":[{"risk":"nihss-stroke"}],"ddx":[{"id":"ischemic-stroke","keep":true}],"frag":"focal neurologic deficit","mdm":"A focal neurologic deficit was present and quantified, consistent with an acute stroke and driving the time-critical pathway."}]},{"id":"str-exam-cortical","dx":"lvo-stroke","q":"Cortical signs suggesting large-vessel occlusion (gaze deviation, aphasia, neglect, dense hemiparesis)?","answers":[{"label":"No cortical signs","tone":"neg","sets":[],"ddx":[],"frag":"no gaze deviation, aphasia, or neglect","mdm":"There were no cortical signs such as gaze deviation, aphasia, or neglect, making a large-vessel occlusion less likely."},{"label":"Yes — cortical signs","tone":"pos","sets":[{"risk":"ct-stroke"}],"ddx":[{"id":"lvo-stroke","keep":true}],"frag":"gaze deviation / aphasia / neglect","mdm":"Cortical signs were present, raising concern for a large-vessel occlusion and the need for vessel imaging and thrombectomy evaluation."}]},{"id":"str-exam-posterior","dx":"posterior-stroke","q":"Posterior-circulation signs (vertigo with nystagmus, ataxia, diplopia, dysarthria)?","answers":[{"label":"No posterior signs","tone":"neg","sets":[],"ddx":[],"frag":"no ataxia, diplopia, or dangerous vestibular signs","mdm":"There were no posterior-circulation signs such as ataxia, diplopia, or a dangerous vestibular pattern, making a posterior stroke less likely."},{"label":"Yes — posterior signs","tone":"pos","sets":[{"risk":"ct-stroke"}],"ddx":[{"id":"posterior-stroke","keep":true}],"frag":"ataxia / diplopia / dangerous vestibular signs","mdm":"Posterior-circulation signs were present, raising concern for a posterior stroke that standard imaging can miss, warranting dedicated evaluation."}]}],"conclusions":["acute ischemic stroke, reperfusion pathway activated","TIA, resolved, admitted for expedited workup","stroke mimic (e.g., hypoglycemia, seizure, migraine)","hemorrhagic stroke, neurosurgery involved"],"checks":[{"if":"ischemic-stroke","needs":["glucose-stroke","lkw-stroke"],"mode":"all","warn":"For a suspected ischemic stroke, document the fingerstick glucose and last-known-well time — both gate reperfusion decisions."},{"if":"ich-stroke","needs":["ct-stroke"],"mode":"any","warn":"Intracranial hemorrhage is on the differential — document emergent non-contrast CT and any anticoagulation reversal."}],"decisionTree":{"title":"Acute stroke — initial approach","intro":"An original, evidence-based decision aid for suspected acute stroke. Apply local protocol and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Stabilize & screen","items":["ABCs; activate the stroke team","Immediate fingerstick glucose; establish last-known-well","Focused neuro exam / NIHSS; IV access; cardiac monitor"],"next":"q_glucose"},"q_glucose":{"type":"decision","q":"Glucose normal (hypoglycemia excluded or corrected)?","cantmiss":"Check glucose first — hypoglycemia is a classic stroke mimic that fully reverses with dextrose.","yes":"a_ct","no":"a_glucose"},"a_glucose":{"type":"action","tone":"danger","title":"Treat hypoglycemia","terminal":true,"items":["Give dextrose (thiamine if malnourished)","Reassess the deficit — resolution points to a mimic","If the deficit persists, return to the stroke pathway"]},"a_ct":{"type":"action","title":"Emergent non-contrast head CT","items":["Non-contrast CT now (± CT angiography / perfusion)","Measure blood pressure; keep the patient NPO","Continue to quantify the deficit"],"next":"q_hemorrhage"},"q_hemorrhage":{"type":"decision","q":"Hemorrhage on CT?","yes":"a_ich","no":"q_window"},"a_ich":{"type":"action","tone":"danger","title":"Intracranial hemorrhage","terminal":true,"items":["Urgently reverse anticoagulation","Careful blood-pressure control","Neurosurgery; if SAH, pursue aneurysm workup"],"pitfall":"Don't over-lower blood pressure in ischemia, but do control it in hemorrhage — and reverse anticoagulation without delay."},"q_window":{"type":"decision","q":"Ischemic, within the reperfusion window, and eligible?","yes":"q_lvo","no":"a_supportive"},"q_lvo":{"type":"decision","q":"Large-vessel occlusion (CTA) or a high deficit burden?","yes":"a_thrombectomy","no":"a_lytic"},"a_thrombectomy":{"type":"action","tone":"danger","title":"Reperfusion — lysis + thrombectomy","terminal":true,"items":["IV thrombolysis if eligible","Endovascular thrombectomy for large-vessel occlusion","Transfer to a comprehensive stroke center as needed"]},"a_lytic":{"type":"action","title":"Thrombolysis if eligible","terminal":true,"items":["IV thrombolytic per criteria and blood-pressure targets","Admit to a stroke unit; monitor for deterioration"]},"a_supportive":{"type":"action","title":"Outside window / ineligible","terminal":true,"items":["Antiplatelet therapy once hemorrhage is excluded; permissive blood pressure","Stroke unit admission and secondary-prevention workup","Consider imaging-based selection for late-window reperfusion"],"cantmiss":"Posterior-circulation strokes are easily missed — dizziness, ataxia, or diplopia with subtle signs still warrant full stroke evaluation."}}}},{"id":"svt","kind":"diagnosis","title":"Supraventricular tachycardia (SVT)","specs":["cards"],"aliases":["svt","supraventricular tachycardia","narrow complex tachycardia","avnrt","avrt","paroxysmal svt","psvt"],"opening":"The patient was evaluated for a regular narrow-complex tachycardia. The priority is to confirm the rhythm, separate it from sinus tachycardia and atrial fibrillation/flutter, terminate it (vagal then adenosine), and cardiovert if unstable — while avoiding AV-nodal blockade in pre-excitation.","ddx":[{"id":"unstable-svt","group":"lifethreat","label":"Unstable SVT","default":true,"tags":[],"ruleout":"Instability from the tachycardia was considered; the patient was normotensive without ischemic chest pain, heart failure, or altered mentation, making unstable SVT requiring immediate cardioversion unlikely.","miss":3},{"id":"preexcited-svt","group":"lifethreat","label":"Pre-excited tachycardia (WPW)","default":false,"tags":[],"ruleout":"Pre-excitation was considered; the QRS was narrow and regular without delta waves or an irregular wide-complex pattern, making a pre-excited tachycardia unlikely.","miss":4},{"id":"vt-svt","group":"lifethreat","label":"VT (wide-complex) masquerading","default":false,"tags":[],"ruleout":"Ventricular tachycardia was considered; the QRS was narrow (<120 ms), making VT unlikely: a wide-complex tachycardia would be treated as VT.","miss":3},{"id":"sinus-svt","group":"common","label":"Sinus tachycardia (secondary)","default":true,"tags":[],"ruleout":"Secondary sinus tachycardia was considered; there was a discrete abrupt onset/offset and no driving cause such as sepsis, hemorrhage, PE, or pain, supporting a primary reentrant SVT.","miss":2},{"id":"aflutter-svt","group":"common","label":"Atrial flutter / fibrillation","default":false,"tags":[],"ruleout":"Atrial flutter or fibrillation was considered; the rhythm was regular and a rhythm strip during vagal/adenosine did not unmask flutter waves or irregularity.","miss":2}],"risk":[{"id":"ecg-svt","label":"12-lead ECG before & after","tags":[],"scale":"low","line":"A 12-lead ECG was obtained before and after treatment to characterize the rhythm and confirm conversion."},{"id":"vagal-svt","label":"Vagal maneuvers attempted","tags":[],"scale":"low","line":"Vagal maneuvers (e.g., modified Valsalva) were attempted first."},{"id":"adenosine-svt","label":"Adenosine given","tags":[],"scale":"low","line":"Adenosine was given by rapid IV push when vagal maneuvers failed."},{"id":"monitor-svt","label":"Continuous monitoring","tags":[],"scale":"low","line":"The patient was on continuous cardiac monitoring throughout."}],"history":[{"id":"svt-hx-onset","dx":"sinus-svt","q":"Abrupt onset/offset with prior similar episodes (vs gradual)?","answers":[{"label":"Gradual / no prior episodes","tone":"neg","sets":[],"ddx":[],"frag":"gradual onset, no prior episodes","mdm":"The onset was gradual without prior paroxysms, raising the possibility of a secondary sinus tachycardia rather than reentrant SVT."},{"label":"Abrupt, recurrent","tone":"pos","sets":[{"risk":"ecg-svt"}],"ddx":[],"frag":"abrupt paroxysmal onset/offset","mdm":"An abrupt paroxysmal onset with prior similar episodes was reported, supporting a reentrant SVT."}]},{"id":"svt-hx-instability","dx":"unstable-svt","q":"Chest pain, dyspnea, presyncope, or other instability symptoms?","answers":[{"label":"No instability symptoms","tone":"neg","sets":[],"ddx":[],"frag":"no chest pain, dyspnea, or presyncope","mdm":"There were no symptoms of instability such as ischemic chest pain, dyspnea, or presyncope."},{"label":"Yes — instability symptoms","tone":"pos","sets":[{"risk":"monitor-svt"}],"ddx":[{"id":"unstable-svt","keep":true}],"frag":"chest pain / dyspnea / presyncope","mdm":"Symptoms of instability were present, prompting readiness for synchronized cardioversion."}]},{"id":"svt-hx-wpw","dx":"preexcited-svt","q":"Known WPW, a delta wave on a prior ECG, or a very rapid irregular rhythm?","answers":[{"label":"No pre-excitation history","tone":"neg","sets":[],"ddx":[],"frag":"no known WPW or delta wave","mdm":"There was no known WPW, prior delta wave, or irregular very-rapid pattern to suggest pre-excitation."},{"label":"Yes — suggests pre-excitation","tone":"pos","sets":[],"ddx":[{"id":"preexcited-svt","keep":true}],"frag":"known WPW / delta wave","mdm":"Features suggesting pre-excitation were present; AV-nodal blocking agents are avoided in this setting."}]}],"exam":[{"id":"svt-exam-perfusion","dx":"unstable-svt","q":"Hypotension or signs of hypoperfusion?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"frag":"normotensive, well-perfused","mdm":"The patient was normotensive and well-perfused, making unstable SVT less likely."},{"label":"Yes — hypotension/hypoperfusion","tone":"pos","sets":[{"risk":"ecg-svt"}],"ddx":[{"id":"unstable-svt","keep":true}],"frag":"hypotension / hypoperfusion","mdm":"Hypotension or hypoperfusion was present, indicating unstable SVT and the need for synchronized cardioversion."}]},{"id":"svt-exam-qrs","dx":"vt-svt","q":"Wide-complex on the monitor/ECG (QRS ≥120 ms)?","answers":[{"label":"Narrow complex","tone":"neg","sets":[],"ddx":[],"frag":"narrow QRS","mdm":"The QRS was narrow, consistent with a supraventricular rhythm."},{"label":"Yes — wide complex","tone":"pos","sets":[],"ddx":[{"id":"vt-svt","keep":true}],"frag":"wide-complex tachycardia","mdm":"A wide-complex tachycardia was present and was treated as ventricular tachycardia until proven otherwise."}]}],"conclusions":["paroxysmal SVT, converted to sinus rhythm","SVT rate-controlled, admitted/observed","sinus tachycardia from a secondary cause, treated"],"checks":[{"if":"preexcited-svt","needs":["ecg-svt"],"mode":"any","warn":"Pre-excitation is on the differential — document the ECG and avoid AV-nodal blocking agents."}],"decisionTree":{"title":"Regular narrow-complex tachycardia (SVT) — management","intro":"An original, evidence-based decision aid for SVT. Apply local protocol (ACLS) and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Confirm & monitor","items":["12-lead ECG; monitor/defibrillator pads; IV access; vitals","Characterize the rhythm: rate, regularity, QRS width"],"next":"q_unstable"},"q_unstable":{"type":"decision","q":"Unstable from the tachycardia? (hypotension, ischemic chest pain, heart failure, altered mentation)","cantmiss":"If the rhythm is causing instability, synchronized cardioversion is first-line — don't chase drugs.","yes":"a_cardiovert","no":"q_wide"},"a_cardiovert":{"type":"action","tone":"danger","title":"Synchronized cardioversion","terminal":true,"items":["Procedural sedation, then synchronized cardioversion","Treat reversible contributors"]},"q_wide":{"type":"decision","q":"Wide-complex (QRS ≥120 ms)?","pitfall":"Treat a regular wide-complex tachycardia as VT unless it is clearly SVT with known aberrancy.","yes":"a_vt","no":"q_regular"},"a_vt":{"type":"action","tone":"danger","title":"Treat as ventricular tachycardia","terminal":true,"items":["Antiarrhythmic (amiodarone or procainamide)","Avoid AV-nodal blockers if irregular or pre-excited","Prepare for synchronized cardioversion"]},"q_regular":{"type":"decision","q":"Regular rhythm?","yes":"a_vagal","no":"a_irregular"},"a_irregular":{"type":"action","title":"Irregular narrow — AF/flutter","terminal":true,"items":["Follow the atrial fibrillation pathway","Rate vs rhythm control; anticoagulation by stroke risk"]},"a_vagal":{"type":"action","title":"Vagal maneuvers","items":["Modified Valsalva first (or carotid sinus massage if no bruit and low stroke risk)","Record a continuous rhythm strip"],"next":"q_conv1"},"q_conv1":{"type":"decision","q":"Converted to sinus rhythm?","yes":"a_post","no":"a_adenosine"},"a_adenosine":{"type":"action","title":"Adenosine","items":["Rapid IV push with immediate saline flush; warn the patient of transient chest discomfort/flushing","Escalate the dose if needed; the strip may unmask atrial flutter"],"next":"q_conv2"},"q_conv2":{"type":"decision","q":"Converted or rate-controlled?","yes":"a_post","no":"a_refractory"},"a_post":{"type":"action","tone":"branch","title":"Post-conversion care","terminal":true,"items":["Observe on monitor; identify and counsel on triggers","Outpatient cardiology/EP for recurrent SVT; discuss ablation"]},"a_refractory":{"type":"action","tone":"danger","title":"Refractory SVT","terminal":true,"items":["Rate control with a calcium-channel or beta-blocker (avoid if pre-excited or borderline BP)","Consider synchronized cardioversion; involve cardiology"]}}}},{"id":"bradycardia","kind":"diagnosis","title":"Symptomatic bradycardia","specs":["cards"],"aliases":["bradycardia","slow heart rate","heart block","av block","bradycardic","complete heart block"],"opening":"The patient was evaluated for bradycardia. The priority is to decide whether the slow rate is causing instability, give atropine and escalate to pacing or chronotropes if needed, and find and treat reversible causes while defining the level of block.","ddx":[{"id":"unstable-brady","group":"lifethreat","label":"Unstable bradycardia","default":true,"tags":[],"ruleout":"Instability from the bradycardia was considered; the patient was normotensive and mentating normally without ischemic chest pain or heart failure, making unstable bradycardia unlikely.","miss":3},{"id":"highgrade-block","group":"lifethreat","label":"High-grade AV block","default":true,"tags":[],"ruleout":"High-grade AV block was considered; the ECG showed no Mobitz II or third-degree block, making it unlikely.","miss":3},{"id":"hyperk-brady","group":"lifethreat","label":"Hyperkalemia","default":false,"tags":[],"ruleout":"Hyperkalemia was considered as a reversible cause; potassium was normal and the ECG showed no hyperkalemic changes, making it unlikely.","miss":4},{"id":"ischemia-brady","group":"lifethreat","label":"Ischemia (inferior MI)","default":false,"tags":[],"ruleout":"Inferior ischemia was considered; there were no ischemic ECG changes or ischemic symptoms, making an ischemic driver unlikely.","miss":3},{"id":"drug-brady","group":"common","label":"Drug effect (beta-blocker, CCB, digoxin)","default":true,"tags":[],"ruleout":"A medication effect was considered; rate-limiting drugs were reviewed and held as appropriate.","miss":2}],"risk":[{"id":"ecg-brady","label":"12-lead ECG / rhythm reviewed","tags":[],"scale":"low","line":"A 12-lead ECG and rhythm were reviewed to define the block level and screen for ischemia."},{"id":"atropine-brady","label":"Atropine given","tags":[],"scale":"low","line":"Atropine was given for symptomatic bradycardia."},{"id":"pacing-brady","label":"Transcutaneous pacing ready/used","tags":[],"scale":"low","line":"Transcutaneous pacing was prepared and used when atropine was inadequate, with analgesia/sedation."},{"id":"k-brady","label":"Potassium / reversible causes checked","tags":[],"scale":"low","line":"Reversible causes (potassium, drugs, hypoxia, ischemia) were assessed and addressed."}],"history":[{"id":"brady-hx-symptoms","dx":"unstable-brady","q":"Syncope, presyncope, dyspnea, or chest pain with the slow rate?","answers":[{"label":"Asymptomatic","tone":"neg","sets":[],"ddx":[],"frag":"no syncope, dyspnea, or chest pain","mdm":"The bradycardia was asymptomatic without syncope, dyspnea, or chest pain."},{"label":"Yes — symptomatic","tone":"pos","sets":[{"risk":"ecg-brady"}],"ddx":[{"id":"unstable-brady","keep":true}],"frag":"syncope / dyspnea / chest pain","mdm":"Symptoms attributable to the bradycardia were present, indicating symptomatic bradycardia."}]},{"id":"brady-hx-meds","dx":"drug-brady","q":"Rate-limiting medications (beta-blocker, calcium-channel blocker, digoxin) or an overdose?","answers":[{"label":"No rate-limiting drugs","tone":"neg","sets":[],"ddx":[],"frag":"no beta-blocker, CCB, or digoxin","mdm":"There were no contributing rate-limiting medications or overdose."},{"label":"Yes — rate-limiting drug/overdose","tone":"pos","sets":[{"risk":"k-brady"}],"ddx":[{"id":"drug-brady","keep":true}],"frag":"beta-blocker / CCB / digoxin effect","mdm":"A rate-limiting medication or overdose was identified, which may require specific antidotal therapy."}]},{"id":"brady-hx-ischemia","dx":"ischemia-brady","q":"Chest pain or features of inferior ischemia?","answers":[{"label":"No ischemic features","tone":"neg","sets":[],"ddx":[],"frag":"no ischemic chest pain","mdm":"There were no ischemic symptoms to suggest an inferior MI as the driver."},{"label":"Yes — possible ischemia","tone":"pos","sets":[{"risk":"ecg-brady"}],"ddx":[{"id":"ischemia-brady","keep":true}],"frag":"ischemic chest pain","mdm":"Ischemic features were present, prompting evaluation for inferior MI as a cause of the bradycardia."}]}],"exam":[{"id":"brady-exam-perfusion","dx":"unstable-brady","q":"Hypotension or signs of hypoperfusion?","answers":[{"label":"Hemodynamically stable","tone":"neg","sets":[],"ddx":[],"frag":"normotensive, well-perfused","mdm":"The patient was normotensive and well-perfused, making unstable bradycardia less likely."},{"label":"Yes — hypotension/hypoperfusion","tone":"pos","sets":[{"risk":"atropine-brady"}],"ddx":[{"id":"unstable-brady","keep":true}],"frag":"hypotension / hypoperfusion","mdm":"Hypotension or hypoperfusion was present, indicating unstable bradycardia requiring atropine and pacing readiness."}]},{"id":"brady-exam-block","dx":"highgrade-block","q":"High-grade AV block on the ECG (Mobitz II or complete)?","answers":[{"label":"No high-grade block","tone":"neg","sets":[],"ddx":[],"frag":"no Mobitz II or complete block","mdm":"The ECG showed no high-grade AV block."},{"label":"Yes — high-grade block","tone":"pos","sets":[{"risk":"pacing-brady"}],"ddx":[{"id":"highgrade-block","keep":true}],"frag":"Mobitz II / complete heart block","mdm":"High-grade AV block was present, which is unlikely to respond durably to atropine and warrants pacing and cardiology."}]}],"conclusions":["symptomatic bradycardia, treated/paced","bradycardia from a reversible cause (drug or electrolyte), corrected","stable bradycardia, monitored with cardiology follow-up"],"checks":[{"if":"hyperk-brady","needs":["k-brady"],"mode":"any","warn":"Hyperkalemia is a reversible cause of bradycardia — document the potassium and ECG."},{"if":"ischemia-brady","needs":["ecg-brady"],"mode":"any","warn":"Inferior ischemia can cause bradycardia — document the ECG."}],"decisionTree":{"title":"Symptomatic bradycardia — management","intro":"An original, evidence-based decision aid for bradycardia. Apply local protocol (ACLS) and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Confirm & monitor","items":["12-lead ECG/rhythm; monitor/pacing pads; IV; vitals","Define the block level; screen for reversible causes"],"next":"q_symptomatic"},"q_symptomatic":{"type":"decision","q":"Symptomatic or unstable from the bradycardia? (hypotension, altered mentation, ischemic chest pain, acute heart failure)","yes":"q_reversible","no":"a_observe"},"a_observe":{"type":"action","title":"Asymptomatic bradycardia","terminal":true,"items":["Monitor; review and hold rate-limiting drugs","Identify the cause; cardiology for high-grade block; pacing on standby"]},"q_reversible":{"type":"decision","q":"Obvious reversible cause? (hyperkalemia, drug effect, hypoxia, inferior ischemia)","cantmiss":"Hunt for hyperkalemia, beta-blocker/CCB/digoxin effect, and inferior MI — each has specific therapy beyond atropine.","yes":"a_reversible","no":"a_atropine"},"a_reversible":{"type":"action","title":"Treat the reversible cause","items":["Calcium + insulin/dextrose for hyperkalemia","Glucagon / high-dose insulin for beta-blocker or calcium-channel-blocker toxicity; digoxin-specific antibody for digoxin","Reperfusion for ischemia; correct hypoxia"],"next":"a_atropine"},"a_atropine":{"type":"action","tone":"danger","title":"Atropine","items":["IV atropine for symptomatic bradycardia","If inadequate, move to pacing and/or chronotropes"],"next":"q_response"},"q_response":{"type":"decision","q":"Improved (rate and perfusion)?","yes":"a_admit","no":"a_pacing"},"a_admit":{"type":"action","tone":"branch","title":"Stabilized","terminal":true,"items":["Continue monitoring; treat the underlying cause","Cardiology for pacing decisions"]},"a_pacing":{"type":"action","tone":"danger","title":"Pacing / chronotropes","terminal":true,"items":["Transcutaneous pacing with analgesia/sedation, and/or an epinephrine or dopamine infusion","Arrange transvenous pacing; urgent cardiology"]}}}},{"id":"ventricular-tachycardia","kind":"diagnosis","title":"Ventricular tachycardia","specs":["cards"],"aliases":["vt","ventricular tachycardia","v-tach","vtach","wide complex tachycardia","wide-complex tachycardia"],"opening":"The patient was evaluated for a wide-complex tachycardia, assumed to be ventricular tachycardia until proven otherwise. The priority is to check for a pulse, defibrillate if pulseless, cardiovert if unstable, treat polymorphic VT distinctly, and find reversible triggers.","ddx":[{"id":"pulseless-vt","group":"lifethreat","label":"Pulseless VT / VF (arrest)","default":true,"tags":[],"ruleout":"Pulseless VT/VF was considered; a pulse was present with a perfusing rhythm, making cardiac arrest not the current state.","miss":3},{"id":"unstable-vt","group":"lifethreat","label":"Unstable VT","default":true,"tags":[],"ruleout":"Unstable VT was considered; the patient was normotensive and mentating without ischemia or heart failure, making immediate cardioversion unnecessary at present.","miss":3},{"id":"polymorphic-vt","group":"lifethreat","label":"Polymorphic VT / torsades","default":false,"tags":[],"ruleout":"Polymorphic VT/torsades was considered; the rhythm was monomorphic and the QT was not prolonged, making torsades unlikely.","miss":4},{"id":"reversible-vt","group":"lifethreat","label":"Reversible trigger (ischemia, electrolytes, QT/tox)","default":true,"tags":[],"ruleout":"A reversible trigger was sought; there was no acute ischemia, electrolyte derangement, or QT-prolonging drug effect identified.","miss":3},{"id":"svt-aberrancy","group":"common","label":"SVT with aberrancy / pre-excited AF","default":false,"tags":[],"ruleout":"SVT with aberrancy was considered, but a regular wide-complex tachycardia was treated as VT until proven otherwise.","miss":2}],"risk":[{"id":"ecg-vt","label":"12-lead ECG","tags":[],"scale":"low","line":"A 12-lead ECG was obtained to characterize the wide-complex tachycardia."},{"id":"defib-vt","label":"Defibrillation (pulseless)","tags":[],"scale":"low","line":"Immediate defibrillation was performed for pulseless VT/VF within the arrest algorithm."},{"id":"cardiovert-vt","label":"Synchronized cardioversion (unstable)","tags":[],"scale":"low","line":"Synchronized cardioversion with sedation was performed for unstable VT."},{"id":"reversible-vt-tool","label":"Reversible causes addressed (K/Mg, ischemia, tox)","tags":[],"scale":"low","line":"Reversible triggers (potassium/magnesium, ischemia, QT-prolonging drugs) were assessed and corrected."}],"history":[{"id":"vt-hx-structural","dx":"reversible-vt","q":"Structural heart disease, prior MI, ICD, or QT-prolonging drugs?","answers":[{"label":"No structural disease / ICD","tone":"neg","sets":[],"ddx":[],"frag":"no structural disease, ICD, or QT drugs","mdm":"There was no structural heart disease, ICD, or QT-prolonging drug to inform the cause."},{"label":"Yes — structural / ICD / QT drugs","tone":"pos","sets":[{"risk":"reversible-vt-tool"}],"ddx":[{"id":"reversible-vt","keep":true}],"frag":"structural disease / ICD / QT-prolonging drugs","mdm":"Structural disease, an ICD, or QT-prolonging drugs were present, informing the cause and recurrence risk."}]},{"id":"vt-hx-instability","dx":"unstable-vt","q":"Syncope, chest pain, or severe dyspnea with the episode?","answers":[{"label":"No instability symptoms","tone":"neg","sets":[],"ddx":[],"frag":"no syncope, chest pain, or severe dyspnea","mdm":"There were no symptoms of instability during the episode."},{"label":"Yes — instability symptoms","tone":"pos","sets":[{"risk":"ecg-vt"}],"ddx":[{"id":"unstable-vt","keep":true}],"frag":"syncope / chest pain / severe dyspnea","mdm":"Symptoms of instability were present, prompting readiness for synchronized cardioversion."}]}],"exam":[{"id":"vt-exam-pulse","dx":"pulseless-vt","q":"Pulse present with a perfusing rhythm?","answers":[{"label":"Pulse present","tone":"neg","sets":[],"ddx":[],"frag":"pulse present, perfusing","mdm":"A pulse was present with a perfusing rhythm, so the arrest algorithm did not apply at this time."},{"label":"No pulse — arrest","tone":"pos","sets":[{"risk":"defib-vt"}],"ddx":[{"id":"pulseless-vt","keep":true}],"frag":"pulseless","mdm":"No pulse was present, indicating pulseless VT/VF and immediate defibrillation within the arrest algorithm."}]},{"id":"vt-exam-perfusion","dx":"unstable-vt","q":"Hypotension or hypoperfusion (if a pulse is present)?","answers":[{"label":"Stable perfusion","tone":"neg","sets":[],"ddx":[],"frag":"normotensive, well-perfused","mdm":"With a pulse present, the patient was normotensive and well-perfused, making unstable VT less likely."},{"label":"Yes — unstable","tone":"pos","sets":[{"risk":"cardiovert-vt"}],"ddx":[{"id":"unstable-vt","keep":true}],"frag":"hypotension / hypoperfusion","mdm":"Hypotension or hypoperfusion was present, indicating unstable VT requiring synchronized cardioversion."}]}],"conclusions":["monomorphic VT, cardioverted","VT from a reversible cause, corrected","stable VT converted pharmacologically, admitted"],"checks":[{"if":"reversible-vt","needs":["reversible-vt-tool"],"mode":"any","warn":"Reversible triggers drive recurrence — document potassium/magnesium, ischemia evaluation, and QT-prolonging drugs."}],"decisionTree":{"title":"Wide-complex tachycardia / VT — management","intro":"An original, evidence-based decision aid for ventricular tachycardia. Apply local protocol (ACLS) and clinical judgment.","root":"start","nodes":{"start":{"type":"action","title":"Wide-complex tachycardia — assume VT","items":["12-lead ECG; monitor/defibrillator pads; IV; assess pulse and perfusion"],"cantmiss":"Treat a regular wide-complex tachycardia as VT until proven otherwise.","next":"q_pulse"},"q_pulse":{"type":"decision","q":"Pulse present?","yes":"q_unstable","no":"a_arrest"},"a_arrest":{"type":"action","tone":"danger","title":"Pulseless VT/VF — arrest pathway","terminal":true,"items":["Immediate defibrillation; high-quality CPR","Epinephrine; antiarrhythmic (amiodarone or lidocaine)","Treat reversible causes (H's and T's)"]},"q_unstable":{"type":"decision","q":"Unstable? (hypotension, ischemia, heart failure, altered mentation)","yes":"a_cardiovert","no":"q_poly"},"a_cardiovert":{"type":"action","tone":"danger","title":"Synchronized cardioversion","terminal":true,"items":["Sedation, then synchronized cardioversion","Follow with an antiarrhythmic infusion; correct reversible causes"]},"q_poly":{"type":"decision","q":"Polymorphic VT (e.g., torsades) or a long QT?","pitfall":"Polymorphic VT/torsades is managed differently — IV magnesium, stop QT-prolonging drugs, correct electrolytes; defibrillate if it sustains.","yes":"a_torsades","no":"a_stable"},"a_torsades":{"type":"action","tone":"danger","title":"Polymorphic VT / torsades","terminal":true,"items":["IV magnesium; stop QT-prolonging drugs; correct potassium/magnesium","Overdrive pacing or isoproterenol for bradycardia-dependent torsades","Defibrillate if sustained or pulseless"]},"a_stable":{"type":"action","title":"Stable monomorphic VT","items":["IV antiarrhythmic (amiodarone or procainamide)","Prepare for synchronized cardioversion if it fails; correct electrolytes"],"next":"q_reversible"},"q_reversible":{"type":"decision","q":"Reversible trigger identified (ischemia, electrolytes, drug/QT)?","yes":"a_cause","no":"a_admit"},"a_cause":{"type":"action","tone":"branch","title":"Treat the trigger","terminal":true,"items":["Reperfusion for ischemia; replete potassium/magnesium; remove offending drugs","Admit/monitor; EP referral for recurrent VT"]},"a_admit":{"type":"action","tone":"branch","title":"Admit & monitor","terminal":true,"items":["Telemetry; cardiology/EP","ICD evaluation for sustained VT without a reversible cause"]}}}},{"id":"drowning","title":"Drowning / submersion","aliases":["drowning","submersion","near drowning","water rescue","pool accident","immersion","swimming accident","delayed drowning","aspiration of water"],"opening":"A patient was evaluated after a submersion event. The assessment focused on hypoxemic lung injury and its evolution over the observation period, the precipitating cause of the submersion — including arrhythmia, seizure, hypoglycemia, and intoxication — and associated trauma, particularly cervical spine injury with a diving or impact mechanism.","specs":["pulm","trauma","peds"],"ddx":[{"id":"resp-drown","group":"lifethreat","label":"Hypoxemic respiratory failure / evolving lung injury","default":true,"tags":["resp-drown"],"miss":4,"ruleout":"Evolving hypoxemic lung injury was considered; the patient had no cough, dyspnea, or hypoxia on arrival, the lungs remained clear with normal oxygen saturation over an observation period of several hours, and the work of breathing was normal throughout, making clinically significant aspiration injury unlikely."},{"id":"precipitant-drown","group":"lifethreat","label":"Medical precipitant of submersion (arrhythmia, seizure, hypoglycemia)","default":true,"tags":["precipitant-drown"],"miss":4,"ruleout":"A medical cause of the submersion was considered: why the patient went under matters as much as the water; there was no syncope before submersion, no seizure activity, no personal or family history of arrhythmia, sudden death, or long QT, glucose was normal, and the ECG showed no QT prolongation or pre-excitation, making an underlying medical precipitant unlikely."},{"id":"cspine-drown","group":"lifethreat","label":"Cervical spine injury (diving / impact mechanism)","default":false,"tags":["cspine-drown"],"miss":4,"ruleout":"Cervical spine injury was considered; the mechanism did not involve diving, a fall, or striking an object, there was no midline cervical tenderness or neurologic deficit, and the patient was neurologically intact, making spinal injury unlikely."},{"id":"hypothermia-drown","group":"lifethreat","label":"Hypothermia","default":false,"tags":["hypothermia-drown"],"miss":3,"ruleout":"Hypothermia was considered given the immersion; the core temperature was normal, the submersion was brief and in warm water, and there was no altered mentation or cardiovascular instability, making clinically significant hypothermia unlikely."},{"id":"aspiration-drown","group":"common","label":"Aspiration pneumonitis","default":false,"tags":["aspiration-drown"],"miss":2,"ruleout":"Aspiration pneumonitis was considered; the patient remained afebrile without productive cough or focal findings on lung examination, and any imaging obtained showed no infiltrate."},{"id":"minor-drown","group":"other","label":"Uncomplicated brief submersion","default":false,"tags":["minor-drown"],"miss":1,"ruleout":"After the concerns above were addressed, this was judged an uncomplicated brief submersion in a patient who remained asymptomatic through observation."}],"risk":[{"id":"obs-drown","label":"Observation period","tags":["resp-drown"],"scale":"low","line":"The patient was observed with serial respiratory assessments and pulse oximetry, recognizing that symptomatic drowning patients can worsen over the first several hours","short":"observed with serial respiratory assessments and oximetry"},{"id":"ecg-drown","label":"ECG for precipitant","tags":["precipitant-drown"],"scale":"low","line":"A 12-lead ECG was reviewed for QT prolongation, pre-excitation, and Brugada pattern as a cause of the submersion","short":"ECG reviewed for QT prolongation and arrhythmic precipitants"}],"checks":[{"if":"resp-drown","needs":["obs-drown"],"mode":"any","warn":"A symptomatic submersion needs a documented observation period with serial respiratory assessments — deterioration over the first hours is the failure mode."},{"if":"precipitant-drown","needs":["ecg-drown"],"mode":"any","warn":"Ask why the patient went under — an ECG for QT prolongation and arrhythmic precipitants belongs in every unexplained submersion."}],"history":[{"id":"drw-hx-event","dx":"general","q":"The event — witnessed? Submersion duration, water type, and rescue circumstances?","answers":[{"label":"Brief, witnessed, rapid rescue","tone":"neg","sets":[],"ddx":[],"mdm":"The submersion was witnessed and brief with rapid rescue, and the patient did not require resuscitation at the scene.","frag":"brief witnessed submersion with rapid rescue"},{"label":"Prolonged / unwitnessed / required resuscitation","tone":"pos","sets":[],"ddx":[{"id":"resp-drown","keep":true}],"mdm":"The submersion was prolonged or unwitnessed, or resuscitation was required at the scene: features that raise the risk of significant hypoxic injury.","frag":""}]},{"id":"drw-hx-symptoms","dx":"resp-drown","q":"Respiratory symptoms since the event — cough, dyspnea, chest discomfort, or vomiting?","answers":[{"label":"Asymptomatic since the event","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no cough, dyspnea, or chest discomfort since the event"},{"label":"Coughing / dyspneic / vomited","tone":"pos","sets":[],"ddx":[{"id":"resp-drown","keep":true}],"mdm":"The patient has had cough, dyspnea, or vomiting since the event, consistent with aspiration and warranting observation with serial reassessment.","frag":""}]},{"id":"drw-hx-precipitant","dx":"precipitant-drown","q":"Why did they go under — preceding syncope, seizure activity, chest pain or palpitations, hypoglycemia risk, or intoxication?","answers":[{"label":"Clear accidental mechanism","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"a clear accidental mechanism without preceding syncope, seizure, or palpitations"},{"label":"Unexplained or preceded by symptoms","tone":"pos","sets":[{"risk":"ecg-drown"}],"ddx":[{"id":"precipitant-drown","keep":true}],"mdm":"The submersion was unexplained or preceded by syncope, seizure activity, or palpitations: a medical precipitant is being actively pursued.","frag":""}]},{"id":"drw-hx-cardiac","dx":"precipitant-drown","q":"Arrhythmia risk — personal or family history of long QT, sudden death, unexplained drowning in a relative, or a known seizure disorder?","answers":[{"label":"No arrhythmia or seizure history","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no personal or family history of long QT, sudden death, or seizure disorder"},{"label":"Concerning personal / family history","tone":"pos","sets":[{"risk":"ecg-drown"}],"ddx":[{"id":"precipitant-drown","keep":true}],"mdm":"There is a personal or family history of arrhythmia, sudden death, or seizures: channelopathy-associated drowning is a recognized presentation and is being evaluated.","frag":""}]},{"id":"drw-hx-trauma","dx":"cspine-drown","q":"Trauma mechanism — diving into shallow water, a fall, boat or watercraft involvement, or striking an object?","answers":[{"label":"No trauma mechanism","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no diving, fall, or impact mechanism"},{"label":"Diving / impact mechanism","tone":"pos","sets":[],"ddx":[{"id":"cspine-drown","keep":true}],"mdm":"The mechanism involved diving or impact, so cervical spine injury is being evaluated with appropriate precautions.","frag":""}]}],"exam":[{"id":"drw-exam-resp","dx":"resp-drown","q":"Respiratory status — SpO2 on room air, respiratory rate, work of breathing, and lung auscultation?","answers":[{"label":"Normal SpO2, clear lungs, no distress","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"normal oxygen saturation on room air with clear lungs and no increased work of breathing"},{"label":"Hypoxic / crackles / increased work","tone":"pos","sets":[],"ddx":[{"id":"resp-drown","keep":true}],"mdm":"The patient is hypoxic or has crackles or increased work of breathing: findings of aspiration-related lung injury that drive observation and escalation.","frag":""}]},{"id":"drw-exam-neuro","dx":"general","q":"Neurologic status — alert and oriented at baseline, or any confusion, agitation, or depressed mentation?","answers":[{"label":"Neurologically at baseline","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"alert and at neurologic baseline"},{"label":"Altered or agitated","tone":"pos","sets":[],"ddx":[{"id":"resp-drown","keep":true}],"mdm":"Mentation is not at baseline: hypoxic injury and a medical precipitant are both being pursued.","frag":""}]},{"id":"drw-exam-cspine","dx":"cspine-drown","q":"Cervical spine — midline tenderness, or any focal neurologic deficit?","answers":[{"label":"No midline tenderness, intact exam","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no midline cervical tenderness and an intact neurologic examination"},{"label":"Midline tenderness / deficit","tone":"pos","sets":[],"ddx":[{"id":"cspine-drown","keep":true}],"mdm":"There is midline cervical tenderness or a neurologic deficit: the spine is immobilized and imaging is being obtained.","frag":""}]},{"id":"drw-exam-temp","dx":"hypothermia-drown","q":"Core temperature?","answers":[{"label":"Normothermic","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"normothermic on a core temperature"},{"label":"Hypothermic","tone":"pos","sets":[],"ddx":[{"id":"hypothermia-drown","keep":true}],"mdm":"The patient is hypothermic and active rewarming has been initiated, recognizing that resuscitation decisions change in the cold patient.","frag":""}]}],"pearls":[{"text":"A symptomatic submersion patient — any cough, dyspnea, or hypoxia — needs 4–8 hours of observation with serial respiratory assessments: aspiration injury evolves over the first hours, not the first minutes.","dx":"resp-drown"},{"text":"An asymptomatic patient with a normal exam and normal room-air SpO2 after 4–8 hours of observation can be discharged — 'dry drowning' and 'secondary drowning' are not real entities; patients who deteriorate were symptomatic first.","dx":"resp-drown"},{"text":"Always ask why the patient went under. Unexplained drowning in a swimmer is an arrhythmia (long QT, catecholaminergic VT), seizure, or hypoglycemia until proven otherwise — get an ECG and a glucose.","dx":"precipitant-drown"},{"text":"Cervical spine imaging is for a concerning mechanism — diving, a fall, watercraft — not for every submersion; routine immobilization of all drowning patients is unnecessary and impedes airway care.","dx":"cspine-drown"},{"text":"Prophylactic antibiotics and corticosteroids do not improve outcomes in aspiration of fresh or salt water — treat pneumonia if it declares itself.","dx":"aspiration-drown"},{"text":"The hypothermic drowning patient is not dead until warm and dead — prolonged resuscitation with active rewarming is indicated in cold-water arrest.","dx":"hypothermia-drown"}]},{"id":"breast-problems","title":"Breast pain / mass / infection","aliases":["breast pain","breast problems","mastitis","breast abscess","breast lump","breast mass","lactational mastitis","breast redness","nipple discharge","inflammatory breast cancer","engorgement","peau d'orange"],"opening":"A patient presented with a breast complaint. The evaluation distinguished infection from abscess, addressed inflammatory breast cancer as the can't-miss mimic of mastitis — particularly in the non-lactating patient or the patient not improving on antibiotics — and ensured that any palpable mass leaves the department with a documented plan for diagnostic imaging.","specs":["obgyn","id","surg"],"ddx":[{"id":"ibc","group":"lifethreat","label":"Inflammatory breast cancer","default":true,"tags":["ibc"],"miss":4,"ruleout":"Inflammatory breast cancer was considered as the mimic of mastitis; the patient is lactating with a clinical picture typical of infection, there was no peau d'orange, nipple retraction, or fixed mass, symptoms are of short duration rather than weeks of progressive change, and the presentation is expected to respond to antibiotics, with explicit instructions to return for re-evaluation and imaging if it does not improve within 48–72 hours."},{"id":"breast-abscess","group":"lifethreat","label":"Breast abscess","default":true,"tags":["breast-abscess"],"miss":3,"ruleout":"A drainable abscess was considered; there was no fluctuance or discrete tender mass within the area of cellulitis, and ultrasound (the reliable discriminator, as examination alone underperforms); showed no drainable collection where obtained, making abscess unlikely today."},{"id":"mastitis","group":"common","label":"Mastitis / cellulitis of the breast","default":true,"tags":["mastitis"],"miss":2,"ruleout":"Mastitis was considered; there was no wedge-shaped erythema, warmth, or tenderness and no fever or systemic symptoms, making infection unlikely."},{"id":"breast-mass","group":"common","label":"Breast mass requiring diagnostic follow-up","default":true,"tags":["breast-mass"],"miss":4,"ruleout":"A discrete mass requiring workup was considered; no dominant mass was palpable apart from the acute process, and the patient was counseled to complete age-appropriate screening: any persistent palpable finding after treatment requires diagnostic imaging regardless of today's diagnosis."},{"id":"engorgement","group":"other","label":"Engorgement / plugged duct","default":false,"tags":["engorgement"],"miss":1,"ruleout":"After infection and mass were addressed, the presentation was most consistent with engorgement or a plugged duct, managed with continued emptying of the breast, warm compresses, and analgesia.","sex":"f"}],"risk":[{"id":"us-breast","label":"Breast ultrasound","tags":["breast-abscess","breast-mass"],"scale":"low","line":"Ultrasound was used to assess for a drainable collection, recognizing that examination alone is unreliable for distinguishing abscess from phlegmonous mastitis","short":"ultrasound assessed for a drainable collection"},{"id":"fu-imaging","label":"Diagnostic imaging referral","tags":["ibc","breast-mass"],"scale":"low","line":"A specific referral for outpatient diagnostic breast imaging was arranged and documented, with explicit instructions that persistent findings after treatment require completion of that workup","short":"outpatient diagnostic breast imaging arranged and documented"}],"checks":[{"if":"ibc","needs":["fu-imaging"],"mode":"any","warn":"Mastitis that isn't classic — non-lactating patient, weeks of symptoms, or failure to improve on antibiotics — needs a documented imaging referral: inflammatory breast cancer is the miss."},{"if":"breast-abscess","needs":["us-breast"],"mode":"any","warn":"Examination alone is unreliable for abscess — ultrasound before calling it cellulitis."}],"history":[{"id":"brst-hx-lactation","dx":"general","q":"Lactation status — currently breastfeeding, recently weaned, or not lactating?","answers":[{"label":"Lactating, typical course","tone":"neg","sets":[],"ddx":[],"mdm":"The patient is lactating with an acute presentation typical of lactational mastitis.","frag":"lactating, with an acute course typical of infection"},{"label":"Not lactating","tone":"pos","sets":[],"ddx":[{"id":"ibc","keep":true}],"mdm":"The patient is not lactating: non-lactational mastitis warrants a lower threshold for imaging and for considering inflammatory breast cancer.","frag":""}]},{"id":"brst-hx-duration","dx":"ibc","q":"Time course — acute onset over days, or weeks of progressive skin change, swelling, or asymmetry?","answers":[{"label":"Acute, over days","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"an acute course over days rather than weeks of progressive change"},{"label":"Weeks of progressive change","tone":"pos","sets":[{"risk":"fu-imaging"}],"ddx":[{"id":"ibc","keep":true}],"mdm":"Symptoms have progressed over weeks rather than days: a pattern concerning for inflammatory breast cancer rather than simple infection; diagnostic imaging and biopsy referral are being arranged.","frag":""}]},{"id":"brst-hx-antibiotics","dx":"ibc","q":"Antibiotic response — is this a return visit for 'mastitis' that has not improved on appropriate antibiotics?","answers":[{"label":"First presentation / improving","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no prior failed antibiotic course for this episode"},{"label":"Failed antibiotics","tone":"pos","sets":[{"risk":"fu-imaging"},{"risk":"us-breast"}],"ddx":[{"id":"ibc","keep":true},{"id":"breast-abscess","keep":true}],"mdm":"The presentation has not improved on appropriate antibiotics: this mandates ultrasound for abscess and a documented imaging referral, since antibiotic-refractory 'mastitis' is inflammatory breast cancer until proven otherwise.","frag":""}]},{"id":"brst-hx-mass","dx":"breast-mass","q":"Mass history — a lump noticed by the patient, nipple discharge or retraction, or family history of breast cancer?","answers":[{"label":"No mass or discharge noticed","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no self-detected lump, discharge, or nipple change"},{"label":"Palpable lump / discharge / strong family history","tone":"pos","sets":[{"risk":"fu-imaging"}],"ddx":[{"id":"breast-mass","keep":true}],"mdm":"The patient reports a lump, discharge, or a concerning family history: a specific plan for diagnostic imaging is documented regardless of today's working diagnosis.","frag":""}]},{"id":"brst-hx-systemic","dx":"mastitis","q":"Systemic symptoms — fever, chills, or feeling unwell?","answers":[{"label":"No systemic symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no fever or systemic symptoms"},{"label":"Febrile / systemically unwell","tone":"pos","sets":[],"ddx":[{"id":"mastitis","keep":true},{"id":"breast-abscess","keep":true}],"mdm":"The patient is febrile or systemically unwell, consistent with infection and raising the priority of excluding an abscess.","frag":""}]}],"exam":[{"id":"brst-exam-skin","dx":"ibc","q":"Skin — peau d'orange, nipple retraction, skin dimpling, or erythema involving more than a third of the breast?","answers":[{"label":"No malignant skin features","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no peau d'orange, nipple retraction, or dimpling"},{"label":"Peau d'orange / retraction / extensive change","tone":"pos","sets":[{"risk":"fu-imaging"}],"ddx":[{"id":"ibc","keep":true}],"mdm":"Skin findings (peau d'orange, retraction, or extensive change) are concerning for inflammatory breast cancer; urgent imaging and surgical/oncologic referral are being arranged.","frag":""}]},{"id":"brst-exam-fluctuance","dx":"breast-abscess","q":"Fluctuance — a discrete, tender, fluctuant collection within the area of erythema?","answers":[{"label":"No fluctuance","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no fluctuance or discrete collection on palpation"},{"label":"Fluctuant collection","tone":"pos","sets":[{"risk":"us-breast"}],"ddx":[{"id":"breast-abscess","keep":true}],"mdm":"There is a fluctuant collection consistent with abscess: ultrasound characterization and drainage are being arranged.","frag":""}]},{"id":"brst-exam-mass","dx":"breast-mass","q":"Dominant mass — a discrete palpable mass separate from the inflamed area? Axillary lymphadenopathy?","answers":[{"label":"No dominant mass or adenopathy","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no dominant mass or axillary adenopathy"},{"label":"Discrete mass / adenopathy","tone":"pos","sets":[{"risk":"fu-imaging"}],"ddx":[{"id":"breast-mass","keep":true}],"mdm":"A discrete mass or axillary adenopathy is present: diagnostic imaging is required and the referral is documented.","frag":""}]}],"pearls":[{"text":"Mastitis in a non-lactating patient, weeks of progressive change, or 'mastitis' that fails antibiotics is inflammatory breast cancer until proven otherwise — document the imaging referral, not just the antibiotic.","dx":"ibc"},{"text":"Examination is unreliable for abscess within mastitis — ultrasound is the discriminator, and needle aspiration (often US-guided) has largely replaced incision and drainage for lactational abscesses to preserve breastfeeding.","dx":"breast-abscess"},{"text":"Continue breastfeeding or pumping through lactational mastitis — emptying the breast is treatment, and abrupt weaning worsens it.","dx":"mastitis"},{"text":"Any palpable mass the patient or you found needs documented outpatient diagnostic imaging even when infection explains today's visit — 'resolved with antibiotics' is how cancers get lost to follow-up.","dx":"breast-mass"},{"text":"Male patients with a breast mass or unilateral changes get the same diagnostic imaging pathway — male breast cancer presents later precisely because it isn't considered.","dx":"breast-mass"}]},{"id":"eyelid-problems","title":"Eyelid swelling / lesion","aliases":["eyelid problems","stye","hordeolum","chalazion","blepharitis","eyelid swelling","swollen eyelid","preseptal cellulitis","periorbital cellulitis","orbital cellulitis","dacryocystitis","eyelid bump","eyelid lesion"],"opening":"A patient presented with an eyelid complaint. The evaluation centered on the preseptal-versus-orbital fork — pain with eye movement, proptosis, and visual change being the discriminators that change disposition — with attention to dacryocystitis, the benign lid lesions, and the recurrent same-site 'chalazion' that is a sebaceous carcinoma until an ophthalmologist says otherwise.","specs":["ophtho","id"],"ddx":[{"id":"orbital-eyelid","group":"lifethreat","label":"Orbital cellulitis","default":true,"tags":["orbital-eyelid"],"miss":4,"ruleout":"Orbital cellulitis was considered; there was no pain with extraocular movement, no proptosis or ophthalmoplegia, visual acuity was normal, and the patient was non-toxic without significant fever, keeping the process anterior to the septum and making orbital involvement unlikely."},{"id":"preseptal-eyelid","group":"common","label":"Preseptal (periorbital) cellulitis","default":true,"tags":["preseptal-eyelid"],"miss":3,"ruleout":"Preseptal cellulitis was considered; the lid findings were localized without spreading erythema, warmth, or tenderness of the periorbital tissues and without fever, making cellulitis unlikely."},{"id":"dacryocystitis-eyelid","group":"common","label":"Dacryocystitis","default":false,"tags":["dacryocystitis-eyelid"],"miss":2,"ruleout":"Dacryocystitis was considered; there was no swelling, erythema, or tenderness over the lacrimal sac medial to the eye and no expressible purulence from the punctum, making it unlikely."},{"id":"sebaceous-ca","group":"common","label":"Sebaceous carcinoma (recurrent 'chalazion')","default":false,"tags":["sebaceous-ca"],"miss":4,"ruleout":"Sebaceous carcinoma masquerading as a benign lid lesion was considered; this is a first presentation rather than a recurrent same-site lesion, there is no madarosis or lid-margin destruction, and the appearance is typical of a hordeolum or chalazion, with instructions that any recurrence at the same site requires ophthalmology referral for biopsy."},{"id":"hordeolum","group":"other","label":"Hordeolum / chalazion","default":false,"tags":["hordeolum"],"miss":1,"ruleout":"With the deeper processes addressed, the lesion is most consistent with a hordeolum or chalazion, managed with warm compresses and lid hygiene."},{"id":"blepharitis","group":"other","label":"Blepharitis","default":false,"tags":["blepharitis"],"miss":1,"ruleout":"Blepharitis was considered as the background process; lid-margin crusting and telangiectasia were addressed with lid hygiene."}],"risk":[{"id":"va-eyelid","label":"Visual acuity","tags":["orbital-eyelid"],"scale":"low","line":"Visual acuity was measured and documented in both eyes: the vital sign of the eye","short":"visual acuity documented in both eyes"},{"id":"eom-eyelid","label":"Extraocular movements","tags":["orbital-eyelid"],"scale":"low","line":"Extraocular movements were tested specifically for pain and restriction, the bedside discriminator between preseptal and orbital cellulitis","short":"extraocular movements tested for pain and restriction"}],"checks":[{"if":"orbital-eyelid","needs":["va-eyelid","eom-eyelid"],"mode":"all","warn":"Preseptal vs orbital lives on the exam: visual acuity AND pain/restriction with eye movement must both be documented — CT the orbit when either is abnormal or the exam is unreliable."}],"history":[{"id":"lid-hx-pain-movement","dx":"orbital-eyelid","q":"Pain with eye movement, double vision, or decreased vision?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no pain with eye movement, diplopia, or visual change"},{"label":"Painful movement / diplopia / vision change","tone":"pos","sets":[{"risk":"va-eyelid"},{"risk":"eom-eyelid"}],"ddx":[{"id":"orbital-eyelid","keep":true}],"mdm":"There is pain with eye movement, diplopia, or visual change: orbital involvement is presumed and CT imaging with ophthalmology consultation is being arranged.","frag":""}]},{"id":"lid-hx-course","dx":"general","q":"Course — acute painful swelling, a slow painless nodule, or chronic lid-margin irritation?","answers":[{"label":"Pattern fits a benign lid lesion","tone":"neg","sets":[],"ddx":[],"mdm":"The course fits a benign lid process: an acute tender hordeolum, a slow painless chalazion, or chronic blepharitic irritation.","frag":"a course typical of a benign lid lesion"},{"label":"Rapidly spreading / systemically unwell","tone":"pos","sets":[],"ddx":[{"id":"preseptal-eyelid","keep":true},{"id":"orbital-eyelid","keep":true}],"mdm":"Swelling is spreading rapidly or the patient is systemically unwell: cellulitis is being treated and orbital extension actively excluded.","frag":""}]},{"id":"lid-hx-recurrent","dx":"sebaceous-ca","q":"Recurrence — has a 'stye' or 'chalazion' recurred at this same site, or failed to resolve after treatment?","answers":[{"label":"First episode at this site","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"a first episode at this site"},{"label":"Recurrent at the same site","tone":"pos","sets":[],"ddx":[{"id":"sebaceous-ca","keep":true}],"mdm":"The lesion has recurred at the same site: sebaceous carcinoma mimics recurrent chalazion, and ophthalmology referral for evaluation and possible biopsy is documented.","frag":""}]},{"id":"lid-hx-sinus","dx":"orbital-eyelid","q":"Preceding sinusitis, recent periocular trauma or surgery, or an immunocompromising condition?","answers":[{"label":"None","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no preceding sinusitis, periocular trauma, or immunocompromise"},{"label":"Sinusitis / trauma / immunocompromised","tone":"pos","sets":[],"ddx":[{"id":"orbital-eyelid","keep":true}],"mdm":"Preceding sinus disease, periocular trauma, or immunocompromise raises the risk of orbital extension and lowers the threshold for imaging.","frag":""}]}],"exam":[{"id":"lid-exam-va","dx":"orbital-eyelid","q":"Visual acuity — measured in both eyes?","answers":[{"label":"Normal and symmetric","tone":"neg","sets":[{"risk":"va-eyelid"}],"ddx":[],"mdm":"","frag":"normal, symmetric visual acuity"},{"label":"Decreased in the affected eye","tone":"pos","sets":[{"risk":"va-eyelid"}],"ddx":[{"id":"orbital-eyelid","keep":true}],"mdm":"Visual acuity is decreased in the affected eye: an orbital process threatening vision is presumed until imaging and ophthalmology say otherwise.","frag":""}]},{"id":"lid-exam-eom","dx":"orbital-eyelid","q":"Extraocular movements — full and painless? Any proptosis?","answers":[{"label":"Full, painless, no proptosis","tone":"neg","sets":[{"risk":"eom-eyelid"}],"ddx":[],"mdm":"","frag":"full painless extraocular movements without proptosis"},{"label":"Painful / restricted / proptotic","tone":"pos","sets":[{"risk":"eom-eyelid"}],"ddx":[{"id":"orbital-eyelid","keep":true}],"mdm":"Extraocular movement is painful or restricted, or there is proptosis: hallmarks of orbital cellulitis; CT and ophthalmology consultation are underway.","frag":""}]},{"id":"lid-exam-lacrimal","dx":"dacryocystitis-eyelid","q":"Lacrimal sac — swelling, erythema, or tenderness medial to the eye, or purulence expressible from the punctum?","answers":[{"label":"Lacrimal sac normal","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no lacrimal sac swelling or expressible purulence"},{"label":"Sac swollen / purulence expressed","tone":"pos","sets":[],"ddx":[{"id":"dacryocystitis-eyelid","keep":true}],"mdm":"The lacrimal sac is swollen and tender with expressible purulence: dacryocystitis is being treated with antibiotics and ophthalmology follow-up.","frag":""}]},{"id":"lid-exam-lesion","dx":"hordeolum","q":"Lid lesion — a tender pustule at the lash line (hordeolum), a firm painless nodule (chalazion), or crusted, inflamed lid margins (blepharitis)?","answers":[{"label":"Typical benign lesion","tone":"neg","sets":[],"ddx":[],"mdm":"The lesion has the typical appearance of a hordeolum, chalazion, or blepharitis without atypical features.","frag":"a typical benign-appearing lid lesion"},{"label":"Atypical — destruction, madarosis, ulceration","tone":"pos","sets":[],"ddx":[{"id":"sebaceous-ca","keep":true}],"mdm":"The lesion has atypical features (lash loss, lid-margin destruction, or ulceration) and ophthalmology referral for biopsy is documented.","frag":""}]}],"pearls":[{"text":"The preseptal-versus-orbital fork lives on three findings: pain with eye movement, proptosis, and visual change. Any one of them — or an exam you can't trust, especially in a young child — buys a CT of the orbits and sinuses.","dx":"orbital-eyelid"},{"text":"Document visual acuity in every eye complaint — it is the vital sign of the eye, and its absence is the first thing a reviewer notices.","dx":"orbital-eyelid"},{"text":"A 'chalazion' that keeps recurring at the same site is sebaceous carcinoma until an ophthalmologist says otherwise — refer for biopsy rather than repeat drainage.","dx":"sebaceous-ca"},{"text":"A hordeolum is treated with warm compresses and lid hygiene — topical antibiotics add little and oral antibiotics are for spreading cellulitis, not the lesion itself.","dx":"hordeolum"},{"text":"Dacryocystitis is a lacrimal sac infection — medial canthal swelling with expressible purulence; in neonates it can seed sepsis and warrants a much lower admission threshold.","dx":"dacryocystitis-eyelid"}]},{"id":"urethritis-std","title":"Urethritis / male STI","kind":"complaint","aliases":["urethritis","male std","male sti","penile discharge","dysuria male","gonorrhea","chlamydia","urethral discharge","std","sti","burning urination male"],"opening":"A male patient presented with urethral discharge or dysuria and was evaluated for urethritis. Gonococcal and non-gonococcal (chlamydial and other) causes were addressed with empiric treatment and testing, and the can't-miss complications and mimics — epididymo-orchitis, testicular torsion, disseminated gonococcal infection, and Fitz-Hugh-Curtis in the partner-relevant history — were actively considered, along with partner treatment and screening for co-infection.","specs":["uro","id"],"ddx":[{"id":"torsion-std","group":"lifethreat","label":"Testicular torsion","default":true,"tags":["torsion-std"],"miss":4,"sex":"m","ruleout":"Testicular torsion was considered even in the setting of presumed infection; the onset was gradual rather than sudden and severe, the testis was in normal vertical lie with an intact cremasteric reflex and no high-riding position, and Doppler flow was preserved where obtained, recognizing that a present cremasteric reflex does not exclude torsion, so any persistent suspicion warrants ultrasound and urology."},{"id":"dgi","group":"lifethreat","label":"Disseminated gonococcal infection","default":false,"tags":["dgi"],"miss":3,"ruleout":"Disseminated gonococcal infection was considered; there was no migratory polyarthralgia, tenosynovitis, or pustular skin rash and the patient was afebrile and non-toxic, making dissemination unlikely."},{"id":"epididymitis-std","group":"common","label":"Epididymo-orchitis","default":true,"tags":["epididymitis-std"],"miss":3,"sex":"m","ruleout":"Epididymo-orchitis was considered; there was no posterior scrotal tenderness or swelling, no relief of pain with elevation, and no fever, making a complicating epididymal infection unlikely."},{"id":"gc-urethritis","group":"common","label":"Gonococcal urethritis","default":true,"tags":["gc-urethritis"],"miss":2,"ruleout":"Gonococcal urethritis was considered; empiric therapy covering gonorrhea was provided and nucleic-acid testing sent, with the recognition that treatment is not delayed for results."},{"id":"ngu","group":"common","label":"Non-gonococcal urethritis (chlamydial/other)","default":true,"tags":["ngu"],"miss":2,"ruleout":"Non-gonococcal urethritis, most often chlamydial, was considered and empirically co-treated, with testing sent and partner treatment addressed."},{"id":"uti-std","group":"other","label":"Urinary tract infection / prostatitis","default":false,"tags":["uti-std"],"miss":1,"sex":"m","ruleout":"A urinary source or prostatitis was considered; there was no frequency, urgency, flank or perineal pain, or boggy tender prostate, making a urinary tract or prostatic infection less likely than urethritis."}],"risk":[{"id":"naat-std","label":"GC/CT nucleic-acid testing","tags":["gc-urethritis","ngu"],"scale":"low","line":"Nucleic-acid amplification testing for gonorrhea and chlamydia was sent, with empiric treatment provided at this visit rather than deferred to results","short":"GC/CT nucleic-acid testing sent with empiric treatment"},{"id":"us-std","label":"Scrotal ultrasound","tags":["torsion-std"],"scale":"low","line":"Scrotal Doppler ultrasound was used to assess testicular perfusion when torsion could not be excluded clinically","short":"scrotal Doppler ultrasound assessed perfusion"}],"checks":[{"if":"torsion-std","needs":["us-std"],"mode":"any","warn":"Sudden severe pain, an abnormal lie, or an uncertain exam turns 'epididymitis' into a torsion rule-out — Doppler and urology, because a present cremasteric reflex does not exclude it."},{"if":"gc-urethritis","needs":["naat-std"],"mode":"any","warn":"Treat empirically at the visit and send GC/CT testing — results do not gate therapy, and partner treatment must be documented."}],"history":[{"id":"ust-hx-discharge","dx":"general","q":"Discharge and dysuria — onset, character (purulent vs mucoid), and duration?","answers":[{"label":"Typical urethral discharge/dysuria","tone":"neg","sets":[{"risk":"naat-std"}],"ddx":[],"mdm":"The patient reports urethral discharge and dysuria consistent with urethritis, and empiric treatment plus testing was arranged.","frag":"urethral discharge and dysuria consistent with urethritis"},{"label":"Predominant scrotal/testicular pain","tone":"pos","sets":[],"ddx":[{"id":"epididymitis-std","keep":true},{"id":"torsion-std","keep":true}],"mdm":"Scrotal or testicular pain dominates the presentation: epididymo-orchitis and torsion are being evaluated rather than isolated urethritis.","frag":""}]},{"id":"ust-hx-onset","dx":"torsion-std","q":"Scrotal pain onset — sudden and severe (torsion pattern) or gradual (infectious pattern)?","answers":[{"label":"Gradual, if any scrotal pain","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"gradual rather than sudden severe scrotal pain"},{"label":"Sudden and severe","tone":"pos","sets":[{"risk":"us-std"}],"ddx":[{"id":"torsion-std","keep":true}],"mdm":"The scrotal pain was sudden and severe: torsion is presumed and Doppler ultrasound with urology involvement is being obtained without delay.","frag":""}]},{"id":"ust-hx-systemic","dx":"dgi","q":"Systemic features — migratory joint pains, tendon sheath pain, pustular rash, or fever?","answers":[{"label":"No systemic features","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no migratory arthralgia, tenosynovitis, pustular rash, or fever"},{"label":"Arthralgia / tenosynovitis / rash / fever","tone":"pos","sets":[],"ddx":[{"id":"dgi","keep":true}],"mdm":"Migratory arthralgia, tenosynovitis, or a pustular rash is present: disseminated gonococcal infection is being evaluated and treated as a systemic infection.","frag":""}]},{"id":"ust-hx-partners","dx":"general","q":"Sexual history — new or multiple partners, prior STIs, HIV status, and partner treatment feasibility?","answers":[{"label":"History taken; partner care addressed","tone":"neg","sets":[],"ddx":[],"mdm":"A sexual history was obtained, HIV and syphilis screening were addressed, and partner treatment and expedited partner therapy were discussed.","frag":"a sexual history taken with partner treatment and co-infection screening addressed"},{"label":"High-risk exposure / partner untreatable","tone":"pos","sets":[],"ddx":[],"mdm":"The exposure history is high-risk or partners are difficult to reach: broader STI screening and public-health follow-up were emphasized.","frag":""}]}],"exam":[{"id":"ust-exam-lie","dx":"torsion-std","q":"Testicular lie and cremasteric reflex — normal vertical lie with intact reflex?","answers":[{"label":"Normal lie, reflex present","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"a normal testicular lie with an intact cremasteric reflex"},{"label":"High-riding / absent reflex","tone":"pos","sets":[{"risk":"us-std"}],"ddx":[{"id":"torsion-std","keep":true}],"mdm":"The testis is high-riding or the cremasteric reflex is absent: findings concerning for torsion that trigger immediate Doppler and urology.","frag":""}]},{"id":"ust-exam-epididymis","dx":"epididymitis-std","q":"Epididymal exam — posterior tenderness/swelling, and does elevation relieve pain (Prehn)?","answers":[{"label":"No epididymal tenderness","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no isolated posterior epididymal tenderness"},{"label":"Tender epididymis, relief with elevation","tone":"pos","sets":[],"ddx":[{"id":"epididymitis-std","keep":true}],"mdm":"There is posterior epididymal tenderness with relief on elevation, consistent with epididymo-orchitis, treated with STI-directed coverage.","frag":""}]},{"id":"ust-exam-discharge","dx":"gc-urethritis","q":"Urethral meatus — expressible discharge, meatal erythema, or lesions suggesting an alternative STI?","answers":[{"label":"Discharge consistent with urethritis","tone":"neg","sets":[{"risk":"naat-std"}],"ddx":[],"mdm":"","frag":"meatal findings consistent with urethritis without ulcerative lesions"},{"label":"Ulcers / vesicles / atypical lesions","tone":"pos","sets":[],"ddx":[{"id":"ngu","keep":true}],"mdm":"Ulcerative or vesicular lesions are present: herpes, syphilis, and other STIs are being tested for alongside urethritis treatment.","frag":""}]}],"pearls":[{"text":"Treat urethritis empirically at the visit and send GC/CT testing — do not wait for results. Cover gonorrhea and chlamydia together, address partner treatment, and screen for HIV and syphilis co-infection.","dx":"gc-urethritis"},{"text":"Sudden severe testicular pain is torsion, not epididymitis, until Doppler says otherwise — a present cremasteric reflex does not exclude it, and 'epididymitis' in an adolescent is the classic missed torsion.","dx":"torsion-std"},{"text":"Migratory polyarthralgia, tenosynovitis, and pustular skin lesions in a sexually active patient are disseminated gonococcal infection — it needs systemic treatment and admission, not a single IM dose.","dx":"dgi"},{"text":"Reserve fluoroquinolone-based epididymitis coverage for the older man with a likely enteric/urinary organism or insertive anal intercourse; the young man gets STI-directed therapy.","dx":"epididymitis-std"},{"text":"Document that expedited partner therapy or partner referral was discussed — untreated partners are the reinfection engine and a real public-health obligation.","dx":"ngu"}]},{"id":"blunt-trauma","title":"Blunt trauma / MVC","kind":"complaint","aliases":["blunt trauma","mvc","mva","motor vehicle collision","motor vehicle accident","trauma","fall from height","pedestrian struck","assault","polytrauma","seatbelt injury","blunt abdominal trauma","multisystem trauma"],"opening":"A patient was evaluated after blunt trauma. The assessment followed a primary-survey framework — airway, breathing, circulation, disability, exposure — and then addressed the occult can't-miss injuries: intracranial and cervical spine injury, intrathoracic injury, intra-abdominal solid-organ and hollow-viscus injury, pelvic fracture with hemorrhage, and the mechanism and anticoagulation context that raise the pretest probability of each.","specs":["trauma","surg"],"ddx":[{"id":"ich-blunt","group":"lifethreat","label":"Intracranial hemorrhage","default":true,"tags":["ich-blunt"],"miss":4,"ruleout":"Traumatic intracranial hemorrhage was considered; there was no loss of consciousness, amnesia, progressive or severe headache, vomiting, or focal deficit, the patient was not anticoagulated, and the mechanism and examination met a validated low-risk rule for imaging, making significant intracranial injury unlikely."},{"id":"cspine-blunt","group":"lifethreat","label":"Cervical spine injury","default":true,"tags":["cspine-blunt"],"miss":4,"ruleout":"Cervical spine injury was considered; by validated criteria the patient had no midline tenderness, no focal neurologic deficit, normal alertness without intoxication, no distracting injury, and painless active rotation, allowing clinical clearance without imaging."},{"id":"thoracic-blunt","group":"lifethreat","label":"Intrathoracic injury (pneumothorax, aortic, cardiac)","default":true,"tags":["thoracic-blunt"],"miss":4,"ruleout":"Significant intrathoracic injury was considered; there was no chest wall tenderness, crepitus, or hypoxia, breath sounds were symmetric, the mechanism was not a high-energy deceleration, and chest imaging showed no pneumothorax, widened mediastinum, or effusion, making occult thoracic injury unlikely."},{"id":"abdominal-blunt","group":"lifethreat","label":"Intra-abdominal injury (solid organ / hollow viscus)","default":true,"tags":["abdominal-blunt"],"miss":4,"ruleout":"Intra-abdominal injury was considered; the abdomen was soft and non-tender without seat-belt sign or distension, the patient was hemodynamically stable with a reliable examination, and FAST or CT where obtained showed no free fluid or organ injury, making significant abdominal injury unlikely."},{"id":"pelvic-blunt","group":"lifethreat","label":"Pelvic fracture with hemorrhage","default":false,"tags":["pelvic-blunt"],"miss":4,"ruleout":"Pelvic fracture with hemorrhage was considered; the pelvis was stable and non-tender, there was no perineal or scrotal hematoma or blood at the meatus, and the patient was hemodynamically stable, making an unstable hemorrhagic pelvic injury unlikely."},{"id":"extremity-blunt","group":"common","label":"Extremity fracture / soft-tissue injury","default":false,"tags":["extremity-blunt"],"miss":2,"ruleout":"Extremity injury was considered and examined for deformity, focal tenderness, and neurovascular compromise, with imaging directed to the areas of concern."},{"id":"minor-blunt","group":"other","label":"Minor blunt trauma / contusions","default":false,"tags":["minor-blunt"],"miss":1,"ruleout":"After the occult injuries above were addressed in a stable patient with a reliable examination, the presentation was consistent with minor blunt trauma and soft-tissue contusions."}],"risk":[{"id":"fast-blunt","label":"FAST / abdominal imaging","tags":["abdominal-blunt","thoracic-blunt"],"scale":"low","line":"A FAST examination was performed and CT imaging directed by mechanism and examination to assess for intrathoracic and intra-abdominal injury","short":"FAST performed with imaging directed by mechanism and exam"},{"id":"ct-head-blunt","label":"Head CT decision rule","tags":["ich-blunt"],"scale":"low","line":"The decision to image the head was anchored to a validated rule (Canadian CT Head / NEXUS-II), with a lower threshold in the anticoagulated or elderly patient","short":"head CT decision anchored to a validated rule"},{"id":"cspine-rule-blunt","label":"C-spine clearance rule","tags":["cspine-blunt"],"scale":"low","line":"Cervical spine clearance was documented against a validated rule (NEXUS or the Canadian C-Spine Rule) rather than by gestalt","short":"c-spine clearance documented against a validated rule"}],"checks":[{"if":"ich-blunt","needs":["ct-head-blunt"],"mode":"any","warn":"Anchor the head-imaging decision to a validated rule — and lower the threshold hard in the anticoagulated or elderly patient, where a benign exam hides a bleed."},{"if":"cspine-blunt","needs":["cspine-rule-blunt"],"mode":"any","warn":"Clear the c-spine by NEXUS or the Canadian C-Spine Rule, not gestalt — intoxication and a distracting injury are exactly when clinical clearance fails."},{"if":"abdominal-blunt","needs":["fast-blunt"],"mode":"any","warn":"A soft abdomen does not exclude injury early — document a FAST and imaging directed by mechanism, especially with a seat-belt sign."}],"history":[{"id":"blt-hx-mechanism","dx":"general","q":"Mechanism — speed, restraint use, airbag deployment, ejection, fall height, or pedestrian-vs-vehicle?","answers":[{"label":"Low-energy mechanism","tone":"neg","sets":[],"ddx":[],"mdm":"The mechanism was low-energy (restrained, low speed, no ejection or significant fall height), lowering the pretest probability of occult injury.","frag":"a low-energy mechanism"},{"label":"High-energy mechanism","tone":"pos","sets":[{"risk":"fast-blunt"}],"ddx":[{"id":"thoracic-blunt","keep":true},{"id":"abdominal-blunt","keep":true}],"mdm":"The mechanism was high-energy (high speed, ejection, significant fall, or pedestrian struck), raising the pretest probability of occult thoracic and abdominal injury and driving imaging.","frag":""}]},{"id":"blt-hx-anticoag","dx":"ich-blunt","q":"Anticoagulation or antiplatelet use, and age over 65?","answers":[{"label":"Not anticoagulated, younger","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no anticoagulant or antiplatelet use"},{"label":"Anticoagulated / elderly","tone":"pos","sets":[{"risk":"ct-head-blunt"}],"ddx":[{"id":"ich-blunt","keep":true}],"mdm":"The patient is anticoagulated or elderly: the threshold for head CT is lowered accordingly and delayed hemorrhage is anticipated in disposition.","frag":""}]},{"id":"blt-hx-loc","dx":"ich-blunt","q":"Head injury — loss of consciousness, amnesia, progressive headache, or repeated vomiting?","answers":[{"label":"No LOC or concerning head symptoms","tone":"neg","sets":[{"risk":"ct-head-blunt"}],"ddx":[],"mdm":"","frag":"no loss of consciousness, amnesia, progressive headache, or vomiting"},{"label":"LOC / amnesia / worsening symptoms","tone":"pos","sets":[{"risk":"ct-head-blunt"}],"ddx":[{"id":"ich-blunt","keep":true}],"mdm":"There was loss of consciousness, amnesia, or progressive symptoms: head CT is being obtained and neurologic status serially reassessed.","frag":""}]},{"id":"blt-hx-seatbelt","dx":"abdominal-blunt","q":"Abdominal or seat-belt symptoms — abdominal pain, a seat-belt mark, or back/flank pain?","answers":[{"label":"No abdominal symptoms","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no abdominal pain or seat-belt symptoms"},{"label":"Abdominal pain / seat-belt sign","tone":"pos","sets":[{"risk":"fast-blunt"}],"ddx":[{"id":"abdominal-blunt","keep":true}],"mdm":"There is abdominal pain or a seat-belt sign: hollow-viscus and mesenteric injury are being pursued with imaging and serial examination even if initial studies are unremarkable.","frag":""}]}],"exam":[{"id":"blt-exam-primary","dx":"general","q":"Primary survey and vitals — airway, breathing, circulation intact with stable vital signs?","answers":[{"label":"Primary survey intact, stable","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"an intact primary survey with stable vital signs"},{"label":"Primary survey abnormal / unstable","tone":"pos","sets":[{"risk":"fast-blunt"}],"ddx":[{"id":"thoracic-blunt","keep":true},{"id":"abdominal-blunt","keep":true},{"id":"pelvic-blunt","keep":true}],"mdm":"The primary survey is abnormal or the patient is hemodynamically unstable: resuscitation is underway with a rapid search for the source of instability.","frag":""}]},{"id":"blt-exam-cspine","dx":"cspine-blunt","q":"Cervical spine — midline tenderness, deficit, distracting injury, intoxication, or painful rotation?","answers":[{"label":"Clinically clearable by rule","tone":"neg","sets":[{"risk":"cspine-rule-blunt"}],"ddx":[],"mdm":"","frag":"no midline tenderness, deficit, distracting injury, or intoxication, with painless rotation"},{"label":"Cannot clear clinically","tone":"pos","sets":[{"risk":"cspine-rule-blunt"}],"ddx":[{"id":"cspine-blunt","keep":true}],"mdm":"The cervical spine cannot be cleared clinically: immobilization is maintained and CT imaging obtained.","frag":""}]},{"id":"blt-exam-chest","dx":"thoracic-blunt","q":"Chest — wall tenderness or crepitus, symmetric breath sounds, and normal oxygenation?","answers":[{"label":"Chest exam reassuring","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no chest wall tenderness or crepitus, with symmetric breath sounds and normal oxygenation"},{"label":"Tenderness / crepitus / decreased sounds / hypoxia","tone":"pos","sets":[{"risk":"fast-blunt"}],"ddx":[{"id":"thoracic-blunt","keep":true}],"mdm":"There is chest wall tenderness, crepitus, asymmetric breath sounds, or hypoxia: intrathoracic injury is being evaluated with imaging.","frag":""}]},{"id":"blt-exam-pelvis","dx":"pelvic-blunt","q":"Pelvis and perineum — pelvic tenderness or instability, perineal hematoma, or blood at the urethral meatus?","answers":[{"label":"Stable, non-tender pelvis","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"a stable non-tender pelvis without perineal hematoma or blood at the meatus"},{"label":"Tender/unstable pelvis or perineal signs","tone":"pos","sets":[{"risk":"fast-blunt"}],"ddx":[{"id":"pelvic-blunt","keep":true}],"mdm":"The pelvis is tender or unstable, or there are perineal signs: a binder is applied and hemorrhage control and imaging prioritized.","frag":""}]}],"pearls":[{"text":"A soft abdomen and a normal initial FAST do not exclude injury — hollow-viscus and mesenteric injuries evolve. A seat-belt sign mandates CT and serial exams regardless of the first look.","dx":"abdominal-blunt"},{"text":"Clear the cervical spine by NEXUS or the Canadian C-Spine Rule, not by gestalt — the intoxicated patient and the one with a distracting injury are exactly where clinical clearance fails.","dx":"cspine-blunt"},{"text":"The anticoagulated or elderly patient with a benign neuro exam still harbors intracranial hemorrhage — lower the CT threshold, and consider a delayed bleed and observation window even after a normal scan.","dx":"ich-blunt"},{"text":"Blood at the urethral meatus, a high-riding prostate, or a perineal hematoma means a urethral injury — do not place a Foley before retrograde urethrography.","dx":"pelvic-blunt"},{"text":"In the hypotensive blunt-trauma patient, the blood is in one of five places: chest, abdomen, pelvis, retroperitoneum, or the street. Apply a pelvic binder empirically for an unstable pelvis rather than repeatedly springing it.","dx":"pelvic-blunt"},{"text":"A widened mediastinum or a first-rib/scapular fracture flags a high-energy deceleration — image the aorta (CT angiography) for blunt aortic injury.","dx":"thoracic-blunt"}]},{"id":"cardiac-arrest","title":"Cardiac arrest","kind":"diagnosis","aliases":["cardiac arrest","post rosc","return of spontaneous circulation","code blue","pulseless","resuscitation","post arrest","rosc care","acls","sudden cardiac arrest"],"opening":"A patient in cardiac arrest was resuscitated, and the decision-making addressed the reversible causes systematically — the Hs and Ts — during the arrest and, after return of spontaneous circulation, the immediate post-ROSC priorities: an early 12-lead ECG for a STEMI needing the cath lab, hemodynamic and oxygenation targets, targeted temperature management, and the hunt for the precipitating cause.","specs":["cards","pulm"],"ddx":[{"id":"acs-arrest","group":"lifethreat","label":"Acute coronary occlusion (STEMI)","default":true,"tags":["acs-arrest"],"miss":4,"ruleout":"An acute coronary occlusion as the arrest trigger was considered; the post-ROSC 12-lead ECG showed no ST-elevation or new left bundle branch block, and cardiology was engaged regarding the role of early catheterization, recognizing that a coronary cause remains possible even without ST-elevation."},{"id":"hypoxia-arrest","group":"lifethreat","label":"Hypoxia / respiratory cause","default":true,"tags":["hypoxia-arrest"],"miss":4,"ruleout":"A hypoxic or primary respiratory cause was considered; the airway was secured with confirmed tube position, oxygenation and ventilation were optimized to target values, and a primary respiratory precipitant was addressed."},{"id":"hypovolemia-arrest","group":"lifethreat","label":"Hypovolemia / hemorrhage","default":true,"tags":["hypovolemia-arrest"],"miss":4,"ruleout":"Hypovolemia, including occult hemorrhage, was considered; volume status was assessed, a source of blood loss was sought clinically and with bedside ultrasound, and resuscitation was directed accordingly."},{"id":"tension-arrest","group":"lifethreat","label":"Tension pneumothorax","default":false,"tags":["tension-arrest"],"miss":4,"ruleout":"Tension pneumothorax was considered; breath sounds were symmetric without tracheal deviation or resistance to ventilation, and bedside ultrasound or decompression addressed it where suspicion arose."},{"id":"tamponade-arrest","group":"lifethreat","label":"Cardiac tamponade","default":false,"tags":["tamponade-arrest"],"miss":4,"ruleout":"Cardiac tamponade was considered; bedside echocardiography showed no pericardial effusion with tamponade physiology, making it unlikely as the arrest cause."},{"id":"metabolic-arrest","group":"lifethreat","label":"Hyperkalemia / metabolic / toxins","default":true,"tags":["metabolic-arrest"],"miss":4,"ruleout":"Metabolic and toxic causes (hyperkalemia, acidosis, hypoglycemia, and drug toxicity) were considered; point-of-care potassium and glucose were obtained, the ECG was reviewed for hyperkalemic changes, and empiric treatment was given where the pattern fit."},{"id":"pe-arrest","group":"lifethreat","label":"Pulmonary embolism / thrombosis","default":false,"tags":["pe-arrest"],"miss":4,"ruleout":"Massive pulmonary embolism was considered as a cause of arrest; there were no antecedent features of VTE, no right-heart strain on bedside echo, and the arrest rhythm and context did not fit, though thrombolysis was weighed where suspicion was high."},{"id":"hypothermia-arrest","group":"common","label":"Hypothermia","default":false,"tags":["hypothermia-arrest"],"miss":3,"ruleout":"Hypothermia was considered; the core temperature was measured and, if low, resuscitation was prolonged with active rewarming, recognizing that the cold patient is not dead until warm and dead."}],"risk":[{"id":"ecg-arrest","label":"Post-ROSC 12-lead ECG","tags":["acs-arrest"],"scale":"low","line":"A 12-lead ECG was obtained immediately after ROSC and interpreted for ST-elevation, with cath-lab activation and cardiology discussion where indicated","short":"immediate post-ROSC 12-lead ECG interpreted for STEMI"},{"id":"poc-arrest","label":"Point-of-care K+/glucose/gas","tags":["metabolic-arrest"],"scale":"low","line":"Point-of-care potassium, glucose, and blood gas were obtained to identify treatable metabolic causes","short":"point-of-care potassium, glucose, and gas obtained"},{"id":"echo-arrest","label":"Bedside echocardiography","tags":["tamponade-arrest","pe-arrest","hypovolemia-arrest"],"scale":"low","line":"Bedside echocardiography assessed for tamponade, right-heart strain, and volume status during and after the resuscitation","short":"bedside echocardiography for tamponade, RV strain, and volume"}],"checks":[{"if":"acs-arrest","needs":["ecg-arrest"],"mode":"any","warn":"Get a 12-lead ECG immediately after ROSC — STEMI is the reversible cause with a door: activate the cath lab and involve cardiology."},{"if":"metabolic-arrest","needs":["poc-arrest"],"mode":"any","warn":"Point-of-care potassium and glucose belong in every arrest — hyperkalemia and hypoglycemia are treatable causes you can fix at the bedside."}],"history":[{"id":"arr-hx-context","dx":"general","q":"Arrest context — witnessed, bystander CPR, downtime, initial rhythm, and prodrome (chest pain, dyspnea)?","answers":[{"label":"Witnessed, shockable, short downtime","tone":"neg","sets":[{"risk":"ecg-arrest"}],"ddx":[{"id":"acs-arrest","keep":true}],"mdm":"The arrest was witnessed with bystander CPR and an initial shockable rhythm and short downtime: a coronary cause is prioritized and the post-ROSC ECG obtained.","frag":"a witnessed arrest with a shockable initial rhythm and short downtime"},{"label":"Unwitnessed / prolonged downtime / non-shockable","tone":"pos","sets":[{"risk":"poc-arrest"}],"ddx":[{"id":"hypoxia-arrest","keep":true},{"id":"metabolic-arrest","keep":true}],"mdm":"The arrest was unwitnessed or prolonged with a non-shockable rhythm: hypoxic, metabolic, and toxic causes are prioritized in the reversible-cause hunt.","frag":""}]},{"id":"arr-hx-precipitant","dx":"pe-arrest","q":"Preceding history pointing to a cause — chest pain, recent immobilization/VTE risk, dialysis, overdose, or trauma?","answers":[{"label":"No specific precipitant clues","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"no antecedent VTE risk, dialysis, overdose, or trauma pointing to a specific cause"},{"label":"Clues to a specific reversible cause","tone":"pos","sets":[{"risk":"echo-arrest"}],"ddx":[{"id":"pe-arrest","keep":true},{"id":"metabolic-arrest","keep":true}],"mdm":"The history points toward a specific reversible cause (VTE risk, dialysis-associated hyperkalemia, overdose, or trauma); targeted evaluation and treatment are directed accordingly.","frag":""}]}],"exam":[{"id":"arr-exam-airway","dx":"hypoxia-arrest","q":"Airway and ventilation — tube position confirmed, symmetric breath sounds, adequate oxygenation post-ROSC?","answers":[{"label":"Airway secure, ventilation adequate","tone":"neg","sets":[],"ddx":[],"mdm":"","frag":"a secured airway with confirmed tube position and adequate post-ROSC oxygenation"},{"label":"Hypoxic / asymmetric / difficult ventilation","tone":"pos","sets":[{"risk":"echo-arrest"}],"ddx":[{"id":"hypoxia-arrest","keep":true},{"id":"tension-arrest","keep":true}],"mdm":"Oxygenation is inadequate or ventilation is asymmetric or difficult: a hypoxic cause and tension pneumothorax are being addressed at the bedside.","frag":""}]},{"id":"arr-exam-ecg","dx":"acs-arrest","q":"Post-ROSC 12-lead ECG — any ST-elevation or new left bundle branch block?","answers":[{"label":"No STEMI pattern","tone":"neg","sets":[{"risk":"ecg-arrest"}],"ddx":[],"mdm":"","frag":"a post-ROSC ECG without ST-elevation or new left bundle branch block"},{"label":"STEMI / new LBBB","tone":"pos","sets":[{"risk":"ecg-arrest"}],"ddx":[{"id":"acs-arrest","keep":true}],"mdm":"The post-ROSC ECG shows ST-elevation or new left bundle branch block: the cath lab is activated and cardiology engaged emergently.","frag":""}]},{"id":"arr-exam-echo","dx":"tamponade-arrest","q":"Bedside echo — pericardial effusion with tamponade, right-heart strain, or a hyperdynamic empty ventricle?","answers":[{"label":"No tamponade or RV strain","tone":"neg","sets":[{"risk":"echo-arrest"}],"ddx":[],"mdm":"","frag":"no pericardial effusion, tamponade physiology, or right-heart strain on bedside echo"},{"label":"Effusion / RV strain / empty ventricle","tone":"pos","sets":[{"risk":"echo-arrest"}],"ddx":[{"id":"tamponade-arrest","keep":true},{"id":"pe-arrest","keep":true},{"id":"hypovolemia-arrest","keep":true}],"mdm":"Bedside echo shows an effusion, right-heart strain, or an empty hyperdynamic ventricle: tamponade, pulmonary embolism, and hypovolemia are being treated as indicated.","frag":""}]}],"pearls":[{"text":"Get a 12-lead ECG immediately after ROSC — STEMI needs the cath lab now. Even without ST-elevation, discuss early angiography with cardiology in the resuscitated arrest with a suspected cardiac cause.","dx":"acs-arrest"},{"text":"Work the Hs and Ts on every arrest: hypoxia, hypovolemia, hydrogen ion (acidosis), hypo/hyperkalemia, hypothermia; tension pneumothorax, tamponade, toxins, thrombosis (coronary and pulmonary). Point-of-care K+ and glucose take seconds.","dx":"metabolic-arrest"},{"text":"Post-ROSC, target normoxia (SpO2 92–98%) and normocapnia — hyperoxia and hyperventilation both worsen outcomes — and support MAP ≥ 65 to protect the brain.","dx":"hypoxia-arrest"},{"text":"Bedside echo during the rhythm check answers tamponade, massive PE (RV strain), and hypovolemia in one look — but keep pulse checks under 10 seconds so imaging never interrupts compressions.","dx":"tamponade-arrest"},{"text":"Hyperkalemic arrest (dialysis missed, crush, ECG with peaked T's or a sine wave) gets empiric calcium — treat the pattern before the level returns.","dx":"metabolic-arrest"},{"text":"The hypothermic arrest is not dead until warm and dead: prolong resuscitation with active rewarming, and consider extracorporeal rewarming where available.","dx":"hypothermia-arrest"}]}],"specialties":[{"id":"peds","label":"Peds"},{"id":"cards","label":"Cardiology"},{"id":"pulm","label":"Pulm / Resp"},{"id":"gi","label":"GI"},{"id":"neuro","label":"Neurology"},{"id":"nsgy","label":"Neurosurgery / Spine"},{"id":"obgyn","label":"OB/Gyn"},{"id":"uro","label":"Urology"},{"id":"vasc","label":"Vascular"},{"id":"ortho","label":"Ortho / MSK"},{"id":"ophtho","label":"Ophtho"},{"id":"ent","label":"ENT"},{"id":"derm","label":"Derm"},{"id":"id","label":"Infectious Dz"},{"id":"tox","label":"Tox / Addiction"},{"id":"psych","label":"Psych"},{"id":"heme","label":"Heme / Transfusion"},{"id":"surg","label":"Surgery"},{"id":"geri","label":"Geriatrics"},{"id":"endo","label":"Endocrine / Metabolic"},{"id":"trauma","label":"Trauma / Injury"}]}