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Preceptor Date Human Chief IssueDiagnosis
Story (pertinent positives)
Investigation Treatments
Lessons learned
Strengths
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Abdominal pain
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Fall/Laceration
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Suicide ideation
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Sensory Loss
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Stye
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Thu
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6/18/2023Back pain Sciatica
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Traumatic fall from scooter
CT head, CT facial bone (r/o zygomatic, TMJ frac), X ray right hand (r/o scaphoid, distal radius)
IV
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Headache Vomitting, photophobia Intracocular pressure
Keterolac (NSAID) , Metaclopromide (anti-nausea), (Dexamethasone (steroid))
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Traumatic fall from scooter
Fibula fracture
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7/12/2023
Acetominophen overdose
Drowsy, vomitting x 2
Acetominophen level, VBG (metabolic acidosis, increase lactate), AST 48 (ele), IINR, PT (ele), urine tox, ECG (QTc 460)
1. (tox) N-acetylcysteine, fomepizole (methanol poison), no activated charcoal , 2. (coag) vit K
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seizure Topiramate
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7/20/2023Cocaine overdose
Rhabdo, AKI, hyperkalemia
including electrolytes, extended electrolytes, LFTs, urea, urine drug screen, urinalysis and blood cultures and CT neck
administering IV fluids, shifting his potassium
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Foley catheter and q4hr UO monitoring, , U/A, Abdominal US, Trend CK and Cr q8hrs until peaked
Ca carbonate
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lytes, telemetry
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RhabdoCK, foley catheter, u/sCalcium carbonate 2.5 g daily given hypocalcemia
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Hyperkalemia lytes q12h(Lokelma) Sodium zirconium cyclosilicate
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AKICr, renal ultrasound
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bupropion overdose seizure
Lactate 16, elevated anion gap
4mg diazepene
neurotoxic at 3g, cardiotoxic at 10g
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38M presenting with 6-day history of acute headache.
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- one episode of vomiting on Tuesday ; vomitted this morning
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#ERROR!
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#ERROR!
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- relieved by ibuprofen (2pills) ; acetaminphen (1pill) does not work
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- no cough, 1-day rhinorrhea, no diarhea, no dysuria
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#ERROR!
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#ERROR!
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#ERROR!
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Social:
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#ERROR!
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Patient seen and examined w CC3 earlier; gradual onset of R hemicranial headache on Wed, with photophobia and R eye pain, vomited multiple times. No prior migraines, no neuro symptoms, no head injury not exertional. No fam hx aneurysms. Yesterday had runny nose and low grade fever, no neck pain no DVT/ PE Rfs, seen by fam MD advised to come to ED.
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O/E: GCS 15, PEARL, EOM N, no nystagmus, no field abnormality. IOP17 R
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Likely migraine, but will do CT/ CTA as well as COVID test.
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On r/a at 2300: headache resolved completely post toradol/ maxeran, CTA result pending. COVID neg.
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