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| Seeking Differential Diagnosis in the Emergency Medicine Setting |
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by Bob Blumm, MA, PA-C, DFAAPA - November 21, 2011
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Please do not construe from the title of this article that it is meant only for the EM clinician. Clinicians will discover these presentations in family practice and in the urgent care setting as well as in the orthopedic office. My personal passion for writing this is to demonstrate that the diagnosis may be hidden if we are in a specialty setting, and that elusive diagnosis may be life threatening. I wish for you to consider the following three scenarios and apply your skills to seeking the answer that is correct not the one that is obvious. Give it a try as this little example of mental gymnastics cannot injure you but make you a better provider.
Scenario 1- An otherwise sedentary 43 year old female has decided to begin exercise due to her recent 20 pound weight gain. Two weeks ago she has a UTI for which her PA treated her with Levaquin 500 mg qd. Today she has gone to the tennis club and has played two games of tennis. During the game she suddenly developed a pain in the right lower ankle region while simultaneously hearing a “pop.” She enters the ER Fast Trak area in a wheelchair with an elevated ankle that has ecchymosis and grade 3 edma and a cold foot.
Scenario 2- A 53 year old business executive from a large Manhattan firm has decided to visit a friend for the Christmas holidays. Seeing a large pile of logs he decided he would chop wood for the morning fire. After having an oversized Starbucks coffee and feeling quite energetic from the caffeine rush, he found an oversized ax in the shed and started to carry large logs to the chopping block to begin his work. He developed a strong swinging motion and brought the ax to his side and then straight down on the log. After 45 minutes of this activity, he suddenly developed a severe pain to his left shoulder that radiated down his left arm. The pain became so severe that he states;”it took my breath away.” The patient was driven to the ER by his host and was sent to Fast Trak with shoulder and elbow pain.
Scenario 3- A 36 y/o fireman from Buffalo, NY was engaged in the firefighters tournament, which was being held on Long Island. Unable to make the trip with his Hook and Ladder Company by plane due to his fear of flying since 9-11, this contestant drove the entire night non-stop except for coffee and to relieve himself. At 11 AM Fireman Woody has been admitted to the ER and triaged to Fast Trak for pain and swelling of the knee and calf while rapidly climbing the tower. Apparently, while carrying the hose, his knee buckled and now he has pain and swelling from the knee to the ankle.
Read the scenarios and take a few minutes to think of a diagnostic plan. Perform the exam and explain your actions to yourself. Mention the physical assessment techniques that you would perform as well as any additional testing you would perform including medications that you would order. What is your final diagnosis? If you wish you can send it to this author and I will respond. Hopefully I will not be inundated with responses.
Robert M. Blumm has received national recognition as a distinguished fellow of the American Academy of Physician Assistants (AAPA). He is the past president of the Association of Plastic Surgery Physician Assistants, and was past-president of the American Association of Surgical Physician Assistants, past president of the American College of Clinicians and NYSSPA, as well as Chairman of the Surgical Congress of the AAPA. In addition, Bob received the John Kirklin MD Award for Professional Excellence from the American Association of Surgical Physician Assistants. Along with his associate, Dr. Acker, Bob was the first recipient of the AAPA PAragon Physician-PA Partnership Award. He has been a contributing author of three textbooks, written 300 plus articles and is a sought out conference speaker throughout the United States.
The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.
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| Bob Blumm (Amityville, NY) |
on 28 Nov 2011 at 8:47 pm |
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Excellent job Leja and a very wonderful thinking cap it was. I tried to throw you off but deductive reasoning and consistent knowledge always win out.
Bob |
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| Leja McKinney-Witt APRN, NNP-BC (Slidell, LA) |
on 28 Nov 2011 at 3:27 pm |
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Hi Bob,
This is way out my realm but putting on my thinking cap was fun. Here goes nothing
Scenario 1: I would work this patient up for a tendon rupture since that is a known complication of quinolones
Scenario 2: Well prior to becoming a NNP, spent 7 years in ICU/SICU/ER, so I fall back to roots. Age 53 of this man makes me want to know his history. left shoulder and arm pain even after exercise at his age would warrant a cardiac work-up. EKG, etc to r/o AMI
Scenario 3: What comes to mind is DVT what with history to long ride and only stopping to gas up and relieve one's self when necessary. He would need to be scanned, labs PT/PTT in preparation for Heparin Rx. This is where I get lost. Never treat DVTs in neonates.
Enjoyed the article made me do a little thinking outside my comfort zone. |
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| Bob Blumm |
on 27 Nov 2011 at 7:48 pm |
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Outstanding. all correct. you can be my provider anytime.
bob |
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| Marcos A. Vargas, MSHA,PA-C (Flushing) |
on 26 Nov 2011 at 11:18 pm |
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First impressions of the respective vignettes in your article:
Scenario # 1: R/O Achille's Tendon Rupture due to Flouroquinolone Tx
Scenario # 2: R/O ACS (suspicious for anginal presentation)
Scenario # 3: R/O acute DVT |
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