Case Vignettes for Teaching VisualDx

Case Vignettes for Teaching VisualDx

Vol. 3Emergency and Urgent Care

Case 1A 32-year-old man, Daniel, was rushed to the

ED by his wife. He was experiencing shortness

of breath, difficulty wallowing, drooling, and

hoarseness that developed over the course of

a day. He had been suffering from an upper

respiratory infection with a high fever several

days and was complaining of a sore throat.

Daniel’s doctor heard stridor when listening to his

breathing.

What is Daniel’s diagnosis?

1. On the VisualDx homepage, enter dyspnea in the search bar. Click on dyspnea (shortness of breath) under Build a differential diagnosis to get started.

2. Change patient info to 30-39 year old and male.

3. Onset of findings: Developed rapidly (minutes to hours)

4. Associated symptoms > General: Fever

5. Associated symptoms > HEENT: Hoarseness, sore throat, and drooling

6. Associated symptoms > Digestive/abdominal: Dysphagia (difficulty wallowing)

7. Lung exam findings: Stridor

Build a Differential in VisualDx

© 2020 VisualDx®. All rights reserved.

Case 2A 6-year-old boy, Jimmy, was brought to urgent

care by his mother after he complained of ear

pain toward the end of an upper respiratory

infection. He still had a runny nose and

complained that his head hurt. Jimmy had an

elevated temperature and seemed to be having

trouble hearing his parents when they talked to

him in quieter voices.

What is Jimmy’s diagnosis?

1. On the VisualDx homepage, enter otalgia in the search bar. Click on otalgia (earache) under Build a differential diagnosis to get started.


3. Onset of findings: Developed acutely (days to weeks)

4. HEENT Symptoms: Hearing loss and rhinorrhea

5. Other Symptoms: Fever and headache



Case 3Sam, a 68-year-old man, with a history of chronic

kidney disease went to the ED complaining of

abdominal pain and pain at his abdominal dialysis

catheter site. The symptoms developed in just

a few days and Sam appeared quite ill when he

was admitted with a fever and vomiting. Sam

told the doctor that his internist was concerned

about his recent fluid etention. Sam’s doctor

noted guarding and rebound tenderness when

examining Sam’s abdomen. Blood tests showed

leukocytosis and a paracentesis showed his

peritoneal fluid as cloudy.

What is Sam’s diagnosis?

1. On the VisualDx homepage, enter rebound tenderness in the search bar. Click on rebound tenderness (abdominal rebound pain) under Build a differential diagnosis to get started.


3. GI symptoms: Vomiting

4. Physical GI signs: Ascites (Rebound tenderness will already be checked)

5. Onset of findings: Developed acutely (days to weeks)

6. Appearance of patient: Patient appears ill

7. Other associated symptoms > General: Fever

8. Lab findings > Hem tology: Leukocytosis

9. Use the Additional Findings box to enter the following (wait for autocomplete and select the symptom):

• History of Chronic kidney disease



Case 4A 26-year-old woman, Kelsey, was brought to

the ED by her roommate, Jess, after she started

acting delirious. Jess reported that Kelsey had

been vomiting and complaining of abdominal

pain since earlier in the evening. She also said

that Kelsey complained of fatigue lately, but

attributed it to her efforts to lose 30 pounds. She

lost the weight surprisingly easily—Kelsey lost

15 pounds in just the past two weeks. Jess also

noticed Kelsey seemed to have increased thirst,

drinking several more bottles of water per day.

What is Kelsey’s diagnosis?

1. On the VisualDx homepage, enter delirium/confusion in the search bar. Click on delirium/confusion under Build a differential diagnosis to get started.

2. Change patient info to 20-29 year old and female.

3. Symptoms/signs > General: Fatigue

4. Symptoms/signs > Digestive/abdominal: Abdominal pain and vomiting


• Polydipsia (excessive thirst)



Case 5A 58-year-old man, George, went to the ED

with chest pain he described as “ripping” that

started suddenly as he was helping his wife move

furniture. The pain radiated down his back. In

the ED, he complained of abdominal pain and

very noticeable weakness of his left leg. The leg

wasn’t numb and he could move it although it

was with less strength. George said he had been

a cigarette smoker for more than 30 years.

What is George’s diagnosis?

1. On the VisualDx homepage, enter chest pain in the search bar. Click on chest pain under Build a differential diagnosis to get started.



4. Symptoms/signs > Digestive/abdominal: Abdominal


• Low back pain

• Cigarette smoking

• Monoparesis of leg



Case 6A 28-year-old woman, Kayla, presents to the ED

with a stabbing pain in the right lower quadrant

of her abdomen. The pain alternates between a

dull ache-like cramp, and then returns suddenly,

lasting for several minutes. She complains of

nausea with the pain and vomited once. Kayla

has elevated blood pressure and appears ill.

She does not have rebound tenderness on

examination. She denies recent changes in her

usual activities or changes in her eating habits.

Kayla’s only medication is a birth control pill.

What is Kayla’s diagnosis?

1. On the VisualDx homepage, enter abdominal pain in the search bar. Click on abdominal pain under Build a differential diagnosis to get started.


3. Abdominal pain subtypes: Right lower quadrant pain (note that making this selection will cancel out abdominal pain because right lower quadrant pain is a more specific findin

4. GI symptoms: Nausea and vomiting

5. Other associated symptoms > Cardiovascular: Hypertension

6. Lab findings > Hem tology: Leukocytosis


• Abdominal cramp

8. Optional findings: Patient appears ill; Developed acutely (days to weeks)



Case 7Marcus, a 68-year-old man, was rushed to the

ED with shortness of breath and hypotension

after briefly losing onsciousness at home.

EMTs reported tachycardia and decreased heart

sounds and noted the patient’s neck vein was

distended. The patient’s wife noted that he

complained of unusual fatigue over the past few

days. An ECG showed low QRS voltage.

What is Marcus’ diagnosis?

1. On the VisualDx homepage, enter shortness of breath in the search bar. Click on dyspnea (shortness of breath) under Build a differential diagnosis to get started.


3. Associated symptoms > Cardiovascular: Tachycardia, hypotension, and syncope


• Decreased heart sounds

• Neck vein distension

• Low QRS voltage



Case 8A 57-year-old woman, Jeanne, went to urgent

care with blurred vision that would come and

go throughout the day. She also noted double

vision in both eyes. She complained of recent

headaches and photophobia. During the exam,

the doctor noticed retinal vascular abnormalities

and found he couldn’t detect venous pulsations.

He told Jeanne he wanted to send her right over

to the ophthalmologist at the nearby hospital to

take a closer look.

What is Jeanne’s diagnosis?

1. On the VisualDx homepage, enter eye in the search bar. Click on eye under Build a differential diagnosis to get started.


3. Eye lesions and abnormalities > Posterior segment abnormality: Retinal vascular abnormality

4. Eye signs/symptoms: Diplopia

5. Eye signs/symptoms > Visual impairment: Blurred vision


• Headache

• Photophobia (increased eye sensitivity to light)

• Bilateral



Case 9Sandra, a 66-year-old woman, was experiencing

severe fatigue and jaw pain for more than an

hour. After taking her morning shower she felt

exhausted. When she started feeling short of

breath, she was worried enough to ask her

husband to bring her to the ED. She vomited

while waiting to be seen and broke out into a

cold sweat. The doctor asked about Sandra’s

recent health and she said other than some low

back pain in the last week she had been in good

health and enjoying her fir t year of retirement.

What is Sandra’s diagnosis?

1. On the VisualDx homepage, enter fatigue in the search bar. Click on fatigue under Build a differential diagnosis to get started.


3. Symptoms/signs > General: Diaphoresis

4. Symptoms/signs > Digestive/abdominal: Vomiting

5. Symptoms/signs > Musculoskeletal: Low back pain

6. Symptoms/signs > Musculoskeletal: Dyspnea


• Jaw pain



Case 10A 34-year-old woman, Alyssa, went to the

emergency room when she experienced a rapid

decline in her vision over one day. The previous

day, Alyssa explained, she had eye pain in one

eye that was worse when she moved the eye

and she noticed she had lost color perception in

the affected eye. Alyssa’s doctor noted each of

her pupils reacted differently to light during the

exam. Alyssa said her only other symptom was a

headache mainly at the front of her head.

What is Alyssa’s diagnosis?

1. On the VisualDx homepage, enter eye pain in the search bar. Click on ocular pain (eye pain) under Build a differential diagnosis to get started.



• Vision loss (loss of vision)

• Unilateral

• Afferent pupillary defect

• Frontal headache



Case 11After a seizure, Eva, a 20-year-old college

student is brought to the ED by ambulance. Her

doctors observe petechiae on her trunk and

extremities. Her dormmate, Mel, reported that

Eva had an upper respiratory infection earlier

in the week and had been complaining about

having muscle aches and vomiting earlier that

day. Eva now appears systemically ill.

What is Eva’s diagnosis?

1. On the VisualDx homepage, enter rash in the search bar. Click on multiple skin lesions (rash) under Build a differential diagnosis to get started.


3. Skin lesion type > Purpura/petechiae: Skin petechiae

4. Location of skin finding > Di tribution: Widespread

5. Appearance of patient: Patient appears systemically ill – toxic



• Seizures

• Myalgia

• Vomiting

8. Optional findings: Dormitory living



Case 12A 25-year-old man, Logan, went to urgent care

after having recurring episodes of nausea and

vomiting. The episodes lasted 24 to 48 hours.

Logan said he tried smoking marijuana, which

he smoked on a regular basis for the last few

years, in the hopes it would soothe his nausea. It

didn’t seem to help. The only thing that relieved

the nausea was taking a hot shower. Logan also

complained of abdominal distention and a feeling

of agitation or anxiety during the episodes.

Logan’s doctor noticed he was very dehydrated

at the time of his visit.

What is Logan’s diagnosis?

1. On the VisualDx homepage, enter marijuana in the search bar.* Click on marijuana under Build a differential diagnosis to get started.


3. Symptoms: Nausea and vomiting


• Recurring episodes or relapses

• Agitation

• Anxiety

• Abdominal distension (abdominal swelling)

• Dehydration

*You can also click on the Drug Reactions icon on the homepage and enter marijuana in the search bar.



Case 13Parents of a 20-month-old boy, Kaden, brought

him to the emergency room after he had a high

spiking fever for more than fi e days, despite

treatment around the clock with Tylenol given

at the direction of their pediatrician. They grew

even more alarmed when they noticed their son’s

hands and feet were swelling and his tongue

was a strawberry red. Kaden’s parents had also

been keeping an eye on what appeared to be

a bad diaper rash, but now they showed the

doctor that the red rash on his perineum was

actually peeling skin. The doctor noticed Kaden’s

eyes appeared red and irritated and felt cervical

lymphadenopathy during the exam.

What is Kaden’s diagnosis?

1. On the VisualDx homepage, enter spiking fever in the search bar. Click on spiking fever under Build a differential diagnosis to get started.

2. Change patient info to 1-23 month old and male.


• Hand edema

• Foot edema

• Diffuse ed tongue (strawberry tongue)

• Desquamation

• Perineum

• Conjunctival injection

• Cervical lymphadenopathy



AnswersCase 1: Epiglottitis Note this diagnosis has a red header and a triangle symbol, these indicate that this a potentially life threatening emergency which could lead to death within 24 hours if left untreated. Diagnoses with just a triangle symbol, but not a red header indicate emergencies that require immediate attention and could leave a patient with permanent organ damage (e.g. blindness) within 24 hours if left untreated. To see all diagnoses in a differential that may be emergencies, click on the Emergencies Tab.

Case 2: Acute otitis media, pediatric

Case 3: Peritonitis

Case 4: Diabetic ketoacidosis

Case 5: Aortic aneurysm dissection

Case 6: Ovarian torsion

Case 7: Cardiac tamponade

Case 8: Papilledema

Case 9: Acute coronary syndrome

Case 10: Optic neuritis

Case 11: Acute meningococcemia

Case 12: Cannabinoid hyperemesis syndromeNote that entering a medication as the chief symptom (the fir t finding ou enter), VisualDx will bring up your differential results in the Drug Induced Tab fir t. If you simply enter a medication along with all the other symptoms, not as the fir t symptom, you will be brought to another appropriate tab fir t such as Consider 1st.

Case 13: Kawasaki disease

Terms of Use: The content and images within this presentation are for local educational purposes only and contain copyrighted material. VisualDx images and illustrations must remain within the context of this presentation and not be removed or repurposed in any way including social media, Internet, or other digital media. If you have any questions, feel free to contact us at [email protected]. Our full image use policy, including prohibited uses, can be found here.


Case Vignettes for Teaching VisualDx

Documents

Transcript of Case Vignettes for Teaching VisualDx