Practice Management
The patient is a 35-year-old male who presents with chest pain, which he reports started after he was hit in the chest with an errant pass during his son’s basketball practice. View the image taken (Figure 1) and consider what your diagnosis and next steps would be. Resolution of the case is described on the next page. Figure 1.
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Urgent message: When a relatively young patient presents to urgent care with chest pain, there may or may not be a “typical” cause. Prompt evaluation and accurate assessment of risk factors are essential to efficient care and, often, the patient’s survival. Max Palatnik, MD Case Presentation A 35-year-old male presented at 21:59 with a chief complaint of chest pain; at 22:03, we noted the following: Temp: 98.9 Pulse: 103 Resp: 16 Syst: 122 Diast: 69 …
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Case The patient is a 73-year-old male smoker who complains that he has had intermittent palpitations for the past 2 weeks. He denies chest pain, diaphoresis, fever, or dizziness. He uses home oxygen, 2 L/min, but denies any new shortness of breath. Upon exam, you find: General: Alert and oriented x 3 Lungs: Scattered minimal wheezing, which is symmetric Cardiovascular: Regular and tachycardic without murmur, rub, or gallop Abdomen: Soft and nontender without rigidity, rebound, …
Read MoreCase A 20-year-old previously healthy man presents with sudden onset of substernal chest pressure after completing football practice. His chest pain is nonradiating, nonreproducible, and nonpositional. He does not have associated palpitations, dyspnea, or diaphoresis. He reports that he has not had recent upper respiratory tract infections or contact with ill people. He does not have a history of using alcohol, tobacco, or illicit drugs. He has no family history of sudden cardiac death or …
Read MoreCase A 36-year-old man presents to an urgent care center with a dry cough that he has had for the preceding 10 days. He has mild dyspnea. He has no rhinorrhea, fever, chest pain, blood in the urine or stool, or lower-extremity pain or swelling. He has no history of previous illnesses. He smokes cigarettes, occasionally drinks alcohol, and has a remote history of intravenous drug use. View the image taken (Figure 1) and consider …
Read MoreCase A 23-year-old man presents to an urgent care with pain at the distal end of his left clavicle that began the previous day after he fell onto his left shoulder while mountain biking. His pain is constant and sharp and worse when moving his left arm and shoulder. He does not have fever, vomiting, chest pain, shortness of breath, or abdominal pain, and he has no head injury, no head or neck pain, and …
Read MoreLee A. Resnick, MD, FAAFP In my last column, I introduced a framework for evaluating chest pain in urgent care. In this month’s column I discuss a risk and probability stratification that can assist in disposition decision-making. The following discussion considers existing evidence, but there is no formal guideline for this process in the outpatient setting. Our goal is to make a risky scenario into something we can live with. This model is for risk-stratification …
Read MoreLee A. Resnick, MD, FAAFP What can Joseph Heller and Goldilocks teach us about managing no-win situations in urgent care? As it turns out, if you look under the covers of Baby Bear’s bed, you might find something meaningful, perhaps even something that’s “just right.” Take the classic no-win situation when patients present to urgent care with chest pain. Without a definitive and reliable test to guide our decision making, we are stuck with the …
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Urgent message: Urgent care clinicians should consider the possibility of cholecystitis when evaluating patients with cardiac symptoms. A delay in diagnosis may lead to serious complications, including sepsis. ALONA D. ANGOSTA, PhD, APRN, NP-C, and BRYAN HOLMES, NREMTP Introduction Patients with acute cholecystitis typically complain of right-upper-quadrant pain that radiates to the right shoulder and back, fever, and leukocytosis.1 The pain may also be associated with nausea or vomiting. However, acute cholecystitis can mimic cardiac …
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