Go through each successive part of the case. At the end of each part, quickly answer the question about your top diagnosis and the next diagnostic step that you think will give you the diagnosis (not necessarily the next step that you would do in real life). Don’t need to spend too much time thinking about these questions—you will review them at the end.
Part 1
55yo man with DM and HTN presents with 2 days of nausea, emesis, and loose stool. Just arrived back from El Salvador 5 days ago. “Poor historian.”
VITALS: T 36.4, HR 101, BP 163/110, RR 23, SpO2 93% on RA.
GENERAL: Appears ill, mod distress.
LUNGS: Clear to auscultation without appreciable crackles.
HEART: Tachycardic. No murmur or edema.
ABDOM: TTP of RUQ with +Murphy’s sign.
NEURO: No focal deficit.
What is your top diagnosis?
What is the next diagnostic step?
Part 2
LABS: WBC 10.3, K 3.2, Cr 1.7 (H), Gluc 243, Lipase 65 (H), Lactate 2.9 (H), tBili 1.6 (H).
What is your top diagnosis?
What is the next diagnostic step?
Part 3
TREATMENTS: IVF x 3L
US RUQ: Gallbladder wall thickening, no gallstones.
What is your top diagnosis?
What is the next diagnostic step?
Part 4
TREATMENTS: Addional IVF × 3L, Zosyn
CT A/P: Gallbladder wall edema. No bil dil. Small ascites. Trace pleural effusion and mild pulm edema.
Repeat Labs: K 5.6 (H), Gluc 323 (H), Cr 1.47, Lactate 4.0 (H), tBili 2.1 (H), βOH-butyr: 1.42 (H)
What is your top diagnosis?
What is the next diagnostic step?
Part 5
CONSULT: Surgery: “findings consistent with acute cholecystitis… lab findings consistent with early, progressing DKA”… recommend admission to Medicine
TREATMENTS: NPH + Regular insulin
What is your top diagnosis?
Part 6
ADDITIONAL HISTORY:
+vertigo. +recent URI-type symptoms.
ADMISSION DIAGNOSIS AT SIGN-OUT TO MEDICINE:
Cholecystitis with mild DKA.
What is the diagnosis?
Part 7
How was the admitting diagnosis reached?
Do you agree with this diagnosis?
What is your next step evaluating/managing this patient for admission?