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  1. In the spirit of EMED's great "its probably nothing, fast track disasters" thread, I've thought of a similar ongoing thread topic that I hope will provide some more good learning content and food for thought. I've found that a lot of newer students / interns / APPs (myself included) often fall into the trap of thinking, "well, the tests are all negative, so that's all there is to it" and discharge the patient. "What else could I even do for this abdominal pain patient with negative labs, CT, etc... surely we've ruled everything out!" Well, I've been spending a lot of time with our ED quality committee, aka morbidity and mortality team, which reviews high risk cases and misses that have went through the group... it really has been a great learning experience - I'd recommend everyone check it out if they haven't yet. The line of thinking noted above is a common pitfall that we see, because there are still emergencies that can be missed even after the "standard workups" come back negative. With that in mind, I made an evernote document on my phone about a year ago where I've been keeping track of situations that arise in practice that fit this general theme... I've got it organized like this: The situation --> the negative test --> it can still miss XYZ targeted ddx for relevant emergency medicine conditions --> so, what to do (and don't forget that you need to document in the MDM to say why you don't think those are occurring) --> why its important, or what are the risks of missing those conditions. Here's a classic example: FOOSH injury --> triage ordered hand and wrist X-rays that are negative --> ddx: occult scaphoid fracture, elbow fractures, proximal humerus fractures --> plan: examine those areas, X-rays other areas if needed, rarely advanced imaging if very high suspicion, otherwise place in thumb spica splint and follow up in 1 week for repeat exam and repeat X-rays --> Why? Because missed scaphoid fractures are a common miss and lawsuit potential because of the bad outcomes and chronic issues that result from them. .................................................................................................. Alright team, in the same fashion as Emed's thread, lets see how you do with a few of the cases I've complied... 1) elderly fall from standing with back and hip pain and not ambulating --> back and hip X-rays negative --> whats your ddx / plan / thoughts / reasoning? 2) closed head injury with significant mechanism, noting head and neck pain --> CT scan head / neck is negative --> ? 3) soccer injury - traumatic knee pain and swelling, unable to ambulate --> knee X-rays negative for fx --> ? 4 - A) RLQ abdominal pain and tenderness in a 23 yo M x 6 hours --> labs, CT scan neg --> ? vs 4 - B) RLQ abdominal pain and tenderness in a 23 yo F --> labs, preg test neg, CT scan neg --> ? 5) Periumbilical and epigastric abdominal pain in a remote roux-en-y gastric bypass patient --> labs and CT negative --> ? 6) infectious / viral syndrome (fever, congestion, cough) with pleuritic chest pain --> CXR negative --> ? Theres probably no specific right or wrong answer to these, but let me know what you'd include for answers and I'll share mine, and hopefully we'll all learn as a result. I've got quite a bit more where these came from... would love it if others would share similar situations that they encounter to make this an ongoing learning thread. -SN
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