Chief Complaint

Table of Contents

• Emergent

• Diagnosis & Acute Care

• Chronic Conditions

• Obstetrics

• Neonatal

• Pediatric

• Vitals

• Labs and Imaging

High Yield Topics

• System-based chief complaint and diagnoses

  • Pain

    • Headache/sinus pressure, ear, abdominal, back, pelvic

    • Joint pain/arthritis including shoulder, elbow, hand/wrist, hip, knee, ankle, foot

  • Respiratory: Asthma, COPD, cough, dyspnea, laryngitis (sore throat), pneumonia, snoring, rhinosinusitis (URI)

  • Cardiovascular: Atrial fibrillation, heart failure, hypertension

  • GI: Dyspepsia/GERD, diarrhea/bloody stool

  • GU: Dysuria and urinary tract infection, incontinence, vaginosis/vaginitis

  • Skin lesions including atopic dermatitis and cellulitis

  • Endocrine: Diabetes mellitus, hypo/hyperthyroidism

  • Other: Anxiety/depression, dizziness/vertigo, edema, fatigue, fever

• Routine Care

  • Immunization

  • Health maintenance exam (adult)

  • Preoperative evaluation

• Imaging and Procedures

  • Signed consent form required for

    • Joint injections

    • Skin and soft tissue: Abscess I&D, lesion biopsy, skin tag removal

    • Women’s health: Pap smear/colposcopy, IUD

  • OB ultrasound

  • Circumcision (Gomco Clamp)

Emergent Conditions

Shock

• Undifferentiated

• Hypovolemic

  • Blood loss: Hemorrhage

  • Water/electrolyte loss: Vomiting, diarrhea, diuresis

  • Plasma loss: Burns

• Cardiogenic/obstructive

  • Heart defect: Acute coronary syndrome, cardiomyopathy, valvular insufficiency

  • Arrhythmia

  • Obstruction

• Distributive: ↑ vasodilation/capillary permeability = ↓ distribution

  • Anaphylaxis

  • Sepsis

  • Myxedema/adrenal crisis

  • Neurogenic (↓ vascular tone)

Cardiovascular

• Acute coronary syndrome

• Tachycardia: Atrial fibrillation with rapid ventricular response

• Bradycardia

Neurologic

• Stroke

  • Ischemic

  • Hemorrhagic

• Status epilepticus

Obstetric

• Shoulder dystocia

• Vaginal breech delivery

• Postpartum hemorrhage

• Preeclampsia with severe features

Pediatric

Emergency Department Presentations (Most to Least Common)

• Respiratory distress

  • Upper respiratory (most common): Deviated nasal septum, allergic rhinitis, acute laryngitis, acute/chronic tonsillitis, streptococcal sore throat

  • Lower respiratory

    • Chief complaint: Cough, wheezing

    • Diagnosis: Influenza, asthma, acute bronchitis, bronchiectasis, pneumonia, aspiration pneumonitis, pneumothorax

• Injury and poisoning

  • Injury per CHOP: Physical abuse, traumatic brain injury, burn, dental trauma, open long bone fracture, pelvic fracture, head trauma, laceration, spinal cord injury

  • Additional injury: Concussion, skull/maxillofacial fracture, ankle sprain, wrist sprain

• Neurologic

  • Headache

  • Convulsion/seizure

  • Gait disturbance

• Gastroenterological

  • Common

    • Colic

    • Nausea/vomiting/diarrhea: Gastroenteritis

    • Constipation: HoldingOrders, CHOP

  • Life threatening: Adhesions, appendicitis, hemolytic uremic syndrome, intussusception, primary bacterial peritonitis

    • Neonate: Malrotation and midgut volvulus, necrotizing enterocolitis

    • < 5 years old: Foreign body ingestion, incarcerated hernia, Hirschsprung disease

    • > 5 years old: Trauma, myo/pericarditis, diabetic ketoacidosis, perforated ulcer

  • Surgical emergencies: Hypertrophic pyloric stenosis, appendicitis, Meckel's diverticulum, intussusception, malrotation, and midgut volvulus

• Fever of unknown origin

• Mental and substance abuse disorders

  • Behavioral health issues including suicidal ideation, aggressive behavior, mental health concerns, developmental/autism spectrum disorders

  • Cannabis use, alcohol use, opioid use

• Genitourinary disorders

  • Urinary tract trauma, urinary tract infection, hydronephrosis, nephrolithiasis, glomerulonephritis, hemolytic uremic syndrome

  • Males: Inguinal hernia, priapism, hydrocele, scrotal/testicular pain (HoldingOrders, CHOP)

  • Females

    • Uterine bleeding (HoldingOrders, CHOP, CHOP DDX)

    • Pelvic pain: Pelvic inflammatory disease, ruptured ectopic pregnancy

• Musculoskeletal disorders

• Skin and subcutaneous tissue disorders

• Endocrine disorders: Diabetes mellitus

• Dehydration

References

• CHOP Clinical Pathways Library - Emergency

• Weight-based resuscitation

• Pharmacology

Diagnosis & Acute Care

Alphabetical

• Altered mental status

• Bleeding: Hypovolemic shock, gastrointestinal bleeding, abnormal uterine bleeding (AUB), bleeding in pregnancy

• Breast issues

• Cough

• Constipation

• Diarrhea

• Dizziness

• Dysphagia

• Dyspnea

• Dysuria

• Edema

• Eye and vision issues

• Facial droop

• Falls in the elderly

• Fatigue

• Fever

• Genital lesions

• Hair loss

• Hearing issues

• Jaundice

• Lymphadenopathy

• Muscle weakness and pain

• Nausea and vomiting

• Neck mass

• Palpitations

• Paresthesia (numbness and tingling)

• Pruritus

• Skin lesions

• Syncope

• Urinary retention and incontinence

• Vaginal discharge

• Vision changes

• Vertigo

Pain

• Headache

• Ear pain and hearing issues

• Throat pain

• Neck, back, and flank pain

• Chest pain and palpitation

• Abdominal pain

• Hip, pelvic, rectal pain

• Dysuria

• Extremity pain

• Joint Pain

  • Shoulder and upper arm pain

  • Elbow pain

  • Hand and wrist pain

  • Hip and pelvic pain

  • Knee pain

  • Calf pain

  • Foot pain and discomfort

Psychiatric

• Anxiety and depression

• Neurodevelopmental disorders and ADHD

• Mania/psychosis

  • Bipolar disorder

  • Schizophrenia

• Substance abuse

Chronic Conditions

Treatment

• Asplenia

• Chronic kidney disease

• COPD

• Cirrhosis

• Diabetes mellitus

• HIV/AIDS

• Hyperlipidemia

• Hypertension

• Insomnia

• Malignancy

• Obesity and weight loss

• Sickle cell crisis

• Tobacco abuse

• Traumatic brain injury

• Tuberculosis

Screening

• Health maintenance

• Abdominal aortic aneurysm

• Latent tuberculosis

• Osteoporosis

Obstetrics

Pregnancy

• Normal pregnancy: Routine exams by gestational age, antenatal genetic testing, counseling

• Potential emergencies: Bleeding, hypertension, decreased fetal movement, postpartum cardiomyopathy

• Nausea and vomiting in pregnancy

• Intrauterine growth restriction

• Gestational diabetes

• Thyroid disorders

• Rash

Pregnancy Prevention/Termination

• Contraception

• Abortion

  • Spontaneous abortion (1st, 2nd, and 3rd trimesters)

  • Induced abortion method depends on gestational age:

    • Medical abortion may be performed up to 9+6 WGA

    • Surgical abortion limit varies by facility

Labor

• Induction of labor

• Labor complications

Neonatal and Infants

Conditions/Findings

• Newborn exam

  • Congenital abnormalities

    • Erb's palsy

    • Developmental hip dysplasia

    • Club foot

  • Cryptorchidism

  • Jaundice

• Bacterial meningitis

• Opioid withdrawal

• Premature infant

• Failure to gain weight

• Vomiting

  • GERD

  • Pyloric stenosis

  • Malrotation with volvulus

Vitals/Lab Results

• Sepsis

• Hypoglycemia

• Hyponatremia

• Hypernatremia

• Hypocalcemia

Pediatric

• Anemia

  • Iron deficiency

  • Lead toxicity and CDC recommendations

• Constipation

  • Functional constipation

  • Hirschsprung's disease

• Cough

  • Upper airway cough syndrome

  • Protracted bacterial bronchitis

  • Pertussis (whooping cough)

• Developmental delays: Duchenne's muscular dystrophy, more coming soon…

• Diarrhea

  • Infectious diarrhea

  • Irritable bowel syndrome

  • Celiac disease

  • Lactose intolerance

• Fever

  • Fever age 0-90 days

  • Kawasaki disease

• Fussiness: Colic

• Groin pain: Testicular torsion

• Hematuria: HUS

• Hyperglycemia: Diabetes mellitus type 1

• Injury: Burns, child abuse

• Multiple issues:

  • Sickle cell disease

  • Malignancy: AML, ALL

• Orthopedics

  • In-toeing: Metatarsus adductus, internal tibial torsion, femoral anteversion

  • Overuse injuries

    • Little league shoulder

    • Little league elbow

    • Calcaneal apophysitis (Sever)

  • Pediatric limp

• Pain

  • Ear pain: Otitis media

  • Abdominal pain

    • Functional abdominal pain

    • Abdominal migraine

    • Inguinal hernia

    • Intussusception

    • Appendicitis

    • Ovarian torsion

  • Back pain: Spondylosis

  • Joint pain

    • Shoulder, elbow, knee

    • Leg pain: Growing pains, osteoid osteoma

    • Foot pain

• Respiratory distress

  • Infectious

    • Acute bronchitis

    • Bronchiolitis (RSV)

    • Croup/laryngitis (parainfluenza)

    • Pertussis (whooping cough)

    • Pneumonia: Viral vs. atypical

  • Reactive airway: Asthma, anaphylaxis

  • Acute chest syndrome

• Scoliosis

• Weakness: Botulism, Duchenne's muscular dystrophy

• Urinary tract infection

Vital Signs

Temperature

• Fever/Hyperthermia

  • Infection: Rule out upper respiratory infection, pneumonia, UTI, cellulitis

  • Malignancy

  • Systemic rheumatic disease: Rheumatoid arthritis, vasculitis, etc.

• Hypothermia

Heart rate

• Tachycardia

• Bradycardia

Respiratory rate

• Tachypnea

• Bradypnea

Blood Pressure

• Overview

• Hypertension

• Hypotension

Labs and Imaging

WBC

• Neutrophilia

• Acute myelogenous leukemia

• Chronic lymphocytic leukemia

Anemia

Microcytic

• Iron deficiency anemia

• Anemia of chronic disease

• Lead toxicity

• Thalassemia

Normocytic

• Hemolytic

  • Adult: Autoimmune hemolytic disease

    • Patients age > 40 years

    • Pathophysiology: Cold-reactive antibodies formed in response to EBV or mycoplasma infections

  • Pediatric

    • DDX: Sickle cell disease, spherocytosis, G6PD deficiency

    • Obtain CBC, corrected reticulocyte index, peripheral blood smear, +/- hemoglobin electrophoresis

• Non-Hemolytic

  • Chronic kidney disease

  • Pediatric: Aplastic crisis, transient erythroblastopenia of childhood

Macrocytic

• Megaloblastic anemia (hypersegmented neutrophils): B12/Folate deficiency

• Non-megaloblastic anemia (neutrophils with < 5 lobes)

  • Alcohol-use disorder

  • Chronic liver disease

  • Pediatric (rare): Blackfan-Diamond syndrome

Platelets

• General thrombocytopenia

• Consider HIT, TTP/HUS, ITP, DIC

BMP/CMP

Individual Values

• Sodium: Hyponatremia, hypernatremia

• Potassium

  • Hypokalemia

    • Common etiologies: Vomiting, diarrhea, bulimia nervosa

    • Less common etiologies: Dialysis/plasmapheresis, VIPoma

    • Medication-induced: Diuretics, laxatives, insulin, albuterol

  • Hyperkalemia (consider if K+ > 5.5, start if > 6)

    • Calcium gluconate 1000 mg (10 mL of 10% solution)

    • Albuterol nebulizer q4-6 hours

    • Regular insulin 10 u in 500 mL 10% dextrose solution

    • Potassium binder: 8.4 g qd (onset of action = 7 hours)

    • Consider nephrology consult

• Chloride

• Bicarbonate

  • Low

    • Unstable: Obtain CBC, CMP, serum lactate, ABG, UDS and consider beta-hydroxybutyrate in setting of hyperglycemia

    • Stable: Obtain CBC, CMP serum albumin and calculate anion gap (Na − [Cl + HCO3]); see acid-base disturbances for further information

• BUN and Creatinine

  • Uremia

  • Elevated creatinine (Cr)

    • Acute kidney injury (≥ 1 of the following): Cr ≥ 1.5x baseline, Cr ≥ 3.0 mg/dL, urine output < 0.5 mL/kg/h for 6-12 hours

    • Chronic kidney disease

    • Hepatorenal syndrome

• Glucose

  • Hyperglycemia

    • Diabetes mellitus: Type 1 and Type 2

    • Diabetic Ketoacidosis (DKA)

    • Hyperosmolar hyperglycemic state (HHS)

    • Stress hyperglycemia

  • Hypoglycemia: Neonatal hypoglycemia

• Elevated serum protein: Consider serum protein electrophoresis

  • Hypogammaglobulinemia: Indicates immunodeficiency

    • Primary: Congenital (pediatric)

    • Secondary: Metabolic (renal disease, DM), loss in urine/stool, malignancy, immunosuppression (HIV, Rx)

  • Hypergammaglobulinemia

    • M-protein negative: Liver disease, autoimmune disease, chronic infection, malignancy

    • M-spike positive: MGUS (no lytic lesions), multiple myeloma (lytic lesions), Waldenström’s macroglobulinemia (monoclonal IgM, Bence-Jones protein)

• Calcium: Hypocalcemia, hypercalcemia

• Liver enzymes (acute elevation)

  • Review risk factors: Recent travel, alcohol use, IV drug use, sexual history, medications. Discontinue offending agents (e.g. statins).

  • Review of systems: Ischemia risk (e.g. CAD, mesenteric ischemia), coagulopathy risk (e.g. previous DVT/PE), abdominal pain, jaundice

  • Obtain: Hepatitis A Ab/IgM, HBSAg, anti-HBs, anti-HBc, albumin, bilirubin, alkaline phosphatase (+/- GGT), PT, PTT, INR

• Vitamin deficiencies

Value Patterns

• Acid-base disturbances

• Liver enzymes

  • Hepatocellular

    • NAFLD

    • Alcohol-induced liver disease (AST:ALT > 2)

    • Cirrhosis

  • Other: Autoimmune, cholestatic, infiltrative

Urinalysis

• Microscopic hematuria

• Proteinuria: Chronic kidney disease, nephrotic syndrome

Other

• Hypertriglyceridemia

• Hepatitis panels: Hepatitis B, hepatitis C

• TSH: high (hypothyroidism), high (hypothyroidism)

• PTH

  • Low (hypoparathyroidism)

  • High (hyperparathyroidism): Primary and secondary

Imaging

• Conditions

  • Solid pulmonary nodule

  • Ovarian cyst

• Modality

  • EKG

  • Radiology ordering guidelines PDF