Bouncebacks The Case of a 37-Year-Old Female with Flu-like Symptoms In Bouncebacks, which appears semimonthly in JUCM, we provide the documentation of an actual patient encounter, discuss patient safety and risk management principles, and then reveal the patient’s “bounceback” diagnosis. The cases are adapted from the book Bouncebacks! Emergency Department Cases: ED Returns (2006, Anadem Publishing, www.anadem.com; also available at www.amazon.com and www.acep.org), which includes 30 case presentations with risk management commentary by Gregory L. Henry, past president of The American College of Emergency Physicians, and discussions by other nationally recognized experts. Ryan Longstreth, MD, FACEP and Michael B. Weinstock, MD factoring in the age of the patient; while uni- lateral weakness and numbness in a 76-year- old is often from a stroke, what are the most likely reasons in a 37-year-old woman? If the differential does not in- clude the diagnosis, then appropri- ate and timely therapy will not oc- cur. This case will add one more item to the differential diagnosis of headaches. The Case of a 37-Year-Old Woman with Headaches In primary care medicine, patients’ symptoms are approached from the “front door;” what are the most likely causes? Urgent care medicine often starts with a “back door” ap- proach; think “worst first,” then proceed backward through the differential after excluding life- m threatening causes. Urgent care .co es ag I / m does not have the luxury of an es- ler tab nS tablished patient relationship or de- r a to B fined return visit—we often have © only one chance to get it right! The differential for an urgent care patient with headache starts with eval- uation for meningitis, subarachnoid hemor- rhage, tumor, and carbon monoxide poisoning. This is usually possible through history and physical alone. Conversely, the primary care physician may start with a differential including migraine, tension, or clus- ter headaches. The practice of empiric medicine allows for an accurate diagnosis after cursory evaluation most of the time; unfor- tunately, however “most” is not often enough. For exam- ple, empiric medicine will be wildly inaccurate without 20 Initial Visit (Note: The following, as well as subsequent visit summaries, is the actual documentation of the providers, including punctua- tion and spelling errors.) CHIEF COMPLAINT (at 08:54): Flu-like symptoms VITAL SIGNS Time Temp (F) Rt. Pulse 08:57 97.8 T 76 11:19 97.3 O 88 Diast Pos O2 sat O2% 94 S 70 S JUCM T h e J o u r n a l o f U r g e n t C a r e M e d i c i n e | D e c e m b e r 2 0 0 8 Resp Syst 18 141 16 120 Pain scale 4 w w w. j u c m . c o m