A 10-year-old female dancer presents with sub-acute onset pain located in her lateral ankle and foot. Denies any history of significant trauma. She has had similar pain occasionally over the past 6 months. Pain is worse while dancing and now has difficulty putting on her shoe. You obtain a foot x-ray and see the adjacent image.
You are working at a small freestanding Emergency Department, and your next patient is a 67-year-old male with flank pain and lower abdominal pain. His heart rate is 105, blood pressure is 106/53, oxygen saturation is 99% on room air, he is breathing 22 times a minute, and he is afebrile. He has a history of hypertension, diabetes, and kidney stones. He looks mildly uncomfortable as he tells you this pain began suddenly this morning and reminds him of a kidney stone he experienced years prior.
A 21-year-old female with a previous medical history of hypothyroidism presents with her parents for suicidal ideation. The patient’s mother discovered an internet search for “methods of suicide” on the family computer, prompting the emergency department (ED) visit. The patient has been living with her parents for two months, following significant work-related stress. Review of systems is remarkable for abdominal pain of two weeks duration, decreased appetite, decreased sleep, and lack of interest in daily activities. During the interview, the patient displays a flat affect; she fails to engage and will not reply to questions regarding substance abuse, previous psychiatric history, or compliance with current medications. The patient’s father denies a history of familial substance abuse or behavioral health diagnoses.
What are the next steps in your evaluation and treatment?
A 36-year-old male with a history of HIV presents to the ED complaining of dyspnea on exertion and fatigue. He is homeless and has been poorly compliant with his anti-retroviral medications. He reports several weeks of non-productive cough and subjective fever. Pulse is 102/min, respirations 22/min, blood pressure 112/68 mm Hg, temperature 38º C (100.4º F), and pulse oximetry 93% on room air. His conjunctivae are pale. There is a painful ulcer to the distal aspect of the tongue and scattered petechiae on his legs. Skin exam demonstrates scattered petechiae. Laboratory evaluation reveals WBC 2,000/microL (70% PMN, 25% lymphocytes, 4% monocytes, eosinophils 0.9%, basophils 0.1%), hemoglobin of 8.5 g/dL, and platelets 90,000/microL. LDH is 220 U/L (normal 140-280 U/L). CD4 cell count and HIV viral load are pending. What do the exam and lab findings suggest?
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