The EM Clerkship Podcast

Patients rarely have the “classic” presentation of appendicitis. Frequently it is misdiagnosed as GASTROENTERITIS!!! Three Stages of Appendicitis Stage 1: ~12 hours of “gastroenteritis” like symptoms Stage 2: Direct somatic irritation This is when pain over McBurney’s develops! Stage 3: Perforation Patient is now sick and septic Approach to Appendicitis Step 1: Consider getting labs […]

Common Complaints Red Eye Decreased Vision Trauma to the Eye Approach to a Vision Complaint Step 1: Assess visual acuity Visual acuity is the “vital sign of the eye” Snellen eye chart is best If patient unable to see chart… Count fingers? Able to see light? Step 2: Examine the conjunctiva/cornea with fluorescein How to […]

Differential Diagnosis Mnemonic: HE DIES Hypothyroidism Elevated intracranial pressure (ICP) Cushings reflex Bradycardia Increased blood pressure Irregular breathing Drugs Beta blockers Calcium channel blockers Digoxin Ischemia Electrolytes Especially potassium!!! Sick Sinus Syndrome Approach to Bradycardia Step 1: Get an EKG Ischemia? Heart block? 1st degree = PR interval >200ms (5 small boxes...

Airway and Epi! Airway and Epi! Airway and Epi! Introduction Anaphylaxis is caused by massive uncontrolled release of chemicals after exposure to “antigen” The antigen causes extensive mast cell and basophil cross-linking/activation Common antigens Foods Drugs Insect venoms Basic Approach Step 1: Diagnose anaphylaxis Consider anaphylaxis if the patient has TWO body systems involved Dermatologic […...

Basic Approach Step 1: Is this SINUS tachycardia? P before every QRS? Treat the underlying condition Step 2: Is this a NARROW and REGULAR rhythm? SVT Treat with vagal maneuvers or adenosine Another new trend is treating with calcium channel blockers!! ORTHOdromic Wolf Parkinson White Treat with adenosine Atrial flutter with fixed block Treat with […]

Introduction Simple seizure Seizure ends in <5 minutes AND Patient wakes up before next seizure No meds required Status epilepticus Seizure lasts >5 minutes OR Patient has a 2nd seizure before waking up from 1st Initiate status epilepticus pathway Approach to Status Epilepticus Step 1: Give a benzodiazepine Lorazepam (IV) Diazepam (IV or PR) Midazolam […]

Basic Approach Step 1: Describe the seizure Did patient have an aura? Was there loss of consciousness? What did the movements look like? Did they have postictal phase? Did they have a trauma as well? Step 2: Ask about TIME (mnemonic) Tongue biting Usually occurs on the lateral sides of tongue Incontinence Medication changes/adjustments Ethanol […]

Hard, fast, unrelenting chest compressions are the core of ACLS!!! Step 1: Check the Patient’s Pulse If the patient does not have a pulse, start CPR Hard, fast, unrelenting compressions Intubated patients Continuous Compressions Non-intubated adults 30 compressions then 2 breaths… Repeat Non-intubated pediatrics 15 compressions then 2 breaths… Repeat Step 2: Determine if the […]

There are 5 key diagnoses classically associated with right upper quadrant (RUQ) abdominal pain. Cholelithiasis and Biliary Colic Cholelithiasis = Gallstones in the gallbladder Frequently seen on CT scan or RUQ ultrasound Present in 15% of the population Biliary colic = Intermittent episodes of pain if stone passes Classically colicky/crampy/spasmy pain in RUQ Frequently radiates […]

Evaluate 5 important structures when evaluating gunshot wounds in an extremity. Blood Vessel Injuries 3 Categories Hard-Signers Mnemonic: HARD Bruit Hypotension Arterial/pulsatile bleeding Rapidly expanding hematoma Deficits (pulse) Audible BRUIT/thrill These patients likely need OR Soft-Signers Significant vascular oozing/bleeding Large hematoma These patients need to be screened with ABI (ankle...

5 core treatments and 5 MORE treatments 5 Core Treatments Albuterol Beta agonist Bronchodilator Core treatment for asthma Ipratropium Anti-muscarinic Relax muscles around the airways Works synergistically with albuterol Steroids Decrease inflammation in the airways Prednisone (PO) Methylprednisone (IV) BiPAP (COPD) Decreases work of breathing Decreases rates of intubation Decreases mortality Antib...

Basic Categories Upper GI Bleed Symptoms Coffee ground emesis Melena Black tarry stool Digested blood Common causes Peptic ulcer disease Varices Lower GI Bleed Symptoms Bright red blood per rectum (BRBPR) Maroon/bloody stools Common causes Diverticulosis Colon cancer Angiodysplasia AV Malformations History Ask about risk factors for upper GI bleed Peptic ulcer risk factors NSAIDS […]

Type and Rh What information it provides Blood type (A, B, AB, O) Rh status (Rh positive or negative) When to order Pregnant patients with vaginal bleeding Need if Rh negative (prevents hemolytic disease of newborn) Type and Screen What information it provides Blood type (A, B, AB, O) Rh status (Rh positive or negative) […]

Introduction Pulmonary embolism (PE) is caused when a deep venous thrombosis from somewhere else in the body “embolizes” and becomes lodged in the pulmonary arteries Can cause pulmonary infarction (which mimics pneumonia on chest x-ray) Basic Approach to the Diagnosis of PE Step 1: Consider PE in any patient with signs or symptoms consistent with […]

There are 3 main “categories” of hemoptysis… Mild, “Streaky” Hemoptysis Most common diagnosis Bronchitis Testing plan Chest xray Rules out alternative causes of hemoptysis Pneumonia Cancer Pulmonary Embolism Vasculitis Scary but Stable Hemoptysis Patient is coughing up frank blood Testing plan CTA of the chest CBC PTT/PT/INR Electrolytes Need renal function if giving IV contrast […]

Salicylate toxicity is the great toxicologic mimicker!!! Step 1: When to Suspect Salicylate Overdose Signs of CNS stimulation Tachypnea Hyperthermia Altered mental status Signs of GI irritation Nausea/Vomiting Abdominal pain Common “mimicker” Sepsis Acute abdomen Step 2: Testing Plan Electrolyte panel Anion gap metabolic acidosis Sodium – Chloride – Bicarb Normal anion gap (AG) is […]

Acetaminophen is the most important overdose in toxicology Step 1: Check a Serum Acetaminophen Level Common situations where testing is ordered Suicidal ideation Severe depression Overdose Step 2: Consult the Rumack-Matthew nomogram Only works for acute/single ingestions of acetaminophen Loses reliability if patient is on drugs that affect bowel motility If the time of ingestion […]

Common Causes Structural Cancer Post-menopausal bleeding is cancer until proven otherwise Fibroids Adenomyosis Polyps Coagulopathy Present in approximately 20% of non-pregnant vaginal bleeding Most common = Von Willebrand Disease Hormonal causes Dysfunctional uterine bleeding Basic Approach to Non-Pregnant Vaginal Bleeding Step 1: Pelvic exam The utility of this is debated It is best to sound […]

The pregnancy test is the most important test in females of reproductive age! Five Important Tests in 1st Trimester Vaginal Bleeding CBC Hemoglobin/Hematocrit Mild anemia in pregnancy is physiologic and normal Thrombocytopenia Type and Screen Required for blood transfusion Determines if patient needs RhoGAM Rho(D) immune globulin Binds fetal Rh antigens from a fetus so […]

Common Causes of Constipation Lifestyle Low fiber diet Minimal water intake Poor exercise Medications Especially opiates Endocrine/electrolytes Hypothyroidism Hypercalcemia Bowel obstruction Delayed colonoscopy Unintentional weight loss Previous abdominal surgeries Rectal problems Anal fissures Fecal impaction Masses How to Treat Constipation Fiber (ex. Metamucil, Citrucel) Adds structure to the s...

The blood sugar is NOT the emergency- Acidosis, Hypokalemia, and Dehydration are!!! Signs and Symptoms Vomiting Abdominal pain Polydipsia Polyuria Step 1: Test for DIABETIC-KETO-ACIDOSIS Diabetes Blood sugar Typically notably elevated (>250 mg/dL) Can be normal in certain circumstances Ketones Easiest test is a urinalysis Serum ketones also can be obtained Acidosis Blood gas (arterial […]

Step 1: Pain Control Local anesthesia Most common agent is lidocaine (frequently already in laceration repair kits) Inject through wound edges (not through epidermis) This decreases pain Alternative is digital/regional nerve block Step 2: Irrigation Laceration repair is not a sterile procedure Copious irrigation is the best method to decrease chance of wound infection Faucet/sink […]

Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!! To Close or Not To Close? Closing a wound with sutures, etc = Healing by “primary intention” INCREASES risk of infection but DECREASES scar Leaving a wound open = Healing by “secondary intention” DECREASES risk of infection but INCREASES scar Step […]

You must know the FOUR emergent causes of sore throat! Step 1: Apply the Centor Criteria Determines if patients is at risk for Group A strep (“strep throat”) 4 Criteria Fever No cough Tonsiller exudates Lymphadenopathy Interpretation If patient has ALL of the criteria Treat for strep throat If patient has NONE of the criteria […]

Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship Common Scenarios Cardioversion Orthopedic reductions Painful procedures Three Step Approach to Procedural Sedation Step 1: Risk stratify the patient Mallampati score (aka “How visible is the uvula?”) Level 1: Can visualize THE WHOLE uvula Level 2: Can […]