EM Clerkship

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are having a busy day in the department when you are paged overhead to the resuscitation bay for an ill appearing patient with a headache… Initial Vitals * Temp 98.9* HR 99* RR 18* BP 180/110* O2 94% Critical Actions * Verbalize a Full Neurologic Examination* Obtain CT Scan Without Contrast* Consult Neurosurgery for Subarachnoid Hemorr...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A 45 year old female is exposed to peanut butter and shrimp pizza and begins to have an apparent allergic reaction… Initial Vitals * Temp 98.8* HR 130* RR 35* BP 70/40* O2 92% Critical Actions * Verbalize Airway Evaluation* Complete a FOCUSED History and Exam* Normal Saline Bolus* Epinephrine both IM and (subsequently) IV* Glucagon 1mg IV...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse brings back a young adult male from the lobby who is having a seizure… Initial Vitals * Temp 98.8* HR 90* RR 10* BP 120/80* O2 92% Critical Actions * Verbalize ABCs on a Critical Patient* Obtain Immediate Blood Glucose Level* Give Benzodiazepine* Initiate Workup of New-Onset Seizures* Give Pyridoxine (Vitamin B6) Final Diagnosis...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction EMS brings in an elderly man who has fallen… Initial Vitals * Temp 98.6* HR 58* RR 16* BP 105/60* 99% Critical Actions * Treat the patient’s pain* Consult orthopedics for a hip fracture* Obtain an EKG* Treat Severe Hyperkalemia* Consult nephrology for dialysis Final Diagnosis Ground level fall resulting in hip fracture, missed dialysis, an...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction Just a routine day at your hospital, your next patient has a chief complaint of headache… Initial Vitals * Temp 98.8* HR 88* RR 16* BP 130/80* O2 99% Critical Actions * Identify Acute Angle Closure Glaucoma* Initiate Appropriate Treatment for Acute Angle Closure Glaucoma* Emergent Consult to Ophthalmology* Recheck Intra-Ocular Pressure Aft...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A notorious, disheveled frequent flyer presents to your emergency department for her back pain and is asking for more Dilaudid… Initial Vitals * Temp 99.0* HR 99* RR 18* BP 118/78* O2 99% Critical Actions * Ask about Red Flags for Spinal Infection* Perform a Thorough Spinal Exam* Obtain MRI Spine with Contrast* Initiate Broad Spectrum Anti...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse is asking you to evaluate a 70 year old male who has been placed in a hall bed after hitting the back of his head. She wants to know if you would like to call a trauma alert… Initial Vitals * Temp 103.7 (Hidden by Examiner)* HR 115* RR 18* BP 110/75* O2 99% Critical Actions * Diagnose Fournier’s Gangrene on Secondary Survey* Obta...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction The nurse tells you that you have a new patient and is requesting a verbal order for nausea medicine. She advises you that the patient is the CEO of your hospital… Initial Vitals * Temp 98.9* HR 99* RR 18* BP 120/80* O2 98% Critical Actions * Perform Genitourinary Exam* Rule Out Abdominal Aortic Aneurysm* Consult Urology* Treat the Patient...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction An ill appearing patient has been rushed back from the lobby, clutching his chest, you are needed immediately at the bedside… Initial Vitals * Temp 99.1* HR 95* RR 20* BP 120/80* O2 98% Courtesy of LITFL Medical Blog https://creativecommons.org/licenses/by-nc-sa/4.0/ Critical Actions * Obtain Early EKG* Notify Cardiology of Inferior STEMI*...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction EMS brings in a postictal 34 year old female after she has a seizure. She is complaining of a headache… Initial Vitals * Temp 98.9* HR 110* RR 10* BP 175/115* O2 95% Critical Actions * Articulate Full Neurologic Exam* Early Blood Glucose* Identification of Pregnancy* Administer Magnesium* Treat the Patient’s Blood Pressure Final Diagnosis...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are called to the resuscitation bay for a poorly responsive patient that has been brought in by EMS. Initial Vitals * Temp 98.8* HR 78* RR 4* BP 124/78* O2 98% Critical Actions * Obtain Early Blood Glucose* Administer Dextrose* Obtain Salicylate and Acetaminophen Levels* Admit for Further Observation* Psychiatry Consult Final Diagnosis...

ABEM-style cases presented on EM Clerkship are not my actual ABEM exam cases, and they are not derived from my actual exam cases. I will never be discussing my specific exam details with anybody, including on this podcast. The cases were created independently, by me, for the purpose of medical education and improving patient care. Topics are chosen from the publicly available ABEM model of clinica...

There are HUNDREDS of other non-GI/GU causes of abdominal pain… Acute coronary syndrome (ACS) * Test with EKG and troponin * Treat with aspirin and heparin Acidosis * Diabetic Ketoacidosis (DKA)* Respiratory Acidosis (COPD)* Salicylate Toxicity (Remember MUDPILES) Abdominal Aortic Aneurysm (AAA) * Older people with abdominal/flank/back pain or syncope* Testing* CT Scan Abdomen with contrast (Good)...

Testicular Torsion History * Pain in the testicles * Referred pain in the flank or lower abdomen* Usually sudden and severe* Usually WITHOUT urinary symptoms Exam * Asymmetric testicular lie* High riding testicle* Tenderness and swelling of the testicle itself* Cremasteric reflex Testing * Testicular Ultrasound Treatment * Immediate call to urology when suspected* Manual detorsion (“Open the Book”...

Women have two additional diseases that must be added to the differential diagnosis of their abdominal pain. PID and ovarian torsion. Pelvic Inflammatory Disease (and Tube-Ovarian Abscess) Deep pelvic infections high in the reproductive tract frequently caused by sexually transmitted infection but can be caused by other infections (especially anaerobic infections) as well History * Symptoms* Lower...

How to Read a Urinalysis * Signs of Inflammation* Leukocyte Esterace* WBCs Multiple conditions cause inflammation on a urinalysis. Anything that causes nearby inflammation (appendicitis, pelvic infections, diverticulitis) or slows urine output (dehydration, renal disease) can commonly elevate these markers. * Signs of bacterial presence (not present in ~25% of proven urinary tract infections!!!)*...

All women of childbearing age who present with abdominal pain need a pregnancy testa core teaching of EMergency medicine Ectopic pregnancy is the leading cause of maternal death in the first trimester History * Abdominal pain present in 90% of cases* Amenorrhea present in 70% of cases* Vaginal bleeding present in 50% of cases The biggest red flag with this complaint is history of receiving fertili...

Bowel Perforations History Perforation takes time, frequently symptoms were either ignored or not noticed as can occurring in… * Elderly, diabetic, or immunosuppressed patients (frequently have minimal symptoms)* Pediatric patients (unable to or scared to mention symptoms) Exam Commonly have “peritoneal signs” * Guarding* Rebound Tenderness* Rigidity Testing * CT Scan* X-Ray? (not your primary tes...

Mesenteric Ischemia * Celiac truck supplies blood to the stomach and duodenum* SMA supplies blood to the rest of the small bowel and proximal colon* IMA supplies blood to the distal colon and rectum Arterial flow can be blocked because of emboli (atrial fibrillation) Venous flow can be blocked because of thrombosis (hypercoagulable states) Effective flow can be severely decreased in shock states (...

Biliary Diseases * Biliary Colic- A gallstone DOES NOT GET STUCK, but it slowly rolls out of the gallbladder, through the cystic duct, then the common bile duct and pancreatic duct. This results in several hours of crampy “colicky” pain as the stone passes.* Cholecystitis- A gallstone gets stuck IN THE NECK OF THE GALLBLADDER OR THE CYSTIC DUCT. Pressure builds up in the gallbladder and inflammati...

Appendicitis History Vague nonspecific abdominal cramping and nausea (Nonspecific Phase) gradually progresses to localized pain (Localized Phase). The pain most commonly localizes in the RIGHT LOWER QUADRANT near McBurney’s Point. Exam * Focal tenderness in the right lower quadrant* McBurney’s Point: 1/3 the distance traveled from anterior superior iliac spine (ASIS) to the navel. * Psoas Sign: Pa...

EM Clerkship’s 10 Step Patient Presentation * Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)* At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)* Red Flags/Pertinent Positives and Negatives* Vital Signs* Focused Physical Exam of the Complaint* Suspected Diagnosis* Can’t Miss Diagnosis* Testing Plan* Treatment Plan* (I...

EM Clerkship’s 10 Step Patient Presentation * Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)* At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)* Red Flags/Pertinent Positives and Negatives* Vital Signs* Focused Physical Exam of the Complaint* Suspected Diagnosis* Can’t Miss Diagnosis* Testing Plan* Treatment Plan* (I...

Tip #26 Update your attending when the nurse is having difficulty with your patient’s IV or drawing blood. Tip #27 Get the urine sample from your patient (there is no greater delay in patient flow than waiting on urine) Tip #28 Round on your patients and repeat your initial scripting. * “It’s Zack the medical student again”* “Anything I can do to make you more comfortable?”* “Do you have any quest...

Tip #21 Review and note if the patient has any IMPORTANT old records. * Any ED visit within the last month for a similar complaint (aka “Bouncebacks” and frequent fliers)* Any echocardiogram or catheterization reports for a patient with cardiac symptoms* H&P and discharge summary for recent hospitalizations* Any large imaging studies (CT, MRI, etc) that have been obtained in last few months Tip #2...