EM Clerkship

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...

Tip #16 Recheck the patient’s heart rate and respiratory rate (and put in your presentation that you did so) * Heart rate frequently falsely elevated when being triaged* Respiratory rate frequently falsely normal when being triaged Tip #17 Fully examine the specific complaint. Some common misses include… * Neurologic complaints (headache, paresthesias, dizziness, asymptomatic hypertension, seizure...

Tip #11 Give 4 descriptors/adjectives for each complaint * Location* Quality* Duration* Modifying Factors* Severity* Context* Timing* Associated Symptoms Tip #12 Get the ACTUAL story. Why did the patient come NOW? * Did something change or worsen?* Did family force them to come?* Do they have a family history of something similar? Tip #13 Present the pertinent RED FLAGS for each complaint (some ex...

Tip #6 Make your patient remember your name. * Introduce yourself clearly* Show the patient your badge* Use a nickname if your name is difficult for people to remember/understand* Repeat your name again and again Tip #7 Keep the patient informed about… * Diagnosis* Anticipated ED course/timeline* Delays Tip #8 Keep your patient comfortable. * Get them blankets* Show them how to use the remote/call...

Tip #1 Introduce yourself. * Attending? “Hello, my name is Zack, I’m one of the medical students” * Resident? “Hello, my name is Zack, I’m one of the medical students”* Nurse? “Hello, my name is Zack, I’m one of the medical students”* Janitor? “Hello, my name is Zack, I’m one of the medical students” Tip #2 Be humble but confident. * Humility- Students know very little about the practice of medici...

Verbalize the out loud prior to performing rapid sequence intubation. The Bougie * Ideal for situations when you’re view is suboptimal* Advance it through the cords and into the trachea BEFORE the endotracheal tube. It will stay in place and guide the tube into position (this is called a Seldinger technique). Video Laryngoscopy (Glidescope) * Laryngoscope with a camera at the tip which displays on...

The most important thing to do when preparing for RSI is to PREOXYGENATE the patient. Step 1: Choose Your Equipment * Miller or Mac blade? * Miller blade is straight (like the ‘L’ in miller)* Frequently used in kids* Mac blade is curved (like the ‘c’ in mac)* (Generally, this is the best choice to use on your clerkship and most common in the ED)* Tube Size?* 7.5 cuffed tube for a small adult* 8.0...

How do you oxygenate a patient (while you are preparing for RSI) if suction, moving the tongue, and basic BVM ventilation are unsuccessful? Pharyngeal Airways * These tools bypass the posterior portion of the tongue to help with BVM ventilation* Nasopharyngeal Airway (NP)* Measure from earlobe to tip of nose* TEST QUESTION: Don’t use in a patient with possible skull fracture* Oropharyngeal Airway...

Most Life Threatening Fungal Infection * Mucormycosis* Black facial discharge* Cranial nerve dysfunction* Facial swelling* Eschar formation When to Suspect a Fungal Infection * Immunocompromised (HIV, Diabetes, Organ Transplants, etc)* Not getting better on typical antibiotics Other Fungal Infections * Aspergillus* Aspergilloma* Bronchopulmonary Aspergillosis* Invasive Aspergillosis* Coccidiomycos...

The Two Objectives During Every Psychiatric-Type Complaint * Medical Clearance* Psychiatric Risk Assessment Medical Clearance * Required by EMTALA to perform a “screening exam” regardless of complaint* Most psychiatric facilities have poor diagnostic/treatment capabilities for non-psychiatric conditions and will want patient to be “medically cleared”* Sometimes they will require specific tests to...

Think A-B-C-P (Airway, Breathing, Circulation, Pregnancy Test) in ALL Women of Child-Bearing Age! * It changes the differential diagnosis* It changes the medications you can give* It changes the tests you can order Vaginal Bleeding Pearls * Non-pregnant vaginal bleeding* Order a pelvic ultrasound (for structural causes)* Order a CBC and coagulation panel (for anemia and coagulopathy)* Pregnant vag...

Stroke * Most appropriate initial tests * Blood Glucose* Hypoglycemia is a common stroke mimic* CT Head without contrast* Rules out HEMORRHAGIC strokes Subarachnoid Hemorrhage * Classic description* “Worst headache of life”* “Sudden and maximal in onset”* “Thunderclap”* Testing* CT Head without contrast* (If negative CT) Lumbar puncture* Xanthochromia (yellowish fluid)* Treatment* Nimodipine (Give...

Pulmonary Embolism * Three types of pulmonary embolism* “Massive”* Hypotension or severe bradycardia* Treat with tPA or thrombectomy* “Submassive”* Normotensive but with Right Heart Strain* S1Q3T3 on EKG* Elevated BNP* Elevated troponin* Dilation of RV on ultrasound* Treat with heparin/lovenox and admit* “Low Risk”* Treat with anticoagulation* Outpatient vs inpatient treatment* Testing* CTA of the...

Acute Mesenteric Ischemia * History of atrial fibrillation* “Pain out of proportion to exam” Bowel Obstruction * History* Abdominal pain* Bloating/Distention* Vomiting* Decrease stool/flatus* Exam* Abdominal tenderness and distention* If guarding/rigidity/rebound tenderness (aka peritonitis)* Consider perforated bowel* Testing* Obtain CT abdomen with IV contrast* Treatment* Fluids* NPO* NG Tube Ac...

Hernia * 3 classifications for hernia* Reducible* Able to be reduced (placed back into the abdomen) at bedside* Incarcerated* Cannot be reduced but not severely tender or erythematous* Can occasionally cause bowel obstructions* Strangulated* Cannot be reduced but LOSING BLOOD SUPPLY* Extremely tender and abnormal exam* Needs emergent surgical consult Esophageal Varices * Classic presentation* Hema...

“Unstable” Arrhythmias * Arrhythmias that cause* Hypotension* Pulmonary Edema* Chest Pain* Altered Mental Status Supraventricular Tachycardia (SVT) * Stable* Vagal maneuver* Adenosine* Beta blocker or calcium channel blocker* Unstable* SYNCHRONIZED cardioversion Monomorphic Ventricular Tachycardia (VT) * Stable* Amiodarone* Procainamide* Lidocaine* Unstable* SYNCHRONIZED cardioversion* Pulseless*...

Corneal Abrasion * Stain the eye with fluorescein and use woods lamp* Look for fixed staining (“uptake”) on the cornea Acute Angle Closure Glaucoma * Symptoms* Eye Pain* Headache* Check for intraocular pressure greater than 20* Commonly precipitants* OTC cough/cold medicine (anticholinergic effect)* Dark environment (such as movie theater)* Treatment* Timolol* Pilocarpine* Acetazolamide* Apracloni...

General Bite Wound Management * Irrigate thoroughly* Update tetanus* LOW RISK bites get sutured* High risk bites to cosmetic areas (face) get sutured AND antibiotics* High risk bites to non-cosmetic areas are left open AND get antibiotics Rabies * Give vaccine if… * ANY suspicion for bat bite (bat in room, cave, etc)* Bite by wild animal that can’t be monitored* Bite by domestic animal that develo...

Febrile Seizures * Simple (All features must be present)* Age 6 months – 5 years* Febrile* Lasts less than 15 minutes* Only one seizure in 24 hour period* No focal neuro deficits on exam* Generalized seizure (must have LOC)* Treat with acetaminophen and reassurance* Complex* Does not meet ALL of the criteria for a simple febrile seizure* Consider full workup including lumbar puncture Pediatric Abd...

Penetrating Abdominal Trauma * Anything below the 4th intercostal space (nipple) is potentially an abdominal injury* Gunshot wounds to the abdomen* Needs immediate exploratory laparotomy* Stab wounds to the abdomen* Needs immediate exploratory laparotomy IF…* Hemodynamically unstable* Peritonitis on exam (rebound, rigidity, guarding)* Organs hanging out of abdomen Blunt Abdominal Trauma * If the p...