The EM Clerkship Podcast

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 be perf...

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) […]

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 (Given orally) Prevents...

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 Chest […]

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 Acute Diverticulitis...

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 Hematemesis/Melena...

“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 Defibrillation Polymor...

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 Apraclonidine Giant Cell...

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 […]

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 […]

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 patient is u...

General Approach to a Test Question Read the last sentence of the question Read the answer choices THEN read the vignette Common Scenarios with Quick Answers Hypotensive patients Give a fluid bolus Altered mental status Check a blood glucose Hypoglycemia Orange juice if can swallow safely D50 if patient cannot swallow and mildly altered IM […]

Why is this Important? It is a poor stewardship of resources to continue a resuscitation when the prognosis is clearly dismal. Hospitals need to steward their resources to distribute equitable care between its patients When is it Appropriate to Stop CPR on a Pulseless Patient? Patient shows signs of irreversible death Rigor mortis Decapitation Rotting/decaying […]

Kidney Stones are a Diagnosis of Exclusion!!! History Risk factors Age >60 Tobacco use Classic presentations Stable with sudden flank/back/abdominal pain or syncope Unstable with pallor, hypotension, and ill appearance Exam Pulsatile abdominal mass Unstable vitals Testing Plan Labs TYPE AND SCREEN CBC Electrolytes Coagulation studies Lactic acid Imaging Bedside ultrasound (optimal) Aorta protoc...

Kidney Stones are a Diagnosis of Exclusion!!! Introduction Testicular torsion is a time sensitive diagnosis (risk of infertility, etc) Commonly mimics kidney stones History Sudden onset pain Epididymitis tends to be slower in onset Flank/lower abdomen/scrotal pain Frequently causes vomiting Uncommon in geriatric patients Exam Perform a GU exam and look for Unequal/horizontal “lie” Testicular […]

Kidney Stones are a Diagnosis of Exclusion!!! Step 1: Consider the Differential Diagnosis for Flank Pain Appendicitis Abdominal Aortic Aneurysm Ectopic Pregnancy Testicular/Ovarian Torsion Kidney Stone Step 2: Diagnose the Kidney Stone Option 1- Renal Ultrasound Findings consistent with kidney stone diagnosis Hydronephrosis Lack of ureteral jets (in bladder) Kidney stones (poor sensitivity for thi...

Step 1: Start Patient on Volume Assist-Control Ventilation The most basic mode of ventilation Provides a FIXED VOLUME at a FIXED RATE If the patient over-breaths… The ventilator will give another FULL breath Can cause breath stacking and be uncomfortable in patients who are poorly sedated This is not a problem in the ED because […]

Introduction What is rabies? A very rare and aggressive encephalitis Global impact with exception of UK/Australia Animals whose bites/scratches may require prophylaxis Bats Dogs, Cats, Ferrits Other carnivorous animals Foxes, Coyotes, Skunks, Raccoons Post exposure prophylaxis Both Rabies vaccine and immunoglobulin When Do You Give Rabies Prophylaxis? Step 1: Bitten or scratched by domesticated pe...

The only chief complaint that you are guaranteed to eventually have to manage in a colleague Respiratory Exposures Meningococcus​ (meningococcemia, meningitis, etc) Give prophylaxis (ceftriaxone) if… Intubated a pt without a mask Suctioned a pt without a mask Performed mouth to mouth resuscitation Tuberculosis​  CDC recommends testing if exposed Treat if positive CDC recommends prophylaxis in.. […...

All breast complaints are cancer until proven otherwise!!! History Increased risk of breast cancer Family history of breast cancer (especially 1st degree) Delayed childbearing (no children until after 30) Age >50 Associated with menstrual cycle Exam Asymmetric appearance of breasts Palpable mass Red Flags Non-mobile Overlying skin changes Lymphadenopathy Located in upper/outer quadrant of breas...

The 3 Worst Causes of Neonatal Conjunctivitis Gonorrhea Causes corneal ulcers and sepsis Red flags 1st week of life Copious purulent drainage Diagnose with cultures Treatment Cefotaxime (3rd generation cephalosporin) Admit Chlamydia Occurs in 1st month of life Treat with PO erythromycin HSV Can disseminate to the brain Red flags Mother tested positive (or had […]

History Sudden and maximal in onset Compared to previous headaches Family history of aneurysm Associated Symptoms Photophobia Visual Changes Neck Stiffness Exam Full neuro examination Cranial nerves Visual fields Speech Cerebellar (finger-nose) Motor Sensation Gait Testing Plan Non-contrast head CT Excellent sensitivity <6 hours from onset Lumbar puncture >100 RBCs in tube 4 Can be […]

The 4 Most Common Causes of Blood in Diaper Urinary crystals Will be guaiac negative Common in first few weeks of life Vaginal bleeding Common in newborn females as they withdraw from maternal estrogen Maternal blood Swallowed during birthing process Breastfeeding with cracked/bleeding nipples Anal fissures Common and will improve on its own Basic Approach […]

Consider In High Risk Patients Alcoholics GI disorders Eating disorders Starvation/poor diet Extremes of age Thiamine (B1) deficiency Causes damage to neurons and cardiac myocytes Manifestations Dry beriberi Neuropathy Paresthesias Wernicke’s encephalopathy Ophthalmoplegia Ataxia Altered mental status Korsakoff syndrome Ophthalmoplegia, ataxia, altered mental status PLUS Confabulation Memory loss...

Mnemonic: DARTH VADER Death Arrhythmia ACS patients need to be placed on cardiac monitor Frequently degenerate into non-perfusing rhythms Rupture of Ventricle Occur within a few days of myocardial infarction Rapid decompensation Bedside ultrasound will show pericardial effusion and tamponade Tamponade Multiple etiologies Rupture of ventricle (see above) Pericarditis Becks Triad Jugular vein disten...