Episodes

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 use* Step 3: Do a FULL neurologic examination* Mental Status* Cranial nerves* Visual fields* Speech* Cerebellar (finger-nose)* Motor* Sens...

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 Rhythm is Shockable or Non-shockable * Shockable rhythms* Ventricular Fibrillation (VF)* Ventricular Tachycar...

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 to right shoulder/flank* Pain is intermittent and resolves after a few hours* Patients need pain control and...

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 brachial index)* ABI <0.9 or asymmetry between extremities is concerning for vascula...

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* Antibiotics (COPD)* Infection common cause of inflammation 5 More Treatments * Magn...

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* Steroids* History of ulcers* Varices risk factors* Heavy alcohol use* History of liver dis...

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 the disease* Common signs/symptoms* Shortness of breath* Chest pain* Syncope* Tachycardia* Hypoxemia* Hypotension* Step 2: Do not do additional t...

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 Oh-My-God-That’s-A-Lot-Of-Blood!!! * Intubate the patient* Consult cardiothoracic surgery/inte...

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 <10* Caused by salicylic acid and lactic acid* Blood gas* Mixed respiratory ALKALOSIS and metabo...

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 is KNOWN* Measure acetaminophen level 4 hours post-ingestion* Plot on nomogram and treat if above line* I...

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 thorough on your clerkship* Have a chaperone present and document this (include the c...

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 that mother doesn’t develop antibodies against future Rh positive children* Prevents hemolytic disease of the newbor...

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 stool* Water (polyethylene glycol/miralax)* Hydrates the stool* Fat (colace)*...

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 or venous)* pH <7.3 Step 2: Check Potassium Level * Patients frequently depleted of whole b...

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 vs saline Step 3: Alternative Wound Closure Techniques * Dermabond/Tissue Adhesive* Works best on easi...

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* Don’t even test for strep throat* If patient has SOME of the criteria* Consider testing for strep throat Step 2: Prescribe Antibiotics * B-lactams work best...

Step 1: Identify Classic Red Flags for Can’t Miss Diagnoses * Aortic Dissection and Abdominal Aortic Aneurysm (AAA)* Age >50* Hypertension* “Ripping” or “Tearing” pain* Absent pulses in lower extremities* Spinal Infections* Fever* Immunocompromized* HIV* Diabetes mellitus* Transplant patients* Spinal cord compression (especially cauda equina)* Urinary retention* Consider obtaining post-void residual* Saddle anesthesia* Fecal incontinence/decreased rectal tone* Fracture* Recent trauma* Advanced ...

Minor complaint. Huge SLOE points! Step 1: Identify Which Tooth is Causing Pain * Bonus points if you number teeth correctly!* Number 1-32* Tooth #1 is top right* Tooth #32 is bottom right* Refer to dental chart for reference Step 2: Correct Terminology When Making Diagnosis * Pulpitis* Pain in the tooth itself* Reversible* Triggered by hot/cold etc (then goes away)* Irreversible* Does not resolve* Gingivitis* Pain of the gingiva around the tooth* Periapical abscess* Pain with percussion of ...

Does the patient have CENTRAL vertigo (bad) or PERIPHERAL vertigo? Step 1: How Does Patient Describe the Vertigo? * Asking the patient to describe their dizziness has since been disproven… (However, the classic teaching is)* Central vertigo* Mild* Vague* Peripheral vertigo* Severe* Sudden Step 2: What Are the Associated Symptoms? * Central vertigo frequently associated with “The Dangerous D’s”* Diplopia (double vision)* Dysphagia (difficulty swallowing)* Dysmetria (uncoordinated movement)* D...

Hyperkalemia = EKG… EKG changes = Calcium… Step 1: Recheck the Potassium * Most common cause of hyperkalemia is PSEUDOhyperkalemia* Caused by too aggressive/fast of a blood draw* Causes RBCs to break open and falsely increase serum potassium Step 2: Get an EKG * Earliest EKG change* Peaked T waves* Late EKG changes* Flattened P wave* Prolonged QRS* Critical/Emergent EKG changes* Sine wave Step 3: Protect the Heart * EKG Changes = Give Calcium* Calcium gluconate (can be given IV)* Stabilize...

A-B-C-D-E-F-G Two Types of X-Rays * Anterior-Posterior (“AP”)* Classic “portable” xray* The beam shoots from in front of the patient (anterior)* TO* The plate sitting behind the patient (posterior)* Posterior-Anterior (“PA”)* Requires trip to radiology* Results in a better picture* The beam shoots from behind the patient (posterior)* TO* The plate sitting in front of the patient (anterior) Three Indicators of a High Quality Chest X-Ray * Well inflated lungs* Visualize spine through cardiac s...

Mom is Scared. You are Scared. Don’t Be Scared. General Principles * Evaluate for intimate partner violence in all poorly explained traumas during pregnancy* Get the scans you would order in a non-pregnant patient, even CTs!* Shield the uterus if necessary Basic Approach to Trauma in Pregnancy * Step 1: Place mother in left lateral decubitus position* This removes the weight of the uterus OFF the inferior vena cava (IVC)* Can significantly improve patient’s hemodynamics* Step 2: Palpate the ...

Four important injuries. Four different imaging studies to obtain. Step 1: Obtain Pelvic X-Ray * Commonly performed at bedside as part of initial trauma evaluation* A pelvic injury significantly increases risk of GU injury Step 2: Examine the Perineum * Common signs of GU injury* Blood at urethral meatus* Bruising of the perineum Step 3: Obtain Urinalysis * Gross hematuria is the red flag* Can be identified at bedside* Importance of microscopic hematuria uncertain* If you decided to send a...

Step 1: Does This Patient Need Surgery NOW? * Obvious penetrating injury to abdomen* Peritonitis* Hypotensive Step 2: FAST Scan * Performed with bedside ultrasound machine* Blood/intra-peritoneal fluid is hypoechoic (black) in appearance* Four views required* Right upper quadrant* Probe marker points towards patient’s head* “Morrisons Pouch”* Potential space between liver and right kidney* Left upper quadrant* Probe marker towards patient’s head* Most difficult view to obtain* Potential space...