Episodes

Kawasaki Disease A small vessel vasculitis that affects children, usually <5 years old. Symptoms – remember the CRASH AND BURN mnemonic! Conjunctivitis Rash – nonspecific morbilliform or maculopapular rash, usually on torso Adenopathy – usually unilateral cervical lymphadenopathy Strawberry Tongue – erythema, swelling, or cracking of lips/mucous membranes Hands – swelling, erythema, or desquamation of the hands/feet BURN – 5 days of fever Diagnosis: * COMPLETE KAWASAKI – 5 days of feve...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when the next chart is handed to you – a four year old male named Tommy with chief complaint of dehydration. Initial Vitals * Temp 100.4F* HR 132* RR 22* BP 98/64* O2 98% Critical Actions * Identify key historical findings (fever >= 5 days)* Identify abnormal physical exam findings (Conjunctivitis, Rash, Adenopathy, Strawberry Tongue)* Diagnose Kawasaki Disease Clinically* Administer...

“The Brady Bunch” – Beta-Blockers, Calcium Channel Blockers, Digoxin, Clonidine Treatment of Beta Blocker OD * Activated Charcoal – Only if ingestion time was <1 hour ago, and only if patient is protecting their airway (or intubated). 2. Glucagon – the best answer for the exam, unlikely to work in real life 3. Epinephrine Drip 4. Calcium 5. High Dose Insulin Therapy

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when you are called to the resuscitation bay to see an elderly patient with unstable vitals brought in by EMS. Initial Vitals * Temp 98.0F* HR 43* RR 18* BP 60/40* O2 98% Critical Actions * Diagnose the etiology for the bradycardia (BB overdose)* Administer Atropine* Administer Glucagon* Administer Epinephrine drip* Attempt transcutaneous/transvenous pacing* Administer high-dose Insu...

Four definitions you must know: * SIRS – Must have at least 2 of 4 SIRS criteria (listed below):* Fever (>38C) or Hypothermia (<36C)* WBC >12k or <4k ; OR Bandemia >10%* Tachycardia > 90* Tachypnea > 20* SEPSIS – Must have SIRS + have a suspected infectious source (eg pulmonary, urinary, intra-abdominal, etc)* SEVERE SEPSIS – Must have Sepsis + ONE of the following criteria indicative of end organ dysfunction:* Hypotension (MAP<65 or SBP<90)* Creatinine > 2.0 (with normal baseline renal functio...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when a 20yo female accompanied by her mother checks into the ER with chief complaint of fatigue. Initial Vitals * Temp 101.2F* HR 122* RR 22* BP 110/90* O2 98% Critical Actions * Obtain travel history in patient presenting with fever of unknown source* Perform sepsis workup and treatment in patient with at least 2 SIRS criteria* Order thick/thin peripheral blood smear* Consult ID* Ad...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at EM Clerkshift General when a sepsis alert is paged overhead for a young female who appears diaphoretic and confused. Initial Vitals * Temp 102.7F* HR 145* RR 32* BP 141/85* O2 93% Critical Actions * Workup and treat for sepsis upfront (Cultures, Lactate, IVF, Abx)* Order TSH with Free T4* Administer non-selective Beta Blocker (Propanolol)* Administer Inhibitor of Thyroid Hormone Synthesis (Methimazole or ...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are sitting at your computer on an otherwise beautiful Friday afternoon when a mother brings her 16 year old son to the ED with chief complaint of allergic reaction. Initial Vitals * Temp 98.7* HR 155* RR 28* BP 125/85* O2 99% Critical Actions * Interpret ECG * Interview patient alone (and identify trigger)* Perform vagal maneuver* Administer Adenosine* Discharge patient Final Diagnosis Supraventricular Tachycardia Tips and ...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working a shift at Clerkship General when a 51 year old female is brought in after a syncopal episode. Initial Vitals * Temp 100.2* HR 132* RR 28* BP 105/69* O2 85% Critical Actions * Give supplemental Oxygen* Diagnose Pulmonary Embolism* Administer Heparin* Assess contraindications for tPA* Administer tPA Final Diagnosis Massive Pulmonary Embolism Tips and Tricks * Reassess vital signs after interventions* Obtain colla...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are sitting at your computer on an otherwise quiet night when a young male is brought into your ED in obvious respiratory distress. Initial Vitals * Temp 98.6* HR 99* RR 34* BP 105/69* O2 95% Critical Actions * Give Albuterol + Ipratropium + Steroids* Obtain Chest Xray* Give Magnesium* Place patient on BiPAP* Give IV Beta Agonist (Epinephrine) Final Diagnosis Status Asthmaticus Tips and Tricks Frequently perform verbal reas...

CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction You are working at your local hospital when the next chart gets put in your rack. You groan. The chief complaint is dizziness.. Initial Vitals * Temp 98.6* HR 109* RR 20* BP 105/69* O2 100% Critical Actions * Diagnose Upper GI Bleed* Initiate IV Proton Pump Inhibitor* Obtain Type and Screen* Admit Patient to the Hospital* Identify Medications That Increase Risk of Ulcer (If Prompted) Final Diagnosis Upper GI Bleed due to Peptic U...

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CAUTION: THESE NOTES CONTAIN SPOILERS!!! Case Introduction A young gentlemen runs out to triage yelling “I can’t breath!” and collapses to the floor in front of the nurse… Initial Vitals * Temp 98.8* HR 145* RR 45* BP 60/30* O2 85% Critical Actions * Give Supplemental Oxygen* Identify Pneumothorax Prior to Imaging* Correctly Perform Needle Thoracostomy* Correctly Perform Tube Thoracostomy Final Diagnosis Pneumothorax Secondary to Penetrating Chest Trauma Tips and Tricks Be careful, lac...

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 Hemorrhage* Reverse Warfarin Coagulopathy* Administer Antihypertensives Final Diagnosis Acute Suba...

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 Final Diagnosis Refractory Anaphylaxis Due to Beta Blockers Tips and Tricks You still need...

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 Isoniazid Toxicity Tips and Tricks When the patient is unable to provide history, attempt ...

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, and severe hyperkalemia Tips and Tricks Patient’s will frequently have more than one final d...

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 After Initiating Treatment Dangerous Actions * Giving NSAIDS (The Patient Had This on Allergy L...

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 Antibiotics* Treat Pain when Pathology Identified Final Diagnosis Spinal Epidural Abscess Tips ...

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* Obtain Full Vital Signs Including Temperature* Perform Sepsis “Core Measures”* Initiate Appropriat...

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’s Pain* Resist Delays on Consultant Pushback Dangerous Actions * Delaying Urology Consultat...

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* Bring Crash Cart to Bedside* Administration of Heparin* Counsel the Family Dangerous Action...

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 Eclampsia Tips and Tricks All women of childbearing age should receive a pregnancy test ea...

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 Intentional Sulfonylurea Overdose Tips and Tricks All unresponsive patients should receiv...