Episodes

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 Abdominal Pain* Fevers* Vaginal Symptoms (especially discharge)* Red Flags* High risk sex* Dela...

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!!!)* Nitrites* Bacteria Asymptomatic Bacteriuria Generally should NOT be treated with antibiotics. I...

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 fertility treatments (increased risk of heterotopic pregnancy) Exam * Abdominal tenderness and perito...

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 test, but a common test question will show you an upright chest X-ray and you will see a rim of...

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 (sepsis, hemorrhage) History * Atrial fibrillation* Pain with PO intake (intestinal angina)* SE...

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 inflammation worsens as the patient develops persistent pain, fevers, and eventually perforation of the gallb...

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: Pain with hyperextension of the right hip (while patient is laying on left side)* Obturator Sign: ...

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* (If Asked) Anticipated Disposition Vital Signs “Vitals in triage showed a MILD TACHYCARDIA which sh...

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* (If Asked) Anticipated Disposition Demographics (Age, Gender, Pertinent Medical/Surgical History, Ch...

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 questions?”* “I’m doing my best to keep things moving fast for you, here’s an update” Tip #29 Per...

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 #22 Give a “Snowy Blizzard” presentation * Step by step by step MARCH through your presentation i...

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, seizures, visual complaints)* Finger-Nose* Heel-Shin* Gait (if possible)* Visual FIELDS* Spinal compla...

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 examples)… * Headache* Sudden and Severe* Fever* Neck Stiffness* Neurologic Complaints* Back P...

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 light* Adjust the bed* Turn down the lights* Get them something to drink Tip #9 Move fast...

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 medicine, the smartest med students actually realize that.* Confidence- You have to be able to act co...

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 a screen at bedside* Ideal for situations when both view and direct access to the cords is subo...

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 cuffed tube for a big adult Step 2: Choose your Meds * You need both a sedative and a paralytic ...

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 (OP)* Measure from earlobe to corner of mouth Laryngeal Mask Airway (LMA) * Essentially a modifi...

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* Coccidiomycosis* Southwestern United States* Histoplasmosis* North Central United States* Blastomycosis* Sou...

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 performed, blood pressure to be treated, etc* My “medical clearance” order set includes* Elect...

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 vaginal bleeding* If sick…* Think ectopic pregnancy (early pregnancy)* Think uterine rupture (late e...

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 vasospasm Causes of Stroke in Young People * Cervical artery dissection* Va...

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* If severe contrast allergy or other contraindication* Ventilation/Perfusion (V/Q) Scan Inf...

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 * NOTE: DiverticulOSIS is what causes GI bleeding* History/Exam* Fever* Left...