EM Clerkship

Special thanks to Fraser Kegal from McGill University for creating this excellent content.

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 Appropriate Treatment for Fournier Gangrene* Immediate Surgical Consultation

Final Diagnosis

Septic Shock due to Fournier Gangrene

Tips and Tricks

Always ask for the patient’s temperature if it is not given with initial vital signs

Additional Reading

* Fournier Gangrene Overview (PubMed)* Basic Approach to Sepsis (EM Clerkship)* Basic Approach to Trauma (EM Clerkship)

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 Consultation to Obtain an Ultrasound

Final Diagnosis

Testicular Torsion with Referred Pain

Tips and Tricks

Don’t forget to verbalize genitourinary exam when appropriate

Additional Reading

* Testicular torsion overview (EM Clerkship)

Corrections

It is rare for testicular torsion to occur at this age

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 Actions

* Giving Nitroglycerine to Patient with Inferior MI and on Sildenafil* Giving Aspirin to Patient with Allergy to Aspirin

Final Diagnosis

Cardiac Arrest due to Inferior STEMI

Tips and Tricks

Ask about allergies prior to administering medications

Additional Reading

* Approach to STEMI (EM Clerkship)* American Heart Association STEMI Guidelines (AHA)

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 early in the case

Additional Reading

* Approach to Eclampsia (EM Clerkship)* American College of OB-GYN Eclampsia Guidelines (ACOG)

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 receive a blood glucose level early in the case

Additional Reading

* Sulfonylurea Toxicity Overview (LITFL)* Approach to Altered Mental Status (EM Clerkship)

ABEM-style cases presented on EM Clerkship are not my actual ABEM exam cases, and they are not derived from my actual exam cases. I will never be discussing my specific exam details with anybody, including on this podcast. The cases were created independently, by me, for the purpose of medical education and improving patient care. Topics are chosen from the publicly available ABEM model of clinical practice and are built from scratch using a my own custom template. If you would like a copy of this template, please email me and I can send you a copy.

-Zack

F→ Episode Summary

There are HUNDREDS of other non-GI/GU causes of abdominal pain…

Acute coronary syndrome (ACS)

* Test with EKG and troponin

* Treat with aspirin and heparin

Acidosis

* Diabetic Ketoacidosis (DKA)* Respiratory Acidosis (COPD)* Salicylate Toxicity (Remember MUDPILES)

Abdominal Aortic Aneurysm (AAA)

* Older people with abdominal/flank/back pain or syncope* Testing* CT Scan Abdomen with contrast (Good)* CTA Abdomen (Better)* Bedside Ultrasound (Best)

Additional Reading

* Approach to STEMI (EM Clerkship)* Approach to Diabetic Ketoacidosis (EM Clerkship)* Approach to Salicylate Overdose (EM Clerkship)* Approach to Abdominal Aortic Aneurysm (EM Clerkship)

Testicular Torsion

History

* Pain in the testicles * Referred pain in the flank or lower abdomen* Usually sudden and severe* Usually WITHOUT urinary symptoms

Exam

* Asymmetric testicular lie* High riding testicle* Tenderness and swelling of the testicle itself* Cremasteric reflex

Testing

* Testicular Ultrasound

Treatment

* Immediate call to urology when suspected* Manual detorsion (“Open the Book”)

Prostatitis

History

* Pelvic pain* Pain with sex* Urinary symptoms* Fevers and chills

Exam

* Tenderness of the prostate/epididymis/testicle

Testing

* Urinalysis* Generally a clinical diagnosis

Treatment

* Commonly sexually transmitted in young men* Commonly E coli in older men* Bactrim or Fluoroquinolones

Additional Reading

* Testicular Torsion (EM Clerkship)* EMRA Antibiotic Guide (Amazon)