Author: Zack (Page 1 of 8)

Round 11 (Headache)

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 Subarachnoid Hemorrhage on Anticoagulation

Tips and Tricks

Always ask the patient if they have allergies prior to administering ANYTHING.

Additional Reading

Round 10 (Allergic Reaction)

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 to obtain a quick history and exam even if you know the diagnosis in the first few seconds of the case

Additional Reading
  • Basic approach to anaphylaxis (EM Clerkship)
  • Tranexamic acid as first-line emergency treatment for episodes of bradykinin-mediated angioedema induced by ACE inhibitors. (PubMed)
  • Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. (PubMed)

Round 9 (Seizure)

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 to obtain the information from external sources

Additional Reading
Corrections

Ketamine not Keppra as potential induction agent for status epilepticus (32:40)

Round 8 (Fall)

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 diagnosis. Do not prematurely close an the initial, obvious, diagnosis.

A man can have as many diseases as he damn well pleases!

Hickam’s dictum
Additional Reading

Round 7 (Headache)

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 List)
  • Performing a Lateral Canthotomy
Final Diagnosis

Acute Angle Closure Glaucoma

Tips and Tricks

Do not be surprised or scared when an examiner has a monotone voice and flat affect

Additional Reading

Round 6 (Back Pain)

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 and Tricks

Don’t let consultants or other members of your team talk you out of appropriate management of a patient

Additional Reading

Round 5 (Geriatric Fall)

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

Round 4 (Flank Pain)

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
Corrections

It is rare for testicular torsion to occur at this age

Round 3 (Chest Pain)

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

Round 2 (Seizure)

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

Round 1 (Altered Mental Status)

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

MUST LISTEN (re ABEM)

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

ACS, Acidosis, AAA and Other Miscellaneous Causes of Abdominal Pain

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)
  • Especially in older people with abdominal/flank/back pain or syncope
Testing
  • CT Scan Abdomen with contrast (Good)
  • CTA Abdomen (Better)
  • Bedside Ultrasound (Best)
Additional Reading

Testicular Torsion and Prostatitis

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

PID and Ovarian Torsion

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
    • Delayed presentations
    • IUD (Don’t need to remove if patient has PID, but needs to be noted)
Exam

It is controversial whether all women with pelvic complaints need a full speculum exam (my opinion is that they don’t and that it almost never changes management)

  • Bimanual Exam
    • Cervical motion tenderness
    • Adnexal/Uterine tenderness
Testing
  • Gonorrhea
  • Chlamydia
  • CBC
  • Ultrasound to evaluate for tubo-ovarian ABSCESS
Treatment

Patients who are septic, unable to keep antibiotics down, getting worse on oral antibiotics, pregnant, immunosuppressed, or with TOA generally get admitted for IV antibiotics.

  • Treat chlamydia
    • Doxycycline
  • Treat gonorrhea
    • Cefoxitin/cefotetan (2nd generation cephalosporins provides better anaerobic coverage than a third generation cephalosporins)
    • Ceftriaxone
  • Treat anaerobes
    • 2nd generation cephalosporin
    • Metronidazole

Ovarian Torsion

Ovary twists on its pedicle and becomes ischemic

NOTE: The ovary actually has a dual arterial blood supply. When the pedicle twists, it’s not the artery is being pinched off that causes ischemia, rather its the venous outflow becoming blocked and resulting in swelling of the ovary and the poor perfusion that results)

History
  • Sudden onset pain
  • Severe pain with vomiting
  • Usually unilateral pain (although 25% have bilateral pain)
Exam
  • Peritonitis in the lower abdomen
  • Large mass or adnexal tenderness on pelvic exam
Testing
  • Pelvic ultrasound (with doppler)
    • Swollen/edematous ovary
    • Large cyst/mass causing the torsion
    • IMPORTANT- You can frequently see normal arterial flow on the doppler (remember DUAL BLOOD SUPPLY)
  • CT scan with NORMAL ovaries 100% negative predictive value for torsion in some studies
Treatment

OBGYN consult for surgery

Additional Reading

Urinary Tract Infections

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. If you were to randomly sample the population you would find bacteria present in approximately…

  • 5% of young people
  • 20% of old people
  • 50% of patients in long term care
When to Diagnose UTI
  • Dysuria AND urinary frequency WITHOUT vaginal symptoms (+LR 20)
  • Patient self reports that they think their UTI is back (+LR 4)
  • Urinalysis shows BOTH signs of inflammation and bacterial presence
  • Combine pretest suspicion with urinalysis findings using clinical judgement
Indwelling Foley Catheters

All patients with an indwelling foley will have a grossly abnormal urinalysis and appearance of urine at baseline. The urinalysis is useless and diagnosis can only be made by clinical judgement

Geriatric Patients

Geriatric patients have minimal symptoms regardless of diagnosis. They can have UTI’s with minimal symptoms. However they can also have appendicitis or kidney stones with minimal symptoms (and asymptomatic bacteriuria at baseline). BE CAREFUL.

Additional Reading
  • The best UTI resource I have seen (First10EM)

Ectopic Pregnancy

All women of childbearing age who present with abdominal pain need a pregnancy test

a 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 peritoneal signs
  • Adnexal tenderness
  • Paradoxical bradycardia (vagal response caused by peritoneal blood)
Testing
  • Type and screen
    • Rh- mother requires RhoGam if exposed to fetal blood
    • Transfusion if develops hemorrhagic shock
  • Pelvic ultrasound
    • If no intrauterine pregnancy (IUP) is seen in a pregnant patient, regardless of B-hCG level, the patient might have an ectopic pregnancy
  • B-hCG quantitative
    • If no IUP is seen and >1500, strongly suspect ectopic pregnancy
    • If no IUP is seen and <1500, ectopic pregnancy is still possibile
Treatment
  • If patient has no IUP and hCG >1500, consult OBGYN
  • If patient has no IUP and hCG < 1500, disposition based on clinical appearance
Additional Reading

Bowel Perforation and Volvulus

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 free air under the diaphragm (should NOT be there in a normal upright X-ray)
Treatment
  • Broad spectrum antibiotics
  • Stat surgical consult

Volvulus

It is common to first learn this as a pediatric condition (Malrotation with Volvulus) however it is common in adults as well. The two most common subtypes are…

  • Cecal Volvulus
  • Sigmoid Volvulus

The history exam and testing plan is the same as with bowel obstruction. The primary difference is that volvulus without ischemia/gangrene is frequently treated with colonoscopy which is a GI CONSULTATION rather than surgical consultation.

Additional Reading

Mesenteric Ischemia and Small Bowel Obstruction

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)
  • SEVERE pain
Exam

The most classic finding is “Pain out of proportion to exam”

Testing
  • Lactic acid reportedly 100% sensitive according to some texts
  • CT scan WITH contrast (or even better, a CTA) for additional confirmation if your pretest suspicion is high
Treatment

Analgesics and antibiotics. Surgery consult if intestines necrotic on imaging. Potentially vascular surgery consult as well if intestines salvageable.

Small Bowel Obstruction

  • QUESTION: What is the most common cause of mechanical small bowel obstruction?
    • ANSWER: Adhesions

Not all small bowel obstructions are mechanical, don’t forget that ileus can cause a similar pattern as well (electrolyte abnormalities, recent surgery, opiates, multi-system trauma)

History

Severe crampy pain with vomiting, bloating, and decreased bowel movements/flatus. History of multiple abdominal surgeries (high risk for adhesions)

Exam

Abdominal distention and tenderness. If peritoneal signs develop, this is a very bad condition and patient may be developing ischemic/necrotic bowel.

Testing
  • Most common test is CT scan with IV contrast
  • Abdominal x-ray sometimes gets ordered but has fallen out of favor for multiple reasons (decreased sensitivity, difficulty localizing obstruction, unable to rule out alternative diagnoses
  • Using oral contrast with the CT scan is also falling out of favor primarily due to the time constraints demanded of modern medicine.
Treatment

Fluids, Analgesics, Antiemetics +/- Antibiotics if ischemia is developing. Obtain a surgery consult.

  • QUESTION: Should you order an NG tube?
    • ANSWER: NG tubes have been reported to be one of the most painful procedures one can endure. On the other hand, you can find online videos of people putting these in without any discomfort. It will end up being a risk/benefit discussion with your attending. The benefit is that decompressing the stomach will frequently improve the patient’s symptoms to a significant extent.
Additional Reading
  • American College of Radiology mesenteric ischemia imaging (ACR)
  • American College of Radiology small bowel obstruction imaging (ACR)

Biliary Diseases and Pancreatitis

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 gallbladder wall.
  • Choledocolithiasis- A gallstone gets past the neck of the gallbladder and the cystic duct. However, it gets stuck IN THE COMMON BILE DUCT (CBD). The liver can’t drain bile and liver function tests increase.
  • Cholangitis- The patient has choledocolithiasis and INFECTION DEVELOPS
  • Gallstone Pancreatitis- A gallstone gets past the neck of the gallbladder AND the cystic duct AND the common bile duct but gets stuck in a PANCREATIC DUCT (ugh, so close). Lipase increases.
History

Asymptomatic gallstones

Biliary colic- Crampy RUQ abdominal pain that frequently radiates to right shoulder and resolves after a few hours

Cholecystitis- RUQ abdominal pain persists for more than a few hours and fevers develop.

Cholangitis- RUQ abdominal pain, fevers, and jaundice (Charcots Triad) eventually leading to shock and altered mental status (Reynolds Pentad)

Exam

Murphy’s Sign- Patient has pain and stops inhalation while you palpate under the right costal margin (Note: the same thing should NOT happen when palpating under the left costal margin)

Testing

The most appropriate test for biliary disease is RIGHT UPPER QUADRANT ULTRASOUND. However, CT scan is quite good as well (negative predictive value ~90% and identifies complications and alternative diagnoses well)

Treatment

Asymptomatic gallstones and resolved biliary colic get outpatient surgery referral

Acute cholecystitis needs a surgery consult

Choledocolithiasis, Cholangitis, and Gallstone Pancreatitis needs a GI consult (for MRCP/ERCP)

Pancreatitis

History

Constant epigastric abdominal pain radiating to the back with lots of vomiting and retching

Exam

Mild pancreatitis may have nothing more than some epigastric tenderness. Severe pancreatitis will look a lot like sepsis (hyperthermia, hypotension, altered mental status)

Testing

Patients will have an elevated lipase and abnormal findings on a CT scan with IV contrast

Treatment

Aggressive treatment of pain and nausea and NPO with slow advancing of the diet as tolerated.

Additional Reading
  • American College of Radiology biliary disease imaging (ACR)
  • American College of Radiology pancreatitis imaging (ACR)
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