Author: Zack (Page 2 of 7)

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.

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)


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)


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)


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)



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


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


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


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)

Appendicitis and Diverticulitis



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.

  • 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: Pain when flexing right hip to 90 degrees and rotating
  • Rovsing Sign: Pain felt in the right lower quadrant when pushing on the left lower quadrant

Fact 1: The urinalysis can be abnormal in appendicitis

Fact 2: The white blood cell count can be normal in appendicitis

As far as imaging when appendicitis is suspected…

  • Most people get a CT scan
  • Most pregnant women get MRI
  • Most pediatric patients get an ultrasound
  • Analgesia (example- 4mg IV morphine)
  • Antiemetics (example- 4mg IV ondansetron… aka Zofran)
  • Antibiotics (example- 4.5mg IV piperacillin/tazobactam.. aka Zosyn aka “pip-tazo”)



Similar to appendicitis. Vague nonspecific cramping and nausea gradually progressing to localized pain. This pain most commonly is located in the LEFT LOWER QUADRANT. Stool related complaints such as constipation and bleeding also common


Tenderness in the left lower quadrant


Easy… Get a CT scan


If the patient has severe symptoms, big risk factors such as immunosuppression, or complications of diverticulitis (abscess, perforations, etc). Treat the same as appendicitis… Admit, antibiotics, surgery consult

If the patient has mild symptoms, they commonly are sent home on oral antibiotics and close follow up.

Additional Reading
  • American college of radiology imaging options for appendicitis (ACR)
  • American college of radiology imaging options for diverticulitis (ACR)

Abdominal Pain Presentations (Exam, Plan, and Disposition)

EM Clerkship’s 10 Step Patient Presentation
  1. Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)
  2. At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)
  3. Red Flags/Pertinent Positives and Negatives
  4. Vital Signs
  5. Focused Physical Exam of the Complaint
  6. Suspected Diagnosis
  7. Can’t Miss Diagnosis
  8. Testing Plan
  9. Treatment Plan
  10. (If Asked) Anticipated Disposition
Vital Signs

“Vitals in triage showed a MILD TACHYCARDIA which she still does have in room. AFEBRILE here. Otherwise stable”

Address the vital signs

It is important you mention any abnormal vital signs from triage and that you rechecked them on your examination. You do not need to repeat normal vitals and it is usually acceptable to say something like “vital signs otherwise within normal limits”

PEARL: Frequently, triage OVERESTIMATES the patient’s heart rate and UNDERESTIMATES the respiratory rate. You get serious bonus points if you recheck vitals yourself and find a true discrepancy.

Focused Physical Exam of the Chief Complaint

“Abdominal exam shows nonspecific tenderness throughout, no focal guarding or rigidity. No masses. No CVA tenderness”

A Focused Exam

A common error by medical students is that they present a brief generalized exam of each body system rather than a detailed examination of the body system most pertinent to the case.

For example, a great medical student will perform the following…

  • If the patient complains of back pain: palpate the spine, perform reflexes, ambulate the patient, do a straight leg raise.
  • If the patient complains of headache: test cranial nerves, visual fields, finger to nose, gait stability, motor, sensation, speech
  • If the patient complains of chest pain: auscultate the heart, examine the legs for DVT, look for JVD, obtain pulses in all 4 extremities.
Suspected Diagnosis

“I don’t have any particular diagnosis that I think is most likely yet”

Identify your most suspected diagnosis (or lack thereof)
Can’t Miss Diagnoses

“We do need to rule out the life threats of ECTOPIC PREGNANCY, DKA, and APPENDICITIS

List several pertinent life threats

List 2-3 life threats you specifically considered and which seem MOST pertinent to the patient’s specific complaint and examination. If your attending requests more, then give more as needed.

Testing Plan



Common tests for abdominal pain potentially include (but are not required)…

  • CBC
  • Electrolytes (CHEM, BMP)
  • Liver Function Tests
  • Lipase
  • Urinalysis
  • Urine Pregnancy Tests
  • Troponin
  • EKG
  • CT scan with (or without) contrast
  • Ultrasound (especially common with right upper quadrant pain, pelvic pain, and with pediatrics)
Treatment Plan

“For my treatment plan I would like to get her 4mg Zofran, 4mg of morphine along with some FLUIDS

a Treatment Plan

With abdominal pain, memorize a few basic antiemetics, pain medications, and types of fluids (with doses) so that you can give a treatment plan during your shift.

(If Asked) Anticipated Disposition

“I think that if everything returns normal she should be safe for OUTPATIENT followup WITHIN THE NEXT 24 HOURS as long as she is looking OK”


If a patient’s tests come back normal and the patient feels better with treatment they will usually go home with close follow up (sometimes as soon as 12 hours if the physician is truly concerned, in the ED if necessary)

Additional Reading

Abdominal Pain Presentations (History)

EM Clerkship’s 10 Step Patient Presentation
  1. Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)
  2. At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)
  3. Red Flags/Pertinent Positives and Negatives
  4. Vital Signs
  5. Focused Physical Exam of the Complaint
  6. Suspected Diagnosis
  7. Can’t Miss Diagnosis
  8. Testing Plan
  9. Treatment Plan
  10. (If Asked) Anticipated Disposition
Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)

“I have a 48 year old, FEMALE with a past medical history of INSULIN DEPENDENT DIABETES, AND NO HISTORY OF ABDOMINAL SURGERY, who presents with ABDOMINAL PAIN

a Typical demographics statement

The reason age is so important (especially with abdominal pain) is because it adds additional (frequently forgotten) items to your basic differential. For example…

  • Pediatric Patients
    • Intussusception
    • Necrotizing Enterocolitis
    • Henoch Schonlein Purpura
    • Testicular and Ovarian Torsion
  • Geriatric Patients
    • Abdominal Aortic Aneurysm
    • Mesenteric Ischemia
    • Volvulus
    • Myocardial Infarction

Interesting Fact: In some studies, geriatric abdominal pain has a mortality of almost 10%!!!


The reason gender is so important (especially with abdominal pain) is because ECTOPIC PREGNANCY is the most important life threatening diagnosis in women of child bearing age.

Pertinent Past Medical and Surgical History

This is the only place in your presentation when the patient’s medical and surgical history is included. Keep it focused on the most important items.

  • Always include previous abdominal surgeries (or say “no history of abdominal surgery”)
  • Always include an overview of previous GI workups
  • Diabetes, immunosuppression, active cancer, and blood thinners are almost always pertinent medical conditions regardless of chief complaint
  • Obvious GI diagnoses should be included such as inflammatory bowel disease, peptic ulcers, cirrhosis, etc
At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)

“She describes it as a SEVERE, GENERALIZED, abdominal pain that STARTED LAST NIGHT and has been GRADUALLY WORSENING since then”

An example of giving 4 Descriptors

Most attendings think about (and document) the history of present illness as a list of descriptors. This is for billing reasons. A “level 5” chart requires 4 “HPI Elements” to be documented.

Red Flags/Pertinent Positives and Negatives


An example of Giving red flags and pertinent positives/negatives

Abdominal pain is not typically a complaint known for having a big list of “red flags” that need to be asked. In my opinion, examples of true red flags with abdominal pain would potentially be the following…

  • History of Atrial Fibrillation
  • History of Bariatric Surgery

However, it is generally expected that you give a thorough list of pertinent positives as well.

  • Fever, Chills, Malaise
  • Chest Pain, Shortness of Breath
  • Nausea, Vomiting, Diarrhea
  • Vaginal Bleeding/Discharge
  • Dysuria, Urinary Frequency/Urgency, Hematuria
  • Melena
Additional Reading
  • Geriatric Abdominal Pain Mortality and Clinical Overview (PubMed)
  • Basic Approach to Pediatric Abdominal Symptoms “Tummy Ache” (EM Clerkship)

How to Crush Your SLOE (Tips 26-30)

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

Perform one of the 4 most important reexamination protocols.

  • The ambulation trial
    • Best for patients with low oxygen on arrival or geriatric patients with weakness/dizziness/etc
  • The repeat physical exam
    • Best for patients with abdominal pain or respiratory complaints
  • The repeat vital signs
    • Best for patients with multiple abnormal vitals documented in triage, hypertension, fever, etc
  • The PO Challenge
    • Best for patients with nausea and vomiting or pediatric patients
Tip #30

Update your attending the MOMENT everything is back (and choose one of 3 dispositions)

  • Admit them
    • Best when you have confirmed a specific, bad diagnosis
  • Discharge them
    • If everything is normal, including your reexamination
    • Recommend follow up in 1-2 days
  • Observe them
    • Best for patients with concerning symptoms, risk factors, or red flags but reassuring testing or no clear diagnosis

How to Crush Your SLOE (Tips 21-25)

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 in a clear, concise, confident manner (please refer to presentation episode for typical presentation format)
Tip #23

Do not forget to give at least a basic treatment plan. Some basic options include…

  • Pain Medicine
  • Nausea Medicine
  • Fluids
Tip #24

Introduce your attending to the patient (demonstrates massive ownership)

Tip #25

Get something set up for your attending

  • Laceration kits
  • I&D kits
  • Consent forms
  • Ultrasound machine
  • Language line

Additional Reading

How to Crush Your SLOE (Tips 16-20)

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 complaints (neck pain, back pain)
    • Straight leg raise
    • Crossed straight leg raise
    • Achilles and patellar reflexes
    • Midline tenderness
Tip #18

Independently OBTAIN stool sample (if clearly appropriate) or articulate in your presentation that you are WILLING to get it

  • Elderly syncope
  • Abdominal pain with dark stool/melena
  • Severe anemia or large drops in hemoglobin/hematocrit

Note: You should NOT be doing full pelvic exams, rectal exams, GU exams INSTEAD of your attending (stool samples probably fine in my opinion), and you should NOT be doing these exams without a CHAPERONE.

Tip #19

Get the patient into a gown (at a minimum you should expose the area of concern)

Tip #20

Bring the ultrasound, gel, and towels to bedside. Appropriate chief complaints for this would include…

  • Patients over 50 with back/flank pain (AAA exam)
  • Patients with severe hypotension/shock (RUSH exam)

How to Crush Your SLOE (Tips 11-15)

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 Pain
    • Saddle Anesthesia
    • Bowel/Bladder Incontinence
    • Fever
    • Trauma
  • Chest Pain
    • Exertional
    • Family history of MI at same age
    • PE risk factors
    • Sudden and Maximal/Tearing
Tip #14

Get their doctor’s names

  • Primary care provider
  • Pertinent specialists
Tip #15

Don’t get bogged down giving too much medical history during your presentation. Simply write down the important facts for reference and present a few notable items in your opening sentence.

How to Crush Your SLOE (Tips 6-10)

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.

  • Spend no more than 10 minutes with the patient
  • Immediately grab your attending if the patient is ill appearing

Tip #10

Use a translator.

  • Learn how to use a medical translator in your department (phone vs consult vs video consult)
  • INDEPENDENTLY use a translator to obtain your history when appropriate

How to Crush Your SLOE (Tips 1-5)

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 confident, be decisive in your presentations, and make decisions. The best way to achieve this is to remember that you have (hopefully) been working hard and studying consistently.
Tip #3

Stay focused.

  • Your humor, hobbies, activities, dress, and “cool” personality, don’t impress anybody in the emergency department.
  • The best students tend to be friendly, focused, hardworking, and generally quiet (yay introverts!)
  • Emergency medicine tends to be a very pragmatic, no b.s, specialty. Let your performance speak for itself.
Tip #4

Do the majority of your learning BEFORE your rotation starts.

Your audition rotation should not be when you are downloading podcasts, studying pretest, or going through practice questions. Your learning should be completed well in advance so you can focus your energy on clinical performance).

Tip #5

HELP around the department.

  • Help patient change into gown
  • Get urine samples
  • Keep patients updated
  • Go back and ask missing information

Airway Part 4- What to Do If Intubation Fails

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 suboptimal (c-collar, poor mallampati). Some physicians use this as their primary technique.
  • Use it like a camera that you advance into position so you can see the cords. Maneuver the endotracheal tube by watching indirectly on the screen.
Flexible Endoscopy
  • It is a flexible stylet that you can control and has a camera at the tip.
  • Advances through the cords like a bougie and the (preloaded) endotracheal tube advances over it.
  • Can intubate through both the nose or mouth with this
LMA (laryngeal mask airway)
  • Placed blindly and sits above the cords, forming a seal.
  • Not a “definitive” airway, but can oxygenate and ventilate the patient when in a difficult situation.
  • Immediately perform this step in “can’t intubate can’t oxygenate” situations
  • The 3-step EMCrit method is best in my opinion (see link below)
    • “Scalpel, Finger, Bougie”
Additional Reading
  • Overview of the bougie with videos (LITFL)
  • The 3-step cricothyrotomy (EMCrit)

Airway Part 3- Rapid Sequence Intubation

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 to perform RSI
  • Paralytic options are succinylcholine or rocuronium
    • Succinylcholine is best if you need something short acting
      • For example, when frequent neurologic checks are required
    • Rocuronium is best because it’s easy to remember (1mg/kg)
      • “Rocuronium Rocks”
  • Sedative options include ketamine, propofol, and midazolam.
    • My favorite is ETOMIDATE.
      • It is hemodynamically neutral.
      • Dosing is 0.3mg/kg
Step 3: Prepare Your Equipment
  • Suction
  • Bag Valve Mask
  • Backup airway (ex. LMA)
  • Cardiac monitor
  • Capnography for tube placement
Step 4: DO IT
  • Push the sedative
  • Push the paralytic
  • Put the blade in your LEFT hand
  • Open mouth with right hand
  • Slowly advance (holding top of blade against tongue) until you see cords
    • The cords will be hiding under the white, cartilaginous, tongue-like epiglottis

NOTE: It’s OK if you don’t get it. It happens and it won’t make you look bad if your form was otherwise great.

Step 5: Advance the Tube and then CLOSING STATEMENT
  • Generally, you want depth to equal 3x the size of the tube
  • Closing statement
    • “Please attach capnography to confirm tube placement”
    • “We will need to get an X-ray, foley, OG tube and start the patient on propofol (or versed)”


Airway Part 2- Bag Valve Mask Adjuncts

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 modified BVM to place inside the mouth
  • It fits OVER the larynx (cords, epiglottis, etc)
Retroglottic Airways
  • “King”
  • “Combitube”
Additional Reading

Common Fungal Infections

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
    • Southeast United States
Additional Reading
  • Fungal infection archive and data sheets (CDC)

Psychiatric Complaints

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
      • Electrolytes
      • CBC
      • Serum Alcohol
      • Urine Drug Screen (UDS)
      • Pregnancy (if appropriate)
      • Tylenol/Salicylate Levels (especially if suicidal)
  • Psychiatric patients frequently have other non-psychiatric emergencies
    • Overdoses (salicylate, acetaminophen, etc)
    • Trauma (alcoholics with subdural hematoma from falls)
    • Encephalopathy (hypoglycemia, encephalitis)
Psychiatric Risk Assessment
  • Will this patient truly put themself or others at risk if sent home due to mental health?
  • Do you need to involuntarily hold patient?
  • Are they having passive thoughts of being dead or true INTENT and PLAN to harm themself?
  • Did they name a specific person/group of people that they intend to harm?
Additional Reading

NBME Shelf Review (Part 11) – OBGYN

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 established pregnancy)
      • Think placental abruption (recent trauma or cocaine)
    • Don’t forget to order a type and screen
      • Rh- mothers will need RhoGam
    • If patient is unstable and you can’t wait for blood type…
      • Transfuse type O negative blood
  • Postpartum vaginal bleeding
    • Most common cause is retained products of conception
      • Order an ultrasound
    • Consider endometritis if patient also has fever
      • Treat with clindamycin and gentamycin
Vaginal Discharge Pearls
  • Cervical motion tenderness?
    • Pelvic Inflammatory Disease (PID)
  • Thin, grey, and smells like fish?
    • Bacterial vaginosis (BV)
      • Treat with metronidazole
      • Warn patient not to mix metronidazole with alcohol
  • Thick like cottage cheese?
    • Vulvovaginal candidiasis
      • Diagnosis with KOH prep
        • Look for yeast and pseudohyphae
      • Treat with fluconazole
  • Thin Yellow/Green and “frothy”?
    • Trichomoniasis
      • Diagnose with wet prep
      • Look for mobile organisms
      • Treat with metronidazole
      • Partners should be checked and treated too
Ovarian Torsion

Severe and sudden pain

  • Can be intermittent
  • Diagnose with Pelvic ultrasound with Doppler
  • PITFALL: Frequently has normal arterial flow (dual blood supply to ovary)
Additional Reading

NBME Shelf Review (Part 10) – Miscellaneous

  • 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
  • Vasospasm
  • Vasculitis
  • Sickle Cell Disease
  • Treatment
    • Vancomycin, Ceftriaxone
    • Add ampicillin (covers listeria) in very young/old
    • Rifampin prophylaxis for close contacts (if patient has petechial rash)
      • Neisseria Meningitidis
HSV Encephalitis
  • Classic symptoms
    • Fevers
    • Headache
    • Altered Mental Status
    • Seizures
  • Treat with acyclovir
Altered Mental Status
  • The two most common causes on your test
    • Hypoglycemia
    • Infections (Especially in elderly)
      • Aka Delirium
Fat embolism
  • Trauma PLUS petechial rash
  • Common with long bone fracture
Schaphoid Fracture
  • Exam shows tenderness over anatomic “snuffbox”
  • Notorious for being missed on X-ray
    • High risk of osteonecrosis
  • If suspicious, place patient in thumb spica splint regardless of X-ray findings
    • Outpatient followup 1-2 weeks for repeat xray
  • Patient complains of chest pain that is…
    • Sharp
    • Positional
    • Worse when laying flat
  • Friction rub on exam
  • EKG Findings
    • Diffuse ST segment elevation
    • Diffuse PR depression
  • Treat with NSAIDS
Kawasaki’s Disease
  • Mnemonic: CRASH and Burn
    • Conjunctivitis
    • Rash
    • Adenopathy
    • Strawberry Tongue
    • Hands/Feet Swelling
    • Burn = Fever for 5 days
  • Treat with aspirin


  • Parkland formula
    • Weight (kg) x BSA (%) x 4 = Volume of fluid needed in first 24 hours
    • Give half over first 8 hours
  • Rule of 9s
    • Estimates % Body surface area burned

Vascular Injury

  • Hard Signs
    • If present patient needs OR
    • Mnemonic: ABCDE
      • Active pulsatile hemorrhage
      • Bruit
      • Cerebral ischemia
      • Diminished Distal pulses
      • Expanding Hematoma
Infectious Disease Pearls
  • Gram positive cocci in CLUSTERS
    • Staphylococcus Aureus
  • Gram positive cocci in CHAINS
    • Streptococcus Pneumoniae
Additional Reading

NBME Shelf Review (Part 9) – Cardiopulmonary

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
Inferior STEMI
  • EKG shows ST elevation in 2, 3, aVF
  • Can involve AV node (bradycardia)
    • Avoid beta blockers
    • Treat with atropine
  • Can involve RV (preload dependent)
    • Avoid nitroglycerine
    • Treat with fluids
Common to Nitroglycerine
  • Hypotension
  • Current sildenafil usage
Aortic Dissection
  • Type A (ascending) Dissection
    • Surgical emergency
  • Type B (descending) Dissection
    • Medical management
  • Testing
    • CTA of the chest
    • Chest X-Ray SOMETIMES shows a widened mediastinum
  • Treatment
    • Esmolol (decrease heart rate)
    • Labetelol (decrease blood pressure)
  • PEARL: Aortic dissection can cause STEMI
Heart Failure
  • Treatment
    • Diuresis
    • Nitroglycerin
    • BiPAP
  • If patient needs fluids
    • Decrease size of fluid bolus
  • Treatments
    • Albuterol/Ipratropium
    • Antibiotics
    • Steroids
    • BiPAP
  • If alcoholic/homeless/dementia/parkinson’s
    • Treat for aspiration (anaerobes)
  • If recent hospitalization/ventilator
    • Treat for pseudomonas and MRSA
  • If pneumonia PLUS atypical symptoms
    • Treat for legionella
  • If recent influenza
    • Treat for MRSA
Additional Reading

NBME Shelf Review (Part 8) – Abdominal Pain

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 lower quadrant pain/tenderness
  • Testing/Treatment
    • CT abdomen with IV contrast
    • Liquid diet
    • Antibiotics
  • Complications
    • Abscess
    • Stricture
    • Fistula
    • Perforation
    • Obstructions

Abdominal Aortic Aneurysm

  • If suspected, perform bedside ultrasound of the abdomen
    • Aortic diameter >3 cm
Spontaneous Bacterial Peritonitis
  • Diagnose by performing a paracentesis
    • Look for >250 white blood cells
  • Treat with ceftriaxone

Kidney Stones

  • CT without contrast
  • If the stone is <5mm
    • Treat with analgesics and tamsulosin
  • If the stone is >5mm
    • Consult urology
Common Indications for Emergency Dialysis
  • Mnemonic: AEIOU
    • Acidosis (pH <7.1)
    • Electrolytes (K > 6.5)
    • Intoxication
      • Lithium
      • Ethylene Glycol
      • Methanol
      • Aspirin
    • Overload of volume resistant to diuresis
    • Uremia that is symptomatic
      • Altered mental status
      • Pericarditis
Ectopic Pregnancy
  • Testing
    • Type and screen for Rh Status
    • Pelvic ultrasound
      • IUP = Gestational sac PLUS a Yolk sac
      • Beware “heterotopic” pregnancy in fertility treatment patients (IVF)
    • Treatment
      • If no IUP visualized, ectopic pregnancy is a possibility, and management depends on hCG
        • If <1500
          • Consider sending stable patients home and repeat hCG in 48 hours
        • If >1500
          • Ectopic until proven otherwise, consult OBGYN
      • Rh- needs RhoGAM
        • Prevents complications in future pregnancies
Additional Reading

NBME Shelf Review (Part 7) – Abdominal Pain

  • 3 classifications for hernia
    • Reducible
      • Able to be reduced (placed back into the abdomen) at bedside
    • Incarcerated
      • Cannot be reduced but not severely tender or erythematous
      • Can occasionally cause bowel obstructions
    • Strangulated
      • Cannot be reduced but LOSING BLOOD SUPPLY
      • Extremely tender and abnormal exam
      • Needs emergent surgical consult
Esophageal Varices
  • Classic presentation
    • Hematemesis/Melena
    • Chronic liver disease (hepatitis, alcoholics)
  • Treatment
    • Fluid bolus if hypotensive
    • Octreotide
    • Ceftriaxone
    • Transfuse blood as needed
      • If hemoglobin <7 transfuse
      • If patient actively bleeding and level <8 transfuse
  • Consult GI for endoscopy
Hepatic Encephalopathy
  • Common findings
    • Altered mental status
    • Asterixis
    • Elevated ammonia level
  • Treat with lactulose or rifamixin
Peptic Ulcer Disease
  • History
    • Hematemesis or Melena
    • Epigastric abdominal pain
    • Chronic NSAIDS or steroids
  • Treatment
    • PPI (such as pantoprazole)
      • Works better than an H2 blocker
  • RUQ ultrasound
    • Thickened gallbladder wall
    • Distended gallbladder
    • Pericholecystic fluid
    • Obvious impacted stone
  • HIDA scan
    • Inject radioactive material
    • Absorbed by hepatocytes
    • Secreted into biliary tree into small intestine
      • If gallbladder not visualized
        • Cystic duct obstruction
      • If common bile duct cannot be visualized
        • Choledocolithiasis
Ascending Cholangitis
  • Charcots Triad
    • Fever
    • RUQ Pain
    • Jaundice
  • Patient requires ERCP (gastroenterology consult)
  • Give antibiotics
Acute Pancreatitis
  • Diagnosis
    • Classic description
      • Epigastric pain radiating to back
      • Severe vomiting
    • Lipase
      • >3x upper limit of normal is diagnostic
    • CT scan to look for complications of pancreatitis
Additional Reading
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