Category: Mock Oral Boards (Page 1 of 2)

Round 24 (Altered Mental Status)

CAUTION: THESE NOTES CONTAIN SPOILERS!!

Case Introduction

You are working a shift at EM Clerkship General when you receive a radio call from EMS who are bringing in a young female who was found unresponsive.

Initial Vitals

  • Temp 98.0F
  • HR 97
  • RR 16
  • BP 120/80
  • O2 98%

Critical Actions

  • Obtain collateral history from EMS/friends
  • Administer Naloxone as needed for respiratory depression
  • Obtain 0-hour and 4-hour acetaminophen levels
  • Administer N-acetyl-cystine
  • Obtain psychiatry consult for suicidal ideation

Further Reading

Acetaminophen Toxicity (EMCrit)

Deep Dive – Round 21

Torsades de Pointes (TdP)

A type of polymorphic ventricular tachycardia that is inherently unstable and often quickly degrades into ventricular fibrillation. It usually occurs in the setting of a prolonged QT interval, which can either be genetic or acquired.

Treatment

  1. Defibrillation – per ACLS, ventricular tachycardia with a pulse should receive synchronized cardioversion. But in real life, the defibrillator often isn’t able to “sync” with TdP, forcing you to perform unsynchronized cardioversion (aka defibrillation).
  2. IV Magnesium – treats and prevents TdP, even when magnesium levels are normal
  3. Overdrive Pacing – by preventing bradycardia, we help prevent TdP (bradycardia prolongs the QT interval).
    • Electrical Overdrive Pacing – transcutaneous or transvenous pacemaker
    • Chemical Overdrive Pacing – beta agonist therapy (isoproterenol)
  4. Lidocaine – anti-arrhythmic therapy that does not prolong QTc.
  5. Fix underlying cause – congenital long QT syndrome, hypokalemia, hypocalcemia, medication induced (psych meds, anti-emetics, methadone, fluoroquinolones, many more)

Defibrillation and IV Magnesium are used for patients who are ACTIVELY in TdP. Once you shock/mag them into a stable rhythm, you can use Overdrive Pacing / Lidocaine / Treat Underlying Cause to PREVENT them from going back into TdP.

Round 20 (Dehydration)

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 Aspirin
  • Administer IVIG

Final Diagnosis

Kawasaki Disease

Tips and Tricks

  • Remember the CRASH & BURN mnemonic
  • Always have a high index of suspicion for this diagnosis
  • Remember the diagnosis is CLINICAL!

Further Reading

EMDocs – Kawasaki Disease

Deep Dive – Round 19

“The Brady Bunch” – Beta-Blockers, Calcium Channel Blockers, Digoxin, Clonidine

Treatment of Beta Blocker OD

  1. 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

Round 19 (Bradycardia)

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 Insulin therapy

Final Diagnosis

Beta Blocker Overdose

Tips and Tricks

  • Keep in mind the broad differential for severe bradycardia – ischemia, ingestion, electrolyte abnormalities, intrinsic arrhythmia/heart block, hypothyroidism, hypothermia, hypoglycemia, hypoxia, increased intracranial pressure, neurogenic shock.

Further Reading

High Dose Insulin Therapy (EMCRIT)

Low and Slow Poisoning (EMCASES)

Deep Dive – Round 18

Four definitions you must know:

  1. 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
  2. SEPSIS – Must have SIRS + have a suspected infectious source (eg pulmonary, urinary, intra-abdominal, etc)
  3. 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 function)
    • Lactate > 2.0
    • Platelets < 100k
    • INR > 1.5
    • Bilirubin > 2
  4. SEPTIC SHOCK – Must have severe sepsis PLUS one of the following
    • Hypotension DESPITE adequate fluid resuscitation (usually 30cc/kg bolus)
    • Lactate > 4.0 DESPITE adequate fluid resuscitation (usually 30cc/kg bolus)

GENERAL GUIDELINES (exact management depends on clinical scenario):

  • If patient meets SIRS criteria you work the patient up for sepsis / severe sepsis:
    • Lactate, Blood Cultures, Urinalysis/Culture, Chest XRay
    • CBC, BMP, Coags, LFTs
  • If patient meets SEPSIS criteria, you add in broad spectrum antibiotics +/- intravenous fluids
  • If patient meets SEVERE SEPSIS criteria, you give a 30cc/kg fluid bolus,
  • If patient meets SEPTIC SHOCK criteria and is HYPOTENSIVE, you start vasopressors (norepinephrine usually)

MDCalc – Sepsis

Sepsis-2 and Sepsis-3 Guidelines Summarized

Round 18 (Fatigue)

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
  • Admit patient

Final Diagnosis

Malaria

Tips and Tricks

  • Always obtain detailed history in patient presenting with fever without obvious source (travel history for infectious agents, IV Drug history for endocarditis, etc)
  • Utilize CDC.org to determine which infections are endemic to each country that your patient traveled in

Further Reading

Malaria (EMDocs)

Round 17 (Postpartum Fever)

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 PTU)
  • Administer Steroids, +/- Iodine (must be given after inhibitor)

Final Diagnosis

Post Partum Thyroid Storm

Tips and Tricks

  • Be aware of common post-partum pathologies (PP depression, hyper/hypothyroidism, cardiomyopathy, infections, eclampsia, etc)
  • Have a DDX for Fever other than infectious (especially if refractory to acetaminophen)
  • Administer treatment in correct order (BB first, inhibitor second, Iodine at least 1 hour after inhibitor, steroids)

Further Reading

Thyroid Storm (EMCrit)

Round 16 (Allergic Reaction)

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 Tricks

  • Interview pediatric patients without family members in the patient’s room
  • Escort family out of patient room during invasive procedures
  • Ask about / rule out potential triggers (caffeine use, drugs, ischemia, electrolyte abnormalities, etc)

Further Reading

The REVERT Trial (RebelEM)

Round 15 (Syncope)

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 collateral history from EMS and family
  • Make sure your diagnosis fits the patient’s symptoms! (EG don’t diagnose pneumonia based on a consolidation on CXR if the patient doesn’t clinically have pneumonia)

Further Reading

Submassive and Massive PE (EMCrit)

Round 14 (Shortness of Breath)

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 reassessments on patients with the examiner (vitals, patient appearance, pain, etc)

Additional Reading

Round 13 (Dizziness)

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 Ulcer

Tips and Tricks

If you get stuck in a case and don’t know what to do next. Identify all abnormal findings that you have been provided

Additional Reading

  • Why You Should Never Ask “What Do You Mean By Dizzy?” (PubMed)

Round 12 (Difficulty Breathing)

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, lack of visual cues during oral cases can mislead you!

Additional Reading

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

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