EM Clerkship

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 * Basic approach to Back Pain (EM Clerkship)* Epidural Abscess Overview (AAFP Website)

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

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

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

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 * 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)

Courtesy of LITFL Medical Blog https://creativecommons.org/licenses/by-nc-sa/4.0/

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

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 * 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 based on my actual cases. I will never be discussing my actual 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