Author: Zack (Page 1 of 9)

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Introduction:

You are working at Clerkship General when the next chart is handed to you. It’s a 35-year-old female with a chief complaint of dizziness and fatigue. She is here accompanied by her husband.

Initial Vitals:

HR: 118

BP: 150/91

Temp: 100.4F

RR: 20

O2: 99% Room Air

Critical Actions:

1. Check pregnancy test
2. Check hemolysis labs
3. Diagnose TTP
4. Consult hematology
5. Initiate treatment for TTP

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You are working at Clerkship General when you hear a woman screaming from triage… It’s baby time!

Initial Vitals:

HR: 120

RR: Shallow

O2: 58%

Critical Actions:

1. Place neonate in warmer
2. Administer positive pressure ventilation
3. Obtain pre-ductal pulse ox
4. Check blood glucose
5. Place umbilical vein catheter
6. Administer dextrose

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You are working at Clerkship General when the nurse comes up to you and says, “Hey doc, EMS dropped off this guy named Randy from the memory care unit at the nursing home down the street. He’s in the hall bed outside of room 7. EMS says he’s here for confusion, we will get him in a room once we can get one clean.

Initial Vitals:

HR: 118

BP: 109/55

Temp: 102.5 F

RR: 22

O2: 99% Room Air

Critical Actions:

1. Check a blood glucose
2. Obtain a full set of vitals
3. Diagnose necrotizing soft tissue infection
4. Consult surgery before a CT scan
5. Correct antibiotic coverage

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You are working at Clerkship General when you hear an EMS call on the radio. “Clerkship General, we are bringing you a 3 year old female with complaints of altered mental status. We are pulling in now.”

Initial Vitals:

HR: 129

BP: 98/66

Temp: 99.7F

RR: 35

O2: 99% Room Air

Critical Actions:

1. Check blood glucose
2. Check ingestion labs
3. Start bicarbonate drip
4. Call nephrology
5. Check venous blood gas

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Guillain-Barre Syndrome (GBS) – Autoimmune polyneuropathy that results in widespread demylination of peripheral nerves

Typically occur 1 week after a triggering infection

Paresthesias/Neuropathic Pain -> Ascending symmetric paralysis -> Respiratory Failure

Major Diagnostic Criteria

1. Progressive limb weakness in multiple limbs that is relatively symmetric
2. Diminished/Absent deep tendon reflexes in affected limbs
3. No alternative diagnosis
4. CSF studies have false-negatives – May see albuminocytologic dissociation (Elevated protein with normal cell counts)

Treatment – IVIG and monitor respiratory status

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You are working at Clerkship General when the next chart is put into your rack. It’s a 76 year-old male who has fallen.

Initial Vitals:

HR: 101

BP: 138/85

Temp: 98.0F

RR: 20

O2: 99% (Room Air)

Critical Actions:

1. Diagnose Retrobulbar Hematoma
2. Diagnose Subdural Hematoma
3. Reverse Anticoagulation
4. Perform a Lateral Canthotomy Procedure
5. Administer Tetanus Shot
6. Elevate the Head of Bed

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You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.”

Initial Vitals:

HR: 51

BP: 201/98

Temp: 98.0F

RR: 18

O2: 99% (Room Air)

Critical Actions:

1. Check a Blood Glucose
2. Activate a Stroke Alert
3. Assess Contraindications to tPA
4. Consent for tPA
5. Transfer via Air for Thrombectomy

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You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting

Initial Vitals:

HR: 119

BP: 104/63

Temp: 98.0F

RR: 20

O2: 99% (Room Air)

Critical Actions:

1. Finger Stick Blood Glucose
2. Treat Patient’s Pain
3. Diagnose Testicular Torsion
4. Immediate Urology Consult
5. Perform Manual Detorsion

References:

Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

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You are working at Clerkship General when you hear an EMS call on the radio. Clerkship General, we are bringing you Arthur. He is intoxicated… Again

Initial Vitals:

HR: 116

BP: 150/70

Temp: 98.8

RR: 26

O2: 85% (Room Air)

Critical Actions:

1. Recognize Hypoxemia
2. Diagnose Toxic Alcohol Ingestion
3. Consult Nephrology Emergent Dialysis
4. Administer Fomepizole
5. Workup Anion Gap Metabolic Acidosis

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You are working at Clerkship General when the next chart is put in your rack. It’s a 41-year-old female with a chief complaint of headache.

Initial Vitals:

HR: 56

BP: 172/93

Temp: 98.8F

RR: 18

O2: 97%

Critical Actions:

1. Check a Blood Glucose
2. Diagnose Preecclampsia/Ecclampsia
3. Administer Magnesium
4. Treat the Hypertension
5. Discuss with OBGYN and Admit

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Diagnosing PE:

Step 1: Consciously consider the diagnosis

Step 2: Risk Stratify into low, intermediate, and high risk

Step 3: Choose appropriate testing based on pre-test probability

Classification of PE

1. High Risk/Massive PE: Hemodynamic Instability
2. Intermediate Risk/Submassive PE: Right Heart Strain without instability ; or PESI Class 3+
3. Low Risk/Non-Massive PE: Everything else (no instability, no heart strain, PESI Class 1-2)

Treatment of PE

1. High Risk/Massive PE: Thrombolytics and often thrombectomy
2. Intermediate Risk/Submassive PE: Heparin and sometimes intervention
3. Low Risk/Non-Massive PE: Either discharge with DOAC or admit with heparin

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You are working at Clerkship General when you overhear the base command radio. “Clerkship General. We have a 57 year-old female coming in for leg pain. She just had surgery at your hospital. Her blood pressure is 85/50. We’ll be there in 5 minutes.”

Initial Vitals:

HR: 122

BP: 75/40

Temp: 100.1

RR: 24

O2: 74%

Critical Actions:

1. Obtain full set of vital signs
2. Treat the patient’s pain
3. Diagnose PE without imaging
4. Stabilize patient prior to imaging
5. Transfer the patient for thrombectomy

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You are working at Clerkship General when you hear and EMS call on the radio. “Clerkship General, we are activating a trauma alert. We are bringing you a 33 year old male from a high-speed single vehicle collision”

Initial Vitals:

HR: 65

BP: 88/50

Temp: 97.0F

RR: 20

O2: 96% Room Air

Critical Actions:

1. Apply Cervical Collar
2. Treat the Patient’s Pain
3. Give Antibiotics for Open Fracture
4. Identify and Prioritize Etiologies of Shock in Trauma
5. Start Vasopressors for Neurogenic Shock

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• Differential
  • Traumatic causes: non-accidental trauma, fracture, dislocation, sprain, strain, tendonitis, osgood schlatter
  • Non-traumatic causes: septic arthritis, transient synovitis, osteomyelitis, SCFE, LCP disease, rheumatologic disease, bony tumors
• Work-up
  • XRay
  • Labs to evaluate for septic arthritis – CBC BMP ESR CRP
• Kocher Criteria
  • Non-weight bearing
  • Fever >38.5C
  • ESR >40
  • WBC >12
• Kocher Criteria Statistics
  • 0 points: 0.2% (or 2% in prospective studies)
  • 1 point: 3% (or 9% in prospective studies)
  • 2 points: 40%
  • 3 points:93%
  • 4 points: 99%
• Septic Arthritis DX
  • >50,000 WBC
    • Age 0-3mo : group B strep
    • Age 3mo – 12 years: Staph Aureus
    • Age 12-18 years: Gonorrhea
    • Sickle Cell Disease: Salmonella

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You are working a beautiful sunny day in Pennsylvania when the next chart gets put in your rack. It is a 2 year-old male with a leg injury.

Initial Vitals:

HR: 112

BP: 97/67

Temp: 99.2F

RR: 20

O2: 97% Room Air

Critical Actions:

1. Consider Non-Accidental Trauma
2. Evaluate for Septic Arthritis
3. Treat the Childs Pain
4. Diagnose Lyme Disease
5. Prescribe Antibiotics (Avoid Doxycycline)

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• Focused Physical Exam
  • Tachypnea and Hypoxemia
  • Able to speak in complete sentences
  • Accessory muscle use/retractions
  • Moving air or quiet on auscultation
• Basic Treatment Algorithm
  • Albuterol Inhaler
  • Albuterol/Ipratropium Nebulized (Duoneb)
  • Steroids
  • IV Magnesium
  • Non Invasive Ventilation (CPAP or BiPAP)
    • Decreases Work of Breathing
  • Epinepherine
• Less Common Treatments
  • Benzodiazepines
  • Ketamine
  • Heliox
• Intubation (Last resort)
  • Use a large ETT (8.0)
  • Increase the Expiratory Time
• “Permissive Hypercapnea”
  • Appropriate ventilator management of asthma frequently results in mild hypercapnia and respiratory acidosis. IT’S OK
• Air Trapping
  • Results in decreased preload, obstructive shock and pneumothorax
  • Suspect with high airway pressures and when waveform doesn’t return to zero (see media)
  • Treat by briefly unhooking ventilator and gently pressing on the patient’s chest to get out the trapped air
• Ventilator Settings
  • Decrease the respiratory rate (ex 10)
  • Increase the tidal volume (although some hypercapnia is permitted)
  • Increase I:E ratio (1:4 or greater)

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You are working at Clerkship General when you hear an EMS call: “Clerkship General, we are bringing you a young female in respiratory distress. ETA 2 minutes”

Initial Vitals:

Critical Actions:

1. Give Albuterol, Steroids, and Magnesium
2. Give either Epinephrine or Terbutaline
3. Post Intubation Checklist: Sedation, Tubes, and Xray
4. Choosing Appropriate Vent Settings
5. Allow permissive hypercapnia

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