A young woman with chest pain

Let’s welcome Dr. Shafer back to the blog.  Between being a chief resident and being accepted in to a critical care fellowship, she has another interesting case presentation for you.  Some really interesting learning points on this one.  Stay tuned for the answer! 

-Bob

Dr. Shafer: 

    A 28 year old female presents to the ED with a chief complaint of chest pain that started acutely at 3am this morning and awoke her from sleep. She reports that pain is in the center of her chest and is constant, nothing makes it better or worse, and it is not positional.  She woke up vomiting this morning and additionally feels short of breath and is diaphoretic. She states that she feels weak all over and has bilateral arm numbness. She has not had any recent URI symptoms. She does not abuse alcohol but she does use marijuana occasionally. She smokes ½ pack of cigarettes per day. There is no family history of cardiac disease or of sudden deaths. She has no prior past medical history and takes no medications. 

    Vital signs are as follows: HR 108, BP 165/98, RR 18, Oral Temp 98.6F, oxygen saturation is 100%. On exam she pale, diaphoretic, is leaning forward clutching her chest and appears uncomfortable. Lungs are clear to auscultation bilaterally, heart is normal rate and rhythm without murmurs/rubs/gallops. She has normal strength and sensation to light touch in bilateral upper and lower extremities, cranial nerves are intact, and has 2+ radial pulses bilaterally. 

    Her EKG is shown below. Cardiology was immediately consulted due to the patient’s appearance; they evaluated the patient at the bedside and diagnosed the patient with pericarditis. CT thorax was obtained which revealed no dissection or PE.  A bedside echocardiogram reveals a normal EF with concerns for apical wall motion abnormalities.  Pertinent labs revealed a white count of 18.8, troponin 3.15, lactic acid 3.6, and a normal BNP.



What is on your differential at this point?

What further testing could be done to evaluate the patient?  

Have a diagnosis in mind?

Episode 24.5: “EBM is crap…”

While making Episode 24, we had a little aside talking about the pitfalls of evidence based medicine.  It did not really fit in with the full episode, so here it is in all its half episode glory.  Dr. Kaminstein makes his feelings known, and we talk about those feelings.  Some great points are raised and debated regarding the art and practice of our specialty, and how EBM fits in.  What do you think?  Let us know in the comments below.  

Episode 24: What do I read, and how do I do it?

In Episode 24, EM Res vets Drs. Kaminstein and Kochert return with Dr. Becker’s debut to talk about how residents should approach reading medical research articles.  Do you need to read everything?  What should you read?  How do you do it?  All this and more in the first of a series on reading original research for residents.  

The first thing you need to know is that if you are an intern, and maybe even a second year, it is ok if you are not keeping up to date on the latest and greatest in original EM research.  The most important thing you can do during this time is to cover the basics.  Develop your basic knowledge and skills in EM.  

Once you do delve into research, pick one or two journals to start out with.  Annals of EM and Journal of EM come to mind (full disclosure: I am on the Annals Social Media team, and on the AAEM YPS board).  Once you have a journal or two, skim the titles and see what interests you.  If you see an interesting title, read the abstract and see if the full article is worth your time.  

Remember, once you start reading, the discussion is the writer’s chance to slant their results as they see fit.  There is a reason this section is last - it should be the least important part of your analysis.  

Think about articles in PICO format.  

P: What type of patient are they looking at/what is the patient population?

I: What is the intervention?

C: What is the control?

O: What are the outcomes?

This should give you the foundation to start.  This is the first in a series of podcasts where we will cover more advanced topics so that you too can be able to critically read and appraise the medical literature by the time you are done with your EM residency.  

Here are some great resources cited during our discussion:

The Skeptics Guide to EM

Emergency Medicine Abstracts

EMCrit

EM Literature of Note

EM Nerd

EM Journal Watch

EM:RAP paper chase

SMART:EM

A few announcements:

  1. I have been away for the last month working on Emergency Board Review!  Go check it out.  Check out our latest review lecture on nervous system disorders.  Find the lectures on our podcast on iTunes, or any podcast software.  Check out the revamped website, rate the board review resources, and get involved.  Are you an upper level resident and want to help out with the Emergency Board Review project?  Get in touch with me at bobstuntzmd@gmail.com, or use the website contact form if you are interested in any of the open topics
  2. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  3. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  
  4. Allowed to use my podcasts for asynchronous learning?  Check out the test below!

Check out the podcast below, or go listen here


If you have gotten approval from your program director to use the EM Res Podcast for individualized interactive instruction (asynchronous learning), the check out the test below or go take it Posted in , , , |

Episode 23: What’s the “Best” Residency?

In Episode 23, with the upcoming US EM residency interview season about to descend upon us all, I talk about a recent survey that claims to list the best EM residencies, why you should ignore it, what applicants should look for in a residency, and our duty as educators to find the right fit.  

f you are a medical student going into the EM Match this year, check out the following great videos to see what you should be doing, and how you can be the best applicant you can be:

The EM Rotation, ERAS, and am I competitive

Interviewing Strategies

Here is the original link I saw to the list of top EM residencies as compiled by Doximity and USNWR’s survey

ere is a link to the consensus document regarding the problems with this report. 

Announcements:

  1. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  2. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  

Listen here or check out the podcast below:

Episode 22: Do an H/P, But Don’t Forget Ultrasound

Episode 22 is a response to an article on KevinMD from April 2014, "Forget Ultrasound, Do a Proper History and Physical Instead."  In this article, written by a radiologist, Dr. Saurabh Jha (@roguerad - follow him.  I do, very interesting thoughts and perspective), the argument is made that POC US is being done indiscriminately, instead of a good H/P.  Amongst other things, the article concludes that POC US is bad for patients, costing taxpayer money and leading to over testing and over diagnosis.  POC US has been similarly accused recently in regards to leading to over testing (see this thought provoking post from EM Nerd).  Dr. Jha’s article was originally written in response to this article from NEJM, which sang praises for POC US, but did have some mischaracterizations.  

Admittedly, we may have overall overreacted a bit to this article as can be seen in the comments (the title alone is inflammatory, but frankly KevinMD often is recently).  Dr. Jha made the following clarification in the comment section:

"I’m advocating against indiscriminate use of ultrasound, as routine, as a substitute or extension of H & P (see NEJM article), not against selective use of imaging within clinical context."

We agree in some respects:

  1. We should all absolutely be doing a good H/P, and using US as a diagnostic test in the clinical context of our patients.  
  2. We should all be properly trained. 
  3. US is not a simple, learn this overnight kind of thing.  It takes dedicated training, and constant learning and practice - which we do well in the POC US community. 
  4. The US is not a stethoscope, nor is it an extension of your physical exam, and should not be used indiscriminately.

But, the physical exam is not so great:

  1. How good is a Rovsing’s sign?
  2. How about a Homan’s sign?  See here or here
  3. Murphy’s sign?

One thing we do know is that POC US does have a positive impact on patient care through faster door to diagnosis times, faster throughput, and improved patient satisfaction, based on previous POC US studies.  

Announcements:

  1. Want to write for the EM Res Blog?  Have an idea for an article, or even a series (US of the week, Image of the week…)?  Want to help with podcast episodes?  I want to expand the EM Res Blog and Podcast, but I need your help to do it.  Residents, educators, anyone anywhere - send your ideas to me at bobstuntzmd@gmail.com or @BobStuntz, and let’s see if we can make this thing even better!
  2. Please go join our Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  Great discussion this week on ketamine for post intubation sedation. 
  3. Tumblr Users: I’m aware of the video issue and will do my best to get it to cross over.  Consider following the blog here at emrespodcast.org, or subscribe to the RSS feed.  Getting a bunch of new Tumblr followers recently, so want to make sure this is working out for you.  

Now, onto the Podcast:

Listen here or listen below:

Episode 21: You’re Not Alone

In this mini-episode, I talk a bit about an incredibly interesting and important article published recently in the New York Times regarding resident suicide and depression.  The bottom line: If you feel like you need help, you’re not alone.  

Check this sobering article out here

Two quick announcements:

1.  Are you interested in helping write for or participate in the EM Res Podcast and blog?  I am looking to expand the blog and podcast, and I’d love for you to help.  Have an idea for a blog post?  A series?  Podcast ideas?  email me at bobstuntzmd@gmail.com, and let me know what you think.  Residents and educators welcome.  

2. Thanks to everyone who has joined the EM Res Google Community.  The goal is to have this be a place that EM residents and educators (you can help answer resident questions) can get together to discuss resident issues and questions, both clinical and non-clinical.  It gives you a chance to discuss in a bit more of a long form than twitter, is more fun than a listserv, and provides a central location for discussion.  Feel free to post items, comment, and share.  

Now, onto the episode: