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August Q-tips

  • Patients with lower quadrant pain should typically have gonadal examinations. There are relative exceptions–such as virginal women without history of pelvic examinations or IBD patients with symptoms very typical of previous IBD flairs–but gonadal examinations should still be considered in these patients. Ideally, these examinations should take place before CT imaging.


  • Patients with previous tracheostomies are likely to be difficult intubations. Tracheostomy history may be an indication of distorted anatomy or a previously failed endotracheal intubation.  Awake intubation, preparation of a fiberoptic intubation, or preparation for repeat surgical airway should be considered ahead of time.


  • When bagging a cardiac arrest patient, use “squeeze release release release release release” to shoot for ~8 breaths per minute.


  • Use of librium in alcoholics continues to be controversial and management of these patients is plagued by significant practice variability. One approach stipulates that all alcoholics who are not discharged/allowed to walk out as soon as they are sober enough to do so (e.g. are to be seen by psychiatry) should get 50-100 mg librium and reassessed specifically for withdrawal symptoms every 2 hours; if hyper-dynamic but well should receive 100-200 mg librium. The purpose is to prevent a medicine admission for withdrawal, which serves nobody’s interests. This practice is not to be confused with discharging patients with a librium prescription, which is less likely to be effective (though there is still a role for outpatient librium in selected motivated patients).


  • Although pelvic exams are uncomfortable and usually non-contributory, it is difficult to defend not performing a pelvic exam in the relevant context; if it turns out the pelvic exam would have been contributory but it was omitted, that is an important error. The threshold to perform a pelvic exam should therefore be low.


  • Set patient expectations low with regard to wait times for tests, consultation, admission. Consider not having ENT scope patients with allergic reaction; there is much practice variation on this point.


  • Don’t forget to introduce yourself to patients.


  • Urine beta is a fallible test, repeat or send serum quantitative beta when negative result is discordant with clinical circumstance.

Spilled Teacup

A 28 yoM comes in with hand pain after falling on an outstretched hand.

His xray is as follows.

Lunate Pic


What is the diagnosis?

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Physical Exam in Septic Arthritis


40yoM no PMHX with a swollen, painful right hip joint.  Worsening x5 days. No history of prior episodes, no other joints involved, no fever, no trauma, no GU symptoms, no rash, no vision changes, no IVDU.

On exam, pt is afebrile, nontoxic appearing.

The hip is warm. You are able to range his hip, with moderate pain.  There is tenderness when compressing the joint space.  Strength exam limited by pain.

Sensation and pulses are intact distally.

Plain films are unremarkable. CT of hip unremarkable.

You consult your friendly orthopedist for further evaluation and to assist with a tap of the hip to rule out septic arthritis. The consultant comes down to examine the patient, ranges the hip (with pain), and gladly tells you, “nope, it’s not septic if it ranges”.  End of story?

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Meconium Staining

26 yoF 36 weeks by dates presents to the ED in labor, and has a precipitous birth in the resus area.  The infant is covered with a greenish liquid the consistency of split-pea soup.

How do you address this?

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Ddavp for Hemorrhage in Esrd Patients


45F h/o ESRD on dialysis presents ped struck.

Pt is obtunded, intubated for airway protection.

CT head shows subdural hematoma with midline shift.

Neurosurgery is activated.

No antiplatelets or anticoagulants.

Is this person coagulopathic simply by having ESRD?

If so, should we address it with any particular medication?

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