The Clerkship Directors in Emergency Medicine (CDEM) Solution Study guide 2022.
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Course
Clerkship Directors in Emergency Medicine (CDEM)
Institution
Palm Beach State College
Book
First Aid for the Emergency Medicine Clerkship, Third Edition
The Clerkship Directors in Emergency Medicine (CDEM) Solution Study guide 2022.
1. primary survey
2. pregnancy test for women of childbearing age
3. order blood products in unstable patients suspected of hemorrhage
4. bedside imaging if concern for pneumoperitoneum or hemoperitoneum
5. Order a...
The Clerkship Directors in Emergency Medicine
(CDEM) Solution Study guide 2022.
1. primary survey
2. pregnancy test for women of childbearing age
3. order blood products in unstable patients suspected of hemorrhage
4. bedside imaging if concern for pneumoperitoneum or hemoperitoneum
5. Order abx if concern for sepsis peritonitis or perforation
6. analgesia
7. surgical consult for hemodynamic instability or rigid abdomen (Answer)- initial
actions for patient with abdominal pain (7)
Those using infertility drugs or assisted reproductive technologies (in normal pt positive
intrauterine pregnancy means ectopic stastistically improbable) (Answer)- population in
which an introuterine pregnancy seen on TVUS does NOT rule out ectopic pregnancy
4.5-5 weeks (double decidual sack) (Answer)- duration of pregnancy at which the
earliest sign can be seen on TVUS
culdocentesis (rarely used since advent of ultrasound) (Answer)- procedure in which
needle is advanced through posterior vaginal wall into peritoneal space, wiht greater
than 2ml of nonclotting blood suggestive of hemoperitoneum and ruptured ectopic
pregnancy
1500-2000 (point at which TVUS SHOULD show intrauterine pregnancy) (Answer)-
discrimatory zone of bHCG
Outpatient serial US exams and bHCG levels (less than doubling of bHCG levels every
2 days worrisome for ectopic)
Return precautions: return to ER immediately if worsening pain, vaginal bleeding,
dizziness, syncope, or weakness (Answer)- management of stable patients with
suspected ectopic pregnancy but the diagnosis is in doubt due to inconclusive
ultrasound findings
Diamater > 7mm and non compressible
Increased Wall thickness
Fecalithh
Increased Vascularity on doppler (Answer)- ultrasound findings of appendicitis
IV fluid resusc
Pain management with opioids and morphine
Anti-emetics
IV Abx (unasyn or metro+cipro)
Surgical COnsult (Answer)- management of appendicitis in the ED once diagnosis
confirmed
,testicles! (Answer)- think someone has a ruptured appy due to acute RLQ pain, be sure
to check the [blank]!
CBC
BMP
UA (rule out pyelo)
US vs CT ABD with contrast (Answer)- basic workup for appendicitis
CBC (anemia could indicate aortoenteric fistula)
Coags (look for potentially reversible bleeding disorders)
CMP and Lipase (look for alternative causes of undifferentiated abdominal pain)
ABD Ultrasound (Answer)- workup for suspected ruptured AAA
Ruptured Triple AAA (Answer)- [blank] should be in the differential of anyone over 50
with abd, back or flank pain
too aggressive resusc can worsen hemorrhage (dislodging clots)
not enough causes underperfusion (Answer)- reason for a target of 90-100 systolic in
ruptured triple AAA during resusc
CBC with diff
Liver Function if Fitz hugh suspected
gonorrhea and chlamydia PCR testing (cervical or urine secretions, more sensitive than
culture and faster)
Gram stain of cervical secretions
TVUS (can show TOA, or evaluate for alternatives such as ovarian torsion or cyst)
Also check HIV, hep panel, and RPR (Answer)- workup for pelvic inflammatory disease
Cefotetan 2 grams IV q12 hours with Doxycycline 100mg PO or IV q 12 hours (oral
preferred because doxy can be caustic to vessels)
(If allergic to cephalosporins can use Unasyn with doxy or Clindamycin+gentamycin)
(Answer)- inpatient treatment for PID
Ceftriaxone 250mg IM and Doxycycline 100mg BID X 14 days +/- flagyl 500mg BID X
14days (if severe or uterine instrumentation in last 3 weeks) (Answer)- outpatient
treatment for PID
Pregnant
IUD
Fitz hugh Curtis
TOA
Peritonitis
,Prepubertal children
(nulliparous patients should be strongly considered to preserve fertility) (Answer)-
indications for admission of PID patients
avoid sexual contact
refer partners for treatment
follow up in 72 hours unless symptoms worsen then return to ER (Answer)- discharge
instructions for outpatient PID patients
>6mm in adults (8mm in elderly) (Answer)- threshold for common bile duct dilation
>5mm (Answer)- threshold for GB wall thickening
lack of visualization of the GB within 4 hours (Answer)- criteria for a positive HIDA scan
study
Pancreatitis
Perforation of the GI tract
Dye reactions
Bleeding (Answer)- risks of ERCP
Female
>40
Obesity
Multiparity
Rapid weight loss
Heme disorders (Answer)- risk factors for gallstones
ABCs
Symptom control with fluids, antiemetics, and analgesics
Cipro+Flagyl
Surgical Consult (delayed cholecystectomy for both, possible immedaite
decompresesion, cholecystostomy, and ERCP for stone removal in cholangitis if that is
the cause) (Answer)- management of cholecystitis/cholangitis
outpatient surgery f/u
Return precautions: >6 hour symptoms, fever> 100.4, or jaundice (Answer)- dispo for
biliary colic
generally admit to surgery to avoid developing complications (Answer)- disposition for
choledocholithiasis
rectal exam to test for gross blood or hemoccult positive stools (suggests strangulation
or malignancy)
, genital exam (look for hernia as cause of obstruction) (Answer)- reason to include
rectal exams and genital exams in patients with suspected bowel obstruction
Upright CXR (look for free air)
Upright abdominal film (look for air fluid levels)
supine abdominal film (look for distended loops of bowel) (Answer)- initial imaging for
suspected small bowel obstruction
CT scan with PO and IV contrast (used to be small bowel follow through) (Answer)-
definitive imaging for bowel obstruction
A serrated beak
Bowel wall thickening
Pneumatosis
Portal venous gas (Answer)- CT findings of bowel strangulation
celiac (followed by SMA) (Answer)- most common artery involved in mesenteric artery
thrombosis
distal portions of SMA (Answer)- most common artery involved in mesenteric artery
embolus
embolectomy and bowel visualization for signs of necrosis (percutaneous tPA
alternative for non operative candidates) (Answer)- treatment of choice for mesenteric
artery embolus
Heparin as soon as diagnosis made + thrombectomy and bowel visualization (Answer)-
treatment of choice of mesenteric artery throbosis
thrombectomy or distal bypass + anticoagulation to prevent recurrence (Answer)-
treatment of choice for mesenteric vein thrombosis
Fluid resusc
ABX PPx
Papervine (reduces mesenteric vasoconstriction)
Definitive care based on cause of ischemia (arterial emboli vs thrombus vs venous
thrombus vs hypotension) (Answer)- general management of mesenteric ischemia
Artery embolus:
Arrythmia
Post MI mural thrombi
Valvular Heart Disease
Structural Heart Disease
Artery thrombosis:
Atherosclerotic Disease
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