A 35-year-old female with abdominal discomfort

A New Chapter Is Just Uploaded To The Website!

A 35-year-old woman presents to the emergency department with right upper quadrant pain of two hours duration. She awoke several hours after eating a large meal. Based on increasing pain and nausea she presents for evaluation. She denies vomiting, fever or dysuria.
Her past history is notable for diet-controlled type II diabetes, dyslipidemia, and essential hypertension. Her BMI is 33. Her only medication is lisinopril 10 mg daily. She has never had surgery. Her social history is unremarkable. She neither drinks alcohol nor uses tobacco. She has begun to diet and reports recent weight loss.

Her temperature is 37ºC, blood pressure: 110 / 70 mm Hg, pulse: 90 beats per minute. Physical exam reveals an overweight female in mild distress secondary to right upper quadrant pain. She cannot find a position of comfort and describes the pain as similar to labor pains. Pertinent exam findings include: chest exam normal, cardiac exam normal, abdominal exam demonstrates normal bowel sounds and no rebound in any quadrant. She has guarding to inspiration with palpation over the gallbladder which called positive Murphy’s sign. Rectal exam normal, stool is hemoccult negative for blood.

Pertinent lab values: glucose 110 mg/dL, alkaline phosphatase 120 U/L, alanine aminotransferase (A.L.T.) 25 U/L, aspartate aminotransferase (A.S.T.) 25 U/L, gamma glutamyl transferase (GGT) 20 U/L, direct bilirubin 0.1 mg/dL, total bilirubin 0.5 mg/dL, lipase 20 U/L.

The emergency physician performs a focused right upper quadrant ultrasound and finds gallstones without associated gallbladder wall thickening or pericholecystic fluid. In addition, the patient has a “sonographic Murphy sign”: there is maximal abdominal tenderness when the ultrasound probe is pressed over the visualized gallbladder.

57 - Gallstones

An I.V. was established, and the patient received an isotonic fluid bolus. In addition, ketorolac 30 mg I.V. and ondansetron 4 mg I.V. were administered.
Over the course of an hour symptoms resolved. Absent evidence of gallbladder inflammation or infection, she was discharged from the emergency department and referred to a general surgeon for elective cholecystectomy. She was advised that her pain might return but if it is prolonged, is associated with fever or jaundice she is to return to the emergency department.

by Dan O'Brien from USA.

iEM Weekly Feed 3

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With this feed, you do not miss anything. You will find all published blog posts during this week. Click the “title” or “read more” to open each page you interested in.

Pulmonary Embolism

by Elif Dilek Cakal Case Presentation A 45-year-old female with no prior medical history presented to the emergency department (ED) with three days of constant shortness

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Three days of constant shortness of breath

Do you recognize these findings in the US and CT scan? https://youtu.be/Dh-Q23xdqeEhttps://youtu.be/lhops90o6_g Pulmonary Embolism by Elif Dilek Cakal from Turkey. Read Listen

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Deep Vein Thrombosis (DVT)

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

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My Leg Is Swollen!

A New Chapter Is Just Uploaded To The Website! An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and

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A Little White Coat and A Stethoscope

Ibrahim Sarbay Turkey I will never forget the time that I acted as a “medical doctor” at the 1st year-end show of the elementary school.

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Fall From Bicycle!

In case you didn’t encounter a child fallen from a bicycle today! Read “Multiple Trauma” Chapter Listen “Multiple Trauma” Chapter iEM Education Project Team uploads

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Core EM Clerkship Topics

Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your

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Left Flank Pain

In case you didn’t encounter flank pain today! iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images

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iEM Image and Video Albums

Uploading Image and Video Archive More than 350 images and videos are uploaded into iEM Flickr channel. Thousands to come… Uploading Image and Video Archive

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Is Troponin Enough?

You are the emergency doc working in a rural ED. It is the Saturday night at 23:25 and you have three patients with chest pain.

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A 13-year-old with testicular pain

In case you didn’t encounter a patient with testicular pain today! iEM Education Project Team uploads many clinical picture and videos to the Flickr and

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Listen chapters on the go!

Uploading Audio Chapters 68% 28 chapters are ready to listen and download, 100 to go…

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Acute Heart Failure (AHF)

by Walid Hammad – USA Case Presentation An ambulance crew rushes into your emergency department (ED) with a 56-year-old man. He is severely short of

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I…can’t…breathe!

A New Chapter Is Just Uploaded To The Website! An ambulance crew rushes into your emergency department with a 56-year-old man. He is severely short

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A kid with wrist pain!

In case you didn’t encounter a kid with wrist pain today! Pediatric fractures affecting growth plate are classified with Salter-Harris classification. It is from I

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A kid with wrist pain!

In case you didn’t encounter a kid with wrist pain today!

Pediatric fractures affecting growth plate are classified with Salter-Harris classification. It is from I to V. 

What is your opinion about below x-ray? I, II, III, IV or V?

Please give your answer at the comment box below.

428.3 - salter harris 2

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

I…can’t…breathe!

A New Chapter Is Just Uploaded To The Website!

35.3 - pulmonary congestion

An ambulance crew rushes into your emergency department with a 56-year-old man. He is severely short of breath, sitting upright on the stretcher, using his accessory respiratory muscles, and gasping for air. You find that he is diaphoretic, tachypneic, and in severe respiratory distress. You ask him, “What’s going on?” He replies: “I…can’t…(pauses and inhales a shallow breath)…breathe!”

The paramedics inform you that they received a call from the patient’s wife about 6:30 that morning, saying that her husband was short of breath and sweaty and that he had vomited once. The wife told them that she and her husband had returned from a long trip the night before and that her husband had not taken his “water pills” because he did not want to stop for frequent restrooms breaks during their drive. When they got home, he still did not take his pills because he wanted to sleep through the night. His breathing problems woke him during the night, and he tried to get more comfortable by adding pillows under his head to the point that he was almost sitting up in bed.

You thank the paramedics and turn back to the patient, who now looks even worse. He is more short of breath, and you sense that he is getting tired, about to give up. He looks like he is about to collapse. What is your next step?

by Walid Hammad from USA

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A 13-year-old with testicular pain

In case you didn’t encounter a patient with testicular pain today!

422 - Right testicular torsion

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Is Troponin Enough?

You are the emergency doc working in a rural ED. It is the Saturday night at 23:25 and you have three patients with chest pain. All have unchanged ECGs and normal troponins. All feel well now and want to go home if you think their results are okay. What is your plan for each of them?

Patient 1. Isabel D. is a 45-year old female with a history of hypertension. She presented to the emergency department with left-sided sharp chest pain. Her pain started after his evening run, and she vomited once. Her pain continued for one hour, but then it lessened spontaneously. Now she is feeling well, and she wants to go home. Her ECG is completely normal. Her 0- and 3-hour troponins are negative.

Paint 2. Daniel B. Is a 65-year old male with a history of smoking, hypotension and left bundle branch block (LBBB). He is obese. He presented to the emergency department with left-sided heavy chest pain, radiating to his left arm, chin, and back. He went to bed early today, and his chest pain woke him up. For half an hour, he has felt sweaty and nauseated but now he is feeling well, and he wants to go home. His ECG shows LBBB, unchanged compared to his previous ECGs and without Sgarbossa Criteria. His 0- and 3- hour troponins are negative.

Patient 3. Hank P. is a 54-year old male with a history of hypertension, diabetes mellitus and prior stroke with no sequel. For twenty minutes, he experienced a sharp pain in the middle of his chest. His pain had started while he was watching TV and he felt sweaty all in a sudden. he had His ECG shows findings related to left ventricular hypertrophy.  His 0- and 3- hour troponins are negative.

HEART Score

HEART Score was developed to predict the 6-week risk of a major adverse cardiac event of patients with chest pain, precisely in the emergency department setting (1). It outperformed the others, especially in exclusion of low-risk patients (2) Patients with a combination of HEART score of 0-3 and two negative troponins can be safely discharged from ED with no major adverse cardiac events (3). Patients with HEART Score of 4-6 requires admission and are candidates for further noninvasive investigations (1). Patients with HEART Score of ≥7 requires admission and are candidates for early invasive strategies (1).

HEART Score

CategoryScoreExplanationRisk Features
HistoryHigh-risk features
• Middle- or left-sided chest pain
• Heavy chest pain
• Diaphoresis
• Radiation
• Nausea and vomiting
• Exertional
• Relief of symptoms by sublingual nitrates

Low-risk features
• Well localized
• Sharp pain
• Non-exertional
• No diaphoresis
• No nausea and vomiting
Slightly Suspicious 0Mostly low-risk features
Moderately Suspicious+1Mixture of high-risk and low-risk features
Highly Suspicious+2Mostly high-risk features
ECG
Normal0Completely Normal
Non-specific Repolarization Disturbance+1Non-specific repolarization disturbance• Repolarization abnormalities
• Non-specific T wave changes
• Non-specific ST wave depression or elevation
• Bundle branch blocks
• Pacemaker rhythms
• Left ventricular hypertrophy
• Early repolarization
• Digoxin effect
Significant ST Depression+2Significant ST depression• Ischemic ST-segment depression
• New ischemic T wave inversions
Age
<450
45-64+1
≥ 65+2
Risk Factors• Obesity (Body-Mass Index ≥ 30)
• Current or recent (≤ 90 days)smoker
• Currently treated diabetes mellitus
• Family history of coroner artery disease (1st degree relative < 55 year old)
• Hypercholesterolemia

OR

Any history of atherosclerotic disease earn 2 points:
• Know Coroner artery Disease: Prior myocardial infarctions, percutan coronary intervention (PCI) or coronary artery bypass graft
• Prior stroke or transient ischemic attack
• Peripheral arterial disease
No known risk factors0
1-2 risk factors+1
≥ 3 risk factors or history of atherosclerotic disease+2
Initial Troponin
≤ normal limit0
1-3 x normal limit+1
> 3x normal limit+2
Please read articles 1,2,4 for more information.

Now, let’s look back on our patients.

Isabel’s pain has both high-risk (exertional, left-sided pain with vomiting) and (sharp pain, no diaphoresis) features; therefore, her pain is moderately suspicious. (H: +1) Her ECG is completely normal. (E: 0) She is 45 years old. (A: +1). She has one risk factor, hypertension. (R: +1) Her troponins are normal. (T: 0) Her HEART score is 3, and she can safely go home from the emergency department. The expected MACE rate in 30 days is 0%.

Daniel’s pain has mostly high-features (left-sided, radiating heavy chest pain with nausea and vomiting); therefore his pain is highly suspicious. (H: +2) His ECG is not completely normal but free of new ischemic changes. (E: +1) He is 65 years old. (A: +2). He has three risk factors, smoking, obesity, and hypertension. (R: +2) His troponins are normal. (T: 0) His HEART score is 7, and he is a candidate for early invasive intervention. You should admit him and call the cardiologist.

Hank’s pain has both high-risk (middle-sided chest pain with diaphoresis) and low-risk (non-exertional, sharp pain) features; therefore, his pain is moderately suspicious. (H: +1) His ECG is not completely normal but free of new ischemic changes. (E: +1) He is 54 years old. (A: +1). He has three risk factors, hypertension, diabetes mellitus and prior stroke. (Note that prior stroke alone earns two points) (R: +2) His troponins are normal. (T: 0) His HEART score is 5, and he is a candidate for noninvasive investigation. You should admit him.

PEARLS and PITFALLS

  1. ECG: If the ECG shows STEMI, do not wait for troponin or consider the HEART score. Call the cardiologist and consider activating angiography unit for the primary PCI.
  2. Troponins: If you first troponin is highly abnormal, do not wait for the second troponin or consider the HEART score. Call the cardiologist and consider activating angiography unit for the primary PCI. Additionally, the magnitude of change between the first and the second troponin is important in diagnosing acute myocardial infarction (5).
  3. Clinical Gestalt: You will gain a clinical gestalt over the years. If your clinical gestalt and any scoring disagree, always stay on the safe side for the patient’s benefit (4).
  4. Patient Safety: In the original study, the HEART score was combined with only one troponin. The adverse event rate was 2.5% for the HEART score 0-3 patients, 20.3% for the HEART score 4-6 patients and 72.7% for the HEART score ≥7 patients. Therefore, the author believes, the HEART score combined with two troponins is safer in the discharge of low-risk patients. Low-risk patients (i.e., HEART Score 0-3) with negative two troponins had no MACE within 30 days (3).

Suggested Chapters

Chest Pain by Asaad S Shujaa

Acute Coronary Syndrome (ACS)

by Khalid Mohammed Ali, Shirley Ooi

REFERENCES

  1. Six, A. J., Backus, B. E., & Kelder, J. C. (2008). Chest pain in the emergency room: value of the HEART score. Netherlands Heart Journal, 16(6), 191-196. – link
  2. Radecki, R. (2013). Time to Move to the HEART Score. Available at: http://www.emlitofnote.com/?p=440 (Accessed: 17/07/2018) – link
  3. Mahler, S. A., Riley, R. F., Hiestand, B. C., Russell, G. B., Hoekstra, J. W., Lefebvre, C. W., … & Herrington, D. M. (2015). The Heart Pathway Randomized Trial: Identifying Emergency Department Patients With Acute Chest Pain for Early Discharge. Circulation: Cardiovascular Quality and Outcomes, 8(2), 195-203. – link
  4. Hyunjoo, L., & Rodriguez, C. (n.d.). HEART Score for Major Cardiac Events. Available at: https://www.mdcalc.com/heart-score-major-cardiac-events#evidence (Accessed: 17/07/2018) – link
  5. Roffi, M., Patrono, C., Collet, J. P., Mueller, C., Valgimigli, M., Andreotti, F., … & Gencer, B. (2016). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). European heart journal, 37(3), 267-315. – link

FURTHER READING

  1. https://catalyst.nejm.org/wp-content/uploads/Acute-Chest-Pain-HEART-Score-Reference-MI.png – link
  2. https://canadiem.org/tiny-tips-heart-score-a-tool-for-acute-coronary-syndrome/ – link
  3. https://www.mdcalc.com/heart-pathway-early-discharge-acute-chest-pain – link

iEM Image and Video Albums

Image and Video - Flickr
Uploading
Image and Video Archive

More than 350 images and videos are uploaded into iEM Flickr channel. Thousands to come…

Image and Video - Youtube
Uploading
Image and Video Archive

87 videos are uploaded into iEM YouTube channel. Hundreds to come…

Left Flank Pain

In case you didn’t encounter flank pain today!

407 - ureteral calculi

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Core EM Clerkship Topics

Core EM Clerkship Topics

Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your colleagues and students. Sharing is caring!

Shock

by Maryam AlBadwawi Introduction Shock, in simple terms, is a reduced circulatory blood flow state within the body. The inadequate circulation deprives the tissues of its

Read More »

Chest Pain

by Asaad S Shujaa Introduction Chest pain is one of the most common symptoms presented in the emergency department (ED), and it is worrisome because

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Gastrointestinal Bleeding

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley Case Presentation A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to

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Headache

by Matevz Privsek and Gregor Prosen Introduction Headache is a subjective feeling of pain, crushing, squeezing or stabbing anywhere in the head. They are typically

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Respiratory Distress

by Ebru Unal Akoglu Case Presentation A 40-year-old female with a history of diabetes mellitus presents with a complaint of 6 days cough and muscle

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Multiple Trauma

by Pia Jerot and Gregor Prosen Case Presentation A 28-year old male was a restrained driver in a head-on motor vehicle collision. He was entrapped and

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Poisonings

by Harajeshwar Kohli and Ziad Kazzi Case An 18-year-old, previously healthy female, presents to the Emergency Department with nausea, vomiting, and tremors. She states 45

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Cardiac Arrest

by Abdel Noureldin and Falak Sayed Introduction A 23-year-old female was brought into the emergency department. Her frantic family members said they found her on

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Altered Mental Status

by Murat Cetin, Begum Oktem, Mustafa Emin Canakci  Case Presentation An 80-year-old female presents to the emergency department with a tendency to sleep (altered mental

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Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

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Fall From Bicycle!

In case you didn’t encounter a child fallen from a bicycle today!

13.1 - clavicle fracture 1

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

A Little White Coat and A Stethoscope

Ibrahim Sarbay

Turkey

I will never forget the time that I acted as a “medical doctor” at the 1st year-end show of the elementary school. A little white coat tailored for me and a stethoscope that my dad borrowed from a nurse were all the needs to become a “medical doctor” for my little self. When I appeared on the scene, saw the audience and realized glimpses of admiration in their eyes, I realized that I want to become a medical doctor. Not for wealth or fame or glory; but for the single cause of “love.” I loved medicine. I loved medicine even before I learned anything about it. I wanted to become a “medical doctor”! Period.

Years passed by and hundreds of exams later, I had the opportunity to graduate from the school of medicine. Here I was, fulfilled the dream of my profession. But there was another fork in the road. Which specialty would I choose? I knew that I want diversity among my patients, and I was eager to work across disciplines. I liked performing diagnostic and therapeutic procedures together in a timely manner. I believed that emergency care should be free and available to everyone. For these reasons, it was obvious to me that I have to select Emergency Medicine. Fast forward, and I am a third-year emergency medicine resident now. 

I think I don’t have the authority to write about the opportunities that emergency medicine offers or to mentor you about choosing any specialty. Among these brilliant minds of iEM family, I am pretty sure there are dozens of experts to guide you for your destination.

But let me just remind you this: Hundreds of thousands of people arrive at emergency departments every day throughout the world. They receive the best care possible, thanks to the Emergency Medicine specialists. They are there 24/7, 365 days of the year with one rule: “Anyone, anything, anytime.” I personally can’t see a more noble approach than that.

Helen Keller once said “Life is either a daring adventure or nothing,” and Emergency Medicine is, for sure, a daring adventure. If you feel the same, then Emergency Medicine is the right choice for you.

Suggested Chapters

Choosing the Emergency Medicine As A Career

C. James Holliman

Emergency Medicine: A Unique Specialty

Will Sanderson, Danny Cuevas, Rob Rogers

My Leg Is Swollen!

A New Chapter Is Just Uploaded To The Website!

An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2 days’ duration. She had been hospitalized for pneumonia one week earlier. Her vitals on arrival were: Blood Pressure: 138/84 mmHg, Pulse Rate: 65 beats per minute, Respiratory Rate: 14 breaths per minute, Body Temperature: 37°C (98.6°F), Oxygen Saturation: 96%. On examination, her right calf was reddish, tender, edematous and 4 cm greater in circumference than the left when measured 10 cm below the tibial tuberosity. Her Wells’ Score for deep vein thrombosis (DVT) was 4 and suggested high-risk for DVT. Compression ultrasonography showed a thrombus in the popliteal vein. Enoxaparin (1 mg/kg, twice a day, SC) was started. No signs and symptoms of pulmonary embolism were observed. The patient was referred to a cardiovascular surgeon as an outpatient after discussion and confirmed understanding of discharge instructions.

Turkey
by Elif Dilek Cakal from Turkey.

Three days of constant shortness of breath

Do you recognize these findings in the US and CT scan?

Turkey
by Elif Dilek Cakal from Turkey.

iEM Weekly Feed 2

Welcome to iEM Weekly Feed!

With this feed, you do not miss anything. You will find all published blog posts during this week. Click the “title” or “read more” to open each page you interested in.

Today’s Headache

In case you didn’t encounter headache today! Read “Headache” Chapter Listen “Headache” Chapter iEM Education Project Team uploads many clinical picture and videos to the

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Managing Psychosis In The ED

Case 1.  It is a quiet Wednesday night in the emergency department when you suddenly hear someone coming down the hall continuously spouting out a

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A Kid With Wrist Pain!

In case you didn’t encounter a wrist pain today! See Lateral X-ray iEM Education Project Team uploads many clinical picture and videos to the Flickr

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Don’t Touch My Belly!

A New Chapter Is Just Uploaded To The Website! A previously healthy 42-year-old male presented to the Emergency Department (ED) with a 3-day history of

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Elbow Pain

In case you didn’t encounter a child with elbow pain today! See Lateral X-ray iEM Education Project Team uploads many clinical picture and videos to

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Doc! My Hand Hurts.

In case you didn’t encounter a patient with hand pain today! iEM Education Project Team uploads many clinical picture and videos to the Flickr and

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Happy week with tons of education!

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ACS in 12 minutes!

The chapter is just uploaded to the website!​ Acute Coronary Syndrome by Khalid Mohammed Ali, Shirley Ooi from Singapore. A 46 years old man with

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Being A Woman In Emergency Medicine

Gül Pamukçu Günaydın Turkey Watching the famous TV series “ER” in my 3rd year of medical school I decided to be an “ER doctor.” I

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I can’t breath Doc!

In case you didn’t encounter shortness of breath today! Go To “Respiratory Distress” Chapter Go To “Chest Pain” Chapter iEM Education Project Team uploads many

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A 68-year-old with wheezing

Chronic Obstructive Pulmonary Disease (COPD) by Ramin Tabatabai, David Hoffman, and Tiffany Abramson, USA A 68-year-old male presents to the emergency department (ED) with audible

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