Core Emergency Medicine

The presence of a LBBB makes the diagnosis of an acute MI challenging. We review the topic here in an effort to shed light on this area.

This post reviews the diagnosis and management of pericarditis with a focus on not missing the hidden STEMI.

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This week we discuss why we use antibiotics in COPD exacerbations and whether we should continue to do so.

Core Procedures See More →

A brief video on how to perform and incision and drainage of a cutaneous abscess.

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This video discusses how a magnet helps you in the management of pacemaker mediated tachycardia + inappropriate shocks

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The program for dasSMACC has been released and the Core EM team is extremely excited. This is the 5th iteration of this amazing conference and we continue to see the program evolve. This year, the conference features a single stage with 2500 seats. While this means no concurrent tracks and fewer speakers, it also means that this will be more than just a conference but rather an incredible event featuring the best in Emergency Medicine,
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“And in the naked light I saw

Ten thousand people, maybe more

People talking without speaking

People hearing without listening.”

Sound of Silence by Simon & Garfunkel

There’s a small park on the other side of First Avenue across from Bellevue. To those that work here,
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I love sports; I’m the type of guy who opens up on his laptop before The New York Times or CNN every morning. I can most definitely name the last ten NBA MVPs faster than all of the PERC criteria. That being said, I am probably more parts “mathlete” than athlete. But that doesn’t mean I haven’t thought about which fellow stars would make up my entourage,
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Core Journal Club See More →


The Impact of Rudeness on Medical Team Performance: A Randomized Trial Pediatrics, 2015

Iatrogenesis is an adverse patient condition directly resulting from medical treatment or error, occurring in nearly 4% of hospitalizations with 50% being preventable and 14% resulting in death (Berwick 1999,
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More than just meds: National survey of providers’ perceptions of patients’ social, economic, environmental, and legal needs and their effect on emergency department utilization Social Medicine, 2016

In our current healthcare system, Emergency Departments (ED) have become central to the health “safety net” of the nation.  Although Emergency Medicine is designed to provide acute medical care,
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Core Case of the Month More Cases →


Bizarre, disorganized behavior


23 yo M with unknown pmh sent from Rikers c/f psychosis and med/psych evaluation in light of “bizarre, disorganized behavior.”  Per records sent from Rikers, patient has history of cannabis and alcohol abuse and tested positive for benzos at Rikers.  No known prior psychiatric history.  Initially sent to CPEP but was brought to ED after witnessed seizure-like activity, though patient responded to sternal rub and did not appear to have have postictal state.

Patient was reportedly yelling and talking to himself in his cell, stating people are “plotting to kill me” and appeared scared and paranoid.  He answers some questions but continues to yell “turn the music off” and intermittently fights against restraints, yells, kicks, and screams at cops begging them to remove handcuffs. Reports benzodiazepine use one month ago. Denies any additional past medical history.

On ROS states his throat hurts a little, unable to state when this started.  Denies any HA, n/v, pain, sob, cp, abd pain, f/c, neck stiffness.


PMH: denies
PSH: denies
Meds: denies
Social: Rikers Island x4 days. Reports occasional etoh, cannabis, and benzodiazepine use

Physical Exam

BP 109/61, HR 96,  RR 24, O2 99% (RA) Temp 99, BG 146

GEN: Becoming increasingly more agitated initially distractable now screaming, kicking. Non-toxic
HEENT: NC/AT, neck supple. Normal ROM. No tonsillar exudate. Uvula midline.
CV: RRR, S1/S2, no mm. Strong and equal peripheral pulses
Pulm: Tachypneic but CTAB, unlabored, no wheezing
Abd: Soft, thin, nt/nd
Ext: No LE edema, wwp
Neuro: Moving all extremities spontaneously. No focal neuro deficit. CN intact. A&O person, month, year, president. Not name of hospital or date. Pt also cannot remember that he is arrested.
Psych: Responding to external stimuli, disorganized thought process.


VBG: pH 7.32, pCO2 43, pO2 111, Lact 0.6
CBC: 18.3>14.9/44.8 BMP: 138/4.3 104/22 17/0.9 Gluc: 121 Ca: 10.0
LFT: AST 54, ALT 39, AlkP 67, Tbil 1.7, Dbil 0.7, Prot 8 , Alb 4.9
EtOH: <10
TSH: 2.5
No utox or UA obtained

Cell Count: RBC 0, WBC 1, Lymph 2%, Mono 1%
Gluc: 87 (range 40-80)
Protein: 21.4
Gram Stain: Rare WBC, no organisms


  1. What diagnosis can you make from these images alone?

  2. What do you suspect was the underlying cause of this diagnosis?

  3. What imaging do you want next?

  4. What are your next steps in management?