ALiEM - Pharm Pearls

MARCH 5, 2024

Which medication can be derived from the bark of the pictured tree? Aspirin Atropine Colchicine Quinine Reveal the Answer 1. Aspirin Background The photo shows a weeping willow, a member of the Salix genus of trees. Willow tree bark contains salicin from which aspirin (acetylsalicylic acid) can be derived. For over 3500 years, willow bark has been used as a traditional medicine to treat fevers and pain [1].

Clinical Pharmacology 280

Clinical Pharmacology Adverse Reactions Compounding 280

ALiEM - Pharm Pearls

MARCH 1, 2024

A 24-year-old female with no pertinent PMHx presents to the ED with a chief complaint of eye pain. She reported a 10-day history of worsening right eye pain following being punched in that eye. She had been managing her pain with ice and had not taken any OTC medications. Her mom convinced her to go to the ED and she first went to an outside hospital, but was referred to come to our institution.

Hospitals 148

Hospitals 148

ALiEM - Pharm Pearls

FEBRUARY 28, 2024

As medical education podcasts, videos, and blogs continue to grow in popularity it is crucial that we cite them correctly, both in publications and on our CVs. We also must recognize the important contributions of media such as clinical photographs, radiology images, and ECGs. The American Medical Association (AMA) Manual of Style released its 11th edition in 2020.

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130

ALiEM - Pharm Pearls

FEBRUARY 26, 2024

An 18-day-old male presented for a rash on his face for two days. The patient was born via spontaneous vaginal delivery full term without complications to a mom who has a history of genital HSV but without active lesions at delivery and on acyclovir. The patient presented with a vesicular rash on his face including around his eyes. He had conjunctival discharge noted by mom.

188

188

ALiEM - Pharm Pearls

FEBRUARY 20, 2024

What agent would most likely be responsible for these ECG findings? Cyclobenzaprine Digoxin Flecainide Sotalol Reveal the Answer 3. Flecainide Background [1-3] Flecainide is a class IC antiarrhythmic that binds to the voltage-gated sodium channel of the myocardium, slowing depolarization and prolonging phase 0 of the action potential. In toxicity, bradydysrhythmias, AV nodal blockade, ventricular tachycardia, and rate-dependent QRS widening occur.

177

177

ALiEM - Pharm Pearls

FEBRUARY 16, 2024

An 86-year-old man with a past medical history of coronary artery disease, hypertension, hyperlipidemia, chronic kidney disease, COPD, choledocholithiasis requiring ERCP and sphincterotomy 2 years ago presented with five days of feeling unwell. History was limited due to cognitive impairment. His daughter had reported to staff he had been feeling unwell for five days, intermittently having nausea and generalized abdominal pain, subjective fevers, chest pain, and shortness of breath.

Hospitals 156

Hospitals 156

ALiEM - Pharm Pearls

FEBRUARY 12, 2024

A 28-year-old female G3P2002 presented to the emergency department for one month of vaginal bleeding. The patient was seen in the emergency department one month earlier for vaginal bleeding in the first trimester of pregnancy. Her estimated gestational age was six weeks by last menstrual period. At the time her beta-hCG was 7225 mlU/mL with no intrauterine pregnancy demonstrated on transvaginal ultrasound.

156

156

ALiEM - Pharm Pearls

FEBRUARY 9, 2024

How do we best use high-sensitivity cardiac troponin (hs-cTn) to risk stratify patients with symptoms concerning for an acute myocardial infarction (AMI)? The 2022 American College of Cardiology (ACC) pathway provides timely guidance [1]. We help you translate this to your clinical practice, by illustrating with a case. Time to know your hs-cTn better.

Hospitals 271

Hospitals Diabetes 271

ALiEM - Pharm Pearls

FEBRUARY 5, 2024

Welcome to the AIR Toxicology Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to toxicology in the Emergency Department. 8 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board.

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210

ALiEM - Pharm Pearls

FEBRUARY 2, 2024

An 18-year-old-female with no known past medical history presented with a lesion on her back that had been present and enlarging for five months. It was not painful unless she touched it, and then only mildly tender. She denied any known cause, wound, prior rash, or other lesions. Her review of systems and past medical history were negative. Additional Images Physical Exam Vitals : Normal Skin : An erythematous lenticular, or biconvex, lesion with distinct borders is noted at the left posterior

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164

ALiEM - Pharm Pearls

JANUARY 29, 2024

A 59-year-old male with no known past medical history other than an incidental abdominal aortic aneurysm presented with sudden onset, painless vision loss in his left eye. The patient was watching TV two days prior when he saw a “brightness” in his left eye and then progressive blurriness until his vision faded away, all occurring within the span of a minute.

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156

ALiEM - Pharm Pearls

JANUARY 26, 2024

An 88-year-old female presented to the ER with a chief complaint of cough, vague abdominal pain, and a rash. The patient stated that she was started on Cipro eyedrops 1 or 2 days prior to presentation for a possible eye infection. A day prior to presentation she developed a purple purpuric rash on her lower extremities that gradually progressed up her legs, and was present on her buttocks thighs, and lower legs.

Nursing Homes 177

Nursing Homes Documentation Hospitals 177

ALiEM - Pharm Pearls

JANUARY 22, 2024

A 40-year-old male, tailor by occupation, was brought to the Emergency Department with complaints of high-grade fever for the past 11 days. Fever was documented to be 102°F and was not associated with any chills or rigors. The patient also complained of shortness of breath for one week associated with a dry cough, as well as an altered sensorium for one day.

Documentation 156

Documentation Hospitals 156

ALiEM - Pharm Pearls

JANUARY 12, 2024

A 42-year old Bengali man with a history of hyperlipidemia presented to the Emergency Department with facial swelling, diffuse rash, renal insufficiency and proteinuria after receiving his COVID-19 vaccine (Moderna) booster dose. There were no adverse events with the first two doses of the vaccine except for mild transient sore throat and cough after the 2nd dose.

Vaccines 130

Vaccines 130

ALiEM - Pharm Pearls

JANUARY 8, 2024

A 49-year-old female with a past medical history of recurrent diverticulitis initially presented with one month of shortness of breath and a minor nonproductive cough for which she was started on doxycycline by her primary care provider. She then developed a rash on her chest, upper back, and face. Antibiotics were switched to amoxicillin and azithromycin.

Hospitals 148

Hospitals 148

ALiEM - Pharm Pearls

JANUARY 5, 2024

Dr. Sara Krzyzaniak (podcast host and Stanford University PD) and Dr. Michelle Lin (ALiEM Founder/UCSF) are joined by Dr. Aaron Kraut (University of Wisconsin PD) in this insightful, rapid-fire, practical episode through the lens of experienced residency program directors. What does the Electronic Residency Application Service (ERAS) preliminary data show just far for the 2024 residency application season?

Communication 171

Communication 171

ALiEM - Pharm Pearls

DECEMBER 22, 2023

An 84-year-old female presented with a chief complaint of right hip pain after a fall 12 hours prior to presentation. The patient reported a history of falls resulting in shoulder, rib, and left hip fractures in the past. The patient stated that upon getting out of bed, she took 4-5 steps, lost her balance, and fell backward onto the bedroom floor. She denied loss of consciousness.

156

156

ALiEM - Pharm Pearls

DECEMBER 18, 2023

A 19-year-old female with a past medical history of epilepsy presented to the emergency department for evaluation of rash and fever. Two days prior to presentation she began to experience fevers with a Tmax of 103°F. One day before presentation she developed a rash that began on her face and slowly spread down her body, now involving her palms. The patient endorsed associated pruritus and cervical lymphadenopathy with the rash.

Immunity 171

Immunity Immunization 171

ALiEM - Pharm Pearls

DECEMBER 8, 2023

A 45-year-old male status-post right nephrectomy secondary to a renal mass presented to the emergency department with right-sided flank pain. He endorsed low-grade intermittent right-sided flank pain since the nephrectomy one year prior, associated with an increasingly enlarging mass extending laterally from his right abdomen. Over the course of the past several days, the mass had become larger and more painful.

Diabetes 148

Diabetes 148

ALiEM - Pharm Pearls

DECEMBER 4, 2023

A 49-year-old male presented to the emergency department of an academic hospital with the chief concern of penile pain. Prior medical history is notable for end-stage renal disease on hemodialysis three times per week, but the patient has not been dialyzed in the past four days, hypertension, insulin-dependent diabetes mellitus, heart failure with reduced ejection fraction (59% two months prior), seizure disorder, prior pulmonary embolism (eight months prior), a left nephrectomy seven months ago

Hospitals 148

Hospitals Medical Schools Diabetes 148

ALiEM - Pharm Pearls

DECEMBER 1, 2023

A 23-year-old female with a past medical history of asthma presented with a rash that began five days ago on her face and spread to her chest. The lesions are painful and pruritic, spreading slightly to her extremities. She noted a slight sore throat and nasal congestion. She denied any known fever and had no known vaginal or oral lesions. She has a 5-year-old daughter at home with no known symptoms.

Immunity 148

Immunity Immunization Vaccines 148

ALiEM - Pharm Pearls

NOVEMBER 29, 2023

Which of the following agents, when injected along with heroin, is associated with the skin changes pictured? Cocaine Fentanyl Methamphetamine Xylazine Photo by Dr. Matthew Salzman Reveal the Answer 4. Xylazine Background Xylazine is a synthetic substance approved by the U.S. Food and Drug Administration for veterinary use, specifically for its muscle relaxant, sedative, and analgesic effects [1].

Hospitals 164

Hospitals 164

ALiEM - Pharm Pearls

NOVEMBER 27, 2023

A 24-year-old G1P0010 female with a PMHx of ovarian cyst (unknown laterality) and emergency contraceptive use 3 months prior presented with sudden onset abdominal pain (upper > lower) that awoke her from sleep four hours prior to presentation with associated nausea and mild lower back pain. The pain is 10/10, sharp, stabbing, and diffuse. Additionally, she reported trace white vaginal discharge at baseline.

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156

ALiEM - Pharm Pearls

NOVEMBER 22, 2023

The toxin from the golden poison dart frog most resembles which of the following in its mechanism of action? Botulinum toxin Bufotoxin Grayanotoxin Palytoxin Tetrodotoxin Photo adapted from Wilfried Berns (Wikimedia Commons) Reveal the Answer 3. Grayanotoxin – a sodium channel opener Background The golden poison dart frog ( Phyllobates terribilis ), often considered one of the most poisonous animals on the planet, secretes onto its skin the lipophilic alkaloid batrachotoxin , which irreversibly

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278

ALiEM - Pharm Pearls

NOVEMBER 17, 2023

A 4-year-old female with no significant past medical history is brought to the Emergency Department by her grandmother for concern for two days of progressive vaginal bleeding. The grandmother first noted blood in the patient’s underwear the previous morning when she was helping the patient wipe and she noticed it again prior to arrival, this time saturating the patient’s underwear.

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248

ALiEM - Pharm Pearls

NOVEMBER 15, 2023

What toxin is found in bitter apricot kernels? Cardiac glycoside Cyanogenic glycoside Dinitrophenol Lysergic Acid Reveal the Answer 2. Cyanogenic glycoside Background Apricot kernels contain a cyanogenic glycoside called amygdalin which is hydrolyzed to hydrogen cyanide in the gastrointestinal tract [1]. There are over 2,000 species of cyanogenic glycoside producing plants, including apricots, almonds, peaches, and cassava [2].

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164

ALiEM - Pharm Pearls

NOVEMBER 13, 2023

A 57-year-old female college counselor living in the northeastern United States with no PMH presented for evaluation of rash, joint pain, and dyspnea for the past three weeks. The patient first noticed the rash on her upper back, describing it as being itchy. The rash then spread to her face, scalp, and thighs. Two weeks ago, she noticed swelling in her hands and had a gradual onset of dyspnea on exertion.

Inpatient 194

Inpatient 194

ALiEM - Pharm Pearls

NOVEMBER 10, 2023

A 33-year-old male presented to the emergency department with a diffuse pruritic rash that appeared several days after starting Trimethoprim/Sulfamethoxazole (TMP-SMX) for a dental infection. Initially beginning on the torso and low back, the rash spread to the palms, soles, and genitalia. Progression stopped after discontinuing TMP-SMX. He conveyed a remote history of a similar rash following use of an unknown medication, and noted that several of the current lesions arose at the same location

156

156

ALiEM - Pharm Pearls

NOVEMBER 8, 2023

Which of the following best describes the pictured rash occurring 4 weeks after starting minocycline? Anaphylaxis Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome Erythema multiforme Serum sickness Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN) Reveal the Answer 2. DRESS Syndrome What is DRESS syndrome? Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) syndrome, also called Drug Induced Hypersensitivity Syndrome (DIHS), is a severe delayed T-cel

Adverse Reactions 156

Adverse Reactions Diabetes 156

ALiEM - Pharm Pearls

NOVEMBER 6, 2023

A 55-year-old female with a history of hyperlipidemia presents after a syncopal episode. She had mild nausea and diarrhea on the morning of presentation but otherwise had no prodromal symptoms before suddenly losing consciousness in a grocery store. Of note, she recalls a similar syncopal episode in the remote past, also preceded by gastrointestinal symptoms at that time.

Grocery Stores 188

Grocery Stores 188

ALiEM - Pharm Pearls

NOVEMBER 3, 2023

Welcome to the AIR Trauma Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to trauma in the Emergency Department. 8 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board.

Labelling 206

Labelling 206

ALiEM - Pharm Pearls

NOVEMBER 1, 2023

What clinical presentation and medication is associated with this urinary discoloration? Critical illness requiring intubation and propofol sedation Cyanide toxicity requiring sodium thiosulfate Iron toxicity treated with deferoxamine Refractory vasoplegic shock treated with methylene blue Septic shock treated with vancomycin and cefepime Reveal the Answer 3.

Clinical Pharmacology 156

Clinical Pharmacology Dosage Compounding 156

ALiEM - Pharm Pearls

OCTOBER 30, 2023

Dr. Garcia is a freshly minted faculty member at Big Name University Medical Center. She’s excited to have finally finished residency and dive into her career as a full time (and fully paid) attending. After spending her first year acclimating to the new department and achieving board certification, Dr. Garcia finds herself at a bit of a crossroad.

Communication 156

Communication 156

ALiEM - Pharm Pearls

OCTOBER 26, 2023

The Problem: Emergency Medicine (EM) in Pakistan has moved from developing to developed stage in the last decade [1]. As the specialty evolves in Pakistan and other countries, there is a need to improve and assimilate novel learning methods to elevate education standards. The COVID-19 pandemic catalyzed the routine use of video-conference platforms such as Zoom.

Hospitals 156

Hospitals 156

ALiEM - Pharm Pearls

OCTOBER 27, 2023

A 26-year-old male with no significant past medical history presented to the ED after slipping on wet pavement and hitting his head on the ground three hours prior. He endorsed a constant, achy 7/10 headache accompanied by nausea and photophobia. He denied vomiting, dizziness, diplopia, loss of consciousness, or seizures. Nothing made it better or worse.

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273

ALiEM - Pharm Pearls

OCTOBER 23, 2023

A 32-year-old man with a history of traumatic globe rupture from a stab wound two months ago, status post repair, presented to the emergency department for worsening right eye pain and green malodorous drainage for the past three days. These symptoms started when he got a fleck of sawdust in the right eye about four days prior to presentation, which he was able to brush out with his finger.

Medical Schools 273

Medical Schools 273

ALiEM - Pharm Pearls

OCTOBER 20, 2023

A 50-year-old Caucasian female with a history of hypertension, coronary artery disease, and insulin-dependent diabetes mellitus presents to the emergency department with a complaint of painful sores on the top of her left foot. She notes that ulcerations have formed over the past two weeks and reports a history of multiple recurrent usually non-tender skin lesions to her lower extremities, forearms, and hands over the past twenty years.

Diabetes 156

Diabetes 156