Courvoisier’s Law
“In a patient with obstructive jaundice and a palpable, non-tender gallbladder, the cause is unlikely to be gallstones.”

It means:
If the gallbladder is enlarged and not painful, the obstruction is probably due to a malignant process — not gallstones.
سو لازم افكر ca حتى يثبت العكس

gallstone ileus, a specific form of mechanical small bowel obstruction caused by a gallstone that enters the intestinal tract through a biliary-enteric fistula (most often a cholecystoduodenal fistula).

Antibiotics of choice for treatment of common adult infections in the ER

Antibiotics and their route of elimination

Safety during pregnancy

عظمة

One large public hospital reported that 47% of 721 consecutive patients with myocardial infarction presented complaining of symptoms other than chest pain. This means ED physicians must consider potential anginal-equivalent symptoms like dyspnea at rest or with exertion, nausea, light-headedness, generalized weakness, acute changes in mental status, diaphoresis, or shoulder, arm, or jaw discomfort.

Epigastric or upper abdominal discomfort, even when relieved with antacids, should raise suspicion for acute coronary syndrome, especially for patients >50 years old and those with known coronary artery disease.

Response to medications is a poor discriminator between cardiac and noncardiac chest pain.

In one study, 25% of ED patients with chest pain met diagnostic criteria for panic disorder. Conversely, 9% of the patients identified as having panic disorder were ultimately diagnosed with acute coronary syndrome on hospital discharge. This means panic disorder is at best a diagnosis of exclusion or a co-diagnosis with acute coronary syndrome (or another cause). Do not assume panic disorder in a patient with chest pain in the ED until further testing allows better risk stratification.

زين؟

Classical Triad for PERFORATED PEPTIC ULCER
1. Sudden severe epigastric pain (“like a stab” or “knife-like”)
2. Board-like rigid abdomen (due to peritonitis)
3. Signs of shock — tachycardia, hypotension, sweating

Misinterpretation of ECGs (i.e., failure to detect ischemic changes that are present) occurs in up to 40% of missed acute myocardial infarc-tion cases. In addition, the initial ECG represents only a single time point in a dynamic pathophysiologic process; the diagnostic value of an ECG is improved by comparing it to a prior ECG or repeating it.

β- blockers are contraindicated in hypertension caused by cocaine, amphetamine, or related sympathomimetic drugs, since β- blockade may cause unopposed α- adrenergic activity with paradoxical hypertension and d coronary blood flow.

You see these beautiful giant T-wave inversions?
They are called cerebral T-waves

A sign of raised ICP

Left arm artefact !!

👆At first glance, the ECG looks scary, it looks like some form of regular wide complex tachycardia (regular WCT), but if you look at lead II, you can see that it is spared (green arrows) and does not show regular WCT. Why?

Let me tell you a little secret about lead II, in fact lead II is the only lead in the ECG that does not need electrical inputs from the left arm electrode, every other ECG lead is dependent directly or indirectly (via Wilson’s central terminal) on left arm electrode except lead II, as lead II is dependent only on the inputs coming from right arm and left leg electrodes.

Therefore, any continuous artefact coming from the left arm will be recorded by all 11 leads except lead II, things like tremor in the left arm can produce an artefact in the ECG that look like regular WCT. Spared lead II is a strong and simple observation that will save a lot of thinking and possibly unnecessary actions.

Another observation that strongly suggests an artefact, is that the amplitude of the waves in the limb leads is much larger than that in the chest leads (normally, cardiac electrical events should be more pronounced in the chest leads as the chest leads are more closer to the heart), it means that the source of these large waves is closer to the limbs compared to the heart (left arm tremor).
The waves in the chest leads are about 1/3 that in bipolar limb leads (lead I, II and III), while the waves in the unipolar limb leads (aVR, aVL, and aVF) are about 2/3 that in lead I, II and III. It means that these waves are not coming from the heart.

Let’s analyse lead II (fortunately lead II is the rhythm strip), you can see that the ventricular rate is around 30bpm, while the atrial rate is around 80bpm, and the P waves are upright (suggesting sinus origin) and regular (red arrows), there is clearly AV dissociation, as there is no relation between atrial and ventricular events, therefore, there is complete AV block, and the QRS complexes are either ventricular escape rhythm or junctional escape rhythm with some form of intrventricular conduction delay (I see slightly wide QRS complexes). I support junctional escape rhythm, as the T waves are concordant with the QRS in lead II. Beat #4 is a PVC.

This patient has Parkinson’s disease, knowing that would make the decision much clear and easier, but I avoided mentioning this important note in the presentation to raise the level of the challenge😁

Thank you for reading, I hope the above helps, I learned this from Dr. Ken Grauer, he kindly explained a similar case for me long time ago.

Ahmed Marai

Additional notes:
▫️Lead III, is the only lead in the ECG that does not depend on electrical inputs coming from right arm electrode
▫️Lead I, is the only lead in the ECG that does not depend on electrical inputs coming from left leg electrode

Why Acute Pyelonephritis is More Common in the Right Kidney?
The uterus is slightly rotated to the right in pregnancy
→ causes more compression on the right ureter
→ which increases urinary stasis on the right side.

the right ovarian vein crosses the right ureter
→ increasing chances of compression.

The anatomical position of the colon
→ The left sigmoid colon protects the left ureter more
→ so the right ureter is more exposed and more easily compressed.