Just what is Methotrexate, anyway…?

22 yo female presents to the ER c/o 11 days of lower abdominal pain, crampy in nature, but unrelenting.  Pain is much worse when she moves, walks, bends over, or tries to walk up stairs.  Denies fever but has had occasional chills.  Able to keep down food, denies any dysuria.  She was seen in another ER 10 days ago and diagnosed with ectopic pregnancy and given methotrexate.  At day 2 post-administration of methotrexate, she was still having minimal abdominal pain with vaginal discharge so she returned to the original ER where she was given methotrexate for reevaluation.  At that time she was passing small clots, and a quantitative bHCG was somewhat reduced from her initial bHCG at diagnosis of ectopic pregnancy (3700 mIU to 3500 mIU). Since it was trending in “the right direction,” she was told she would feel better in a few days and that she could follow up with her PCP.  She can’t get in to she them, and she is at the point where she can barely walk without severe pain.  This was her first pregnancy and she has been sexually active since being given the methotrexate.  Other than still passing clots, denies other vaginal D/C.

PMH/PSH – bipolar D/O

Med: Lamictal

Allergies: None

She is a smoker and drinks occasionally – no illicit or recreational drug use.

BP 114/70
HR – 80
RR 16
O2Sat 98% RA
Pain 7/10 without movement, 10/10 with palpation or any movement involving belly

Physical Exam
AOx3, appears very uncomfortable, cannot find a comfortable position on the stretcher, cool to touch
Chest – RRR, no M/R/G
Abdomen – very TTP, (+ rebound tenderness in lower quadrants).  Does have good bowel sounds.  CVAT unremarkable.  10/10 pain elicited when palpating LLQ area
Vaginal – passing blood – speculum exam deferred until seen by OB
Skinis pale, cool and moist.
Rest of physical exam is non-contributory

Ok, a few things:

1)   What is the most likely diagnosis?
2)   What do you want to do to test for this?
3)   What is the definitive treatment?
4)   What argues against the most likely diagnosis?
5)   Can you postulate a theory that encompasses all of the facts as presented to provide a single, unifying diagnosis?

Feel free to ask about other labs, imaging, etc – but I want you to think through this first as to what’s going on before jumping into labs, etc.  This is one of those diagnoses that exam alone diagnoses.  You have everything you need.  I will post final picts as well, along with labs, once we get to that point.


Ectopic OR

Posted in OB/Gyn | 11 Comments

Edison’s contribution to medicine…

EMS calls in with a 14 yo female who fell off her skateboard, not helmeted, and after the fall she felt a “pounding” in her chest. Since the fall, she hasn’t felt right. In the field, EMS finds the patient to be very tachycardic, pale, cool and moist, but maintaining a BP of 110/70. Her HR is reportedly in the low 200s. Per EMS, patient denies headache, neck or back pain, and had no LOC. EMS has tried adenosine (2 rounds), Cardizem (2 rounds) and lidocaine (2 doses) enroute to the ER. Upon arrival at the ER, patient is still tachycardic.

Upon presentation to the ER, mom reports child had a major cardiac surgery at 23 months (repair of transposition of great vessels) and has been event-free since. Child is normally in good health and last saw his cardiologist 8 months ago for routine follow-up.

Patient still c/o “funny-feeling” in her chest, some mild SOB, denies headache, head, neck or back pain. Does complain of R shoulder pain with movement. Otherwise, she has a few abrasions on his R forearm only. Of note, no bruising noted on chest wall or belly. She is tall and lanky, about 125 lbs, pale, dusky appearing, sweaty, and cool to touch. No JVD, but you can appreciate her chest wall is fluttering as his heart is beating.

– Transposition of great vessels with surgical repair

– None

BP 100/70
HR – 230 BPM, regular
RR 18, shallow
O2 sat – 95% on 2lpm
Temp 36.8C

Exam – as noted above; HR too fast to appreciate any murmer/rubs.

Here is the first strip:
First Strip






1) Sick or not sick?

2) What is the diagnosis?

3) What is the cause of the diagnosis?

4) What is the treatment?

5) Would you consider further pharmaceutical intervention? If so, what would you use? Why?

6) What cannot be overlooked as a cause of this condition? What is one way to see if this is the cause of this condition?

7) How lucky is this kid?

Here is Strip 2 run at 50mm/sec:

Strip 2



Here is Strip 3 after conversion:

Strip 3





8) What is the final diagnosis? Any further thoughts or comments?

Posted in Cardiac | 5 Comments

My Belly Hurts…

Ok, this case is pretty complex – let’s get to it.

68 yo female presents to your ED by EMS c/o severe LLQ and epigastric abdominal pain for 3 days. She was discharged from your facility 21 days ago s/p cholecystectomy with concomitant mild gallstone pancreatitis. While here, her enzymes normalized and at D/C all prior ABD pain had resolved. She hasn’t been on antibiotics since surgery, and she has been able to eat without difficulty. Of note, she has lost 40lbs over last 8 months and has had an extensive history of prior bouts of abdominal pain – all of which were non-diagnostic until this recent bout of cholecystitis. States pain is 10/10, cramps, achy pain. Last BM 4 hours ago. Solid stool, no obvious discoloration, blood or mucus. Denies CP or SOB. Appears very uncomfortable.

PMHx includes:

Undifferentiated ABD pain
AAA at thoracoabdominal junction – 4.8cm last exam 30 days ago.
-has had this for 5 years
Smoker 2 packs/day 50+ years
Drinks 1-2 glasses of wine daily


Hydrocodone with APAP

Allergies: Morphine (hives per patient)

BP: 210/112 R arm, 146/90 L arm
Pulse: 130-140 bpm at rest
RR 20  Temp 98.7F
O2 sat 96% on 2lpm via NC

Physical Exam

Gen: AOx3, appears very uncomfortable, dusky can’t find position of comfort. Appears frail amd unkempt. In obvious pain.
HEENT: patent airway, PERRLA, EOMI, bounding carotid pulses
Chest: Tachycardic, regular, no M/R/G. Mild wheezing all fields, no rhonchi or rales. Able to move air without significant distress
ABD: Soft, moderately TTP all quads with increased pain on palpating of epigastrium and LLQ. No rebound tenderness. Negative leg lift, Rovsing’s or CVA TTP. Bilateral femoral pulses equal but moderately weaker than carotids.
Ext: full ROM, no calf tenderness, no CCE. Very pale and dusky
Neuro: AOx3, no gross deficits noted

Ok, there is a lot going on here but at the same time, from an EM perspective, think about the case and put the following in perspective:

1)  Sick or not sick?
2)  What are the immediate life-threatening concerns?
3)  What is your differential diagnosis – most likely to least
4)  What one test do you want to do?
5)  What is the definitive treatment?
6)  What else do you want to know?

Remember, you have 2 nurses, a respiratory therapist, and a general surgeon on call.  If you can’t handle it, it needs to go elsewhere.

Below are some key studies to help with the case:
SMA IMA occlusion 20

SMA IMA occlusion1

SMA IMA occlusion 21

SMA IMA occlusion2


Posted in Abdominal, Case Types | 9 Comments

When snowboarding goes wrong…

26 yo male comes into the ER after falling while attempting a jump during a snowboarding competition.  When he fell, he heard and felt a “snap” in his R leg.  He cannot bear weight on the R leg.  He has no other significant history.  He was helmeted, denies LOC, and has no head, neck, or back pain.  His pain is an 8/10 after EMS has given him 8 mg of morphine IV (he weighs ~80kg).

What’s the fracture?

What’s the treatment?

What is the timeframe to healing?

How would you consider pain controlling this patient?

What else matters for this patient?

Femur Fx 2

Posted in Case Types, Orthopedics | 8 Comments

New Education and Discussion site for EM PAs (and other providers)


The focus of this site is to serve as an educational and commentary tool for EM PAs, PA students, and anyone interested in discussing aspects of care for emergency medicine patients.  Patients presented with run the gambit of acuity.  Posts will occur every 2 weeks with 1-2 cases presented for discussion or comment.  The point is to stimulate discussion on the art of medicine, not just the technical aspects of it.  Please feel free to voice an opinion.  

Posted in General Information | Leave a comment