The Internship Preparation Camp at the University of Maryland.

BACKGROUND: Specialty-specific 'boot camps' boost the competence and confidence of medical school graduates as they prepare to enter a residency programme. OBJECTIVE: We sought to evaluate the efficacy of a specialty-neutral Internship Preparation Camp (IPC) that we developed and made available to senior medical students at our medical school. The primary goal of the IPC is to educate students in the cognitive and procedural skills that are applicable to postgraduate year 1 trainees in all fields of specialisation. METHODS: The curriculum was developed through input from senior medical students and faculty from multiple specialties. The course used small-group sessions and skills labs led by distinguished speakers from various professions (medicine, nursing and pharmacy) to teach senior medical students the information and skills common to the needs of all new physicians, regardless of the specialty they have chosen. The course was presented across 3 half-days and was offered just prior to graduation. RESULTS: Of 166 possible participants, 65 attended the course; 39 (60%) of them completed evaluations immediately following the course and 29 (45%) of participants completed a follow-up evaluation 3 months later. All respondents reported increased confidence in caring for patients in all subject areas taught. In the follow-up survey, 82% of respondents reported using information learned during the course on an hourly, daily or weekly basis in their care of patients. CONCLUSIONS: A specialty-neutral IPC is of benefit to its attendees, regardless of the medical specialty in which they train.

54-year-old Woman with Chest Pain.

Chest pain is a common presentation to the emergency department (ED) that can be caused by a multitude of etiologies. It can be challenging to differentiate life-threatening conditions from more benign causes. A 54-year-old woman presented to the ED complaining of chest pain with dyspnea in the setting of recent blunt trauma. This case offers a thorough yet practical approach to the diagnostic workup of chest pain with dyspnea in the ED setting. The surprising final diagnosis and case outcome are then revealed.

A 77-Year-Old Male with a Rapid Change in Mental Status.

A 77-year-old male who presented to the emergency department with generalized weakness and worsening chronic dysphagia was diagnosed with pneumonia. Shortly after receiving vascular access for his treatment, he had a rapid change in his mental status and neurological examination.

57-Year-Old Male Veteran with Recurrent Fevers.

A 57-year-old male veteran presented to the emergency department for recurrent fevers for 10 days. The patient was febrile but had an overall benign physical exam. This interesting case explores the broad differential diagnosis and evaluation in a patient who presents with fever of unknown origin.

44-year-old Man with Hemoptysis and Hypoxemic Respiratory Failure: A Case Report.

INTRODUCTION: Hemoptysis can be a highly alarming presentation in the emergency department (ED). Even seemingly minor cases may represent potentially lethal underlying pathology. It requires thorough evaluation and careful consideration of a broad differential diagnosis. CASE PRESENTATION: A 44-year-old man presented to the ED with a concern of hemoptysis in the setting of recent fever and myalgias. DISCUSSION: This case takes the reader through how to approach the differential diagnosis and diagnostic work-up of hemoptysis in the ED setting and then reveals the surprising final diagnosis.

45-year-old Male with Bilateral Lower Extremity Wounds, Swelling, and Rash.

A 45-year-old male presented to the emergency department (ED) with bilateral lower extremity pain, swelling, and associated atypical rash in the setting of polysubstance use and unstable housing. Laboratory tests showed an elevated white blood cell count and inflammatory markers.

60-year-old Female with Edema.

INTRODUCTION: Many patients present to the emergency department (ED) with nonspecific, acute-on-chronic complaints. It requires a thorough diagnostic approach and broad differential diagnosis to determine whether there is serious, undiagnosed pathology. CASE PRESENTATION: A 60-year-old female presented to the ED for gradually worsening bilateral lower extremity swelling with associated abdominal distension, ascites, diarrhea, vomiting, and weight loss. DISCUSSION: This case takes the reader through the evaluation of a patient with acute-on-chronic complaints who presented in a decompensated state.

58-year-old Male with a Headache, Hand Numbness, and Phantosmia.

INTRODUCTION: A 58-year-old male presents to the emergency department with headache, hand numbness, and phantosmia. CASE PRESENTATION: Magnetic resonance imaging showed multiple acute and early subacute lesions involving the cortex and subcortical white matter of the left frontal lobe, left parietal lobe, left temporal lobe, left caudate, and left putamen. DISCUSSION: This case takes the reader through the subtle findings that led to the diagnosis and ultimately to treatment.

57-year-old Female with Unusual Left-arm Movements.

INTRODUCTION: A 57-year-old, right-hand dominant female presented to the emergency department striking herself with her left hand. CASE PRESENTATION: The astute medical staff looked beyond a behavioral health etiology. A detailed history, physical examination, and workup reveals the fascinating final diagnosis. DISCUSSION: This case takes the reader through the differential diagnosis and systematic workup of uncontrolled limb movements with discussion of the studies which ultimately led to this patient's diagnosis.

55-year-old Male with Fatigue.

This clinicopathological case presentation from the University of Maryland details the initial assessment and management of a 55-year-old, dialysis-dependent man with fatigue. We present how one of our emergency medicine faculty develops her differential when faced with this complaint. She describes how she arrives at the suspected diagnosis and the test she believes is needed to prove her hypothesis. The final surprising diagnosis is then revealed.

40-year-old Female with Sudden Onset Dyspnea.

A 40-year-old female presented to the emergency department (ED) after the acute onset of dyspnea. The patient was tachypneic with accessory muscle usage and diffuse wheezing on initial examination. Despite aggressive treatment, the patient deteriorated and was intubated. This case takes the reader through the differential diagnosis and systematic workup of a patient presenting to the ED with dyspnea and arrives at the unexpected cause for this patient's presentation.

19-year-old Woman with Intermittent Weakness.

INTRODUCTION: Systemic weakness is a common chief complaint of patients presenting to the emergency department (ED). A well thought out approach to the assessment and workup of these patients is key to diagnostic accuracy and definitive therapy. CASE PRESENTATION: In this case, a 19-year-old female presented to the ED with generalized weakness and near syncope. She had global weakness in her extremities and multiple electrolyte abnormalities. DISCUSSION: This case takes the reader through the differential diagnosis and evaluation of a patient with weakness and profound electrolyte derangements. It includes a discussion of the diagnostic studies and calculations that ultimately led to the patient's diagnosis.

73-year-old Female with Syncope and Motor Vehicle Collision.

INTRODUCTION: Patients with traumatic injuries can be difficult to assess, and their evaluation often evolves in the emergency department (ED). We describe how an ED attending physician member developed a differential diagnosis for this presentation, arrived at a suspected diagnosis, and what test he proposed to prove his hypothesis. CASE PRESENTATION: This clinicopathological case presentation details the initial assessment and management of a 73-year-old female who presented to the ED following a motor vehicle collision precipitated by a syncopal episode. CONCLUSION: The final surprising diagnosis is then revealed.

36-year-old Male with Syncope.

CASE PRESENTATION: A 36-year-old incarcerated male presented to the emergency department (ED) after an episode concerning for syncope. The patient had nystagmus and ataxia on initial examination. DISCUSSION: There is a broad differential diagnosis for syncope, and for patients presenting to the ED we tend to focus on cardiogenic and neurologic causes. This case takes the reader through the differential diagnosis and systemic work-up of a patient presenting to the ED with syncope.

40-year-old Male with a Headache and Altered Mental Status.

A 40-year-old man presents to the emergency department with headache, nausea and paresthesias, with subsequent fever and mental status change. Magnetic resonance imaging showed increased fluid-attenuation inversion recovery signal involving multiple areas of the brain, including the pons. This case takes the reader through the differential diagnosis of rhombencephalitis (inflammation of the hindbrain) with discussion of the unanticipated ultimate diagnosis and its treatment.

Evidence of fentanyl use is common and frequently missed in a cross-sectional study of emergency department patients in Baltimore, Maryland.

Objective: Fentanyl-associated deaths have risen in Maryland, but the prevalence of illicit fentanyl use is unknown. Our objective was to measure whether fentanyl is present among emergency department (ED) patients seeking care for a drug overdose.Design: The prevalence of fentanyl use was determined using a cross-sectional study of a convenience sample of adult ED patients with complaints of apparent opioid overdose, withdrawal from opioids, and/or requesting treatment for their substance use disorder (SUD) between February and April, 2018. Subjects were consented, interviewed, and underwent urine point-of-care (POC) fentanyl testing.Results: A total of 102 patients met inclusion criteria and were approached, 76 consented, 63 (83%) of whom tested positive for recent fentanyl use. 60 (80%) were male, 26 (34%) had overdosed, 41 (54%) were seeking SUD treatment, and 13 (17%) were in withdrawal (4 had multiple complaints). Of those who underwent both standard hospital urine drug screen and POC fentanyl testing, 56% (22/39) were positive for fentanyl and negative for opiates. Only 5% (4/76) reported knowledge of using fentanyl.Conclusions: Fentanyl use was common and frequently missed among these ED patients. Hospitals who treat patients taking illicit fentanyl should consider adding fentanyl to their urine drugs of abuse panel.

55-year-old Male with Exertional Dyspnea.

INTRODUCTION: Dyspnea is a common presenting complaint for many patients in the emergency department. CASE PRESENTATION: A 55-year-old man with type I diabetes presented to the emergency department with one month of intermittent palpitations and dyspnea. His lungs were clear to auscultation, and his chest radiograph was normal. DISCUSSION: This case takes the reader through the differential diagnosis and systematic work-up of dyspnea with discussion of the diagnostic study, which ultimately led to this patient's diagnosis and successful treatment.

Tracheostomy Emergencies.

Tracheostomy is a common procedure for long-term airway management. Although the overall complication rate is greater than 50%, the incidence of serious complications is low. These serious complications can, however, lead to significant morbidity and mortality and it is incumbent on the emergency provider to be prepared to deal with such tracheostomy-related emergencies. The greatest life threats to the tracheostomy patient are decannulation, obstruction, and hemorrhage. Other important but lower-acuity complications include tracheoesophageal fistula formation, tracheal stenosis, infection, and tracheocutaneous fistula formation.

50-year-old Male With Chest Pain.

A 50-year-old male presented to the emergency department with four days of intermittent chest pain and shortness of breath, which progressively worsened in severity. Testing revealed a troponin I greater than 100 times the upper limit of normal and an electrocardiogram with non-specific findings. This case takes the reader through the differential diagnosis and systematic work-up of the deadly causes of chest pain, ultimately leading to this patient's diagnosis.

Eight-year-old Boy with New-onset Seizure.

An eight-year-old boy presented to the emergency department for a first-time seizure. The patient had only signs of mild dehydration on physical exam and had an uneventful postictal recovery. First-time seizures in pediatric patients are often benign and require only an outpatient workup; some are dangerous. This case takes the reader through the differential diagnosis and systematic work-up of new-onset pediatric seizures, leading to an unanticipated diagnosis.