Emergency & Ambulatory Care

Emergency & Ambulatory Care: Step 3 & Residency

Master emergency and ambulatory care principles with free flashcards and spaced repetition practice. This lesson covers triage protocols, common ambulatory presentations, acute stabilization techniques, and evidence-based management strategies—essential concepts for USMLE Step 3 success and effective residency performance.

Welcome to Emergency & Ambulatory Care

Welcome! Emergency medicine and ambulatory care represent two critical settings where you'll apply clinical reasoning under pressure. Emergency departments demand rapid assessment, stabilization, and disposition decisions, while ambulatory care requires longitudinal management, preventive strategies, and patient-centered communication. This lesson bridges acute and chronic care paradigms, preparing you for both Step 3 scenarios and real-world clinical practice. 🏥

Core Concepts

🚨 Emergency Department Triage & Stabilization

Triage is the systematic process of determining treatment priority based on severity of illness or injury. The Emergency Severity Index (ESI) uses a 5-level system:

ESI Level	Description	Resource Needs	Example
1	Resuscitation	Immediate	Cardiac arrest, severe trauma
2	Emergent	High (multiple)	Chest pain, stroke symptoms
3	Urgent	Moderate (2+)	Abdominal pain, asthma exacerbation
4	Less Urgent	Low (1)	Simple laceration, UTI symptoms
5	Non-urgent	Minimal	Medication refill, cold symptoms

Primary Survey (ABCDE Approach)

The trauma primary survey ensures life-threatening conditions are addressed first:

┌────────────────────────────────────────────────┐
│           PRIMARY SURVEY SEQUENCE              │
└────────────────────────────────────────────────┘

    🫁 A - AIRWAY (with C-spine protection)
           |
           ↓
    💨 B - BREATHING (ventilation/oxygenation)
           |
           ↓
    ❤️ C - CIRCULATION (hemorrhage control)
           |
           ↓
    🧠 D - DISABILITY (neurologic status)
           |
           ↓
    🌡️ E - EXPOSURE (remove clothing, prevent hypothermia)
           |
           ↓
    🔄 Reassess continuously

💡 Pro Tip: The mnemonic "AMPLE" helps gather critical history: Allergies, Medications, Past medical history, Last meal, Events leading to presentation.

Shock Recognition & Management

Shock represents inadequate tissue perfusion. Recognize the four main types:

Shock Type	Mechanism	HR	BP	CVP	Example
Hypovolemic	Volume loss	↑	↓	↓	Hemorrhage, dehydration
Cardiogenic	Pump failure	↑	↓	↑	MI, heart failure
Distributive	Vasodilation	↑	↓	↓	Sepsis, anaphylaxis
Obstructive	Mechanical obstruction	↑	↓	Varies	PE, tension pneumothorax

⚠️ Common Mistake: Not all shock presents with tachycardia! Patients on beta-blockers, with spinal cord injury, or in late-stage decompensated shock may be bradycardic or normocardic.

🩺 Common Emergency Presentations

Chest Pain Evaluation

Chest pain requires systematic exclusion of life-threatening causes:

        CHEST PAIN DIFFERENTIAL
              (Priority Order)

    ┌─────────────────────────────┐
    │  🚨 LIFE-THREATENING         │
    ├─────────────────────────────┤
    │  • ACS (MI/Unstable angina) │
    │  • Aortic dissection        │
    │  • Pulmonary embolism       │
    │  • Tension pneumothorax     │
    │  • Esophageal rupture       │
    └─────────────────────────────┘
              ↓
    ┌─────────────────────────────┐
    │  ⚠️ SERIOUS BUT STABLE       │
    ├─────────────────────────────┤
    │  • Pericarditis             │
    │  • Pneumonia                │
    │  • Stable angina            │
    └─────────────────────────────┘
              ↓
    ┌─────────────────────────────┐
    │  ✓ LESS URGENT              │
    ├─────────────────────────────┤
    │  • Costochondritis          │
    │  • GERD                     │
    │  • Musculoskeletal          │
    └─────────────────────────────┘

Initial workup includes: ECG within 10 minutes, troponin, CXR, and risk stratification (HEART score, TIMI score).

Altered Mental Status (AMS)

The mnemonic "AEIOU TIPS" covers common reversible causes:

• A - Alcohol/Acidosis
• E - Encephalopathy/Electrolytes/Endocrine
• I - Insulin (hypo/hyperglycemia)
• O - Opiates/Oxygen (hypoxia)
• U - Uremia
• T - Trauma/Temperature
• I - Infection
• P - Psychosis/Poison
• S - Seizure/Stroke/Shock

🧠 Clinical Pearl: Always check fingerstick glucose FIRST in any AMS patient—hypoglycemia is rapidly reversible and can mimic stroke, intoxication, or psychiatric disease.

Abdominal Pain Assessment

Systematic approach prevents missed diagnoses:

Location	Concerning Diagnoses	Key Tests
RUQ	Cholecystitis, hepatitis, pneumonia	RUQ US, LFTs
RLQ	Appendicitis, ectopic pregnancy, ovarian torsion	CT abdomen/pelvis, β-hCG
LUQ	Splenic infarct/rupture, pancreatitis	CT, lipase
LLQ	Diverticulitis, ectopic, ovarian torsion	CT abdomen/pelvis
Epigastric	PUD, pancreatitis, MI, AAA	Lipase, ECG, CT if AAA suspected
Periumbilical	Early appendicitis, SBO, mesenteric ischemia	CT, lactate

⚠️ Red Flags: Hypotension, peritonitis, pulsatile mass, bloody stool, or abdominal distention with absent bowel sounds demand immediate surgical consultation.

🏥 Ambulatory Care Fundamentals

Preventive Care Guidelines

Age-appropriate screening is cornerstone of ambulatory medicine:

Screening	Population	Frequency	Organization
Colorectal cancer	50-75 years	Colonoscopy q10y or FIT yearly	USPSTF
Mammography	50-74 years	Every 2 years	USPSTF
Cervical cancer	21-65 years	Pap q3y (21-29); Pap+HPV q5y (30-65)	USPSTF
Hypertension	≥18 years	Every visit or yearly	USPSTF
Diabetes (T2DM)	40-70 years with BMI ≥25	Every 3 years	USPSTF
Lipids	40-75 years	Every 5 years	USPSTF
AAA screening	Men 65-75 who ever smoked	Once	USPSTF

💡 Step 3 Strategy: USPSTF Grade A and B recommendations are high-yield. Know the age cutoffs and intervals cold!

Chronic Disease Management

Hypertension Management

Follow the 2017 ACC/AHA guidelines:

BLOOD PRESSURE CLASSIFICATION
┌─────────────────────────────────────────────┐
│  Normal: <120/<80 mmHg                      │
├─────────────────────────────────────────────┤
│  Elevated: 120-129/<80 mmHg                 │
├─────────────────────────────────────────────┤
│  Stage 1 HTN: 130-139/80-89 mmHg            │
├─────────────────────────────────────────────┤
│  Stage 2 HTN: ≥140/≥90 mmHg                 │
└─────────────────────────────────────────────┘

TREATMENT APPROACH
┌─────────────────────────────────────────────┐
│  Goal: <130/80 for most patients            │
│                                             │
│  First-line agents (monotherapy/combo):     │
│  • ACE-I or ARB                             │
│  • Thiazide/thiazide-like diuretic          │
│  • CCB                                      │
│                                             │
│  Special populations:                       │
│  • Black patients: CCB or thiazide first    │
│  • CKD: ACE-I or ARB preferred              │
│  • DM: ACE-I or ARB preferred               │
└─────────────────────────────────────────────┘

Diabetes Management (Type 2)

Goals and treatment algorithms:

Parameter	Goal	Notes
HbA1c	<7% (individualize)	Less stringent (7.5-8%) for elderly, comorbidities
Preprandial glucose	80-130 mg/dL	Adjust based on hypoglycemia risk
Postprandial glucose	<180 mg/dL	1-2 hours after meal
BP	<130/80 mmHg	ACE-I/ARB first-line
LDL	<70 mg/dL (high risk)	Statin therapy indicated

Medication approach:

1. First-line: Metformin (unless contraindicated)
2. Add second agent based on comorbidities:
   • ASCVD or high risk → GLP-1 RA or SGLT2i with CV benefit
   • Heart failure → SGLT2i
   • CKD → SGLT2i or GLP-1 RA
   • Cost concern → Sulfonylurea, TZD
3. Insulin if HbA1c >10% or symptomatic hyperglycemia

COPD Exacerbation Management

Ambulatory vs. ED management depends on severity:

COPD EXACERBATION SEVERITY ASSESSMENT

┌─────────────────────────────────────────────┐
│  MILD (Outpatient management)               │
├─────────────────────────────────────────────┤
│  • Increased dyspnea but no distress        │
│  • No hypoxemia                             │
│  • No accessory muscle use                  │
│  • Mental status normal                     │
│  Rx: Bronchodilators ± antibiotics ±        │
│      prednisone 40mg x 5 days               │
└─────────────────────────────────────────────┘
              ↓
┌─────────────────────────────────────────────┐
│  MODERATE-SEVERE (ED/Hospital)              │
├─────────────────────────────────────────────┤
│  • Significant dyspnea at rest              │
│  • Hypoxemia (SpO2 <90%)                    │
│  • Accessory muscle use                     │
│  • Altered mental status                    │
│  • Acute respiratory acidosis               │
│  Rx: O2, bronchodilators, steroids,         │
│      antibiotics, consider NIV/intubation   │
└─────────────────────────────────────────────┘

🧠 Clinical Pearl: "AECOPD antibiotics indication": Increased dyspnea + increased sputum volume + increased sputum purulence (all 3 = definite; 2 of 3 = probable benefit).

📞 Disposition & Follow-up

ED Disposition Decision-Making

Disposition	Criteria	Examples
Discharge home	Stable vitals, diagnosis established, outpatient management appropriate, reliable follow-up	Uncomplicated UTI, simple laceration, viral illness
Observation unit	Brief monitoring needed (6-24h), unclear diagnosis, response to treatment uncertain	Chest pain with negative troponin, mild asthma exacerbation
Hospital admission	Requires IV therapy, monitoring, or procedures not available outpatient	Pneumonia with hypoxia, CHF exacerbation, cellulitis requiring IV antibiotics
ICU admission	Organ failure, hemodynamic instability, airway compromise	Septic shock, respiratory failure, severe DKA

Ambulatory Follow-up Intervals

Condition	Follow-up Timing	Purpose
New hypertension	1-4 weeks	Assess response, side effects
Diabetes (stable)	3-6 months	HbA1c monitoring
New medication	2-4 weeks	Tolerability, efficacy
Abnormal screening test	Variable	Further workup, repeat testing
Post-hospitalization	7-14 days	Medication reconciliation, complications

💡 Communication Tip: Use the "teach-back method"—ask patients to explain instructions in their own words to verify understanding. Studies show this reduces readmission rates.

Examples with Detailed Explanations

Example 1: Chest Pain Risk Stratification 🫀

Clinical Scenario: A 58-year-old man with hypertension presents to the ED with substernal chest pressure for 2 hours, radiating to left arm. Initial ECG shows no ST changes. First troponin is negative.

Question: Should this patient be discharged with outpatient stress test?

Answer: No—this patient requires admission or observation.

Detailed Explanation:

The HEART score helps risk-stratify chest pain:

Component	Points (0-2)	This Patient
History	0=low suspicion, 1=moderate, 2=high	2 (typical angina)
ECG	0=normal, 1=nonspecific, 2=significant	0 (normal)
Age	0=<45, 1=45-64, 2=≥65	1 (58 years)
Risk factors	0=none, 1=1-2 factors, 2=≥3 or h/o CAD	1 (HTN)
Troponin	0=normal, 1=1-3x normal, 2=>3x normal	0 (negative)
TOTAL SCORE		4 points

Risk stratification:

• 0-3 points: Low risk (1.7% MACE) → Consider discharge with close follow-up
• 4-6 points: Moderate risk (12-17% MACE) → Admission/observation
• 7-10 points: High risk (50-65% MACE) → Admission, likely catheterization

Management: This patient needs serial troponins (typically at 0, 3, and 6 hours), continuous monitoring, and likely stress testing or coronary angiography before discharge. A single negative troponin does not rule out ACS in a moderate-risk patient.

🧠 Key Takeaway: Risk stratification tools like HEART score guide disposition, but clinical judgment is paramount. When in doubt, err on the side of caution with chest pain.

Example 2: Diabetic Patient with Foot Ulcer 🦶

Clinical Scenario: A 62-year-old woman with poorly controlled type 2 diabetes (HbA1c 9.2%) presents to your ambulatory clinic with a 2 cm ulcer on the plantar surface of her right foot for 3 weeks. No fever. Pedal pulses palpable. Ulcer is shallow with surrounding erythema.

Question: What is the appropriate management?

Answer: The patient needs:

1. Wound culture (including probe-to-bone test)
2. X-ray of foot (rule out osteomyelitis)
3. Vascular assessment (ABI if not already done)
4. Offloading device (walking boot or special shoe)
5. Empiric antibiotics (erythema suggests infection)
6. Glycemic optimization
7. Close follow-up (weekly initially)

Detailed Explanation:

Diabetic foot ulcers require systematic assessment:

DIABETIC FOOT ULCER EVALUATION
┌────────────────────────────────────────────────┐
│  1. INFECTION ASSESSMENT                       │
│     • Erythema >2cm = likely infected          │
│     • Purulence, warmth, tenderness            │
│     • Probe-to-bone test (if positive → osteo) │
│     • Systemic signs (fever, leukocytosis)     │
├────────────────────────────────────────────────┤
│  2. VASCULAR STATUS                            │
│     • Pedal pulses, ABI                        │
│     • If ABI <0.7 → vascular surgery referral  │
│     • Consider TBI if calcified vessels        │
├────────────────────────────────────────────────┤
│  3. NEUROPATHY                                 │
│     • Monofilament testing                     │
│     • Vibration sense                          │
├────────────────────────────────────────────────┤
│  4. DEPTH/SEVERITY (Wagner Classification)     │
│     Grade 0: Intact skin, high-risk foot       │
│     Grade 1: Superficial ulcer                 │
│     Grade 2: Deep ulcer (tendon/bone)          │
│     Grade 3: Deep ulcer with abscess/osteo     │
│     Grade 4: Forefoot gangrene                 │
│     Grade 5: Full foot gangrene                │
└────────────────────────────────────────────────┘

Antibiotic Selection (for infected ulcers):

• Mild infection (localized): Cephalexin or amoxicillin-clavulanate
• Moderate infection: Fluoroquinolone + clindamycin OR amoxicillin-clavulanate
• Severe infection (systemic): Hospital admission, IV antibiotics (piperacillin-tazobactam or carbapenem + vancomycin)

Common pathogens: S. aureus (including MRSA), Streptococcus, gram-negative rods, anaerobes.

⚠️ Red Flags for Hospital Admission: Systemic toxicity, deep tissue infection, gas in tissues, concern for necrotizing fasciitis, critical limb ischemia, inability to comply with outpatient treatment.

💡 Prevention Tip: All diabetic patients need annual comprehensive foot exams. High-risk patients (prior ulcer, neuropathy) need more frequent assessment and should NEVER walk barefoot.

Example 3: Acute Asthma Exacerbation 🫁

Clinical Scenario: A 28-year-old woman with known asthma presents to the ED with worsening dyspnea over 2 days, not relieved by albuterol inhaler. She's speaking in short phrases. Vitals: HR 118, RR 28, SpO2 91% on RA, BP 138/82. Peak flow is 45% of personal best. No wheezing on exam (minimal air movement).

Question: What is the immediate management?

Answer: This is a severe exacerbation requiring:

1. Continuous albuterol nebulization (5 mg) or 3 back-to-back treatments
2. Ipratropium (0.5 mg) added to albuterol
3. Systemic corticosteroids (prednisone 40-60 mg PO or methylprednisolone 125 mg IV)
4. Supplemental oxygen (goal SpO2 >90%)
5. Consider magnesium sulfate (2g IV over 20 minutes)
6. Consider ICU consultation (silent chest is ominous)

Detailed Explanation:

Severity assessment guides treatment intensity:

Severity	Symptoms	Peak Flow	Management
Mild	Minimal dyspnea, full sentences	>70% predicted	Albuterol PRN, consider oral steroids
Moderate	Moderate dyspnea, phrases	40-69% predicted	Albuterol q20min x3, ipratropium, oral steroids, O2
Severe	Severe dyspnea, words, accessory muscles	<40% predicted	Continuous albuterol, ipratropium, IV steroids, O2, Mg
Life-threatening	Drowsy, confused, silent chest, bradycardia	Unable to perform	Prepare for intubation, ICU, all above therapies

Why is "silent chest" concerning?

Absence of wheezing in a dyspneic asthmatic suggests severe bronchospasm with minimal air movement—it's paradoxically MORE dangerous than loud wheezing. This patient may tire and develop respiratory failure.

Reassessment after initial treatment (60-90 minutes):

• Good response (PEF >70%, minimal symptoms, SpO2 >90%) → Consider discharge with 5-7 day oral steroid taper, inhaled steroids, bronchodilator
• Incomplete response (PEF 40-69%, persistent symptoms) → Continue treatment, observe 4-6 hours
• Poor response (PEF <40%, no improvement, altered mental status) → Admit (ICU if severe)

Discharge criteria:

• PEF or FEV1 >70% predicted
• SpO2 >90% on room air
• Symptoms minimal and stable
• Adequate home medications and follow-up arranged
• Patient understands action plan

🧠 Clinical Pearl: Never use sedatives (benzos, opioids) in acute asthma—respiratory depression can be fatal. Also avoid empiric antibiotics unless clear evidence of bacterial infection (fever, purulent sputum, infiltrate).

Example 4: Syncope Evaluation 🧠

Clinical Scenario: A 72-year-old man with CAD presents after syncopal episode while standing in church. No prodrome. Bystanders report he was unconscious for ~30 seconds, then alert. No post-ictal confusion. No incontinence. Denies chest pain. ECG shows sinus rhythm with occasional PVCs.

Question: What is the risk stratification and appropriate disposition?

Answer: This patient is high-risk and requires admission for cardiac monitoring and evaluation.

Detailed Explanation:

Syncope risk stratification uses multiple tools. The San Francisco Syncope Rule identifies high-risk patients:

SAN FRANCISCO SYNCOPE RULE (CHESS-BP)
┌────────────────────────────────────────────────┐
│  Any ONE of following = HIGH RISK              │
├────────────────────────────────────────────────┤
│  C - CHF (history)                             │
│  H - Hematocrit <30%                           │
│  E - ECG abnormal (any non-sinus rhythm or     │
│      new changes)                              │
│  S - Shortness of breath                       │
│  S - Systolic BP <90 mmHg at triage            │
│                                                │
│  If positive → 4-10% risk serious outcome      │
│  If negative → <1% risk                        │
└────────────────────────────────────────────────┘

This patient has:

• ✅ History of CAD (cardiac disease)
• ✅ ECG with PVCs (abnormal)
• ✅ Age >60 (independent risk factor)
• ✅ No warning (suggests cardiac cause vs. vasovagal)

Syncope etiologies by category:

Category	Causes	Features
Cardiac (15-20%)	Arrhythmia, structural heart disease, PE	No prodrome, exertional, abnormal ECG/cardiac exam
Reflex/Vasovagal (40-50%)	Neurally mediated, carotid sinus hypersensitivity	Prodrome (nausea, diaphoresis), triggers (pain, emotion, standing)
Orthostatic (10-15%)	Volume depletion, medications, autonomic dysfunction	Occurs with position change, medications (diuretics, antihypertensives)
Neurologic (5-10%)	Seizure, stroke/TIA, SAH	Focal neuro signs, post-ictal confusion, severe headache

Workup approach:

1. All patients: ECG, orthostatic vitals, detailed history
2. High-risk features: CBC, BMP, troponin, CXR, continuous cardiac monitoring
3. Consider: Echocardiogram (structural disease), Holter/event monitor (arrhythmia)
4. Rarely indicated emergently: Head CT (only if concerning for neurologic cause), carotid ultrasound

Disposition:

• Admit: Age >60, cardiac disease, abnormal ECG, exertional syncope, sudden onset without prodrome, family history sudden death
• Discharge: Young, benign history, clear vasovagal trigger, normal ECG and vitals, good follow-up

This patient needs telemetry monitoring and likely echocardiogram and stress test or coronary angiography. Arrhythmia (VT, heart block) is most concerning etiology given his CAD.

💡 Step 3 Tip: Syncope questions often hinge on risk stratification. Know which patients can go home vs. need admission. When unsure, err toward admission for cardiac evaluation.

Common Mistakes

⚠️ Mistake #1: Anchoring bias in chest pain evaluation

Error: Discharging a patient with "atypical" chest pain and negative first troponin without serial testing or risk stratification.

Why it's wrong: Troponins rise over time; a single negative troponin doesn't exclude MI, especially if drawn within 2-3 hours of symptom onset. "Atypical" presentations are common in women, elderly, and diabetics.

Correct approach: Use validated risk scores (HEART, TIMI), obtain serial troponins, and have low threshold for observation or admission in moderate-risk patients.

---

⚠️ Mistake #2: Over-relying on pulse oximetry in COPD exacerbation

Error: Assuming a COPD patient with SpO2 88-90% is "at baseline" without obtaining ABG or assessing work of breathing.

Why it's wrong: Chronic hypoxemia doesn't mean acute hypercapnia and respiratory acidosis aren't developing. CO2 retention can occur with minimal change in O2 saturation.

Correct approach: In dyspneic COPD patients, assess respiratory rate, accessory muscle use, mental status. Consider ABG if concerned for hypercapnia. Target SpO2 88-92% in COPD (over-oxygenation can worsen hypercapnia).

---

⚠️ Mistake #3: Missing sepsis by focusing on fever

Error: Ruling out sepsis because patient is afebrile or hypothermic.

Why it's wrong: Elderly, immunosuppressed, and severely septic patients may be afebrile or hypothermic. Sepsis is defined by infection + organ dysfunction (qSOFA ≥2 or SOFA score increase ≥2).

Correct approach: Use qSOFA criteria for screening (RR ≥22, altered mentation, SBP ≤100). Any patient with suspected infection and organ dysfunction needs aggressive resuscitation with IV fluids and early antibiotics (within 1 hour).

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⚠️ Mistake #4: Prescribing NSAIDs to everyone with musculoskeletal pain

Error: Giving ibuprofen or naproxen without screening for contraindications.

Why it's wrong: NSAIDs have significant adverse effects: GI bleeding (especially with anticoagulants or steroids), acute kidney injury (especially with dehydration, CHF, CKD), hypertension, MI/stroke risk.

Correct approach: Screen for CKD, heart failure, PUD history, anticoagulation. Consider acetaminophen or topical NSAIDs as safer alternatives. If oral NSAIDs necessary, use lowest effective dose for shortest duration, with PPI if high GI risk.

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⚠️ Mistake #5: Inadequate discharge instructions

Error: Sending a patient home without clear return precautions, follow-up plan, or medication reconciliation.

Why it's wrong: Poor transitions of care lead to medication errors, missed follow-up, and preventable readmissions. Up to 20% of patients discharged from ED have adverse events within 2 weeks.

Correct approach: Every discharge should include:

• Written and verbal instructions in patient's preferred language
• Specific return precautions (red flags)
• Follow-up appointment scheduled or clear instructions for scheduling
• Medication reconciliation with clear instructions
• Teach-back to verify understanding

---

⚠️ Mistake #6: Not considering pregnancy in reproductive-age women

Error: Ordering CT abdomen or prescribing teratogenic medications without pregnancy test.

Why it's wrong: Undiagnosed early pregnancy is common. Radiation and certain medications (ACE inhibitors, warfarin, tetracyclines, NSAIDs in 3rd trimester) can cause fetal harm.

Correct approach: Obtain urine or serum β-hCG in all women of childbearing age (generally 12-50 years) before imaging with ionizing radiation or prescribing potentially teratogenic drugs. When pregnancy test unavailable or refused, document discussion of risks.

Key Takeaways

📚 Further Study

Deepen your understanding with these evidence-based resources:

1. ACEP Clinical Policies - https://www.acep.org/patient-care/clinical-policies/ - Official emergency medicine guidelines on chest pain, syncope, stroke, and other time-sensitive conditions.

2. USPSTF Recommendations - https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics - Comprehensive preventive care screening guidelines with evidence summaries (essential for Step 3).

3. UpToDate: Emergency Medicine - https://www.uptodate.com/contents/table-of-contents/emergency-medicine - Gold-standard clinical reference with regularly updated algorithms for emergency and acute care management.

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Congratulations! 🎉 You've completed the Emergency & Ambulatory Care module. You now have the framework to approach acute presentations systematically, risk-stratify effectively, and manage chronic diseases in the outpatient setting. Remember: emergency medicine demands rapid pattern recognition and decisive action, while ambulatory care requires longitudinal thinking and preventive strategies. Master both, and you'll excel on Step 3 and in clinical practice. Keep practicing with these concepts, use the flashcards regularly, and you'll build the clinical reasoning skills that define excellent physicians. Good luck! 🏆