A 58-year-old woman with a history of smoking complains of days of worsening
shortness of breath, now worsening today.  She has associated chest pain that appears to be constant, without waxing or waning; she has no other associated symptoms.

On examination, vital signs show: T 100.1 HR 88 BP 130/80 RR 22 SpO2 87% on room air that increases to 96% on oxygen. She has rales heard in both lung bases and seemingly distant heart sounds.  She exhibits some lower extremity edema.  When you sit her up to perform a better lung examination, she becomes very uncomfortable and has worsening shortness of breath – her oxygen saturation decreases to 75%.

Your patient asks you in a panic to bring the head of the bed back down, where she
feels more comfortable, and her oxygen saturation on supplemental oxygen  improves.

Based on what we know this far, which is the MOST likely etiology:

    A. Congestive heart failure
    B. Pneumonia
    C. Pulmonary embolism
    D. Chronic obstructive pulmonary disease 


In the meantime, a quote – 
 
A man is a poor physician who has not two or three remedies ready for use in every
case of illness.

– Asclepiades, 1st century BC; Greek-born Roman physician

A 17-year-old boy was playing football when he was tackled and pinned under
a few players after the ball was fumbled and a pile-on ensued.  He complains only of right knee pain and swelling.  The boy is otherwise healthy, has normal vital signs, and his total body check shows no other evidence of trauma.

On examination, he has a mild effusion of the right knee and is neurovascularly intact.  Due to the patient’s pain, further knee stress testing is deferred until analgesia is offered and radiography is performed:

He improves with pain medication, and the other components of his knee examination are either inconclusive or non-confirmatory.  Which of the following is the BEST
management approach:

    A. Crutches, weight bear as tolerated
    B. Knee immobilizer, primary care follow up
    C. Knee immobilizer, orthopedic follow up
    D. CT arthrogram



In the meantime, a quote – 
 
La notte che le cose ci nasconde.

[The night that hides things from us.]

– Durante (Dante) degli Alighieri (1265-1321)
   Canto XXIII, La Divina Commedia

A 59-year-old woman with a history of dyspepsia complains of one day of crampy
epigastric pain associated with nausea.  She describes this pain as different from her chronic post-prandial pain.  She reports no fever, back pain, chest pain, or other associated symptoms.  The woman recalls a “gall bladder surgery” years ago for gall stones.

On examination, T 98.4 C 160/70 HR 82 RR 12 SpO2 98% RA.  She is uncomfortable and has moderate epigastric tenderness to palpation without evidence of peritonitis. Her rectal examination is normal; stool is guaiac negative.

WBC 12.1 with elevated polymorphonuclear cells; chemistries, liver function tests,
and lipase are normal.  Her bedside right upper quadrant ultrasound was technically difficult, thought to be due to interference with intestinal gas scattering.  Due to her significant symptoms, tenderness to palpation, elevated white blood cell count with left shift, and unclear picture, a CT was performed:

Which of the following is the MOST likely etiology of her CT findings?

     A. Mesenteric ischemia
     B. Cholecystitis
     C. Small bowel obstruction
     D. Ulcerative colitis


In the meantime, a quote ‒

Symptoms, then are in reality nothing but the cry from suffering organs.

Leçons cliniques sur les maladies des vieillards et les maladies chroniques

Jean Martin Charcot (1825-1893)

A 9-year-old boy was skateboarding with his friends over a hill when he entered a
major intersection and was hit by a car going approximately 40 mph down the
cross street. On arrival to the ED, HR 160 BP 110/70 RR 26, SpO2 96% RA. 
His primary survey was significant for thoraco-abdominal ecchymosis; secondary survey showed a GCS of 11 with agitation.  He was endotracheally intubated for declining clinical course and behavior control.

CT of his abdomen shows grade III liver laceration; initial hemoglobin is 9 g/dL.  On return from radiology, HR 170 BP 88/60.  He is started on a massive transfusion protocol in a 1:1:1 ratio (PRBCs:Plasma:Platelets); after 40 mL/kg of PRBCs, his repeat vital signs show HR 110 BP 100/80 with normal urine output and skin signs.  
 
While awaiting a bed in the intensive care unit, he develops a wide-complex
tachycardia:

What action should be taken immediately?

     A. Perform thoracotomy, cross-clamp aorta, open cardiac massage
     B. Membrane-stabilization therapy
     C. Re-initiate massive blood transfusion to optimize oxygenation
     D. Emergent hemodialysis
 

In the meantime, a quote – 
 
Every man prefers belief to the exercise of judgment.

– Lucius Annaeus Seneca, Roman Stoic philosopher (4 BC – AD 65)

…and…

Experts often possess more data than judgment.

– Colin Powell, retired US Army general (1937 - ) 

A 72-year-old woman with a history of COPD, hypertension, and chronic constipation
arrives to the ED after feeling weak and dizzy earlier today when standing from
a sitting position.  She denies preceding or subsequent chest pain; shortness of breath; nausea; head, back, or abdominal pain.  There is no history of trauma and she has had no recent changes to her medications.  On review of systems, over the past few months she has had generalized weakness and family reports her slow progression of having less energy, needing more time to get dressed, and becoming easily confused and fatigued.  They are concerned that they can no longer care for her at home.

On examination, our patient’s vital signs are: T 97.0 °F HR 66 BP 118/70 RR 12 SpO2 96% RA.  In general, she is slow to respond but attends well to questioning; her
voice is coarse, which her family attributes to her previous smoking history.  Her cardiovascular and pulmonary exams are unremarkable.  Total body check shows no evidence of trauma, infection, or toxidrome; her skin is dry and flaky, but with normal turgor.  Her electrocardiogram, chest x-ray, metabolic panel, and urinalysis are
all inconclusive.  She remains hemodynamically stable in the ED.

Which is the next BEST step in her management?

    A. Admit her for observation and likely placement
    B. Stop all medications and admit for medication washout
    C. Discharge home with follow up and likely placement as outpatient
    D. Admit for likely hormone replacement therapy


In the meantime, a quote – 

"Old age hath yet his honour and his toil." 

– Alfred Lord Tennyson (1809-1892)

A two-week-old baby boy is brought in by his mother for a “bump” on his head that
has recently become more apparent.  The child was born full term via normal spontaneous delivery without complication.  There has been no history of trauma, fever, or change in intake, output, or behavior.  The boy’s first well-child appointment is tomorrow morning, but an alarmed family member convinced the family to seek help tonight.

On examination, the child is well appearing with normal vital signs and an otherwise normal total body check.  The area of concern is shown below:

Which of the following is the BEST course of action?

    A. CBC, blood cultures, incision and drainage, admission to the hospital
    B. Tie base of lesion with silk suture, observe briefly, outpatient follow-up
    C. Watchful waiting and referral to primary medical doctor
    D. Obtain stat MRI


In the meantime, a quote – 
 
Festina lente.

[Make haste slowly.]

– Classical adage

A 27-year-old woman with no past medical history complains of one week of dizziness and palpitations, especially when she gets up quickly; she is now asymptomatic in the ED.  She states that she “gets this way from time to time”, and she is sure that it “must just be my stress”.  The woman is not taking any medications, and denies illicit substances, recent illness, or change in her diet.  Her vital signs and cardiovascular and neurologic examinations are normal, and she is not pregnant.

Her electrocardiogram shows a heart rate of 68, no evidence of pre-excitation, and no ST or T wave changes from a previous electrocardiogram done for the same complaint three months ago: QT interval 480 ms, corrected QT (QTc) 512 ms.

Which of the following would be the MOST helpful in establishing a diagnosis:

    A.    Serum potassium level
    B.    Serum magnesium level
    C.    Serum calcium level
    D.    Repeat electrocardiogram


In the meantime, a quote – 
 
“To each one of you the practice of medicine will be very much as you make it – to one a worry, a care, a perpetual annoyance; to another, a daily joy and life of as much happiness and usefulness as can well fall to the lot of man.”

–William Osler

A three-month-old girl is brought in by her parents for decreased intake by mouth and “breathing fast”. The parents know that she was “born with a problem with her heart”, but are unable to explain further – “all of her information is in the computer” – except that computer is in another tertiary hospital, miles away.
 
Parents are unaware of any fevers; there has been no vomiting, diarrhea, change in urinary output, or change in behavior, other than increasing fussiness and refusing to take her bottle.  On examination, you see a small-for-age infant in mild respiratory distress, with intercostal retractions and nasal flaring; she has bibasilar rales and trace hepatomegaly.  
 
T 37.9 HR 160 RR 40 80/60 SpO2 88%
 
You reposition her and place her on high-flow nasal cannula and repeat her vital signs:

HR 150 RR 38 SpO2 90%
 
Which of the following is an example of this physiology?

    A.    Cyanotic congenital heart disease
    B.    Bronchial circulation
    C.    Blood flow through atelectatic lung segments
    D.    Thebesian circulation
    E.    All of the above


In the meantime, a few quotes – 
 
“The axiom of medicine is that natural science is its mother.”

…and…

“Widespread experience in the field of pathological anatomy must be the foundation, unless the whole procedure is to eventuate in deception.”
 
Karl von Rokitansky (1804-1878)
Viennese pathologist

A 23-year-old man with no past medical history comes to the ED for pain and swelling around his forearm tattoo, which he received three days prior during a weekend-long celebration with his friends.  To help with the pain, he continued drinking when he arrived home.  His review of systems is unclear, and he may have had chills with some nausea over the past day.  He is a smoker and denies illicit drug use.

On arrival, T 99.9  HR 92 136/90  RR 20 SpO2 98% RA

In general, he is anxious but in no acute distress.  His general exam is reassuring; the extremity shows no streaking, crepitus, or lymphadenopathy.  His tattoo is shown below:

Which is the most likely diagnosis?

    A.    Aseptic inflammatory reaction
    B.    Subcutaneous ink diffusion
    C.    Contact dermatitis
    D.    Pyogenic infection

In the meantime, a quote –

“The physician can do all he has to do with speed and precision, but he must never appear to be in a hurry, and never absent-minded.”

Theodor Billroth 1829-1894

Prussian-born Professor of Surgery, Vienna

A 12-year-old boy complains of three months of right foot pain, made worse with running and jumping.  He was playing a football scrimmage today when the pain worsened and it became difficult for him to walk.  On arrival, his vital signs and general exam are normal.  He has a normal right foot exam by inspection, but on palpation has focal tenderness.  His radiograph is below:

Which of the following is the MOST helpful in narrowing the differential diagnosis?

    A.    Tenderness to palpation at the base of the 5th metatarsal
    B.    Preservation of metatarsal-cuboid joint
    C.    Increased pain with bearing weight
    D.    Increased pain with inversion

In the meantime, a quote –

“It is by poultices, not by words, that pain is ended, although pain is by words both eased and diminished.”

– Petrarch (1304-1374)

Italian poet and scholar