A 67-year-old man with a history of hypertension and myocardial infarction 6 years ago presents to the ED with his wife.  He is not interested in coming to the ED, but his wife explains that he has been complaining of dizziness and fatigue over the past week.  On directed questioning, the man has no complaints of chest pain or palpitations.  He has baseline mild shortness of breath, but this does not appear to be much worse than usual.

His current medications include furosemide, lisinopril, and carvedilol; no allergies to report.  He denies past surgical history and his family and social histories are unremarkable.

You see a fatigued overweight man in no acute distress.

T 37.8     HR 60     110/60     RR 20     SpO2     98% RA

His examination is significant for a well healed incision in his left upper chest with a pulse generator pocket that is non-erythematous, non-edematous, and non-tender to palpation.  When you enquire about this, he explains that a pacemaker was placed when he had his heart attack.  The remainder of his physical examination is unremarkable, except for trace crackles at bilateral pulmonary bases.

His electrocardiogram follows:



Which of the following is the most likely explanation for his presentation:

    A.    Runaway pacemaker
    B.    Failure to capture
    C.    Pacemaker syndrome
    D.    Failure to sense


In the meantime, a quote –

“Diagnosis is a system of more or less accurate guessing, in which the endpoint achieved is a name.”  Lancet I: 619 (1944)

Thomas Lewis (1881-1945)

Physician and clinical scientist

A 28-year-old woman G3P2 is brought in by ambulance in active labor.  She is sitting up and frantically squirming on the gurney shouting “it’s not supposed to be like this!”  You see an agitated obese woman in active labor, with green, thick particulate matter on a wet gurney.  The only information you can gather from her is that she is expecting a singleton child, due last week.  The baby is crowning.

The child is delivered precipitously and appears limp and apneic.  His heart rate by umbilical cord approximation is 90 beats per minute.

Which of the following is the CORRECT approach?

A.   Dry, warm, and stimulate the child

B.   Start positive pressure ventilation via bag-valve mask

C.   Start an IO line and give 0.01 mg/kg epinephrine

D.   Intubate and connect the ETT to suction


In the meantime, a quote --  

"Love and pregnancy and riding on a camel cannot be hid"  

-- Arabic proverb

A 38-year-old man is brought to the ED by police for erratic behavior from the downtown area.  The man was found screaming at patrons of a local restaurant that he would “cut out their eyes”, then ran out and began thrashing in the bushes.  The police called for back-up, and 6 officers were eventually able to restrain him.

In the ED, he is violently bucking restraints, threatening to kill everyone who touches him.  His general exam shows a diaphoretic man pulling at his four-point restraints and rocking the gurney back-and-forth.  There is no obvious trauma, deformity, source of infection.  On questioning he is inattentive and tangential.  He does not answer any of your questions.

HR 168 BP 190/100 RR 30; temperature and oxygen saturation measurements are not feasible at this point.

Regarding this patient’s presentation, what is the BEST answer:


    A.  A thorough medication history is needed to evaluate dangerous etiologies such             as serotonin syndrome
    B.  Treat him acutely for likely withdrawal from his psychotropic medications for                   schizophrenia
    C.  After sedation, obtain a stat echocardiogram
    D.  Avoid a prone position for the patient during initial restraint


In the meantime, a quote –

“Well, now, there’s a remedy for everything except death.”

Don Quixote

-- Miguel de Cervantes (1547-1616)

Happy New Year!
 
A 17-month-old boy is brought in by his mother approximately 20 minutes after getting into her “beauty cream”.  Mother reports that the child was found with an open tube of skin cream, smeared on his face and mouth; according to mother, approximately one-quarter to one-half of the tube could have been ingested.  He vomited once “with all of the excitement”, but has not vomited since.
 
You see a happy, drooling, active toddler with normal vital signs and a normal general exam.  He has some mild erythema and irritation of the lips and buccal mucosa, but is tolerating his secretions, and drinking juice in the ED.  
 
On further questioning, the family is originally from Nigeria, and she uses the cream from back home as a skin lightener.
 
Regarding this child’s assessment and management, which of the following is the BEST answer:

A.    After NS bolus, give 1mEq/kg sodium bicarbonate IV followed by 1.5 maintenance of sodium bicarbonate infusion
B.    Start DMSA 10 mg/kg PO
C.    Observe the child for four hours and if asymptomatic, discharge home
D.    Admit for upper endoscopy

In the meantime, a quote –
 
“All who drink of this remedy recover in a short time, except those whom it does not help, who all die.  Therefore, it is obvious that it fails only in the incurable cases.”
 
-- Galen, Roman physician (AD 130-200)