Case of the Week
A 27-year-old woman with no past medical history was riding her mountain bike
downhill when she encountered “gnarly terrain”, lost control, and over-corrected
her handlebars to the right.  Arms locked, she fell with full force to her left and her handlebar impacted her chest at the terminus of her fall.  Winded but resilient, she rode several miles to her car and drove herself to the ED after she noticed a painful “popping” and transient deformity each time she coughed.

In the ED, T 37.8 HR 52 118/72 RR 14 98% RA.  In general, she is tired but in no apparent distress.  Her lungs are clear bilaterally with a somewhat diminished tidal volume, due to painful splinting.  Her total body check reveals no other trauma. 
The visual inspection of her chest reveals:
Her bedside ultrasound and chest radiograph show no evidence of hemothorax,
pneumothorax, pericardial effusion, or opacity.  Her electrocardiogram shows no evidence of dysrhythmia or conduction delay.  She is feeling somewhat better after an

Based on her presentation, which of the following is the MOST likely etiology?

    A. Sternalis syndrome
    B. Tietze syndrome
    C. Arthroidal subluxation
    D. Slipping rib syndrome

In the meantime, a few quotes –

“Deliberate with caution, but act with  decision; and yield with graciousness, or oppose with firmness.” 

– Publilius Syrus, Latin writer, 1st century BC

 "Among mortals second thoughts are wisest.”

– Euripides, tragedian of classical Athens, 480–406 BC
A 13-year-old boy was riding his bicycle two days ago when he began to have sharp, pleuritic pain in his right chest.  He has no shortness of breath or fevers.  He has no past medical history, but on a review of systems he reports a two-month history of back pain with “good days and bad days”.  Although he had mentioned it to his parents in passing some time ago, there appear to be some distracting social stressors in the family.  

His vital signs are normal, and when you examine him you see this:
As you consider your differential diagnosis, you try to ask the correct screening questions.

Which of the following has NOT been validated as a screening measure in US children?

    A. Has a family member or contact had tuberculosis disease?

    B. Has a family member had a positive tuberculin skin test result?

    C. Has your child complained of a prolonged cough (longer than you thought to
         be normal) or a cough with bloody sputum?

    D. Was your child born in a high-risk country (countries other than the United
         States, Canada, Australia, New Zealand, or Western and North European
In the meantime, a few quotes – 

“Man ought to be man and master of his fate; but children are at the mercy of those around them.”

– Sir John Lubbock (1834-1913), English educationalist and reformer

“I prefer to be called a fool for asking the question, rather than to remain in ignorance.”

– John Homans (1836-1903), US professor of surgery
   Boston Medical and Surgical Journal 87:1 (1872)
A 58-year-old woman presents to the ED altered, hypotensive, and tachycardic.  While you assess the possible etiology of her undifferentiated shock, you gain peripheral intravenous access, start crystalloid resuscitation, and mentally prepare for what seems to be the inevitability of vasopressor use.

Given her current intravenous access, which of the following vasopressors may be the MOST problematic:

    A. Dopamine
    B. Norepinephrine
    C. Epinephrine
    D. Vasopressin

In the meantime, a few quotes – 

“The risk of a wrong decision is preferable to the terror of indecision.”

– Maimonides

"[In the end] 'M.D.' stands for: 'Make a Decision'."

– John Rose
A 12-year-old boy complains of right leg pain “on and off” for the past several weeks without alleviating or exacerbating features or history of trauma.  He has no systemic complaints, otherwise feels well, and is active in sports.  The boy has no past medical history and is not taking medications or supplements.  The family comes to the ED at 3 am because the boy woke up his parents complaining of worse pain.  He has not tried to take anything for this prior to his ED visit.

On examination, the boy has normal vital signs and a reassuring physical exam.  Due to the indolent nature of his complaints, you perform plain films:

Something unexpected catches your eye, and you magnify the image:
Based on his presentation and plain films, which is the MOST likely diagnosis?

    A. Osteoid osteoma
    B. Osteochondroma
    C. Unicameral bone cyst
    D. Aneurysmal bone cyst

In the meantime, a few quotes –

“Physicians think they do a lot for a patient when they give his disease a name.”

– Immanuel Kant (1724-1804), German Philosopher


“More is missed by not looking than by not knowing.”

– Thomas McCrae (1870-1935), physician and student of William Osler
A 27-year-old woman with no past medical history complains of dizziness, palpitations, nausea, and sweating intermittently over the past few months.  She worked as a receptionist for the past two years for a real estate agency while   she studied to be an agent.  A few weeks ago, she began to work as a realtor and she relates that her symptoms are more frequent and intense; she now feels mentally “cloudy” and is exhausted at the end of her work day.   The woman comes to the ED today because she is afraid that this is affecting her performance and that she will lose her job.

In the ED, she is comfortable if not slightly anxious. T 99.9 HR 89 BP 118/70 RR
12 SpO2 98% on ambient air.  She is a thin woman with normal heart, lung, and neurologic examinations.  After ordering an electrocardiogram and select auxiliary laboratories, you expect to reassess and discharge her, but when you return to the bedside you see her nervously pacing.  You notice that bilateral legs are ruborous without evidence of edema.  Her repeat vital signs are significant for BP 124/80 HR 124.  She has an otherwise normal repeat examination.  She feels “cloudy” again.

After IV fluids, a normal investigation, and an unremarkable brief observation period, your patient feels well and wants to go home.

What is your best advice for her until a diagnosis can be established?

    A. Follow a low-sodium diet
    B. Rest as much as possible until you see your primary care physician
    C. Avoid hot environments
    D. Wear loose-fitting clothes when at all possible

In the meantime, a quote – 

The two fulcra of medicine are reason and observation.  Observation is the clue to guide the physician in his thinking.

– Giorgio Baglivi (1669-1707), Professor of Anatomy at Sapienza, Papal University, Rome 

Introduction to De Praxi Medica
A 9-year-old boy is brought in by his foster mother because “I can’t handle him anymore”.  She describes his screaming, cursing, and refusing to do anything she asks.  Today he burst into rage, kicking her and throwing objects: “I hate you!”, “I just want to die!”, and “My head is gonna explode!”.

The child has been living with this foster mother for the past month, and she knows little of his past medical history, other than “he is bipolar, has ADHD, and has obsessive-compulsive disorder”.  The child is on risperidone, depakote, and methylphenidate.   His foster mother leaves briefly to recover an item in her car.

In the ED, the child is sitting quietly eating a snack. His vital signs are normal,
and his head-to-toe physical examination is normal.

During the ED course the child becomes agitated, attempting to leave, cursing, kicking, and is unresponsive to a concerted effort in verbal and situational de-escalation.  A decision to restrain the child chemically is made.

Of the following medications, which is the best first-line treatment in this agitated child?

    A. Antihistamine
    B. Typical antipsychotic
    C. Atypical antipsychotic
    D. Benzodiazepine

In the meantime, a few quotes – 

“Strategy without tactics is the slowest route to victory.  Tactics without strategy
is the noise before defeat.”  

― Sun Tzu (544–496 BC), Zhou dynasty general and philosopher


“Be kind, for everyone you meet is fighting a harder battle.” 

― Plato (428–347 BC), Classical Greek philosopher




A 64-year-old woman with diabetes mellitus and hypertension complains of slow
onset shortness of breath, weight gain, orthopnea, and bilateral leg  swelling.  

In the ED, HR 90 BP 200/100 RR 22 SpO2 91% RA.  She is in mild respiratory distress, and has rales up to half of her lung fields and bilateral pitting edema.  Her chest radiograph shows pulmonary congestion and her electrocardiogram demonstrates an R wave of 13 mm in aVL.  You decide to perform a bedside ultrasound which reveals a thickened concentric left ventricular wall, no pericardial effusion, and what appears to be a grossly normal ejection fraction.

Regarding her presentation, which of the following is the MOST likely?

A. Left ventricular failure from systolic dysfunction
B. Left ventricular failure from diastolic dysfunction
C. Right heart strain from pulmonary hypertension
D. Right heart strain from tamponade physiology

In the meantime, a few quotes – 

“Diagnosis is not the end, but the beginning of practice.” 

“A conclusion is the place where you got tired thinking.”

– Martin H. Fischer (1879 – 1962), German-born American physician and author
An 8-month-old boy is brought in by his parents for two days of vomiting and 
diarrhea.  It appears that “everyone in the house has it”, including the dedicated now also slightly peaked parents in front of you, who have been trying to keep him hydrated at home with juice, water, and an electrolyte solution.  He has had
no fever, is otherwise behaving normally (except for some fussiness), his vomit
is non-bilious, and his diarrhea is frequent and watery.  Although difficult to say given his current problems, his mother does not believe that he has urinated today. 
The boy is otherwise healthy, born full-term, vaccinated, and has no medications or allergies.

On arrival, you see a tired but relatively well appearing infant with slightly dry
mucous membranes, normal abdominal and genitourinary exams, and an otherwise
unremarkable physical examination with reassuring vital signs.

After a trial of an oral antiemetic and small frequent aliquots of PO fluids, the
child continues to vomit.

Of the following options, which may be the most appropriate for this child?

    A. Oral rehydration
    B. Nasogastric tube hydration
    C. Intraosseous hydration
    D. Hypodermic hydration

In the meantime, a few quotes – 

“When we can no longer change a situation, we are challenged to change ourselves.” 

– Viktor Emil Frankl, M.D., Ph.D. (1905 – 1997), Austrian neurologist, psychiatrist, and Holocaust survivor


“For just when ideas fail, a word comes in to save the situation.”

– Johann Wolfgang von Goethe (1749 – 1832)




A 57-year-old-woman with diabetes mellitus and hypertension complains of two days
of fatigue and shortness of breath.  She states that she often has similar symptoms, but they usually are “not like this” and pass in a day.  The woman has been considerably more fatigued lately with increased stress over family finances and complains of chest pain “on and off all day” last week.  She felt so poor she spent most of that day in bed.

Your patient is a former smoker of 12 years (she quit 10 years ago when diagnosed with diabetes), and takes her PO anti-hyperglycemic and anti-hypertensive medications “on most days”.

In the ED, she is uncomfortable in moderate respiratory distress.  She has wheezes throughout both lung fields, her pulse is elevated, and her skin is pale.  She has no
murmur and her monitor shows no acute changes.

You are called away unexpectedly from the bedside briefly and when you return, your
patient appears worse.  Vital signs are repeated immediately to show a HR of 128, BP 85/60, RR 24, SpO2 93% on ambient air.  She is in respiratory distress and her neck veins appear full.  A transthoracic probe is technically difficult due to her hyperinflated lungs from chronic disease.

Which of the following is the MOST LIKELY cause of her shock?

    A. Acute myocardial infarction
    B. Myocardial wall rupture
    C. Dysrhythmia
    D. Peri-myocarditis

In the meantime, a quote –

“The value of experience is not in seeing much, but in seeing wisely.”

– William Osler
A 9-month-old baby boy is brought in for fussiness and a pruritic rash he has had for the past week.  The child was born full-term without complications, and his vaccines are up-to-date. He has no personal or family history of atopy and has not been ill

He was recently visiting relatives out of the area, and when asked, his mother remembers some contacts there with a rash.  The boy has been afebrile and eating
well; he is not sleeping through the night lately.  His vital signs and general examination are normal, except for his skin examination:
Which of the following is the MOST likely diagnosis?

    A. Urticaria
    B. Eczema
    C. Drug eruption
    D. Scabies

In the meantime, a quote – 

“The defects and faults of the mind are like wounds in the body; after all imaginable
 care has been taken to heal them up, still there will be a scar left behind, and they are in continual danger of breaking the skin and bursting out again.”

François de La Rochefoucauld (1613 – 1680) French author of maxims