A four-year-old boy with no past medical history is brought in by his father for
two weeks of intermittent fever, body aches, and headache.  He has sick contacts at home, who have all improved.  His father gave him an antipyretic before leaving home, and the child feels better on arrival.

On examination, his vital signs are normal and his general exam is reassuring.  He has some scattered palatal petechiae  without exudate, and has a slightly enlarged right testicle without pain, erythema, or tenderness to palpation.  He is comfortable and playing with his truck. 

Which of the following would be MOST helpful to confirm his diagnosis?

    A.     Chest radiograph
    B.     Nasal aspirate assay
    C.     Complete blood count (CBC)
    D.     Urinalysis


In the meantime, a quote – 
 
From the bitterness of disease man learns the sweetness of health.

–  Catalan proverb

A 67-year-old man with hypertension and a history of smoking complains of days of nausea, chest pain, and shortness of breath.  He is being evaluated at triage when he collapses to the ground.  He is brought to the resuscitation bay, where he is weak and diaphoretic, but alert.

At triage, his vital signs are: HR 138 BP 72/40 RR 28 SpO2 96% RA

He has clear breath sounds with low tidal volume and muffled heart sounds.  Primary body check shows no evidence of trauma, source of infection, or toxidrome.  While you are gathering information, getting help to the bedside, and obtaining intravenous access, you place an ultrasound probe on his chest.  He has a moderate pericardial effusion, IVC dilation, and aortic root dilation.

Based on the information available in your brief exam and goal-directed echocardiography, which is the MOST likely cause of his shock?

    A.    Pulmonary Embolism
    B.    Aortic dissection
    C.    Sepsis
    D.    Myocardial infarction


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.

Introduction to De Praxi Medica

– Giorgio Baglivi (1669-1701)
Professor of Anatomy at Sapienza, Papal University, Rome

A 6-month-old baby girl is brought to the ED with a one-day history of emesis and 2 days of loose stools.  She was born full-term without complications, her vaccinations are up-to-date, and she is in daycare most of the day.  The child is diagnosed with acute gastroenteritis, tolerates fluids by mouth, and is discharged home.
 
Five days later, the loose stools have resolved, but mother brings her in again today for recurrent daily emesis and irritability for the past two days.  The baby “felt warm” earlier today.
 
On examination, the child is afebrile and has normal vital signs.  She appears difficult to console and has dry mucous membranes.  The girl cries with exam, and her right knee is warm and tender.  As part of her work-up, you order a radiograph of the affected area:

Which is the next BEST step in her management:
 
    A.    Intravenous access, fluids, laboratory investigation including ESR
    B.    Obtain MRI of the knee for possible periosteal involvement
    C.    CT head non-contrast
    D.    Full septic work-up for possible bacteremia
 
In the meantime, a quote –
 
“In the practice of medicine more mistakes are made from lack of accurate observation and deduction than from lack of knowledge.”
 
– George Howard Bell (1905 - 1986)
Physician and physiologist

A 20-year-old man with a history of asthma complains of two weeks of unrelenting cough.  He denies fever, shortness of breath, myalgias, rhinorrhea, chest pain, and hemoptysis.  His asthma is generally well controlled, but this cough does not appear to be amenable to his bronchodilator.  He became concerned when, after a sudden bout of prolonged coughing, he vomited.

In the ED, you see a well appearing man in no respiratory distress.  His vital signs are normal, and he has trace intermittent end-expiratory wheezing bilaterally with a normal tidal volume and effort.  The remainder of his exam is reassuring.  He states that he feels tired, but relatively well now that he has seen you.

Which of the following is the BEST management approach:

    A.    Penicillin G benzathine (Bicillin) 1.2 million units IM
    B.    Oseltamivir (Tamiflu) 75 mg PO daily for 5 days
    C.    Azithromycin PO for 5 days
    D.    Ondansetron (Zofran) 8 mg PO prn


In the meantime, a quote –

In illness the physician is a father; in convalescence, a friend; when health is restored, he is a guardian.

– Hindu proverb

A three-year-old boy with a history of hypospadias status-post urethroplasty at six months of age is brought in to the ED for dysuria.  He was admitted for influenza pneumonia one week prior at which time he had an “in-and-out” urethral catheterization.  The child has been doing well at home until he began to complain of pain with urination today.  No fever, abdominal pain, rash, or hematuria.  He has been able to void at home with straw-colored urine.  He is fearful of medical staff and hesitates to urinate in the ED on request.

On arrival, you see a well appearing child with normal vital signs and a normal physical exam.

Which is the BEST approach to his management?


    A.    After thorough cleaning of the perineum with antiseptic, obtain a bag specimen             for urinalysis and culture
    B.    Place a urinary (Foley) catheter and leave in place to ensure urine output and             to treat possible stricture
    C.    Observe patient until he is able to perform a clean catch specimen
    D.    Perform suprapubic catheterization


In the meantime, a quote –

“A clinician is complex.  He is part craftsman, part practical scientist, and part historian.”

– Thomas Addis, Scottish-born U.S. clinical scientist and pioneer in nephrology (1881-1949)