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

A 34-year-old woman G3P2 arrives to the ED in active labor.  Her bag of waters broke in the car ride here, and as you get her into the gurney she is crowning.  You have an assistant call Obstetrics and have another retrieve the infant warmer and neonatal resuscitation cart.

The mother begins to push and the child’s head is delivered, then it retracts back, his cheeks pressed against the vulva.

Which is the next BEST step to take in the delivery?

    A.  Push the baby’s head back into the birth canal gently, hold there, and transport  to the OR for emergency Caesarean section
    B.  Manipulate the mother’s hips to perform an anterior pelvic tilt
    C.  Have the mother on all fours and then push with contractions
    D.  Coach the mother to continue to push in short, coordinated efforts as she feels the contraction, counting up to 10


In the meantime, a quote –

“Good judgement comes from experience; experience comes from bad judgement.”

– C Lillehei, MD