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 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 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.” 
 
…and…

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

– Martin H. Fischer (1879 – 1962), German-born American physician and author

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 78-year-old woman with hypertension complains of chest discomfort that woke her
from sleep. Over the past several weeks, she has been complaining of increased bilateral pedal edema, shortness of breath, and fatigue.

When she stands from sitting, she predictably becomes dizzy, which now happens at
times even while sitting or lying down.  

She has no back pain, abdominal pain, fever, nausea, diaphoresis, or confusion.

Her primary physician prescribed her a loop diuretic and a beta blocker last month
for the same symptoms; after some initial improvement, her symptoms have 
worsened.

In the ED, T 99.9 F HR 68 BP 110/90 RR 22 SpO2 98% RA.  In general, she is a fatigued, uncomfortable woman in mild respiratory distress.  Her pulmonary exam shows low tidal volume with clear breath sounds.  Her heart exam is significant for a late-systolic ejection murmur, with radiation to the right neck.  You think you hear an S4.  She has trace edema to bilateral ankles.

Your patient’s ECG shows non-specific T wave flattening.

Regarding her presentation, which of the following statements is FALSE?

    A. Left ventricular outflow obstruction causes concentric ventricular hypertrophy
    B. Fusion of valvular commissures or leaflet thickening are the most common 
        causes
    C. This is a structural calcific process not associated with coronary artery disease
    D. There is beat-to-beat variation in cardiac output


In the meantime, a quote – 

It is not a case we are treating; it is a living, palpitating, alas, too often suffering fellow creature.

– John Brown (1810-1882), Edinburgh physician and author

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 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 with a palpable peripheral pulse:

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 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 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