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

 
…and…

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

– Thomas McCrae (1870-1935), physician and student of William Osler

A 2-year-old boy is brought in by his mother for constipation and “not acting right” from time to time over the past several weeks.  Clearly frustrated, his mother relates that he has been eating less and his bowel movements are infrequent but non-painful.  She describes his being “sleepy” more often than usual, but “perks up”
after meals or visits with his cousins.  She denies nausea, vomiting, rash, or change in urine output.  There is no history of trauma, fever, or environmental exposures.

In the ED, T 37.8 HR 122 BP 126/70 RR 24 SpO2 99% RA.  The boy is active and well appearing considering his mother’s recounting.  His head and neck, cardiopulmonary, neurologic, and skin examinations are normal.  The boy’s abdomen is full and slightly distended.  He has a non-tender mass that extends midway from his left anterior costal line to his symphysis pubis.  His genitourinary examination is normal.

Which of the following is the MOST likely diagnosis?

    A. Intussusception
    B. Wilms’ tumor
    C. Stercoral concretion
    D. Lead poisoning


In the meantime, a quote – 

"Never, no never does Nature say one thing and wisdom another."

– Johann Christoph Friedrich von Schiller (1759 – 1805), German philosopher and
historian

A 49-year-old man with a history of hypertension presents to the ED feeling weak
and complaining of “black vomit” and “black diarrhea” for the past several
days.  He has no history of dyscrasia; he takes aspirin “from time to time”.  The man reports no other medications, herbal remedies, or over-the-counter preparations. 
He is elusive about his drinking history, later remarking that he drinks beer once or twice a week; however, when he does he describes drinking a ‘six-pack at a time’.

On examination, HR 90 BP 110/70 RR 28 SpO2 98% RA.  He is slightly anxious, but able to cooperate with the history and physical examination.  His pulmonary and cardiovascular exams are normal; abdominal exam shows no mass or tenderness; he has melena on rectal exam; skin signs are normal.

This man’s hemoglobin is 10.1 g/dL; on chart review it was 14.3 g/dL one year prior.

You suspect an upper gastrointestinal (GI) bleed in a relatively stable patient and
you treat him with gentle fluids, NPO, and a proton-pump inhibitor.  His repeat examination, vital signs, and hemoglobin are unchanged.  You call the admitting team who requests a nasogastric tube (NGT) aspirate “to see if GI needs to come down now or if he needs the ICU”.

You identify an opportunity to discuss the utility of an NGT in this case.  Of the many points that could be made in the discussion, which of the following is TRUE:

    A. The NGT aspirate can rule out an upper GI source
    B. The NGT aspirate predicts morbidity or mortality
    C. The NGT is necessary to clear contents for the endoscopy
    D. The NGT is not necessary to diagnose an upper GI bleed


In the meantime, a few quotes – 
 
“It was a lie but he believed in telling lies to people. Truth telling and medicine just didn't go together except in dire emergencies, if then.”
 
― Mario Puzo, The Godfather

…and…

"Declare the past, diagnose the present, foretell the future.” 

― Hippocrates

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 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