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
NSAID.  

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 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 49-year-old man with a history of smoking and hypertension complains of acute
onset severe headache and neck pain since last night.  On further investigation, his symptoms began after an all-night revelry fueled by intranasal cocaine.

On examination, HR 99 BP 132/90 RR 22 SpO2 95% RA

He is alert and mildly agitated, but attends to your questioning.  He has no cranial nerve deficits, and his neurologic examination is normal.  His head-to-toe
examination is otherwise non-contributory except for what appears to be mild
meningismus.

CT of his head shows subarachnoid hemorrhage.

You give nimodipine, consider a prophylactic antiepileptic, and arrange for a 
neurosurgical consult while providing good supportive care.

Shortly after, your patient becomes drowsy and confused and begins to have increased work of breathing with a pulse oximetry reading of 92% on ambient air.  A stat chest xray is performed:

The tempo and extent of his mental status changes and hypoxia prompt you to place a definitive airway.  Regarding optimization of his oxygenation and ventilation status, which of the following may be beneficial:

    A. Increase positive end  expiratory pressure (PEEP) slowly
    B. Provide gentle diuresis
    C. Place patient in the prone position
    D. Slow respiratory rate to avoid high peak pressures


In the meantime, a quote –

“A thing long expected takes the form of the unexpected when at last it comes."

– Samuel Langhorne Clemens – better known as Mark Twain – American author 
(1835-1910)

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 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 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

An 11-year-old boy with a history of cystic fibrosis and frequent lower respiratory tract infections complains of 3 days of rhinorrhea and cough.  He has been using his bronchodilator with some improvement, until he was traveling with his family across state when his symptoms precipitously worsened -- they drove to the closest ED, yours.  The boy has mild shortness of breath, with no history of fever, productive sputum, abdominal pain, or decreased urine output.  The family is anxious that this is not “their hospital”.

On examination, his vital signs show T 37.7 HR 120 RR 22 100/60 98% RA.  You see a thin chronically ill boy in mild respiratory distress, sitting up in the gurney, playing a game with his older brother.  He has slightly diminished tidal volume bilaterally, and end-expiratory mid-pitched wheezing. The rest of his exam is non-contributory. 

He is placed on a nebulized bronchodilator, and appears to relax initially, then to have slow onset increased work of breathing and more air hunger.  He has no chest pain.  Repeat vital signs show HR 122 RR 24 110/60 96% RA.  His breath sounds are equal and now reveal low-pitched wheezing in both inspiratory and expiratory phases. You order a chest x-ray.

While you await the chest x-ray, which is the next BEST step in his management:

    A.    Prepare to insert bilateral chest tubes
    B.    Stop bronchodilators and start inhaled hypertonic saline
    C.    Prepare to intubate
    D.    Start inhaled N-acetylcysteine


In the meantime, a quote –

“If you cannot make a diagnosis at least make a decision.”

-- Sir Henry Platt (1897-1986)

A 56-year-old woman with a history of myasthenia gravis complains of generalized fatigue and shortness of breath over the past day, without fever, chest pain, weakness, or rash.  She otherwise feels well; she was treated for a urinary tract infection earlier this week, and her dysuria is much improved.

Your patient’s vital signs are: T 37.8 °C HR 110 BP 144/84 RR 26 95% RA.  She is in no distress, has no obvious bulbar weakness, is able to take a reasonably deep breath on auscultation, and has a clear chest, regular heart rate, and an otherwise unremarkable examination.

Which of the following is the next most important step in her evaluation and management:

A. Early non-invasive positive-pressure ventilation (NIPPV) to avoid respiratory muscle fatigue

B. CT angiography for other possible etiologies of her shortness of breath

C. Ask her about her recent visit to her primary care physician

D. Observe her in ED, and if she continues to be stable, discharge home with close follow-up

  In the meantime, a quote --   "The treatment of a disease must be entirely impersonal; the care of a patient must be completely personal."   --Francis Weld Peabody (1881-1927) U.S. pathologist, hematologist, and author

A 13-year-old boy with a history of acute intermittent asthma is brought in by his family for cough and chest pain that started today.  He tried his inhaler, which did not seem to help.  His pain is intermittent, pleuritic, with no other alleviating or aggravating features; the rest of his history is unremarkable.  His family is upset and concerned that this could be pneumonia, because his grandmother recently died from the same.

On exam, he is well appearing, but slightly anxious, has mild increased work of breathing, speaks effortlessly in full sentences with a normal tidal volume.  He is afebrile, and his vital signs are normal.  On auscultation his lungs are clear, if perhaps slightly diminished on the right.

Regarding his presentation, which of the following is the single BEST answer:

A.      He has normal vital signs and is not hypoxic; he should receive oral steroids, no antibiotics, and close follow-up

B.      He likely has a primary spontaneous pneumothorax and will need admission

C.      He should receive a small gauge right chest tube now, based on your exam, in order to prevent his decompensating

D.      His treatment and disposition should be based on signs, symptoms, and radiographic evidence

  In the meantime, a quote --   "The medical profession is a noble and pleasant one, though laborious and often full of anxiety."   --Andrew James Symington, 19th century Scottish author, who established a famous wine "empire" in Oporto, Portugal