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 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

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)