A 33-year-old G1P1 Caucasian female presents with intermittent episodes of weakness, abdominal discomfort and nausea lasting days at a time over the past 3 months. Except for treated hypothyroidism she has no other medical problems.

On exam she is alert, thin, well-tanned, in no acute distress and non-toxic. Vitals are normal except for a BP of 84/56. Her exam is otherwise unremarkable. She looks well hydrated. Her abdomen is benign.  Pelvic exam is refused because “the pain isn’t down there.”

Look at the picture below and use the few clues from the case narrative. What does she have?

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A 32-year-old male presents to the ED with a wrist injury after falling from his skateboard. He has no other injuries or complaints. His x-ray is shown below. How may injuries can you find?

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After witnessing you having a bad interaction with a difficult consultant, your boss walks over to you and says, “That looked rough.  You know, Shakespear wrote ‘Give every man thy ear, but few thy voice.’  That’s my mantra when dealing with consultants like that guy.”  You ponder this sage advice, but only for a moment before you hear an overhead announcement from the MICN, “Cardiac arrest 2 minutes out.”

Which character said, “Give every man thy ear, but few thy voice”?  To whom was it said and in which play?

This famous passage is full of sage advice.  How does it end?

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A woman in her mid 30’s presents with lower adbominal pain for 2 days accompanied by light bleeding. She has no other associated symptoms and cannot remember her LMP. Her pregnancy test comes back positive. Her transvaginal ultrasound is shown below.

Is this a normal pregnancy? What is the most likely diagnosis? What are the pitfalls to avoid?

Note: Image courtesy of Julie Vajnar, PA-C

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You are working in a double-covered ED when your colleague asks you for a second opinion on a rash.  The patient is a 43 year old businessman who complains of fever, rash, headaches and body aches, all of which come and go, and have been present for the past 3 days.  The rash, which is all over his body, is shown below.

You ask the patient one question and nail the diagnosis. Of course it helps that your friend recently had the same condition. What is the question? What is the diagnosis? Hint: His only abnormal lab is a white count of 1.7.

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