Went through some more board review cases yesterday.  I was struck by a couple of things:

–Making a diagnosis is so much easier when the “patients” give a good history, present classically, and you know that they have to have something.

–Board cases and my job have little in common.

A headache on the boards will likely be some sort of horrible intracranial bleed.  A headache at work will be just a headache, nothing more, 99 times out of a 100.

Attention ABEM: if you want your boards to be more reflective of the actual practice of emergency medicine, feel free to use the following examples.

Examiner: A 14 month old female with a fever.

Me: I walk into the room and what do I see?

Examiner: A well developed, well nourished female in no apparent distress.  She appears somewhat fussy but consolable.  She is held by her mother, who is breast feeding her. 

Me: Vital signs?

Examiner: Blood pressure 85/45.  Pulse 140.  Respirations 36.  Temperature 102.4.  Pulse ox 99% on room air.  Weight 10 kg.

Me: Hello, what brings you to the emergency department?

Examiner: My baby’s stomach hurts.

Me: How can you tell?

Examiner: By the way she cries.

Me: Has she had fever?

Examiner: Yes, and chills.

Me: For how many days?

Examiner: Two.

Me: Any associated symptoms?

Examiner: She has had nothing to eat for three days.  She moves her arms strangely when she cries.

Me: Has she vomited?

Examiner: Yes.

Me: How many times?

Examiner: I don’t know, lots.

Me: Diarrhea?

Examiner: Yes

Me: Is she coughing?

Examiner: Yes

Me: How many wet diapers today?

Examiner: None. 

Me: She’s had nothing to eat for three days?

Examiner: Nothing.

Me: She’s breast feeding now?

Examiner: Yes, but not as strong as she should.

Me: Anyone sick at home?

Examiner: Her brother has a runny nose.

Me: Vaccines current?

Examiner: Yes

Me: Have you tried any medicines at home?

Examiner: No.

Me: I would like to proceed with the physical exam.

Examiner: The child is happy and playful during the exam.  She appears 0% dehydrated.  Her head is atraumatic and normocephalic.  Pupils equally round and reactive to light.  Extraocular movements are intact.  TM’s clear bilaterally.  Nares are patent.  Dried rhinorrhea is present.  Oropharynx clear without erythema or exudate.  Mucus membranes are moist.  Neck is supple.  No lymphadenopathy.  No meningeal signs.  Chest clear to ascultation bilaterally.  No wheezes or retractions.  Heart regular rate and rhythm.  Abdomen soft, non-distended, non-tender to palpation.  Bowel sounds present.  Extremities normal to inspection.  Skin is warm without rash. 

Me: Nurse please give this child 150mg of tylenol for her fever, and see if she will take some pedialyte.

Me: Ma’am, we will look for a source of fever by ordering a chest xray and a urine test.

Examiner: Shrugging shoulders.

Me: Have the test results returned?

Examiner: Yes.  The urine is negative for infection.  Specific gravity is 1.010.  The chest xray shows perihilar prominence but no infiltrates, consistant with a viral infection.

Me: Nurse, did the patient take pedialyte?

Examiner: Yes, she took four ounces without difficulty.  Her repeat temperature is 98.9.

Me: Ma’am, I believe your child has a viral infection.  I did not find a source of bacterial infection on her exam or tests.  She should be fine to go home and follow up with her pediatrician in the morning.  You should give her motrin or tylenol as needed for fever.

Examiner: Doesn’t she need a prescription?

Me: No, just keep her fever under control to make her more comfortable.

Examiner: What about an antibiotic?

Me: Antibiotics treat bacteria.  This is a virus.  An antibiotic would not make her get better any faster, and would probably give her diarrhea.

Examiner: Why did I even bother coming here?

Me: I don’t know.

Examiner: This concludes your case. 

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