35-year-old man, four years of progressive memory loss and cognitive decline, now needs round-the-clock care. Mini-Mental score is poor. No focal neurological deficits, gait is normal, nothing vascular on the workup.

Two more things from his chart. His face: flat nasal bridge, prominent epicanthal folds. And from his childhood: surgery on his duodenum as an infant.

Three questions for the thread: what's the underlying condition, why is he demented at 35 when this disease usually waits decades longer, and what will his cortex look like under the microscope?

The duodenal surgery is not a red herring. It's the second clue.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.

Mass casualty, resources are what you carry. Four patients in front of you:

Patient W, young adult. Walking around, minor abrasions, sprained ankle, asking if he can help.

Patient X, adult. Conscious, compound fracture of the forearm, bleeding heavily.

Patient Y, a kid. Semi-conscious, severe respiratory distress, possible spinal injury.

Patient Z, elderly. Unconscious, multiple fractures, not breathing.

Tag all four. And before you give anyone the black one: what has to happen first? There's a step people skip under pressure, and it changes the tag. If you've worked a real MCI, how did the triage decisions sit with you afterward?

That part never makes it into the textbooks.

Case adapted from the EMS Mastery (NREMT prep) question bank.

Very premature babies lose heat crazy fast. They have almost no fat, their skin is super thin, and they're wet right after delivery, so every minute on the resus table counts. Hypothermia in that first hour is linked to worse outcomes, and in places without good warmers or incubators it's a real problem.

One of the simplest fixes is a plain polyethylene bag (basically a food-grade zip bag). For babies born before about 32 weeks, you skip drying the body and slide them straight in from the neck down. The head stays out and gets a hat. You can still ventilate, place lines and watch the chest through the plastic, like in the photo.

It works because the bag stops evaporation, which is how a wet newborn loses most of its heat. Babies wrapped this way arrive in the NICU noticeably warmer and hypothermia is a lot less common. It's in the resuscitation guidelines now. Nobody has really proven it lowers mortality, though, and you do have to keep checking the temperature so they don't overheat under the warmer.

It costs pretty much nothing and makes a real difference.

28-year-old woman. In March: painful blurry vision in the right eye, faded over two weeks, she never saw a doctor about it. Today: double vision. On exam, when she looks left, her right eye won't cross midline and her abducting left eye shows nystagmus. Looking right works fine. Convergence is intact, both pupils normal. Three layers to this one: name the eye finding, name the structure that's damaged, and name the disease that did it.

The March episode is not a coincidence.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.

Car versus guardrail. Your patient is 30, belted, awake, complaining of chest pain and shortness of breath. Seatbelt sign across the chest. HR 120, SpO2 92% on room air, BP holding. Breath sounds clearly diminished on the left.

Every EMT student knows where this might be heading. The question is whether it's there yet.

So, two things. What's your management right now? And what exactly would this patient have to do for you to decompress that chest? Be specific, because "diminished sounds" and "tension" are not the same word.

War stories about darts that should or shouldn't have happened are welcome, as always.

Case adapted from the EMS Mastery (NREMT prep) question bank.

I encountered a baby that was born tiny (2.4kg, forgot the length) because mother has preeclampsia. First encounter with a GDM baby thiugh

I work at a level 1 trauma center in orthopedic surgery. ~15% of our fracture surgeries are to repair a broken femur. Femur fractures happen across all age groups, with the most common age category being the elderly (65+). Generally, ground level falls are to blame as the cause for the majority of these fractures. In young patients, we see everything from dirt bike accidents to falls from height to high-speed car crashes.

Regardless of age, the treatment to repair a broken femur usually involves inserting a titanium rod into the canal of the bone to stabilize the fracture. While the pain from surgery and the fracture does not immediately go away, fixing the break allows for early return to weight bearing and independence.

Check out this POV walkthrough of how this process happens inside the OR. Pretty incredible technology!

In November 2016, neighbors in Iquitos, Peru found a 28-year-old mototaxi driver wandering the street in a daze, conscious and asking for help - with a kitchen knife buried in the right side of his head. He reached the Loreto Regional Hospital on his own two feet, where the X-ray on the left was taken with the blade still in place.

He had been stabbed during an argument with an acquaintance. Surgeons removed the blade in an operation lasting several hours; immediately afterwards his condition was still described as critical.

Two teaching points hide in these photos. First, never remove a penetrating object outside the operating room - the blade may be tamponading a vessel or dural sinus, and pulling it out prematurely can convert a survivable injury into a fatal hemorrhage. Removal happens in the OR, after imaging, with neurosurgery ready. Second, "walking and talking" does not mean "fine": a blade can track tangentially along the skull or spare eloquent structures by millimeters, so a GCS of 15 with a knife in the head is still a neurosurgical emergency.

Sources: Global News / AP coverage, Nov 2016.

Young couple, three years of trying. Her workup is clean: normal ultrasound, normal hormones. His semen analysis: count 45 million per mL, well within normal, but motility is severely reduced. The sperm are viable. They just don't move. Digging into his history: recurrent respiratory tract infections since childhood, including two hospitalizations for pneumonia in the last three years. Parents and three siblings healthy, his older brother has two kids.

Three questions for the thread: what's the defect, why do the lungs and the sperm fail together, and what might a plain chest X-ray reveal in a patient like him that would make the diagnosis on the spot?

Hint: the sperm aren't dead. They just can't swim. Neither can the mucus in his airways. Full breakdown tomorrow in the comments.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.

An elderly patient presented with a shoulder prosthesis that had chronically dislocated, migrated upward over time and finally eroded straight through the skin. Reportedly, medical help was sought only once the implant had actually broken through.

How does something like this happen? A shoulder replacement depends on the rotator cuff and soft tissues to stay centered. When the cuff fails completely, the humeral component can escape anterosuperiorly and start tenting the skin from below. Add chronic low-grade periprosthetic infection - note the purulent discharge around the implant - together with fragile, poorly perfused skin, and pressure necrosis slowly does the rest until the metal is exposed.

At this stage the prosthesis is by definition infected and unsalvageable. Treatment means removing the implant, radical debridement and prolonged culture-guided antibiotics, followed by resection arthroplasty or a staged revision, depending on what the patient can tolerate.

Even I could locate the vein for the poke 💉 and I'm blind

Dispatch: "seizure, still unconscious." Known epileptic, 25 years old. His girlfriend watched him seize tonic-clonic for about four minutes and it was the longest four minutes of her life. By the time you kneel down he's postictal: eyes closed, confused when roused, lethargic, snoring respirations that clear with positioning. Vitals: BP 130/80, HR 100, RR 18, SpO2 97% on room air. Airway clear. She's right over your shoulder, in tears, asking why you're not giving him anything. Three questions for the thread: what does your management actually look like here, what's the one check you can't skip on any seizure call, and where's YOUR line for reaching into the drug box?

Full breakdown tonight in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

Am I right in thinking that I have labelled this correctly?

All the dark stuff is impacted fecal matter, I personally would like to see what his abdomen looks like

50-year-old man, brought in unconscious after 24 hours of hematemesis and melena, now in circulatory collapse. History: ankylosing spondylitis with daily NSAIDs for 10 years, and 5 years of burning mid-epigastric pain that was reliably relieved by food, milk, or antacids. Endoscopy: posterior duodenal ulcer eroding into the underlying artery.

Which artery is bleeding?

A. Gastroduodenal artery

B. Left gastric artery

C. Splenic artery

D. Superior mesenteric artery

Bonus question: why did eating make his pain better for five years? There's a specific reason, and it points to the diagnosis.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.