Cauda equina syndrome (CES) is a serious pathologic condition that occurs when the cauda equina nerve roots are compressed. As illustrated in this case, it can present with various signs and symptoms, including low back pain, sciatica, motor weakness, sensory loss, bladder and/or bowel dysfunction, and saddle anesthesia. It is most often caused by lumbar disk herniation, but can also be caused by malignancy, epidural spinal abscess, localized hematoma, or vascular malformations. The key to making this diagnosis is having a high index of suspicion through information obtained in the history and physical. The treating emergency physician should have a high index of suspicion for CES in any patient presenting with low back pain and urinary retention. MRI is the gold standard for diagnosis; it should be obtained urgently when history and physical examination suggest CES. As emergency physicians prepare for their oral board examination, they should consider analgesia, appropriate neurologic, urogenital, and rectal examinations, MRI, and emergent neurosurgical consultation to all be critical actions.

This is a clinical presentation of a patient with chest pain. The candidate is challenged with the task of correctly diagnosing and treating a pulmonary embolus. This is relevant to emergency medicine residents preparing for the oral and written board exams. This would also be helpful for medical students preparing for the emergency medicine shelf exam.

This case demonstrates the emergency medicine approach to evaluating a patient with a painful foot and a diagnosis of acute gout. Key components of the history include timing, location, number of joints involved, pertinent past medical history, and any precipitating factors. A focused physical exam reveals swelling and erythema overlying the first MTP joint of the foot with painful range of motion, consistent with a diagnosis of acute gout. Key interventions include joint aspiration to rule out septic arthritis, revealing negatively birefringent crystals; and appropriate medication treatment with NSAIDs as first-line therapy, followed by colchicine or oral steroids. Patients should receive counseling regarding dietary guidelines and follow-up, with consideration of long-term treatment in cases of recurrence.

This case study presents a classic example of acute mesenteric ischemia caused by an embolism to the superior mesenteric artery in a 73-year-old female. The patient exhibits sudden-onset severe abdominal pain disproportionate to physical findings, with a history suggestive of atrial fibrillation. The diagnostic work-up includes CT angiography revealing a thrombus and bowel ischemia. Management involves fluid resuscitation, broad-spectrum antibiotics, anticoagulation with intravenous heparin, and surgical consultation. The case emphasizes the importance of early recognition and intervention in mesenteric ischemia, a condition with high mortality if untreated.

A septic cavernous sinus thrombosis (CST) is a rare, but serious, infection of a dural venous sinus that can be life-threatening if left untreated. As illustrated in this case, it often presents with headache, fever, eye pain, and photophobia. Proptosis and ophthalmoplegia are also commonly seen. The etiology of CST is often an adjacent sinus infection, but it can also result from odontogenic sources, trauma, bacteremia, or ear infections. The treating emergency physician should also consider orbital cellulitis, meningitis, or a brain abscess with this presentation. As emergency physicians prepare for their oral board examination, they should consider early and aggressive antibiotic therapy, imaging, and a lumbar puncture to all be critical actions. If CT is nondiagnostic, MRI should be pursued for more definitive diagnostic testing.

Hydrofluoric acid is a chemical known to cause chemical burns. It is commonly used in glass etching. Common hydrofluoric acid burns include dermal exposures, inhalation exposures, gastrointestinal exposures, and ophthalmic exposures. The higher the concentration of hydrofluoric acid and the body surface area and exposure all determine the cause of toxicity, which can be life-threatening. When hydrofluoric acid is exposed to tissue it will dissociate and bind to calcium and magnesium, leading to hypocalcemia, hypomagnesemia, and hyperkalemia, which can in turn cause cardiotoxicity manifesting with dysrhythmias, including VFib, VTach, or torsades de pointes (polymorphic VTach). Treatment depends on the types of exposure and includes calcium gluconate gel or intradermal calcium gluconate injection (dermal injuries) or intraarterial calcium gluconate (dermal injuries), NG tube drainage and oral or NG tube calcium and magnesium (GI exposures), nebulized calcium gluconate (inhalation), and eye irrigation with calcium eye drops (ophthalmic exposures).

This clinical vignette centers on the emotionally charged task of delivering news of death to a patient’s family. After resuscitative efforts are exhausted, the emergency physician meets with the deceased patient’s daughter and her partner to explain what happened. The conversation emphasizes compassion, presence, and clear communication, while modeling professionalism and emotional stewardship. This case highlights the critical importance of knowing patients and families by name, setting, and tone; using the SPIKES framework; and recognizing “residue,” the emotional imprint of threshold moments. It offers a framework for navigating grief compassionately while caring for both the family and yourself in the process. It also introduces tools for reflection, including Dr. Cline’s DR5 framework, and invites learners to reframe suffering as a catalyst for resilience and growth.

This clinical vignette features a 23-year-old female college student presenting with a gradual-onset, left-sided, throbbing headache accompanied by photophobia, phonophobia, and nausea. With stable vitals and no focal neurologic deficits, her history and physical exam are consistent with a primary headache disorder, likely migraine. The case illustrates a methodical approach to ruling out serious secondary causes of headache, such as subarachnoid hemorrhage, meningitis, encephalitis, cerebral venous sinus thrombosis, and toxic exposures, through targeted history, neurological exam, and pregnancy testing. The absence of red flags allows for a clinical diagnosis of migraine and the initiation of evidence-based symptomatic therapy, including IV fluids, antiemetics, NSAIDs, and rescue therapy with droperidol. This case emphasizes the importance of differentiating benign from life-threatening etiologies in young adults and reinforces key diagnostic and therapeutic strategies in migraine management within the emergency department.

This case presents a clinical vignette of a 21-year-old male college student who experiences a syncopal episode in class. The learner is given the opportunity to formulate their own patient presentation and clinical note before reviewing an ideal version. The case emphasizes the importance of distinguishing benign from life-threatening causes of syncope. Key discussion points include the evaluation of vasovagal versus cardiogenic etiologies, the use of tools like ECG and family history to risk-stratify patients, and the identification of red flags such as exertional syncope or sudden death in relatives. A systematic review of dangerous ECG findings (e.g., Brugada, WPW, HOCM) is highlighted, along with appropriate disposition planning for outpatient versus inpatient workup.

This clinical vignette describes a woman who presents with acute, constant vertigo and unsteadiness, beginning suddenly while sitting. Her symptoms are not positional and are associated with nausea but no focal neurological findings. A HINTS exam reveals findings consistent with a peripheral vestibular cause. The diagnosis is acute vestibular syndrome, likely vestibular neuritis. This case illustrates how bedside examination and GRACE-3 guideline-informed reasoning can help avoid unnecessary imaging, appropriately triage dizziness, and improve diagnostic accuracy in the emergency department.

This scenario outlines the management of a 61-year-old female patient who suffered multiple traumatic injuries after being caught in an EF4 tornado outside Birmingham, Alabama. The patient, who has a history of diabetes, hypertension, and obesity, was helmeted and riding her bike when the tornado struck, causing her to be thrown into a field. Her injuries include a closed fracture of the right femur, multiple contaminated lacerations and impalements to her hands, and a suspected globe rupture of the left eye. The scenario emphasizes the importance of a structured approach to trauma care, including a thorough primary and secondary survey, pain management, and the need for rapid stabilization and consultation with specialists. The patient requires immediate initiation of broad-spectrum antibiotics and antifungal therapy due to the high risk of infection from soil-contaminated wounds. Essential actions include immobilization of the femur fracture, detailed ocular examination, and prompt ophthalmologic and orthopedic consultations. This case highlights the complexities of managing multiple trauma in the aftermath of a natural disaster, emphasizing the need for coordinated care, communication, and reassessment to prevent complications and optimize patient outcomes.

The case features a 34-year-old male firefighter who suffers an asthma exacerbation due to inhaling volcanic ash while attempting to rescue civilians. Despite initially avoiding more severe physical injuries from pyroclastic flows or burns, he develops significant respiratory distress and requires escalating interventions, including nebulized bronchodilators and eventual intubation. Additionally, the patient presents with a head injury from debris, though imaging confirms there is no acute intracranial pathology. The case outlines key teaching objectives, emphasizing the recognition and management of inhalational injuries and asthma exacerbations, the challenges of managing a potentially difficult airway in the context of a volcanic eruption, and the specific medical interventions necessary for both respiratory support and trauma care. It also addresses the importance of effective communication and teamwork, such as the use of appropriate personal protective equipment (PPE) for responders, activation of disaster plans, use of local resources, and management of distressed family members.

This case study examines the management of a dog bite injury in a flood-prone coastal region following a Category 5 hurricane. The scenario involves a 58-year-old male with hypertension and type 2 diabetes who was bitten by a large dog while attempting a rescue operation. The patient presents with multiple deep lacerations and puncture wounds on his right forearm, significant pain, and swelling. The case highlights the critical steps in evaluating and managing bite wounds in a disaster setting, including scene safety, situational awareness, personal protective equipment (PPE), wound irrigation, decontamination, dressing, and splinting. Emphasis is placed on the importance of communication and teamwork among the rescue team, coordination with animal control, and effective communication with receiving medical facilities. The scenario also addresses the need for advanced management, including imaging, antibiotics, and postexposure prophylaxis for tetanus and rabies. This study serves as an educational tool for medical professionals in emergency medicine and disaster response, providing insights into the complexities of managing animal bite injuries in challenging environments.

The scenario aims to teach participants the importance of recognizing heat stroke early, understanding its pathophysiology, and implementing appropriate management strategies. Key actions include obtaining core temperature, initiating aggressive cooling measures, fluid resuscitation, and managing complications such as rhabdomyolysis, hyperkalemia, and neurological symptoms. The simulation also emphasizes the need for advanced airway management and timely admission to intensive care for further treatment. Through this scenario, learners gain hands-on experience in managing a critically ill patient with heat stroke, enhancing their clinical skills and understanding of the complexities involved in treating heat-related emergencies. The article provides a comprehensive framework for educators to facilitate discussions on heat stroke pathophysiology, management strategies, and the role of interdisciplinary collaboration in patient care.

This scenario presents a detailed simulation of a chlorine gas exposure incident following a freight train derailment. The scenario begins with a standardized patient and transitions to a manikin, set in a community hospital in the United States. The patient, a 47-year-old male freight engineer, was exposed to chlorine gas after a train derailment caused by a track defect. The simulation covers the initial emergency response, patient decontamination, and subsequent medical management, including the challenges of airway stabilization and treatment of acute respiratory distress syndrome (ARDS). Key teaching objectives include identifying hazardous materials, diagnosing and managing chlorine exposure, and effective teamwork and communication during a medical crisis. The scenario emphasizes the importance of rapid identification and treatment of chemical exposures and provides a comprehensive guide for healthcare professionals in managing similar emergencies.