Go through each successive part of the case. At the end of each part, quickly answer the question about your top diagnosis and the next diagnostic step that you think will give you the diagnosis (not necessarily the next step that you would do in real life). Don’t need to spend too much time thinking about these questions—you will review them at the end.
Part 1
Sign-out from the ED:
24yo man with no past medical history presents with sharp left-sided chest pain and dyspnea. He had an episode of flu-like symptoms (cough, runny nose, subjective fever) 2 weeks ago, but this resolved 2 days ago.
VITALS: T 37.4, HR 119, BP 136/49, RR 24, SpO2 94% on RA
GENERAL: Appears ill, mildly distressed
NECK: Bounding carotid pulse
LUNGS: Clear to auscultation without appreciable crackles.
HEART: Tachycardic, regular, without appreciable murmurs, rubs or gallops.
What is your top diagnosis?
What is the next diagnostic step?
Part 2
EKG: Sinus tachycardia. Left posterior fascicular block. No PR or ST deviation.
CXR: Cardiac enlargement, somewhat globular. No vascular congestion or pneumonic consolidation.
WBC: 11.6
Troponin: 1.176
BNP: 582
What is your top diagnosis?
What is the next diagnostic step?
Part 3
Echocardiogram: Aortic valve annulus thickened, bicuspid. Mass/vegetation present on anterior cusp 10.5×10.2mm with severe regurgitation. LVEF 50-55%. Small pericardial effusion.
Blood Culture: Staphylococcus warneri
What is the diagnosis?
Now that you have finished the case, go back to the beginning, review your answers, and determine what cognitive processes led you to each answer.