Somewhere, something incredible is waiting to be known. -Sharon Begley Welcome back to Roshcast Episode 32! We are returning to our regular format – letting the question back randomly generate this week’s material. We will have another collaborative episode with the EM Clerkship podcast soon. We start this episode off with another rapid review based on a recent blog posts by Yehuda Wolf. Make sure you keep checking the blog for rapid reviews. * Rocky mountain spotted fever often presents with an abrupt onset of severe headaches, photophobia, vomiting, diarrhea, and myalgias, along with a maculopapular eruption on the patients’ palms and soles. * Rocky mountain spotted fever is transmitted by the Dermacentor tick. * Rocky mountain spotted fever is treated with doxycycline, even in children. Now onto this week’s podcast Question 1 A 2-year-old boy is brought to the emergency department by his pregnant mother with complaints of hematemesis and bloody diarrhea and an episode of shaking that looked like a seizure. The patient has no past medical history; immunizations are up-to-date. His vital signs are BP 68/32 mm Hg, HR 170 beats per minute, RR 30 breaths per minute, temperature is 36.8°C, and oxygen saturation is 96% on room air. On physical exam, the child appears pale and lethargic. HEENT exam is normal with moist mucosa. His abdomen is nondistended but tender on palpation with active bowel sounds. His skin is cool and clammy. Laboratory results are as follows: Sodium 137 mEq/L   WBC 17,000/µL Potassium 5 mEq/L   Platelets 250/µL Chloride 99 mEq/L   Stool guaiac Neg BUN 10 mg/dL   UA Neg Creatinine 0.5 mg/dL   UDS Neg CO2 16 mg/dL   Serum tox screen Neg Glucose 280 mg/dL   aPTT, PT w/INR Normal Which of the following arterial blood gases is most consistent with the patient’s diagnosis? A. pH 7.23, pCO2 47, HCO320 B. pH 7.33, pCO2 32, HCO314 C. pH 7.43, pCO2 40, HCO324 D. pH 7.52, pCO2 28, HCO324 E. pH 7.55, pCO2 33, HCO334 Teaching Image  Question 2 Where is the uterine fundus palpable at 36 weeks gestation? A. At the umbilicus B. At the xiphoid process C. Between the pubic symphysis and umbilicus D. Between the umbilicus and xiphoid process Teaching Image Question 3 A 3-week-old boy presents with two days of non-bilious projectile vomiting. Examination reveals a mass in the infant’s right upper quadrant. On a barium upper GI series report, the radiologist states a “string sign” is present. Which of the following is this infant at greatest risk of developing? A. Hyperchloremia B. Hyperkalemia C. Hypokalemia D. Hyponatremia Teaching Image Question 4 The ultrasound clip above is from an 18-year-old woman with her LMP six weeks ago. Which of the following is associated with this condition? A. Double decidual sac B.