The best preparation for tomorrow is doing your best today.    -H. Jackson Brown Jr. Welcome back to Episode 12! This week we once again continued our theme based review. We focused on a few high-yield bites and envenomation. This material is easy to gloss over since we do not come across it too often clinically. Not only will this prepare you at the bedside, but it will also help you pick up a few easy points on the In-Training Exam, which, by the way, is right around the corner. * Envenomation by a Portuguese Man O’ War is treated by immediate removal of the nematocyst followed by a salt-water wash. * Black widow spiders have a red hourglass on their abdomen. * Bites form a black widow spider produce a local papule with a halo. Severe symptoms include muscle fasciculations and a peritonitic abdomen. * Brown recluse spider bites cause a papule that blisters and then necroses. Severe symptoms include renal failure, pulmonary edema, and shock. * A pit viper snake envenomation causes local swelling and oozing from the wound. Severe envenomation can cause a DIC-like coagulopathy with hemorrhagic bullae. Now onto this week’s podcast! Question 1 A 4-year-old boy is brought to the Emergency Department after a drowning. Bystanders noted the child was under water for less than a minute. After quickly being pulled up from the bottom of the pool, he coughed and vomited once. He arrived to the ED awake and alert with a GCS 15. On examination, he is afebrile with heart rate 105 beats/minute, respiratory rate 20 breaths/minute, and oxygen saturation 96 % on room air. His lungs are clear to auscultation. What is next step in management? A. Admit to telemetry unit for 24-hour observation B. Discharge home C. Observe for 4-6 hours and discharge home if there is no change in his clinical status D. Positive pressure ventilation Teaching image Question 2 Which of the following is true regarding older patients with abdominal pain in comparison to younger patients? A. More likely to need an emergent surgical procedure B. More likely to present with an elevated white blood cell count C. More likely to present with fever D. More likely to present with peritoneal signs Teaching image Question 3    Which of the following conditions, other than postoperative adhesions, is most likely responsible for causing the diagnosis seen in the image above? A. Adenocarcinoma B. Incarcerated hernia C. Intussusception D. Volvulus Teaching image Question 4 How do you calculate mean arterial pressure (MAP)? A. MAP = [DBP + (2 x SBP)]/3 B. MAP = DBP + 1/3(SBP-DBP) C. MAP = DBP + 2/3(SBP-DBP) D. MAP = SBP + 1/3(SBP-DBP) Teaching image Question 5 A 23-year-old man presents with chest pain after a motor vehicle collision. The patient’s chest struck the steering wheel. He has no other complaints or injuries. Chest X-ray is unremarkable. ECG shows sinus tachycardia with anterior ST depressions. A troponin is sent and is positive at 3.50 mg/dl. What management is indicated? A. Activate the cardiac catheterization laboratory B. Discharge home with cardiology follow up C. Echocardiogram D.