A patient presents with a chronic diabetic heel ulcer that has worsened over the past few weeks.  Could this be osteomyelitis?

It turns out that physical examination findings can significantly raise or lower the probability of this diagnosis. According to JAMA’s rational clinical examination series (Butalia 2008), 2 findings on physical examination have more powerful likelihood ratios than MRI:

-A crater breadth of 2 square cm or more has a positive LR of 7.2.

-Probing to bone has a positive LR of 6.4.

Take Home Points:

Osteomyelitis is more likely when the chronic wound is more deep and more broad



A 40 year old female presents with nausea and dizziness, with 3 recent visits to the emergency department. Could this be benign paroxysmal positional vertigo (BPPV)?


You ask the patient whether it is episodic or continuous. “Continuous.” The resident accepts that and starts to ask the next question.


“Hang on” and you gesture that you want to explore that a bit more. Patients sometimes say continuous when they mean “I get episodes all day long” or “I continue to feel nausea after the episode.”


You rephrase the question. “During an episode, how long does it take for the vertigo to stop?” Answer: “A few seconds.”


The resident, curious why the patient used the term “continuous,” asks her and she explains that she has persistent nausea even when the vertigo stops.


Dix-Hallpike testing showed the classic vertical/torsional nystagmus and Epley canalith repositioning maneuver led to complete resolution of symptoms.


Take Home Points:

-Patients with BPPV sometimes mischaracterize their symptoms as continuous. Ask how long the spinning lasts.