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39) A 56-year-old woman with a history of chronic renal disease presents to the emergency department because of severe, sharp, retrosternal chest pain that radiates to her jaw. The pain worsens when the patient lies down, and she is most comfortable leaning forward and hugging her knees. She takes erythropoietin, furosemide, calcitriol, and sodium polystyrene sulfonate. She is scheduled for dialysis three times per week, but she admits to sometimes missing sessions. She stopped drinking and smoking 20 years ago, and she has no family history of heart or renal problems. Auscultation of the heart reveals a friction rub. Laboratory tests show: WBC count: 12,000/mm3, Hemoglobin: 10.0 g/dL, Hematocrit: 30.0%, Platelet count: 150,000/mm3, Na+: 141 mEq/L, K+: 4.8 mEq/L, Cl: 101 mEq/L, HCO3 : 22 mEq/L, Blood urea nitrogen: 63 mg/dL, Creatinine: 3.2 mg/dL, Glucose: 111 mg/dL. The emergency medicine physician urges the patient to be more compliant with her dialysis, but the patient complains that she is too tired to go to dialysis all of the time and that it is ruining her life. Which of the following is the most likely complication if the patient’s condition remains untreated?

40) A 39-year-old white man with essential hypertension presents for a routine health maintenance visit. He has no complaints and reports compliance with his hydrochlorothiazide. His pulse is 70/min, blood pressure is 145/92 mmHg, and respiratory rate is 16/min. His body mass index is 24 kg/m2. His physical examination is within normal limits. For which condition is the patient at increased risk?

41) A 40-year-old man is brought to the emergency room after his wife found him alone in a confused state. He admits to overdosing in a suicide attempt, but does not specify the drug taken. En route to the hospital, he is drowsy and ataxic with blurred vision. His past medical history is significant for asthma, insomnia, depression, and substance abuse. His temperature is 38.3°C (100°F), blood pressure is 130/80mmHg, pulse is 100/min, and respirations are 22/min. Examination shows dry mucus membranes and skin; pupils are 8mm bilaterally. There is no neck stiffness. Lungs are clear to auscultation. Heart sounds are within normal limits. Abdominal examination shows reduced bowel sounds with no tenderness. A Foley catheter is placed in the ER and 600 ml of urine is collected over one hour. Which of the following is the most likely diagnosis?

42) A 46-year-old male is admitted to the hospital because of right hand cellulitis. He has a history of intravenous drug use, hepatitis C infection and septic arthritis of the knee. He smokes one pack of cigarettes and drinks one pint of vodka daily. He is started on vancomycin. On the following day, the swelling and redness of his arm decreases. However, he complains of bugs crawling on his skin. His temperature is 38.3°C (100.9°F), blood pressure is 160/90 mmHg, pulse is 110/min, and respirations are 18/min. Examination shows mild hand tremors and diaphoresis. Which of the following is the most appropriate next step in management?

43) A 35-year-old woman is brought to the emergency room after an apparent suicide attempt. Her current prescription of imipramine was found at her bedside along with a suicide note. En route to the hospital, she suffered a seizure. She has been treated with many different anti-depressants over the past several years without improvement. Her temperature is 38.3°C (101°F), blood pressure is 90/50 mmHg, pulse is 120/min and respirations are 24/min. EKG shows QRS widening (0.18sec). She is given sodium bicarbonate along with supportive treatment. Which of the following is the most likely mechanism that explains the beneficial effects of sodium bicarbonate?

44) A 32-year-old male is admitted to the hospital because of confusion. He was recently diagnosed with schizophrenia His temperature is 38.6°C (101.6°F), blood pressure is 160/100 mmHg, pulse is 116/min, and respirations are 22/min. He is not oriented to time, place or person. Mucus membranes are dry. Profuse diaphoresis is present. Lungs are clear to auscultation. Abdominal, neck and extremity muscles are rigid. Muscle tone is increased. Deep tendon reflexes are 2+. Laboratory studies show a serum CK of 50,000 IU/L. CSF fluid analysis shows a total white blood cell count of 5/microL. Which of the following is the most appropriate next step in management?

45) A 38-year-old homeless man is brought to the emergency room. He is obtunded and unable to speak. No previous medical history is known. His temperature is 34.0°C (93.2°F), blood pressure is 90/60 mmHg, pulse is 60/min and respirations are 6/min. Oxygen saturation is 86% on room air. Pupils are 5 mm in size, bilaterally. Oropharynx is dry. Lungs are clear to auscultation. Abdomen is soft; bowel sounds are decreased; there is no organomegaly. Extremities reveal several needle marks. Babinski sign is negative. Deep tendon reflexes are 2+ throughout. Which of the following is the most appropriate next step in management?

46) A mother brings her 16-year-old daughter to the ER after she had two episodes of coffee ground emesis. The mother reports that for the past two weeks, the teen has not been acting like herself; she has been especially isolated and has had a poor appetite and poor sleep. Her medical history is significant for anemia, for which she takes iron sulfate and folic acid. She also takes acetaminophen for occasional back pain. Presently, the patient's blood pressure is 110/70 mmHg and heart rate is 120/min. Which of the following is most likely to establish the diagnosis?

47) A 47-year-old man is brought to the ED by EMS after being found wandering in the street mumbling. His BP is 150/75 mmHg, HR is 110 beats per minute, temperature is 100.5°F, RR is 16 breaths per minute, oxygen saturation is 99% on room air, and fingerstick glucose is 98 mg/dL. On examination, the patient is confused with mumbling speech. His pupils are dilated and face is flushed. His mucous membranes and skin are dry. Which of the following toxic syndromes is this patient exhibiting?

48) A 25-year-old man is carried into the ED by two of his friends who state that he is not breathing. The patient has a history of heroin abuse. His vital signs are BP 115/70 mmHg, HR 99 beats per minute, temperature 98.9°F, RR 3 breaths per minute, and oxygen saturation 87% on room air. You notice fresh needle marks and miotic pupils. You begin bag-valvemask ventilation and his oxygen saturation increases to 99%. Which of the following is the most appropriate next step in management?

49) A 42-year-old man who is actively seizing is brought to the ED by EMS after a massive ingestion of an unknown substance. The man is known to have a history of acquired immunodeficiency syndrome (AIDS). An intravenous (IV) line is established and anticonvulsant therapy is administered. After high doses of diazepam, phenobarbital, and phenytoin, it is determined that the seizures are refractory to standard anticonvulsant therapy. Which of the following substances did this patient most likely ingest?

50) A 26-year-old man is brought to the emergency room by police with depressed mental status. Out of fear of arrest, he swallowed a handful of pills as the police officers approached him. On examination, he responds to painful stimuli but is somnolent. His respiratory rate is 8/min and after naloxone bolus infusion increases to 12/min. Lungs are clear to auscultation. Which of the following additional findings is most likely to be present in this patient?

51) A 29-year-old male is brought to the emergency room because of sudden onset confusion and fever. He was recently admitted to the hospital for hallucinations and was discharged instable condition. His temperature is 38.6°C (101.6°F), blood pressure is 150/100 mmHg, pulse is 112/min, and respirations are 24/min. Mucus membranes are dry. Profuse diaphoresis is present. Lungs are clear to auscultation. Abdominal muscles are rigid. Muscle tone is increased; "lead pipe rigidity" is noted in all four extremities. Deep tendon reflexes are 2+. Tremor is noted. Which of the following is the most likely diagnosis?

52) A 26-year-old man is brought to the emergency room after an attempted suicide by medication overdose. For the past hour, he has suffered two seizures. His temperature is 38.8°C (102°F), blood pressure is 110/85 mmHg, pulse is 90/min, and respirations are 22/min. He is not oriented to time, place, and person. Pupils are dilated, but reactive to light and accommodation; skin is flushed and dry. Abdominal examination shows reduced bowel sounds. EKG shows prolonged QRS complexes (0.19 sec). Toxicology studies are pending. Which of the following is the most appropriate indicator of severity of intoxication?

54) A 34-year-old homeless man is brought to the emergency room in a confused state. He complains of epigastric pain, vomiting and blurred vision. His temperature is 36.8°C (98.2°F), blood pressure is 110/60 mmHg, pulse is 110/min and respirations are 22/min. Physical examination shows poor oral hygiene and dry mucous membranes. Lungs are clear to auscultation. Abdominal exam shows mild epigastric discomfort. Funduscopic examination reveals optic disc hyperemia. Laboratory studies show: Serum sodium 136 mEq/L, Serum potassium 3.0 mEq/L, Chloride 93 mEq/L, Bicarbonate 6 mEq/L, Blood urea nitrogen (BUN) 30 mg/dL, Serum creatinine 0.8 mg/dL, Blood glucose 80 mg/dL, Serum ketones negative, Plasma lactate 2.2 mEq/L. Which of the following is the most likely cause of his symptoms?

55) You receive notification from EMS that they are bringing in a 17-yearold adolescent boy who was found unconscious by a police officer. The police officer at the scene states that he snuck up on a group of kids that he thought were using drugs. Two of them got away and one just fell to the ground seconds after standing up. Lying on the ground next to the adolescent were plastic bags. The emergency medical technician (EMT) states that the patient was in ventricular fibrillation. He was shocked in the field and is now in a sinus rhythm. The EMT also administered IV dextrose, thiamine, and naloxone without any change in mental status. Which of the following substances was the patient most likely abusing?

56) A 61-year-old man with a history of depression and hypertension is brought to the ED by EMS for altered mental status. The patient’s wife states that he stopped taking his fluoxetine 1 month ago and now only takes metoprolol for his hypertension. The patient’s BP is 75/40 mmHg, HR is 39 beats per minute, RR is 14 breaths per minute, oxygen saturation is 99% on 100% oxygen, and fingerstick glucose is 61 mg/dL. The patient is awake and moaning, responding only to deep stimuli. His extremities are cool to the touch. You suspect an overdose of metoprolol. You endotracheally intubate the patient for airway control. Which of the following is the most appropriate next step in management?

57) A 22-year-old woman presents to the ED by ambulance from a dance club. The paramedics report that the patient was agitated in the club and had a generalized seizure. Her BP is 165/100 mmHg, HR is 119 beats per minute, temperature is 101.9°F, RR is 17 breaths per minute, oxygen saturation is 98% on room air, and fingerstick glucose is 92 mg/dL. On examination, the patient is hyperactive and appears to be hallucinating. Her pupils are dilated to 6 mm bilaterally and reactive. Her neck is supple. Examination of the heart is unremarkable except for tachycardia. Her lungs are clear and abdomen is soft and nontender. The patient moves all four extremities. Laboratory results are as follows: Sodium 109 mEq/L, WBC 12,000/mm3, Potassium 3.5 mEq/L, Hct 49%, Chloride 83 mEq/L, Platelets 350/μL, Bicarbonate 20 mEq/L, BUN 10 mg/dL, Creatinine 1 mg/dL, Glucose 103 mg/dL. Which of the following substances did this patient most likely consume?

58) A 32-year-old woman is brought to the emergency department by her husband because of slurred speech and difficulty walking. She has also been very drowsy for the past several hours, a non-typical behavior for a very active woman. She has a history of bipolar disorder, insomnia, migraine headaches, seizures and hypothyroidism. Her temperature is 37°C (98.6°F), blood pressure is 110/70 mmHg, pulse is 76/min, and respirations are 16/min. She is lethargic and falls asleep during the interview and physical examination. Pupils are 5 mm in size and reactive to light. Neck is supple. Oropharynx is clear. Chest auscultation is unremarkable. Abdomen is soft and non-tender; bowel sounds are normal. Limited neurologic examination shows 1+ deep tendon reflexes in all four extremities; there is no Babinski sign; strength is 5/5 throughout. There is no nystagmus or hand tremor. Blood sugar is 130 mg/dL. Which of the following is the most likely cause of her symptoms?

59) A 31-year-old woman with a known psychiatric history presents to the ED after ingesting an unknown quantity of pills from her medication vial. In the ED, she complains of nausea, abdominal cramping, and feels unsteady on her feet. On physical examination, you observe that she is tachycardic and ataxic. Which of the following substances will best be treated by activated charcoal that could present like this?

60) A 27-year-old man presents to the ED extremely agitated complaining of mild chest pain and dyspnea. He states that he was snorting cocaine all afternoon. You place him on a monitor and get his vital signs. His BP is 215/130 mmHg, HR is 112 beats per minute, temperature is 100.1°F, RR is 17 breaths per minute, and oxygen saturation is 98% on room air. An ECG reveals sinus tachycardia at a rate of 116. Which of the following is the most appropriate medication to administer?

61) A 30-year-old man is brought to the ED by police officers. The patient is agitated, vomiting, and complaining of body aches. He states that he is withdrawing from his medication. His vital signs are BP 160/85 mmHg, RR 20 breaths per minute, HR 107 beats per minute, and temperature 99.7°F. On examination he is diaphoretic, has rhinorrhea, piloerection, and hyperactive bowel sounds. Which of the following substances is this patient most likely withdrawing from?

62) A 25-year-old man is brought into the ED by two police officers because of suspected drug use. The patient is extremely agitated and is fighting the police officers. It takes three hospital staff members and the two police officers to keep him on the stretcher. His vital signs are BP 150/80 mmHg, HR 107 beats per minute, temperature 99.7°F, RR 18 breaths per minute, and oxygen saturation 99% on room air. Physical examination is unremarkable except for cool, diaphoretic skin, persistent vertical and horizontal nystagmus, and occasional myoclonic jerks. Which of the following is the most likely diagnosis?

63) A 20-year-old female is brought to the emergency room after getting struck by a motor vehicle. She appears confused. According to her parents, she has no other medical problems and does not take any prescription medications. However, they have noticed her increase in appetite recently. She occasionally drinks alcohol and smokes half a pack of cigarettes daily. Her temperature is 37.2°C (99°F), blood pressure is 150/90mmHg, pulse is 110/min, and respirations are 22/min. Examination reveals dry mouth and conjunctival injection. Pupils are equal, reactive to light and accommodation. She has impaired time orientation and shortterm memory. Which of the following is the most likely explanation for this patient's symptoms?

64) A 34-year-old male is brought to the emergency department by his neighbor. The neighbor found the man lying on the floor beside an empty bottle of unknown substance. At the hospital, the patient is conscious and alert, but in severe pain. His temperature is 36.8°C (98.2°F), blood pressure is 130/70 mmHg, pulse is 90/min and respirations are 20/min. Abdomen is benign, with normal bowel sounds. Pupils are 5 mm, bilaterally. His tongue is white, heavy drooling of saliva is noted and he is unable to swallow. Which of the following is the most likely explanation for this patient's symptoms?

65) A 35-year-old woman calls her family physician after her 7-year old son accidentally splashed an unknown liquid containing acid on his face. Some liquid likely entered his eye, as the child is complaining of severe pain in his right eye. She knows a doctor living in her immediate neighborhood but is hesitant about what to do next. Which of the following is the most appropriate initial course of action that the mother should take?

66) A worried and anxious pregnant mother brings her 3-year-old son to the emergency room after he experienced several episodes of vomiting and abdominal pain for the past two hours. His vomit is coffee ground in appearance. He is irritable and lethargic. His blood pressure is 80/50mmHg and pulse rate is 120/min. Examination shows a normal oropharynx; chest auscultation is within normal limits. Abdomen is soft and mildly tender at the epigastrium; there is no hepatosplenomegaly. Extremities are cold to touch. Initial laboratory studies show: Hemoglobin 10.3 g/L, Leukocyte count 14,500/mm3, Bicarbonate 18 mEq/L. Chest x-ray is within normal limits. Abdominal imaging shows radio opaque tablets in the stomach. Intravenous normal saline is started. Which of the following is the most appropriate next step in management?

67) A 32-year-old male comes to the hospital complaining of pain, swelling and redness of his right arm. His past medical history is significant for substance abuse. His temperature is 38.9°C (102.0°F), blood pressure is 110/60 mmHg, pulse is 110/min and respirations are 14/min. He is started on intravenous clindamycin. The next day the swelling and pain improve, but he develops nausea, vomiting, abdominal cramps and diarrhea. He is restless and asks for pain medication to treat his aching muscles and joints. His temperature now is 37.3°C (99.1°F), blood pressure is 120/70 mmHg, pulse is 80/min and respirations are 16/min. His laboratory studies at the time of admission and the following day show: Hemoglobin 13.0 g/L (12.8 g/L), Leukocyte count 17,500/mm3 (8,500/mm3), NeutrophiIs 86% (64%), Lymphocytes 14% (26%). Which of the following is the most appropriate next step in management?

68) A 34-year-old homeless male is brought to the ER in a confused state. He complains of flank pain. His past medical history is unknown. His temperature is 36.8°C (98.2F), blood pressure is 110/60 mmHg, pulse is 110/min and respirations are 22/min. His appearance is disheveled. Pupils are equal, 4 mm in size and reactive to light. Funduscopic examination is within normal limits. Lungs have crackles at both bases. Mild costovertebral angle tenderness is present. Foley catheter is placed and urine appears red. Laboratory studies show: Serum sodium 136 mEq/L, Serum potassium 3.5 mEq/L, Chloride 93 mEq/L, Bicarbonate 6 mEq/L, Blood urea nitrogen (BUN) 34 mg/dl, Serum creatinine 2.8 mg/dl, Blood glucose 80 mg/dl, Calcium 6.5 mg/dl, Serum ketones negative, Plasma lactate 2.4 mEq/L. Which of the following is the most appropriate next step in management?

69) A 26-year-old bar employee is brought to the emergency room because of agitated, combative behavior in which three people had to restrain her. She has also been hallucinating during this entire period. Her temperature is 37.7°C (100°F), blood pressure is 160/90 mmHg, pulse is 126/min, and respirations are 18/min. She is confused and agitated during the examination. Pupils are 6 mm in diameter and respond to light; prominent nystagmus is present. The remainder of her examination is unremarkable. Which of the following is the most likely diagnosis?

70) A 38-year-old man is brought to the emergency room by EMS after an apparent suicide attempt. En route to the hospital, he appeared confused and suffered a seizure. He has a history of hypertension and major depression. His temperature is 37.7°C (100°F), blood pressure is 70/40 mmHg, pulse is 40/min, and respirations are 12/min. Examination shows normal heart sounds and diffuse wheezing. Extremities are cold and clammy. EKG shows AV block. The patient is given intravenous fluids and atropine; however, his bradycardia and hypotension do not improve. Which of the following is the most appropriate next step in management?

71) A 24-year-old woman is brought to the emergency room after ingesting 14 acetaminophen tablets, 500 mg each, two hours ago. She does not smoke but drinks alcohol on the weekends. She is alert and oriented. Her temperature is 37.2°C (99°F), blood pressure is 110/60mmHg, pulse is 90/min and respirations are 18/min. Examination shows no abnormalities. Laboratory studies show: Hct 40%, WBC 6,000/mm3, Platelet 390,000/mm3. Which of the following is the most appropriate next step in management?

72) A group of teenagers attend an indoor barbecue on a cold winter night. They all ate servings of potato salad and barbecue chicken. A few hours later, they present to the local emergency room with headache, nausea, vomiting, vague abdominal discomfort and confusion. One of the teenagers mentions a pet dog that was in the room with them had similar symptoms. A quick physical examination of one patient reveals tachycardia, tachypnea and a pinkish-skin hue. Which of the following is the most likely diagnosis?

73) A 40-year-old man is brought to the emergency room for retrosternal and epigastric pain after ingesting an unknown amount of "lye" (drain cleaner) 45 minutes ago. His past medical history is significant for major depression and suicide attempt. He is unable to swallow his saliva and is drooling. His temperature is 36.8°C (98.2°F), blood pressure is 120/70 mmHg, pulse is 110/min, and respirations are 20/min. Examination shows oropharyngeal erythema and edema. Lungs are clear to auscultation. Abdominal examination reveals tenderness at the epigastrium without rebound or guarding. Chest x-ray shows no abnormalities. Intravenous hydration is started. Which of the following is the most appropriate next step in treatment?

74) A 34-year-old farmer is brought to the hospital after attempting suicide. His body and clothes are soiled with vomitus. He is short of breath and appears agitated. His family reports no previous medical history or regular use of prescription medications. His temperature is 36.6°C (98°F), blood pressure is 110/60 mmHg, pulse is 50/min, and respirations are 22/min. His oxygen saturation is 86% on room air. Examination shows watering of the eyes and 1 mm pupils, bilaterally. Lung examination shows widespread rhonchi with prolonged expiration. Abdominal examination shows increased bowel sounds. Neurologic examination shows muscle fasciculations. What would be the most appropriate next step in management of this patient?

75) A 60-year-old male is found lying down on the street by police one winter morning. He has been taking ibuprofen for headaches, fluphenazine for his schizophrenia and amitriptyline for chronic painful neuropathy secondary to post-herpetic neuralgia. He is also receiving cephalexin for cellulitis of the right lower leg. His temperature is 34°C (90°F), blood pressure is 80/50 mmHg, pulse is 88/min, and respirations are 12/min. Which of the following medications most likely have contributed to the development of hypothermia in this patient?

76) A 45-year-old woman is brought to the ER by ambulance after a neighbor found her to be in a somewhat obtunded state with an empty bottle of medication next to her. While en route to the ER she suffered a tonic clonic seizure. Her past medical history is significant for major depression. Her temperature is 38.3°C (100.9°F), blood pressure is 90/70 mmHg, pulse is 120/min, and respirations are 16/min. She is able to respond to painful stimuli. Pupils are 8 mm in size bilaterally. Skin is warm and flushed. Lungs are clear to auscultation. Abdomen is soft and non-tender. Bowel sounds are decreased. There is no neck stiffness. EKG shows QRS duration of 130 msec, a change from her previous EKG a month ago. Which of the following is the most appropriate next step in management?

77) After being fired from his job, a 35-year-old man attempts suicide by drinking from a bottle labeled “insecticide.” Three hours later, emergency medical services (EMS) brings him into the emergency department (ED) and you notice that he is extremely diaphoretic, drooling, and vomiting. He is awake but confused. His vital signs include a blood pressure (BP) of 170/90 mmHg, heart rate (HR) of 55 beats per minute, respiratory rate (RR) of 22 breaths per minute, temperature of 98.6°F, and oxygen saturation of 95% on room air. Physical examination demonstrates pinpoint pupils and crackles and wheezing on lung examination. What is the treatment to reverse this patient’s poisoning?

78) A 19-year-old man is brought to the ED by EMS after he was found lying on the floor at a dance club. EMS states that the patient seemed unconscious at the dance club, but as soon as they transferred him onto the gurney, he became combative. Upon arrival in the ED, his BP is 120/65 mmHg, HR is 75 beats per minute, temperature is 98.9°F, RR is 12 breaths per minute, and oxygen saturation is 98% on room air. On physical examination, his pupils are midsized, equal, and reactive to light. His skin is warm and dry. Lung, cardiac, and abdominal examinations are unremarkable. As you walk away from the bedside, you hear the monitor alarm signaling zero respirations and the oxygen saturation starts to drop. You perform a sternal rub and the patient sits up in bed and starts yelling at you. As you leave him for the second time, you hear the monitor alarm again signal zero respirations. You administer naloxone, but there is no change in his condition. Which of the following is most likely the substance ingested by this patient?

79) A 43-year-old woman presents to the ED with a 3-week history of intermittent headache, nausea, and fatigue. She was seen at her private doctor’s office 1 week ago along with her husband and children, who also have similar symptoms. They were diagnosed with a viral syndrome and told to increase their fluid intake. She states that the symptoms began approximately when it started to get cold outside. The symptoms are worse in the morning and improve while she is at work. Her BP is 123/75 mmHg, HR is 83 beats per minute, temperature is 98.9°F, and oxygen saturation is 98% on room air. Physical examination is unremarkable. You suspect her first diagnosis was incorrect. Which of the following is the most appropriate next step to confirm your suspicion?

81) A 60-year-old woman with a history of diabetes is brought into the ED by EMS workers who state that the patient was found on a bus in a lethargic and diaphoretic condition. Her fingerstick glucose level at the scene was 35 mg/dL. EMS workers quickly administered dextrose through an IV line. The patient became alert and responsive, stating that she just took her normal medication. Her blood sugar went up to 110 mg/dL and she remained this way throughout her trip to the ED. However, in the ED you notice that the patient is again diaphoretic and is mumbling her speech. Her fingerstick glucose is now 47 mg/dL. You administer dextrose and she perks right up. Which of the following diabetes medications commonly causes hypoglycemia for which the patient is likely to require hospital admission?

82) A 23-year-old woman presents to the ED complaining of abdominal pain, nausea, and vomiting. She has a history of depression but is not currently taking any antidepressant medications. Upon further questioning, the patient states that she ingested a bottle of pills in her medicine cabinet approximately 3 hours ago. Her BP is 115/65 mmHg, HR is 101 beats per minute, temperature is 100.1°F, RR is 29 breaths per minute, and oxygen saturation is 100% on room air. Physical examination is unremarkable except for mild diffuse abdominal tenderness. Laboratory results reveal a white blood cell (WBC) count of 10,300/μL, hematocrit 46%, platelets 275/μL, aspartate transaminase (AST) 70 U/L, alanine transaminase (ALT) 85 U/L, alkaline phosphatase 75 U/L, sodium 143 mEq/L, potassium 3.7 mEq/L, chloride 98 mEq/L, bicarbonate 8 mEq/L, blood urea nitrogen (BUN) 22 mg/dL, creatinine 0.9 mg/dL, and glucose 85 mg/dL. Arterial blood gas values on room air are pH 7.51, PCO2 11 mm Hg, and PO2 134 mm Hg. Which of the following substances did this patient most likely ingest?

83) A 35-year-old agitated man presents to the ED in police custody. He denies any past medical history and takes no medication. He admits to using some drugs today. His BP is 195/90 mmHg, HR is 121 beats per minute, temperature is 100.1°F, RR is 18 breaths per minute, and oxygen saturation is 99% on room air. On examination, he is diaphoretic, and has pupils that are 8 mm in diameter, along with 3+ patella reflexes bilaterally. Electrocardiogram (ECG) reveals sinus tachycardia with a rate of 123. Which of the following toxic syndromes is this patient exhibiting?

84) An undomiciled 49-year-old man presents to the ED with altered mental status. His BP is 149/75 mmHg, HR is 93 beats per minute, temperature is 97.5°F, RR is 18 breaths per minute, and O2 saturation is 99% on room air. Physical examination reveals an unkempt man with the odor of “alcohol” on his breath. His head is atraumatic and pupils are 4 mm, equal, and reactive. The neck is supple. Cardiovascular, pulmonary, and abdominal examinations are unremarkable. There is no extremity edema and his pulses are 2+ and symmetric. Neurologically, he withdraws all four extremities to deep stimuli. ECG is sinus rhythm. Laboratory results reveal: Sodium 141 mEq/L, Potassium 3.5 mEq/L, Chloride 101 mEq/L, Bicarbonate 14 mEq/L, BUN 15 mg/dL, Creatinine 0.7 mg/dL, Glucose 89 mg/dL, Arterial blood pH 7.26, Lactate 1.7 mEq/L, Ethanol level undetectable, Measured serum osmolarity 352 mOsm/L, Calculated serum osmolarity 292 mOsm/kg. Urinalysis: no blood, ketones, or protein. Which of the following statements best describes the laboratory findings?

85) A 26-year-old woman with a history of depression is brought into the ED. She was found lying on the floor of her apartment next to an unlabeled empty pill bottle. Her HR is 117 beats per minute, BP is 95/65 mmHg, RR is 14 breaths per minute, and oxygen saturation is 97% on 2-L nasal cannula. On examination, the patient appears obtunded, and her pupils are 3 mm and reactive. Her oropharynx is dry and there is no gag reflex to pharyngeal stimulation. Her neck is supple. The heart is tachycardic without murmurs, the lungs are clear to auscultation, and the abdomen is soft. There is normal rectal tone and brown stool that is heme negative. Her skin is cool and moist with no signs of needle tracks. Neurologically, she is unresponsive but withdraws all extremities to deep palpation. Fingerstick blood glucose is 85 mg/dL. Her ECG reveals sinus tachycardia at 119 with a QRS complex of 140 milliseconds and a terminal R wave in lead aVR. Which of the following is the most appropriate next step in management?

86) A 37-year-old woman is brought into the ED by her friend who states that the patient swallowed approximately 50 capsules of 325-mg acetaminophen (APAP) 6 hours ago in an attempted suicide. The patient states she feels nauseated and vomits while you take her history. Her BP is 100/75 mmHg, HR is 97 beats per minute, temperature is 98.9°F, RR is 18 breaths per minute, and oxygen saturation is 99% on room air. Examination is unremarkable except for mild epigastric tenderness. Which of the following is the correct antidote for APAP overdose?

87) A 31-year-old man is brought to the ED by EMS who state that the man was found lying on the floor of his garage. He is rousable in the ED, speaks with slurred speech, and vomits. His BP is 140/85 mmHg, HR is 94 beats per minute, temperature is 98.8°F, RR is 17 breaths per minute, and oxygen saturation is 99% on room air. You place an IV line, draw blood, and start a liter of normal saline running through the line. Laboratory results reveal serum sodium 139 mEq/L, potassium 3.5 mEq/L, chloride 101 mEq/L, bicarbonate 14 mEq/L, BUN 15 mg/dL, creatinine 1 mg/dL, glucose 105 mg/dL, arterial blood pH 7.27, COHb 4%, and lactate 2.8 mEq/L. Urinalysis shows 1+ protein, trace ketones, WBC 4/hpf (high-power field), red blood cell (RBC) 2 to 3/hpf, and multiple envelope-shaped and needle shaped crystals. Which of the following conditions would best explain his metabolic acidosis?

88) A 35-year-old man who is employed as a forklift operator was found sitting outside a warehouse. He came stumbling out complaining of dizziness and headaches. Co-workers in an adjoining warehouse also complained of headache and nausea. After collapsing outside, he regained consciousness immediately but appeared confused. In the ED, his BP is 100/54 mmHg, HR is 103 beats per minute, temperature is 100°F, pulse ox is 91% on room air, and RR is 23 breaths per minute. Physical examination is unremarkable. Laboratory results reveal WBC 10,500/μL, hematocrit 45%, platelets 110/μL, sodium 137 mEq/L, potassium 4 mEq/L, chloride 103 mEq/L, bicarbonate 21 mEq/L, BUN 8 mg/dL, creatinine 0.5 mg/dL, and glucose 89 mg/dL. Arterial blood gas results are pH 7.32, PCO2 32 mm Hg, and PO2 124 mm Hg. Which of the following is the most likely diagnosis?

89) A 51-year-old man presents to the ED complaining of nausea and abdominal pain after drinking some “bitter stuff.” He is considered one of the “regulars” who is usually at triage with ethanol intoxication. His temperature is 97.9°F, BP is 130/65 mmHg, HR is 90 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 97% on room air. Physical examination is unremarkable, except for slurred speech and the smell of acetone on the patient’s breath. Laboratory results reveal serum sodium 138 mEq/L, potassium 3.5 mEq/L, chloride 105 mEq/L, bicarbonate 23 mEq/L, BUN 10 mg/dL, creatinine 2.1 mg/dL, glucose 85 mg/dL, arterial blood pH 7.37, and lactate 1.4 mEq/L. Urinalysis shows moderate ketones. Which of the following is the most likely diagnosis?

90) A 55-year-old man presents to the ED 6 hours after ingesting two bottles of his baby aspirin. He complains of nausea, vomiting, dizziness, and tinnitus. His temperature is 100.3°F, BP is 140/80 mmHg, HR is 105 beats per minute, RR is 31 breaths per minute, and oxygen saturation is 99% on room air. Arterial blood gas on room air reveals a pH of 7.52, PCO2 10 mmHg, and PO2 129 mmHg. The blood salicylate level returns at 45 mg/dL. Which of the following is the most appropriate next step in management?

91) A 40-year-old man with a known history of ethanol abuse states that 2 hours ago he ingested two bottles of extra strength Tylenol. The patient has no medical complaints except for some nausea. At 4 hours post ingestion, you send blood to the laboratory to measure the serum acetaminophen concentration. The level returns and falls above the treatment line when you plot it on the APAP nomogram. You administer activated charcoal and decide to start IV NAC. Which of the following is a known adverse effect of IV NAC administration?

92) A 19-year-old woman presents to the ED with abdominal pain, nausea, vomiting, diarrhea, and hematemesis after ingesting an unknown substance in a suicide attempt. Which of the following antidotes are correctly paired?

93) A 34-year-old woman presents to the ED after ingesting an unknown quantity of her antidepressant pills. EMS workers found an empty bottle of amitriptyline on her apartment floor. She is awake but appears delirious. Her BP is 130/65 mmHg, HR is 101 beats per minute, temperature is 99.1°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. On examination, her pupils are 7 mm and reactive. Her face is flushed and mucous membranes are dry. Her lungs are clear and heart is without murmurs. The abdomen is soft, nontender, and with decreased bowel sounds. She is moving all four extremities. ECG reveals sinus rhythm at a rate of 99 and QRS just under 100 milliseconds. In a TCA overdose, which of the following is responsible for her mydriasis, dry mucous membranes, and delirium?

94) An asymptomatic young adult was brought to the ED by a police officer after his home was raided. The patient swallowed five small packets of an unknown substance before being arrested. His BP is 125/75 mmHg, HR is 85 beats per minute, temperature is 98.7°F, and RR is 16 breaths per minute. Physical examination is unremarkable. An abdominal radiograph confirms intraluminal small bowel densities. Which of the following is the most appropriate treatment?

95) A 33-year-old woman presents to the ED with a painful sprained ankle. She has a past medical history of depression for which she is taking phenelzine, a monoamine oxidase inhibitor. After you place an elastic wrap on her ankle, she asks you to prescribe her some pain medication. Which of the following medications is contraindicated in patients taking a monoamine oxidase inhibitor?

96) A 27-year-old woman presents to the ED 6 hours after the onset of body aches, abdominal cramping, and diarrhea. She is currently visiting relatives and normally lives in another state. She regularly takes six to eight tablets daily of hydrocodone for chronic low-back pain, sumatriptan for migraines, and amitriptyline and paroxetine for bulimia nervosa. Her BP is 130/80 mmHg, HR is 100 beats per minute, temperature is 98.6°F, RR is 16 breaths per minute, and oxygen saturation is 99% on room air. Examination shows diaphoresis, dilated pupils, and piloerection. Neurologically she is moving all four extremities and you do not note tremors. She is alert and cooperative but seems restless. She denies hallucinations or suicidal ideations. She becomes very angry when you ask her for the phone numbers of her regular physicians. Which of the following is the most likely explanation of her symptoms?

97) A 58-year-old woman is brought to the emergency department (ED) by emergency medical service (EMS) after slipping on a patch of ice while walking to work and hitting her head on the cement pavement. Bystanders acknowledged that the patient was unconscious for approximately 1 minute. On arrival, her vital signs are blood pressure (BP) 155/75 mmHg, heart rate (HR) 89 beats per minute, respiratory rate (RR) 18 breaths per minute, and pulse oxygenation 98% on room air. She has a 5-cm laceration to the back of her head that is actively bleeding. You ask the patient what happened but she cannot remember. You inform her that she is in the hospital as a result of a fall. Over the next 10 minutes she asks you repeatedly what happened and where she is. You do not find any focal neurologic deficits. As you bring the patient to the CT scanner, she vomits once. CT results show a normal brain scan. Which of the following is the most likely diagnosis?

98) A 41-year-old man, the restrained driver in a high-speed motor vehicle collision, is brought to the ED by EMS. The patient is breathing without difficulty with bilateral and equal breaths sounds. He has strong pulses peripherally indicating a BP of at least 90 mmHg. The HR is 121 beats per minute. His Glasgow coma scale (GCS) is 14. A secondary survey reveals chest wall bruising. You suspect a cardiac injury. Which of the following locations most commonly involve cardiac contusions?

99) A 25-year-old man is brought into the trauma resuscitation room after his motorcycle is struck by another vehicle. EMS reports that the patient was found 20 ft away from his motorcycle, which was badly damaged. His vital signs include a BP of 90/60 mmHg, HR 115 beats per minute, RR 22 breaths per minute, and pulse oxygenation of 100% on facemask. Which of the following is the smallest amount of blood loss that produces a decrease in the systolic BP in adults?

100) You are notified by the EMS dispatcher that there is a multiple-car collision on the local highway with many injuries. He states that there are two people dead at the scene, one person is critically injured and hypotensive, and three people have significant injuries but with stable vital signs. Which of the following is the leading cause of death and disability in trauma victims?

101) Paramedics bring a 17-year-old high school football player to the ED on a backboard and with a cervical collar. During a football game, the patient “speared” another player with his helmet and subsequently experienced severe neck pain. He denies paresthesias and is able to move all of his extremities. A cervical spine CT scan reveals multiple fractures of the first cervical vertebra. Which of the following best describes this fracture?

102) A 20-year-old man presents to the ED with multiple stab wounds to his chest. His BP is 85/50 mmHg and HR is 123 beats per minute. Two large-bore IVs (intravenous) are established and running wide open. On examination, the patient is mumbling incomprehensibly, has good air entry on lung examination, and you notice jugular venous distension (JVD). As you are listening to his heart, the nurse calls out that the patient has lost his pulse and that she cannot get a BP reading. Which of the following is the most appropriate next step in management?

103) A 22-year-old man calls the ED from a local bar stating that he was punched in the face 10 minutes ago and is holding his front incisor tooth in his hand. He wants to know what the best way is to preserve the tooth. Which of the following is the most appropriate advice to give the caller?

104) A 19-year-old man is brought into the trauma room by EMS after a head-on cycling accident. The patient was not wearing a helmet. Upon presentation his BP is 125/75 mmHg, HR is 105 beats per minute, RR is 19 breaths per minute, and oxygen saturation is 100% on mask. His eyes are closed but open to command. He can move his arms and legs on command. When you ask him questions, he is disoriented but able to converse. What is this patient’s GCS score?

105) An 18-year-old man presents to the ED after getting stabbed in his abdomen. His HR is 140 beats per minute and BP is 90/40 mmHg. He is yelling that he is in pain. Two large-bore IVs are inserted into his antecubital fossa and fluids are running wide open. After 2 L of fluids, his BP does not improve. Which of the following is the most common organ injured in stab wounds?

106) A 61-year-old man presents to the ED with chest wall pain after a motor vehicle collision. He is speaking full sentences, breath sounds are equal bilaterally, and his extremities are well-perfused. His BP is 150/75 mmHg, HR is 92 beats per minute, and oxygen saturation is 97% on room air. Chest radiography reveals fractures of the seventh and eighth ribs of the right anterolateral chest. He has no other identifiable injuries. Which of the following is the most appropriate treatment for this patient’s rib fractures?

107) A 27-year-old man brought to the ED by paramedics after a motor vehicle collision. His RR is 45 breaths per minute, oxygen saturation is 89%, HR is 112 beats per minute, and BP is 115/75 mmHg. You auscultate his chest and hear decreased breath sounds on the left. Which of the following is the most appropriate next step in management?

108) A 29-year-old man is brought to the ED by EMS after being stabbed in the left side of his back. His BP is 120/80 mmHg, HR is 105 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. On the secondary survey, you note motor weakness of his left lower extremity and the loss of pain sensation in the right lower extremity. Which of the following is the most likely diagnosis?

109) A 33-year-old man, who was drinking heavily at a bar, presents to the ED after getting into a fight. A bystander tells paramedics that the patient was punched and kicked multiple times and sustained multiple blows to his head with a stool. In the ED, his BP is 150/75 mmHg, HR is 90 beats per minute, RR is 13 breaths per minute, and oxygen saturation is 100% on non-rebreather. On examination, he opens his eyes to pain and his pupils are equal and reactive. There is a laceration on the right side of his head. He withdraws his arm to pain but otherwise does not move. You ask him questions, but he just moans. Which of the following is the most appropriate next step in management?

110) A 74-year-old man presents to the ED after being involved in a motor vehicle collision. He states he was wearing his seat belt in the driver’s seat when a car hit him from behind. He thinks his chest hit the steering wheel and now complains of pain with breathing. His RR is 20 breaths per minute, oxygen saturation is 98% on room air, BP is 145/75 mmHg, and HR is 90 beats per minute. On examination, you notice paradoxical respirations. Which of the following best describes a flail chest?

111) A 29-year-old man presents to the ED after being stabbed in his neck. The patient is speaking in full sentences. His breath sounds are equal bilaterally. His BP is 130/75 mmHg, HR is 95 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 99% on room air. The stab wound is located between the angle of the mandible and the cricoid cartilage and violates the platysma. There is blood oozing from the site although there is no expanding hematoma. Which of the following is the most appropriate next step in management?

112) A 45-year-old man is brought to the ED after a head-on motor vehicle collision. Paramedics at the scene tell you that the front end of the car is smashed. The patient’s BP is 130/80 mmHg, HR is 100 beats per minute, RR is 15 breaths per minute, and oxygen saturation is 98% on room air. Radiographs of the cervical spine reveal bilateral fractures of the C2 vertebra. The patient’s neurologic examination is unremarkable. Which of the following best describes this fracture?

113) A 71-year-old man is found lying on the ground one story below the balcony of his apartment. Paramedics bring the patient into the ED. He is cool to touch with a core body temperature of 96°F. His HR is 119 beats per minute and BP is 90/70 mmHg. His eyes are closed, but they open when you call his name. His limbs move to stimuli, and he answers your questions but is confused. On examination, you note clear fluid dripping from his left ear canal and an area of ecchymosis around the mastoid bone. Which of the following is the most likely diagnosis?

114) A 34-year-old construction worker is brought to the ED by EMS after falling 30 ft from a scaffold. His vital signs are HR 124 beats per minute, BP 80/40 mmHg, and oxygen saturation 93% on 100% oxygen. He has obvious head trauma with a scalp laceration overlying a skull fracture on his occiput. He does not speak when asked his name, his respirations are poor, and you hear gurgling with each attempted breath. Auscultation of the chest reveals diminished breath sounds on the right. There is no JVD or anterior chest wall crepitus. His pelvis is unstable with movement laterally to medially and you note blood at the urethral meatus. His right leg is grossly deformed at the knee and there is an obvious fracture of his left arm. Which of the following is the most appropriate next step in management?

116) An 81-year-old woman presents to the ED after tripping over the sidewalk curb and landing on her chin causing a hyperextension of her neck. She was placed in a cervical collar by paramedics. On examination, she has no sensorimotor function of her upper extremities. She cannot wiggle her toes, has 1/5 motor function of her quadriceps, and only patchy lower extremity sensation. Rectal examination reveals decreased rectal tone. Which of the following is the most likely diagnosis?

117) A 22-year-old man presents to the ED after being ejected from his vehicle following a high-speed motor vehicle collision. Upon arrival, his BP is 85/55 mmHg and HR is 141 beats per minute. Two large-bore IVs are placed in the antecubital veins and lactated Ringer solution is being administered. After 3 L of crystalloid fluid, the patient’s BP is 83/57 mmHg. Which of the following statements is most appropriate regarding management of a hypotensive trauma patient who fails to respond to initial volume resuscitation?

118) A 24-year-old man is brought into the ED by paramedics after being run over by a car. His systolic BP is 90 mmHg by palpation, HR is 121 beats per minute, RR is 28 breaths per minute, and oxygen saturation is 100% on non-rebreather. The airway is patent and breath sounds are equal bilaterally. You establish large-bore access and fluids are running wide open. Secondary survey reveals an unstable pelvis upon movement with lateral to medial force. Bedside focused abdominal sonography for trauma (FAST) is negative for intraperitoneal fluid. Which of the following is the most appropriate immediate next step in management?

119) A 32-year-old man is brought to the ED by paramedics after a diving accident. The lifeguard on duty accompanies the patient and states that he dove head first into the shallow end of the pool and did not resurface. On examination, the patient is speaking but cannot move his arms or legs and cannot feel pain below his clavicle. He is able to feel light touch and position of his four extremities. A cervical spine radiograph does not reveal a fracture. Which of the following is the most likely diagnosis?

120) A 22-year-old man is brought to the ED 20 minutes after a head-on motor vehicle collision in which he was the unrestrained driver. On arrival, he is alert and coherent but appears short of breath. His HR is 117 beats per minute, BP is 80/60 mmHg, and oxygen saturation is 97% on a nonrebreather. Examination reveals bruising over the central portion of his chest. His neck veins are not distended. Breath sounds are present on the left but absent on the right. Following administration of 2 L of lactated Ringer solution, his systolic BP remains at 80 mmHg. Which of the following is the most appropriate next step in management?

121) An 87-year-old man is brought to the ED on a long board and in a cervical collar after falling down a flight of steps. He denies losing consciousness. On arrival, his vital signs include an HR of 99 beats per minute, BP of 160/90 mmHg, and RR of 16 breaths per minute. He is alert and speaking in full sentences. Breath sounds are equal bilaterally. Despite an obvious right arm fracture, his radial pulses are 2+ and symmetric. When examining his cervical spine, he denies tenderness to palpation and you do not feel any bony deformities. Which of the following is a true statement?

122) A 45-year-old man is brought into the ED after a head-on motor vehicle collision. His BP is 85/45 mmHg and HR is 130 beats per minute. He is speaking coherently. His breath sounds are equal bilaterally. After 2 L of fluid resuscitation, his BP is 80/40 mmHg. A FAST examination reveals fluid in Morison pouch. Which of the following organs is most likely to be injured in blunt abdominal trauma?

123) A 47-year-old man is brought into the ED after falling 20 ft from a ladder. His HR is 110 beats per minute, BP is 110/80 mmHg, RR is 20 breaths per minute, and oxygen saturation is 100% on face mask. He is able to answer your questions without difficulty. His chest is clear with bilateral breath sounds, abdomen is nontender, pelvis is stable, and the FAST examination is negative. You note a large scrotal hematoma and blood at the urethral meatus. Which of the following is the most appropriate next step in management?

124) A 17-year-old man presents to the ED after getting hit in the right eye with a tennis ball during a tennis match. On arrival to the ED, you note periorbital swelling and ecchymosis. The patient’s visual acuity is 20/20. When you are testing his extraocular muscles, you note that his right eye cannot look superiorly but his left eye can. He also describes pain in his right eye when attempting to look upward. Which of the following is the most likely diagnosis?

125) A 24-year-old man is brought to the ED after being shot once in the abdomen. On arrival, his BP is 100/60 mmHg, HR is 115 beats per minute, and RR is 22 breaths per minute. His airway is patent and you hear breath sounds bilaterally. On abdominal examination, you note a single bullet entry wound approximately 1 cm to the right of the umbilicus. During the log roll, you see a single bullet exit wound approximately 3 cm to the right of the lumbar spine. His GCS score is 15. The patient’s BP is now 85/65 mmHg and HR is 125 beats per minute after 2L of fluid. Which of the following is the most appropriate next step in management?

126) A 43-year-old man, who currently uses drugs intravenously (IV), presents to the emergency department (ED) with 2 weeks of fever, back pain, and progressive weakness in his legs bilaterally. He denies any history of trauma or prior surgery. His blood pressure (BP) is 130/75 mmHg, heart rate (HR) is 106 beats per minute, temperature is 103°F, and respiratory rate (RR) is 16 breaths per minute. On physical examination, he has tenderness to palpation in the mid-lumbar spine, increased patellar reflexes, and decreased strength in the lower extremities bilaterally, with normal range of motion. Laboratory results reveal a white blood cell (WBC) count of 15,500/μL, hematocrit 40%, and platelets 225/μL. Urinalysis and spinal x-rays are unremarkable. Which of the following is the most likely diagnosis?

127) An 81-year-old woman is brought to the ED by her children who state that the patient is acting more tired than usual, has had fever for the last 2 days, and is more confused. Ordinarily, the patient is high functioning: she is ambulatory, cooks for herself, and walks on a treadmill 30 minutes a day. Her vital signs are BP 85/60 mmHg, HR 125, RR 20, temperature 101.3°F, and pulse oxygenation 97% on room air. On examination, the patient has dry mucous membranes but is otherwise unremarkable. She is oriented to person and place but states that the year is 1925. Her laboratory results show a WBC 14,300/μL, hematocrit 31%, and platelets 350/μL. Her electrolytes are within normal limits. Blood glucose is 92 mg/dL. A chest radiograph does not show any infiltrates. Urinalysis reveals 2+ protein, trace ketones, WBC > 100/hpf, red blood cell (RBC) 5 to 10/hpf, nitrite positive, and leukocyte esterase positive. After administering a 500-cc normal saline fluid bolus and broad-spectrum antibiotics through her peripheral IV line, the patient’s BP is 82/60 mmHg. You suspect that the patient is in septic shock due to an acute urinary tract infection. Which of the following is the next most appropriate course of action to manage this patient with earlygoal-directed therapy (EGDT)?

128) A 23-year-old man presents to the ED with left lower abdominal pain and left testicular pain that started 1 to 2 weeks ago and has gradually worsened. He has some nausea and vomiting. His HR is 98 beats per minute, BP is 125/65 mmHg, temperature is 100.9°F, and RR is 18 breaths per minute. Physical examination reveals a tender left testicle with a firm nodularity on the posterolateral aspect of the testicle. Pain is relieved slightly with elevation of the testicle and the cremasteric reflex in normal. You make the presumptive diagnosis of epididymitis. Which of the following is the next best step?

129) A 40-year-old man with insulin-dependent diabetes presents to the ED with complaints of 2 days of increasingly severe perineal pain and subjective fevers. His HR is 118 beats per minute, BP is 95/55 mmHg, temperature is 103.4°F, and RR is 22 breaths per minute. The bedside sugar reading is “high.” Physical examination demonstrates crepitus over the medial thigh and widespread erythema and purple discoloration with sharp demarcation over the scrotum. The scrotum is markedly tender, warm, and edematous. Which of the following is the most likely diagnosis?

130) A 55-year-old man with a history of diabetes presents with complaints of developed left knee pain several days following a fall from standing height. The patient was brought to the ED by ambulance after being found on a park bench stating he was unable to walk because of the pain. On physical examination, there are no rashes or external signs of trauma. His left knee is warm, diffusely tender, and swollen with a large effusion. He has pain on passive range of motion and is refusing to walk. His BP is 150/85 mmHg, HR is 105 beats per minute, temperature is 102.7°F, RR is 16 breaths per minute, and fingerstick glucose is 89 mg/dL. Which of the following is the most appropriate diagnostic test?

131) A 35-year-old woman with systemic lupus erythematosus (SLE) is brought to the ED by her brother after he found her febrile and confused. Physical examination reveals fever, tachycardia, a waxing and waning mental status, petechiae over her oral mucosa, pallor, and mildly heme-positive stool. Her urinalysis is positive for blood, red cell casts, and proteinuria. Laboratory results reveal blood urea nitrogen (BUN) of 40 mg/dL and creatinine of 2 mg/dL. Her bilirubin is elevated (unconjugated > conjugated) and her international normalized ratio (INR) is 0.98. Her complete blood count reveals WBC 12,000/μL, hematocrit 29%, and platelet count 17,000/μL with schistocytes on the peripheral smear. Which of the following is the most appropriate next step in management?

132) A 30-year-old woman presents to the ED with fever, headache, a “sunburn-like” rash, and confusion. A friend states that the patient has complained of nausea, vomiting, diarrhea, and a sore throat over the past few days. Her last menstrual period began 4 days ago. Vital signs are HR 110 beats per minute, BP 80/45 mmHg, RR of 18 breaths per minute, and temperature of 103°F. On physical examination, you note an ill-appearing woman with a diffuse blanching erythroderma. Her neck is supple without signs of meningeal irritation. On pelvic examination, you remove a tampon. You note a fine desquamation of her skin, especially over the hands and feet, and hyperemia of her oropharyngeal, conjunctival, and vaginal mucous membranes. Laboratory results reveal a creatine phosphokinase (CPK) of 5000, WBC 15,000/μL, platelets of 90,000/μL, BUN 40 mg/dL, creatinine 2 mg/dL, and elevated liver enzymes. You suspect thediagnosis of toxic shock syndrome and initiate IV fluids. You target antibiotics at which of the following causative organism?

133) A 32-year-old diabetic man presents to the ED with a fever and 1 week of increasing right foot pain. He states he stepped on a nail while running barefoot 2 weeks ago but didn’t think much of it at that time. On physical examination, his heel is mildly erythematous and diffusely tender to palpation, with overlying warmth and edema. There is a small amount of purulent drainage through the puncture hole in his heel. A plain radiograph of his foot demonstrates a slight lucency of the calcaneus. He has decreased range of motion, but you are able to passively dorsiflex and plantarflex his ankle without difficulty. His vital signs include a temperature of 101.4°F, HR of 98 beats per minute, BP of 130/75 mmHg, and RR of 16 breaths per minute. Which of the following is the most common causative organism of this condition?

134) A 75-year-old woman is transferred to your ED from the local nursing home for fever, cough, and increasing lethargy. Over the past 3 days, the nursing home staff noticed increasing yellow sputum and decreasing urine output from the patient. Her BP is 118/75 mmHg, RR is 20 breaths per minute, HR is 105 beats per minute, temperature is 100.9°F, and pulse oxygenation is 94% on room air. On examination, auscultation of the lungs reveals bibasilar crackles. Laboratory results reveal WBC 14,500/μL, hematocrit 39%, platelets 250/μL, sodium 132 mEq/L, potassium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 18 mEq/L, BUN 27 mg/dL, creatinine 1.5 mg/dL, and glucose 85 mg/dL. Serum lactate is 4.7 mmol/dL. Chest radiography reveals bilateral lower lobe infiltrates. Based on this patient’s presentation, which of the following is the most likely diagnosis?

135) A 55-year-old man presents to the ED with fever, drooling, trismus, and a swollen neck. He reports a foul taste in his mouth caused by a tooth extraction 2 days ago. On physical examination, the patient appears anxious. He has bilateral submandibular swelling and elevation and protrusion of the tongue. He appears “bull-necked” with tense and markedly tender edema and brawny induration of the upper neck, and he is tender over the lower second and third molars. There is no cervical lymphadenopathy. These lungs are clear to auscultation with good air movement. His vital signs are HR 105 beats per minute, BP 140/85 mmHg, RR 26 breaths per minute, and temperature 102°F. Which of the following is the most appropriate next step in management?

136) A 67-year-old woman with a history of steroid-dependent COPD, non–insulin-dependent diabetes, and hypertension presents to the ED with complaints of a painful, red, swollen left lower leg. She states she noted a “bug bite” in that area 1 week ago and since then has had gradually increasing symptoms. On examination, you note a 12 cm × 10 cm sharply demarcated area of blanching erythema, warmth, and tenderness on the medial thigh with ascending erythema to the groin. You also note tender adenopathy in the left inguinal region. Her BP is 90/55 mmHg, RR is 24 breaths per minute, HR is 105 beats per minute, temperature is 102.4°F, and pulse oxygenation is 98% on room air. Laboratory results reveal WBC 19,500/μL, hematocrit 39%, platelets 175/μL, sodium 132 mEq/L, potassium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 14 mEq/L, BUN 32 mg/dL, creatinine 1.7 mg/dL, and glucose 455 mg/dL. Serum lactate is 4.7 mmol/dL. Which of the following best describes her clinical state?

137) An 84-year-old man presents to the ED with his family due to concerns that his condition is worsening despite being placed on levofloxacin for a urinary tract infection 5 days ago by his primary care physician. His is obtunded and unable to give any additional history. Physical examination does not reveal the source of infection. His BP is 84/45 mmHg, HR is 135 beats per minute, temperature is 102.8°F, and his RR is 28 breaths per minute. Laboratory results reveal WBC 24,500/μL, hematocrit 19%, platelets 90/μL, sodium 132 mEq/L, potassium 7.5 mEq/L, chloride 100 mEq/L, bicarbonate 12 mEq/L, BUN 37 mg/dL, creatinine 6.5 mg/dL, and glucose 255 mg/dL. Serum lactate is 11.3 mmol/dL. Cardiac enzymes and troponin are mildly elevated, and he has hyperacute T-waves on electrocardiogram (ECG). His chest radiograph shows cardiomegaly with bilateral patchy opacities and pulmonary vascular congestion. Rapid urinalysis reveals 3+ WBCs and blood and nitrates. You secure his airway with intubation, initiate broad-spectrum antibiotics, IV fluids, and other supportive therapies, and emergently consult nephrology, cardiology, and pulmonology. Which of the following best describes his clinical state?

138) A 37-year-old man presents to the ED with complaints of 2 days of a sore throat and subjective fever at home. He denies cough or vomiting. His BP is 130/75 mmHg, HR is 85 beats per minute, temperature is 101°F, and his RR is 14 breaths per minute. He has diffuse tonsillar swelling and bilateral exudates with bilaterally enlarged and tender lymph nodes of the neck. Which of the following is the next best step in management?

139) A 37-year-old man who just finished a full course of penicillin for pharyngitis presents to the ED requesting to be checked out again. He states he took the antibiotics exactly as prescribed and initially felt somewhat improved, but over the last 2 to 3 days has had increased pain and progressive difficulty swallowing. His BP is 130/65 mmHg, HR is 95 beats per minute, temperature is 100.1°F, RR is 16 breaths per minute, and oxygen saturation is 99%. On examination, the patient is in no acute distress but has a fluctuant mass on the right side of his neck. You visualize a normal soft palate with swelling of the right tonsillar arch and deviation of the uvula to the left, but additional examination is limited because he is unable to open his mouth fully. Review of his records reveals a throat culture that was positive for Streptococcus. Which of the following is the most appropriate next step in management?

140) A 50-year-old man presents to the ED complaining of fever, headache, and neck pain for 24 hours. He states that 1 week ago he had rhinorrhea, nasal congestion, a sore throat, and occasional dry cough. He noted generalized weakness, myalgias, and malaise yesterday afternoon, and woke up today “feeling terrible.” His BP is 145/75 mmHg, HR is 102 beats per minute, temperature is 101.2°F, and his RR is 16 breaths per minute. On examination, he is awake, alert, and nontoxic appearing although he has discomfort in his neck with flexion. He has a nonfocal neurologic examination without increased deep tendon reflexes or opthalmoplegia. There are no rashes. Which of the following CSF results is most consistent with your clinical diagnosis of viral meningitis?