USMLE_Emergency III

A 62-year-old woman with a history of diabetes mellitus presents to the emergency department complaining of severe abdominal pain for the past 12 hours, first beginning as dull pain near the umbilicus but now localized to the right lower quadrant. She initially thought she was suffering from heartburn, but decided to come to the hospital because of the unrelenting pain. The patient reports that just prior to examination by the physician, she experienced a sudden decrease in intensity of pain, but she remains feeling very uncomfortable and must remain on the stretcher. On examination the patient appears in distress secondary to pain, tachycardic, slightly hypotensive, and febrile at 39°C (102°F). She has a diffusely tender abdomen with point tenderness over her right lower quadrant, accompanied by guarding and rebound. Laboratory values showed a leukocytosis of 20,000/mm3 with 95% polymorphonuclear lymphocytes. After confirming the diagnosis with imaging, which of the following is the most appropriate management?

A 63-year-old man presents to the emergency department with a 6-hour history of slurred speech and right hand weakness. His past medical history is significant for chronic hypertension and a myocardial infarction 2 years ago. His current medications include enalapril and aspirin. He smokes 2 packs of cigarettes daily and consumes alcohol occasionally. His blood pressure is 165/95 mmHg, pulse is 80/min, and respirations are 14/min. Physical examination reveals right hand weakness and mild motor aphasia without sensory abnormalities Which of the following is the most probable cause of this patient's condition?

A 64-year-old Caucasian male presents to the Emergency Room with a sharp, left-sided chest pain. He says that the pain is worse when he takes deep breaths, but he gets relief with leaning forward. He had an acute non-ST elevation myocardial infarction six months ago and had undergone angioplasty for the right coronary artery. His other medical problems include: diabetes, hypertension, hyperlipidemia, peripheral neuropathy, diabetic retinopathy, paroxysmal atrial fibrillation, hypothyroidism, and chronic renal insufficiency. His vital signs are BP 142/86 mmHg, PR 78/min, RR 16/min, and T 36.1°C (97°F). On examination, you find a pericardial rub. EKG shows diffuse ST elevation. Lab results are: Hb 9.0 g/dl, WBC 8,000/cmm, Platelets 210,000/cmm, Blood Glucose 248 mg/dl, Serum Na 135 mEq/L, Serum K 5.8 mEq/L, Bicarbonate 17 mEq/L, BUN 86 mg/dl, Serum Creatinine 4.4 mg/dl. Which of the following is the most appropriate management of this patient?

A 64-year-old male is brought to the emergency department (ED) due to a sudden onset of lower extremity weakness. He was swimming in the pool, when he suddenly felt his legs become weak. He then felt that his legs had no more strength, and he was not able to move them. He struggled out of the pool, called EMS, and was rushed to the ED. He denies any trauma, loss of consciousness, visual or speech problems. He cannot pass urine. He has a long history of back problems. The physical examination reveals significant motor weakness in both legs, and numbness from the buttocks to the soles of the feet. He has no sensation in the perineal area. The rectal tone is absent. A Foley catheter is placed, and 800 cc of urine is collected. What is the best treatment for this patient?

A 64-year-old male presents to the emergency department with chest pain. An ECG reveals ST elevations in leads II, III, and aVF. Thrombolytic therapy and heparin are administered, and the pain resolves. Eight hours after admission, the patient develops hypotension. He denies recurrence of chest pain. His temperature is 37.5°C (99.6°F), blood pressure is 84/55 mm Hg, pulse is 90/min, and respirations are 15/min. His medications include a nitroglycerin drip, beta-blocker, aspirin, heparin, and simvastatin. Examination reveals an elevated jugular venous pressure of 14 cm, cold clammy extremities, and clear lung fields. Based on this information, what is the next best step in this patient's management?

A 64-year-old man is brought to the ER after an episode of coffee ground emesis followed by lightheadedness. He has been having black, tarry stools for the past few days. He has a history of coronary artery disease and he underwent coronary artery bypass surgery three years ago. He is currently taking aspirin, metoprolol, lisinopril, and pravastatin. He drinks 2-3 beers over the weekend but he quit smoking after the bypass surgery. His temperature is 36.7°C (98°F), pulse is 110/min, respirations are 16/min, and blood pressure is 90/60 mmHg. Examination shows coffee ground-like material in the oropharynx. His lungs are clear. Abdomen is slightly tender in the epigastrium. Laboratory studies show: Complete blood count: Leukocyte count 9,500/mm3, Hemoglobin 8.1 g/L, Platelets 130,000/mm3. Chemistry panel: Serum sodium 140 mEq/L, Serum potassium 3.5 mEq/L, Bicarbonate 27 mEq/L, Blood urea nitrogen (BUN) 54 mg/dL, Serum creatinine 1.2 mg/dL Which of the following is the most appropriate next step in management of this patient?

A 64-year-old man with chronic obstructive pulmonary disorder (COPD) is hospitalized for an acute exacerbation of chronic bronchitis (AECB). At the time of admission, the patient is suffering from dyspnea, a productive cough with green-tinged sputum, and pleuritic chest pain. At that time his oxygen saturation is 80%. A blood gas reveals a pH of 7.35, a pO2 of 51 mm Hg, and a pCO2 of 58 mm Hg. The patient is treated with oxygen therapy, nebulized ipratropium and albuterol treatments, and azithromycin. Over the course of 5 days, the patient’s respiratory status improves. His cough and sputum production diminish and he is weaned from supplemental oxygen. At the time of discharge, his oxygen saturation is 90% on room air. A blood gas reveals a pH of 7.37, a pCO2 of 50 mm Hg, and a pO2 of 70 mm Hg. At this time, which of the following is an appropriate treatment for this patient?

A 64-year-old man with history of severe emphysema is admitted for hematemesis. The bleeding ceases soon after admission, but the patient becomes confused and agitated. Arterial blood gases are as follows: pH 7.23; PO2 42 mm Hg; PCO2 75 mm Hg. Which of the following is the best initial therapy for this patient?

A 65-year-old female who lives in nursing home and is bed ridden due to severe right hemiparesis is brought to the ER because of altered mental status and decreased oral intake. Her past medical history includes hypertension, diabetes, hyperlipidemia, and myocardial infarction. She has a chronic indwelling Foley catheter to avoid contamination of a sacral decubitus ulcer. She is febrile in the ER. Examination shows dry mucus membranes and clear lungs. She is disoriented. The decubitus ulcer has good granulation tissue and does not appear infected. Labs show: Hemoglobin 12.0 g/L, Leukocyte count 12 500/mm3, Blood urea nitrogen (BUN) 28 mg/dL, Serum creatinine 0.8 mg/dL, Serum bicarbonate 24 mg/dL. Urinalysis: Specific gravity 1.036, Protein 1+, pH 8.5, Blood negative, Glucose 1+, Ketones negative, Leukocyte esterase positive, WBC 50-100/hpf, Bacteria few. Which of the following is the most likely cause of her altered mental status?

A 65-year-old male presents to the emergency department complaining of fever, chills, and a productive cough for the past 3 days. He also complains of right-sided chest pain and shortness of breath. He says that his chest pain worsens with deep breathing. The patient's past medical history is significant for diabetes and hyperlipidemia. He takes aspirin, simvastatin, metformin, glipizide and rosiglitazone. He does not use tobacco, alcohol or drugs. On physical exam, he has a temperature of 39.2°C (102.5°F), a blood pressure of 110/70 mm Hg, a pulse of 112/min, and respirations of 24/min. His mucus membranes are dry. Chest x-ray reveals a right lower lobe pneumonia. Laboratory studies show: Hemoglobin 17.0 g/L, Platelets 250,000/mm3, Leukocyte count 16,500/mm3, Serum sodium 140 mEq/L, Serum potassium 4.5 mEq/L, Blood urea nitrogen (BUN) 48 mg/dL, Serum creatinine 2.0 mg/dL, Serum calcium 10.3 mg/dL, Blood glucose 128 mg/dL. Blood cultures are obtained and antibiotics are administered. What is the appropriate next step in the management of this patient?

A 65-year-old man is brought to the emergency department due to the sudden onset of weakness. He was lying on the floor for several hours before he was brought in. His other medical problems include hypertension, diabetes mellitus, coronary artery disease, transient ischemic attacks and osteoarthritis. CT scan of the head shows evidence of a right middle cerebral artery territory stroke. Laboratory studies show: Serum Na 137 mEq/L, Serum K 64 mEq/L, Chloride 104 mEq/L, Bicarbonate 18 mEq/L, BUN 36 mg/dl, Serum creatinine 3.0 mg/dl, Calcium 8.3 mg/dl, Blood glucose 178 mg/dl. His serum creatinine level one month ago was 1.4 mg/dl. EKG shows tall 'T' waves. CK level is pending. Which of the following is the most appropriate next step in management?

A 65-year-old man presents to the emergency department following the acute onset of palpitations. His wife states that he was eating dinner when he noticed the palpitations, lightheadedness, and shortness of breath. The patient has a history of treated hypertension, but no other medical history. The patient is not able to relate any meaningful history. Blood pressure is 80/40 mmHg, heart rate is 126/ min, respiratory rate is 20/min, and oxygen saturation is 99% on room air; he is afebrile. His heart rate is irregularly irregular with no murmurs, clicks, or rubs. Respiratory examination is unremarkable. X-ray of the chest shows no acute disease. ECG shows no discernible P waves and an irregularly spaced QRS response. Which of the following is the best first step in management?

A 65-year-old man presents to the emergency department with a two-day history of fever, headache, altered mental status, and vomiting. His past medical history is significant for renal transplantation secondary to polycystic kidney disease, hypertension, and diabetes. He takes aspirin, insulin, nifedipine, cyclosporine, and prednisone. He has no known drug allergies. His temperature is 39.2°C (102.5°F), pulse is 102/min, respirations are 18/min, and blood pressure is 120/75 mm Hg. He is alert but confused. Fundoscopy does not show any abnormalities. His neck is stiff. Lungs are clear to auscultation. He has a normal S1 and S2 with a II/IV systolic ejection murmur heard best in the right infraclavicular area. Complete blood count shows a WBC count of 17,000/cm3 with neutrophilic leukocytosis. His blood is drawn and sent for culture. Lumbar puncture is performed and the results are pending. Which of the following is the most appropriate empiric antibiotic therapy for this patient?

A 65-year-old man presents to the emergency department with an abrupt onset of excruciating chest pain 1 hour ago. The pain is localized to the anterior chest, but radiates to the back and neck. On examination, the patient is afebrile, with a BP of 210/110 mmHg, pulse rate of 95/min, and a respiratory rate of 12/min. He appears pale and sweaty. Unequal carotid, radial, and femoral pulses are noted. An electrocardiogram (ECG) shows nonspecific ST-T segment changes. Chest x-ray shows a slightly widened mediastinum and normal lung field. Which of the following is the first step in management of this patient?

A 65-year-old woman brought into the ED by her family, states that she has been weak, lethargic, and saying “crazy things” over the last 2 days. Her family also states that her medical history is significant only for a disease of her thyroid. Her BP is 120/90 mmHg, HR is 51 beats per minute, temperature is 94°F rectally, and RR is 12 breaths per minute. On examination, the patient is overweight, her skin is dry, and you notice periorbital nonpitting edema. On neurologic examination, the patient does not respond to stimulation. Which of the following is the most likely diagnosis?

A 67-year-old Caucasian male is hospitalized in the intensive care unit (ICU) with an episode of prolonged hypotension and shortness of breath. His skin is cold and clammy. Intra-arterial blood pressure monitoring is established, and pulmonary artery catheterization is performed to control basic hemodynamic parameters. His blood pressure is 70/40 mmHg, and heart rate is 100/min. Cardiac output (CO) measured by thermodilution method is 2.3 L/min. Pulmonary capillary wedge pressure (PCWP) is estimated to be 22 mmHg. Systemic vascular resistance (SVR) calculated using data on mean arterial pressure, right atrial pressure and cardiac output is 2000 dynes*s/cm5 (N= 700 -1200 dynes*s/cm5). Which of the following is the most likely underlying problem in this patient?

A 67-year-old man is brought to the ED by emergency medical service (EMS). His wife states that the patient was doing his usual chores around the house when all of a sudden he started complaining of severe abdominal pain. He has a past medical history of coronary artery disease and hypertension. His BP is 85/70 mm Hg, HR is 105 beats per minute, temperature is 98.9°F, and his RR is 18 breaths per minute. On physical examination, he is diaphoretic and in obvious pain. Upon palpating his abdomen, you feel a large pulsatile mass. An electrocardiogram (ECG) reveals sinus tachycardia. You place the patient on a monitor, administer oxygen, insert two largebore IVs, and send his blood to the laboratory. His BP does not improve after a 1-L fluid bolus. Which of the following is the most appropriate next step in management?

A 67-year-old man is brought to the ED in respiratory distress. His initial vitals include an HR of 112 beats per minute, a BP of 145/88 mmHg, and an RR of 18 breaths per minute with an oxygen saturation of 92% on room air. He is also febrile at 102°F. After obtaining IV access, placing the patient on a monitor, and administering oxygen via nasal cannula, a chest radiograph is performed and shows patchy alveolar infiltrates with consolidation in the lower lobes. On review of systems, the patient tells you that he had five to six watery bowel movements a day for the last 2 days with a few bouts of emesis. Which of the following infectious etiologies is most likely responsible for the patient’s presentation?

A 67-year-old woman is brought to the ED by paramedics complaining of dyspnea, fatigue, and palpitations. Her BP is 80/50 mmHg, HR is 139 beats per minute, and RR is 20 breaths per minute. Her skin is cool and she is diaphoretic. Her lung examination reveals bilateral crackles and she is beginning to have chest pain. Her ECG shows a narrow complex irregular rhythm with a rate in the 140s. Which of the following is the most appropriate immediate treatment for this patient?

A 67-year-old woman with a history of hypertension and congestive heart failure presents with “burning” epigastric pain that began 2 hours after eating a meal. She states that she has had similar pain over the past several weeks, and has been taking antacids and a medication that her primary care physician had prescribed with moderate relief. The pain has occurred with increasing frequency and now awakens her from sleep. She states she came to the ED today because the pain was not relieved with her usual medications. She denies nausea, vomiting, diarrhea, or fever. She also denies hematemesis, black stool, or bright red blood per rectum. On physical examination, she is tender at the epigastrium, with an otherwise normal abdominal, pulmonary, and heart examination. Stool guaiac tests positive for occult blood. Which of the following is the most common serious complication of peptic ulcer disease?

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?

A 68-year-old male was intubated in the emergency room because of pulmonary edema. Stat echocardiogram reveals an ejection fraction of 45% and severe mitral regurgitation. In spite of aggressive diuresis with furosemide, the patient continues to require mechanical ventilation secondary to pulmonary edema. What is the best next step in treating this patient?

A 69-year-old man is brought to the ER by his family for increasing confusion. At baseline the patient is interactive and pleasant, but he has become withdrawn and confused over the last several months. He has also complained of abdominal pain, nausea, vomiting and back pain over the same period of time. His medical history is significant for diabetes controlled with metformin and hypertension treated with hydrochlorothiazide. Exam reveals normal vital signs and a disheveled, confused man. His neurologic exam is otherwise normal. Examination of the heart and lungs is unremarkable and no neck masses or nodes are appreciated. Laboratory results are given below: Sodium 139 mEq/L, Potassium 4.2 mEq/L, Chloride 111 mEq/L, Bicarbonate 26 mEq/L, Creatinine 1.4 mg/dl, Glucose 142 mgldl, Calcium 12.8 mEq/L, WBC 3,200/mm3, Hematocrit 32%, Platelets 47,000/mm3. What is the most appropriate next step for this patient?

A 7 -year-old Caucasian male with a history of peanut allergy develops sudden shortness of breath after lunch at school. On physical examination, his blood pressure is 70/50 mmHg and his heart rate is 130/min. Inspirations and expirations are labored and noisy. Which of the following is the best initial treatment?

A 7-year-old Caucasian boy with a history of cystic fibrosis presents to the emergency department with a two-day history of high-grade fever and cough productive of purulent, green-colored sputum. He also complains of chest pain, which is worsened by breathing. His temperature is 39.6°C (103.2°F), pulse is 112/min, respirations are 26/min, and blood pressure is 90/60 mm Hg. Chest examination shows dullness on percussion and increased tactile fremitus in the right lung base. Chest x-ray shows a right lower lobe infiltrate. Which of the following is the most appropriate pharmacotherapy for this patient?

A 70-year-old man is admitted to the ICU after repair of an abdominal aortic aneurysm. He has a prior history of hypertension and mild congestive heart failure, which were adequately controlled with digoxin and diuretics. To facilitate perioperative management, a Swan-Ganz (multilumen pulmonary artery) catheter was inserted in the operating room. During the first few hours postoperatively, the patient is noted to have a blood pressure of 140/70 mmHg, heart rate of 110/min, flat neck veins, a pulmonary arterial wedge pressure of 9 mmHg, and poor urine output. Which of the following is the most appropriate next step in management of this patient?

A 70-year-old man with a history of constipation has been experiencing intermittent left-sided abdominal pain and fevers for 2 days. He came to the emergency department immediately after he noticed blood in his toilet this morning. His heart rate is 110/min, blood pressure is 90/50 mm Hg, respiratory rate is 18/ min, and oxygen saturation is 95% on room air. On physical examination the physician notes copious amounts of bright red blood per rectum. The physician immediately places two large bore intravenous lines, administers fluid, and sends blood for type and screen. Which of the following is the best next step in management?

A 70-year-old woman is brought to the emergency department by her daughter because of altered mental status. She lives alone and is able to perform all daily activities. She experienced a minor febrile illness with decreased appetite several days ago, but has otherwise been in good health. She takes no medications. Her temperature is 37.2°C (99°F), blood pressure is 92/50 mm Hg, pulse is 100/min, and respirations are 18/min. Physical examination shows dry oral mucosa. Laboratory studies show: Hematocrit 45%, Serum sodium 147 mEq/L, Serum potassium 5.2 mEq/L, BUN 70 mg/dl, Serum creatinine 1.8 mg/dl. Which of the following is the most appropriate next step in management?

A 70-year-old woman presents to the emergency department complaining of dizziness. She is disoriented to the date and her location and it is difficult to gather an accurate history. Her pulse is 48/min, blood pressure is 84/60 mmHg, and respiratory rate is 12/min. On examination her extremities are cool and clammy. Her capillary refill time is 5 seconds. What is the most appropriate therapy?

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?

A 71-year-old man with inclusion body myositis is brought to the emergency department from his nursing home after becoming less interactive. His temperature is 37.1°C, blood pressure is 90/60, heart rate is 98/min, and respiratory rate is 16/min. He has orthostatic vital signs. Physical examination reveals a frail man with dry oral mucosa and decreased axillary perspiration. Laboratory studies reveal the following: Sodium 164 mEq/L, Potassium 4.9 mEq/L, Bicarbonate 29 mEq/L, Chloride 122 mEq/L. What is the most appropriate next step in the management of this patient?

A 71-year-old woman is brought to the physician by her distressed daughter. The daughter relates that, 3 days ago, her mother began to complain of right upper quadrant abdominal pain. She did not want to eat and "took to her bed sick." The daughter recalls that she complained of chills, nausea, and some vomiting. Physical examination reveals an obtunded, hypotensive, and obviously very sick elderly woman. She has impressive pain to deep palpation in the right upper quadrant, along with muscle guarding and rebound. Her temperature is 40C (104F), and laboratory analysis shows a white cell count of 22,000/mm3 with multiple immature forms, a bilirubin of 5 mg/dL and alkaline phosphatase of 840 U/L. The serum amylase is normal. An emergency sonogram shows multiple stones in the gallbladder, normal thickness of the gallbladder wall without pericholecystic fluid, dilated intrahepatic ducts, and common duct with a diameter of 2.1 cm. The sonographer cannot identify stones in the common duct. In addition to IV fluids and antibiotics, which of the following is the most appropriate next step in management?

A 71-year-old woman presents to the ED after a reported mechanical fall 2 days ago. Her initial vitals include an HR of 55 beats per minute, a BP of 110/60 mmHg, an RR of 14 breaths per minute, and an oxygen saturation of 96% on room air. The patient does not appear to be taking deep breaths. Her physical examination is significant for decreased breath sounds bilaterally and tenderness to palpation along the right side of her chest. After initial stabilization, which of the following is the diagnostic test of choice for this patient’s condition?

A 72-year-old man has multiple injuries and an altered sensorium after a high-speed motor vehicle collision. He is intubated for his decreased mental status. During intubation, a large amount of gastric contents are noted in the posterior pharynx and he aspirates. Which of the following is the appropriate initial treatment?

A 72-year-old man presents to the ED during the month of January complaining of non-productive cough, fever, malaise, runny nose, and severe body aches. The symptoms came on suddenly last night. He has no other medical problems. Physical examination reveals a temperature of 38.9°C (102.0°F) and oxygen saturation of 88% on room air. His lung exam reveals diffuse crackles with occasional wheezes. Laboratory values are: Hematocrit 44%, Platelets 219,000/mm3, Leukocyte count 4,100/mm3, Neutrophils 65%, Lymphocytes 32%. His chest x-ray reveals diffuse interstitial infiltrates bilaterally. What is the most appropriate initial therapy for this patient?

A 72-year-old man presents to the ED with worsening dyspnea. His initial vitals include an HR of 93 beats per minute, BP of 110/50 mmHg, and RR of 20 breaths per minute with an oxygen saturation of 88% on room air. The patient appears thin and anxious. He is using accessory muscles to breathe. Despite distant breath sounds, you hear end-expiratory rhonchi and a prolonged expiratory phase. An ECG shows peaked P waves in leads II, III, and aVF. Given this patient’s history and physical examination, which of the following conditions does this patient most likely have?

A 72-year-old man with atrial fibrillation presents with complaints of fatigue and feeling cold. He also notes constipation and dry skin. His daughter states he has seemed more forgetful over the past several months. His temperature is 37.3°C (99.1°F), heart rate is 48/min, and blood pressure is 130/82 mmHg. Cardiac examination shows bradycardia but normal rhythm, and normal S1 and S2 with no murmurs; the lungs are clear to auscultation bilaterally and the abdomen is soft and nontender. The patient’s extremities are cool and puffy with dry, coarse skin. Laboratory studies show a thyroid-stimulating hormone level of 32 μU/L, free thyroxine of 0.3 ng/dL, and total tri-iodothyronine of 30 ng/dL. What medication is the patient likely taking for his atrial fibrillation?

A 73-year-old man presents to the emergency department complaining of lower abdominal pain and nausea. He denies any vomiting or diarrhea, and his last bowel movement was two days ago. The patient also notes that several days ago he began taking amitriptyline for chronic neck pain. He does not smoke or consume alcohol. On physical examination, his blood pressure is 160/70 mmHg and his heart rate is 100/min. His lung fields are clear to auscultation. Palpation of the abdomen reveals fullness and tenderness along the midline below the umbilicus. Which of the following is the best initial management for this patient?

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?

A 74-year-old woman who is a known diabetic is brought to the ED by emergency medical service (EMS) with altered mental status. The home health aide states that the patient ran out of her medications 4 days ago. Her BP is 130/85 mmHg, HR is 110 beats per minute, temperature is 99.8°F, and RR is 18 breaths per minute. On examination, she cannot follow commands but responds to stimuli. Laboratory results reveal white blood cell (WBC) count of 14,000/L, hematocrit 49%, platelets 325/L, sodium 128 mEq/L, potassium 3.0 mEq/L, chloride 95 mEq/L, bicarbonate 22 mEq/L, blood urea nitrogen (BUN) 40 mg/dL, creatinine 1.8 mg/dL, and glucose 850 mg/dL. Urinalysis shows 3+ glucose, 1+ protein, and no blood or ketones. After addressing the ABCs, which of the following is the most appropriate next step in management?

A 75-year-old Caucasian male who was diagnosed with carcinoma of the prostate presents to ER with worsening back pain for the past 2-3 days. He never had this pain before. He denies any weakness of the legs. On examination, his muscle power in the lower extremities is 4.5/5 and has brisk reflexes. Rectal sphincter tone is weak. He has point tenderness over the L5 and S1 region. His vital signs are, BP: 122/80 mm Hg, PR 80/min, RR 16/min and Temperature 37°C (98°F). What is the most appropriate next step in management of this patient?

A 75-year-old man develops increased ventilatory requirements several days after requiring intubation for respiratory failure. X-ray of the chest shows bilateral infiltrates, and based on his ventilatory settings, the ratio of the partial arterial pressure of oxygen to the fraction of inspired oxygen (PaO2:FiO2) is 190. Which of the following is the most common underlying etiology of acute respiratory distress syndrome?

A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. Which of the following is the most appropriate next step in management of this patient?

A 75-year-old man slips and falls at home, hitting his right chest wall against the kitchen counter. He has an area of exquisite pain to direct palpation over the seventh rib, at the level of the anterior axillary line. A chest x-ray film confirms the presence of a rib fracture, with no other abnormal findings. Which of the following is the most appropriate initial step in management?

A 75-year-old man with a history of coronary artery disease, hypertension, and diabetes mellitus undergoes a right hemicolectomy for colon cancer. On the second postoperative day, he complains of shortness of breath and chest pain. He becomes hypotensive with depressed mental status and is immediately transferred to the intensive care unit. After intubation and placement on mechanical ventilation, an echocardiogram confirms cardiogenic shock. A central venous catheter is placed that demonstrates a central venous pressure of 18 mm Hg. Which of the following is the most appropriate initial management strategy?

A 75-year-old woman is brought to the ED by EMS after she had a witnessed seizure on the street. A bystander reports that the patient fell to the ground, had tonic-clonic activity, and was drooling. Her BP is 162/85mmHg, HR is 95 beats per minute, temperature is 99.4°F, and RR is 16 breaths per minute. On examination, the patient is unresponsive and has a bleeding superficial scalp laceration. Which of the following electrolyte disturbances is least likely to cause a seizure?

A 75-year-old woman is brought to the emergency department after being found unresponsive at her home. She was last spoken to by her daughter on the phone 24 hours earlier, at which time she complained of chills, lethargy, and weakness. The woman has had a heart attack in the past, she has high blood pressure, and she had a total thyroidectomy performed a decade ago for cancer. The daughter had returned from several months out of town, and is unsure if the patient was taking her medications. Her temperature is 34.9°C (94.9°F), pulse is 48/min, blood pressure is 110/65 mmHg, oxygen saturation is 99% on 100% oxygen, and glucose is 85 mg/dL. On examination the patient is unresponsive, obese, and edematous with periorbital edema. Her cardiac and pulmonary examinations are normal. CT of the head reveals no signs of trauma or increased intracranial pressure, and ECG demonstrates no acute ischemic changes. Blood is drawn for laboratory testing. Which of the following is most appropriate for treating the patient’s mental status change?

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?

A 76-year-old man presents to the ED in acute respiratory distress, gasping for breath while on face mask. Paramedics state that he was found on a bench outside of his apartment in respiratory distress. Initial vitals include an HR of 90 beats per minute, a BP of 170/90 mmHg, and an RR of 33 breaths per minute with an oxygen saturation of 90%. Upon physical examination, the patient is coughing up pink, frothy sputum, has rales two-thirds of the way up both lung fields, and has pitting edema of his lower extremities. A chest radiograph reveals bilateral perihilar infiltrates, an enlarged cardiac silhouette, and a small right-sided pleural effusion. After obtaining IV access and placing the patient on a monitor, which of the following medical interventions is most appropriate?

A 78-year-old woman is brought to the emergency department with agitation and insomnia. She screams out loudly and tries to run away while being examined. She is a nursing home resident and has a recent medical history that includes severe memory loss, gait disturbance and urinary incontinence. Her chronic medical issues include hypertension, diabetes mellitus, atrial fibrillation, peptic ulcer disease and chronic pyelonephritis. Her blood pressure is 160/100 mmHg and heart rate is 95/min and irregular. ECG reveals atrial fibrillation but no acute ischemic changes. Laboratory investigations reveal the following: Hematocrit 41%, WBC count 9,000/mm3, Platelets 160,000/mm3, Sodium 137 meq/L, Potassium 5.5 meq/L, Chloride 95 meq/L, Creatinine 1.4 mg/dl, BUN 25 mg/dl. Urinalysis shows trace protein, numerous leukocytes and occasional erythrocytes. Which of the following is the best initial treatment for this patient?

A 79-year-old woman is brought to the emergency department due to a suspected cerebrovascular accident on her right side. She complains of diffuse paresthesias and tingling in her right hand. She did not lose consciousness. The physical examination reveals normal speech, symmetric deep tendon reflexes (2/4 on both upper extremities, 2/4 both patellar reflexes, and 0/4 both Achilles reflexes), a cold right hand, and undetectable arterial radial pulse. Tinel and Phalen's signs are negative. The rest of the examination is normal. What is the most appropriate next step in the management of this patient?

A 9-month-old infant is brought to the emergency department with lethargy and tachypnea. He was healthy before developing fever and diarrhea four days ago. He has been taking some formula, but has had two to three episodes of diarrhea with each bottle. He has lost three pounds (1 .4 kg) since his routine check-up two weeks ago. He has had one wet diaper in the past twenty four hours. On examination, his temperature is 102.5F (39.1c), pulse is 200/min, respiratory rate is 42/min, and blood pressure is 70/45 mm Hg. He is lethargic with decreased tone and decreased deep tendon reflexes. His mucous membranes are dry. Cardiopulmonary exam reveals tachycardia and tachypnea. His abdominal exam is unremarkable. Capillary refill is four seconds. Laboratory results are shown below. Chemistry panel: Serum sodium 165 mEq/L, Serum potassium 4.5 mEq/L, Chloride 108 mEq/L, Bicarbonate 14 mEq/L, Blood urea nitrogen (BUN) 20 mg/dl, Serum creatinine 0.8 mg/dl, Calcium 10.0 mg/dl, Blood glucose 98 mg/dl. Which of the following fluids should be used as a bolus in the resuscitation of this infant?

A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystectomy. A transfusion of FFP is planned to minimize the risk of bleeding due to surgery. What is the optimal timing of this transfusion?

A couple presents to your office to discuss sterilization. They are very happy with their four children and do not want any more. You discuss with them the pros and cons of both female and male sterilization. The 34-year-old male undergoes a vasectomy. Which of the following is the most frequent immediate complication of this procedure?

A family brings their 82-year-old grandmother to the emergency room stating that they cannot care for her anymore. They tell you, “She has just been getting sicker and sicker.” Now she stays in bed and won’t eat because of stomach pain. She has diarrhea most of the time and can barely make it to the bathroom because of her weakness. Her symptoms have been worsening over the past year, but she has refused to see a doctor. The patient denies symptoms of depression. Blood pressure is 90/54 mmHg with the patient supine; it drops to 76/40 mmHg when she stands. Heart and lungs are normal. Skin examination reveals a bronze coloring to the elbows and palmar creases. What laboratory abnormality would you expect to find in this patient?

A father brings his 18-month-old daughter to the office for the evaluation of fever for the past 10 days. The father, who works as a phlebotomist, says that the temperature seems higher in the morning and again at night, often reaching 40.5C (105F), and is sometimes associated with shaking chills. He remembers that the child developed severe respiratory distress and skin rash when treated with penicillin in the past. He has heard about the development of 'liver toxicities' in children treated with aspirin, and he is interested in knowing everything about his daughter's condition. On examination, the child is in no acute distress. Her temperature is 39.4C (103F), pulse rate is 90/min, and blood pressure is 100/60 mmHg. Her sclerae are anicteric. There is bulbar conjunctival injection, and the oropharynx shows diffuse mucosal injection with fissuring and crusting of the lips. There are numerous hyperemic macules over her entire body, and her palms appear edematous. Based on the above description, which of the following is the most accurate statement?

A fully immunized 2-year-old presents to the emergency room with several days of low-grade fever, barking cough, and noisy breathing. Over the past few hours he has developed a fever of 40°C (104°F) and looks toxic. He has inspiratory and expiratory stridor. The family has not noticed drooling, and he seems to be drinking without pain. Direct laryngoscopy reveals a normal epiglottis. The management of this disease process includes which of the following?

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?

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?

A newborn infant becomes markedly jaundiced on the second day of life, and a faint petechial eruption, first noted at birth, is now a generalized purpuric rash. Hematologic studies for hemolytic diseases are negative. Acute management should include which of the following?

A patient at 17 weeks gestation is diagnosed as having an intrauterine fetal demise. She returns to your office 5 weeks later and her vital signs are: blood pressure 110/72 mm Hg, pulse 93 beats per minute, temperature 36.38C, respiratory rate 16 breaths per minute. She has not had a miscarriage, although she has had some occasional spotting. Her cervix is closed on examination. This patient is at increased risk for which of the following?

A patient involved in a high-speed automobile collision arrives in the emergency department unconscious, with multiple facial fractures; brisk bleeding into his nose, mouth, and throat; and gurgly, irregular, noisy breathing. Which of the following would be the best method to secure an airway in this patient?

A previously heathy 3-year-old boy is brought to the emergency department (ED) due to stridor of sudden onset. Last night, he suddenly developed a high fever followed by breathing difficulty. His temperature is 40C (104F), pulse is 130/min, and respirations are 40/min. In the ED, the child is toxic-appearing, sitting up, leaning forward and drooling. His lungs are clear, and oxygen saturation is 85% in room air. What is the most appropriate next step in management?

A severely traumatized woman is seen in the emergency room (ER) with decreased mental status. Prior to intubation, she does not open her eyes, withdraws with all of her extremities, and makes incomprehensible sounds. What is her Glasgow coma scale score?

A tall, thin 18-year-old man presents to the ED with acute onset of dyspnea while at rest. The patient reports sitting at his desk when he felt a sharp pain on the right side of his chest that worsened with inspiration. His past medical history is significant for peptic ulcer disease. He reports taking a 2-hour plane trip a month ago. His initial vitals include an HR of 100 beats per minute, a BP of 120/60 mmHg, an RR of 16 breaths per minute, and an oxygen saturation of 97% on room air. On physical examination, you note decreased breath sounds on the right side. Which of the following tests should be performed next?

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?

A young mother is at the pediatrician's office for a routine well-baby visit for her 18-month-old son. It is immediately noticed that one of the baby's pupils is white, while the other one is black. When asked about it, the mother relates that she saw that curious situation for the first time 1 week ago, but since the baby was otherwise asymptomatic, she did not think it merited special attention. Which of the following is the most appropriate course of action?

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?

An 18-month-old infant is found with the contents of a bottle of drain cleaner in his mouth. Which of the following treatment options is most appropriate?

An 18-year-old G1 at 8 weeks gestation complains of nausea and vomiting over the past week occurring on a daily basis. Nausea and emesis are a common symptom in early pregnancy. Which of the following signs or symptoms would indicate a more serious diagnosis of hyperemesis gravidarum?

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?

An 18-year-old woman develops urticaria and wheezing after an injection of intravenous contrast for an abdominal CT scan. Her blood pressure is 120/60 mm Hg, heart rate is 155 beats per minute and respiratory rate is 30 breaths per minute. Which of the following is the most appropriate immediate therapy?

An 18-year-old woman presents to the emergency department with acute mental status changes, rapid and deep breathing, abdominal pain, and vomiting. On examination she is tachypneic and tachycardic, her abdomen is soft and nontender, and her mucous membranes are dry. Laboratory values are notable for a potassium level of 5.5 mEq/L, bicarbonate of 12 mEq/L, and serum glucose of 400 mg/dL. Which of the following is the most appropriate strategy during the first 24 hours?

An 18-year-old woman presents to the emergency departmentfor right lower quadrant abdominal pain. The pain started suddenly with a sharp, stabbing pain. The patient denies nausea, vomiting, diarrhea, and constipation. Her last menstrual period (LMP) was 6 weeks ago. Vital sign: BP, 115/75 mm Hg; P, 82 beats/min; R, 12 breaths/min; T, 98.6°F. Physical examination: Gen: Awake, alert, oriented x3, mild pain distress, CVS: Normal, Lungs: Clear bilaterally, Abd: Tender in right lower quadrant (RLQ), rebound tenderness present, nondistended, bowel sounds present. Which of the following is the next best step in the management of this patient?

An 8-month-old male infant is brought to the emergency department (ED) by his mother due to vomiting and a decreased urine output. Three days ago, he had a fever, sore throat and ear pain. He was subsequently diagnosed with otitis media and treated with oral amoxicillin. Today, in the ED, his temperature is 40.0C(104F), pulse is 80/min, respirations are 40/min and irregular, blood pressure is 100/60 mm Hg, and weight is 8kgs ( 15 lbs). He is lethargic and arousable only to painful stimuli. His anterior fontanel is full and tense. His tympanic membranes are red and bulging. His pupils are reactive, but his eyes do not focus well on his parents. What is the most appropriate next step in the management of this patient?

An 8-year-old boy from an impoverished inner- city area has never been vaccinated appropriately. He develops fever, cough, and coryza. The next day, blue white spots develop on the buccal mucosa. On the third day, an erythematous, nonpruritic maculopapular rash develops on the face and spreads over the entire body. Which of the following is the most likely complication?

An 81-year-old man is brought to the hospital due to complaints of very severe pain in his back and thighs. Seven months ago, he was diagnosed with stage IV prostate cancer which reached the spine. He has had palliative radiotherapy of his spine, and is now taking leuprolide. He is restless and very irritable, even after the nursing home staff gave him ibuprofen. He has never received any narcotics. What is the best next step in this patient's pain management?

An 81-year-old nursing home resident is brought to the hospital because of altered mental status for the past day. Her husband states that she was in her usual state of health yesterday. He states she had a “coughing fit” after he fed her dinner last night. Her past medical history is significant for noninsulin-dependent diabetes mellitus and cerebral vascular accident that had left her with some residual dysarthria. Her blood pressure is 95/55 mm Hg, pulse is 97/min, and respirations are 19/min. Her temperature is 38.3 C (101.0 F) and oxygen saturation is 94% on room air (corrects to 99% with 4 liters of oxygen). She is awake, minimally responsive, and in no respiratory distress. On her lung examination you note localized rales at the right lower lung field. You suspect aspiration pneumonia and place an intravenous line and obtain a chest x-ray. The x-ray shows a right-sided consolidation that obscures the right heart border. Which of the following is the most appropriate course of management?

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)?

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?

An 81-year-old woman presents to the ED with acute onset of shortness of breath just before arrival. She refuses to answer questions for the interview, but repeatedly states that she is feeling short of breath. Her initial vitals include an HR of 89 beats per minute, a BP of 168/76 mmHg, and an RR of 18 breaths per minute with an oxygen saturation of 89% on room air. A portable chest x-ray appears normal. Her physical examination is unremarkable, except for a systolic ejection murmur. Intravenous (IV) access is successfully obtained. After placing the patient on oxygen and a monitor, which of the following should be performed first?

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?

An 84-year-old woman with coronary artery disease, congestive heart failure, peripheral vascular disease, and atrial fibrillation presents to the emergency department with dizziness, weakness, and sudden-onset crampy periumbilical pain. The pain is associated with one episode of diarrhea and one episode of emesis. The patient notes she has been having similar pain after meals for “several months” but never this severe. Her temperature is 37.2°C (98.9°F), heart rate is 135/min, blood pressure is 96/60 mm Hg, and respiratory rate is 16/min. Physical examination is notable for a slightly distended abdomen that is extremely tender to palpation with diminished bowel sounds. There is no rigidity or rebound tenderness noted on the abdominal examination. In addition, the patient has heme positive stool. Her WBC count is 19,500/mm3, hemoglobin is 10.9 g/dL, and platelet count is 159,000/mm3. Liver function testing results are normal. After stabilizing the patient, what is the best next step in management?

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?

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?

An infant is born at terrn to a 27-year-old Caucasian female. The prenatal course was uncomplicated. The amniotic fluid is clear. Immediately after the delivery, the infant starts crying and is moving all four extremities actively. Heart rate is 140/min. He is making a grimace on the attempt to put the suction catheter into his nostrils. His body is pink, but extremities are cyanotic. Which of the following is the next best step in the management of the infant?

403) An infant who appears to be of normal size is noted to be lethargic and somewhat limp after birth. The mother is 28 years old, and this is her fourth delivery. The pregnancy was uncomplicated, with normal fetal monitoring prior to delivery. Labor was rapid, with local anesthesia and intravenous meperidine (Demerol) administered for maternal pain control. Which of the following therapeutic maneuvers is likely to improve this infant’s condition most rapidly?

An undomiciled 41-year-old man walks into the ED complaining of abdominal pain, nausea, and vomiting. He tells you that he has been drinking beer continuously over the previous 18 hours. On examination, his vitals are BP 150/75 mm Hg, HR 104 beats per minute, RR 16 breaths per minute, oxygen saturation 97% on room air, temperature of 99.1°F rectally, and finger stick glucose 81 mg/dL. The patient is alert and oriented, his pupils anicteric. You notice gynecomastia and spider angiomata. His abdomen is soft but tender in the RUQ. Laboratory tests reveal an AST of 212 U/L, ALT 170 U/L, alkaline phosphatase of 98 U/L, total bilirubin of 1.9 mg/dL, international normalized ratio (INR) of 1.3, WBC 12,000/μL. Urinalysis shows 1+ protein. Chest x-ray is unremarkable. Which of the following is the most appropriate next step in management?

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?

As you evaluate a patient with shortness of breath, you appreciate decreased breath sounds at the left-lung base. You suspect the patient has a small pleural effusion. In which of the following views of the chest is this small pleural effusion most likely to be detected?

At 43 weeks’ gestation, a long, thin infant is delivered. The infant is apneic, limp, pale, and covered with “pea soup” amniotic fluid. Which of the following is the best first step in the resuscitation of this infant at delivery?

Aunt Mary is helping her family move to a new apartment. During the confusion, 3-year-old Jimmy is noted to become lethargic. The contents of Aunt Mary’s purse are strewn about on the floor. In the ER, the lethargic Jimmy is found to have miosis, bradycardia, and hypotension. He develops apnea, respiratory depression, and has to be intubated. His condition would most likely benefit from which of the following therapies?

Following a vaginal delivery, a woman develops a fever, lower abdominal pain, and uterine tenderness. She is alert, and her blood pressure and urine output are good. Large gram-positive rods suggestive of clostridia are seen in a smear of the cervix. Which of the following is most closely tied to a decision to proceed with hysterectomy?

Following a weekend of snowmobiling, a 42-year-old man comes to the emergency department with pain, numbness, and discoloration of his right forefoot. You diagnose frostbite. Which of the following is the proper initial treatment?

In a rollover car accident, a 42-year-old woman is thrown from the car. The car subsequently lands on her and crushes her. On physical examination in the emergency department, it is determined that she has a pelvic fracture, which is confirmed by portable x-rays done as she is being resuscitated. Her initial blood pressure is 50/30 mm Hg, and her pulse is 160/min and barely perceptible. Thirty minutes later, after 2 L Ringer's lactate and 2 U packed cells have been infused, her pressure is only 70/50 mm Hg, and her pulse is 130/min. A sonogram done in the emergency department shows no intra-abdominal bleeding, and a diagnostic peritoneal lavage confirms that there is no blood in the abdomen (the recovered fluid is pink, but not grossly bloody). Rectal and vaginal exams show no injuries to those organs. There is no blood in her urine. Which of the following is the most appropriate next step in management?

In the ICU, a patient suddenly becomes pulseless and unresponsive, with cardiac monitor indicating ventricular tachycardia. The crash cart is immediately available. What is the best first therapy?

Neighbors find a 65-year-old male unconscious in his garden and immediately call EMS. The man is intubated at the scene. In the ER, he develops sustained ventricular tachycardia and requires cardioversion. He is started on an antiarrhythmic agent and, once recovered, is discharged to home. Three months later he returns to his physician complaining of dyspnea on exertion. Chest x-ray reveals bilateral lung fibrosis. All cultures are negative and lung biopsy reveals lipoid pneumonitis. Which of the following medications is most likely responsible for his current condition?

On the 5th postoperative day after abdominal surgery, a patient has been draining copious amounts of clear pink fluid from his midline laparotomy wound. A medical student removes the dressing, confirms that it is soaked, and sees a normal-appearing fresh wound with a row of skin staples in place. The student asks the patient to sit up so he can get out of bed and be helped to the treatment room for a more thorough examination. When the patient complies, the wound opens widely, and a handful of small bowel suddenly rushes out. Which of the following is the most appropriate management at this time?

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?

Parents bring a 5-day-old infant to your office. The mother is O negative and was Coombs positive at delivery. The term child weighed 3055 g (6 lb, 1 oz) at birth and had measured baseline hemoglobin of 16 g/dL and a total serum bilirubin of 3 mg/dL. He passed a black tarlike stool within the first 24 hours of life. He was discharged at 30 hours of life with a stable axillary temperature of 36.5°C (97.7°F). Today the infant’s weight is 3000 g, his axillary temperature is 35°C (95°F), and he is jaundiced to the chest. Parents report frequent yellow, seedy stool. You redraw labs and find his hemoglobin is now 14 g/dL, and his total serum bilirubin is 13 mg/dL. The change in which of the following parameters is of most concern?

Several days following esophagectomy, a patient complains of dyspnea and chest tightness. A large pleural effusion is noted on chest radiograph, and thoracentesis yields milky fluid consistent with chyle. Which of the following is the most appropriate initial management of this patient?

Shortly after the administration of an inhalational anesthetic and succinylcholine for intubation prior to an elective inguinal hernia repair in a 10-year-old boy, he becomes markedly febrile, displays a tachycardia of 160, and his urine changes color to a dark red. Which of the following is the most appropriate treatment at this time?

Ten days after an exploratory laparotomy and lysis of adhesions, a patient, who previously underwent a low anterior resection for rectal cancer followed by postoperative chemoradiation, is noted to have succus draining from the wound. She appears to have adequate source control—she is afebrile with a normal white blood count. The output from the fistula is approximately 150 cc per day. Which of the following factors is most likely to prevent closure of the enterocutaneous fistula?

The left ureter is partially transected (50% of circumference) during the course of a difficult operation on an unstable, critically ill patient. Which of the following would be the most appropriate management of this injury given the patient’s unstable condition?

You admitted to the hospital the previous evening a 1-year-old boy who presented with cough, fever, and mild hypoxia. At the time of his admission, he had evidence of a right upper lobe consolidation on his chest radiograph. A blood culture has become positive in less than 24 hours for Staphylococcus aureus. Approximately 20 hours into his hospitalization, the nurse calls you because the child has acutely worsened over the previous few minutes, with markedly increased work in breathing, increasing oxy- gen requirement, and hypotension. As you move swiftly to the child’s hospital room, you tell the nurse to order which of the following?

You are called to a delivery of a woman with no prenatal care; she is in active labor but has no history of amniotic rupture. The biophysical profile done in the emergency center revealed severe oligohydramnios. When you get this infant to the nursery, you should carefully evaluate him for which of the following?

You are called to the emergency department to consult on a 34-year-old woman at 22 weeks’ gestation with a skin rash and shortness of breath. She states that the skin rash started 2 days ago on her trunk and has spread to her extremities. Earlier today she developed shortness of breath. She has been feeling like she has fever and chills, but she has not taken her own temperature. She has no other medical problems and has never had surgery. She works as a third-grade teacher. She has not been traveling recently, but one of her students recently had the chicken pox. On physical examination, her temperature is 38.1 C (100.6 F), blood pressure is 100/70 mm Hg, pulse is 116/min, and respirations are 18/min. Her lungs have diminished breath sounds bilaterally. Chest x-ray demonstrates diffuse, nodular, peribronchial infiltrates. Which of the following is the most appropriate next step in management?

You are doing postpartum rounds on a 22-year-old G1P1, who vaginally delivered an infant male at 36 weeks after an induction for severe preeclampsia. During her labor she required hydralazine to control her blood pressures. She is on magnesium sulfate for seizure prophylaxis. Her vital signs are: blood pressure 154/98 mm Hg, pulse 93 beats per minute, respiratory rate 24 breaths per minute, and temperature 37.3C. She has adequate urine output at greater than 40 cc/h. On examination, she is oriented to time and place, but she is somnolent and her speech is slurred. She has good movement and strength of her extremities, but her deep tendon reflexes are absent. Which of the following is the most likely cause of her symptoms?

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?

You receive notification from EMS that they are bringing in a 17-year-old 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?