Med-Emergency P2

1) An 81-year-old diabetic woman with a history of atrial fibrillation is transferred to your emergency department (ED) from the local nursing home. The note from the facility states that the patient is complaining of abdominal pain, having already vomited once. Her vital signs in the ED are temperature 100.1°F, blood pressure (BP) 105/75 mmHg, heart rate (HR) 95 beats per minute, and respiratory rate (RR) 18 breaths per minute. You examine the patient and focus on her abdomen. Considering that the patient has not stopped moaning in pain since arriving to the ED, you are surprised to find that her abdomen is soft on palpation. You decide to order an abdominal radiographic series. Which of the findings on plain abdominal film is strongly suggestive of mesenteric infarction?
. Sentinel loop of bowel
. No gas in the rectum
. Presence of an ileus
. Pneumatosis intestinalis
. Air fluid levels
2) A husband and wife present to the ED with 1 day of subjective fever, vomiting, watery diarrhea, and abdominal cramps. They were at a restaurant a day before for dinner and both ate the seafood special, which consisted of raw shellfish. In the ED, they are both tachycardic with temperatures of 99.8°F and 99.6°F for him and her, respectively. Which of the following is responsible for the majority of acute episodes of diarrhea?
. Parasites
. Viruses
. Enterotoxin-producing bacteria
. Anaerobic bacteria
. Invasive bacteria
3) A 49-year-old man presents to the ED with nausea, vomiting, and abdominal pain that began approximately 2 days ago. The patient states that he usually drinks a six pack of beer daily, but increased his drinking to 2 six packs daily over the last week because of pressures at work. He notes decreased appetite over the last 3 days and states he has not had anything to eat in 2 days. His BP is 125/75 mmHg, HR is 105 beats per minute, and RR is 20 breaths per minute. You note generalized abdominal tenderness on examination. Laboratory results reveal the following: White blood cells (WBC) 9000/μL, Hematocrit 48%, Platelets 210/μL, Aspartate transaminase (AST) 85 U/L, Alanine transaminase (ALT) 60 U/L, Alkaline phosphatase 75 U/L, Total bilirubin 0.5 mg/dL, Lipase 40 IU, Sodium 131 mEq/L, Potassium 3.5 mEq/L, Chloride 101 mEq/L, Bicarbonate 10 mEq/L, Blood urea nitrogen (BUN) 9 mg/dL, Creatinine 0.5 mg/dL, Glucose 190 mg/dL, Nitroprusside test weakly positive for ketones. Which of the following is the mainstay of therapy for patients with this condition?
. Normal saline (NS) solution
. Half normal saline (1/2 NS)
. Glucose solution (D5W)
. Solution containing both saline and glucose (D5/NS or D5 1/2 NS)
. The type of solution is irrelevant
4) As you palpate the right upper quadrant (RUQ) of a 38-year-old woman’s abdomen, you notice that she stops her inspiration for a brief moment. During the history, the patient states that over the last 2 days she gets pain in her RUQ that radiates to her back shortly after eating. Her vitals include a temperature of 100.4°F, HR of 95 beats per minute, BP of 130/75 mmHg, and RR of 16 breaths per minute. What is the initial diagnostic modality of choice for this disorder?
. Plain film radiograph
. Computed tomography (CT) scan
. Magnetic resonance imaging (MRI)
. Radioisotope cholescintigraphy (HIDA scan)
. Ultrasonography
5) A 31-year-old man from Florida presents to the ED complaining of severe pain that starts in his left flank and radiates to his testicle. The pain lasts for about 1 hour and then improves. He had similar pain last week that resolved spontaneously. He noted some blood in his urine this morning. His BP is 145/75 mmHg, HR is 90 beats per minute, temperature is 98.9°F, and his RR is 24 breaths per minute. His abdomen is soft and nontender. As you examine the patient, he vomits and has trouble lying still in his stretcher. Which of the following is the most appropriate next step in management?
. Call surgery consult to evaluate the patient for appendicitis
. Order an abdominal CT
. Start intravenous (IV) fluids and administer an IV nonsteroidal anti-inflammatory drug (NSAID) and antiemetic
. Perform an ultrasound to evaluate for an abdominal aortic aneurysm (AAA)
. Perform an ultrasound to evaluate for testicular torsion
6) A 48-year-old man with a past medical history of hepatitis C and cirrhosis presents to the ED complaining of acute-onset abdominal pain and chills. His BP is 118/75 mmHg, HR is 105 beats per minute, RR is 16 breaths per minute, temperature is 101.2°F rectally, and oxygen saturation is 97% on room air. His abdomen is distended, and diffusely tender. You decide to perform a paracentesis and retrieve 1 L of cloudy fluid. Laboratory analysis of the fluid shows a neutrophil count of 550 cells/mm 3. Which of the following is the most appropriate choice of treatment?
. Metronidazole
. Vancomycin
. Sulfamethoxazole/trimethoprim (SMX/TMP)
. Neomycin and lactulose
. Cefotaxime
7) A 24-year-old man woke up from sleep 1 hour ago with severe pain in his right testicle. He states that he is sexually active with multiple partners. On examination, the right scrotum is swollen, tender, and firm. You cannot elicit a cremasteric reflex. His BP is 145/75 mmHg, HR is 103 beats per minute, RR is 14 breaths per minute, temperature is 98.9°F, and oxygen saturation is 99% on room air. Which of the following is the most appropriate next step in management?
. Administer one dose of ceftriaxone and doxycycline for 10 days and have him follow-up with a urologist
. Swab his urethra, send a culture for gonorrhea and Chlamydia, and treat if positive
. Send a urinalysis and treat for a urinary tract infection (UTI) if positive
. Treat the patient for epididymitis and have him return if symptoms persist
. Order a statim (STAT) color Doppler ultrasound and urologic consultation
8) A 55-year-old woman with a past medical history of diabetes walks into the emergency department (ED) stating that her tongue and lips feel like they are swollen. During the history, she tells you that her doctor just started her on a new blood pressure (BP) medication. Her only other medication is a baby aspirin. Her vitals at triage are: BP 130/70 mmHg, heart rate (HR) 85 beats per minute, respiratory rate (RR) 16 breaths per minute, oxygen saturation 99% on room air, and temperature 98.7°F. On physical examination, you detect mild lip and tongue swelling. Over the next hour, you notice that not only are her tongue and lips getting more swollen, but her face is starting to swell, too. What is the most likely inciting agent?
. Metoprolol
. Furosemide
. Aspirin
. Lisinopril
. Diltiazem
9) A 45-year-old woman presents to the ED immediately after landing at the airport from a transatlantic flight. She states that a few moments after landing she felt short of breath and felt pain in her chest when she took a deep breath. Her only medications are oral contraceptive pills and levothyroxine. She is a social drinker and smokes cigarettes occasionally. Her BP is 130/75 mmHg, HR is 98 beats per minute, temperature is 98.9°F, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. You send her for a duplex ultrasound of her legs, which is positive for deep vein thrombosis. What is the most appropriate management for this patient?
. Place patient on a monitor, provide supplemental oxygen, and administer unfractionated heparin
. Place patient on a monitor, order a chest computed tomography (CT) scan to confirm a pulmonary embolism (PE), and then administer unfractionated heparin
. Place patient on a monitor and administer aspirin
. Instruct the patient to walk around the ED so that she remains mobile and does not exacerbate thrombus formation
. Place the patient on a monitor, provide supplemental oxygen, and administer warfarin
10) 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?
. Electrocardiogram (ECG)
. D-dimer
. Ventilation perfusion scan (V/Q scan)
. Upright abdominal radiograph
. Chest radiograph
11) A 30-year-old obese woman with no significant past medical history presents to the ED complaining of shortness of breath and coughing up blood-streaked sputum. The patient states that she traveled to Moscow a month ago. Upon returning to the United States, the patient developed a persistent cough associated with dyspnea. She was seen by a pulmonologist, who diagnosed her with bronchitis and prescribed an inhaler. However, over the following weeks, the patient’s symptoms worsened, and she developed pleuritic chest pain. In the ED, she lets you know that she smokes half a pack per day. Her vitals include a temperature of 99°F, BP of 105/65 mmHg, HR of 124 beats per minute, RR of 22 breaths per minute, and an oxygen saturation of 94% on room air. Physical examination is noncontributory, except for rales at the left-mid lung. Her ECG reveals sinus tachycardia with large R waves in V1 to V3 and inverted T waves. Given this patient’s history and presentation, what is the most likely etiology of her symptoms?
. Mycoplasma pneumoniae (“walking” pneumonia)
. Q fever pneumonia
. Pneumocystis jiroveci pneumonia (PCP)
. PE
. Acute respiratory distress syndrome (ARDS)
12) A 24-year-old woman is brought to the ED after being found on a nearby street hunched over and in mild respiratory distress. Upon arrival, she is tachypneic at 24 breaths per minute with an oxygen saturation of 97% on face mask oxygen administration. Upon physical examination, the patient appears to be in mild distress with supraclavicular retractions. Scattered wheezing is heard throughout bilateral lung fields. Which of the following medications should be administered first?
. Corticosteroids
. Magnesium sulfate
. Epinephrine
. Anticholinergic nebulizer treatment
. β2-Agonist nebulizer treatment
13) 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?
. Evaluation of troponin level
. Evaluation of D-dimer level
. Rectal temperature
. Repeat chest x-ray
. ECG
14) 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?
. Supine
. Lateral decubitus right-side down
. Lateral decubitus left-side down
. Lateral
. Posterior-anterior (PA)
15) A 32-year-old firefighter presents to the ED in acute respiratory distress. He was taken to the ED shortly after extinguishing a large fire in a warehouse. His initial vitals include an HR of 90 beats per minute, a BP of 120/55 mmHg, and an RR of 18 breaths per minute with an oxygen saturation of 98% on 2-L nasal cannula. An ECG shows a first-degree heart block. Upon physical examination, there are diffuse rhonchi bilaterally. The patient is covered in soot and the hairs in his nares are singed. Given this clinical presentation, which of the following maybe responsible for this patient’s respiratory distress?
. Reactive airway disease
. Foreign body aspiration
. Decompression sickness
. Thermal burns
. Pneumothorax
16) 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?
. Morphine sulfate only
. Nitroglycerin only
. Nitroglycerin and a loop diuretic
. Aspirin
. Antibiotics
17) 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?
. Streptococcus pneumoniae
. Haemophilus influenzae
. Mycoplasma pneumoniae
. Chlamydophila pneumoniae
. Legionella pneumophila
18) A 32-year-old woman presents to the ED with a 1-month history of general malaise, mild cough, and subjective fevers. She states that she is human immunodeficiency virus (HIV) positive and her last CD4 count, 6 months ago, was 220. She is not on antiretroviral therapy or any other medications. Initial vitals include an HR of 88 beats per minute, a BP of 130/60 mmHg, and an RR of 12 breaths per minute with an oxygen saturation of 91% on room air. Her chest radiograph shows bilateral diffuse interstitial infiltrates. Subsequent laboratory tests are unremarkable except for an elevated lactate dehydrogenase level. Given this patient’s history and physical examination, which of the following is the most likely organism responsible for her clinical presentation?
. Coccidioides immitis
. Mycobacterium tuberculosis
. Pneumocystis jiroveci
. Mycoplasma pneumoniae
. Haemophilus influenzae
19) A 27-year-old woman presents to the ED complaining of an intensely pruritic rash all-over her body, abdominal cramping, and chest tightness. She states that 1 hour ago she was at dinner and accidentally ate some shrimp. She has a known anaphylactic allergy to shrimp. Her BP is 115/75 mmHg, HR is 95 beats per minute, temperature is 98.9°F, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. She appears anxious, and her skin is flushed with urticarial lesions. Auscultation of her lungs reveals scattered wheezes with decreased air entry. Which of the following is the most appropriate next step in management?
. Administer oxygen via non-rebreather, place a large-bore IV, begin IV fluids, and administer methylprednisolone intravenously
. Administer oxygen via non-rebreather, place a large-bore IV, begin IV fluids, and administer methylprednisolone and diphenhydramine intravenously
. Administer oxygen via non-rebreather, place a large-bore IV, begin IV fluids, administer methylprednisolone and diphenhydramine intravenously, and give intramuscular epinephrine
. Administer oxygen via non-rebreather, place a large-bore IV, begin IV fluids, and start aerosolized albuterol
. Administer oxygen via non-rebreather, place a large-bore IV, begin IV fluids, and start aerosolized epinephrine
20) 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?
. Chronic bronchitis
. Asthma
. Emphysema
. Congestive heart failure (CHF)
. Pneumothorax
21) 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?
. Chest x-ray
. Chest CT scan
. ECG
. Rib radiographs
. Thoracentesis
22) A 29-year-old woman presents to the ED for hyperventilation. Her initial vitals include an RR of 28 breaths per minute with an oxygen saturation of 100% on room air. She is able to speak in full sentences and tells you that she cannot breathe and that her hands and feet are cramping up. She denies any trauma, past medical history, or illicit drug use. Chest auscultation reveals clear breath sounds bilaterally. A subsequent chest radiograph is normal. Upon reevaluation, the patient reports that she is breathing better. Her vitals include an RR of 12 breaths per minute with an oxygen saturation of 100% on room air. Which of the following conditions is most likely the etiology of this patient’s symptoms?
. Pneumothorax
. Hemopneumothorax
. Pleural effusion
. Anxiety attack
. Asthma exacerbation
23) A 42-year-old man presents to the ED via ambulance after activating EMS for dyspnea. He is currently on an oxygen face mask and was administered one nebulized treatment of a β2-agonist by the paramedics. His initial vitals include an RR of 16 breaths per minute with an oxygen saturation of 96% on room air. The patient appears to be in mild distress with some intercostal retractions. Upon chest auscultation, there are minimal wheezes localized over bilateral lower lung fields. The patient’s symptoms completely resolve after two more nebulizer treatments. Which of the following medications, in addition to a rescue β2-agonist inhaler, should be prescribed for outpatient use?
. Magnesium sulfate
. Epinephrine injection (EpiPen)
. Corticosteroids
. Cromolyn sodium
. Ipratropium
24) A 22-year-old woman is brought to the ED by paramedics who state that they found the patient hunched over on a park bench barely breathing. The patient is rousable only to painful stimuli. Her initial vitals include an HR of 78 beats per minute, a BP of 125/58 mmHg, and a respiratory rate of 6 breaths per minute with an oxygen saturation of 94% on 2-L nasal cannula. Upon physical examination, the patient has clear breath sounds bilaterally and no signs of trauma. Her pupils are 2 mm bilaterally and reactive to light. Which of the following agents may be used to restore this patient’s respirations?
. Oxygen
. Flumazenil
. Anticholinergic inhaler treatment
. β2-Agonist nebulized treatment
. Naloxone
25) A 43-year-old undomiciled man is brought to the ED after being found intoxicated on the street. He is currently rousable and expresses a request to be left alone. Initial vitals include an HR of 92 beats per minute, a BP of 125/80 mm Hg, and an RR of 14 breaths per minute with an oxygen saturation of 93% on room air. His rectal temperature is 101.2°F. A chest radiograph shows infiltrates involving the right lower lobe. Given this clinical presentation, what initial antibiotic coverage is most appropriate for this patient?
. Gram-negative coverage only
. Gram-positive coverage only
. Broad-spectrum with anaerobic coverage
. PCP coverage
. Antifungal therapy
26) A 32-year-old man is brought into the ED by EMS with fever, shortness of breath, and stridor. The patient was treated yesterday in the ED for a viral syndrome. His BP is 90/50 mmHg, HR is 110 beats per minute, temperature is 101.2°F, and his RR is 28 breaths per minute. A chest radiograph reveals a widened mediastinum. The patient is endotracheally intubated, given a 2-L bolus of normal saline, and started on antibiotics. His BP improves to 110/70 mmHg and he is transferred to the intensive care unit (ICU). You see a friend that accompanied the patient to the hospital and ask him some questions. You find out that the patient is a drum maker and works with animal hides. What is the most likely organism that is responsible for the patient’s presentation?
. Streptococcus pneumoniae
. Corynebacterium diphtheriae
. Coxiella burnetii
. Haemophilus influenzae
. Bacillus anthracis
27) A 62-year-old man presents to the ED with gradual dyspnea over the last few weeks. He reports that he is a daily smoker and has not seen a physician in years. Upon physical examination, there are decreased breath sounds on the right as compared to the left. A chest radiograph indicates blunting of the right costophrenic angle with a fluid line. A thoracentesis is performed. Given this patient’s history, which of the following most likely describes his effusion?
. Transudative effusion
. Exudative effusion
. Transudative and exudative effusion
. Lactate dehydrogenase < 200 units
. Fluid-to-blood protein ratio < 0.5
28) A 40-year-old man with a history of untreated HIV for 8 years comes into the ED complaining of cough, fever, and malaise for 3 days. He is tachypneic and diaphoretic. Chest radiograph reveals bilateral infiltrates. Arterial blood gas (ABG) analysis is significant for a PaO2 of 62 on room air. His chest radiograph is seen below. Which of the following is the most appropriate initial management?
. Treat with corticosteroid prior to antibiotic therapy
. Treat immediately with IV trimethoprim/sulfamethoxazole (TMP/SMX)
. Administer antibiotics after a rapid sputum Gram stain is obtained
. Treat with nebulizer
. Treat with racemic epinephrine
29) A 34-year-old Caucasian female comes to the emergency department and complains that her heart is "racing out of control." She began to feel this way only this morning. She denies any chest pain or shortness of breath. Over the past few months, she has unintentionally lost 10 pounds. Her past medical history is significant for panic attacks, but she claims she has not had an attack for over 10 years. She is very concerned because her father died of a heart attack at the age of 40. The EKG reveals sinus tachycardia at a rate of 120/min. The initial labs show: CBC: Hb 12.9g/dL, Ht 39%, MCV 88 fl, Platelet count 200,000/cmm, Leukocyte count 8,500/cmm, Neutrophils 67%, Eosinophils 1%, Lymphocytes 24%, Monocytes 8%. Serum: Serum Na 139 mEq/L, Serum K 4.2 mEq/L, Chloride 100 mEq/L, Bicarbonate 25 mEq/L, BUN 10 mg/dL, Serum Creatinine 1.0 mg/dL, Calcium 9.1 mg/dL, Blood Glucose 102 mg/dL, TSH < 0.1 microU/mL, Free T4 4.6 ng/dL (N0.9-24). Which of the following is the best immediate step to control this patient's symptoms?
. Propylthiouracil
. Subtotal thyroidectomy
. Alprazolam
. Radioactive Iodine
. Propanolol
30) A 45-year-old male, found unconscious, is brought to the emergency room. His airway is maintained, and oxygen is administered. His temperature is 39.0°C (102.5°F), pulse is 102/min, blood pressure is 90/65 mmHg and respirations are 23/min. Intravenous access is secured and blood and urine samples are drawn. Lab results are as follows: Sodium 134 mEq/L, Potassium 5.9 mEq/L, Chloride 101 mEq/L, Bicarbonate 22 mEq/L, Blood urea nitrogen 110 mg/dl, Glucose 1000 mg/dl, Serum calcium 10.2 mg/dl, Amylase 100 U/L, Aspartate aminotransferase 15 U/L, Alanine aminotransferase 17 U/L, Ammonia 15 micro-moi/L (Normal is 9-33 micro-moi/L), PT 13 sec, APTT 30 sec. Arterial blood gases: PH 7.40, PaCO2 38 mm Hg, PaO2 90 mm Hg. Which of the following is the most appropriate initial infusion you should order for this patient?
. Normal saline
. 0.45% saline
. 5% dextrose
. Regular insulin
. Potassium
31) A 24-year-old woman comes into the emergency department with recurrent episodes of palpitations, headache, and tremor. Her blood pressure is 155/95 mmHg, heart rate is 135/min, temperature is 37.9°C (100.2°F), and respiratory rate is 12/min. A CT of the abdomen shows a suprarenal mass. After confirming the diagnosis with a laboratory test, the physician informs the patient that she will require immediate therapy and surgical resection of the mass within the next few weeks. In order to achieve short-term control of her blood pressure, which of the following agents is most appropriate?
Furosemide
Hydralazine
Phenelzine
Prazosin
Propanolol
32) 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?
Diuresis and ventilatory support
Diuresis, strict potassium restriction, and insulin
Intravenous fluids, insulin, and potassium
Intravenous fluids, insulin, and strict potassium restriction
Intravenous fluids, loop diuretic, and potassium
33) A 13-year-old boy is brought to the pediatrician by his mother because of increasing body hair. Several months earlier he had been diagnosed with 17α-hydroxylase deficiency and treated with hydrocortisone. Physical examination reveals an overweight boy with a moderate amount of both chest and genital hair, and some facial hair growth. His physical examination is otherwise unremarkable. Which of the following is the best treatment for this patient?
Add cosyntropin
Add dexamethasone
Add spironolactone
Increase hydrocortisone
Keep the current dose of hydrocortisone
34) 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?
Amiodarone
Flecainide
Lithium
Methimazole
Sotalol
35) 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?
Aspirin
Glucagon
Hemodialysis
Levothyroxine
Metoprolol
36) 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?
. Low serum Ca+
. Low serum K+
. Low serum Na+
. Normal serum K+
. Microcytic anemia
37) A 58-year-old woman presents to her physician because of neck discomfort and difficulty swallowing. She first began to have difficulty with swallowing solids 2 years ago, but the problem is getting progressively worse. She denies hemoptysis, hematemesis, abdominal pain, or change in bowel habits. She is a nonsmoker and past medical history is significant only for mild hypertension. Her temperature is 36.9°C (98.4°F), heart rate is 72/min, and blood pressure is 132/78 mmHg. She has an asymmetrically enlarged thyroid gland that is particularly firm on the right, with poorly palpable borders. Laboratory evaluation reveals a free thyroxine level of 4.1 ng/dL and thyroid-stimulating hormone of 5μU/mL. Based on the results of a radioisotope scan and a fine needle aspiration biopsy, the physician decides to perform surgery. For which of the following is the patient at increased risk postoperatively?
Bone metastases
Hypercalcemia
Hypocalcemia
Hypophosphatemia
Pheochromocytoma
38) A 53-year-old woman presents to the clinic with complaints of headache and blurred vision for the past several months. She also says her family has commented that her face looks different, and her nose is bigger than it used to be. In addition, she says her shoes feel tighter. On physical examination she has coarse facial features with a prominent mandible and widely spaced incisors. MRI of the brain reveals a mass in the pituitary. This patient may be at increased risk of developing which of the following malignancies?
Colon cancer
Hepatocellular carcinoma
Lung cancer
Malignant brain tumor
Pancreatic adenocarcinoma
39) A 35-year-old white female comes to her primary care physician for the evaluation of palpitations, weight loss, increased appetite and diarrhea for the past 2 months. She denies smoking cigarettes or drinking alcohol. Her temperature is 37.1°C (98°F), blood pressure is 135/80 mmHg, respirations are 14/min, and pulse is 90/min. Physical examination shows exophthalmos, lid lag, lid retraction, and a diffusely enlarged, non-tender thyroid gland. Lab studies show very low levels of serum TSH, and increased levels of serum free T4 and T3. The diagnosis of Graves' disease is established. Various treatment options are discussed with the patient, and she opts for long-term treatment with propylthiouracil. Which of the following conditions is this patient at risk for developing?
. Agranulocytosis
. Hypocalcemia
. Permanent hypothyroidism
. Recurrent laryngeal nerve palsy
. Thyroid cancer
40) A 35-year-old white female presents with complaints of weight gain, lethargy and constipation for the last 2 months. She also complains of cold intolerance and oligomenorrhea. She is not taking any medication. She is a non-smoker, and does not drink alcohol. Her pulse is 67/min, and blood pressure is 130/90 mmHg. She is afebrile. Her hands are dry and cold. There is a non-tender, diffuse rubbery enlargement of the thyroid gland without any discrete nodularity. She does not have exophthalmos, lid lag or lid retraction. Labs show decreased serum T4 levels, elevated serum TSH levels and positive anti-thyroperoxidase (TPO) antibodies. Which of the following complications may develop in this patient?
. Lymphoma of the thyroid
. Papillary carcinoma of the thyroid
. Follicular carcinoma of the thyroid
. Anaplastic carcinoma of the thyroid
. Medullary carcinoma of the thyroid
41) A 36-year-old female presents with weight loss, palpitations, mild shortness of breath, heat intolerance, tremors, and increased sweating. She does not have any past medical problems. Her family history is unremarkable. Her blood pressure is 140/70 mmHg, heart rate is 104/min and regular, temperature is 99.0°F (37.2°C) and respiratory rate is 22/min. Physical examination reveals a 2 x 2 cm nodule in her left thyroid lobe. The rest of her thyroid gland feels normal. There are no palpable lymph nodes in her neck. Eye examination reveals minimal lid lag, but no signs of proptosis or chemosis. She has tremors in both of her upper extremities. Her hands are moist and warm. Thyroid function testing reveals: Serum TSH < 0.03 micro IU/ml, Total T3 330 ng/dl, Total T4 14 mcg/dl. Radioactive iodine scan shows uptake only in her left-sided nodule. Which of the following disorders is this patient at risk of developing if she is left untreated?
. Bone loss
. Airway compression
. Thyroid cancer
. Coronary artery disease
. Proptosis
42) A 55-year-old male presents with complaints of an ulcer over the sole of his right great toe for one week. His medical problems include a ten year history of hypertension, diabetes and hypercholesterolemia. His current medications are ramipril, aspirin, metformin, glibenclamide and pravastatin. He has a 20-pack year history of smoking and occasionally drinks alcohol. He denies illegal drug use or multiple sexual partners. Which of the following is most likely contributing to the development of his foot ulcer?
. History of smoking
. Diabetic neuropathy
. Poor glycemic control
. Peripheral vascular disease
. Bony abnormality of the foot
43) A 49-year-old woman presents to the emergency department (ED) with profuse, foul-smelling, watery diarrhea and abdominal pain. Five days ago, she was hospitalized for urosepsis and treated with amoxicillin and sulbactam. She recovered well, and was discharged three days ago with a prescription for oral amoxicillin plus clavulanic acid. Her current temperature is 38.8°C (101.9°F), blood pressure is 110/70 mmHg, pulse is 102/min, and respirations are 15/min. Abdominal examination shows tenderness in the left lower quadrant. CBC shows a WBC count of 25,000/microl. She is started on intravenous normal saline in the ED. Which of the following is the most appropriate next step in management?
. Continue rehydration
. Start oral metronidazole
. Discontinue antibiotics
. Discontinue antibiotics and start oral metronidazole
. Discontinue antibiotics and start oral vancomycin
44) 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?
. Whole blood transfusion
. Packed red blood cell transfusion
. Fresh frozen plasma infusion
. Hemodialysis
. Platelet transfusion
45) A 50-year-old female presents with heartburn and gnawing abdominal pain. She was diagnosed with peptic ulcer disease 3 years ago, but she has been non-adherent to her medications. She asks you if her nonadherence puts her at increased risk of any complications. Which of the following is the most common complication of peptic ulcer disease?
. Perforation
. Penetration
. Gastric outlet obstruction
. Hemorrhage
. Atrophic gastritis
46) A 37 -year-old male is brought to the emergency department due to an episode of hematemesis. He has a history of peptic ulcer disease. A nasogastric tube lavage yields coffee-ground-like material. Physical examination reveals pallor and delayed capillary refill, without cyanosis. His temperature is 36.7°C (98°F), blood pressure is 85/40 mmHg, pulse is 125/min, and respirations are 18/min. Which of the following is the most appropriate first step in management?
. Intravenous octreotide
. Upper GI endoscopy
. Surgical intervention
. Intravenous pantoprazole
. Fluid resuscitation
47) A 54-year-old man is brought to the ER because of an episode of coffee ground emesis and lightheadedness. He has a history of intravenous drug use, hepatitis C infection, and alcohol use. He says he has not had an alcoholic drink for about three days. He has been noncompliant with medications and follow-ups. He takes no medications. His temperature is 36.7°C (98°F), pulse is 110/min, respirations are 16/min, and blood pressure is 90/60 mmHg. Scleral icterus is present. Examination shows coffee ground material in the oropharynx. His lungs are clear. His abdomen is distended and a fluid wave is present. He is slightly tender to palpation in the epigastrium. Laboratory studies show: Complete blood count:Leukocyte count 9,500/mm3, Hemoglobin 10.0 g/L, Platelets 120,000/mm3. Chemistry panel:Serum sodium 140 mEq/L, Serum potassium 3.5 mEq/L, Bicarbonate 27 mEq/L, Blood urea nitrogen (BUN) 34 mg/dL, Serum creatinine 0.8 mg/dL. Coagulation studies :Prothrombin time 27 sec, Partial thromboplastin time 42 sec. Which of the following is the most appropriate next step in the management of this patient?
. Whole blood transfusion
. Fresh frozen plasma infusion
. Hemodialysis
. Pooled platelet transfusion
. Plasmapheresis
48) 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?
. Place a nasogastric tube in the patient’s stomach to remove any remaining ethanol
. Order a HIDA scan to evaluate for acute cholecystitis
. Administer hepatitis B immune globulin
. Send viral hepatitis titers
. Provide supportive care by correcting any fluid and electrolyte imbalances
49) 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?
Barium enema
Colonoscopy
Laparotomy
Obstruction series
Warfarin therapy
50) A 51-year-old man is brought to the emergency department (ED) by emergency medical services (EMS) with a blood pressure (BP) of 90/60 mm Hg, heart rate (HR) of 110 beats per minute, respiratory rate (RR) of 18 breaths per minute, and oxygen saturation of 97% on room air. The patient tells you that he has a history of bleeding ulcers. On examination, his abdomen is tender in the epigastric area. He is guaiac positive, with black stool. He has a bout of hematemesis and you notice that his BP is now 80/50 mm Hg, HR is 114 beats per minute, as he is slowly starting to drift off. Which of the following is the most appropriate next step in therapy?
. Assess airway, establish two large-bore intravenous (IV) lines, cross-match for two units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy
. Assess airway, establish two large-bore IVs, cross-match for 2 units of blood, and administer a proton pump inhibitor
. Place two large-bore IVs, cross-match for 2 units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy
. Intubate the patient, establish two large-bore IVs, cross-match for 2 units of blood, administer 1 to 2 L of normal saline, and schedule an emergent endoscopy
. Intubate the patient, establish two large-bore IVs, cross-match for 2 units of blood, and administer a proton pump inhibitor
51) A 19-year-old woman presents to the ED with 1 hour of acute-onset progressively worsening pain in her RLQ. She developed nausea shortly after the pain and vomited twice over the last hour. She had similar but less severe pain 2 weeks ago that resolved spontaneously. Her BP is 123/78 mm Hg, HR is 99 beats per minute, temperature is 99.1°F, and her RR is 16 breaths per minute. On physical examination, the patient appears uncomfortable, not moving on the gurney. Her abdomen is nondistended, diffusely tender, worst in the RLQ. Pelvic examination reveals a normal-sized uterus and moderate right-sided adnexal tenderness. Laboratory results reveal WBC 10,000/μL, hematocrit 38%, and a negative urinalysis and β-hCG. Pelvic ultrasound reveals an enlarged right ovary with decreased flow. Which of the following is the most appropriate management for this patient?
. Admit to the gynecology service for observation
. Administer IV antibiotics and operate once inflammation resolves
. Attempt manual detorsion
. Order an abdominal CT
. Go for immediate laparoscopic surgery
52) A 22-year-old woman is brought to the ED by ambulance complaining of sudden onset of severe abdominal pain for 1 hour. The pain is in the RLQ and is not associated with nausea, vomiting, fever, or diarrhea. On the pelvic examination you palpate a tender right adnexal mass. The patient’s last menstrual period was 6 weeks ago. Her BP is 95/65 mm Hg, HR is 124 beats per minute, temperature is 99.8°F, and RR is 20 breaths per minute. Which of the following are the most appropriate next steps in management?
. Provide her oxygen via face mask and administer morphine sulfate
. Administer morphine sulfate, order an abdominal CT with contrast, and call an emergent surgery consult
. Send the patient’s urine for analysis and order an abdominal CT
. Bolus 2 L NS, order a type and crossmatch and β-hCG, and call gynecology for possible surgery
. Provide oxygen via face mask, give morphine sulfate, and order a transvaginal ultrasound
53) 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?
. Order a CT scan to evaluate his aorta
. Call the angiography suite and have them prepare the room for the patient
. Order a portable abdominal radiograph
. Call surgery and have them prepare the operating room (OR) for an exploratory laparotomy
. Call the cardiac catheterization laboratory to prepare for stent insertion
54) A 32-year-old man with Crohn’s disease presents to the emergency department with acute-onset diffuse abdominal pain and emesis. The patient states these symptoms are different than his usual Crohn’s disease flare-ups. The pain is severe (10/10) and is cramping in nature. He says his abdomen feels larger than usual. His Crohn’s disease has been well managed on 6-mercaptopurine for the past 6 months. The patient denies any recent sick contacts or eating underprepared foods. He states he had a bowel movement and flatus since the abdominal pain began. In addition to Crohn’s disease, the patient had appendicitis for which he underwent an appendectomy 12 years ago. His temperature is 37.1°C (98.7°F), blood pressure is 135/86 mm Hg, pulse is 84/min, and respiratory rate is 14/ min. On physical examination the abdomen is distended and diffusely tender with high-pitched bowel sounds. There is rebound tenderness throughout the abdomen along with guarding. The remainder of the physical examination is noncontributory. An x-ray of the abdomen shows dilated small loops of bowel along with absence of gas in the colon. What is the best next step in management?
Bowel rest only
Intravenous fluids and antibiotics only
Laparotomy
MRI of the abdomen
Ultrasound
55) A 24-year-old man with a history of depression is brought to the emergency room because of a drug overdose. He is experiencing some nausea and vomiting, but no other symptoms. Physical examination and vital signs are normal. Six hours prior to presentation, he intentionally took 40 tablets of acetaminophen (500mg/tablet). Which of the following is the most appropriate next step in management?
. Give ethanol to compete with the parent drug for metabolism, therefore preventing formation of toxic metabolites
. give Narcan to block its actions directly
. Give intravenous prostacyclins to maintain cellular integrity
. give N-acetylcysteine to allow binding of the toxic metabolite
. Give glucocorticoids to block the immune cascade
56) A 58-year-old man comes to the emergency department complaining of colicky abdominal pain over the past 3 days that suddenly became more severe and constant over the past 6 hours. A contrast study is performed and results are shown in the image. What is the first-line treatment after fluid resuscitation and nasogastric tube placement?
Colonoscopy
Hemicolectomy
Proximal colostomy with delayed resection
Sigmoid colectomy
Sigmoidoscopy
57) A 59-year-old woman with renal cell carcinoma presents to the emergency department with severe right upper quadrant (RUQ) pain. She is afebrile, acutely tender in the RUQ, and has shifting dullness and a palpable liver edge. Murphy’s sign is negative. Laboratory studies show: Na+: 138 mEq/L, K+: 3.6 mEq/L, Glucose: 80 mg/dL. Aspartate aminotransferase: 50 U/L Alanine aminotransferase: 43 U/L Alkaline phosphatase: 138 U/L Total protein: 6.4 g/dL, Albumin: 3.8 g/dL, Total bilirubin: 1.1 mg/dL. Imaging demonstrates a spider web of collateral veins in the liver. Although extensive measures are taken, the patient dies 6 hours after arriving. Which of the following was the most likely initial treatment?
β-Blocker followed by lactulose
Cholecystectomy
Endoscopic retrograde cholangiopancreatography with dilation of the common bile duct
Exploratory laparotomy
Tissue plasminogen activator followed by anticoagulation
58) 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?
. GI haemorrhage
. GI perforation
. GI penetration
. Gastric outlet obstruction
. Pernicious anemia
59) 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?
Arteriography
Colonoscopy
Endoscopy
Nasogastric tube aspiration
Surgical consultation
60) A 75-year-old woman with a history of diabetes and coronary heart failure presents to the emergency department because of increasing abdominal girth. In recent months she has been feeling increasingly fatigued, and although she has had decreased appetite, she has gained weight. Her heart rate is 100/min and blood pressure is 112/70 mm Hg. She has scleral icterus; the skin over her face, neck, and lower legs is slightly bronze in color; she has palmar erythema; and she has numerous ecchymoses over her body. Her abdominal examination is significant for ascites. Laboratory tests show: Aspartate transaminase: 102 U/L, Alanine transaminase: 97 U/L, Alkaline phosphatase: 300 U/L, Total bilirubin: 1.9 mg/dL, Albumin: 2.9 g/dL, Prothrombin time: 22 sec, Partial thromboplastin time: 42 sec. An ultrasound of her abdomen shows a shrunken and nodular liver. A liver biopsy using Perls Prussian blue stain is shown in the image. Which of the following is the most likely complication of her disease?
Acute pancreatitis
Amyloidosis
Bone marrow failure
Hepatocellular carcinoma
Splenomegaly
61) 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?
Emergent appendectomy and postoperative antibiotics
Give nothing by mouth with intravenous hydration
Percutaneous drainage and interval appendectomy
Serial abdominal examinations
Urgent ECG and cardiac enzymes
62) A 47-year-old woman presents to the emergency department with an 8-day history of left lower quadrant pain and semi-formed stools. Starting this afternoon, she has noticed blood in her stool as well as dizziness when she gets up from sitting. She denies fever, nausea, vomiting, weight loss, and night sweats. Her temperature is 37°C (98.6°F), heart rate is 104/ min, blood pressure is 120/82 mm Hg supine and 103/63 mm Hg when she sits up, and respiratory rate is 18/min. Physical examination reveals no peritoneal signs and is remarkable only for fecal occult blood on rectal examination. Laboratory results reveal a WBC count of 13,000/mm³ and hematocrit of 29%. Results of an x-ray of the abdomen are shown in the image. What is the best next step in management?
Angiography with embolization
Immediate surgery for partial colectomy
Intravenous hydration and blood transfusion
Nothing by mouth, nasogastric tube, and broad-spectrum antibiotics
Place the patient on a high-fiber diet
63) A 57-year-old woman presents to the ED with a basin in her hand and actively vomiting. You insert an IV catheter, start IV fluids, and administer an antiemetic agent. The patient feels much better but also complains of severe crampy abdominal pain that comes in waves. You examine her abdomen and note that it is distended and that there is a small midline scar in the lower abdomen. Upon auscultation, you hear high-pitched noises that sound like “tinkles.” Palpation elicits pain in all four quadrants but no rebound tenderness. She is guaiac negative. Which of the following is the most common cause of this patient’s presentation?
. Travel to Mexico
. Ethanol abuse
. Hysterectomy
. Hernia
. Constipation
64) A 48-year-old woman comes to the office because her regular screening mammogram revealed irregular densities. Radiographic-guided needle biopsy shows evidence of invasive lobular carcinoma. The tumor is hormone receptor positive (HR +). Further investigation reveals involvement of the axillary lymph nodes; the other breast seems to be spared. No distant metastasis is detected. She undergoes modified radical mastectomy, along with radiotherapy. She is then prescribed adjuvant chemotherapy and tamoxifen for 5 years. This patient's use of tamoxifen increases her risk for developing which of the following cancers:
. Ovarian cancer
. Endometrial cancer
. Lung cancer
. Pancreatic cancer
. Cervical cancer
65) A 54-year-old Caucasian woman presents to your office with fatigue. She also reports dizziness and palpitations after moderate physical activity. Additionally, her feet feel "numb" and are less sensitive to cold than they used to be. She has no significant past medical history. Physical examination reveals pale conjunctivae and a shiny tongue. Ankle reflex is decreased bilaterally. Laboratory findings include: Hemoglobin 7.6 mg/dL, MCV 110 fL, MCHC 36 g/dL, WBC count 3,900/mm3, Platelet count 150,000/mm3. This patient should be monitored for which of the following long-term complications?
. Acute myelogenous leukemia
. Hodgkin's disease
. Celiac sprue
. Gastric cancer
. Liver cirrhosis
66) A 34-year-old male is brought to the emergency room after being involved in a motor vehicle accident. He suffers blunt abdominal trauma and bilateral femur fractures. He has no significant past medical history. On physical examination, his blood pressure is 80/40 mmHg and his heart rate is 110/min. He receives several units of packed red blood cells. Once stabilized, the patient begins complaining of a tingling sensation in his toes and fingers. His serum calcium level is noted to be 7.2 mg/dL. Which of the following is the most likely cause of this patient's current symptoms?
. Increased renal tubular secretion of calcium
. Calcium chelation by a substance in the transfused blood
. Electrolyte leakage from red blood cells during pre-transfusion storage
. Antibody-mediated red blood cell membrane damage
. Parathyroid gland suppression due to fluid overload
67) 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?
. Give high dose NSAIDs
. T ransdermal fentanyl patch
. Start with short-acting morphine
. Long-acting opiates
. Repeat radiotherapy
68) A 45-year-old previously healthy male is brought to the emergency room because of headaches and confusion for 2 days. He denies any focal weakness or sensory symptoms. He has no significant past medical history and does not use any medications. He does not use tobacco, alcohol or drugs. On physical exam, the patient has a temperature of 37.9°C (100.2°F), a blood pressure of 140/86 mm Hg, a pulse of 96/min, and respirations of 16/min. Mild icterus is present. The patient's oropharynx is clear and his neck is supple and without rigidity. Examination of the patient's chest and abdomen is unremarkable. Neurologic examination reveals no focal deficits. Laboratory studies show: Complete blood count: Hemoglobin 84 g/L, Platelet count 80,000/mm3, Leukocyte count 5,500/mm3. Chemistry panel:Blood urea nitrogen (BUN) 30 mg/dL, Serum creatinine 2.2 mg/dL, Serum calcium 10.0 mg/dL, Blood glucose 98 mg/dL. A peripheral blood smear shows many fragmented red blood cells. The prothrombin time is normal. Which of the following is the most appropriate next step in the management of this patient?
. Hemodialysis
. MRI of the brain
. Electroencephalogram
. Plasma exchange
. Platelet transfusion
69) A 54-year-old male comes to the emergency department with complaints of cough and bloody sputum. He used to smoke 2 packs of cigarettes daily for 22 years, but states that he quit last month. He also complains of weight loss, anorexia, constipation, increased thirst, and easy fatigability, which he attributes to depression. He lost his wife 4 months ago and "life never felt the same after that." He is sure that he cannot have cancer because he does not smoke anymore. His vital signs are stable. He appears slim, pale, slightly irritable, and short of breath. The laboratory studies and chest x-ray results are as follows: Sodium 144 mEq/dL, Potassium 4.3 mEq/dL, Chloride 98 mEq/dL, Bicarbonate 21 mEq/dL, Calcium 14.5 mg/dl, BUN 48 mg/dl, Creatinine 2.0 mg/dl, Chest x-ray hilar mass in the left lung. While in the ED, he becomes more somnolent and vomits twice. What is the best next step in the management of this patient?
. IV furosemide
. CT scan of the head
. IV normal saline
. Emergency hemodialysis
. IV pamidronate
70) 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?
. Radiotherapy.
. Intravenous dexamethasone.
. Immediate MRI of spine
. Decompression surgery of spine.
. CT myelogram.
71) A 55-year-old woman complains of right leg swelling and tenderness following an international flight. A venous scan of the right lower extremity showed thrombosis of the right popliteal vein. She is sent home with oral warfarin and subcutaneous enoxaparin. One week later, she returns to the office for a follow-up appointment. Laboratory studies at the time of discharge and now are shown below: This patient's current condition predisposes her to which of the following?
. Acute interstitial nephritis
. Arterial thrombosis
. Hemarthrosis
. Pneumothorax
. Fat embolism
72) A 22-year-old African American male suffering from sickle cell anemia presents in the emergency department with a sustained painful penile erection for the last 4 hours. Previously, he had one episode of acute chest syndrome that was treated with oxygenation, hydration and blood transfusion. His pulse is 76/min, respirations are 16/min, blood pressure is 115/76 mm Hg, and temperature is 37°C (98.6°F). Examination of all his systems is unrevealing. What is the best next step in the management of this patient?
. Observation
. Hyperbaric oxygen therapy
. Exchange transfusion
. Surgical intervention
. Hydroxyurea
73) 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?
. Ceftriaxone
. Ceftriaxone and vancomycin
. Cefotaxime and ampicillin
. Ceftriaxone, vancomycin, and ampicillin
. Ceftazidime and vancomycin
74) 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?
. Ceftriaxone and gentamicin
. Azithromycin
. Piperacillin and tobramycin
. Piperacillin and ciprofloxacin
. Dicloxacillin
75) A 28-year-old man presents to ER with fever, chills, and generalized weakness for the past one week. He has no history of pre-existing heart disease, but he was admitted to the hospital six months ago for cellulitis of the right arm. His temperature is 40.0°C (104°F), pulse is 110/min, respirations are 22/min, and blood pressure is 110/65 mmHg. Oropharynx is clear. Lungs are clear to auscultation. A holosystolic murmur is heard at the lower sternum which increases in intensity with inspiration. His blood is drawn and sent for culture. What is the most appropriate initial antibiotic therapy for this patient?
. Ampicillin-sulbactam
. Clindamycin
. Oxacillin
. Penicillin G and gentamycin
. Vancomycin
76) A 45-year-old female presents to emergency room complaining of urinary frequency, burning during urination, and weakness. Her last menstrual period was one year ago, and she is not sexually active. She is not taking any medications. Her temperature is 37.8°C (100°F), blood pressure is 120/76 mmHg, pulse is 80/min, and respirations are 14/min. Very mild costovertebral angle tenderness is present. IV ceftriaxone is started. Two days later, the patient feels much better. Antibiotic susceptibility testing returned with an uropathogen (E.coli) highly sensitive to ceftriaxone, gentamicin, ciprofloxacin and trimethoprim/sulfamethoxazole (TMP/SMX). Which of the following is the most reasonable next step in the management of this patient?
. Add ciprofloxacin to the regimen
. Switch to TMP/SMX
. Switch to gentamicin
. Continue ceftriaxone
. Discontinue antibiotic therapy
77) 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?
. Ceftriaxone
. Ceftriaxone and vancomycin
. Cefotaxime and ampicillin
. Ceftriaxone, vancomycin. And ampicillin
. Ceftazidime and vancomycin
78) A 29-year-old male, known intravenous drug user presents to the emergency department with a chief complaint of dyspnea. Over the last few days, he has become short of breath and he has very little exercise tolerance. His other symptoms are a persistent dry cough, low-grade fever for the past two days, watery diarrhea, abdominal cramps, and general malaise. He self-treated his fever with acetaminophen. He has a history of anaphylaxis with sulfonamides. Physical examination reveals an emaciated man with numerous needle marks on his hands. Arterial blood gas analysis reveals a PCO2 of 32 mm Hg and PO2 of 64 mm Hg on room air. The chest x-ray is shown below. Which of the following is the most appropriate initial treatment regimen for this patient?
. Penicillin and acyclovir
. Pentamidine and azithromycin
. Tetracycline and azithromycin
. Acyclovir and azithromycin
. Ganciclovir and azithromycin
79) A 54-year-old diabetic woman comes to the emergency department because of increasing neck and facial pain, fever, and chills. A few weeks ago, she developed an infection on the side of her neck. She thought it would go away with over-the-counter medication, but the infection has now started to drain. For the past twenty years, she has had diabetes, which is well-controlled with an oral hypoglycemic. She denies trauma, travel, and smoking. Physical examination reveals an area of erythema and induration at the base of the neck. Serosanguineous fluid is draining from a small defect in the skin near the center of the lesion. There is no crepitus. Histological analysis of the discharge reveals the presence of gram positive, branching bacteria. The treatment for this patient is?
. Surgical debridement
. Start triple combination TB therapy
. Start amphotericin
. Hyperbaric oxygenation
. Intravenous penicillin
80) 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?
. Ganciclovir
. Tenofovir
. Oseltamivir
. Valacyclovir
. Nevirapine
81) A 23-year-old man is brought to the emergency room because of confusion and hallucinations. While in ER, he has an episode of generalized tonic-clonic seizures. His past medical history is significant for illicit drug use. His temperature is 40.0°C (104.0°F), pulse is 95/min, and blood pressure is 120/80 mm Hg. He is confused and disoriented. Fundoscopy is with in normal limits. There is no neck stiffness. The neurological examination shows upgoing plantar reflexes bilaterally. Lumbar puncture is performed and CSF analysis shows the following: Glucose 35mg/dl, Protein 80mg/dl, WBC count 150/cm3, Neutrophils 10%, Lymphocytes 90%, Gram stain Negative. CT scan of the brain without contrast is normal. Which of the following is the most appropriate next step in the management of this patient?
. Intravenous acyclovir
. MRI of the brain
. Intravenous ceftriaxone and vancomycin
. CSF culture for herpes simplex virus
. Urine toxicology screen
82) 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?
. Urinary tract infection from Escherichia coli
. Urinary tract infection from Klebsiella species
. Urinary tract infection from Proteus species
. Urinary tract infection from Pseudomonas aeruginosa
. Urinary tract infection from Candida species
83) A 21-year-old man presents with symptoms of headache, fever, chills, and discomfort in both sides of his jaw. He has also noticed discomfort in his testes, but no dysuria or urethral discharge. Physical examination reveals bilateral enlargement of the parotid glands, as well as bilateral testicular enlargement and tenderness on palpation. His temperature is 38.5°C pulse rate of 92/min, and the remaining examination is normal. Laboratory data show hemoglobin 15 g/dL; hematocrit 40%; WBC 12000/mL, with 30% segmented neutrophils, 8% monocytes, and 62% lymphocytes. Which of the following statements concerning this dis- ease is true?
The disease is caused by a herpesvirus
The incubation period is 3–5 days
The most common complication of this disease in post pubertal boys and men is orchitis
Recurrent infections may occur
An increased serum amylase is proof of the existence of pancreatitis as a complication
84) 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?
Pneumonia
Encephalitis
Otitis media
Bronchitis
Mastoiditis
85) A 6-year-old boy develops symptoms of cough, fever, and malaise followed by a generalized maculopapular rash that has spread from the head downwards. A clinical diagnosis of measles is made. A few days after the onset of the rash he is drowsy, lethargic, and complaining of headache. A lumbar puncture, electroencephalogram (EEG), and computerized tomography (CT) of the brain exclude other etiologies and confirm the diagnosis of encephalitis. Which of the following is the most likely delayed neurologic complication of measles virus encephalitis?
Meningitis
Pure motor paralysis
Autonomic neuropathy
Mental retardation or epilepsy
Stocking-glove peripheral neuropathy
86) A 24-year-old man complains of fatigue, malaise, fever, and a sore throat. He was previously well, but now feels tired all the time and has to rest multiple times a day. Physical examination shows enlarged tonsils and palpable anterior and posterior cervical, axillary, and inguinal lymph nodes. There is also tenderness in the right upper quadrant with a liver span of 10 cm. Laboratory data is significant for a heterophil antibody (sheep cell agglutination) test that is positive. Which of the following rare complications can be associated with this condition?
Retinitis
Esophagitis
Splenic rupture
Kaposi sarcoma
Hemorrhage
87) 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?
. Add lisinopril
. Discontinue rosiglitazone
. Discontinue metformin
. Discontinue glipizide
. Begin bisphosphonate therapy
88) 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?
. Intravenous colloids
. Intravenous crystalloids
. Order packed red blood cells
. Intravenous antibiotics
. Diuretics
89) A 45-year-old woman presents to the emergency department (ED) with vomiting and severe right flank pain that radiates to her groin. She has been to the ED twice in the past due to similar episodes of renal colic, and was subsequently discharged on both occasions. She admits to not seeking further medical care because she has no insurance. KUB shows a renal stone. 24-hour urine collection shows a urinary calcium excretion of 350 mg (normal is less than 250 mg in women). Laboratory studies show a serum calcium concentration of 8.9 mg/dL; serum PTH is normal. An x-ray film of the chest shows no abnormalities. Further investigations fail to reveal the cause of her hypercalciuria. Apart from advising her to increase her fluid intake, which of the following interventions will benefit this patient?
. Restriction of calcium in her diet
. Thiazide diuretics
. Low dose furosemide
. High sodium intake
. Potassium citrate
90) 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?
. Insulin with dextrose
. Kayexalate
. Sodium bicarbonate
. Calcium gluconate
. Regular insulin
91) A 3-year-old girl is brought to the emergency department because of fever, chills, vomiting, and abdominal pain. Her temperature is 39.5°C (103.1°F), blood pressure is 70/40 mm Hg, pulse is 110/min, and respirations are 20/min. She is restless and diaphoretic. The abdominal examination shows right costovertebral tenderness. Laboratory studies show: Hemoglobin 15.0 g/L, Platelets 260,000/mm3, Leukocyte count 16,500/mm3, BUN 20 mg/dL, Serum creatinine 1.1 mg/dL. Urinalysis: Blood Negative, Glucose Negative, Ketones Negative, Leukocyte esterase Positive, Nitrites Positive, WBC 40-50/hpf, RBC 5-9/hpf. Blood and urine cultures are taken. Which of the following is the most appropriate next step in management?
. Empiric therapy with oral antibiotics
. Empiric therapy with intravenous antibiotics
. Renal ultrasound
. Voiding cystoureterogram
. Plain abdominal x-ray
92) A 45-year-old man comes to the emergency department (ED) with severe right flank pain. He is tossing in bed due to the pain. KUB done in the ED shows no abnormalities; however, abdominal ultrasound shows a 5 mm stone in the right ureter. Urinalysis shows: Urine pH 4.5 (normal is 5-6), WBC Absent, RBC 2-3/HPF, Bacteria Absent, Nitrites Negative, Esterase Negative. Which of the following is the most beneficial next step in management?
. Oral sodium bicarbonate
. Hydrochlorothiazide
. Furosemide
. High-protein diet
. Calcium-restricted diet
93) A 35-year-old man comes to the physician due to a one-month history of weight gain and facial edema. The facial edema resolves at the end of the day, but ankle edema develops. His temperature is 37.2°C (99°F), blood pressure is 142/80 mm Hg, pulse is 80/min, and respirations are 16/min. Examination shows 2+ ankle edema. Laboratory studies show: Hb 11.0 g/dl, WBC 8,000/cmm, Platelets 200,000/cmm, Serum Na 135 mEq/L, Serum albumin 2.2 g/dl, BUN 16 mg/dl, Serum creatinine 1.0 mg/dl. Urinalysis: Glucose Absent, Protein 4+, WBC 1-2/HPF, RBC Absent, Casts Fatty casts. This patient is most likely at risk for developing which of the following?
. Rupture of brain aneurysm
. Abdominal aortic aneurysm
. Hypercoagulability
. Pulmonary hemorrhage
. Gall stone pancreatitis
94) 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?
. Abdominal CT scan
. Upright abdominal x-ray
. Barium enema
. Broad spectrum antibiotics
. Urinary catheterization
95) A 34-year-old woman comes to the physician's office because of occasional headaches and palpitations. She has no other medical problems. She takes no medications. She smokes one and a half packs of cigarettes daily. Her blood pressure is 170/100 mm Hg in both arms, and heart rate is 80/min. Physical examination shows bilateral flank masses. Laboratory studies show: Serum sodium 140 mEq/L, Serum potassium 4.4 mEq/L, BUN 26 mg/dL, Serum creatinine 1.3 mg/dL. Urinalysis shows 10-12 red blood cells/hpf, but otherwise shows no abnormalities. The most likely complication that can occur in this patient is which of the following?
. Liver necrosis
. Intracranial aneurysms
. Restrictive cardiomyopathy
. Pancreatic cancer
. Aortic dissection
96) A 47-year-old HIV-positive man is brought to the emergency room because of weakness. The patient has HIV nephropathy and adrenal insufficiency. He takes trimethoprim-sulfamethoxazole for PCP prophylaxis and is on triple-agent antiretroviral treatment. He was recently started on spironolactone for ascites due to alcoholic liver disease. Physical examination reveals normal vital signs, but his muscles are diffusely weak. Frequent extrasystoles are noted. He has mild ascites and 1+ peripheral edema. Laboratory studies show a serum creatinine of 2.5 with a potassium value of 7.3 mEq/L. An EKG shows peaking of the T waves and QRS duration of 0.14. What is the most important immediate treatment?
. Sodium polystyrene sulfonate (Kayexalate)
. Acute hemodialysis
. IV normal saline
. IV calcium gluconate
. IV furosemide 80 mg stat
97) 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?
. Hemodialysis
. Pamidronate
. Calcitonin
. Furosemide
. 0.9% saline infusion
98) A 38-year-old woman presents to the emergency department and complains of persistent vomiting that has increased in severity over the last week. Her other complaints are muscular weakness, twitching and cramps. Her urine output has decreased over the last 20 hours. Her past medical history is significant for a previously diagnosed prepyloric peptic ulcer. Her pulse is 100/min, blood pressure is 100/60 mmHg, respirations are 12/min, and temperature is 37.2°C (99°F). Physical examination reveals dry oral mucosa and decreased skin turgor. Abdominal examination reveals hypoactive bowel sounds and mild tenderness on palpation of the epigastrium. Nasogastric suction is started, and intravenous normal saline is given. Laboratory studies show: Serum sodium 135 mEq/L, Serum potassium 2.8 mEq/L, Chloride 81 mEq/L, Bicarbonate 40 mEq/L, Blood urea nitrogen (BUN) 42 mg/dl, Serum creatinine 1.3 mg/dl, Calcium 8.6 mg/dl, Ionized calcium 0.7 mmoi/L (1.1-1.3 mmoi/L), Serum pH 7.54. Which of the listed agents should be added to the patient's current therapy?
. Ammonium chloride
. Potasium chloride
. Calcium chloride
. Furosemide
. Sodium bicarbonate
99) A 22-year-old man presents to the emergency department complaining of fever, nausea, vomiting, and right lower quadrant pain. He has no significant medical history and does not take any medications. He is a senior in college and denies cigarette smoking or drug use. He drinks alcohol occasionally. Physical examination reveals a temperature of 38.6°C, with all other vital signs within normal limits. ACT scan of his abdomen confirms acute appendicitis. Laboratory analyses reveal a leukocytosis but no electrolyte abnormalities. He is taken to the operating room and undergoes a successful laparoscopic appendectomy. Following the procedure, he is given intravenous fluids containing 5% dextrose in a 0.45% (½normal) saline solution at a rate of 150 ml/hr. The next morning the patient feels well but he then becomes progressively confused throughout the afternoon. You are called to his bedside after he has two grand mal seizures lasting 30 seconds apiece. Serum chemistries drawn at that time reveal a sodium concentration of 115mEq/L. What is the most appropriate therapy for this patient?
. Fosphenytoin
. 3% saline
. Normal saline
. Phenobarbital
. Lorazepam
100) 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?
. Oral free water
. IV 0.9% saline
. IV 5% dextrose in water
. IV 5% dextrose in 04 5% saline
. IV free water
101) A 55-year-old male is brought to the emergency department with a gunshot wound to his abdomen. He went to the operating room for repair of his injuries. On postoperative day 4, he develops a waxing and waning fever, tachypnea and shortness of breath. His temperature is 40°C (104°F), blood pressure is 90/60 mm Hg, pulse is 110/min and respirations are 22/min. Physical examination reveals an altered sensorium, crackles at the right lung base and a well healing abdominal wound. His urine output over the last 12 hours is 100ml. His laboratory profile shows: Blood pH 7.23, PaO2 60 mm Hg, PaCO2 32 mmHg, HCO3- 16 mEq/L. Broad-spectrum antibiotics are started. Which of the following additional treatments is most appropriate in this patient?
. Intravenous sodium bicarbonate
. Intravenous Dextrose in water (D5W)
. Intravenous 3% saline
. Intravenous 0.9% saline
. Intravenous dopamine
102) A 34-year-old Mexican male comes to the emergency department and complains of severe episodic headache, especially at night, for the past month. He also complains of unilateral, sharp, stabbing pain in the eye, which wakes him from sleep. The pain often starts suddenly just behind the right eye, and spreads to his face and temple region. It is not associated with nausea or visual disturbances, but is associated with watering of the eyes and nose, and with red eye. He had a similar episode one year ago, and it lasted for 2 months. Which of the following is the best treatment regimen for aborting the patient's pain during an acute attack?
. Oral NSAIDs
. Verapamil
. Nasal sumatriptan
. 100 % oxygen
. Ergotamine
103) 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?
. Large artery atherosclerosis
. Cardiac embolus
. Berry aneurysm
. Hypertension
. Arterial dissection
104) A 37-year-old white female with myasthenia gravis presents to the office with a fever and cough productive of yellow-green sputum. She has been on pyridostigmine for the past few months. She refuses to have a thymectomy. Her pulse is 90/min, blood pressure is 120/76 mm Hg, respirations are 18/min, and temperature is 38.9°C (102°F). Her respiratory effort is weak. Pulse oximetry reveals 86% oxygen saturation on room air. There is a consistent decline on serial measurement of vital capacity. Which of the following is the most appropriate next step in management?
. Increase the dose of pyridostigmine
. Treatment with edrophonium
. Treatment with atropine
. Treatment with prednisolone
. Endotracheal intubation
105) A 36-year-old white female is brought to the emergency department due to paraplegia and bladder incontinence. She immediately tells you that she has, "multiple sclerosis in remission." She has a history of optic neuritis and internuclear ophthalmoplegia, and both resolved with treatment. At that time, MRI showed plaques in the periventricular region. She is currently not taking any medications. Which of the following is the most appropriate next step in the management of this patient?
. Corticosteroids
. Plasmapheresis
. Interferon
. Cyclophosphamide
. Intravenous Immunoglobulins
106) A 64-year-old Caucasian female is rushed to the emergency department (ED) due to a sudden onset of severe headache and altered mental status. By the time she arrived at the ED, she had deteriorated to a stuporous state. She developed a fever and severe dry cough yesterday, but did not take any medicine nor consult her physician. Her medical problems include hypertension, coronary artery disease, atrial fibrillation, mitral valve regurgitation, and psoriasis. Her medications include aspirin, metoprolol, warfarin, amiodarone, and multivitamin tablets. Her blood pressure is 162/80 mm Hg, pulse is 80/min, respirations are 16/min and temperature is 37°C (98°F). Her lab results are: Hb 13 g/dl, WBC 11,000/cmm, Platelets 180,000/cmm, Blood Glucose 118 mg/dl, Serum Na 138 mEq/L, Serum K 4.5 mEq/L, BUN 16 mg/dl, Serum Creatinine 1.0 mg/dl, PT 25.0sec, INR 4.0. Which of the following is the most appropriate next step in management?
. Give fresh frozen plasma
. IV infusion of vitamin K
. Order t-PA
. Stop warfarin and start heparin
. Obtain liver function panel
107) A 24-year-old male is brought to the emergency room after he fainted while practicing football on a bright sunny day. He complained of dizziness and headache before he collapsed. He was in his usual state of health until today and has no medical problems. He takes no medication. On arrival to the emergency room, his temperature is 41°C (105.8°F), blood pressure is 90/60 mm Hg, pulse is 140/min, and respirations are 22/min. He is not oriented. Skin is dry and hot. Neck is supple. Auscultation of the chest is unremarkable. Abdomen is soft and non-tender. Muscle tone and reflexes are within normal limits. Intravenous hydration is started. Which of the following is the most appropriate next step in management?
. Evaporation cooling of the patient
. Empirical antibiotic therapy
. Gastric lavage with cold water
. Immersion of the patient in cold water
. High dose acetaminophen therapy
108) A 23-year-old male with a history of drug abuse is brought to the emergency department (ED) by an ambulance while having a tonic-clonic seizure. His mother soon arrives at the ED and says that she found him on the floor, where "he must have fallen." She says his seizure has lasted for more than 30 minutes now, and that he never regained consciousness since she found him. In the ED, he is unresponsive and cyanotic. He is biting his tongue and is incontinent. Despite resuscitation and administration of intravenous lorazepam, phenytoin, and glucose, the seizures continue. What is the best next step in the management of this patient?
. Obtain CBC and electrolytes as soon as possible
. Stat electroencephalogram (EEG)
. Anesthesia with midazolam and intubation
. Obtain CT scan of the head
. Do a drug screen and attempt detoxification
109) A 27 -year-old white female comes to the office and complains of a headache for the last two weeks. She characterizes the headache as intermittent, "feels like a dull ache", 5/10 in severity, and associated with nausea and vomiting. She is afebrile and never had such a headache before. She has no visual complaints. She is a non-smoker and drinks alcohol only on weekends. Her only drugs are oral contraceptive pills (OCPs). Her menses are regular, and she has never conceived. She has no family history of similar problem. Her pulse is 80/min, temperature is 37.1°C, blood pressure is 120/75mmHg and respirations are 15/min. She is 5 feet 10 inches tall, and her weight is 210 lbs. The neurological examination is non-focal, and there are no signs of meningeal irritation. Funduscopy reveals papilledema. MRI of the brain is normal. Which of the following complications is likely to develop if this patient is left untreated?
. Seizures
. Blindness
. Intracranial bleed
. Paralysis
. Urinary incontinence
110) 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?
. CT head without contrast
. Complete bed rest for 24 hours
. Physiotherapy and NSAIDs
. Emergency surgery
. Nerve conduction studies
111) 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?
. Heparin
. Aspirin
. Haloperidol
. Lorazepam
. Amitriptyline
112) 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?
. CT scan of the brain without contrast
. MRI scan of the brain with diffusion images
. Doppler of the carotid arteries
. Schedule for EMG, and nerve conduction studies
. Immediate vascular surgery consultation for intervention
 
113) A 34-year-old male presents to the emergency department with a red eye. He says, "I just woke up this morning and saw that my right eye was red." He denies any itching, pain or discharge. He has no known drug or environmental allergies. He takes no medication. His vital signs are stable. The photo of his eye is shown below. What is the best next step in his management?
. Check intraocular pressure
. Refer to ophthalmologist
. Check coagulation parameters
. Observation
. Antibiotics
114) A 24-year-old woman presents to the emergency department (ED) complaining of right eye pain and blurry vision since waking up this morning. She states that the pain began after taking out contact lenses that were in her eyes for over 1 week. Her blood pressure (BP) is 120/75 mm Hg, heart rate (HR) is 75 beats per minute, temperature is 99.1°F, and respiratory rate (RR) is 16 breaths per minute. Her right and left eye visual acuity is 20/60 and 20/20, respectively. Her conjunctivae are injected. The slitlamp examination reveals a large area of fluorescein uptake over the visual axis. Which of the following is the most appropriate therapy?
. Call the ophthalmology consult for an emergent corneal transplant
. Prescribe a systemic analgesic for pain control and advise the patient to not wear her contact lenses for the next week
. Prescribe ciprofloxacin eye drops, oral analgesia, update tetanus prophylaxis, and arrange for ophthalmology follow-up
. Prescribe oral amoxicillin, a topical anesthetic, such as tetracaine, and have patient follow-up with an ophthalmologist
. Prescribe ciprofloxacin eye drops and have patient strictly wear an eye patch until her pain resolves
115) A 60-year-old woman presents to the ED complaining of pain in her right eye and burning sensation over half of her forehead and scalp. On physical examination, you notice a patch of grouped vesicles on an erythematous base located in a dermatomal distribution on her scalp and forehead. There are also a few vesicles located at the tip of the patient’s nose. Her visual acuity is 20/20 bilaterally, heart is without murmurs, lungs are clear, abdomen is soft, and there are no gross findings on neurologic examination. Which of the following is the most concerning complication of this patient’s clinical presentation?
. Central nervous system (CNS) involvement leading to meningitis
. Ophthalmic involvement leading to anterior uveitis or corneal scarring
. Cardiac involvement leading to endocarditis
. Permanent scarring of her face
. Nasopalatine involvement leading to epistaxis
116) A 24-year-old woman presents to the ED at 4 AM with severe left eye pain that woke her up from sleep. She wears soft contact lenses and does not routinely take them out to sleep. She is in severe pain and wearing sunglasses in the examination room. You give her a drop of proparacaine to treat her pain prior to your examination. On examination, her vision is at baseline and she has no afferent pupillary defect. There is some perilimbic conjunctival erythema. On fluorescein examination, a linear area on the left side of the cornea is highlighted when cobalt blue light is applied. No underlying white infiltrate is visualized. No white cells or flare are visualized in the anterior chamber. What is the most appropriate treatment for this condition?
. Immediate ophthalmology consult
. Tobramycin ophthalmic ointment
. Erythromycin ophthalmic ointment
. Eye patch
. Proparacaine ophthalmic drops
117) A 45-year-old man lacerated his right forehead after an altercation in a local bar. Instead of seeking medical attention, the patient applied super glue to his wound. He successfully stopped the bleeding, but some of the glue got into his right eye and now he comes to the ED with difficulty opening his right eye. What is the most appropriate treatment of this patient?
. Call ophthalmology immediately
. Wash eye with acetone
. Wash eye with normal saline
. Use forceps to remove all the glue from the eye
. Apply erythromycin ointment
118) A 12-year-old girl presents to the ED for left eye pain and swelling for 2 days. The patient has had cough, congestion, and rhinorrhea for the last week that is improving. On examination, her temperature is 100.8°F, HR 115 beats per minute, RR 12 breaths per minute, and BP 110/70 mm Hg. On eye examination, there is purple-red swelling of both upper and lower eyelids with injection of the conjunctiva. Pupils are equal and reactive to light. There is restricted lateral gaze. Visual acuity is 20/70 in the left eye and 20/25 in the right eye. The rest of the physical examination is normal. What is the most appropriate next step in management?
. Administer diphenhydramine
. Administer amoxicillin/clavulanate
. Administer vancomycin IV
. Perform computed tomographic (CT) scan of orbits and sinuses
. Administer artificial tears
119) A 48-year-old male presents to the doctor with a history of persistent cough, tenacious mucopurulent sputum, and intermittent chills. He has been treated with several courses of antibiotics without resolution of his symptoms. On examination, he has an emaciated appearance and there is decreased air entry in the right lung base. His sputum has a foul smell. High resolution CT scan of the chest is shown below. Which of the following is the most feared complication of this patient's condition?
. Pneumonia
. Hemoptysis
. Respiratory failure
. Pneumothorax
. Pulmonary embolism
120) A 67-year-old white male with a long history of bronchial asthma and chronic obstructive pulmonary disease (COPD) presents to the emergency room complaining of acute onset of shortness of breath for the last 30 minutes. He says that for the past 2 or 3 days he has been having some difficulty breathing and a productive cough with thick phlegm, but nothing as bad as the current episode. He also has a history of congestive heart failure after suffering a myocardial infarction for which he is taking furosemide and lisinopril. While talking to you in halting sentences, you note that he appears cyanotic, confused and are sweating profusely. He normally takes albuterol, ipratropium and budesonide inhalers for his breathing difficulties, but they have not relieved his current symptoms. On examination, he is found to be markedly dyspneic and his PaO2 is 55 mm Hg. A chest x-ray done in the ER is shown below. Which of the following is the most appropriate next step in the management of this patient?
. Start intravenous theophylline
. Urgent thoracocentesis
. Urgent bronchoscopy
. Place central venous line
. Increase furosemide and start digoxin
121) A 32-year-old man presented to the emergency department five hours ago with an acute asthma exacerbation. He has been receiving continuous albuterol nebulizer treatments since that time. He has a 20-year history of asthma but notes that recently the frequency of his attacks has increased. Presently, his blood pressure is 110/70 mmHg and heart rate is 120 and regular. On physical exam, the patient appears drowsy. Breath sounds are diminished bilaterally but there are no wheezes. The most recent ABG reveals: pH 7.32, pO2 65mmHg, pCO2 50mmHg. Which of the following is the best next step in managing this patient?
. Inhaled corticosteroids
. Ipratropium inhalation
. Intravenous theophylline
. Oral prednisone
. Endotracheal intubation
122) 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?
Aspiration of gastric contents
Drug overdose
Lung or bone marrow transplantation
Massive blood transfusion
Sepsis
123) A 25-year-old Caucasian woman presents as a new patient after having recently moved to the neighborhood. She says that she was diagnosed with anorexia nervosa two years ago, and that her disorder resolved after intensive psychotherapy. Although her eating pattern is normal now, she is still underweight. Her menstrual cycles have been regular for the past year. She recently married and is now interested in starting a family with her husband. She asks whether her history of anorexia nervosa will affect her ability to conceive or carry a healthy child to term. Given this clinical presentation, which of the following complications is most likely?
. Congenital anomalies
. Macrosomia
. Small for gestational age baby
. Infertility
. Postpartum psychosis
124) A 22-year-old woman is seen in the emergency room after a suicide attempt. She swallowed 10 aspirin in the presence of her mother, with whom she had just had an argument. The patient has a long history of cutting herself superficially with razor blades, which her psychiatrist of the last 5 years confirms by telephone. The patient currently lives in a stable environment (a halfway house) where she has been for 3 years. Which of the following option is the best course of action for the physician in the emergency room?
. Admit the patient involuntarily
. Admit the patient voluntarily
. Admit the patient to a medical floor
. Discharge the patient to outpatient therapy after meeting with the patient’s mother
. Discharge the patient back to outpatient therapy and the halfway house
125) A 62-year-old Caucasian female complains of frequent headaches, fatigue and recent weight loss. Her shoulder muscles feel stiff in the morning. Her ESR is 85 mm/hr. Which of the following will be the most likely complication of this patient's condition?
. Chronic lymphocytic leukemia
. Hypothyroidism
. Aortic aneurysm
. Ulcerative colitis
. Membranous glomerulonephritis
{"name":"Med-Emergency P2", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"1) An 81-year-old diabetic woman with a history of atrial fibrillation is transferred to your emergency department (ED) from the local nursing home. The note from the facility states that the patient is complaining of abdominal pain, having already vomited once. Her vital signs in the ED are temperature 100.1°F, blood pressure (BP) 105\/75 mmHg, heart rate (HR) 95 beats per minute, and respiratory rate (RR) 18 breaths per minute. You examine the patient and focus on her abdomen. Considering that the patient has not stopped moaning in pain since arriving to the ED, you are surprised to find that her abdomen is soft on palpation. You decide to order an abdominal radiographic series. Which of the findings on plain abdominal film is strongly suggestive of mesenteric infarction?, 2) A husband and wife present to the ED with 1 day of subjective fever, vomiting, watery diarrhea, and abdominal cramps. They were at a restaurant a day before for dinner and both ate the seafood special, which consisted of raw shellfish. In the ED, they are both tachycardic with temperatures of 99.8°F and 99.6°F for him and her, respectively. Which of the following is responsible for the majority of acute episodes of diarrhea?, 3) A 49-year-old man presents to the ED with nausea, vomiting, and abdominal pain that began approximately 2 days ago. The patient states that he usually drinks a six pack of beer daily, but increased his drinking to 2 six packs daily over the last week because of pressures at work. He notes decreased appetite over the last 3 days and states he has not had anything to eat in 2 days. His BP is 125\/75 mmHg, HR is 105 beats per minute, and RR is 20 breaths per minute. You note generalized abdominal tenderness on examination. Laboratory results reveal the following: White blood cells (WBC) 9000\/μL, Hematocrit 48%, Platelets 210\/μL, Aspartate transaminase (AST) 85 U\/L, Alanine transaminase (ALT) 60 U\/L, Alkaline phosphatase 75 U\/L, Total bilirubin 0.5 mg\/dL, Lipase 40 IU, Sodium 131 mEq\/L, Potassium 3.5 mEq\/L, Chloride 101 mEq\/L, Bicarbonate 10 mEq\/L, Blood urea nitrogen (BUN) 9 mg\/dL, Creatinine 0.5 mg\/dL, Glucose 190 mg\/dL, Nitroprusside test weakly positive for ketones. Which of the following is the mainstay of therapy for patients with this condition?","img":"https://cdn.poll-maker.com/23-884738/b.bmp?sz=1200"}
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