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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?