USMLE, Emergency_exam_DES

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

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

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

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

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

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

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

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

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

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

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

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

13. A 42-year-old male is admitted to the hospital with fever and shortness of breath. He has HIV infection, hepatitis C infection, and alcohol induced cardiomyopathy. His temperature is 38.6 C (101.5 F). Thrush is noted in the oropharynx. Chest x-ray reveals right lower lobe consolidation. He is started on fluconazole and moxifloxacin. His pneumonia and thrush improve over the next 2 days. However, on the third day, he develops palpitations. His EKG strip is shown below: Which of the following is the most appropriate next step in management?