THE LAST 1

A 19-year-old woman presents with 4 days of bilateral lower abdominal pain right greater than left. She also complains of a fever, nausea, vomiting, and general malaise. Her last menstrual period was 5 days ago. Vitals are HR 98 beats per minute, BP 110/65 mmHg, RR 18 breaths per minute, and temperature of 102.7°F. Pelvic examination demonstrates exquisite cervical motion tenderness and right adnexal tenderness. Laboratory reports are notable for a WBC 15,000/μL, an ESR of 95 mm/h, and a negative urine β-human chorionic gonadotropin (β-hCG). Transvaginal ultrasound demonstrates a right complex mass with cystic and solid components. Which of the following is the most appropriate next step in management?

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

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

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?

A 51-year-old man with a long history of hypertension presents to the ED complaining of intermittent chest palpitations lasting for a week. He denies chest pain, shortness of breath, nausea, and vomiting. He recalls feeling similar episodes of palpitations a few months ago but they resolved. His blood pressure (BP) is 130/75 mmHg, heart rate (HR) is 130 beats per minute, respiratory rate (RR) is 16 breaths per minute, and oxygen saturation is 99% on room air. An ECG is seen below. Which of the following is the most appropriate next step in management? 

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

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

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

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

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

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