Part 38

91) A 40-year-old man with a known history of ethanol abuse states that 2 hours ago he ingested two bottles of extra strength Tylenol. The patient has no medical complaints except for some nausea. At 4 hours post ingestion, you send blood to the laboratory to measure the serum acetaminophen concentration. The level returns and falls above the treatment line when you plot it on the APAP nomogram. You administer activated charcoal and decide to start IV NAC. Which of the following is a known adverse effect of IV NAC administration?

92) A 19-year-old woman presents to the ED with abdominal pain, nausea, vomiting, diarrhea, and hematemesis after ingesting an unknown substance in a suicide attempt. Which of the following antidotes are correctly paired?

93) A 34-year-old woman presents to the ED after ingesting an unknown quantity of her antidepressant pills. EMS workers found an empty bottle of amitriptyline on her apartment floor. She is awake but appears delirious. Her BP is 130/65 mmHg, HR is 101 beats per minute, temperature is 99.1°F, RR is 16 breaths per minute, and oxygen saturation is 100% on room air. On examination, her pupils are 7 mm and reactive. Her face is flushed and mucous membranes are dry. Her lungs are clear and heart is without murmurs. The abdomen is soft, nontender, and with decreased bowel sounds. She is moving all four extremities. ECG reveals sinus rhythm at a rate of 99 and QRS just under 100 milliseconds. In a TCA overdose, which of the following is responsible for her mydriasis, dry mucous membranes, and delirium?

94) An asymptomatic young adult was brought to the ED by a police officer after his home was raided. The patient swallowed five small packets of an unknown substance before being arrested. His BP is 125/75 mmHg, HR is 85 beats per minute, temperature is 98.7°F, and RR is 16 breaths per minute. Physical examination is unremarkable. An abdominal radiograph confirms intraluminal small bowel densities. Which of the following is the most appropriate treatment?

95) A 33-year-old woman presents to the ED with a painful sprained ankle. She has a past medical history of depression for which she is taking phenelzine, a monoamine oxidase inhibitor. After you place an elastic wrap on her ankle, she asks you to prescribe her some pain medication. Which of the following medications is contraindicated in patients taking a monoamine oxidase inhibitor?

96) A 27-year-old woman presents to the ED 6 hours after the onset of body aches, abdominal cramping, and diarrhea. She is currently visiting relatives and normally lives in another state. She regularly takes six to eight tablets daily of hydrocodone for chronic low-back pain, sumatriptan for migraines, and amitriptyline and paroxetine for bulimia nervosa. Her BP is 130/80 mmHg, HR is 100 beats per minute, temperature is 98.6°F, RR is 16 breaths per minute, and oxygen saturation is 99% on room air. Examination shows diaphoresis, dilated pupils, and piloerection. Neurologically she is moving all four extremities and you do not note tremors. She is alert and cooperative but seems restless. She denies hallucinations or suicidal ideations. She becomes very angry when you ask her for the phone numbers of her regular physicians. Which of the following is the most likely explanation of her symptoms?

97) A 58-year-old woman is brought to the emergency department (ED) by emergency medical service (EMS) after slipping on a patch of ice while walking to work and hitting her head on the cement pavement. Bystanders acknowledged that the patient was unconscious for approximately 1 minute. On arrival, her vital signs are blood pressure (BP) 155/75 mmHg, heart rate (HR) 89 beats per minute, respiratory rate (RR) 18 breaths per minute, and pulse oxygenation 98% on room air. She has a 5-cm laceration to the back of her head that is actively bleeding. You ask the patient what happened but she cannot remember. You inform her that she is in the hospital as a result of a fall. Over the next 10 minutes she asks you repeatedly what happened and where she is. You do not find any focal neurologic deficits. As you bring the patient to the CT scanner, she vomits once. CT results show a normal brain scan. Which of the following is the most likely diagnosis?

98) A 41-year-old man, the restrained driver in a high-speed motor vehicle collision, is brought to the ED by EMS. The patient is breathing without difficulty with bilateral and equal breaths sounds. He has strong pulses peripherally indicating a BP of at least 90 mmHg. The HR is 121 beats per minute. His Glasgow coma scale (GCS) is 14. A secondary survey reveals chest wall bruising. You suspect a cardiac injury. Which of the following locations most commonly involve cardiac contusions?

99) A 25-year-old man is brought into the trauma resuscitation room after his motorcycle is struck by another vehicle. EMS reports that the patient was found 20 ft away from his motorcycle, which was badly damaged. His vital signs include a BP of 90/60 mmHg, HR 115 beats per minute, RR 22 breaths per minute, and pulse oxygenation of 100% on facemask. Which of the following is the smallest amount of blood loss that produces a decrease in the systolic BP in adults?

100) You are notified by the EMS dispatcher that there is a multiple-car collision on the local highway with many injuries. He states that there are two people dead at the scene, one person is critically injured and hypotensive, and three people have significant injuries but with stable vital signs. Which of the following is the leading cause of death and disability in trauma victims?

101) Paramedics bring a 17-year-old high school football player to the ED on a backboard and with a cervical collar. During a football game, the patient “speared” another player with his helmet and subsequently experienced severe neck pain. He denies paresthesias and is able to move all of his extremities. A cervical spine CT scan reveals multiple fractures of the first cervical vertebra. Which of the following best describes this fracture?

102) A 20-year-old man presents to the ED with multiple stab wounds to his chest. His BP is 85/50 mmHg and HR is 123 beats per minute. Two large-bore IVs (intravenous) are established and running wide open. On examination, the patient is mumbling incomprehensibly, has good air entry on lung examination, and you notice jugular venous distension (JVD). As you are listening to his heart, the nurse calls out that the patient has lost his pulse and that she cannot get a BP reading. Which of the following is the most appropriate next step in management?

103) A 22-year-old man calls the ED from a local bar stating that he was punched in the face 10 minutes ago and is holding his front incisor tooth in his hand. He wants to know what the best way is to preserve the tooth. Which of the following is the most appropriate advice to give the caller?

104) A 19-year-old man is brought into the trauma room by EMS after a head-on cycling accident. The patient was not wearing a helmet. Upon presentation his BP is 125/75 mmHg, HR is 105 beats per minute, RR is 19 breaths per minute, and oxygen saturation is 100% on mask. His eyes are closed but open to command. He can move his arms and legs on command. When you ask him questions, he is disoriented but able to converse. What is this patient’s GCS score?

105) An 18-year-old man presents to the ED after getting stabbed in his abdomen. His HR is 140 beats per minute and BP is 90/40 mmHg. He is yelling that he is in pain. Two large-bore IVs are inserted into his antecubital fossa and fluids are running wide open. After 2 L of fluids, his BP does not improve. Which of the following is the most common organ injured in stab wounds?

106) A 61-year-old man presents to the ED with chest wall pain after a motor vehicle collision. He is speaking full sentences, breath sounds are equal bilaterally, and his extremities are well-perfused. His BP is 150/75 mmHg, HR is 92 beats per minute, and oxygen saturation is 97% on room air. Chest radiography reveals fractures of the seventh and eighth ribs of the right anterolateral chest. He has no other identifiable injuries. Which of the following is the most appropriate treatment for this patient’s rib fractures?

107) A 27-year-old man brought to the ED by paramedics after a motor vehicle collision. His RR is 45 breaths per minute, oxygen saturation is 89%, HR is 112 beats per minute, and BP is 115/75 mmHg. You auscultate his chest and hear decreased breath sounds on the left. Which of the following is the most appropriate next step in management?

108) A 29-year-old man is brought to the ED by EMS after being stabbed in the left side of his back. His BP is 120/80 mmHg, HR is 105 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. On the secondary survey, you note motor weakness of his left lower extremity and the loss of pain sensation in the right lower extremity. Which of the following is the most likely diagnosis?

109) A 33-year-old man, who was drinking heavily at a bar, presents to the ED after getting into a fight. A bystander tells paramedics that the patient was punched and kicked multiple times and sustained multiple blows to his head with a stool. In the ED, his BP is 150/75 mmHg, HR is 90 beats per minute, RR is 13 breaths per minute, and oxygen saturation is 100% on non-rebreather. On examination, he opens his eyes to pain and his pupils are equal and reactive. There is a laceration on the right side of his head. He withdraws his arm to pain but otherwise does not move. You ask him questions, but he just moans. Which of the following is the most appropriate next step in management?

110) A 74-year-old man presents to the ED after being involved in a motor vehicle collision. He states he was wearing his seat belt in the driver’s seat when a car hit him from behind. He thinks his chest hit the steering wheel and now complains of pain with breathing. His RR is 20 breaths per minute, oxygen saturation is 98% on room air, BP is 145/75 mmHg, and HR is 90 beats per minute. On examination, you notice paradoxical respirations. Which of the following best describes a flail chest?

111) A 29-year-old man presents to the ED after being stabbed in his neck. The patient is speaking in full sentences. His breath sounds are equal bilaterally. His BP is 130/75 mmHg, HR is 95 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 99% on room air. The stab wound is located between the angle of the mandible and the cricoid cartilage and violates the platysma. There is blood oozing from the site although there is no expanding hematoma. Which of the following is the most appropriate next step in management?

112) A 45-year-old man is brought to the ED after a head-on motor vehicle collision. Paramedics at the scene tell you that the front end of the car is smashed. The patient’s BP is 130/80 mmHg, HR is 100 beats per minute, RR is 15 breaths per minute, and oxygen saturation is 98% on room air. Radiographs of the cervical spine reveal bilateral fractures of the C2 vertebra. The patient’s neurologic examination is unremarkable. Which of the following best describes this fracture?

113) A 71-year-old man is found lying on the ground one story below the balcony of his apartment. Paramedics bring the patient into the ED. He is cool to touch with a core body temperature of 96°F. His HR is 119 beats per minute and BP is 90/70 mmHg. His eyes are closed, but they open when you call his name. His limbs move to stimuli, and he answers your questions but is confused. On examination, you note clear fluid dripping from his left ear canal and an area of ecchymosis around the mastoid bone. Which of the following is the most likely diagnosis?

114) A 34-year-old construction worker is brought to the ED by EMS after falling 30 ft from a scaffold. His vital signs are HR 124 beats per minute, BP 80/40 mmHg, and oxygen saturation 93% on 100% oxygen. He has obvious head trauma with a scalp laceration overlying a skull fracture on his occiput. He does not speak when asked his name, his respirations are poor, and you hear gurgling with each attempted breath. Auscultation of the chest reveals diminished breath sounds on the right. There is no JVD or anterior chest wall crepitus. His pelvis is unstable with movement laterally to medially and you note blood at the urethral meatus. His right leg is grossly deformed at the knee and there is an obvious fracture of his left arm. Which of the following is the most appropriate next step in management?

116) An 81-year-old woman presents to the ED after tripping over the sidewalk curb and landing on her chin causing a hyperextension of her neck. She was placed in a cervical collar by paramedics. On examination, she has no sensorimotor function of her upper extremities. She cannot wiggle her toes, has 1/5 motor function of her quadriceps, and only patchy lower extremity sensation. Rectal examination reveals decreased rectal tone. Which of the following is the most likely diagnosis?

117) A 22-year-old man presents to the ED after being ejected from his vehicle following a high-speed motor vehicle collision. Upon arrival, his BP is 85/55 mmHg and HR is 141 beats per minute. Two large-bore IVs are placed in the antecubital veins and lactated Ringer solution is being administered. After 3 L of crystalloid fluid, the patient’s BP is 83/57 mmHg. Which of the following statements is most appropriate regarding management of a hypotensive trauma patient who fails to respond to initial volume resuscitation?

118) A 24-year-old man is brought into the ED by paramedics after being run over by a car. His systolic BP is 90 mmHg by palpation, HR is 121 beats per minute, RR is 28 breaths per minute, and oxygen saturation is 100% on non-rebreather. The airway is patent and breath sounds are equal bilaterally. You establish large-bore access and fluids are running wide open. Secondary survey reveals an unstable pelvis upon movement with lateral to medial force. Bedside focused abdominal sonography for trauma (FAST) is negative for intraperitoneal fluid. Which of the following is the most appropriate immediate next step in management?

119) A 32-year-old man is brought to the ED by paramedics after a diving accident. The lifeguard on duty accompanies the patient and states that he dove head first into the shallow end of the pool and did not resurface. On examination, the patient is speaking but cannot move his arms or legs and cannot feel pain below his clavicle. He is able to feel light touch and position of his four extremities. A cervical spine radiograph does not reveal a fracture. Which of the following is the most likely diagnosis?

120) A 22-year-old man is brought to the ED 20 minutes after a head-on motor vehicle collision in which he was the unrestrained driver. On arrival, he is alert and coherent but appears short of breath. His HR is 117 beats per minute, BP is 80/60 mmHg, and oxygen saturation is 97% on a nonrebreather. Examination reveals bruising over the central portion of his chest. His neck veins are not distended. Breath sounds are present on the left but absent on the right. Following administration of 2 L of lactated Ringer solution, his systolic BP remains at 80 mmHg. Which of the following is the most appropriate next step in management?

121) An 87-year-old man is brought to the ED on a long board and in a cervical collar after falling down a flight of steps. He denies losing consciousness. On arrival, his vital signs include an HR of 99 beats per minute, BP of 160/90 mmHg, and RR of 16 breaths per minute. He is alert and speaking in full sentences. Breath sounds are equal bilaterally. Despite an obvious right arm fracture, his radial pulses are 2+ and symmetric. When examining his cervical spine, he denies tenderness to palpation and you do not feel any bony deformities. Which of the following is a true statement?

122) A 45-year-old man is brought into the ED after a head-on motor vehicle collision. His BP is 85/45 mmHg and HR is 130 beats per minute. He is speaking coherently. His breath sounds are equal bilaterally. After 2 L of fluid resuscitation, his BP is 80/40 mmHg. A FAST examination reveals fluid in Morison pouch. Which of the following organs is most likely to be injured in blunt abdominal trauma?

123) A 47-year-old man is brought into the ED after falling 20 ft from a ladder. His HR is 110 beats per minute, BP is 110/80 mmHg, RR is 20 breaths per minute, and oxygen saturation is 100% on face mask. He is able to answer your questions without difficulty. His chest is clear with bilateral breath sounds, abdomen is nontender, pelvis is stable, and the FAST examination is negative. You note a large scrotal hematoma and blood at the urethral meatus. Which of the following is the most appropriate next step in management?

124) A 17-year-old man presents to the ED after getting hit in the right eye with a tennis ball during a tennis match. On arrival to the ED, you note periorbital swelling and ecchymosis. The patient’s visual acuity is 20/20. When you are testing his extraocular muscles, you note that his right eye cannot look superiorly but his left eye can. He also describes pain in his right eye when attempting to look upward. Which of the following is the most likely diagnosis?

125) A 24-year-old man is brought to the ED after being shot once in the abdomen. On arrival, his BP is 100/60 mmHg, HR is 115 beats per minute, and RR is 22 breaths per minute. His airway is patent and you hear breath sounds bilaterally. On abdominal examination, you note a single bullet entry wound approximately 1 cm to the right of the umbilicus. During the log roll, you see a single bullet exit wound approximately 3 cm to the right of the lumbar spine. His GCS score is 15. The patient’s BP is now 85/65 mmHg and HR is 125 beats per minute after 2L of fluid. Which of the following is the most appropriate next step in management?

126) A 43-year-old man, who currently uses drugs intravenously (IV), presents to the emergency department (ED) with 2 weeks of fever, back pain, and progressive weakness in his legs bilaterally. He denies any history of trauma or prior surgery. His blood pressure (BP) is 130/75 mmHg, heart rate (HR) is 106 beats per minute, temperature is 103°F, and respiratory rate (RR) is 16 breaths per minute. On physical examination, he has tenderness to palpation in the mid-lumbar spine, increased patellar reflexes, and decreased strength in the lower extremities bilaterally, with normal range of motion. Laboratory results reveal a white blood cell (WBC) count of 15,500/μL, hematocrit 40%, and platelets 225/μL. Urinalysis and spinal x-rays are unremarkable. Which of the following is the most likely diagnosis?

127) An 81-year-old woman is brought to the ED by her children who state that the patient is acting more tired than usual, has had fever for the last 2 days, and is more confused. Ordinarily, the patient is high functioning: she is ambulatory, cooks for herself, and walks on a treadmill 30 minutes a day. Her vital signs are BP 85/60 mmHg, HR 125, RR 20, temperature 101.3°F, and pulse oxygenation 97% on room air. On examination, the patient has dry mucous membranes but is otherwise unremarkable. She is oriented to person and place but states that the year is 1925. Her laboratory results show a WBC 14,300/μL, hematocrit 31%, and platelets 350/μL. Her electrolytes are within normal limits. Blood glucose is 92 mg/dL. A chest radiograph does not show any infiltrates. Urinalysis reveals 2+ protein, trace ketones, WBC > 100/hpf, red blood cell (RBC) 5 to 10/hpf, nitrite positive, and leukocyte esterase positive. After administering a 500-cc normal saline fluid bolus and broad-spectrum antibiotics through her peripheral IV line, the patient’s BP is 82/60 mmHg. You suspect that the patient is in septic shock due to an acute urinary tract infection. Which of the following is the next most appropriate course of action to manage this patient with earlygoal-directed therapy (EGDT)?

128) A 23-year-old man presents to the ED with left lower abdominal pain and left testicular pain that started 1 to 2 weeks ago and has gradually worsened. He has some nausea and vomiting. His HR is 98 beats per minute, BP is 125/65 mmHg, temperature is 100.9°F, and RR is 18 breaths per minute. Physical examination reveals a tender left testicle with a firm nodularity on the posterolateral aspect of the testicle. Pain is relieved slightly with elevation of the testicle and the cremasteric reflex in normal. You make the presumptive diagnosis of epididymitis. Which of the following is the next best step?

129) A 40-year-old man with insulin-dependent diabetes presents to the ED with complaints of 2 days of increasingly severe perineal pain and subjective fevers. His HR is 118 beats per minute, BP is 95/55 mmHg, temperature is 103.4°F, and RR is 22 breaths per minute. The bedside sugar reading is “high.” Physical examination demonstrates crepitus over the medial thigh and widespread erythema and purple discoloration with sharp demarcation over the scrotum. The scrotum is markedly tender, warm, and edematous. Which of the following is the most likely diagnosis?

130) A 55-year-old man with a history of diabetes presents with complaints of developed left knee pain several days following a fall from standing height. The patient was brought to the ED by ambulance after being found on a park bench stating he was unable to walk because of the pain. On physical examination, there are no rashes or external signs of trauma. His left knee is warm, diffusely tender, and swollen with a large effusion. He has pain on passive range of motion and is refusing to walk. His BP is 150/85 mmHg, HR is 105 beats per minute, temperature is 102.7°F, RR is 16 breaths per minute, and fingerstick glucose is 89 mg/dL. Which of the following is the most appropriate diagnostic test?

131) A 35-year-old woman with systemic lupus erythematosus (SLE) is brought to the ED by her brother after he found her febrile and confused. Physical examination reveals fever, tachycardia, a waxing and waning mental status, petechiae over her oral mucosa, pallor, and mildly heme-positive stool. Her urinalysis is positive for blood, red cell casts, and proteinuria. Laboratory results reveal blood urea nitrogen (BUN) of 40 mg/dL and creatinine of 2 mg/dL. Her bilirubin is elevated (unconjugated > conjugated) and her international normalized ratio (INR) is 0.98. Her complete blood count reveals WBC 12,000/μL, hematocrit 29%, and platelet count 17,000/μL with schistocytes on the peripheral smear. Which of the following is the most appropriate next step in management?

132) A 30-year-old woman presents to the ED with fever, headache, a “sunburn-like” rash, and confusion. A friend states that the patient has complained of nausea, vomiting, diarrhea, and a sore throat over the past few days. Her last menstrual period began 4 days ago. Vital signs are HR 110 beats per minute, BP 80/45 mmHg, RR of 18 breaths per minute, and temperature of 103°F. On physical examination, you note an ill-appearing woman with a diffuse blanching erythroderma. Her neck is supple without signs of meningeal irritation. On pelvic examination, you remove a tampon. You note a fine desquamation of her skin, especially over the hands and feet, and hyperemia of her oropharyngeal, conjunctival, and vaginal mucous membranes. Laboratory results reveal a creatine phosphokinase (CPK) of 5000, WBC 15,000/μL, platelets of 90,000/μL, BUN 40 mg/dL, creatinine 2 mg/dL, and elevated liver enzymes. You suspect thediagnosis of toxic shock syndrome and initiate IV fluids. You target antibiotics at which of the following causative organism?

133) A 32-year-old diabetic man presents to the ED with a fever and 1 week of increasing right foot pain. He states he stepped on a nail while running barefoot 2 weeks ago but didn’t think much of it at that time. On physical examination, his heel is mildly erythematous and diffusely tender to palpation, with overlying warmth and edema. There is a small amount of purulent drainage through the puncture hole in his heel. A plain radiograph of his foot demonstrates a slight lucency of the calcaneus. He has decreased range of motion, but you are able to passively dorsiflex and plantarflex his ankle without difficulty. His vital signs include a temperature of 101.4°F, HR of 98 beats per minute, BP of 130/75 mmHg, and RR of 16 breaths per minute. Which of the following is the most common causative organism of this condition?

134) A 75-year-old woman is transferred to your ED from the local nursing home for fever, cough, and increasing lethargy. Over the past 3 days, the nursing home staff noticed increasing yellow sputum and decreasing urine output from the patient. Her BP is 118/75 mmHg, RR is 20 breaths per minute, HR is 105 beats per minute, temperature is 100.9°F, and pulse oxygenation is 94% on room air. On examination, auscultation of the lungs reveals bibasilar crackles. Laboratory results reveal WBC 14,500/μL, hematocrit 39%, platelets 250/μL, sodium 132 mEq/L, potassium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 18 mEq/L, BUN 27 mg/dL, creatinine 1.5 mg/dL, and glucose 85 mg/dL. Serum lactate is 4.7 mmol/dL. Chest radiography reveals bilateral lower lobe infiltrates. Based on this patient’s presentation, which of the following is the most likely diagnosis?

135) A 55-year-old man presents to the ED with fever, drooling, trismus, and a swollen neck. He reports a foul taste in his mouth caused by a tooth extraction 2 days ago. On physical examination, the patient appears anxious. He has bilateral submandibular swelling and elevation and protrusion of the tongue. He appears “bull-necked” with tense and markedly tender edema and brawny induration of the upper neck, and he is tender over the lower second and third molars. There is no cervical lymphadenopathy. These lungs are clear to auscultation with good air movement. His vital signs are HR 105 beats per minute, BP 140/85 mmHg, RR 26 breaths per minute, and temperature 102°F. Which of the following is the most appropriate next step in management?

136) A 67-year-old woman with a history of steroid-dependent COPD, non–insulin-dependent diabetes, and hypertension presents to the ED with complaints of a painful, red, swollen left lower leg. She states she noted a “bug bite” in that area 1 week ago and since then has had gradually increasing symptoms. On examination, you note a 12 cm × 10 cm sharply demarcated area of blanching erythema, warmth, and tenderness on the medial thigh with ascending erythema to the groin. You also note tender adenopathy in the left inguinal region. Her BP is 90/55 mmHg, RR is 24 breaths per minute, HR is 105 beats per minute, temperature is 102.4°F, and pulse oxygenation is 98% on room air. Laboratory results reveal WBC 19,500/μL, hematocrit 39%, platelets 175/μL, sodium 132 mEq/L, potassium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 14 mEq/L, BUN 32 mg/dL, creatinine 1.7 mg/dL, and glucose 455 mg/dL. Serum lactate is 4.7 mmol/dL. Which of the following best describes her clinical state?

137) An 84-year-old man presents to the ED with his family due to concerns that his condition is worsening despite being placed on levofloxacin for a urinary tract infection 5 days ago by his primary care physician. His is obtunded and unable to give any additional history. Physical examination does not reveal the source of infection. His BP is 84/45 mmHg, HR is 135 beats per minute, temperature is 102.8°F, and his RR is 28 breaths per minute. Laboratory results reveal WBC 24,500/μL, hematocrit 19%, platelets 90/μL, sodium 132 mEq/L, potassium 7.5 mEq/L, chloride 100 mEq/L, bicarbonate 12 mEq/L, BUN 37 mg/dL, creatinine 6.5 mg/dL, and glucose 255 mg/dL. Serum lactate is 11.3 mmol/dL. Cardiac enzymes and troponin are mildly elevated, and he has hyperacute T-waves on electrocardiogram (ECG). His chest radiograph shows cardiomegaly with bilateral patchy opacities and pulmonary vascular congestion. Rapid urinalysis reveals 3+ WBCs and blood and nitrates. You secure his airway with intubation, initiate broad-spectrum antibiotics, IV fluids, and other supportive therapies, and emergently consult nephrology, cardiology, and pulmonology. Which of the following best describes his clinical state?

138) A 37-year-old man presents to the ED with complaints of 2 days of a sore throat and subjective fever at home. He denies cough or vomiting. His BP is 130/75 mmHg, HR is 85 beats per minute, temperature is 101°F, and his RR is 14 breaths per minute. He has diffuse tonsillar swelling and bilateral exudates with bilaterally enlarged and tender lymph nodes of the neck. Which of the following is the next best step in management?

139) A 37-year-old man who just finished a full course of penicillin for pharyngitis presents to the ED requesting to be checked out again. He states he took the antibiotics exactly as prescribed and initially felt somewhat improved, but over the last 2 to 3 days has had increased pain and progressive difficulty swallowing. His BP is 130/65 mmHg, HR is 95 beats per minute, temperature is 100.1°F, RR is 16 breaths per minute, and oxygen saturation is 99%. On examination, the patient is in no acute distress but has a fluctuant mass on the right side of his neck. You visualize a normal soft palate with swelling of the right tonsillar arch and deviation of the uvula to the left, but additional examination is limited because he is unable to open his mouth fully. Review of his records reveals a throat culture that was positive for Streptococcus. Which of the following is the most appropriate next step in management?

140) A 50-year-old man presents to the ED complaining of fever, headache, and neck pain for 24 hours. He states that 1 week ago he had rhinorrhea, nasal congestion, a sore throat, and occasional dry cough. He noted generalized weakness, myalgias, and malaise yesterday afternoon, and woke up today “feeling terrible.” His BP is 145/75 mmHg, HR is 102 beats per minute, temperature is 101.2°F, and his RR is 16 breaths per minute. On examination, he is awake, alert, and nontoxic appearing although he has discomfort in his neck with flexion. He has a nonfocal neurologic examination without increased deep tendon reflexes or opthalmoplegia. There are no rashes. Which of the following CSF results is most consistent with your clinical diagnosis of viral meningitis?

141) A 32-year-old woman presents to the ED with 7 days of vaginal discharge and pelvic pain. She is sexually active and admits to several recent “one night stands.” She denies trauma/injury and does not have any urinary or other abdominal complaints. Her HR is 85 beats per minute, BP is 135/90 mmHg, RR is 18 breaths per minute, and temperature is 101.4°F. On bimanual examination, you note a copious, thin, white discharge with mild diffuse adnexal tenderness with significant cervical motion tenderness. There are no rashes, skin lesions, or adenopathy. Laboratory results are notable for a WBC of 18,000/μL. A urinalysis shows WBCs but is otherwise within normal limits. Which of the following is the most appropriate next step in management?

142) A 45-year-old woman presents to the ED complaining of 3 days of fever and worsening throat pain and painful odynophagia without cough or coryza. She sits on a chair, leaning forward with her mouth slightly open. She is refusing to swallow and has a cup of saliva and a box of facial tissues at her side. Vitals are HR of 120 beats per minute, BP of 110/70 mmHg, RR of 22 breaths per minute, oxygen saturation of 99% on room air, and temperature of 102.8°F. You note a slight wheezing noise coming from her anterior neck. Her voice is hoarse and she is able to open her mouth fully, making her examination quite difficult. From what you can visualize, her posterior oropharynx is moderately hyperemic, without exudates or tonsillar enlargement. A soft tissue lateral cervical radiograph shows marked edema of the prevertebral soft tissues and absence of the vallecular space. Which of the following is the most likely diagnosis?

143) 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?

144) A 42-year-old IV drug user presents to the ED with fever, chills, pleuritic chest pain, myalgias, and general malaise. The patient’s vitals include an HR of 110 beats per minute, BP of 110/65 mmHg, RR of 18 breaths per minute, and temperature of 103.4°F. Physical examination is notable for retinal hemorrhages, petechiae on the conjunctivae and mucous membranes, a faint systolic ejection murmur, and splenomegaly. Which of the following is the most likely diagnosis?

145) A 51-year-old diabetic man complains of intense right-ear pain and discharge. On physical examination, his BP is 145/65 mmHg, HR 91 beats per minute, and temperature 101°F. He withdraws when you retract the pinna of his ear. The external auditory canal is erythematous, edematous, and contains what looks like friable granulation tissue in the external auditory canal. The tympanic membrane is partially obstructed but appears to be erythematous, as well. You make the presumptive diagnosis of necrotizing (malignant) otitis externa. Which of the following statements regarding this condition is true?

146) A 26-year-old woman presents to the ED with fever, malaise, and an evolving rash in the right axilla that she initially thought was from an insect bite that she received while hiking 1 week earlier. She complains of generalized fatigue, nausea, headache, and joint pain over the past several days. Her vitals are BP of 120/75 mmHg, HR of 75 beats per minute, RR of 16 breaths per minute, and temperature of 101°F. On physical examination, she is awake and alert, with a nonfocal neurologic examination. Her neck is supple, but she is diffusely tender over the shoulder, knee, and hip joints bilaterally without any distinct effusions. Her abdomen is soft and nontender. She has a 9-cm erythematous annular plaque with partial central clearing and a bright red outer border and a target center under her right axilla. Which of the following is the next best step?

147) A 22-year-old man without medical complaints presents to the ED with a 3-day history of fever, malaise, and myalgias. He denies chest pain, shortness of breath, nausea or vomiting, abdominal pain, cough, sore throat, genitourinary symptoms, or respiratory tract complaints. On examination, the patient’s BP is 100/60 mmHg, HR is 110 beats per minute, RR is 20 breaths per minute, and temperature is 102°F. He appears awake, alert, and comfortable. His physical examination is normal. Which of the following is the most appropriate next step in management?

148) A 54-year-old man with a history of hepatitis C, alcohol abuse, and cirrhotic ascites presents with increasing abdominal girth and abdominal pain. He complains of increasing difficulty breathing, especially when lying down, caused by worsening ascites. On physical examination, the patient is cachectic and appears older than his stated age. He has a diffusely tender abdomen and tense ascites. The liver is palpable 4 cm below the costal margin. Vitals include a BP of 110/65 mmHg, HR of 110 beats per minute, RR of 22 breaths per minute, and temperature of 102°F. Which of the following is the most common organism seen in spontaneous bacterial peritonitis?

149) A 30-year-old man with type 1 diabetes presents to the emergency department (ED). His blood pressure (BP) is 100/70 mmHg and heart rate (HR) is 140 beats per minute. His blood glucose is 750 mg/dL, potassium level is 5.9 mEq/L, bicarbonate is 5 mEq/L, and arterial pH 7.1. His urine is positive for ketones. Which of the following is the best initial therapy for this patient?

150) A 39-year-old woman, brought into the ED by her family, states that she has had 4 days of diarrhea and has now started acting “crazy” with mood swings and confusion. The family states that she usually takes a medication for a problem with her neck. Her BP is 130/45 mmHg, HR is 140 beats per minute, temperature is 101.5°F, and her respiratory rate (RR) is 22 breaths per minute. An electrocardiogram (ECG) reveals atrial fibrillation with a normal QRS complex. After you address the airway, breathing, and circulation (ABCs), which of the following is the most appropriate next step in management?

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

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

153) A 21-year-old man presents to the ED. He has a known history of type 1 diabetes. He is hypotensive with BP of 95/65 mmHg, tachycardic at 120 beats per minute, and tachypneic at 30 breaths per minute. Laboratory results reveal a WBC 20,000/μL, hematocrit 45%, platelets 225/μL, sodium 131 mEq/L, potassium 5.3 mEq/L, chloride 95 mEq/L, bicarbonate 5 mEq/L, BUN 20 mg/dL, creatinine 0.9 mg/dL, and glucose 425 mg/dL. Arterial blood gas reveals a pH of 7.2. Urinalysis reveals glucosuria and ketosis. There is a fruity odor to his breath. Which of the following provides the strongest evidence for the diagnosis?

154) A 32-year-old man is brought to the ED by EMS for confusion. EMS reports that the patient was at a local pharmacy filing his prescriptions when the pharmacist noticed the patient sweating and having difficulty answering questions. In the ED, the patient’s BP is 130/68 mmHg, HR is 120 beats per minute, temperature is 98.9°F, and RR is 12 breaths per minute. The patient is unable to explain what happened. His fingerstick glucose is 410 mg/dL and his urine is positive for ketones. An electrolyte panel reveals Na + 131 mEq/L, K + 4 mEq/L, Cl − 91 mEq/L, and Ca 2+ 11 mEq/L. Which of the following electrolytes are most important to supplement during the management of his medical condition?

155) A 36-year-old immigrant woman is brought to the ED from her workplace. She was found to be agitated and behaving bizarrely. The patient’s past medical history and medications are unknown. Her BP is 162/92 mmHg, HR is 140 beats per minute, temperature is 101.8°F, and RR is 18 breaths per minute. On examination, the patient is delirious, tremulous, and has a large goiter. Which of the following is the most appropriate management of this patient?