EM Exam 2 Cases&Qs

List the classifications of asthma

1. Intermittent 2. Mild persistent 3. Moderate persistent 4. Severe persistent

What is the acute management of massive hemoptysis?

1. Protect the nonbleeding lung by positioning the patient "bleeding side down" 2. Establish an airway with at least #8 endotracheal tube or ETT (for bronchoscopy and intervention)— either single lumen ETT into nonbleeding lung ± fiberoptic bronchoscopic guidance or double lumen ETT with bronchial cuff inflated to protect good lung from bleeding lung 3. Reverse any coagulopathies 4. Stop the bleeding

Medication timeline for asthma (typically)?

1. SABA PRN (always; keep in all "steps") 2. Add low-dose ICS 3. Increase to med-dose ICS OR add LABA 4. Add a LABA OR increase to med-dose ICS 5. Increase to high-dose ICS6. Add PO steroids

How many cm must the colon be dilated to dx toxic megacolon?

>6cm

A 59 year-old otherwise healthy female develops acute dyspnea and chest pain one week post total abdominal hysterectomy. Echocardiogram demonstrates normal heart size with normal right and left ventricular function. Lung scan demonstrates two segmental perfusion defects. Which of the following is the next step in the management of this patient? A Anticoagulation B Embolectomy C Thrombolysis

A Anticoagulation

Which of the following tests is generally the next step after clinical prediction rule results indicate that a patient has a low or moderate pretest probability of pulmonary embolism? A D-dimer measurement B Troponin level measurement C Brain natriuretic peptide (BNP) measurement D Activated partial thromboplastin time (aPTT) measurement

A When clinical prediction rule results indicate that the patient has a low or moderate pretest probability of pulmonary embolism, D-dimer testing may be the next step.

A 45 year-old male presents with sudden onset of pleuritic chest pain, productive cough and fever for 1 day. He relates having symptoms of a "cold" for the past week that suddenly became worse yesterday. Which of the following findings will most likely be seen on physical examination of this patient? A spoken "ee" heard as "ay" B hyperresonant percussion note C wheezes over the involved area D vesicular breath sounds over involved area

A This patient most likely has a bacterial pneumonia with consolidation, which would produce egophony, where a spoken "ee" is heard as "ay."

Which of the following causes of pneumonia is most likely to be complicated by diarrhea? A Legionella B Chlamydophila C Mycoplasma D Pneumococcal

A legionella

Which test will best help you identify CP of cardiac origin? A ECG B CXR C CT thorax D Barium esophagram

A. ECG is the best initial test for cardiac CP since it is easy to obtain, is not invasive, and can be specific for ischemia. A CXR, CT of the thorax, and barium esophagram all evaluate for other causes of CP.

Patients in DKA often have other illnesses or precipitating factors that initiated the ketoacidosis. Which one of the following is unlikely to precipitate DKA? A Asthmatic exacerbation B Cocaine use C Cholecystitis D Missed insulin doses E Urinary tract infection

A. Many serious illnesses can precipitate an episode of DKA in the susceptible patient, including infection, stroke, myocardial infarction, pancreatitis, trauma, and surgery. Associated or precipitating illness should always be sought diligently. In most studies, infection is the single most common underlying cause. Noncompliance with insulin therapy is also a very common cause. Asthma exacerbation is not strongly associated with DKA.

What is the usual cause of death from hemoptysis?

Asphyxia (not hemorrhagic shock)

What can we send asthmatics home with that are discharged from the ED?

Asthmatics who are discharged from the ED should receive albuterol, an MDI spacer device, and a 3- to 10-day course of oral steroids.

You are evaluating a patient whom you suspect has asthma. You perform spirometry before and after administration of an inhaled short-acting bronchodilator. After administration of the bronchodilator, which of the following spirometry results would suggest reversibility? A Decrease In FEV1 B Increase in FEV1 C Decrease in FVC D Increase in FVC

B In asthma, the airway obstruction should be at least partially relieved be a short-acting bronchodilator. This would be reflected in an increased forced expiratory volume in 1 second (FEV1).

A 33 year-old HIV-positive woman develops an 8mm area of induration following the administration of a purified protein derivative (PPD) test. Her chest radiograph shows no evidence of active tuberculosis (TB) infection. Which of the following is the most appropriate clinical intervention? A Four-drug regimen for 4 months B Isoniazid with Rifampin C Observation only D Repeat PPD and chest radiograph in 3 months

B Isoniazid with Rifampin

A 30-year old lady complains to you that she's been having diarrhea, abdominal pain and vomiting for the past 48 hours. 8 hours prior to onset of symptoms, she ingested 3 raw eggs. Which of the following is most like responsible for her diarrhea? A Salmonella B Staphylococci C C. perfringens D Giardia lamblia

B Staphylococci

A 2-year old child was brought in by her mother on account of a 2-day history of profuse watery diarrhea, vomiting, anorexia and lethargy? On examination, child appears lethargic, eyes are very sunken, dry buccal mucosa, decreased skin turgor, drinks water poorly when given, capillary refill: 3s, Pulse rate: 152/min. What is the first step you would take in the management of this patient? A Oral rehydration B Intravenous rehydration C Stool culture D Empirical antibiotics

B The first and most important step in managing a severely dehydrated patient is intravenous rehydration in order to rapidly restore circulatory volume and prevent acute kidney injury, cardiogenic shock, and even death. Be careful so as not to overhydrate the patient.

An elderly nursing home resident is admitted with methicillin-resistant Staphylococcus aureus pneumonia. Which of the following is the most appropriate treatment to initiate? A Nafcillin B Vancomycin C Clindamycin D Doxycycline

B Vancomycin

A 15 year-old male was seen last week with complaints of sore throat, headache, and mild cough. A diagnosis of URI was made and supportive treatment was initiated. He returns today with complaints of worsening cough and increasing fatigue. At this time, chest x-ray reveals bilateral hilar infiltrates. A WBC count is normal and a cold hemagglutinin titer is elevated. The most likely diagnosis is A tuberculosis. B mycoplasma pneumonia. C pneumococcal pneumonia. D staphylococcal pneumonia

B Mycoplasma The insidious onset of symptoms, the interstitial infiltrate on chest x-ray, and elevated cold hemagglutinin titer make this diagnosis the most likely.

Hamman's sign

Crunching sound on auscultation Emphysematous mediastinum Seen with Boerhaave's syndrome, pneumomediastinum, etc.

Several workers develop watery diarrhea and significant emesis within 4 hours after eating food at a potluck dinner. A E. coli B Giardia lamblia C Rotavirus D S. aureus E Vibrio species F Cryptosporidium

D.S. aureus usually causes prominent vomiting and diarrhea within a few hours of food ingestion as a consequence of the toxin produced.

The type of pneumonia organism seen in smokers:

H. flu

A 34-year-old man presents to the emergency department (ED) complaining of shortness of breath and right-sided chest pain that increases with deep breathing. He states it started suddenly when he woke up and was worse with activity. He denies fever, chills, nausea, vomiting, or cough. He has a recent history of multiple gunshot wounds, resulting in ongoing pain in his upper back and T-10 paraplegia. One week ago, he was discharged from the hospital to a rehabilitation facility. He is currently taking acetaminophen/hydrocodone and ibuprofen for his pain, which has increased with his physical therapy and occupational therapy. He is also taking hydrochlorothiazide and lisinopril for hypertension and fluoxetine for depression. He recently quit smoking tobacco since he was hospitalized and denies any alcohol or illicit drug use. On physical examination, he is an otherwise fit young man who appears slightly short of breath and uncomfortable. His heart rate is 101 beats per minute, his blood pressure is 110/78 mm Hg, and his respiratory rate is 26 breaths per minute. His pulse oximetry is 96% on 2 L of O2 by nasal canula. His lungs are clear to auscultation. There is mild swelling of his left calf. He has no sensation in his lower extremities. Laboratory studies reveal a white blood cell (WBC) count of 10,000/mm3. Hemoglobin, hematocrit, electrolytes, and renal function are all within normal limits. A 12-lead electrocardiogram (ECG) reveals a sinus rhythm at a rate of 103 beats per minute. His chest radiograph reveals minimal bibasilar atelectasis but no evidence of infiltrates or effusions. What is the most likely diagnosis? What are your next diagnostic steps?

Most likely diagnosis: Pulmonary embolism (PE) secondary to deep venous thrombosis (DVT) in the left lower extremity. Next diagnostic steps: For evaluation of PE/DVT, d-dimer level, venous duplex ultrasonography, ventilation-perfusion scan (V/Q scan), pulmonary CT angiography, and catheter pulmonary angiography are available and may be applied on a selective basis.

How may the elderly present with pneumonia?

Patients at the extremes of age may have minimal or no respiratory symptoms. The elderly may present with altered mental status or a decline in baseline function.

Best way to assess asthma exacerbation severity and patient response in ED?

Peak expiratory flow

A 45-year-old man eats raw oysters and 2 days later develops abdominal cramping, fever of 38.3°C (101°F), and watery diarrhea. A E. coli B Giardia lamblia C Rotavirus D S. aureus E Vibrio species F Cryptosporidium

Raw seafood may harbor Vibrio spp; thus, the history of eating raw oysters makes Vibrio-related infection likely.

Dilation of proximal pulmonary vessels with collapse of distal vasculature is noted seen on xray

Westermark sign, for PE

Which of the following is (are) a common cause(s) of antibiotic-associated diarrhea in infants and children? A ampicillin B clindamycin C amoxicillin D cephalosporins E all of the above

all of the above

What is the drug of choice in treating pneumonia from mycoplasma?

azithromycin

Which atb would be first line in treating chlamydia penumoniae?

doxycycline

what is the MCC of acute mesenteric ischemia?

emboli from afib

What is the study of choice in upper GI bleeds?

endoscopy

What is the first like atb for pneumonia in pts with COPD?

levaquin

What is US imaging of thrombosis most accurate for (which veins)?

most accurate for assessment of the iliac, femoral, and popliteal veins

Middle age smoker w/ h/o flu like sxs 2 wks ago, now with high fever & cough associated w diarrhea and bradycardia:

mycoplasma

FEV1/FVC <70%

obstructive lung disease

This type of pneumonia is a lobar pneumonia and the treatment is PCN G

pneumococcal

The most common type of pneumonia in a 60 year old patient is:

pneumoncoccal

Initial diagnostic test for asthma?

pulmonary function tests

What is the most common area of the colon to be affected in diverticulitis?

sigmoid

A 55 year-old female presents to the emergency department with complaints of dyspnea, chest pain and coughing with hemoptysis. Past medical history includes breast cancer 5 years ago, currently in remission. Vital signs are Temp. 98.6 degrees F, BP 150/90 mmHg, P 110 bpm, RR 20. Physical examination shows her right leg swollen with pain on palpation of deep veins. Which of the patient's history or examination findings is most suggestive of a pulmonary embolus (PE)? A Leg swelling and pain with palpation of deep veins B Heart rate > 100 C Hemoptysis D Past history of cancer

A Leg swelling and pain with palpation of deep veins

An adult patient who is HIV positive receives a PPD. He develops an area of induration that measures 8 mm after 48 hours. Which of the following is the most appropriate interpretation of this test result? A positive B negative C active infection D falsely negative

A A reaction size of greater than or equal to 5 mm in a HIV positive patient is considered a positive tuberculin skin test reaction.

A 22-year-old college student takes a trip during spring break to Cozumel and develops diarrhea. A E. coli B Giardia lamblia C Rotavirus D S. aureus E Vibrio species F Cryptosporidium

A. Enterotoxic E. coli is the most common etiology for diarrhea in travelers visiting Mexico. This is followed by Campylobacter jejuni, Shigella spp, and Salmonella spp.

A 30-year-old woman presents with epigastric pain that developed following dinner. The patient describes having similar pain prior to the current episode, but previous episodes were less severe. The patient was diagnosed as having gastroesophageal reflux disease by her primary care physician and prescribed a proton pump inhibitor, which has been ineffective in resolving her pain. The current pain episode has been severe and persistent for 3 hours. The patient has a temperature of 38°C (100.4°F), heart rate of 100 beats per minute, respiratory rate of 20 breaths per minute, and blood pressure of 130/90 mm Hg. The abdominal examination reveals no abdominal tenderness. The administration of 30 mL of antacids and 4 mg of morphine sulfate resulted in some relief of pain. Which of the following is the most appropriate next step? A Obtain CBC, amylase, liver function tests, and ultrasound of the gallbladder. Discuss with surgical consultants regarding admission to the hospital. B Follow-up with her primary care physician in 2 weeks. C Admit the patient to the hospital for upper GI endoscopy. D Prescribe antacids and discharge the patient from the ED, with follow-up by her primary care physician. E Obtain an ultrasound of the gallbladder, prescribe oral antibiotics, analgesics, and arrange for an outpatient follow-up with her primary care physician.

A. This patient has recurrent epigastric pain that was formerly attributed to gastroesophageal reflux disease. However, the fact that her symptoms have been poorly controlled with proton pump inhibitors in the past suggests that the diagnosis is probably inaccurate. Her recurrent symptoms are likely caused by biliary tract disease, and her current presentation is highly suspicious for complicated biliary tract disease, such as acute cholecystitis. Choice A represents testing for the evaluation of biliary tract disease, which is appropriate in this setting. Because of her fever, the outpatient management approach described in choice E is inappropriate.

A 36-year-old male who is hospitalized because of severe injuries from a motor vehicle accident develops rapid onset of profound dyspnea. Initial chest x-ray shows a normal heart size with diffuse bilateral infiltrates. Follow-up chest xray shows confluent bilateral infiltrates that spare the costophrenic angles. Which of the following is the best clinical intervention for this patient? A Tracheal intubation B Bilateral chest tube insertion C Type-specific packed cells D Colloid solutions E Provide supplemental oxygen

A. Tracheal intubation with lowest level of PEEP is required to maintain the PaO2 above 60 mmHg or SaO2 above 90% in a patient with ARDS.

A 60-year-old female with a 30-pack year smoking history complains of new onset shortness of breath. On physical examination, dullness is noted on percussion with diminished breath sounds over her left base. Chest x-ray shows a new left pleural effusion. Which of the following is the next step in the management of this patient? A Repeat chest x-ray in two months B Perform diagnostic thoracentesis C Order MRI of the chest D Treat with antibiotic

B Perform diagnostic thoracentesis Diagnostic thoracentesis should be performed whenever there is a new pleural effusion and no clinically apparent cause.

A 16-year old female presents to you on account of a 3-day history of passage of nonbloody watery stool up to 3 times per day with mild abdominal pain, nausea and vomiting. No history of fever. No significant findings on examination. Which of the following is most the appropriate in managing this patient? A Empirical antibiotic therapy. B Prescribe an antidiarrheal agent. C Stool culture. D Stool for ova and parasite.

B Prescribe an antidiarrheal agent.

An elderly patient with poorly-controlled Type 2 diabetes and renal disease develops a fever of 102°F orally, productive cough, and dyspnea. Physical examination demonstrates a respiratory rate of 32/min, labored breathing, and rales at the left base. Pulse oximetry is 90%. Which of the following is the next appropriate step in the management of this patient? A Administer nebulized corticosteroids B Admit to the hospital C Oral antimicrobial therapy D Endotracheal intubation

B Admit Community acquired pneumonia is the most deadly infectious disease in the U.S. Important risk factors for increased morbidity and mortality include advanced age, alcoholism, comorbid medical conditions, altered mental status, respiratory rate greater than 30 breaths/min, hypotension, and a BUN greater than 30.

A 28 year-old man presents to the emergency department complaining of sudden onset of shortness of breath associated with sharp right-sided chest pain increased with breathing. On physical examination, respirations are 20 per minute and blood pressure is 120/76 mm Hg. Auscultation of the chest reveals absent breath sounds over the right apex with normal heart sounds. Percussion of the right apex is noted to be hyperresonant. Which of the following is the most likely diagnosis? A Hemothorax B Pneumothorax C Pulmonary embolus D Foreign body aspiration

B This patient most likely has a spontaneous pneumothorax which is supported by the presenting symptoms of sudden onset of dyspnea and pleuritic chest pain as well as the physical exam findings of absent breath sounds and hyperresonance to percussion.

Which of the following patients with shortness of breath has the lowest clinical probability for PE? A A 67-year-old man who underwent bilateral total knee replacements 2 weeks ago. B A 38-year-old man who underwent an uncomplicated open appendectomy 3 weeks ago. C A 35-year-old woman undergoing treatment for ovarian cancer. D A 35-year-old man with a history of a DVT 15 years ago, which occurred after an accident. E A 26-year-old woman who had an uncomplicated vaginal delivery 10 days ago.

B. Malignancy, acquired or inherited hypercoagulable states, previous DVT or PE, immobility, and pregnancy are all risk factors for DVT and PE. Although surgery is a known risk factor, the length of the operation and time of postoperative immobility are factors that contribute to thrombosis. The patient who underwent an uncomplicated appendectomy is at minimal risk for a DVT. The patient with the bilateral knee replacement would have very limited mobility for a long period time, putting him at risk for DVT and PE. The patient with ovarian cancer is at risk because of her malignancy. A patient with a previous DVT certainly has a greater lifetime risk for recurrence of a DVT. The patient with a normal vaginal delivery 10 days previously would have a higher risk of DVT than the general population.

Which of the following features best characterizes somatic pain? A Midline location B Sharp, persistent, and well-localized pain in the left lower quadrant C Intermittent pain D Pain improved with body movement E Poorly localized

B. Somatic pain is generally associated with irritation of the parietal peritoneum, resulting in localized, persistent, and sharp pain. This type of pain is aggravated by movement and can produce spasm in the overlying abdominal wall musculature, which is manifested as involuntary guarding.

Which of the following is the most likely cause of small-bowel obstruction in a 25-year-old woman with no previous abdominal operations? A Adhesions B Hernia C Crohn disease D Adenocarcinoma of the small bowel E Endometriosis

B. Statistically speaking, a hernia would be the most likely cause of small-bowel obstruction in a patient without previous abdominal operations or other causes of adhesions.

A 55-year-old man with a history of alcoholism complains of a month of subjective fevers and a productive cough with greenish sputum tinged with blood. Examination reveals poor dentition with halitosis, coarse breath sounds, and clubbing of his fingers. On chest x-ray, there is a 2-cm cavitary lesion with an air-fluid level in the right lower lobe. Which of the following is the most appropriate treatment? A Isolate the patient and initiate antituberculosis treatment B Admit and start intravenous clindamycin C Schedule an outpatient bronchoscopy D Discharge with oral amoxicillin-clavulanate

B. The history of alcoholism, presence of periodontal disease, duration of illness, and radiographic findings suggest aspiration pneumonia. The differential diagnosis for a cavitary lesion includes anaerobes, Staphylococcus aureus, Klebsiella, Pseudomonas, tuberculosis, and fungal infections. Clindamycin provides the appropriate antimicrobial coverage for a presumed anaerobic infection.

The patient in Question 5.2 is undergoing therapy. Which of the following principles is most accurate in the treatment of DKA? A Isotonic saline with no dextrose should be used during the hospitalization because the patient is diabetic. B Insulin and dextrose solution will need to be continued until the acidosis has resolved. C Since the patient is hyperkalemic, potassium replacement will not be necessary. D Sodium bicarbonate is helpful to resolve the anion gap more quickly

B. The serum glucose often drops much more rapidly than the ketoacidosis resolves; insulin is necessary to metabolize the ketone bodies but dextrose prevents hypoglycemia. Potassium replacement is usually necessary but should wait until hyperkalemia is excluded or has resolved. Bicarbonate does not hasten resolution of DKA.

Which of the following statements regarding DVT is most accurate? A A patient with thrombosis of the superficial femoral vein is never at risk for PE. B Venography is the definitive test for the diagnosis of DVT. C Thrombosis of the vena cava, subclavian veins, and right atrium are frequent sources of PE. D Venous duplex ultrasonography is most useful in diagnosing DVT in the pelvic veins. E Cancer successfully treated 5 years ago is associated with a higher risk for DVT.`

B. Venography is the gold standard for diagnosing thromboses of the deep veins of the extremities and is useful when duplex studies are inconclusive in high-risk, high-probability patients. Duplex ultrasonography combines direct visualization of the vein with Doppler flow signals. Part of the study relies on the examiner's ability to visualize compression of the veins to rule out an occluding thrombus. Because intra-abdominal and pelvic veins are difficult to compress, their evaluation by this method is limited. Most clinically significant PE derives from the large veins of the lower extremity, especially the iliofemoral veins that can embolize large clots to the pulmonary vasculature with disastrous hemodynamic consequences. Infrequent sources of PE can be central veins of the upper extremity, the vena cava, or even the right atrium. Despite its name, the superficial femoral vein is considered a deep vein (it accompanies the superficial femoral artery) and can be the source of clinically significant thromboemboli. Active cancer, rather than a history of treated cancer (>5 years), is associated with a higher risk of DVT.

A 45-year-old man presents to the ED with the acute onset of CP. Which of the following would point to a non-life threatening etiology of CP? A Shortness of breath B Worse when laying down and after large meals C Diffuse ST segment elevation D Cervical subcutaneous emphysema E Unilateral pleuritic CP

B.Pain that worsens with lying down and after a large meal is more suggestive of GERD. While GERD is a cause of pain that may eventually lead to esophagitis or even malignancy, it is not an immediate life threatening cause of CP. Aortic dissection, pulmonary embolism, cardiac tamponade, pneumothorax, and acute myocardial infarction can all lead to imminent death and therefore must be diagnosed and intervened upon immediately if found.

A 2-year-old boy is brought to the emergency department (ED) because of an episode of "choking." The patient was playing with marbles when his mother left the room for a few minutes. She ran back in when she heard the patient gagging and coughing. She denies any recent fever, cough, or other upper respiratory infectious symptoms. When asked, she denies her son turning blue, having difficulty breathing or vomiting. The patient was a term baby without any significant past medical history. He is not taking any medications, and his immunizations are all up-to-date. He attends day care and has no recent sick contacts. On examination, his temperature is 37.7°C (99.9°F), blood pressure is 93/55 mm Hg, heart rate is 105 beats per minute, respiratory rate is 24 breaths per minute, and the O2 saturation is 98% on room air. The patient is playful and alert. His examination is unremarkable except for intermittent gagging. He has no intercostal retractions or accessory muscle use. What is the most appropriate next step?

Because the child is stable, x-ray to localize the foreign body.

Which of the following conditions will produce a transudative pleural effusion? A Kaposi's sarcoma B Pneumonia C Cirrhosis D Mesothelioma

C

Which of the following is the most likely presentation of an acute pulmonary embolism (PE) in a patient without preexisting cardiac or pulmonary disease? A Anginal chest pain B Cough C Tachypnea D Palpitations

C Tachypnea

Which of the following diagnostic studies is indicated in the evaluation of an upper gastrointestinal bleed? A Esophageal manometry B Bleeding scan C Upper endoscopy D Barium swallow

C Upper endoscopy

A 62 year-old homeless patient presents complaining of fever, weight loss, anorexia, night sweats and a chronic cough that recently became productive of purulent sputum that is blood streaked. On physical examination, the patient appears chronically ill and malnourished. Which of the following chest x-ray findings supports your suspected diagnosis? A Hyperinflation and flat diaphragms B Interstitial fibrosis and pleural thickening C Cavitary lesions involving the upper lobes D "Eggshell" calcification of hilar lymph nodes

C This patient most likely has tuberculosis. A chest x-ray finding of cavitary lesions involving the upper lobes would support this suspected diagnosis.

A 23 year-old female with history of asthma for the past 5 years presents with complaints of increasing shortness of breath for 2 days. Her asthma has been well controlled until 2 days ago and since yesterday she has been using her albuterol inhaler every 4-6 hours. She is normally very active, however yesterday she did not complete her 30 minutes exercise routine due to increasing dyspnea. She denies any cough, fever, recent surgeries or use of oral contraceptives. On examination, you note the presence of prolonged expiration and diffuse wheezing. The remainder of the exam is unremarkable. Which of the following is the most appropriate initial diagnostic evaluation prior to initiation of treatment? A chest x-ray B sputum gram stain C peak flow D ventilation - perfusion scan

C. A peak flow reading will help you to gauge her current extent of airflow obstruction and is helpful in monitoring the effectiveness of any treatment interventions.

An 89-year-old was brought by ambulance from a nursing home for fever and cough. His vital signs are as follows: temperature 39.9°C (103.9°F), heart rate 120 beats per minute, blood pressure 89/69 mm Hg, respiratory rate 36 breaths per minute, and pulse oximetry 88% on a nonrebreather face mask. He is clammy and lethargic. He has coarse breath sounds bilaterally although decreased on the left. Which of the following is the most appropriate initial intervention? A Administer intravenous antibiotics and IV fluids B Draw blood cultures C Intubation D Obtain a chest x-ray

C. Although these are all appropriate interventions, this patient has hypoxic respiratory failure requiring intubation. This patient will need a definite airway and ventilatory support, early antibiotics and IV fluid resuscitation, appropriate cardiovascular support, and ICU admission.

A 24-year-old man is brought into the ED complaining of an exacerbation of his asthma. Which of the following is the most appropriate method of assessing the severity of his disease? A Spirometry B Measurement of the diffusion capacity of the lungs C History and physical and peak expiratory flow D Measurement of the alveoli oxygen tension

C. History and physical examination, along with peak expiratory flow, if needed, are a reliable and fairly accurate method of assessing asthma severity. Spirometry, although providing important information, is very cumbersome and rarely available in the ED.

An 18-year-old woman is brought to the ED with suspected anaphylaxis. Which of the following symptoms is most specific for anaphylaxis rather than a simple allergic reaction? A Itching B Watery eyes C Blood pressure of 80/40 mm Hg D Hives E Headache

C. Hypotension indicates a systemic reaction and cardiovascular compromise, thereby classifying this allergic reaction as anaphylaxis. The other options may all be part of an anaphylactic response but may also just be simple allergic reactions

A 3-year-old girl accidentally swallowed a button battery from her mother's camera. She does not appear to be in respiratory distress. She has normal vital signs and is afebrile. Plain x-ray shows the battery in the esophagus. Which of the following is the best management for this patient? A Avoidance of citrus drinks B Avoidance of magnets C Endoscopy D Expectant management

C. Immediate endoscopy is required. Button battery ingestion is a true emergency if lodged in the esophagus, with the potential for mucosal burns within 4 hours and esophageal perforation within 6 hours of ingestion. A button battery in the esophagus must be removed as soon as possible.

A 53 year-old female status post abdominal hysterectomy 3 days ago suddenly develops pleuritic chest pain and dyspnea. On exam she is tachycardic and tachypneic with rales in the left lower lobe. A chest x-ray is unremarkable and an EKG reveals tachycardia. Which of the following is the most likely diagnosis? A atelectasis B pneumothorax C pulmonary embolism

C. Risk factors for pulmonary embolism include advanced age, surgery and prolonged bedrest. While the diagnosis of pulmonary embolism is difficult due to nonspecific clinical findings, the most common symptoms include pleuritic chest pain and dyspnea associated with tachypnea. Chest x-ray and EKG are usually normal.

During the winter, a 24-year-old woman who works at a day care develops profuse watery diarrhea. A E. coli B Giardia lamblia C Rotavirus D S. aureus E Vibrio species F Cryptosporidium

C. Rotavirus usually causes a watery diarrhea and is especially common in the winter. It is the most common cause of diarrhea in infants and children worldwide. The vaccine has decreased the incidence in the United States significantly, but rotavirus is still a common infection. This patient who works at a day care would be susceptible to exposure

A 45-year-old man is brought into the emergency center due to significant dehydration and weakness. His potassium level is noted to be 7.2 mEq/L. Which of the following statements is most accurate regarding his potassium level? A Hyperkalemia can usually be diagnosed by symptoms alone. B An ECG showing peaked T waves means the patient is stable and treatment can safely wait until laboratory results are obtained. C Hyperkalemia can mimic a myocardial infarction on the ECG. D Hyperkalemia is synonymous with kidney disease.

C. The ST-segment and T-wave changes of hyperkalemia may mimic the ECG appearance of myocardial infarction. The nonspecific symptoms typical of hyperkalemia are also often seen in patients with MI, particularly elderly patients. Peaked T waves indicate that the heart is significantly affected by hyperkalemia and the patient should not be considered stable. Many conditions and medications may cause hyperkalemia, not just renal failure.

A 17-year-old adolescent boy who is a type I diabetic is brought in by his parents with concern for DKA. He has had several prior episodes of DKA. Which of the following is most diagnostic of DKA? A Polyuria, polydipsia, fatigue B Hypotension, dehydration, fruity breath odor C Hyperglycemia, ketosis, metabolic acidosis D Serum blood sugar of 600 mg/dL in the face of high concentrations of insulin E Elevated HCO3 and elevated glucose

C. The triad of hyperglycemia, ketosis, and acidosis is diagnostic of DKA. Many other conditions cause one or two of the triad, but not all three. Although a fruity breath odor may suggest acetone, it is not reliably present, and not all clinicians can distinguish it.

A 25-year-old woman with no past medical history presents with fever and productive cough. Her vital signs include temperature 38.8°C (101.9°F), heart rate 115 beats per minute, respirations 20 breaths per minute, blood pressure 115/89 mm Hg, and pulse oximetry 97% on room air. On examination, rhonchi are present in the right lung field. Chest x-ray shows a right middle lobe infiltrate. Which of the following should her treatment include? A Admission for intravenous ceftriaxone and vancomycin B Admission for intravenous ceftriaxone and azithromycin C Outpatient treatment with oral azithromycin D Outpatient treatment with oral amoxicillin

C. This is a healthy individual with CAP who can be treated as an outpatient with an oral macrolide. She has no risk factors for drug-resistant Streptococcuspneumonia.

A 58-year-old woman is brought into the ED complaining of bright red bleeding per rectum that was of acute onset. She denies abdominal pain. She is hemodynamically stable. Which of the following is the most likely etiology of her condition? A Varices B Gastritis C Diverticulosis D Mallory-Weiss tear E Peptic ulcer disease

C. This patient's clinical presentation is suggestive of lower GI bleeding. Common causes of lower GI bleeding are diverticulosis, upper GI bleeding, hemorrhoids, angiodysplasia, malignancy, inflammatory bowel disease, and infectious conditions. Bleeding with diverticulosis is described as painless and abrupt, "as though a water faucet was suddenly turned on." The other choices are common causes of upper GI bleeding

A 65-year old man who is being managed for lung cancer on the ward makes a complaint of a 2-day history of passage of non bloody watery stool up to 4 times per day, anorexia, cramping abdominal pain, and fever. Meanwhile he had a 10-day course of antibiotic 4 weeks ago on account of a lung infection. Which of the following is the most likely cause of his diarrhea: A Salmonella B Rotavirus C Clostridium difficile D E. coli

Clostridium difficile

A 21 year-old male presents to the ED with increasing dyspnea and pleuritic chest pain of sudden onset after getting hit in the left side of the chest during a bar fight. Examination reveals moderate respiratory distress with absence of breath sounds and hyperresonance to percussion on the left, with tracheal deviation to the right. Which of the following is the most appropriate next step? A order a V/Q scan B order a chest x-ray C administer a sclerosing agent D insert large bore needle into left 2nd ICS stat

D Simple aspiration by insertion of a needle into the involved side will decompress the tension pneumothorax until a chest tube can be inserted. Patients in respiratory distress and evidence of a tension pneumothorax, such as tracheal deviation, should have treatment initiated without waiting on a chest x-ray to be taken.

A 57-year-old man presents to the ED complaining of sudden onset of shortness of breath with pleuritic chest pain. He was recently released from the hospital after being diagnosed with lymphoma. He had an indwelling catheter placed in his left subclavian vein the day before for chemotherapy administration. He was previously healthy without significant medical history. His vital signs are heart rate of 105 beats per minute, blood pressure of 126/86 mm Hg, respiratory rate of 28 breaths per minute, and O2 saturation of 100% on room air. The breath sounds are clear bilaterally. His heart sounds are normal without an S3 or S4 gallop. His left arm is mildly edematous but otherwise painless, with a normal pulse examination. There is no swelling of his lower extremities, and he has no pain with palpation of his calves. His catheter incision site is clean and intact. Which of the following studies is inappropriate for this patient? A Chest x-ray B ECG C Contrast CT scan of the chest D d-dimer assay E Duplex ultrasonography of the deep veins of the upper and lower extremities

D This patient may very well have a PE, but other sources of his chest pain and shortness of breath must also be considered. A chest x-ray will show other possible pulmonary processes, including pneumonia or a pneumothorax from the central line placement (as well as confirm the position of the line). An ECG will aid in the diagnosis of cardiac etiologies, including heart attacks or arrhythmias. CTA would be appropriate, as it can diagnose a PE as well as other etiologies of his symptoms. A d-dimer assay is not useful in this patient because he is a high-probability patient, and this test should only be ordered in low-probability patients. Duplex ultrasonography will help examine the venous system for thromboses and possible sources of PE, including the deep veins of the upper extremity, because this patient now has an indwelling catheter that can be a source of thrombus formation.

A 42 year-old male is brought to the emergency department with a stab wound to his right lateral chest wall. On physical examination, the patient is stable with decreased breath sounds on the right with dullness to percussion. An upright chest x-ray reveals the presence of a moderate pleural effusion. Subsequent diagnostic thoracentesis contains bloody aspirate. Which of the following is the next most appropriate intervention? A Thoracotomy B Needle aspiration C Close observation D Tube thoracostomy

D This patient has a hemothorax. Drainage of a hemothorax is best obtained through insertion of a chest tube (tube thoracostomy).

Which of the following is a benefit of using PPV in acute severe asthma? A Recruits collapsed alveoli B Improves ventilation/perfusion mismatch C Reduces the work of breathing D All of the above

D. All of the answers are believed to be benefits provided by PPV in acute severe asthma.

A 42 year-old male with unremarkable past medical history is admitted to the general medical ward with community-acquired pneumonia. He has a 20 pack-year history of cigarette smoking. He is empirically started on ceftriaxone (Rocephin). Which of the following antibiotics would be most appropriate to add to his empiric treatment regimen? A Piperacillin B Vancomycin C Clindamycin D Azithromycin

D. Azith Patients with community-acquired pneumonia who require hospitalization on the general medical ward are treated with an extended-spectrum beta-lactam antibiotic, such as ceftriaxone, with a macrolide, such as azithromycin. Addition of a macrolide is also recommended due to the patient's smoking history and possible involvement of Haemophilus influenzae.

A 55-year-old man collapses pulseless and with a wide bizarre-looking rhythm. A dialysis fistula is present in the right arm. In addition to standard ACLS therapies, which of the following is most appropriate for this patient? A 25 g of 50% dextrose, IV push. B Sodium bicarbonate, 50-mL IV push. C Begin immediate hemodialysis. D Calcium chloride, 20-mL slow intravenous push.

D. Calcium is the only agent with rapid and reliable enough onset to potentially help this patient. Bicarbonate might be appropriate, but its onset is slower than calcium and its effect is more disputed. Dialysis requires a hemodynamically stable patient. If the patient is resuscitated, dextrose and insulin will be important in the ongoing management of hyperkalemia.

Which of the following statements is incorrect regarding treatment of hyperkalemia in patients with some renal function? A Administration of normal saline may hasten the excretion of potassium. B Administration of furosemide can hasten the excretion of potassium. C The combination of saline with a diuretic is often indicated because hyperkalemic patients are frequently dehydrated. D Patients with some preserved renal function do not need dialysis, even for severe hyperkalemia.

D. Dialysis is the definitive therapy for hyperkalemia. Patients who have residual kidney function can sometimes be managed without resorting to dialysis, but it should always be available for those who fail to respond quickly.

A 52-year-old healthy man presents with a 3-day history of a pleuritic chest pain and SOB. He has normal vital signs and physical examination. Which test is most useful in ruling out pulmonary emboli in this patient? A Electrocardiogram (ECG) B Chest x-ray C Arterial blood gas (ABG) D d-dimer level E Oxygen saturation

D. ECG findings are often normal or nonspecific in patients with PE and thus are not the most useful in ruling out PE in this patient. Chest radiographs are also usually normal, though the Westermark sign or Hampton Hump may be noted. ABG findings are often confusing, and abnormalities are usually a result of underlying pathology such as chronic obstructive pulmonary disease (COPD) or pneumonia. A low Po2 in an otherwise healthy patient at risk for DVT/PE is more useful. O2 saturation is rarely depressed and not very useful in the workup of PE. High-sensitivity d-dimer levels are most useful for their negative predictive value in helping to rule out PE in low-to-moderate pretest-probability patients. It is a very sensitive but nonspecific test. A normal high-sensitivity d-dimer level in a low-to-moderate pretest probability patient makes PE unlikely, and further diagnostic workup is not indicated.

A 28-year-old insulin-requiring woman is found at home by her husband. She is stuporous and cannot provide any history. She is brought to the ED, and a diagnosis of severe DKA is made. Her blood pressure is 78/40 mm Hg and heart rate 140 beats per minute. The glucose level is 950 mg/dL, potassium level 6 mEq/L, and HCO3 4 mEq/L. Which of the following is the most appropriate initial treatment? A Administer 20 units regular insulin intramuscularly, and normal saline at 250 mL/h. B Begin intravenous pressors to raise BP above 90, then insulin at 10 U/h. C Initiate normal saline 2 L with KCl 20 mEq/L and insulin 10 U/h. D Provide an intravenous normal saline 2 L bolus, then start an insulin drip at 10 U/h

D. Fluid resuscitation via isotonic crystalloid solution to reverse shock, and IV insulin to reverse ketoacidosis, are the mainstays of therapy. Though most patients will require potassium, it should not be given while the serum K is elevated, and typically not until urine output is seen. Pressors have a limited role until the intravascular volume is restored.

A 35-year-old woman presents to her physician's office with CP of 1 week's duration. The physician suspects possible musculoskeletal etiology. Which of the following would be the best evidence to confirm this diagnosis? A Relief with nitroglycerin B Tracheal deviation C Radiation down the left arm D Reproduced with palpation

D. Musculoskeletal causes are the most common etiologies of NCCP. The best way to confirm the diagnosis is to reproduce the pain with palpation in the anatomical region or with movement. Nitroglycerin is a treatment of CAD. Tracheal deviation suggests tension pneumothorax. Radiation down the left arm may be associated with angina.

A 43-year-old man complains of an acute onset of vomiting bright red blood. He denies alcohol use and history of peptic ulcer disease. He complains of dizziness, appears anxious, and his blood pressure is 120/70 mm Hg and heart rate is 90 beats per minute. Which of the following is the best next step in managing his condition? A Morphine sulfate B Endoscopic examination C Chest radiograph D Intravenous fluid resuscitation E Orotracheal intubation

D. Stabilization of the patient is always the first priority. The ABCs come first; assuming that his airway and breathing are stable, then circulation is next. Fluid administration very likely will be helpful, as the patient's dizziness and anxiety are signs of hypovolemic shock.

For which of the following patients is CT of the abdomen contraindicated? A A 60-year-old man with persistent left lower quadrant pain, fever, and a tender mass B A 45-year-old alcoholic man with diffuse abdominal pain, WBC 18,000 cells/mm3, and serum amylase of 2000 C A nonpregnant 18-year-old woman with suprapubic and right lower quadrant pain, fever, right lower quadrant mass, and WBC of 15,000 cells/mm3 D A 70-year-old man with abdominal pain and distention, a 10-cm pulsatile mass in the epigastrium, and blood pressure of 70/50 mm Hg E A 24-year-old man with a new finding of painful, irreducible umbilical hernia who presents with 12-hour history of abdominal distention and vomiting

D. The patient in "D" is hemodynamically unstable and possesses signs and symptoms suggestive of ruptured abdominal aneurysm. A CT scan would likely delay his care and is contraindicated in this situation. The patient described in choice A likely has diverticulitis, where CT may be appropriate for severity staging. The patient described in choice B likely has AP, where CT is helpful for the stratification of disease severity. The patient described in choice C may have complicated appendicitis or some other complicated GI or gynecological process, where CT can be useful for differentiation. The patient described in choice E has an incarcerated umbilical hernia with signs and symptoms of intestinal obstruction related to this finding. Surgical intervention is indicated based on his presentation alone.

A 22 year-old female with a history of asthma presents with complaints of increasing "asthma" attacks. The patient states she has been well controlled on albuterol inhaler until one month ago. Since that time she notices that she has had to use her inhaler 3-4 times a week and also has had increasing nighttime use averaging about three episodes in the past month. Spirometry reveals > 85% predicted value. Which of the following is the most appropriate intervention at this time? A. Oral CS B. Oral theophylline C. Salmeterol inhaler D. CS inhaler

D. This patient has progressed to mild persistent asthma. In addition to her inhaled beta2- agonist (albuterol), she should be started on an anti-inflammatory agent. Inhaled corticosteroids, such as beclomethasone, are preferred for long-term control. Other options may include cromolyn or nedocromil.

A 65-year-old man collapsed in a park and is brought to the ED by paramedics. He was stung by a bee and known to be highly allergic. He appears cyanotic and had extreme stridor in the ambulance. Severe laryngeal edema is notable. Which of the following is the best treatment? A Nebulized albuterol, H1 and H2 antagonists, corticosteroids, and crystalloids. B Intramuscular epinephrine, H1 and H2 antagonists, and corticosteroids. C Rapid sequence intubation, intramuscular epinephrine, and corticosteroids. D Intramuscular epinephrine, rapid sequence intubation, and corticosteroids. E Nebulized albuterol, H1 and H2 antagonists, IV fluid resuscitation, and reassessment for improvement.

D. This patient has severe anaphylaxis, and epinephrine should be administered immediately. If intravenous dosing is not immediately available, then intramuscular epinephrine should be given. Attention should then be turned to managing the airway. Because of the significant laryngeal edema, endotracheal intubation will be nearly impossible; hence, cricothyroidotomy may be required. After securing the airway, fluids, steroids, beta agonists, and H1 and H2 antagonists should be administered.

A 19-year-old woman is admitted to the hospital for an exacerbation of asthma likely precipitated by pollen and colder weather. Her inpatient regimen includes both intravenous and inhalant medications. Which of the following medications is most likely to be used as part of her discharge plan? A Theophylline B Antibiotics C Magnesium D Histamines E Corticosteroids

E. Corticosteroids are often used after a hospitalization to treat the inflammatory component. Other standard medications include beta-agonists and oral leukotriene antagonists. None of the other medications listed as answer choices are used routinely for discharged asthma patients.

Which of the following conditions is the strongest risk factor for peptic ulcer disease? A Age greater than 50 years B Estrogen replacement therapy C Acetaminophen use D Chlamydia trachomatis E Helicobacter pylori infection

E. Risk factors for peptic ulcer disease include H. pylori infection, NSAID use, alcohol use, heredity, and tobacco use.

What are some signs of perforation due to swallowing a foreign object?

Findings such as fever, subcutaneous air, or peritoneal signs suggest perforation and necessitate an emergent surgical consult.

At 3 am the paramedics call to inform you that they are en route to the emergency department with a 33-year-old woman with a history of asthma. As she is brought in, you identify she is in severe respiratory distress. Sweat pours from her face and body as her neck and chest heave in an attempt to inhale another breath. Her efforts are ultimately futile as her consciousness slips away and she becomes apneic. Initial priorities: Treatment options:

Initial priorities: The first priority in this patient's management is addressing the ABCs (airway, breathing, circulation). Based on this presentation, immediate protection of her airway with rapid-sequence endotracheal intubation is indicated. While setting up for urgent intubation, two provider bag-valve-mask ventilation should be attempted. Her lungs should be auscultated to assess for air movement and her pulses assessed for quality and strength. Simultaneously, this patient should be placed on a cardiac monitor with automated blood pressure measurement, establishment of IV access, and continuous pulse oximetry. Treatment options: Treatment options include adrenergic agonists (eg, albuterol and terbutaline), anticholinergic agents, and corticosteroids. Intravenous magnesium sulfate is often given to patients with severe asthma exacerbations; however, its efficacy and routine administration is being challenged.

A 26-year-old woman with a known peanut allergy is brought to the ED after accidentally consuming salad with a peanut dressing. She is wheezing and reports abdominal cramping. Which of the following should be the first intervention? A Endotracheal intubation B Normal saline 20 cc/kg IV C Examination of the skin D Epinephrine 0.3 mg intramuscular E Nebulized epinephrine

Intramuscular epinephrine should be administered immediately. If there is significant respiratory or airway compromise, then the patient's airway should be controlled. Subsequent interventions include fluid resuscitation for hypotension, as well as H2 blockers and systemic steroids to mitigate further histamine and cytokine release.

You are working in the emergency department (ED) of a 15-bed rural hospital without CT scan capabilities, and a 25-year-old, previously healthy woman presents for evaluation of abdominal pain. The patient describes her pain as having been present for the past 3 days. The pain is described as constant, exacerbated by movements, and associated with subjective fevers and chills. She denies any recent changes in bowel habits, urinary symptoms, or menses. Her last menstrual period was 6 days ago. The physical examination reveals temperature of 38.4°C (101.1°F), pulse rate of 110 beats per minute, blood pressure of 112/70 mm Hg, and respiratory rate of 18 breaths per minute. Her skin is nonicteric. Cardiopulmonary examination is unremarkable. The abdomen is mildly distended and tender in both right and left lower quadrants. Involuntary guarding and localized rebound tenderness are noted in the right lower quadrant. The pelvic examination reveals no cervical discharge; cervical motion tenderness and right adnexal tenderness are present. The rectal examination reveals no masses or tenderness. Laboratory studies reveal white blood cell (WBC) count of 14,000 cells/mm3, a normal hemoglobin, and a normal hematocrit. The urinalysis reveals 3-5 WBC/high-power field (HPF), few bacteria, and trace ketones. What are the most likely diagnoses? How can you confirm the diagnosis?

Most likely diagnoses: Likely diagnoses include complicated acute appendicitis, pelvic inflammatory disease (PID), ovarian torsion, or other pelvic pathology. Confirmatory studies: Begin with pregnancy test and pelvic ultrasonography to evaluate for possible ovarian and pelvic pathology. If these suggest pelvic source of pathology, then strong consideration should be given to perform exploratory laparoscopy or laparotomy.

A 19-year-old woman is brought into the emergency department (ED) complaining of abdominal pain and diarrhea of 3-day duration. She has also been nauseous and has not been able to drink much liquid. Five days ago she returned from a camping trip in New Mexico but did not drink from natural streams. She denies fever but states that she has had some chills. Her stools have been watery, brown, and profuse. The patient denies health problems. On examination, the patient is thin and pale. Her mucous membranes are dry. Her temperature is 37.2°C (99°F), heart rate is 110 beats per minute, and blood pressure is 90/60 mm Hg. The skin has no lesions. Her heart and lung examinations are unremarkable except tachycardia. The abdominal examination reveals hyperactive bowel sounds and no masses. There is diffuse mild tenderness but no guarding or rebound. Rectal examination demonstrates no tenderness or masses and is hemoccult negative. The complete blood count reveals a leukocyte count of 16,000 cells/mm3. The pregnancy test is negative. Questions What is the most likely diagnosis? What is the next diagnostic step?

Most likely diagnosis: Acute volume depletion and possible electrolyte abnormalities secondary to acute diarrhea. Next diagnostic step: Test stool for fecal leukocytes. Next step in therapy: Intravenous fluid hydration.

A 55-year-old man presents to the emergency department (ED) complaining of abdominal pain. The patient relates that he has been having intermittent pain throughout the abdomen for the past 12 hours, and since the onset of pain, he has vomited twice. His past medical history is significant for hypertension and colon cancer, for which he underwent laparoscopic right colectomy 8 months ago. The patient indicates that he has not had any recent abdominal complaints. His last bowel movement was 1 day ago, and he denies any weight loss and hematochezia. On physical examination, the patient is afebrile. The pulse rate is 98 beats per minute, blood pressure is 132/84 mm Hg, and respiratory rate is 22 breaths per minute. His cardiopulmonary examination is unremarkable. His abdomen is obese and mildly distended, with well-healed surgical scars. No tenderness, guarding, or hernias are noted. His bowel sounds are diminished, with occasional high-pitched sounds. The rectal examination reveals normal tone, empty rectal vault, and hemoccult-negative stool. What is the most likely cause of this patient's problems? What are the next steps in this patient's evaluation?

Most likely diagnosis: Bowel obstruction. It is unclear whether the intestinal obstruction is involving the large or small bowel or whether it is complete or partial obstruction. Next steps in evaluation: Diagnostic radiography, which can be either plain x-rays or a computed tomography (CT).

A 57-year-old man presents to the emergency department (ED) with a 1-month history of worsening low back pain. The pain radiates down the back of both legs and suddenly increased yesterday. For the past 2 days, the patient has been having difficulty voiding and has had "to force the urine out." He has also noticed that the skin around his anus feels numb when he wipes with toilet tissue. He works in a warehouse but has been on light duty for the past month due to his back pain. He denies prior trauma to or surgery on his back. What is the most likely diagnosis? What is the next diagnostic step?

Most likely diagnosis: Cauda equina syndrome (CES). Next diagnostic step: STAT magnetic resonance imaging (MRI) of the lumbar and sacral spine, since this is a potential surgical emergency.

A 70-year-old woman is transferred from a nursing home to the emergency department (ED) due to fever and shortness of breath. As per her daughter, the patient has had a productive cough for 2 days and became more short of breath and less responsive earlier today. The patient's past medical history is significant for diabetes mellitus, hypertension, and high cholesterol. Her vital signs include: temperature 38.9°C (102.1°F), heart rate 104 beats per minute, blood pressure 130/85 mm Hg, respiratory rate 28 breaths per minute, and room air oxygen saturation 87% (96% with 3L oxygen by nasal cannula). On examination, she is awake but slow to answer questions. The daughter states that her mother is usually more alert than this. Her skin is dry and warm to touch. Her heart sounds are regular and mildly tachycardic without any S3 or S4. On auscultation, she has rhonchi at the right lung base. She does not have any jugular venous distention, lower extremity edema, or calf tenderness. What is the most likely diagnosis? How should this patient be managed?

Most likely diagnosis: Healthcare-associated pneumonia. Management: Supplemental oxygen, intravenous antibiotics, blood and sputum cultures, and admission.

A 28-year-old man arrives at the emergency department (ED) complaining of 1 day of chest pain (CP) beginning suddenly after multiple episodes of retching and vomiting following a night of heavy drinking. Since the pain began, he has had subjective fevers, feels very weak, is unable to tolerate any food or water, and has urinated only once. He describes lower anterior CP that is non-radiating and of moderately severe intensity, aggravated by swallowing. While he is speaking in full sentences, he states that he has to control his breathing to avoid a "tight feeling in his throat," and he is concerned that his voice sounds "different." The review of systems is otherwise negative. His temperature is 38°C, hear rate is 132 beats per minute, blood pressure is 148/74 mm Hg, and respiration rate is 22 breaths per minute with an O2 saturation of 98% on room air. Physical examination shows an ill and uncomfortable appearing man who is tachycardic, diaphoretic, and borderline febrile. He has dry mucous membranes and faint bibasilar crackles. He has no past medical history and is taking no medications. What is the most likely diagnosis? What are the next steps in management? What therapies should be instituted immediately?

Most likely diagnosis: Spontaneous esophageal perforation or Boerhaave syndrome. Next management steps: Place the patient on a cardiac monitor, establish IV access and obtain an electrocardiogram (ECG) immediately. A chest x-ray (CXR) should be obtained as soon as possible. Immediate therapies: Nil per os (NPO), nasogastric tube (NGT), IV resuscitation with isotonic fluids, broad spectrum antibiotics, pain management, and urgent surgical consultation.

A 43-year-old man is brought in on an EMS (emergency medical services) stretcher after a syncopal episode. After obtaining a palpated pressure of 80 mm Hg systolic and heart rate of 120 beats per minute, EMS placed an 18-gauge IV and initiated normal saline (NS) infusion en route to the hospital. The patient relates a history of a 3 to 4 days of dark, tarry stools (about 3-4 times per day). Today he passed out when rising from a seated position. He is currently complaining of mild epigastric pain and lightheadedness. He denies any hematemesis, hematochezia, chest pain, shortness of breath, and any similar past episodes. He admits to tobacco use and drinking 1-2 beers each day and is not regularly under the care of a physician. On examination, his vital signs are temperature 36.6°C (97.9°F), blood pressure 92/45 mm Hg (after 900-mL IV fluid prior to arrival), heart rate 113 beats per minute, and respiratory rate 24 breaths per minute. The patient is pale with dried, dark stool on the perineum. He has mild tenderness to palpation in the epigastrium but no rebound or guarding. He does not have spider angioma, gynecomastia, palmar erythema, or ascites. The rectal examination reveals grossly melenic stool. What is the most likely diagnosis? What is the best therapy?

Most likely diagnosis: Upper gastrointestinal (GI) bleed with hemorrhagic shock. Best therapy: Stabilization of the ABCs (airway, breathing, and circulation), including IV access and volume resuscitation. Consider the use of blood products and proton pump inhibitors. Endoscopy is indicated for early diagnosis and treatment.

A 20-year-old woman is brought to the emergency department (ED) by ambulance after collapsing at home. She was seen by her regular doctor earlier in the day and prescribed penicillin for bacterial pharyngitis. Paramedics report field vital signs remarkable for a blood pressure of 70/30 mm Hg, heart rate of 140 beats per minute, respiratory rate of 40 breaths per minute, and an oxygen saturation of 76%. Intravenous fluids and oxygen were administered during transport. Paramedics are assisting the patient's breathing with bag-valve mask ventilation, but oxygen saturations remains low. On physical examination, the patient is obtunded with perioral cyanosis, tongue swelling, stridor, wheezing, and labored breathing. Her skin is cool and clammy with large urticarial lesions

Next steps: A definitive airway will need to be immediately established in the face of impending airway obstruction (see Cases 1 and 48), and the patient's cardiovascular compromise must be treated with epinephrine. Consider the emergent approach to anaphylaxis by adding "DE" to the traditional ABCs of emergency medicine. ABCDE: Airway, Breathing, Circulation, "Deliver Epinephrine." The first dose of epinephrine should be administered intramuscularly in the anterolateral thigh. In the setting of a severe reaction like the one described earlier, moving quickly to intravenous infusion of epinephrine is recommended. Further treatments: This patient requires rapid resuscitation and stabilization. While preparing for intubation, high-flow oxygen therapy should be administered. Her lower extremities should be elevated to improve venous return. Additional therapies include volume resuscitation with crystalloid, nebulized beta agonists, corticosteroids, antihistamines (H1 and H2 blockers), and removal of any remaining antigen (ie, bee stinger in applicable cases). Patients who are taking β-blockers may be less responsive to standard therapy and therefore also require administration of glucagon.

Does a response to a trial of sublingual nitroglycerin distinguish between coronary artery disease and GERD induced esophageal spasm?

No