Emergency Medicine EOR

A 58-year old man presents with two days of fever and lower back pain. Digital rectal exam reveals a swollen and tender prostate. His urinalysis reveals 100 WBC/hpf, leukocyte esterase, and nitrites. What is the most likely pathogen causing this condition?

Escherichia coli

A 65-year-old man with a past medical history of hypertension presents to the emergency department with "tearing" chest and abdominal pain radiating towards his back. His blood pressure is 185/98 mm Hg. Which of the following medications should be administered first?v

Esmolol

A 45-year-old man with a history of alcoholic cirrhosis presents to the emergency department for confusion. His family brought him. They deny recent trauma, infection, bloody emesis, or stool. He is unable to give a coherent history but seems pleasantly confused. He denies pain. Family report that he no longer drinks alcohol and has not used any medications or drugs recently. On exam, he is drowsy and delirious. His hands flap when held up, and his tongue gyrates back and forth when protruded. Guaiac testing is negative. His abdomen is distended, but soft and nontender. A noncontrast computed tomography scan of the head shows no evidence of bleeding. His renal function is normal, sodium levels are within normal ranges, liver function tests are within his normal ranges, and blood counts are normal. His ammonia level is elevated at 114 µmol/L. What therapy should be initiated?

Lactulose

Which of the following is the most common cause of status epilepticus in a patient with known epilepsy?

Medication noncompliance

An 18-year-old presents to the emergency department with severe pain in his penis. He indicates he has had some mild irritation to the glans and foreskin areas recently. After intercourse tonight he was unable to reduce the foreskin and now has severe pain in the tip of his penis. On examination, the penis is flaccid and the foreskin is retracted proximally. There is swelling to the tip of the penis with mild erythema. What is the most likely diagnosis?

Paraphimosis

A 67-year-old man with a history of bronchogenic carcinoma presents with fever and shortness of breath. His vital signs are T 101.5°F, HR 112 beats/minute, RR 22 breaths/minute, BP 100/60 mm Hg, and oxygen saturation 92% on room air. He has right basilar crackles on auscultation and dullness to percussion. A chest X-ray demonstrates a right lower lobar consolidation with costophrenic angle blunting. Which of the following values suggests the presence of an exudative pleural effusion?

Pleural fluid LDH twice that of serum LDH

Which of the following is the most common pulmonary complication of influenza?

Pneumonia secondary to superimposed bacterial infection

A 38-year-old man with a past medical history of hypertension and stage III chronic kidney disease presents with severe left foot pain that began in the middle of the night. He appears comfortable but has exquisite tenderness to palpation of the left, first metatarsophalangeal joint. The joint is erythematous and warm. His vital signs include a temperature of 99.1°F, BP 132/85 mm Hg, RR 16 breaths/minute, and oxygen saturation 99% on room air. Arthrocentesis of the involved joint is performed and synovial fluid analysis reveals negatively birefringent crystals. Which of the following is the most appropriate therapy at this time?

Prednisone

Which of the following is true regarding the condition seen in the image above?

Pregnant women should be treated with permethrin

Which of the following is one of the most helpful signs to rule out testicular torsion?

Presence of the cremasteric reflex

A 22-year-old man presents with upper extremity weakness. He notes that he was drinking heavily last night and when he woke up this morning he was unable to move his hand. On examination, he has normal strength in the biceps and triceps but weakness of the wrist extensors, finger extensors, and brachioradialis. Injury to what nerve accounts for his symptoms?

Radial nerve

A 21-year-old woman presents with pain, tearing, photophobia, and left eye redness. She has been wearing her contact lenses continuously for the last two weeks. A slit lamp examination reveals a white, hazy opacity on the cornea at the 3 o'clock position of the cornea with associated limbal flush. Which of the following is the most appropriate pharmacotherapy?

Topical ciprofloxacin

The rash seen above is associated with which one of the following conditions?

Acute glomerulonephritis

A 22-year-old woman presents with lower abdominal pain that started two days ago. Today, she had three episodes of vomiting but denies any diarrhea or dysuria. On examination, her temperature is 38.8°C, heart rate 105 beats per minute, and blood pressure 128/72 mm Hg. She is ill-appearing with bilateral lower quadrant tenderness. Pelvic examination reveals moderate yellow discharge and uterine tenderness. There are no adnexal masses appreciated. Pregnancy test is negative. What is the next step in the management of this patient?

Admission for intravenous cefotetan and doxycycline

A 45-year-old woman presents to the emergency department with palpitations. She is placed on the monitor which shows a rapid narrow-complex tachycardia. Her heart rate is 160 bpm and blood pressure is 120/70 mm Hg. Vagal maneuvers are attempted and fail. Next, adenosine 6 mg IV is given intravenously without a change in her rhythm. Repeat vitals show a heart rate 165 bpm and blood pressure 120/70 mm Hg. What is the most appropriate next step in management?

Adenosine 12 mg intravenous

What is the most common site of compartment syndrome?

Anterior compartment of the lower leg

A 56-year-old woman with a history of hypertension, diabetes mellitus, and hypercholesterolemia presents with acute substernal chest pain that is worse with exertion and associated with nausea and shortness of breath. Her sister and her mother both had "heart attacks" before age 55 years. Which of the following offers a proven mortality benefit in acute coronary syndrome?

Aspirin

A 50-year-old woman presents to the emergency department following a syncopal episode. On physical exam she is diaphoretic. She is alert and oriented. Her blood pressure is 90/50 mm Hg and respirations are 12 per minute. Her rhythm strip is shown above. What is the most appropriate pharmacologic treatment for this patient's condition?

Atropine

What is the most common symptom of hemorrhoids?

Bleeding with defecation

Which of the following conditions has a negative Nikolsky sign?

Bullous pemphigoid

A 23-year-old man with a history of insulin-dependent diabetes presents to the ED with vomiting and shortness of breath. He recently became homeless and has not been using his insulin. On physical exam, he has a fruity odor to his breath. After two hours of treatment in the ED, his serum labs include glucose 190 mg/dL, sodium 133 mEq/L, chloride 101 mEq/L, and bicarbonate 12 mmol/L. Which of the following is the most appropriate next step in management?

Change to dextrose-containing intravenous fluid

A 61-year-old previously healthy man presents with three days of gross hematuria and clots in his urine. He denies any dysuria, flank pain, fever, or trauma. On examination, his heart rate is 78 beats per minute, blood pressure 142/72 mm Hg, and temperature 37.4°C. He has no abdominal tenderness or fullness on palpation. Genitourinary exam is unremarkable. Urinalysis is negative for leukocyte esterase and nitrites. There are > 100 red blood cells/hpf and 6 white blood cells/hpf. Creatinine is 1.1. What is the next step in the management of this patient?

Computed tomography of the abdomen and pelvis with intravenous contrast

A 28-year-old woman presents to the ED following a finger injury while playing flag football. She states that she sustained a direct blow to the pointer finger when the ball struck her fingertip. On physical exam, the patient has swelling and tenderness at the distal interphalangeal joint. The fingertip rests in 45 degrees of flexion. She is unable to demonstrate active extension of the distal interphalangeal joint but has full passive extension. The skin is intact. X-ray of the finger is obtained, which shows soft tissue swelling but no fracture or dislocation. Which of the following is the most appropriate management for this patient?

Extension splinting of the distal interphalangeal joint

Which of the following correctly describes electrocardiographic features of second-degree type I atrioventricular block?

Grouped beats

A 39-year-old man presents to the emergency department with left hand pain. He denies recent trauma, genital or oral lesions, or fever. His medical history is significant for diabetes mellitus and tobacco abuse. His examination is shown above. Which of the following is the most appropriate initial therapy for this patient?

Incision and drainage

A 25-year-old man presents to the emergency department after a gunshot wound to the chest. He is awake and following commands. His vital signs are T 97.5°F, BP 89/50 mm Hg, HR 120 bpm, RR 35/min, and oxygen saturation 87% on a nonrebreather face mask. Jugular venous distension is present and he has diminished breath sounds on the left. Which of the following is the next best step in management?

Needle decompression of the chest

A 5-year-old boy with a history of sickle cell anemia presents with dyspnea and fatigue. His mother notes that 1 week prior, he had a fever, headache, and bright red rash on his cheeks, which has since resolved. Laboratory studies show a decrease in his baseline hemoglobin by 30%. Infection with which virus likely precipitated his current symptoms?

Parvovirus B19

A 6-week-old infant presents with decreased appetite. The child is underweight for her age, and her mother says that she is not eating well. Physical exam reveals a continuous heart murmur in the left infraclavicular space and a thrill in the suprasternal notch. Which of the following findings would be expected on echocardiogram?

Patent ductus arteriosus

A 31-year-old man presents to the emergency department in police custody after he was found unclothed, confused, and running down a snowy street. His urine drug test is positive for phencyclidine (PCP). Which of the following ocular findings is most likely present on physical examination?

Rotary nystagmus

A 35-year-old woman with a history of migraines and polycystic kidney disease presents to the Emergency Department with a severe, diffuse headache. The onset was abrupt approximately one hour prior to arrival. Her vital signs are within normal limits. She has photophobia and phonophobia, as well as pain with extraocular movements. Which of the following is the most likely diagnosis?

Subarachnoid hemorrhage

An 81-year-old man with a history of atrial fibrillation presents with abdominal pain. He fell two weeks ago and was advised to stop his anticoagulation medication after the fall. He reports diffuse, severe abdominal pain but is minimally tender on examination. He has symmetric pulses in his extremities. What is the most likely anatomic location of his pathology?

Superior mesenteric artery

Which muscle is most commonly involved with rotator cuff injuries?

Supraspinatus

Which of the following is correct when estimating an adult burn patient's percent of total body surface area affected?

The perineum is approximately 1%

Which of the following patients presenting to the emergency department with suicidal ideation would be considered highest risk for suicide if released from the department?

A 50-year-old white man who works as a physician and has been diagnosed with severe depressive disorder

A 75-year-old man with a history of renal colic presents with right flank pain radiating to the right groin. During triage, the patient has a syncopal event. Urinalysis shows no red cells. His blood pressure is 110/60 mm Hg. What is the best management indicated for this patient?

CT abdomen and pelvis with contrast

A 61-year-old man presents with intermittent shock-like spasms of pain in his right cheek. The pain only lasts a few seconds at a time but recurs frequently. He notes that shaving each morning causes intense spasms of pain, as does chewing. What is the first-line treatment for his likely diagnosis?

Carbamazepine

A 32-year-old man presents with severe, acute left knee pain that occurred while wrestling with his brother. He is unable to bear weight. His knee is held in flexion and he is unable to actively extend it. His leg is shown above. Which of the following is the best next step in management?

Closed reduction

A 30-year-old man presents to the ED with three weeks of diarrhea. He reports colicky abdominal pain associated with frequent episodes of pale, loose, foul-smelling stools. He returned from a camping trip in New Hampshire one month prior. His vital signs are temperature 37.1°C, heart rate 85 bpm, and blood pressure 125/80 mm Hg. Which of the following is the most appropriate treatment for this condition?

Metronidazole 250 mg tid for seven days

A 55-year-old woman presents with right finger pain. She reports she habitually bites her nails. On examination, the lateral nail fold and cuticle of the right ring finger is erythematous, fluctuant and tender to palpation. Which of the following is the most likely diagnosis?

Paronychia

A 45-year-old woman, who works as a day laborer, presents with epigastric abdominal pain that began one hour prior to arrival. She has been having abdominal discomfort after meals for the past several weeks. Today, she developed sudden onset, severe abdominal pain far worse than what she has been experiencing. She denies back pain, nausea, and vomiting. On exam, she is tachycardic but has otherwise normal vital signs. Her abdomen is significantly tender in the epigastric region with rebound and guarding. Chest X-ray is as above. What is the most likely diagnosis?

Perforated gastric ulcer

A 14-year-old boy presents complaining of intense pruritus in his groin, axillae, and between his fingers after returning home from 4-week summer camp one week ago. He reports several other campers had similar symptoms. On exam, you note excoriations in the inguinal region and axillae, surrounding scattered erythematous papules. Which of the following is the most appropriate treatment?

Permethrin

Which of the following types of traumatic events has the highest probability of resulting in post-traumatic stress disorder?

Rape

A 25-year-old man is brought to the emergency department by police for bizarre behavior. His family arrives and states that his behavior changed about eight months ago. He does not abuse drugs or alcohol. On examination, he has a flat affect and appears to be responding to internal stimuli. His speech is disorganized and he says, "I've been running from the Russians who are trying to steal my thoughts." His laboratory and urine studies are unremarkable. What is the most likely diagnosis?

Schizophrenia

A 54-year-old woman presents with a swollen knee. On examination, a large joint effusion is present. With which of the following spaces does the knee joint communicate?

Suprapatellar bursa

A 7-year-old girl presents to the ED with noisy breathing, fever, and drooling. On physical exam, she is in obvious respiratory distress with audible stridor at rest. Vital signs are BP 90/60 mm Hg, HR 150 beats/minute, RR 40 breaths/minute, and T 103.8°F. Which of the following are you likely to see on a lateral radiograph of the soft tissues of the neck?

Thumbprint sign

A 24-year-old woman presents to the emergency department with a headache and receives a lumbar puncture. She is eventually discharged home in improved condition, but returns 24 hours later with a worsened headache, now throbbing in nature, which is worse in the standing position and relieved in the supine position. Which of the following reduces the risk of post-lumbar puncture headache?

Using a higher gauge needle

A 30-year-old woman presents complaining of vaginal itching and irritation. She also complains of vaginal discharge. Which of the following supports a diagnosis of uncomplicated candidial vaginitis?

Vaginal pH < 4.5

A 57-year-old man presents to the ED with headache, blurred vision, and fatigue. His wife notes he has a "blood problem" that his doctor is monitoring. Which of the following underlying conditions is most frequently complicated by hyperviscosity syndrome?

Waldenstrom macroglobulinemia

A 55-year-old man presents with fever and right upper quadrant pain. On examination, you note that the patient is jaundiced and slightly altered. Clinically you make the diagnosis of cholangitis. Which of the following is the final component of Reynold's pentad?

Hypotension

A 42-year-old man with a history of alcohol abuse presents with severe abdominal pain and vomiting following an alcohol binge. Lab values are as follows: WBC 14,000, Hgb 10, platelets 98, lipase 9000, AST 200, ALT 107, T. bill 1.6, Na 134, K 5.1, Cr. 3.1, and glucose 313. Which of the following lab values is associated with increased mortality?

Glucose of 313

What is the most likely cause of acute anemia in an African-American patient with an HIV infection who recently began pneumocystis pneumonia prophylaxis?

Glucose-6-phosphate-dehydrogenase deficiency

A 26-year-old man presents to the ED after briefly losing consciousness when hit in the head by a foul baseball. The patient was initially alert and talking to you. He is now becoming progressively more somnolent. Which of the following would you expect to see on a non-contrast computed tomography scan of the head?

A lenticular-shaped hematoma in the temporal region

A 34-year-old woman presents to the ED with severe right eye pain. The pain began after she entered a dark movie theatre. On physical exam, you note a mid-dilated pupil (4 mm) and corneal edema. Which of the following is the correct combination of medications in the treatment for this process?

Acetazolamide IV, topical apraclonidine, topical timolol

A 61-year-old man with a history of severe chronic obstructive pulmonary disease presents with altered mental status. His oxygen saturation is 90% on 4 liters of oxygen via nasal cannula. A venous blood gas is obtained with the following results: pH: 7.15 pO2: 45 mm Hg pCO2: 100 mm Hg HCO3: 38 mEq/L The patient has which of the following acid-base disturbances?

Acute on chronic respiratory acidosis

A 52-year-old man with a history of diabetes mellitus and hypertension presents to the ED with palpitations and dyspnea that have been present intermittently over the past week. His vital signs include HR 150 beats/minute, blood pressure 136/87 mm Hg, RR 15 breaths/minute, and oxygen saturation of 97% on room air. His electrocardiogram is shown above. Which of the following is the most appropriate initial management?

Administer intravenous diltiazem

A 27-year-old previously healthy man comes to the ED with chest pain. He had a viral syndrome with a low-grade fever a few days earlier. He describes the chest pain as sharp, retrosternal in location, with radiation to the left trapezius ridge. It improves with sitting forward and worsens when he lays down. Vital signs are normal. His electrocardiogram is shown above. His initial cardiac biomarkers are negative. Which of the following treatments is most appropriate?

Administration of ibuprofen and colchicine and discharge home

A 6-year-old boy with a past medical history of glucose 6-phosphate dehydrogenase deficiency presents to the Emergency Department for a cough associated with vomiting. His parents state that he has been coughing every day for the last week. He is unimmunized but otherwise healthy. He appears well on exam with a dry cough and occasional wheezes. His laboratory workup reveals a leukocytosis with lymphocytic predominance and a chest X-ray with peribronchial thickening. Based on the suspected diagnosis, which of the following is the most appropriate therapy at this time?

Azithromycin

A 76-year-old man presents to the emergency department with shortness of breath and lightheadedness. Vital signs include blood pressure 70/56 mm Hg, heart rate 124 beats/minute, respiratory rate 22 breaths/minute, and temperature 37.6°C. He has distended neck veins and occasional dropped radial beats. His lungs are clear to auscultation, but his heart sounds are distant. He has some fullness to palpation of the right upper quadrant of his abdomen. Which of the following is the most appropriate diagnostic test?

Bedside echocardiography

A 28-year-old woman is brought to the clinic by her sister, who is concerned about her recent reckless behavior. The patient has been spending money excessively, acting sexually promiscuous, speaking delusionally, and has not slept for three days. The patient is visibly irritated by her sister's comments. The patient reports periods of depression in the past, which were untreated, but now feels "absolutely great." She is extremely talkative, easily distracted in her thought process, and reports several different grand new ideas, which she explains within the space of a ten-minute discussion. What is the most likely diagnosis?

Bipolar disorder

A 77-year-old woman presents to the ED with acute painless vision loss. On funduscopic exam, you note the above. Which of the following is the most likely diagnosis?

Central retinal artery occlusion

A 79-year-old man presents to the ED complaining of dyspnea. His rhythm strip is shown above. What is the most likely underlying process?

Chronic obstructive pulmonary disease

A 49-year-old woman presents with chest pain and shortness of breath. Her pain is constant, non-exertional and does not radiate into the back. She denies hemoptysis, history of previous venous thromboembolism, trauma or surgery within the last four weeks or unilateral leg swelling. She takes no medications. She smokes a half pack of cigarettes per day. Her vital signs at triage are temperature 98.6°F, blood pressure 120/80 mm Hg, and heart rate 108 bpm. Her heart rate improves to 97 bpm upon reevaluation. Her physician decides to evaluate her for a pulmonary embolism. In addition to an ECG and a chest X-ray, which of the following is the most appropriate next step in the diagnosis of pulmonary embolism?

D-dimer followed by a CT pulmonary angiogram if positive

41-year-old man with a long history of alcohol use disorder presents to the ED with several weeks of worsening shortness of breath and lower extremity edema. An echocardiogram shows biventricular chamber enlargement, increased systolic and diastolic volumes, and an ejection fraction of 35 percent. What is the most likely diagnosis?

Dilated cardiomyopathy

A 46-year-old woman without significant past medical history presents with drooping of the left side of her face which she noticed this morning when she looked into the mirror. She is unable to completely close her left eye and cannot raise her eyebrows on the left side. Her vision is intact. When asked to puff out her cheeks, air leaks out the left side. The rest of her neurologic exam is normal. Which of the following is the most appropriate initial management?

Discharge home with prednisone and eye lubricant and patch at night

Which of the following tests is used to diagnose benign paroxysmal positional vertigo?

Dix-Hallpike maneuver

A 32-year-old woman presents with dysuria and lower abdominal discomfort. She is sexually active with one male partner and uses condoms inconsistently. She denies vaginal bleeding or discharge, and her pelvic examination is unremarkable. Urinalysis shows 10 WBC/hpf with positive nitrites. Which of the following is the most likely causative organism?

E. coli

A 51-year-old man with a history of diabetes mellitus and hypertension presents with approximately 60 minutes of left-sided jaw pain that began while he was shoveling snow. Which of the following tests should be ordered?

Electrocardiogram

A 22-year-old woman presents with symmetric lower extremity weakness. She recently had a diarrheal illness. Which of the following might you expect on further work-up?

Elevated protein of the cerebrospinal fluid

A 32-year-old G0P0 woman presents with dull, crampy pelvic pain that has been intermittent over the last six months. She is currently menstruating and notes the pain seems to worsen with menses. She also reports pain with intercourse but denies any vaginal discharge. On examination, she is in no acute distress and is afebrile. She has scant blood in the vaginal vault and no significant focal tenderness. No masses are felt. Her pregnancy test is negative. What is the most likely diagnosis?

Endometriosis

A 59-year-old woman presents with pain and swelling of the face that began yesterday. She states that the symptoms began abruptly with a fever and chills. Physical exam reveals well-demarcated bright red, indurated skin in a malar distribution. The skin has a peau d'orange appearance. What is the most likely diagnosis?

Erysipelas

A 5-year-old boy presents to the emergency department complaining of right hip pain. He is febrile and refuses to bear weight on the right foot. There is no history of trauma. X-rays are obtained and are unremarkable. Which of the following diagnostic tests would best exclude a diagnosis of osteomyelitis?

Erythrocyte sedimentation rate

A 22-year-old woman who is sexually active with multiple partners presents with dysuria for two days. Urine pregnancy test is negative. Her urinalysis reveals 36 WBC/hpf and is nitrite and leukocyte esterase positive. She is diagnosed with cystitis. What is the most likely bacterial pathogen?

Escherichia coli

25-year-old woman with a history of hypertension presents to the emergency department after a syncopal event. She is complaining of lower abdominal pain. Her heart rate is 132 beats/minute and her blood pressure is 85/41 mm Hg. Her urine pregnancy test is positive. Which of the following is the most appropriate next step in management?

Establish intravenous access

A 32-year-old Nigerian man presents to the emergency department for blurry vision. He immigrated to the United States six months ago. He was diagnosed with a "lung disease" and was prescribed several medications in Nigeria. Which of the following agents is most likely responsible for his symptoms?

Ethambutol

An 8-year-old girl with a history of sickle cell anemia presents with diffuse pain consistent with an acute sickle cell pain crisis. While in the emergency department, she develops acute onset headache, right-sided facial droop, and right arm weakness. A CT scan confirms the diagnosis. Which of the following is the next best step in management?

Exchange transfusion

A 38-year-old man presents to the emergency department with low back pain that began this morning when he rolled over in bed. Throughout the day, he tried ibuprofen and acetaminophen without relief, which prompted him to come to the Emergency Department for further evaluation. Which of the following historical findings is an indication for further investigation?

Fever

A 34-year-old man presents to the emergency department with left arm pain after a fall on an outstretched hand while walking his dog. He has tenderness and swelling of the forearm as well as wrist pain with attempted pronation and supination. An X-ray is obtained as seen above. What eponym is associated with this fracture?

Galeazzi fracture

A 72-year-old man presents to the emergency department with left eye pain. Earlier this evening he was involved in a fistfight. He reports getting punched in the eye with no loss of consciousness. He now has eye pain and blurry vision. On physical exam his visual acuity is 20/50 in the left eye and 20/20 in the right eye. His intraocular pressure is 14 on the left. His left eye is shown above. What is the most likely diagnosis?

Hyphema

A 42-year-old man presents to the ED with racing heart rate and difficulty breathing. On physical exam, you note bilateral ocular proptosis and 3+ non-pitting edema of the bilateral lower extremities. His electrocardiogram is shown above. Which of the following complications of this disease is this patient most likely experiencing?

High output heart failure

A 65-year-old man presents to the ED with diffuse bone pain, abdominal cramping, and severe constipation. He is currently undergoing dialysis for end-stage renal disease but has not been to dialysis this week. Physical exam reveals a lethargic man with diffuse abdominal tenderness without rebound or guarding. Which of the following is the most likely etiology for his symptoms?

Hypercalcemia

A 23-year-old professional soccer player collapses during a match. He is pulseless, and cardiopulmonary resuscitation is initiated. Which of the following is the most common cause of sudden death in competitive athletes?

Hypertrophic cardiomyopathy

A 28-year-old woman presents with pain and swelling of her left breast, fever, and myalgias. She had a full-term vaginal delivery one week ago and is breastfeeding her infant. On examination, she has a temperature of 38.1°C. The superior lateral quadrant of the left breast is erythematous, warm, and tender to palpation. There is no fluctuance appreciated. What is the next step in management of this patient?

Instruct her to continue breastfeeding and start oral cephalexin

A 62-year-old woman was walking her dog when she began to experience intense substernal chest pressure. She became very diaphoretic and felt nauseated. She called 911 and was brought to the ED. Her electrocardiogram is shown above. Which of the following best describes the location of the patient's myocardial infarction?

Inferior

A 44-year-old woman presents to the emergency department with one week of crampy abdominal pain that is worse after she eats. She denies alcohol consumption or tobacco abuse. On physical examination, she is overweight and has epigastric and right upper quadrant abdominal tenderness to palpation. Which of the following examination findings is most consistent with cholecystitis?

Inspiratory arrest with right upper quadrant palpation

A 35-year-old woman presents to the ED with facial swelling. On physical exam, you note the above. Which of the following medications is most likely the cause of this process?

Lisinopril

A 44-year-old man with systemic lupus erythematosus presents to the ED with chest pain and dyspnea. Vital signs are notable for tachycardia and hypotension with a narrow pulse pressure. Bedside ultrasound confirms a large pericardial effusion with collapse of the right ventricle during diastole. Which classic electrocardiogram findings are associated with this disease process?

Low voltage and electrical alternans

An 80-year-old woman, with a history of type 2 diabetes mellitus, presents with slowly worsening vision. Her vision is worse in low-intensity light and she has blurring in the center of her vision. Physical examination shows intact peripheral visual fields with a positive Amsler grid distortion. Fundoscopic exam reveals drusen located in the macula of the retina. What is the most likely diagnosis?

Macular degeneration

A 46-year-old man with a history of diabetes mellitus and chronic alcohol use presents to the emergency department with lower back pain that has progressively worsened over the last five days. He denies a history of trauma. On examination, he has a temperature 37.9oC, heart rate 87 beats/minute, and blood pressure 146/75 mm Hg. He has tenderness with percussion over the midline lower lumbar spine. Achilles and patellar reflexes are intact. He has mild decreased sensation of both feet, but his strength is intact. What is the next best step in management?

Magnetic resonance imaging of the lumbosacral spine

A 60-year-old man with a history of chronic obstructive pulmonary disease presents by EMS in respiratory distress. He is diaphoretic and is sitting up in bed leaning forward. His vital signs are T 100.1°F, HR 95 beats/minutes, RR 30 breaths/minute, BP 150/90 mm Hg, and oxygen saturation 79% on room air. There is poor air movement with prolonged expiratory wheezes. A nonrebreather face mask is placed, but his work of breathing and oxygen saturation are not improving. In addition to intravenous glucocorticoid and nebulized beta-agonist medications, which of the following is most appropriate next step in management?

Noninvasive positive pressure ventilation

A 32-year-old woman presents with progressive fatigue, shortness of breath and chest discomfort that has worsened over the last two days. She had a mild upper respiratory infection last week but otherwise denies any significant past medical history. She does not take any medications and denies any illicit drug use. On examination, she has a temperature 37.9°C, heart rate 132 beats per minute, respiratory rate 16 breaths per minute, and oxygen saturation 98% on room air. Lungs are clear to auscultation. Chest radiograph demonstrates mild cardiomegaly without infiltrates. Electrocardiogram shows sinus tachycardia with nonspecific ST segment and T wave changes. Troponin is 0.25 ng/mL. What is the likely cause of her symptoms?

Myocarditis

A 74-year-old woman with a history of hypothyroidism presents to the ED with confusion, rigors, and lightheadedness. Vital signs are BP 110/64 mm Hg, HR 48 beats per minute, RR 12 breaths per minute, and T 95.2°F. Her electrocardiogram is shown above. Which of the following is the most likely diagnosis?

Myxedema coma

Which of the following is a known complication of chronic lithium toxicity?

Nephrogenic diabetes insipidus

Which of the following is more consistent with the diagnosis of encephalitis rather than meningitis?

New psychiatric symptom

A 50-year-old man presents to the emergency department with sudden onset of shortness of breath. He has a history of heart failure with an ejection fraction of 25%. Vital signs include temperature 100°F, blood pressure 220/110 mm Hg, heart rate 125 beats/minute, and respiratory rate 30 breaths/minute. On examination, he appears anxious and tachypneic. Chest X-ray demonstrates diffuse bilateral interstitial opacification. Which of the following is the most appropriate initial treatment?

Nitroglycerin

A 58-year-old man presents with chest pain. His electrocardiogram is shown above. A right-sided electrocardiogram is also performed and shows elevated ST segments in V4R and V5R. Which of the following medications is contraindicated?

Nitroglycerin

A 54-year-old woman with a history of hyperthyroidism presents to the ED with fever, vomiting, palpitations, and tremors. Which of the following would you expect to find on physical exam?

Ocular proptosis

Which of the following causes acute painful loss of vision?

Optic neuritis

A 27-year-old woman presents with chest pain. The patient reports that she was about to give a presentation at her job and suddenly had a feeling of impending doom. In addition to chest pain, she had palpitations and sweating. Which of the following is the most likely diagnosis?

Panic attack

A 22-year-old healthy man presents with acute onset pleuritic, left-sided chest pain and mild dyspnea. Social history includes smoking a pack of cigarettes a week. Vital signs include blood pressure 142/74 mm Hg, heart rate 82 beats/minute, and oxygen saturation 97% on room air. He is in no acute distress. His chest radiograph is shown above. Which of the following is the best next step in management?

Place patient on 100% oxygen and repeat chest radiograph in six hours

A 32-year-old woman, who is at 20 weeks gestational age, presents to the ED after a seizure. Her vital signs are BP 115/70 mm Hg, HR 105 bpm, RR 16/min, T 38.5°C, and pulse oximetry 98% on room air. On exam, you note some confusion, but otherwise there are no focal deficits. Lab results reveal a hemoglobin of 7 g/dL and platelets of 12,000/µL. A peripheral blood smear reveals schistocytes. Which of the following is the most appropriate treatment for her condition?

Plasmapheresis

A 65-year-old woman presents to the emergency department with acute onset vertigo. She denies associated decreased hearing or tinnitus. Vital signs are normal. Horizontal head impulse test shows a corrective saccade when the head is turned to the left. Dix-Hallpike maneuver elicits a leftward horizontal nystagmus that is fatigable. Which of the following mechanisms will provide the most definitive treatment of this condition?

Relocation of free floating otoconia

Which of the following is the most common injury seen in a child with severe blunt chest trauma such as being struck by a motor vehicle?

Pulmonary contusion

A 61-year-old woman with no past medical history or family history of heart disease presents with a trimalleolar ankle fracture after a fall. As part of her preoperative workup, an electrocardiogram is obtained. A portion of the rhythm strip is shown above. Which of the following is the most appropriate next step?

Reassure the patient and the orthopedic surgeon that no treatment is necessary

An 18-month-old boy presents to the emergency department with worsening shortness of breath. The parents report he has had a cough, runny nose, and fussiness for the past five days. On exam, the patient demonstrates subcostal retractions, tachypnea, and diffuse wheezing. The patient is given an albuterol nebulizer treatment without any improvement of his wheezing. Chest X-ray does not show any abnormality. Which of the following organisms is the most likely cause of his symptoms?

Respiratory syncytial virus

A 67-year-old man with a history of hypertension and diabetes mellitus presents to the emergency department with sudden onset of left leg weakness. His examination is notable for 3/5 strength in his left lower extremity as well as diminished sensation over his left toes, foot, and leg. He has a flat affect and appears slow in his speech. Which of the following vascular territories is most likely affected in this patient?

Right anterior cerebral artery

An 18-year-old man presents complaining of fever, right-sided abdominal pain, anorexia, and vomiting. When you palpate his left lower quadrant, he complains of pain in his right lower quadrant. Based on this information, which of the following signs is considered positive?

Rovsing sign

A 51-year-old man with a history of alcohol use presents with three days of anorexia, nausea, vomiting, and right upper quadrant abdominal pain. Vital signs are HR 115, BP 114/83, RR 20, and oxygen saturation 96% on room air. On physical examination, he appears jaundiced and tender hepatomegaly is noted. Liver function tests are notable for AST 433 IU/L, ALT 206 IU/L, and total bilirubin 8.0 mg/dL. INR is prolonged at 1.6. Which of the following is the appropriate treatment for this condition?

Supportive care

SupraspinatusSurgical consultation

Surgical consultation

A 56-year-old woman with a history of lung cancer presents to the emergency department with confusion, nausea, and vomiting. She is unable to provide much history due to her confusion. She is dehydrated and is oriented only to self. She is afebrile. Her renal function is normal. Her serum calcium level is 14 mg/dL. What is the most likely mechanism for her hypercalcemia?

Secretion of parathyroid hormone related protein from the tumor

A 39-year-old woman presents to the emergency department with right leg pain and mild swelling. She denies any previous medical history or trauma. She does not take any medication. Examination is remarkable for tenderness along the right calf venous distribution and minimal swelling of the right lower leg. What is the most appropriate diagnostic workup of this patient?

Send a D-dimer. If negative, the patient may be discharged.

A 33-year-old man presents with pain and swelling in his left knee since yesterday. He has also had a fever with a maximum temperature of 100.9°F. Physical exam reveals swelling of the left knee with erythema and warmth noted. There is pain with passive range of motion. What is the most likely diagnosis?

Septic arthritis

A 75-year-old man with a long-standing history of constipation presents complaining of abdominal pain for the last two days. He is now experiencing abdominal distention, constipation, and inability to pass gas for the last 12 hours. On examination, his abdomen is distended and tympanitic to percussion. You obtain an upright abdominal X-ray as seen above. What is the most likely diagnosis?

Sigmoid volvulus

A 93-year-old man on aspirin presents to the ED with epistaxis. On physical exam, you note bleeding from bilateral nares and down the posterior pharynx. You are unable to visualize the source of bleeding. Which of the following vessels is most likely the source of bleeding in this patient?

Sphenopalatine artery

An 18-month-old boy presents with his father for a cough and difficulty breathing. The father states that the child has had nasal congestion and coryza for the last two days. On exam, he has a barking cough, inspiratory stridor, and a prolonged inspiratory phase. Which of the following would you expect to see on radiographic evaluation?

Subglottic narrowing

A 30-year-old man presents to the emergency department with an ankle injury after he twisted his ankle when stepping off of the curb. The patient mainly complains of pain near the right lateral malleolus. Which of the following examination findings would be more indicative of an ankle sprain that would not require further diagnostic imaging?

Swelling over the bilateral malleoli

A 32-year-old man presents to the emergency department with complaints of fever and shortness of breath. On physical exam, he is noted to have coarse breath sounds bilaterally and a systolic murmur. A chest radiograph is obtained and shown above. Which of the following abnormalities is likely to be noted on echocardiogram?

Tricuspid valve vegetations

A 24-year-old woman presents with right thumb pain. She recently fell while skiing. On examination, she has swelling and tenderness over the base of the thumb on the ulnar side. She has weakness when pinching an object between her thumb and index finger. Which of the following structures is most likely to be injured?

Ulnar collateral ligament

A 25-year-old G1P0 woman at 38 weeks gestation presents to the ED after feeling a gush of fluid. On tocometry you note variable decelerations of the fetal heart rate. You perform a sterile vaginal exam and feel a pulsating mass protruding from the cervical os. Which of the following appropriately matches the diagnosis with the next step in management?

Umbilical cord prolapse, elevate presenting part

A 32-year-old woman presents to the emergency department with dysuria, back pain, and fever for two days. She indicates she has had urinary tract infections in the past but never this severe. She denies other past medical history and does not take any medications. Vital signs show HR 114, BP 132/80, R 16, T 102.2°F. Examination shows a moderately ill-appearing woman with right costovertebral angle tenderness. What test or tests are required in making an appropriate diagnosis in this patient?

Urinalysis

Which of the following is the most sensitive finding in cauda equina syndrome?

Urinary retention