Emergency

A 65-year-old woman is involved in a motor vehicle collision and sustains multiple left-sided rib fractures. Upon presentation to the ER her vital signs are stable and she is in no respiratory distress. Chest x-ray reveals fractures of ribs 4 to 7 on the left side without evidence of hemothorax or pneumothorax. She is admitted for observation and a few hours later she develops shortness of breath. A repeat chest x-ray demonstrates a well-defined infiltrate in her left lung. What is the most likely diagnosis?

Pulmonary contusion

A 24-year-old G2P0010 in her second trimester presents to the ED with vaginal spotting for the past day. She denies any abdominal pain and is otherwise in her usual state of health. Her vital signs are HR of 76 beats per minute, BP of 120/65 mm Hg, respiratory rate (RR) of 16 breaths per minute, and temperature 98.9°F. Which of the following conditions does this patient most likely have?

Placenta previa

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

Protect airway, administer acetaminophen, propranolol, and PTU.

A 19-year-old man is brought into the ED by paramedics with a stab wound to the right lower abdomen. The medics applied a pressure dressing and started an IV line en route to the hospital. On arrival, the patient has no complaints and wants to leave. His temperature is 98.4°F, BP is 130/95 mm Hg, HR is 111 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 98% on room air. He is alert and oriented to person, place, and time. His abdomen is soft and nontender, with normal bowel sounds. He has a 2-cm stab wound with visible subcutaneous fat in his right lower quadrant (RLQ). You initiate the focused abdominal sonogram for trauma (FAST) examination. Which type of fluid should you start for his initial resuscitation?

0.9% Sodium chloride

A 20-month-old child is brought to the ED because of fever and irritability and refusal to move his right lower extremity. Physical examination reveals a swollen and tender right knee that resists passive motion. Which of the following is the most likely to yield the diagnosis in this patient?

Examination of joint fluid

A 51-year-old man presents to the ED complaining of epigastric pain that radiates to his back. He states that he drinks a 6 pack of beer daily. You suspect he has pancreatitis. His BP is 135/75 mm Hg, HR is 90 beats per minute, temperature is 100.1°F, and his RR is 17 breaths per minute. Laboratory results reveal WBC 13,000/μL, hematocrit 48%, platelets 110/μL, amylase 1150 U/L, lipase 1450 IU, lactate dehydrogenase (LDH) 150 U/L, sodium 135 mEq/L, potassium 3.5 mEq/L, chloride 105 mEq/L, bicarbonate 23 mEq/L, BUN 15 mg/dL, creatinine 1.1 mg/dL, and glucose 125 mg/dL. Which of the following laboratory values are most specific for pancreatitis?

Elevated lipase

A 71-year-old man presents to the ED with diffuse, crampy abdominal pain that began 1 hour after eating lunch today. The pain is intermittent over the last 8 hours with increasing severity. He also complains of nausea and chills, and vomited once on his way to the ED. He has not had a bowel movement or flatus since the pain began. His past medical history includes prostate cancer, left total hip replacement, appendectomy 25 years ago, right iliac artery aneurysm repair 5 years ago, incisional hernia repair 4 years ago, and irritable bowel syndrome. Which of the following is the most common cause of SBO in adults?

Adhesion

A 52-year-old woman is brought to the ED by her husband for altered mental status for 1 day. The patient has hypertension and diabetes but has not been taking her medications for the last 5 days since she lost her insurance and could not afford her prescriptions. Her BP is 168/91 mm Hg, HR is 125 beats per minute, temperature is 99.8°F, and RR is 18 breaths per minute. Her fingerstick glucose is 900 mg/dL. There is glucose in her urine, but no ketones. Which of the following is the most appropriate next step in management?

Administer IV fluids and insulin

A 44-year-old woman returns from a mountain excursion with headache symptoms, nausea, and vomiting that are improving. Her initial vital signs in the ED are HR of 93 beats per minute, BP of 120/60 mm Hg, RR of 18 breaths per minute, and oxygen saturation of 96% on 2-L nasal cannula. Her chest examination is clear to auscultation with no palpable overlying crepitus and there are no signs of peripheral edema. Which of the following medications is indicated in this patient?

Acetazolamide

A 75-year-old man goes out to shovel snow from his driveway. After 5 minutes of shoveling, he feels short of breath, chest pain, and then passes out. He awakens minutes later to his wife shaking him. In the ED, he denies chest pain or dyspnea. His BP is 160/85 mm Hg, HR is 71 beats per minute, and oxygen saturation is 97% on room air. On examination, you hear a harsh systolic ejection murmur. An ECG reveals a sinus rhythm with left ventricular hypertrophy. Which of the following is the most likely diagnosis?

Aortic stenosis

A 60-year-old man is brought to the ED complaining of generalized crampy abdominal pain that occurs in waves. He has been vomiting intermittently over the last 6 hours. His BP is 150/75 mm Hg, HR is 90 beats per minute, temperature is 99.8°F, and his RR is 16 breaths per minute. On abdominal examination you notice an old midline scar the length of his abdomen that he states was from surgery after a gunshot wound as a teenager. The abdomen is distended with hyperactive bowel sounds and mild tenderness without rebound. An abdominal plain film confirms your diagnosis. Which of the following is the most appropriate next step in management?

Begin fluid resuscitation, bowel decompression with a nasogastric tube, and request a surgical consult.

A 6-month-old child is brought to the emergency room after having a generalized seizure at home. She is found to have a temperature of 102.5°F (39.16°C). Which of the following correctly reflects why this patient should be investigated with a spinal tap?

Children this age may have meningitis with no manifestations other than fever and seizures.

A 3-year-old girl is brought to the ED with acute onset of respiratory distress. She recently emigrated from Africa. Her initial vitals include HR of 115 beats per minute, BP of 110/60 mm Hg, and RR of 28 breaths per minute with oxygen saturation of 88% on room air. She is also febrile to 103.5°F. She is ill- and anxious-appearing, sitting forward in her mother's lap, and drooling. Her mother tells you that she had a sore throat that began 2 days prior and that she was going to see her pediatrician this week for her initial vaccinations. Given this patient's history and presentation, which of the following should be of particular concern?

Epiglottitis

A 20-year-old man presents to the ED with fever and severe right lower quadrant (RLQ) pain for 1 day. Prior to this episode, he reports 2 months of crampy abdominal pain, generalized malaise, a 10-lb weight loss, and occasional bloody diarrhea. On examination, his HR is 115 beats per minute, BP is 125/70 mm Hg, RR is 18 breaths per minute, and temperature is 100.8°F. His only significant past medical history is recurrent perirectal abscesses. On physical examination, the patient appears uncomfortable and has a tender mass in the RLQ, without guarding or rebound. Rectal examination is positive for trace heme-positive stool. An abdominal computed tomography (CT) scan reveals no peri-appendiceal fat stranding. There is inflammation of the distal ileum and several areas of the colon. There are no rectal inflammatory changes. Which of the following is the most likely diagnosis?

Crohn disease (CD)

A 27-year-old man undergoes general anesthesia for a hernia repair. As the anesthesia begins, his jaw muscles tense and he becomes generally rigid. He becomes febrile, tachycardic, and tachypneic. Intravenous administration of which of the following agents may be lifesaving?

Dantrolene

A 25-year-old woman arrives in the ER following an automobile accident. She is acutely dyspneic with a respiratory rate of 60 breaths per minute. Breath sounds are markedly diminished on the right side. Which of the following is the best first step in the management of this patient?

Decompress the right pleural space

A 40-year-old man who is an employee of the hospital is brought to the ED actively seizing. A coworker states that the patient has a known seizure disorder and currently takes phenytoin for the disorder. He also tells you that the patient has been under stress recently and may not have taken his last few doses of medication. You call for the nurse to place a face mask with 100% oxygen and gain IV access. You then ask for a medication to be drawn up. Which is the most appropriate initial medication you should administer in this actively seizing patient?

Diazepam

A 6-year-old boy had been in his normal state of good health until a few hours prior to presentation to the ER room. His mother reports that he began to have difficulty walking, and she noticed that he was falling and unable to maintain his balance. Which of the following is the most likely cause for his condition?

Drug intoxication

A 17-year-old boy is brought to the emergency department by his parents with the complaint of coughing up blood. He is stabilized, and his hemoglobin and hematocrit levels are 11 mg/dL and 33%, respectively. During his hospitalization, he is noted to have systolic blood pressure persistently greater than 130 mm Hg and diastolic blood pressure greater than 90 mm Hg. His urinalysis is remarkable for hematuria and proteinuria. You are suspicious the patient has which of the following?

Goodpasture syndrome

A 68-year-old man presents to the ED complaining of a daily headache for almost a month. He describes the headache as being dull, difficult to localize, most intense in the morning, and abating in the early afternoon. He also noticed progressive weakness of his right upper and lower extremity. Which of the following headache syndromes are the signs and symptoms most consistent with?

Headache caused by a mass lesion

A 70-year-old man presents to the ER with several fractures and a ruptured spleen after falling 20 ft. Which of the following best represents his body's response to the injury?

Hepatic synthesis of acute-phase reactants

A 19-year-old woman presents to the ED with 1 hour of acute onset progressively worsening pain in her RLQ. She developed nausea shortly after the pain and vomited twice over the last hour. She had similar but less severe pain 2 weeks ago that resolved spontaneously. Her BP is 123/78 mm Hg, HR is 99 beats per minute, temperature is 99.1°F, and her RR is 16 breaths per minute. On physical examination, the patient appears uncomfortable, not moving on the gurney. Her abdomen is nondistended, diffusely tender, worst in the RLQ. Pelvic examination reveals a normal sized uterus and moderate right-sided adnexal tenderness. Laboratory results reveal WBC 10,000/μL, hematocrit 38%, and a negative urinalysis and β-hCG. Pelvic ultrasound reveals an enlarged right ovary with decreased flow. Which of the following is the most appropriate management for this patient?

Immediate laparoscopic surgery

A 71-year-old woman is brought to the emergency room by her daughter because of sudden onset of right-sided weakness and slurred speech. The patient, a recent immigrant from Southeast Asia, has not seen a doctor in 2 decades. Her symptoms began 75 minutes ago while she was eating breakfast. A stat noncontrast CT scan of the head is normal. Labs are normal. Physical examination reveals an anxious appearing woman with dense hemiplegia of the R upper and lower extremities. Deep tendon reflexes are not discernible on the R side and 2+ on the left. Aspirin has been given. What is the best next step in management of this patient?

Immediate thrombolytic therapy

A 63-year-old man presents to the emergency room with a right hemiparesis and nonfluent aphasia that began acutely 45 minutes ago. Blood pressure is 160/80 mm Hg, coagulation studies are normal, and there is no recent history of bleeding. A head CT scan shows no evidence of intracranial hemorrhage. Which of the following is the most appropriate therapy at this point?

Intravenous rTPA

A 45-year-old alcoholic man with a history of blackouts when intoxicated presents with fever, chills, and cough productive of putrid, foul-smelling sputum. On physical examination the patient appears inebriated. He is febrile with a temperature of 39.5°C (103.2°F). Mouth examination reveals numerous dental caries and poor dental hygiene. Which of the following is the most likely diagnosis?

Lung abscess

A 53-year-old man presents to your ED stating he has had an excruciating right-sided headache since leaving the movie theater. He states that the headache is unilateral, severe, and associated with nausea and vomiting. His vision is blurry and notes seeing halos around objects. He denies trauma or a history of headaches in the past. Physical examination reveals right conjunctival injection and a pupil that reacts only marginally. Which examination is likely to yield the correct diagnosis?

Measurement of intraocular pressure

A 37-year-old woman is brought into the ED by her friend who states that the patient swallowed approximately 50 capsules of 325-mg acetaminophen 6 hours ago in an attempted suicide. The patient states she feels nauseated and vomits while you take her history. Her BP is 100/75 mm Hg, HR is 97 beats per minute, temperature is 98.9°F, RR is 18 breaths per minute, and oxygen saturation is 99% on room air. Examination is unremarkable except for mild epigastric tenderness. Which of the following is the correct antidote for APAP overdose?

NAC

A 78-year-old woman is transferred from a nursing home with altered mental status and fever. The nursing home reports that the patient was febrile to 102.3°F, disoriented, confused, and incontinent of urine. Her past medical history includes hypertension, a stroke with residual right-sided weakness, and nighttime agitation for which she was started on haloperidol 3 days ago. Her BP is 215/105 mm Hg, HR is 132 beats per minute, temperature is 102.8°F, and RR is 20 breaths per minute. On examination, the patient is oriented to name only, tremulous, diaphoretic and has marked muscular rigidity and three out of five right upper and lower extremity strength. What is the most likely diagnosis?

Neuroleptic malignant syndrome

A 55-year-old man presents to the ED at 2:00 AM with left-sided chest pain that radiates down his left arm. He takes a β-blocker for hypertension, a proton-pump inhibitor for gastroesophageal reflux disease, and an antilipid agent for high cholesterol. He also took sildenafil the previous night for erectile dysfunction. His BP is 130/70 mm Hg and HR is 77 beats per minute. Which of the following medication is contraindicated in this patient?

Nitroglycerin

A 9-month-old is brought to the emergency center by ambulance. The child had been having emesis and diarrhea with decreased urine output for several days, and the parents noted that she was hard to wake up this morning. Her weight is 9 kg, down from 11 kg the week prior at her 9-month checkup. You note her heart rate and blood pressure to be normal. She is lethargic, and her skin is noted to be "doughy." After confirming that her respiratory status is stable, you send electrolytes, which you expect to be abnormal. You start an IV. Which of the following is the best solution for an initial IV bolus?

Normal saline (154 mEq sodium/L)

A 32-year-old woman presents to the ED with a persistent fever of 101°F over the last 3 days. The patient states that she used to work as a convenience store clerk but was fired 2 weeks ago. Since then, she has been using drugs intravenously daily. Cardiac examination reveals a heart murmur. Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal white blood cells (WBC) 14,000/μL with 91% neutrophils, hematocrit 33%, and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart block. Which of the following is the most appropriate next step in management?

Obtain four sets of blood cultures, order a transthoracic echocardiogram (TTE), and start antibiotic treatment.

The parents of a 2-year-old bring her to the emergency center after she had a seizure. Although the parents report she was in a good state of health, the vital signs in the emergency center reveal a temperature of 39°C (102.2°F). She is now running around the room. Which part of the story would suggest the best outcome in this condition?

Otitis media on examination.

Hg, HR 107 beats per minute, temperature 99.7°F, RR 18 breaths per minute, and oxygen saturation 99% on room air. Physical examination is unremarkable except for cool, diaphoretic skin, persistent vertical and horizontal nystagmus, and occasional myoclonic jerks. Which of the following is the most likely diagnosis?

PCP intoxication

An 8-year-old sickle-cell patient arrives at the emergency room (ER) in respiratory distress. Over the previous several days, the child has become progressively tired and pale. The child's hemoglobin concentration in the ER is 3.1 mg/dL. Which of the following viruses commonly causes such a clinical picture?

Parvovirus B19

A 5-month-old boy, ex-34 week preemie, is brought to the ED by his mother who reports that the infant has been breathing with extra effort for the last 2 days. He has no other past medical history and is current on immunizations having received the full course of vaccines at both 2 and 4 months. The mom reports the child has had rhinorrhea and a cough. Upon physical examination, the patient has a temperature of 101.1°F, HR 160 beats per minute, RR 70 breaths per minute, pulse oximetry of 87% on room air. The infant has copious nasal discharge, audible wheezing with diffuse rhonchi and rales upon chest auscultation. He also has intercostal retractions and nasal flaring. A chest radiograph shows increased perihilar markings, hyperinflation and diffuse patchy areas of atelectasis versus infiltrates. Given this patient's history and physical examination, which of the following is the most likely etiology of his symptoms?

Respiratory syncytial virus (RSV)

A 29-year-old man presents to the ED complaining of RLQ pain for 24 hours. He states that the pain first began as a dull feeling around his umbilicus and slowly migrated to his right side. He has no appetite, is nauseated, and vomited twice. His BP is 130/75 mm Hg, HR is 95 beats per minute, temperature is 100.9°F, and his RR is 16 breaths per minute. His WBC is 14,000/μL. As you palpate the LLQ of the patient's abdomen, he states that his RLQ is painful. What is the name of this sign?

Rovsing sign

A 26-year-old woman presents to the ED with a history of spilling hot soup over her left arm earlier in the day. She states that she immediately put her hand under cold water and applied ice. Upon physical examination, the involved area covers the dorsum of her hand and extends up to the middle of her forearm with no circumferential or digital involvement. She can freely flex and extend all joints of that upper extremity. In addition, two large fluid-filled bullae are noted in the area of the forearm. What is the burn degree and relative area of involvement in this patient?

Second-degree/2.25%

A 58-year-old woman is brought in to the ED after a witnessed syncopal event. Upon arrival, the patient appears confused and agitated. Her vitals include HR of 89 beats per minute, BP of 145/70 mm Hg, RR of 16 breaths per minute, and oxygen saturation of 98% on room air. Within a few minutes, the patient is more alert and oriented. She denies any chest pain, headache, abdominal pain, or weakness preceding the event and is currently asymptomatic. She also states that she has not taken her antiepileptic medications in 2 days. The patient's examination is unremarkable including a nonfocal neurological examination. Given this patient's history and evolving examination, what is the most likely etiology of this patient's syncopal event?

Seizure

An 85-year-old man is rambling incoherently and not eating at his nursing home. Records indicate that he has a past medical history of hypertension, diabetes, dementia, and benign prostatic hypertrophy. On arrival to the ED, the patient is combative and oriented only to name. His temperature is 101°F rectally, BP is 85/50 mm Hg, HR is 125 beats per minute, RR is 22 breaths per minute, and blood sugar is 154 mg/dL. He appears uncomfortable and cachectic. His lungs are clear to auscultation, with scant crackles at the bases, and his abdomen is soft, nontender, and nondistended. He has a Foley catheter in place draining cloudy, white urine. He has no peripheral edema. Which of the following is the most likely diagnosis?

Septic shock

A 43-year-old man, who currently uses drugs intravenously (IV), presents to the emergency department (ED) with 2 weeks of fever, back pain, and progressive weakness in his arms bilaterally. He reports having a cough with whitish sputum. He denies any history of recent trauma. His blood pressure (BP) is 130/75 mm Hg, heart rate (HR) is 106 beats per minute, temperature is 103°F, and respiratory rate (RR) is 16 breaths per minute. On physical examination, he has tenderness to palpation in the mid-thoracic spine, and decreased strength in the upper extremities bilaterally, with normal range of motion. Laboratory results reveal a white blood cell (WBC) count of 15,500/μL, hematocrit 40%, and platelets 225/μL. Which of the following is the most likely diagnosis?

Spinal epidural abscess

A 67-year-old woman is brought to the ED by paramedics complaining of dyspnea, fatigue, and palpitations. Her BP is 80/50 mm Hg, heart is 139 beats per minute, and RR is 20 breaths per minute. Her skin is cool and she is diaphoretic. Her lung examination reveals bilateral crackles and she is beginning to have chest pain. Her ECG shows a narrow complex irregular rhythm with a rate in the 140s. Which of the following is the most appropriate immediate treatment for this patient?

Synchronized cardioversion

As you palpate the right upper quadrant (RUQ) of a 38-year-old woman's abdomen, you notice that she stops her inspiration for a brief moment. During the history, the patient states that over the last 2 days she gets pain in her RUQ that radiates to her back shortly after eating. Her vitals include a temperature of 100.4°F, HR of 95 beats per minute, BP of 130/75 mm Hg, RR of 16 breaths per minute. What is the initial diagnostic modality of choice for this disorder?

Ultrasonography

A 3-day-old infant born at home is brought to the emergency center with bloody stools, hematemesis, and purpura. His circumcision is oozing blood. Choose the one most appropriate vitamin or trace element—replacement therapy to treat this condition.

Vitamin K