ER part 1 of 4

Sigmoidoscopy dx:Sigmoid volvulus

92-year-old man from a nursing home presents with constipation. On physical examination, his abdomen is tympanitic, distended, and tender to palpation. An X-ray demonstrates a single, large distended loop of bowel as shown above. What is the most appropriate next step?

An 18-year old woman is diagnosed with a spontaneous first trimester complete abortion at 10 weeks. Her blood type is found to be O-negative. She does not know the father's blood type. Which of the following is true?

Anti-D immune globulin must be administered within 72 hours to be effective in preventing Rh-isoimmunization

A 60-year-old woman presents to the emergency department for progressive, bilateral hand and finger pain. While evaluating her, which of the following would be most suggestive of a diagnosis of osteoarthritis?

Bony, hard swelling of the distal interphalangeal joints dx:Osteoarthritis

Which combination of findings prior to treatment is most likely to indicate the diagnosis of hyperosmolar hyperglycemic state?

Confused mental status, signs of hypoperfusion, poor skin turgor, blood glucose 700 mg/dL, trace urine ketones, serum sodium of 140 mmol/L

What is the most common presentation of Hodgkin lymphoma in a 17-year-old boy?

Painless cervical lymphadenopathy

Which of the following drugs can cause hypothyroidism in either therapeutic usage or overdose?

Lithium

A 67-year-old woman presents with generalized fatigue and malaise for the past week. She also notes melenic stool for the past few months. Her vital signs include HR of 112 bpm, BP of 105/37 mm Hg, and RR of 15/minute. Laboratory studies show a hemoglobin level of 4.0 g/dL and platelet count of 110,000/µL. How many units of packed red blood cells should be given to raise her hemoglobin level to 8 g/dL?

4 units

Lisfranc injury Any widening or malalignment > 1 mm in these areas is considered pathological. In addition, any fractures of the proximal metatarsals should be concerning for a possible Lisfranc injury. Initial treatment consists of immobilization with a short-leg cast, elevation, and pain control. The patient should be non-weight bearing. Orthopedic consultation is necessary.

42-year-old man presents with pain in his foot after falling while descending the stairs. He is unable to bear weight on the foot. Pulses and sensation are intact. He has pain with palpation of the midfoot and a small area of ecchymosis on the plantar surface of the foot. His X-ray is shown above. What is the likely diagnosis?

Mycoplasma pneumoniae ==================================================================== Haemophilus influenzae (A) and Streptococcus pneumoniae (D) are both organisms classically described in typical pneumonia. These organisms are more likely to cause lobar pneumonia, and usually patients have a more severe presentation with fevers, tachypnea, and shortness of breath. Mycoplasma pneumoniae: young Legionella: smokers, aerosolized water, air travel, GI symptoms, hyponatremia Chlamydophila pneumoniae: close quarters outbreaks, young, follows pharyngitis Coxiella burnetii: livestock exposure, include LFTs Chlamydophila psittaci: bird exposure, hyperpyrexia, severe HA

A 16-year-old boy presents to the local urgent care with cough and chest pain. He states his symptoms started 14 days ago and have been constant since. He reports no improvement or worsening of symptoms, nor any nausea, vomiting, or diarrhea associated with his cough. His past medical history is unremarkable. The chest pain is described as a sharp retrosternal pain that is worsened with coughing. Vital signs and physical examination are both normal. Chest X-ray is performed and shown above. What is the most likely causative organism? AHaemophilus influenzae BLegionella CMycoplasma pneumoniae DStreptococcus pneumoniae

Cardiology consultation and admission possible dx : HOCM

A 23-year-old man presents with a syncopal event while running. His ECG is shown above. Physical examination is unremarkable as are a CBC and basic metabolic panel. What management is required for the patient?

Ciprofloxacin ophthalmic solution Corneal abrasions

A 23-year-old woman who wears contacts presents to the emergency department with left eye pain that started while she was cutting wood with a power saw. On examination, her left eye is injected and tearful, and she prefers to keep her eyelid closed. Fluorescein staining reveals the findings seen in the above image. Which of the following is the most appropriate initial treatment?

Perform pericardiocentesis ECG will typically show low voltage and may demonstrate the classic finding of electrical alternans.

A 48-year-old woman with a history of lupus and thromboembolic disease presents to the emergency department with a 6-day history of chest pain and shortness of breath. Vital signs are remarkable for BP 85/40 mm Hg, RR 30/min, and pulse oximetry 91%. JVD and tachycardia with clear breath sounds are noted on examination. ECG is performed and is demonstrated above. Which of the following is the best next step in management?

Epinephrine 1 mg IV dx:Ventricular fibrillation

A 59-year-old man with hypertension and coronary artery disease presents to the ED unresponsive. He is placed on a cardiac monitor, which reveals the rhythm shown above. While preparing to defibrillate, which of the following therapies is indicated at this time?

Which of the following patients may obtain the most benefit from treatment with oseltamivir twice a day for 5 days during influenza season? AA 50-year-old man with a history of hypertension and high cholesterol diagnosed with influenza A after 3 days of symptoms BA 73-year-old woman with a history of arthritis diagnosed with influenza A after 3 days of symptoms CA 9-year-old healthy boy diagnosed with influenza A after 3 days of symptoms DAn asymptomatic 35-year-old woman with two children at home who are ill with influenza A for 1 day

A 73-year-old woman with a history of arthritis diagnosed with influenza A after 3 days of symptoms =================================== The 50-year-old man with a history of hypertension and high cholesterol diagnosed with influenza after 3 days of symptoms (A) would not meet high-risk criteria based on his age and chronic medical conditions, and he has had symptoms for more than 48 hours. A 9-year-old healthy boy who has had symptoms for 3 days (C) also would not benefit as much from treatment with antiviral therapy because of his age and health status. He has a low risk of complications. Additionally, he has had symptoms for 3 days. Finally, an asymptomatic 35-year-old woman with two children at home with influenza for 1 day (D) would not benefit from treatment with antivirals since she is asymptomatic. She may be considered for preventative therapy instead.

Supportive care dxMultifocal atrial tachycardia (MAT) is an irregular rhythm resulting from at least three different atrial foci

A 75-year-old man presents to the emergency department with dyspnea. He has a history of COPD, hypertension, hyperlipidemia, and coronary artery disease. He has recently been fighting an upper respiratory infection and found he needed to use his albuterol inhaler more frequently. Today he started experiencing worsening shortness of breath and decided to come in for evaluation. Vital signs are remarkable for HR 120 bpm, BP 130/80 mm Hg, RR 28/minute, and oxygen saturation 87%. A rhythm strip is shown above. What is the best next step in management?

A 65-year-old asymptomatic man is noted to have a murmur on cardiac auscultation. Which of the following findings is suggestive of chronic mitral regurgitation?

A holosystolic murmur with radiation to the axilla

Which of the following patient history elements is most indicative of cardiac syncope?

Absence of a postdrome -------------------------------------------------------- Postevent confusion (B), or a postictal phase, is indicative of a seizure as opposed to a true episode of syncope. Cardiac syncope does not typically have any prolonged postdromal symptoms. A prodrome with dizziness and nausea (C) and provocation with prolonged standing (D) are findings seen with vasovagal etiologies of syncope and are typically absent in cardiac causes.

A 22-year-old man who was pitching a baseball game presents to the emergency department by ambulance after being struck in the head by a batted baseball thirty minutes prior to arrival. The paramedics report that the patient was conscious and alert on their arrival but that his teammates noted he was unconscious for a short period of time on the pitcher's mound after being struck. One of his teammates also informed the paramedics that the patient has a history of Christmas disease. On arrival, the patient's vital signs include a heart rate of 108 bpm, respiratory rate of 18 breaths/minute, a blood pressure of 144/96 mm Hg, and he is estimated to weigh 70 kg. His GCS is 11; he responds to loud verbal stimuli, but is slow to answer questions posed to him. Physical examination is notable for a large, tender, ecchymotic region along his left temporal bone. What is the appropriate course of management?

Administer 7,000 units of factor IX, followed by a noncontrast CT of his head dx: hemophilia B

A 24-year-old woman with a history of developmental delay and generalized anxiety disorder presents with crying, intermittent yelling, and retching. Her vital signs are significant for a heart rate of 104 bpm. She is inconsolable and unable to provide significant history due to agitation. She reports no pain but tells you her chest feels tight and she cannot breathe. Her lungs are clear to auscultation. What is the most effective management?

Administer IV lorazepam panic attack

A 45-year-old man presents to the emergency department for a headache. He has a history of diabetes mellitus type 1, hypertension, and alcohol use disorder. He states he started feeling unwell 3 days ago, and the headache started this morning. He also reports having blurred vision and nausea without vomiting and no chest pain or shortness of breath. Vital signs are remarkable for a temperature of 39°C, HR 115 bpm, BP 100/60 mm Hg, RR 23 breaths/min, and SpO2 of 97%. Physical examination is remarkable for a man who appears lethargic. Upon passively flexing the patient's neck.he flexes at the hips and knees. Which of the following sequences is the best next step in this patient's management?

Administer ceftriaxone, ampicillin, and vancomycin; CT head; lumbar puncture Meningitis

A 66-year-old man presents with chest pain. He has a history of hypertension and coronary artery disease. His symptoms started acutely 30 minutes prior to arrival and have been constant and worsening since. He rates the pain a 10/10 and describes it as sharp and severe. He is also now complaining of numbness in his left hand. Vital signs are significant for HR 120 bpm, BP 210/120 mm Hg, RR 20/min, and oxygen saturation of 99%. The examination is remarkable for a man who is in severe distress and grossly diaphoretic. He has clear breath sounds bilaterally and is tachycardic. A neurologic exam reveals 3/5 strength in the left upper extremity compared to 5/5 strength in the right upper extremity with sensory deficits in the left upper extremity compared to the right. The exam is otherwise unremarkable. ECG is performed and is shown above. What is the next step in management? AActivate catheterization lab BAdminister esmolol CCT angiography of the chest DNoncontrast CT of the head

Administer esmolol dx:Aortic dissection

A 14-year-old boy presents to the ED with severe abdominal pain. You notice a painful papule on his right arm where he said he was bit by something when he was working in the garage. On physical exam, his abdomen is rigid. Vital signs are BP 140/90 mm Hg, HR 120 bpm, RR 18/min, and T 98.4°F (36.7°C). Which of the following is the most appropriate next step in management?

Administer intravenous lorazepam dx: black widow spider envenomation almost universally supportive with analgesia and benzodiazepines such as lorazepam for cramping. Antivenin should be reserved only for the most severe symptoms due to the risk of anaphylaxis and serum sickness as it is derived from equine serum.

A 48-year-old man presents to the clinic with intermittent chest pain and pressure over the past two months. The pain is of an aching quality and does not radiate. Nothing seems to aggravate or alleviate the pain. He can also feel his heart beating rapidly during these episodes, which he does not experience at other times. He notes feeling a bit short of breath at random times of the day and has a mild cough. He denies fever, nausea or vomiting, dizziness, or loss of consciousness. He has no history of blood clots and he has not been recently hospitalized. Vital signs include BP 143/90 mm Hg, HR 90 bpm, RR 18/minute, and O2 saturation 95%. There is jugular venous distention of 4 cm bilaterally. Cardiac auscultation reveals a distant S1 and S2 without murmurs, rubs, or gallops. Auscultation of the lungs reveal mild crackles at the lung bases. An electrocardiogram is performed which reveals diffuse low QRS voltage. No ST changes or Q waves are seen. A chest X-ray shows enlargement of the cardiac outline in a water bottle-like shape and blunting of the costophrenic angles. The patient's troponin and D-dimer levels are negative. Which pattern on the electrocardiogram suggests that the patient's condition is progressing to cardiac tamponade?

Alternating high and low QRS complex amplitudes Pericardial Tamponade Patient presents with dyspnea and chest pain PE will show muffled heart sounds, JVD, hypotension (Beck triad), pulsus paradoxus ECG will show low-voltage QRS, electrical alternans EchocardiographyDiastolic collapse of RA (highly sensitive and specific)Early diastolic collapse of RV (less sensitive but very specific) Treatment is pericardiocentesis

A 21-year-old man presents with a cough and fevers. He describes the cough as productive of green sputum that began 3 days ago, and he has had intermittent fevers since then. He reports no myalgias, chest pain, or dyspnea. He has no pertinent past medical history and is up to date on vaccinations. He attends college at the local university. His vital signs include a BP of 110/69 mm Hg, HR of 92 bpm, T of 101.1°F, and RR of 18 breaths/min. Chest X-ray reveals a left lower lobe hazy infiltrate without an effusion. Which of the following is the most appropriate initial antibiotic choice for this patient?

Amoxicillin dx:Community-acquired pneumonia (CAP

A 43-year-old woman presents with a complaint of 11 days of sinus congestion and nasal drainage. The patient reports that she had a sore throat, cough, and runny nose in the preceding week, which initially seemed to improve but now seems to be worsening for the last seven days. She notes that now her right maxillary area is painful and her upper teeth hurt on the right side. The postnasal drainage has a foul taste. She reports she has a similar infection every year around this time. Temperature is 101.2°F, blood pressure is 124/69 mm Hg, heart rate is 73 bpm, and oxygen saturation is 99% on room air. Her examination reveals tenderness to percussion over her sinuses. Which of the following is the most appropriate initial therapy?

Amoxicillin-clavulanate 875 mg/125 mg orally twice daily dx:acute sinusitis following symptoms: nasal congestion, inability to smell, facial pain or pressure, and mucopurulent nasal discharge. Symptoms may also include foul breath, tooth pain, fever, and worsening facial pain when bending forward. Symptoms commonly present after a recent viral upper respiratory tract infection. Sx: nasal congestion, pain or pressure over sinuses, ear pain or pressure, headache, fever PE: purulent rhinorrhea Most commonly caused by viral URIIf viral, tx: supportive care Bacterial sinusitis: purulent nasal secretions and severe symptoms for ≥ 10 daysAmoxicillin or Amoxicillin-clavulanate

A 13-year-old girl presents complaining of sudden onset right-sided facial swelling associated with a foul taste in her mouth. Physical exam reveals an underweight teenage girl. She has difficulty opening her mouth and the oropharynx is clear without swelling or exudates. There is swelling and tenderness to the right preauricular space, extending beyond the angle of the mandible. Temperature is 39.7°C, blood pressure is 114/64 mm Hg. Which of the following is the most appropriate treatment for this patient?

Ampicillin/sulbactam acute bacterial parotitis.

A 30-year-old healthy woman presents to the emergency department for severe perianal pain and difficulty with defecation for one day, which is not associated with fever, bleeding, or decreased oral intake. Examination is significant for a purple-colored mass external to the anal verge that is firm and tender. Which of the following is the best management of this patient's condition?

Anesthetize the lesion and evacuate with elliptical incision dx: thrombosed external hemorrhoid. Acutely thrombosed hemorrhoids (for less than 48 hours) with severe symptoms in healthy patients can be treated by anesthetizing the lesion and evacuating with an elliptical incision.

A 65-year-old man presents in acute respiratory distress. He has a history of hypertension, hyperlipidemia, and coronary artery disease. Paramedics state they were told his symptoms started abruptly 20 minutes prior to arrival. Vital signs include a BP of 180/60 mm Hg, HR 120 bpm, RR 35/min, and oxygen saturation of 85%. The physical exam is remarkable for a man in severe respiratory distress with rales noted bilaterally. Accessory muscle use, tachypnea, and tachycardia are also noted. A high-pitched blowing murmur occurring after S2 is heard best along the left sternal borderin the third intercostal space. Which of the following is the most likely diagnosis?

Aortic regurgitation

A 66-year-old woman presents for acute headache. She has a history of hypertension and migraines. She states the headache started suddenly after walking into a movie theater. She has associated nausea and vomiting and states she has never had anything like this in the past. Physical examination is remarkable for the finding noted above. What is the best first step in the treatment of the patient above?

Apraclonidine acute angle-closure glaucom the lens or the peripheral iris blocks the trabecular meshwork, obstructing the outflow of aqueous humor and resulting in a rapid increase in intraocular pressure. A topical beta-blocker and alpha-agonist,such as timolol and apraclonidine, respectively, along with acetazolamide, should be given immediately.Emergency consultation with ophthalmology should occur, as patients will likely require more definitive care.

A 67-year-old man with a history of coronary artery disease and congestive heart failure presents to the emergency department with 3 days of palpitations and fatigue. A rhythm strip is obtained and shown above. Which of the following is the most likely diagnosis?

Atrial flutter due to underlying structural heart disease such as heart failure, chronic obstructive pulmonary disease (COPD), or obstructive sleep apnea (OSA), one ventricular beat indicated by the QRS complex. Therefore, the atrial flutter in the electrocardiogram is 2:1. Treatment: cardioversion if unstable, rate control, ablation of foci What is the treatment for rate control of rapid atrial flutter in a stable patient? Answer: A non-dihydropyridine calcium channel blocker or a beta-blocker.

A 35-year-old woman presents to the emergency department with complaints of fatigue, weakness, and shortness of breath. Symptoms started about a month ago when she began to have trouble keeping her eyes open towards the end of the day. Over the last few days she has noted overall weakness and shortness of breath. Vital signs including a respiratory rate of 16 breaths/minute and 96% SpO2. You note bilateral ptosis and clear lung sounds. Ice bags were applied to the eyes for two minutes. After the ice bags were removed, the distance between her upper and lower eyelids had improved by greater than 2 mm. Which of the following describes the pathophysiology of the most likely underlying diagnosis?

Autoimmune destruction of acetylcholine receptors on the postsynaptic membrane Myasthenia gravis fatigue develops. Fatigue and muscular weakness are the hallmarks of myasthenia gravis. Ocular symptoms are often the first manifestation improves with rest

A 62-year-old woman with a history of COPD presents with shortness of breath. She states she has a chronic cough, but this week, she has had increased sputum production and worsening dyspnea with activity. She denies any prior hospitalizations for COPD. On examination, she speaks in complete sentences and has diffuse expiratory wheezing with moderate air movement. Her vital signs are within normal limits other than a respiratory rate of 22 breaths/minute. Chest X-ray is negative for acute changes. She is treated with nebulized albuterol and ipratropium and oral prednisone with significant improvement such that she requests discharge. In addition to a short course of steroids and inhaled bronchodilators, which of the following should be prescribed?

Azithromycin acute COPD exasperation

A 65-year-old man with hypertension presents to the emergency department for a progressive skin nodule on his face for several months. Examination reveals a 1 cm skin-colored lesion with raised pearly margins and visible vessels on his left cheek. He reports no other associated symptoms or lesions. Which of the following is the most likely diagnosis?

Basal cell carcinoma Most common type of skin cancer ================================================== Kerion (B) is a fungal infection caused by Trichophyton spp that presents with painful raised, purulent scalp lesions leading to hair loss in the affected area. Kerions should be treated with oral griseofulvin. Melanoma (C) is a malignant growth of melanocytes commonly seen in middle-aged patients. They appear as rapidly enlarging pigmented lesions with irregular borders, and treatment involves dermatology referral for definitive diagnosis and management. Squamous cell carcinoma (D) is the second most common nonmelanotic skin cancer, presenting with ulcerated papules on the head, neck, and in chronic wounds. Patients with these lesions should also be referred for dermatology follow-up.

A 48-year-old woman presents with progressive neck pain over the last six weeks. The pain radiates down her posterior arm to the dorsum of her forearm. She reports numbness and tingling of the forearm and third digit. On examination, she has mild weakness with pronation of the forearm and decreased triceps reflex. What is her likely diagnosis?

C7 radiculopathy C7 is the most commonly affected nerve root and results in pain that radiates down the posterior arm to the dorsum of the forearm and third digit.

A 60-year-old woman is diagnosed with a small bowel obstruction. She denies any prior surgeries. Which of the following diagnoses is the most likely cause of her small bowel obstruction?

Cancer -------adhesions from previous surgery, followed by cancer.-------

A 40-year-old woman presents to the emergency department with fatigue. She also notes increased shortness of breath when she goes on her daily runs which is unusual for her. Physical exam reveals bilateral nonpitting edema and dry skin. Which of the following is a complication of this disease process?

Carpal tunnel syndrome dx:Hypothyroidism-----------------------Pulmonary hypertension (C) is a complication of chronic obstructive pulmonary disease or recurrent pulmonary embolisms. Patients with hypothyroidism are unlikely to develop pulmonary hypertension. Pulmonary edema (D) is an unlikely complication of hypothyroidism. Patients with congestive heart failure present with dyspnea during acute exacerbations

A 4-day-old neonate born at 38 weeks gestation following an uncomplicated pregnancy and delivery presents to the emergency department with his father due to bilateral eye redness and discharge. On exam, the patient has bilateral conjunctivitis and copious amounts of purulent discharge from both eyes. What is the treatment for the most likely diagnosis?

Cefotaxime or ceftriaxone dxgonococcal ophthalmia neonatorum within the first 5 days of life.

A 60-year-old man presents to the emergency department for a painful hernia. The hernia has been present for years and has been easily reducible, but today it became red, exquisitely tender to palpation, and associated with nausea. Examination is significant for a heart rate of 105 bpm and palpation of a 3 cm mass in the right inguinal crease with overlying redness. Which of the following is the most appropriate management of this patient's condition? AAdmission for pain control and serial abdominal exams BCefoxitin intravenously and emergent surgical consultation

Cefoxitin intravenously and emergent surgical consultation strangulated hernia.

A 28-year-old man presents with dysuria. He reports no associated penile discharge or any other symptoms. He also reports having had two new sexual partners in the last three weeks. Vital signs and physical examination are unremarkable with a negative genitourinary exam. Urinalysis shows 2 WBC/hpf with 1 bacteria. Which of the following antibiotic regimens represents the most appropriate treatment?

Ceftriaxone 500 mg IM and doxycycline 100 mg BID x 7 days dx: urethritis

An 18-year-old man presents to the emergency department after overdosing on medication. He is somnolent, only arousing to noxious stimuli. His vital signs are normal and his pupils are midposition and briskly reactive. You are unable to elicit nystagmus. He is not tremulous, his reflexes are normal, and he displays no clonus. Toxicity from which of the following agents is most likely responsible for his presentation?

Chlordiazepoxide dx:benzodiazepine toxicity Coma or central nervous system depression with essentially normal vital signs and midposition pupils are characteristic findings Benzodiazepine Toxicity Ataxia, lethargy, respiratory depression No change in pupil size (unlike opioid toxicity) Supportive care, flumazenil in benzodiazepine-naive patients (can precipitate seizures)

A 44-year-old woman presents with right upper quadrant pain. She has a history of obesity and tobacco use. She states her pain started tonight after eating dinner. She has had symptoms similar to this in the past, but tonight the symptoms have persisted and are worse than usual. Vital signs are within normal limits with the exception of an HR of 115 bpm. Physical examination is remarkable for severe right upper quadrant pain. Labs are remarkable for WBC of 15,000 cells/microliter and an ALT and AST of 300 U/L and 250 U/L, respectively. Total bilirubin and alkaline phosphatase are normal. Ultrasound is performed and is demonstrated above. What is the most likely diagnosis?

Cholecystitis Early laparoscopic cholecystectomy is the treatment of choice, with ED management including analgesia, antiemetics for nausea and vomiting, volume and electrolyte replacement, and administration of antibiotics.

A 65-year-old man presents with dysuria and urinary urgency. He has a history of hypertension, chronic kidney disease, and hyperlipidemia. He states over the past 6 months, he has had difficulty with urination and wakes up frequently to go to the bathroom. He relates there has been some associated back and perineal pain, and he has not had any penile discharge. He reports having only one sexual partner. Vital signs are remarkable for a temperature of 37.8°C but are otherwise unremarkable. Exam is remarkable for suprapubic pain and exquisite tenderness to prostate palpation. Which of the following is the most appropriate treatment option for this patient?

Ciprofloxacin daily for 28 days dx:Acute prostatitis complain of irritative or obstructive symptoms such as fevers, chills, dysuria, urinary urgency, low back pain, and perineal, suprapubic, or genital discomfort. < 35 years old: N. gonorrhoeae, C. trachomatis > 35 years old: E. coli Treatment < 35 years old: ceftriaxone IM and doxycycline > 35 years old: fluoroquinolone or TMP-SMX for 4 weeks

A 60-year-old woman presents to the emergency department with knee pain. She has a history of diabetes, peripheral arterial disease, CAD, and hypertension. She reports no obvious trauma to the affected knee and states this is worse than her typical arthritis pain. Vital signs are remarkable for a temperature of 39°C, HR 120 bpm, BP 100/60 mm Hg, RR 22/min, and SpO2 of 97%. Physical exam is notable for a warm, edematous, and erythematous right knee. The patient has severe pain with range of motion testing and holds the knee in slight flexion. An arthrocentesis is performed. Which group of findings on synovial fluid analysis is most expected in this patient?

Cloudy, yellow in appearance, 85,000 WBCs/µL with a predominance of neutrophils, no crystals present on analysis dx:bacterial septic arthritis until proven otherwise. Although no clinical pattern is diagnostic of septic arthritis, joint pain, joint swelling, and fever are the three most common features,

Which of the following additional symptoms suggests her gastroenteritis is from a bacterial source instead of a viral source?

Clues to a bacterial source of gastroenteritis are a diarrheal onset high stooling frequency, high fevers greater than 40°C, grossly bloody stools, and severe abdominal pain.

What historical feature of this patient's illness would most suggest viral pharyngitis as a more likely etiology rather than bacterial pharyngitis caused by group A Streptococcus?

Conjunctivitis

A patient presents to the emergency department after a skiing collision and is diagnosed with a fibular head fracture. Which of the following findings on neurovascular examination would most likely be seen with this injury? ADecreased sensation between the first and second toe BDecreased sensation to the calf CWeakened dorsalis pedis pulse DWeakness with plantar flexion of the ankle

Decreased sensation between the first and second toe PE: foot drop Tx: ankle splint to keep foot dorsiflexed common peroneal nerve courses around the fibular head deep peroneal nerve providessensation between the first and second toe and motor function to the tibialis anterior (dorsiflexion and inversion of the ankle) and extensor hallucis longus

A 48-year-old woman presents to the emergency department with reports of shortness of breath and cough for 3 weeks. She states she initially had fevers, but they stopped 1 week ago. She has had progressive dyspnea on exertion since that time. On examination, she has a temperature of 99.5°F, heart rate of 105 beats per minute, blood pressure of 110/60 mm Hg, respiratory rate of 14 breaths per minute, and oxygen saturation of 95% on 2 liters of oxygen. Lung sounds are diminished at the left base, and there is a normal S1 and S2 but with mild tachycardia. Which of the following additional physical examination findings is expected?

Decreased tactile fremitus dx:pleural effusion Physical examination findings include decreased breath sounds, decreased tactile fremitus, and dullness to percussion, but these findings are dependent on the size of the effusion. Chest radiographs can detect pleural effusions on an anteroposterior or posteroanterior upright film with a volume of 200 mL, with obscuration of the costophrenic angle. Thoracic ultrasound is more sensitive than chest radiograph

A 45-year-old man presents with diarrhea. He reports he has had diarrhea for the past 2 months. Additionally, he reports bloating and notes that the diarrhea is pale, foul smelling, and voluminous. Chart review reveals a weight loss of 10 pounds since his last visit 6 months ago. He reports no recent fevers, bloody bowel movements, nausea, or vomiting. A tissue transglutaminase antibody test is positive. Which of the following extraintestinal manifestations might be seen in a patient with the most likely diagnosis?

Dermatitis herpetiformis dx:celiac disease

Which of the following is more common in ulcerative colitis than in Crohn disease?

Development of malignancy

A 32-year-old healthy man presents to the emergency department with 10 days of a cough productive of green sputum. He was seen in the emergency department 1 week ago for fever, dyspnea, and a similar cough. At that time, a chest X-ray was negative and he was diagnosed with an upper respiratory infection. Today, his vital signs are unremarkable, a cardiopulmonary exam is benign, and a repeat chest X-ray is negative for acute pulmonary disease. Which of the following is the best management for this patient?

Dextromethorphan as needed acute bronchitis

A 47-year-old man with a history of HIV, who takes his antiretroviral therapies, reports progressively worsening shortness of breath, pedal edema, and orthopnea over the past 2 weeks. Vital signs include an HR of 100 bpm, BP 156/94 mm Hg, RR 24/min, and T 37.6°C. On physical examination, he has mild jugular venous distention and rales on lung auscultation. He has 2 pitting edema in his lower legs. What will be the most likely findings visualized on echocardiography?

Dilation and impaired contraction of both ventricle

A 23-year-old woman presents with fever, cough, and shortness of breath. Her vital signs are normal, and her chest X-ray shows nonspecific infiltrative changes. Which of the following is the optimal treatment?

Discharge with PO doxycycline community-acquired pneumonia (CAP)

A 55-year-old man presents to the emergency department for rectal bleeding. The patient states he has noticed blood in his stool for the past week, but it has been increasing in volume. This morning, he noticed a large amount of red blood with one of his bowel movements. The patient has a past medical history of obesity, gastroparesis, constipation, and diabetes. He has a 40-pack-year smoking history and drinks three alcoholic beverages every night. His temperature is 99.5°F (37.5°C), blood pressure is 167/108 mm Hg, pulse is 90/min, respiratory rate is 15/min, and oxygen saturation is 99% on room air. Rectal exam reveals bright red blood. There is no tenderness upon palpation of the patient's abdomen. Which of the following is the most likely diagnosis?

Diverticulosis Treatment of diverticulosis with bleeding includes keeping the patient NPO ("bowel rest"), administering IV fluids, and monitoring their CBC to track for anemia secondary to bleeding. Most cases resolve spontaneously. Diagnostic tests can include a colonoscopy to search for the site of bleeding and rule out colon cancer. If colonoscopy does not reveal an underlying lesion, angiography can be performed followed by embolization if the bleeding does not self-resolve with supportive management. For bleeding refractory to embolization, a surgical intervention can be indicated and is needed in up to 25% of patients who require transfusion secondary to their bleed.

A 38-year-old man with a history of underlying psychiatric disease presents to the emergency department with strange facial and tongue movements. He was recently started on a new medication, but he cannot remember the name. He has difficulty describing his exact underlying psychiatric problem, and the friend with him also does not know the details regarding the patient's chronic medical issues. On exam, the patient is smacking his lips periodically and twisting his tongue in and out of his mouth. He is also holding his head stiffly and tilted to the left. What neurotransmitter imbalance is responsible for the development of this syndrome?

Dopamine receptor blockade leading to increased cholinergic activity

A 65-year-old man presents with left leg pain. He reports progressive erythema and pain of his left lower leg after cuttingit while working on his car. His examination is notable for a 5 x 5 cm area of induration and erythema with yellow purulent drainage. The area is warm to touch and tender to palpation. Which of the following is the most appropriate medication for outpatient management of this patient's condition?

Doxycycline dxCellulitis MRSA. Oral antibiotics with MRSA coverage include doxycycline, trimethoprim-sulfamethoxazole, clindamycin, and linezolid. Patients with systemic symptoms requiring admission should receive parenteral antibiotics with coverage for MRSA, which include vancomycin, clindamycin, telavancin, daptomycin, andlinezolid.

A 45-year-old previously healthy man presents to the emergency department with a chief complaint of epigastric burning and gnawing pain. While in the waiting room, he has an episode of dark, coffee-ground emesis and continues to vomit while being wheeled to the resuscitation bay. Which of the following is the most likely cause of the patient's symptoms?

Duodenal ulcer due to H. pylori infection

A 36-year-old man is brought to the emergency department by his family because he has not been sleeping and has been more irritable. The patient says that he feels "like a hundred trillion bucks" and that he wants to be discharged as soon as possible because he is preparing for a meeting with the chief executive officers of five major car brands to discuss his ideas for developing a hovercraft. The family says that the patient recently spent his entire month's paycheck buying gardening tools with the intent of starting an urban farm. What other piece of history is required to make a formal diagnosis?

Duration of symptoms of the current episode For the diagnosis of bipolar I disorder Patients are usually treated initially with antipsychotics and transitioned to lithium or carbamazepine for maintenance

A 25-year-old woman presents with abdominal pain. She was discharged 3 days ago after undergoing an uncomplicated cesarean section. On the day of discharge, she only had some minor discomfort, but she states that, over the past day and a half, the pain has significantly worsened. Vital signs are remarkable for a temperature of 39°C, HR 120 bpm, BP 95/50 mm Hg, RR 28/min, and SpO2 of 99%. Physical exam is remarkable for severe pelvic discomfort with palpation in the RLQ or LLQ of the abdomen. Her incision is intact without drainage or erythema. Pelvic exam reveals a foul-smelling vaginal discharge and uterine tenderness. Which of the following is the best next step in the patient's management?

Establish IV access and administer clindamycin and gentamicin dx: endometritis

A 39-year-old woman presents with vaginal bleeding. She reports a history of heavy menstrual periods and has been going through multiple pads an hour for the past one day. Physical exam reveals heavy bleeding with large clots. She is tachycardic with a blood pressure of 92/54 mm Hg. Her pregnancy test is negative, and her hemoglobin is 7.2 g/dL. In addition to fluid resuscitation and transfusion, which of the following medications is most appropriate to help stop the bleeding?

Estrogen Non-pregnant patients with acute hemorrhage due to AUB may be given intravenous estrogen to stabilize the endometrium and slow the bleeding.

A 63-year-old man with a history of hypertension presents to the emergency department with dizziness described as a spinning sensation. He also reports feeling off-balance and has been falling to the side. From the following options, what factor found on history or physical examination would make a clinician concerned that this patient has central vertigo? AFalling when walking BRecurrent episodes lasting minutes to hours

Falling when walking

A 4-year-old girl presents to the emergency department with fatigue. Her history is only remarkable for a resolved cold a few weeks ago. Her heart rate is 160 bpm, blood pressure is 112/76 mm Hg, and oxygen saturation is 99% on room air. She is pale and tachycardic on exam but will wake and interact appropriately. Laboratory work shows a white blood cell count of 18.4 x109/L, hemoglobin of 5.5 g/dL, and platelets of 260 x109/L. She has a positive direct antiglobulin test (i.e., Coombs). Which of the following is the most appropriate next step in management?

Glucocorticoid administration dx:Autoimmune hemolytic anemia

A 55-year-old man presents to the emergency department with shoulder pain. The patient has a past medical history of hypertension and hyperlipidemia. He states the symptoms started three days ago. He denies any traumatic events leading up to his symptoms. Which positive physical exam finding is most consistent with supraspinatus tendonitis?

Hawkins-Kennedy test The Neer or Hawkins-Kennedy tests are the best tests for impingement, Initial treatment consists of ice, rest, and the use of nonsteroidal anti-inflammatory drugs.

Which of the following lab values is most consistent with the diagnosis of disseminated intravascular coagulation?

Hemoglobin 7.5 g/dL, platelets 80,000/µL, D-dimer 2000 µg/mL, fibrinogen 50 mg/dL, international normalized ratio 4.0, AST 90 U/L, ALT 95 U/L Thrombocytopenia, prolonged PT and elevated international normalized ratio (INR), low fibrinogen, elevated fibrin-related markers, and anemia from intravascular hemolysis are classic laboratory markers. Management focuses on treating the underlying cause.

A 22-year-old woman presents to the emergency department due to abdominal pain. On initial evaluation, her abdominal exam is benign, vital signs are within normal limits, and blood work and urinalysis are unremarkable. A rapid response for another patient is called, and you have to exit the room. On re-evaluation, the patient has put lipstick on and is deeply offended that you left her, stating, "I thought I meant something to you," and starts crying loudly. You apologize for abruptly needing to leave, and the patient smiles and asks when you finish your shift. Which of the following personality disorders is the most likely diagnosis?

Histrionic cluster B personality disorder Hallmarks of histrionic personality disorder include attention-seeking behavior, excessive emotionality, and the use of sexuality to draw attention and manipulate.Patients are often dramatic, exhibit rapidly labile emotions, and become uncomfortable or upset when they are not the center of attention. Their interactions are often sexually seductive or provocative ================================================ Antisocial personality disorder (A) is characterized by a disregard for and violation of the rights of others, impulsivity, criminality, and a lack of remorse. Patients with borderline personality disorder (B) have unstable mood and interpersonal relationships, impulsivity, self-harming behavior, suicidality, and employ splitting as a major defense mechanism. Narcissistic personality disorder (D) is characterized by grandiosity, a sense of entitlement, the need for admiration, and a lack of empathy. Patients classically demand the best and often react poorly to criticism.

A 36-year-old woman presents to the ED with sudden onset lower abdominal pain and vaginal bleeding. She is 35-weeks pregnant. She reports constant lower abdominal pain and vaginal bleeding for the last 4 hours. On examination, her cervix is closed and she has dark blood coming from the cervical os. Her uterus is firm to the touch. What is the most common risk factor associated with this condition?

Hypertension most common risk factor for the development of placental abruption is hypertension. Patients will generally complain of sudden onset, constant abdominal pain and vaginal bleeding that is generally darker in color.

A 22-year-old man with a known seizure disorder presents after having brief, seizure-like activity that spontaneously resolved shortly prior to arrival. On initial evaluation, he is noted to be protecting his airway with stable vital signs but appears somnolent. Blood glucose is unremarkable, and IV access is established. Family notes no recent illnesses or injuries, but they are concerned that he has been unable to afford his prescriptions recently. Shortly thereafter, he begins to exhibit generalized convulsions that do not spontaneously resolve after several minutes. Which of the following medications should be given next?

IV lorazepam dx:Status epilepticus

26-year-old man presents with low back pain after helping his friend move yesterday. He denies any trauma, fever, weakness, numbness, or change in bowel or urinary habits. He has no midline tenderness but has spasm and tenderness noted in the paraspinal muscles. Which of the following medications is most appropriate for this patient's pain?

Ibuprofen dx:Muscle strains Patients should be encouraged to engage in activity as toleratedand may benefit from physical therapy if their pain does improve over the next several days. In a patient allergic to NSAIDs, what alternative medication can be prescribed to a patient with subacute thyroiditis? Answer: Prednisone.

A 9-year-old boy with no past medical history presents to the emergency department with facial swelling. He states that his symptoms started 1 day ago. He also notes that his urine has been more foamy than it usually is. His mom reports that he recently recovered from a sore throat and fever 2 weeks ago, which was treated with antibiotics. Urinalysis shows red blood cells and proteinuria. What is the pathophysiology of this disease process?

Immune complex deposition poststreptococcal glomerulonephritis PE: hypertension, hematuria, and periorbital edema Management includes mainly supportive measures, e.g., salt and water restrictionIf edema and hypertension present, concurrent furosemide can help Most common infectious cause of acute glomerulonephritis

A 66-year-old woman presents with new-onset lower extremity edema and shortness of breath. She states this has progressively worsened over the past 2 months, during which time she has also had a 10-pound weight gain. She notes that earlier in the week, she had substernal chest pain that lasted for 10 hours before resolving on its own. She has an unknown medical history as she does not typically see a primary care clinician. Vital signs include a heart rate of 106 bpm, a respiratory rate of 22 breaths/minute, and an oxygen saturation of 92% on room air. Physical examination is remarkable for the patient sitting upright with rales noted in the lung bases, tachycardia, and 3+ pitting edema noted to the bilateral mid-thighs. What is the most likely pathophysiology for this patient's presentation? ADecreased protein synthesis BDecreased urinary output CIncreased capillary pressure DIncreased urinary protein excretion

Increased capillary pressure LE edema

A 45-year-old woman presents to the emergency department with eye pain and blurry vision after a cleaning solution accidentally splashed into her eyes. She was using a rust remover agent that contains hydrofluoric acid. On exam, she has difficulty opening her left eye due to intense pain. What is the most important management step to perform next to treat this patient? AInstill tetracaine anesthetic drops and begin copious saline irrigation of both eyes BInstill tetracaine anesthetic drops and begin topical erythromycin therapy CProvide intravenous opiate pain medicine and instill calcium gluconate gel into the eye DTest the pH of the eye and consult ophthalmology for emergent evaluation

Instill tetracaine anesthetic drops and begin copious saline irrigation of both eyes dx:chemical injury

A healthy 30-year-old man presents to the emergency department for a prolonged erection. He reports using cocaine last night while partying, and the erection has been present for 6 hours. Examination reveals tachycardia to 110 bpm and a rigid penile shaft with soft glans penis. Penile blood gas has a pH of 7.10. Which of the following is the most appropriate management of this patient?

Intracavernosal phenylephrine

A 60-year-old man presents to urgent care with acute onset of right-sided weakness that began three hours ago while he was preparing breakfast. He decided to seek medical attention after experiencing double vision. He has no significant past medical history. His blood pressure is 170/89 mm Hg, heart rate is 90 beats/minute, respiratory rate is 14 breaths/minute, and O₂ saturation on room air is 97%. A noncontrast head CT is negative for intracranial hemorrhage and has findings of an acute infarction. Which of the following is the best first step in the management of this patient?

Intravenous alteplase. --------Clopidogrel plus aspirin secondary stroke prevention may be beneficial for patients with high-risk transient ischemic attack or minor strokes.-----

acute ischemic stroke. Which of the following is considered an absolute contraindication for thrombolytic therapy?

Ischemic stroke within the past three months

A 20-year-old man presents to the ED complaining of a headache after a skiing injury. His friend witnessed the fall and reports that the patient was "out for a few minutes" but confirms that he appears back to his normal self now, other than amnesia about the circumstances of the fall and two episodes of vomiting. Physical exam reveals only crepitus and swelling over the left parietal skull. What do you most likely expect to find on the patient's computed tomography of the head?

Lens-shaped hyperdensity not crossing suture lines biconcave / lens appearance = middle meningeal artery epidural hematoma

A 65-year-old man with a history of hypertension presents with gradual right testicular pain over the past three days. He is monogamous with his wife of 30 years. His vital signs are within normal limits. On exam, he has tenderness and firmness at the posterolateral aspect of the right testicle. His pain is somewhat relieved with elevation of the right testicle. A urinalysis shows pyuria and positive leukocyte esterase. Which of the following is the most appropriate treatment for the suspected diagnosis?

Levofloxacin dx:epididymitis

A 57-year-old man with a history of depression presents to the emergency department with a tremor, nausea, and vomiting. He states that he drinks 5 to 10 alcoholic beverages per day and smokes cigarettes. His blood pressure is 157/108 mm Hg, pulse is 115/min, respiratory rate is 26/min, and oxygen saturation is 99% on room air. Physical exam is notable for a tremor both at rest and with action and sweaty skin. Which of the following is the best treatment for this patient?

Lorazepam dx:alcohol withdrawal,

A 47-year-old man presents to the emergency department with a nonhealing ulcer on his heel. Past medical history is significant for uncontrolled diabetes. The patient states that the ulcer has been present for the past couple weeks but is now worsening in appearance. His vital signs are unremarkable. Physical examination demonstrates a left heel ulcer with purulent discharge and surrounding erythema. You are concerned for osteomyelitis of the calcaneus. Which of the following is the most sensitive test for suspected osteomyelitis?

Magnetic resonance imaging

A 25-year-old woman presents to the emergency department with a painful unilateral loss of vision. She states it started this evening and has persisted. The patient has no known medical history and is not currently taking any medications. Her vital signs and an initial ECG are within normal limits. When the patient's neck is flexed, an electrical pain is felt down her neck and back. An afferent pupillary defect is present in the affected eye. Which of the following is the best initial treatment for this patient?

Methylprednisolone acute exasperation of MS symptoms including paresthesias, weakness, urinary or bowel incontinence, and loss of pain or temperature sensation. Ophthalmoplegia can be seen in this condition, which presents with an inability to adduct the affected eye. Other unique symptoms include optic neuritis, which can present with a painful unilateral loss of vision and Lhermitte sign that presents with electrical pain that radiates down the neck and spine when the head is flexed. The diagnosis of multiple sclerosis can be supported with MRI (preferred) or lumbar puncture demonstrating oligoclonal bands,

A 24-year-old woman presents to the emergency department with tremors, anxiety, and palpitations for 3 days. She has been evaluated for these symptoms before, but no diagnosis was made aside from a presumptive psychiatric disorder. However, her symptoms are more severe now. Vital signs are HR of 126 bpm, BP of 157/89 mm Hg, RR of 20 bpm, and T of 37.9°C. She has exophthalmos on the exam, so you check a thyroid-stimulating hormone level and find it to be < 0.05 mU/L. What is the most appropriate treatment to initiate at this time?

Metoprolol Once a diagnosis of hyperthyroidism is made, patients should be treated with a beta-blocker such as atenolol, metoprolol, or propranolol to mitigate cardiac complications. Treatment with a beta-blocker relieves palpitations, tachycardia, tremulousness, anxiety, and heat intolerance associated with hyperthyroidism. Hyperthyroidism Sx: heat intolerance, palpitations, weight loss, tachycardia, and anxiety PE: hyperreflexia, goiter, exophthalmos, pretibial edema Labs: low TSH and high free T4 Most commonly caused by Graves disease (autoimmune against TSH receptor) Tx: methimazole or PTU PTU in the first trimester of pregnancy

An 88-year-old woman with a history of hypertension presents to the emergency department with palpitations and shortness of breath for one week. She has intermittent mild chest pain but denies any of those symptoms while sitting in the emergency department. She takes metoprolol for her hypertension and is compliant with her daily dose. Vital signs show HR 146 bpm, BP 126/68 mm Hg, RR 12/min, and T 37.4°C. She has an unremarkable physical examination aside from tachycardia. An electrocardiogram is obtained and is shown above. What is the most appropriate treatment at this time?

Metoprolol intravenously dx: AFIB Atrial Fibrillation Rate will be irregular Rhythm will be irregular Notable feature: No defined P waves Treatment Unstable: cardioversion Stable: rate control is mainstay (diltiazem, metoprolol) > 48 hours: anticoagulate 21 days prior to cardioversion Determine the need for anticoagulation by using CHA2DS2-VASc score Most common sustained dysrhythmia in adults

A 38-year-old man presents to the emergency department with a new-onset rash. He has a past medical history significant for epilepsy and hypertension, for which he currently takes levetiracetam and lisinopril. The patient was feeling well until two days ago when he started developing fevers, chills, malaise, and body aches. Yesterday, he noticed a rash had started on his face and trunk. He states the rash has since spread to all four extremities. A review of systems is positive for recently completing a course of azithromycin for walking pneumonia. Vital signs are remarkable for a temperature of 40°C, HR 138, BP 90/60, RR 29, and pulse oximetry 98%. Physical examination is remarkable for a toxic-appearing man with blisters and erythematous macules with a purple core covering the trunk, face, and extremities. Mucositis is noted on examination as well as a positive Nikolsky sign. Which of the following is most related to his likely diagnosis of Stevens-Johnson syndrome?

Mycoplasma infection The next most common cause after medications is Mycoplasma pneumoniae infections Drugs commonly known to cause SJS (remembered by the mnemonic PEC SLAPP) include penicillin, ethosuximide, carbamazepine, sulfa medications, lamotrigine, allopurinol, phenytoin, and phenobarbital.

A 55-year-old man with a history of hyperlipidemia, diabetes mellitus, hypertension, and uric acid crystal arthropathy presents with right great toe pain, redness, and swelling. His examination reveals a right metatarsophalangeal tophus. Which of the following regimens represents appropriate medical therapy for this patient?

Naproxen and topical ice dx:gout

A 14-month-old girl without significant past medical history presents with cough and difficulty breathing. Her parents note that she developed a low-grade fever and nasal congestion two days ago. Today she has had an increased cough and mild difficulty breathing but seems to be feeding well and is still active. She has not had similar symptoms previously. On examination, she has a temperature of 38.2 ºC, heart rate 120 beats per minute, respiratory rate 42 breaths per minute and oxygen saturation 97% on room air. She is well-appearing with rhinorrhea and crusting at the nares. She has scattered expiratory wheezes with fine crackles noted on auscultation. What is the next step in management of this patient? A 1-year-old boy presents to the ED with shortness of breath and cough. Vital signs are BP 90/60 mm Hg, HR 110 beats per minute, RR 40 breaths per minute, oxygen saturation of 91% on room air, and T 97.5°F. Physical exam reveals intercostal retractions, rhinorrhea, and wheezing. Which of the following is the most appropriate next step in management?

Nasal suctioning dx:bronchiolitis bug:RSV one to three day prodrome of mild upper respiratory symptoms such as low-grade fever and rhinorrhea before the onset of cough and respiratory difficulty. Characteristic exam findings include nasal drainage, tachypnea, cough, intercostal and subcostal retractions, wheezing and fine or coarse crackles. Patients with mild disease benefit most from supportive care and anticipatory guidance. This includes nasal suctioning, ensuring adequate hydration and education of the parents.

A 58-year-old man presents to the emergency department with abdominal pain and distension. He states his symptoms started last night and are accompanied by nausea and vomiting. Abdominal exam is notable for distension as well as generalized discomfort and tenderness. Radiography is performed, as seen above. Which of the following is the best treatment for this patient?

Nasogastric tube placement dx:Small bowel obstructions

An 8-year-old boy with moderate persistent asthma presents to the emergency department with difficulty breathing. His mother is giving 4 puffs of his home albuterol every 2 hours without effect. He is awake and alert but seems breathless, as he speaks in incomplete sentences. He has moderate accessory muscle use and tachypnea. He has a prolonged expiratory phase and diffuse expiratory wheezes on auscultation. Which of the following is the most appropriate next step?

Nebulized albuterol The cornerstone for treatment of asthma remains a short-acting beta-agonist, such as albuterol, along with corticosteroids. dx: acute asthma exasperation

A 25-year-old healthy man presents to the emergency department with several days of sore throat associated with fever and voice change. Examination is significant for a temperature of 101.5°F, HR 110 bpm, oxygen saturation 99% on room air, right tonsillar erythema and swelling with uvula deviation to the left, no pooling of oral secretions, and tender anterior cervical lymphadenopathy. Which of the following is the most appropriate management of this patient's condition?

Needle aspiration peritonsillar abscess. Treatment is I&D or needle aspiration followed by antibiotics

A 30-year-old man presents to the emergency department after a motor vehicle collision, complaining of chest and back pain. His vital signs are significant for a blood pressure of 85/50 mm Hg, heart rate of 115 bpm, and an oxygen saturation of 92% on room air. Exam reveals ecchymosis of the left anterior chest wall, no crepitus, diminished breath sounds on the left hemithorax, and a Glasgow Coma Scale of 15. Which of the following is the best next step in the management of this patient?

Needle thoracostomy in the left second midclavicular intercostal space dx: Tension pneumothorax These patients will present with diminished breath sounds, distended neck veins, hypotension, and tracheal deviation. Diagnosis should be made clinically

A 65-year-old man presents in respiratory distress. He has a known history of hypertension, heart failure, diabetes mellitus, and hyperlipidemia. He arrives unable to speak in more than two-word phrases secondary to severe distress and tachypnea. Vital signs are remarkable for BP 220/130 mm Hg, HR 105 bpm, RR 40/min, and pulse oximetry 75%. Accessory muscle use, intercostal retractions, and diffuse rales are noted on examination. In addition to placing the patient on BPAP, which of the following should be administered next for blood pressure control?

Nitroglycerin hypertensive emergency

healthy 20-year-old woman presents to the emergency department for evaluation of a hand laceration caused by her pet cat's teeth two hours prior to arrival. Examination reveals a 2 cm laceration to the dorsum of her hand, involving the skin and subcutaneous tissues without significant bleeding or surrounding erythema; her hand is neurovascularly intact. After assessment for tetanus and rabies immunization and copious irrigation of the wound, which of the following would be appropriate management of the laceration?

No wound closure and oral amoxicillin-clavulanic acid bacteria in cat bites is Pasturella multocida

A 62-year-old man with a history of myocardial infarction three months ago, diabetes, hypertension, and chronic obstructive pulmonary disease presents to the emergency department by ambulance for shortness of breath. The patient reports worsening dyspnea over 24 hours with mild chest discomfort. He denies fever. He reports swelling in his legs over several weeks. He is sometimes compliant with his medications. Paramedics found him with an oxygen saturation of 88% on room air when they arrived at his home. Current vital signs show a HR of 117 bpm, BP of 201/112 mm Hg, RR of 30/min, and oxygen saturation of 100% on nonrebreather mask. Diffuse crackles and mild wheezing are heard diffusely on lung examination. The patient has a protuberant abdomen and 2+ pitting edema of both legs. While awaiting further diagnostic tests, what is the most appropriate treatment of this patient?

Noninvasive positive pressure ventilation, nitroglycerin drip, and intravenous furosemide

A 40-year-old woman presents to the ED complaining of neck pain. For the past three days, she has had a fever, myalgias, and increasing fatigue. Vital signs are BP 130/90 mm Hg, HR 100 beats per minute, RR 14 breaths per minute, oxygen saturation of 97% on room air, and T 100.4°F. On physical exam, she has tenderness over her anterior, midline neck. Which of the following is the most appropriate treatment?

Nonsteroidal anti-inflammatory drugs subacute thyroiditis viral infection or a post-viral inflammatory process. Common symptoms include fever, myalgias, fatigue, and malaise. Patients will complain of anterior neck pain,

A 60-year-old woman presents to the emergency department with chest pain. ECG shows ST-segment elevation in leads V2-V4. Vitals are BP 80/40 and HR 65. In addition to dobutamine, the most appropriate next step is administration of which of the following?

Norepinephrin

A 43-year-old woman presents to the emergency department with acute-onset headache and right eye pain. On examination, you notice she has a cloudy cornea with a fixed midposition pupil. She is stating that, in addition to pain, she is also starting to see halos form around lights. Which of the following mechanisms is the main cause of this condition?

Obstruction of aqueous humor outflow acute angle-closure glaucoma,

A 55-year-old man presents to the emergency department with a cough and altered mental status. Past medical history is unknown. Vital signs are remarkable for temperature 39°C, HR 130 bpm, RR 30/min, BP 70/30 mm Hg, and pulse oximetry 89%. On exam, the patient is toxic appearing, tachycardic, and tachypneic, with rales noted bilaterally. Capillary refill is greater than 5 seconds and the mucosal membranes are dry. The patient receives a 30 mL/kg fluid bolus but remains hypotensive. A bedside ultrasound is performed of the IVC and is shown above. What is the next step in management? AAdditional fluid bolusYour Answer BAdminister hydrocortisone IV CObtain central venous access and start norepinephrine DObtain central venous access and start vasopressin

Obtain central venous access and start norepinephrine What is the first-line vasopressor or inotropic agent of choice for cardiogenic shock? Answer: Norepinephrine. Although norepinephrine acts primarily on the vasculature to increase vascular tone, it is still the first recommended agent for cardiogenic shock.

A 10-year-old boy presents to the pediatrician with his mother. She states the patient has become difficult to deal with over the past several years. He refuses to follow instructions, both in school and at home, and has been found trying to skip class multiple times by hiding in the bathroom. She reports he is verbally aggressive when told something he does not like. The patient has several friends but is hostile to peers outside his group of friends. Initially, she thought this was just due to the move they made 2 years ago, but his behaviors have persisted. Which of the following is the most likely diagnosis?

Oppositional defiant disorder

A 27-year-old man presents to the emergency department in January with a nonproductive cough, fever, headache, myalgias, weakness, nausea, and vomiting for the past three days. His temperature is 102°F (38.9°C), blood pressure is 127/68 mm Hg, pulse is 110/min, respiratory rate is 16/min, and oxygen saturation is 99% on room air. Physical exam is notable for a fatigued-appearing young man. Lungs are clear to auscultation. Which of the following is the best treatment for this patient?

Oral rehydration and rest dx:Influenza

A healthy 30-year-old woman presents to the emergency department for frequency and burning on urination. She reports no vaginal discharge, fever, nausea, or back pain, and on exam, she has normal vital signs and does not have vaginal discharge, cervical motion tenderness, or costovertebral angle tenderness. Her urine pregnancy test is negative, and her urinalysis is significant for 8 WBC/hpf and positive for bacteria and nitrite. Which of the following is the most appropriate treatment for this patient's condition?

Oral trimethoprim-sulfamethoxazole for 5 days dx: uncomplicated acute cystitis.

70-year-old man with atrial fibrillation on warfarin daily and dementia presents to the emergency department after being referred from a coagulation clinic for elevated international normalized ratio. He is asymptomatic and reports no bleeding, bruising, or melena but states he may have unintentionally taken extra doses of warfarin. His vital signs are significant for an irregular heart rate of 88 bpm and a blood pressure of 150/80 mm Hg. His laboratory values are significant for an international normalized ratio of 11, and his hemoglobin is unchanged from baseline. Which of the following is the best next step in the management of this patient?

Oral vitamin K, hold next warfarin dose, and repeat labs in 24-48 hours What blood product may be used to reverse warfarin? Answer: Fresh frozen plasma.

An 18-year-old man presents to the emergency department with ear pain. He states that pain started after he went swimming in a local pond several days ago. He also reports purulent drainage from his ear. Physical examination reveals an erythematous, edematous external auditory canal. The tympanic membrane is partially visible, and tenderness with tragal pressure is also present. Which of the following is the best treatment for this patient?

Otic ciprofloxacin with hydrocortisone The patient in question has moderate otitis externa mld = acetic acid

What is the most common ultrasound finding in ovarian torsion?

Ovarian enlargement due to venous and lymphatic engorgemen

A 55-year-old man with a history of tobacco abuse, hypertension, and diabetes mellitus controlled with metformin presents to the ED with severe, sudden-onset retrosternal chest pressure that began while he was moving furniture in his apartment. Paramedics gave him sublingual nitroglycerin that reduced the pain somewhat. He appears diaphoretic and reports nausea. His ECG does not show ST segment elevation or depression or T wave abnormalities. His serum troponin I level is 0.84 ng/mL. He is given chewable aspirin 325 mg. Which of the following is the best next step in management?

P2Y12 antagonist Acute Coronary Syndrome: Management Reperfusion PCI - increased survival, decreased ICH and recurrent MIPCI center: < 90 minutes "door to device" timeNon-PCI center: transfer for PCI if "door to device" time can be <120 minutes Thrombolysis - if PCI is not available or "door to device" time > 120 minutesAdminister within 30 minutes, can be given up to 12 hours of symptom onsetContraindications: ICH, intracranial malignancy, stroke within 3 months, aortic dissection Medical Therapy Oxygen - indicated for O2 sat < 90%, dyspnea, heart failure Nitroglycerin - relieves ongoing chest pain, lowers BP Morphine - relieves pain, reduces work of breathing in setting of pulmonary edemaonly used if nitroglycerin fails to relieve the paincan be associated with negative outcome Beta Blockers - prevent recurrent ischemia and dysrhythmia Antiplatelet agents - reduce recurrent coronary artery thrombosis, stent thrombosis, and deathAspirin - given before PCI and continued indefinitelyP2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) - continue for 1 year if stent placedGPIIb/IIIa antagonists for patients undergoing PCI Anticoagulation - if LV thrombus or Afib present and all patients receiving thrombolytic therapy ACE Inhibitors - reduce cardiovascular events, prevent LV remodeling High dose statin - lipid lowering, lowers risk of death, recurrent MI, and stroke

A patient presents to the emergency department for a painful, swollen finger. Which of the following features, if present, would be most consistent with a diagnosis of flexor tenosynovitis?

Pain on passive extension of the affected finger Kanavel signs may be identified that can help with the diagnosis of flexor tenosynovitis: pain on passive extension of the affected finger (often the first finding), finger held in partial flexion, tenderness of the full tendon sheath, and fusiform swelling of the digit Most commonly caused by S. aureus infection treated with intravenous antibiotics such as vancomycin plus extended-spectrum penicillins. They should have emergent hand surgery consultation, as this infection can rapidly spread through the fascial planes of the hand. Inappropriate management of flexor tenosynovitis can lead to loss of function in the affected hand.

A 26-year-old woman with a history of polycystic ovary syndrome presents with five days of diffuse headache that has not responded to over-the-counter medications. She also reports one day of intermittent blurring and "blacking out" of vision with positional changes. Temperature is 37°C (98.6°F), pulse rate is 78/min, respirations are 20/min, blood pressure is 135/90 mm Hg, and SaO₂ is 99%. The physical exam is notable for an obese, uncomfortable-appearing woman who is moving all extremities and answering you appropriately. Her visual fields are intact, but visual acuity is 20/40 OD and 20/70 OS, and she tells you that she has never had vision issues. What is an additional physical exam finding that is likely to be associated with the condition?

Papilledema hallmark funduscopic finding of idiopathic intracranial hypertension

A 2-year-old boy presents to the ED at 3:00 AM for three days of cough and shortness of breath. Symptoms are worse at night. His symptoms were preceded by runny nose, low-grade fever, and nasal congestion. He appears calm but has stridor at rest, supraclavicular retractions, a hoarse voice, and drooling on exam. His lungs are clear to auscultation. This condition is most commonly caused by which of the following?

Parainfluenza virus Croup

A 6-year-old girl with a history of sickle cell disease presents to the emergency department with a fever. Her father notes that she has been less playful but is continuing to eat and drink well. Her vital signs on arrival are T 39.0°C, HR 130 bpm, RR 18/min, BP 94/60 mm Hg, and oxygen saturation 98% on room air. Her physical examination is notable for normal tympanic membranes, clear lungs, no joint swelling, and no rashes. Her chest X-ray is shown above. Her laboratory workup is notable for a white blood cell count of 16,000/µL, a hemoglobin of 7.5 g/dL, and a reticulocyte count of 0.4%. Which of the following is the most likely cause of her symptoms?

Parvovirus B19 infection Aplastic crisis is an important complication of sickle cell disease in which the body is unable to make enoughreticulocytes to compensate for hemolysis.

A 48-year-old woman presents to the ED with chest pain and nausea. She describes right subcostal postprandial cramping and two episodes of nonbloody, nonbilious emesis today. She has inspiratory arrest during deep palpation of her right upper quadrant. Which of the following sonographic findings is consistent with her most likely diagnosis

Pericholecystic fluid

A 21-year-old man presents with a stab wound to the right chest. His vitals are HR 157 bpm, BP 81/43 mm Hg, RR 28/min, and oxygen saturation 91%. The patient is intubated, and packed red blood cells are started. Physical examination reveals a bleeding wound to the right chest, a midline trachea, and decreased breath sounds on auscultation of the right hemithorax. Which of the following should be performed next?

Placement of a right thoracostomy tube dx:hemorrhagic shock from a hemothora

A 44-year-old man presents to the emergency department with a severe headache and sweating. Although his symptoms are already beginning to improve, he is concerned because similar episodes have occurred in the past several weeks during which he feels anxious, sweaty, and experiences flushing. The patient is a current smoker and drinks alcohol every night. His temperature is 99.5°F (37.5°C), blood pressure is 167/94 mm Hg, pulse is 90/min, and respiratory rate is 15/min. Which of the following is the best initial diagnostic test for this patient?

Plasma fractionated metanephrine levels pheochromocytoma Treatment of hypertension in these patients typically involves an alpha-blocker with phenoxybenzamine as the preferred agent as it is an irreversible alpha-1 blocker. A beta-blocker can be administered after an alpha-blocker to avoid the possible complication of exacerbating severe hypertension secondary to excess alpha stimulation. Surgical removal of the neoplasm is indicated unless there is metastasis, in which case medical therapy is the optimal intervention.

A 62-year-old man presents to the emergency department with a chief complaint of prolonged generalized weakness, fatigue, and headache over the past month. Vital signs are within normal limits. Physical exam reveals plethoric facies and splenomegaly. His blood work shows WBC 18,000/μL, hemoglobin 19.8 g/dL, hematocrit 61%, platelets 517,000/μL, and LDH 370 U/L. Which of the following is the most likely diagnosis?

Polycythemia vera JAK2 mutation considered to be one of the chronic myeloproliferative disorders.

zA 27-year-old man sustains a knee injury when he falls in a rock-climbing gym and lands on his leg, hyperextending it at the knee. He complains of severe pain in the knee and is unable to bear weight. There is no obvious deformity. The knee is grossly unstable in all directions of stress testing. X-rays are negative for a fracture. Which of the following is the most serious immediate complication of his injuryz

Popliteal artery injurz

A 28-year-old man presents to the emergency department with lethargy and vomiting. He has a history of type I diabetes mellitus. Vital signs include heart rate 112 bpm and blood pressure 110/80 mm Hg. Laboratory analysis reveals sodium 135 mEq/L, potassium 4.0 mEq/L, chloride 100 mEq/L, bicarbonate 10 mEq/L, creatinine 1.4 mg/dL, glucose 558 mg/dL, pH 7.2. Normal saline and insulin have been ordered. Which of the following should be administered next?

Potassium chloride dx:diabetic ketoacidosis

A 29-year-old woman presents to the emergency department after she coughed up blood-tinged sputum this morning. She is also experiencing some shortness of breath and chest pain with deep inspirations. The patient is otherwise healthy and is a foreign exchange student who just arrived from India. She takes oral contraceptive pills, smokes two packs of cigarettes per day, and drinks alcohol on the weekends. She has had recent multiple sick contacts this past week. Her temperature is 99.9°F, blood pressure is 127/68 mm Hg, pulse is 126/min, and respirations are 24/min. Physical exam is notable only for pleuritic chest pain during the pulmonary exam. Which of the following is the most likely diagnosis?

Pulmonary embolism A pulmonary embolism can present with shortness of breath, fatigue,pleuritic chest pain, signs of a deep vein thrombosis (such as a tender and inflamed calf), as well as a history of risk factors for clotting including stasis (such as a long flight, malignancy, or oral contraceptive use), and endothelial dysfunction (typically associated with smoking)

A 45-year-old woman presents to the ED complaining of shortness of breath. Her ECG is shown above. Which of the following is most closely associated with the findings seen in this ECG?

Pulmonary embolism What is the treatment for pulmonary embolism? Answer: Hemodynamically unstable patients are treated with thrombolysis. Stable patients are treated with heparin.

1)What are the three cluster A personality disorders? Answer: Schizoid, schizotypal, and paranoid. 2)In a patient allergic to NSAIDs, what alternative medication can be prescribed to a patient with subacute thyroiditis? Answer: Prednisone. 3)What medication class is first-line treatment for PTSD? Answer: Selective serotonin reuptake inhibitors. 4)What is the treatment for rate control of rapid atrial flutter in a stable patient? Answer: A non-dihydropyridine calcium channel blocker or a beta-blocker. 5)How does the back pain of a herniated disc present? Answer: Electrical pain that radiates down the back of the leg. 6)How long after a brachial plexus injury does it take for electromyography to accurately identify denervation? Answer: Three weeks. 7)What is the appropriate dosing of heparin in ST elevation myocardial infarction patients? Answer: A 60 units/kg bolus (up to 4,000 units) followed by a 12 units/kg/hr infusion (up to 1,000 units/hr). 8)When is the false-negative rate highest for the heterophile antibody test? Answer: During the first week of symptoms. 9)When is the false-negative rate highest for the heterophile antibody test? Answer: During the first week of symptoms. 10)What characteristics of mammal bite wounds indicate that they should be closed primarily? Answer: Injury to the face or scalp, presentation within six hours, and no host immunosuppressive conditions.

Q/A 1

1) What laboratory value will be decreased (aside from hemoglobin or hematocrit) in an acute episode of hemolytic anemia? Answer: The haptoglobin level as it scavenges free hemoglobin released by lysed red blood cells. 2)If a child under one year of age aspirates a foreign body and is choking, what is the appropriate management? Answer: Holding the head lower than the feet, alternate five back blows with five chest thrusts. 3)What is the treatment for pulmonary embolism? Answer: Hemodynamically unstable patients are treated with thrombolysis. Stable patients are treated with heparin. 4)What is a common cause of cathartic colon in bulimia nervosa? Answer: Prolonged laxative use. 5)What are the structures injured in lateral ankle sprain? Answer: Anterior talofibular ligament, calcaneofibular ligament, and posterior talofibular ligament. 6)Which antibiotic is recommended for the acute treatment of closed fist injuries (fight bite) of the hand? Answer: Amoxicillin-clavulanate. 7)What disease is associated with urinary incontinence, ataxia, and dementia? Answer: Normal pressure hydrocephalus. 8)What is the best initial treatment in gout? Answer: Nonsteroidal anti-inflammatory drugs, such as ibuprofenz 9z 10zz

Q/A2

1)Which pathogen is most responsible for infantile malnutrition from persistent diarrhea in low-resource countries? Answer: Shiga toxin-producing enteropathogenic Escherichia coli. 2)In underdeveloped countries, what underlying disease is most frequently associated with atrial fibrillation? Answer: Rheumatic heart disease. 3)What is the most appropriate test to diagnose a bile leak status post cholecystectomy? Answer: Hepatic iminodiacetic acid (HIDA) scan. 4)True or false: systemic glucocorticoids are a recommended adjunctive treatment of acute sinusitis. Answer: False. 5)What is the pathophysiology that causes hyperthermia in neuroleptic malignant syndrome? Answer: Increased metabolic myocyte activity and hypothalamic thermoregulation dysfunction. 6)What blood product may be used to reverse warfarin? Answer: Fresh frozen plasma. 7)Which of the following dysrhythmias can be triggered by premature ventricular contractions?Ventricular tachycardia 8)What physical exam finding of the distal extremity is associated with a radial nerve injury? Answer: Wrist drop. The radial nerve provides innervation to the extensor muscles of the wrist. 9zzWhat is the treatment for cauda equina syndrome secondary to a malignancy? Answer: Emergent radiation therapy.zz

Q/A3

A 57-year-old man presents with low back pain radiating down his right lower extremity. On physical exam, he has decreased sensation in the L5 distribution. What is the most likely cause of his symptoms?

Repetitive flexion

A 32-month-old girl presents to the ED with her mother after an episode of choking and "turning blue." Her mother notes that she was playing with her brother's toys when she choked and turned blue. After coughing, she seems to be back to normal. On physical exam, you note wheezing on the right side. Which of the following will aid in confirming the diagnosis?

Right lateral decubitus chest radiograph If a child under one year of age aspirates a foreign body and is choking, what is the appropriate management? Answer: Holding the head lower than the feet, alternate five back blows with five chest thrusts.

50-year-old man presents with acute onset chest pain. His ECG shows an inferior ST segment elevation myocardial infarction (STEMI). Which of the following ECG findings are suggestive of left circumflex occlusion rather than right coronary artery occlusion?

ST segment elevation in leads V5 and V6

A 37-year-old woman with a history of hypertension, depression, and intravenous heroin use presents with sudden-onset abdominal pain and vomiting. Symptoms began one hour prior to arrival. Her vital signs are temperature 98.9°F, HR 126 beats/minute, RR 32 breaths/minute, BP 89/50 mm Hg, and oxygen saturation 98% on room air. She appears distressed and is writhing on the bed. Her abdomen is soft without ecchymosis or guarding. Which of the following studies is most useful to aid in the diagnosis of her condition?

Serum lactate dx: Acute mesenteric ischemia

37-year-old man presents to urgent care with pain and swelling in his fingertip. A football struck the patient's right fourth finger while he was playing a game of football with friends the day before. On examination, the distal interphalangeal joint of the right fourth finger has full passive range of motion, but the patient is not able to actively extend the joint. An X-ray confirms a small avulsion fracture of the dorsum of the proximal fourth distal phalanx. Which of the following is the most appropriate treatment for this fracture?

Splinting of the joint in extension for six to eight weeks dx= mallet finger injury Forced flexion of the distal interphalangeal joint, causing a partial or complete rupture of the extensor tendon insertion at the distal interphalangeal joint. Examination findings include pain and swelling, deformity of the distal interphalangeal flexor, and an inability to actively extend the dorsal interphalangeal joint. \\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\\ : What views should radiographs of a mallet finger injury include? Answer: Anterior-posterior, lateral, and oblique views. surgical referral is recommended for the following: full laceration of the extensor tendon, volar subluxation of the distal phalanx, a fracture involving greater than 30% of the joint surface, and an inability to passively extend the joint as this suggests the presence of entrapped bony or soft tissue.

A 4-year-old boy presents to the emergency department with a limp and fever. His mother states that he began limping two days ago, and it has gotten progressively worse. He will no longer walk. His fever started today. His mother denies any known injuries. On physical examination, his temperature is 102.1°F with a heart rate of 130 beats per minute. His right hip is warm to the touch with overlying erythema present. He has limited range of motion of the right hip due to pain. Laboratory analysis reveals a leukocytosis with elevated erythrocyte sedimentation rate and C-reactive protein. X-ray of his right hip reveals periosteal thickening. An ultrasound of the right hip reveals a hip effusion. Which of the following is the most common cause of the patient's presentation?

Staphylococcus aureus most common cause of osteomyelitis in children, Clinical features include constitutional symptoms along with focal pain or limited function with a leukocytosis, an elevated erythrocyte sedimentation rate (ESR) and C-reactive protein(CRP), as well as imaging abnormalities.

24-year-old man presents after being hit by a car while walking across the street. During the secondary survey, it is noted that the right lower leg hangs at an awkward angle, concerning for a distal tibia-fibula fracture and dislocation near the ankle. He has abrasions, cuts, and punctate lacerations throughout the lower leg, including near the ankle. The patient is neurovascularly intact distal to the area of concern and has no other apparent injuries. Tetanus is updated, and the X-ray technicians and orthopedic surgery are on their way. What is the most appropriate next step regarding his right lower leg while waiting?

Start antibiotics

A 40-year-old man presents to the emergency department with sudden-onset back pain after lifting a box. The pain radiates down to the mid-thigh and is worse with bending and walking. Physical exam reveals left para-lumbar muscular tenderness without spasm. Which of the following exam maneuver(s) has the highest sensitivity and specificity for sciatica, respectively?

Straight leg raise, crossed straight leg raise dx: Sciatica

Which of the following organisms is the most common bacterial cause of acute otitis media in children between 1 month and 10 years of age?

Streptococcus pneumoniae

A 23-year-old man presents to the emergency department with fever and mental status changes. According to his sister, he was involved in a motor vehicle collision four weeks ago and underwent splenectomy because of uncontrolled bleeding in that area. He improved during his hospital stay and did not have other complications from the collision or injury. He has been doing well at home for over one week until today when he developed a fever. Vital signs show HR 142 bpm, BP 89/51 mm Hg, RR 24 breaths per minute, and T 39.4°C. The patient will open his eyes and attempt to interact, but he does not answer all questions appropriately. He does not have other focal examination findings or significant abdominal tenderness. You are concerned about underlying sepsis and initiate the appropriate workup and empiric antibiotic treatment. What organism is the most likely cause of this patient's infection?

Streptococcus pneumoniae no spleen

An 8-year-old boy presents with his mother to the ED via EMS following six days of rhinorrhea, cough, and nasal congestion. He has been taking an over-the-counter medication for fever. Two days ago, he started having multiple bouts of vomiting, despite restricting his oral intake, and on the day of arrival, he became disoriented and confused. On exam, he has T 37.16°C, BP 110/70 mm Hg, HR 155 bpm, RR 28/min, and glucose 78 mg/dL. He is altered and stuporous, has a palpable liver edge but no jaundice or icterus, and has no meningeal signs or focal neurologic deficits. His labs reveal elevated levels of AST, ALT, lactate, and ammonia. Which of the following is the most appropriate treatment for this condition?

Supportive care Reye syndrome, characterized by encephalopathy and fatty degeneration of the liver. It has been associated with aspirin exposure in the setting of a viral illness. Its major cause of morbidity and mortality is cerebral edema leading to increased intracranial pressure. There is no specific cure, and management is supportive.

A 32-year-old man presents with arm pain. He was practicing parkour, jumped off a ledge and caught onto an overhead bar but then slipped and fell on his wrist. His neurologic exam reveals weak finger abduction, weak thumb opposition, and decreased sensation to the ulnar aspect of the forearm. Which nerve is most likely damaged? A C7 nerve root B Median nerve C. T1 nerve root D Ulnar nerve

T1 nerve root A T1 nerve root injury is most likely in hyperextension, as it is the most inferior and subject to the greatest degree of pulling. The T1 nerve root's motor function includes finger abduction, finger adduction,thumb opposition, and wrist flexion. It also provides sensation to the ulnar aspect of the forearm How long after a brachial plexus injury does it take for electromyography to accurately identify denervation? Answer: Three weeks. ================================================= The C7 nerve root (A) innervates finger flexion/extension, wrist flexion, and elbow extension. Its sensory distribution includes the thumb, index, and middle fingers. The median nerve (B) does control thumb opposition but does not control finger abduction. Its sensory distribution includes the palmar aspect of the thumb, index, and middle fingers. The ulnar nerve (D) does control finger abduction and sensation of the ring and little fingers but does not control thumb opposition.

A 17-year-old boy presents after injuring his left ankle while playing soccer. Which of the following indicates the need for imaging of the ankle?

Tenderness over the posterior edge of the distal lateral malleolus

A 78-year-old woman is brought to the ED by her daughter with concern for altered mentation and somnolence over the past three days. The patient has a history of hypertension and elevated cholesterol, both well controlled with medication. Her vitals are significant for a blood pressure of 148/72 mm Hg, heart rate of 82 beats per minute, oxygen saturation of 99% on room air, and a temperature of 100.58°F (38.1°C). Physical exam reveals a well-appearing elderly female who is sleeping but easily arousable. Laboratory values show a WBC of 8.2/microL with 2% bands, hemoglobin of 13.6 g/dL, platelets of 120,000/microL, sodium of 136 mEq/L, potassium of 3.4 mEq/L, a BUN of 12 mg/dL, and a creatinine of 0.8 mg/dL. Urinalysis is positive for leukocyte esterase, nitrites, and 15 WBC/HPF. Which of the following statements best describes the diagnosis and next step of management?

The patient has pyelonephritis; start parenteral ceftriaxone and admit

A 9-year-old girl previously in a normal state of health presents to the emergency department due to epistaxis for the past 4 hours. Her parents have applied pressure to her nose and have sprayed oxymetazoline intranasally with intermittent improvement, however, she continues to rebleed. Physical exam reveals a well-appearing girl with oozing epistaxis from the left nare. She also has petechiae scattered throughout her back and on both anterior thighs. Her parents have no medical problems, and the patient does not have a history of malignancy or easy bleeding or bruising. Which of the following lab findings is most consistent with the diagnosis?

Thrombocytopenia dx:immune thrombocytopenia (ITP) of childhood in more than half of cases, in the absence of other causes (such as drugs, malignancy, or infection). Cutaneous findings are present in the majority of children diagnosed with ITP. Primary Immune Thrombocytopenia Patient will be a child 2-6 years old History of recent viral infection Red spots on skin or easy bleeding PE will show petechiae, purpura, and gingival bleeding Labs will show platelets < 100,000/µL Most commonly caused by antiplatelet antibodies Treatment is observation, steroids, IVIG Most cases of ITP are self-limited and resolve within 6 months. Management is guided by hematology consultation, but it generally involves steroids or IVIG, along with admission in the case of spontaneous bleeding or platelet count < 20,000/microL

A 51-year-old woman with no significant medical history presents to the ED with fever and shortness of breath. Over the last 3 months, she has noted weight loss, decreased appetite, diarrhea, palpitations, dyspnea on exertion, and generalized anxiety. Her only travel history was a mission trip to the Dominican Republic 6 months ago. She is fully immunized. Her BP is 156/89 mm Hg, HR is 131 bpm, RR is 28/minute, T is 102.3°F, and oxygen saturation is 94% on room air. She appears thin and diaphoretic and has jugular venous distension to the mandible, bibasilar crackles, warm extremities, and bounding peripheral pulses. Her sclera can be seen above and below her iris bilaterally. Her ECG shows sinus tachycardia, and her chest X-ray shows pulmonary edema. Which of the following is the most likely diagnosis?

Thyroid storm

A 56-year-old man presents with penile and prepuce redness, swelling, and discharge as pictured above. The symptoms have been ongoing for several days. He reports worsening redness and pain and notes a mild odor that has not been present previously. What is the most appropriate treatment for this patient?

Topical clotrimazole cream Balanitis has a wide range of causes but is most related to inadequate hygiene in uncircumcised men Candidal infection is the most common cause

50-year-old man with a history of schizophrenia, seizure disorder, chronic back pain, and hypertension presents to the emergency room with altered mental status. His temperature is 40.0°C (104°F), blood pressure is 174/89 mm Hg, pulse is 112/min, respirations are 22/min, and oxygen saturation is 96% on room air. On physical exam, he is agitated, diaphoretic, hypersalivating, and has mydriasis. Lower extremity hyperreflexia, rigidity, and clonus are noted. Review of his chart indicates that he was started on a cough medication 1 day ago. Which of the patient's current medications is the most likely cause of this patient's suspected diagnosis?

Tramadol dx:Serotonin syndrome Treatment is BZDs, cyproheptadine, removing the offending agent(s) most common class of drugs associated with serotonin syndrome is antidepressants such as selective serotonin reuptake inhibitors (SSRI), monoamine oxidase inhibitors (MAOI), serotonin and norepinephrine reuptake inhibitors (SNRI), tricyclic antidepressants (TCA), and atypical antidepressants such as trazodone and bupropion. Several other drugs are associated with serotonin syndrome such as tramadol, lithium, linezolid, triptans, meperidine, and dextromethorphan

27-year-old man with a past medical history of sickle cell disease presents to the emergency department with shortness of breath and chest discomfort with exertion. The patient is requesting hydromorphone. His temperature is 100°F (37.8°C), blood pressure is 102/68 mm Hg, pulse is 120/min, respiratory rate is 18/min, and oxygen saturation is 99% on room air. Physical exam is notable for an uncomfortable-appearing, pale young man who vomits during his exam. His lungs are clear to auscultation. Laboratory values are notable for a hemoglobin of 5.5 mg/dL and a reticulocyte count of 0.5%. An initial ECG is notable for sinus tachycardia and his chest X-ray is shown above. Which of the following is the best next step in management?

Transfuse packed red blood cells This patient is presenting with a history of sickle cell disease and exertional dyspnea in the setting of severe anemia without a reticulocytosis, suggesting a diagnosis of an aplastic crisis. If a patient with sickle cell disease presents with severe anemia with a decreased reticulocyte count (keep in mind that the reticulocyte count should be elevated in anemia), then the most likely diagnosis is an aplastic crisis, most commonly secondary to infection . These patients should immediately be transfused with packed red blood cells, in particular, if they are experiencing signs of decreased end-organ perfusion such as demand ischemia or exertional dyspnea. Sickle cell disease typically presents with recurrent episodes of pain (termed pain crises). In a patient who presents with a pain crisis, the best initial step in management is to administer oxygen, IV fluids, and analgesics in addition to a workup for an underlying infectious etiology and broad-spectrum antibiotics if the patient has a fever =================================================== Perform an exchange transfusion (C) would be indicated in a sickle cell patient who presented with visual disturbances (secondary to retinal infarction), shortness of breath or pleuritic chest pain (secondary to pulmonary infarction), priapism, or stroke.

A 34-year-old woman with a history of sickle cell anemia and depression presents to the emergency department with an episode of dysarthria. According to her husband, approximately 30 minutes ago, she was slurring her speech and having difficulty getting words out. She seemed confused at the time and was drooling from the right side of her mouth. He attempted to shake her and speak to her, but she would not stand up or respond clearly. While he was finding his phone to call 911, her symptoms resolved. She was confused as to what had happened but was then speaking clearly. She continues to be at her baseline now but complains of a mild headache. Vital signs indicate a BP of 168/92 mm Hg, HR of 88 bpm, RR 16 breaths/minute, and T of 37.3°C. Her exam is unremarkable. Laboratory results show anemia with a hemoglobin of 7.9 g/dL but otherwise are unremarkable. CT imaging of the brain is normal. What is the most likely diagnosis in this patient?

Transient ischemic attack -------------------------------------------------------- What is the primary treatment intervention for a patient with sickle cell anemia who presents to the emergency department with an acute ischemic stroke? Answer: Transfusion therapy complicated migraine headache (B). These patients often complain of a preceding aura that can include progressive neurologic deficits. Visual disturbances are the most common type of aura followed by somatosensory symptoms. It is atypical for a migraine headache to be mild and present with weakness or speech deficits. In this anemic patient with a risk factor for neurovascular ischemia, it is important to consider TIA as the primary concern. Another manifestation of disease that causes transient neurologic deficits is a seizure (C). Although this patient was reported to be confused about what had happened, there is not a clear description of a postictal period. Additionally, there was no report of clinical epileptic activity. It is not unheard of for a seizure to present this way, but it would be atypical and should not be the primary diagnosis to consider in this patient.

A 28-year-old woman presents with a two-week history of dyspnea, nonproductive cough, fever, and fatigue. She is HIV-positive and noncompliant with her medications. She has no known drug allergies. Laboratory results reveal an arterial blood gas with a PaO2 of 72 mm Hg and an elevated LDH level. Her chest X-ray is significant for bilateral diffuse interstitial infiltrates. Which one of the following treatments should be initiated?

Trimethoprim-sulfamethoxazole(Bactrim dx:Pneumocystis jirovecii pneumonia, steroids are not indicated with a PaO2 of > 70 mm Hg.

A 45-year-old man with HIV-AIDS and a CD4 count of 150 cells/mm3 presents with several days of fever and dry cough. His oxygen saturation is 85% on room air. Lung auscultation is notable for decreased breath sounds bilaterally and crackles at the bases. A chest X-ray reveals bilateral interstitial infiltrates. Which of the following medication regimens is most appropriate?

Trimethoprim/sulfamethoxazole and prednisone in severe cases of Pneumocystis jiroveci pneumonia (PJP

An older man is brought from the nursing home for evaluation of altered mental status. On laboratory testing he is found to have acute kidney failure with a BUN of 75 mg/dL and creatinine of 5.0 mg/dL. Which of the following is most likely to be elicited on history or physical examination?

Urinary retention Which class of medication prevents calculation of an accurate FENa? Answer: Diuretics, which alter the amount of urinary sodium.

A 27-year-old Japanese woman with a history of Raynaud disease presents to the emergency room for chest pain. This is the third time this week she has presented for chest pain. Her prior visits have all been at night and she tends to arrive pain-free after receiving nitroglycerin from the paramedics. Her ECGs after the nitroglycerin have been normal. Upon arrival to the emergency room tonight, she is again pain-free with a normal ECG after nitroglycerin. While sitting down and awaiting her discharge paperwork, she begins having sharp chest pain. An ECG performed while having symptoms shows ST segment elevations in contiguous leads. Nitroglycerin is given and she rapidly becomes asymptomatic. Her repeat ECG is now normal. A repeat set of blood work, including cardiac enzymes, is normal. What is the most likely diagnosis?

Vasospastic angina

A 44-year-old woman presents to the emergency department with hyperglycemia and back pain. She has truncal obesity with relatively thin extremities as well as a protrusion over the nape of her neck. She has midline lower spine tenderness, and an X-ray demonstrates a compression fracture of the 12th thoracic vertebral body. The presence of which of the following additional findings supports your diagnosis?

Violaceous striae Cushing disease

Wolff-Parkinson-Whit procainamide and cardioversion are the only two appropriate treatments What class of antiarrhythmics does procainamide belong to? Answer: Class 1a.

What is the treatment of choice for this patient?

Left hemiparesis and sensory loss with left facial droop

Which of the following deficits is the lesion above most likely to produce?

Tube 1: WBC 7/microL, RBC 4,000/microL; tube 2: protein 75 mg/dL, glucose 60 mg/dL; tube 3: RBC 3,200/microL The head CT scan shows a subarachnoid hemorrhage. Most subarachnoid hemorrhages are caused by a ruptured berry aneurysm in the circle of Willis.

Which of the following lumbar puncture results would you expect to find with the head CT seen above? ATube 1: WBC 5/microL, RBC 4,000/microL; tube 2: protein 70 mg/dL, glucose 60 mg/dL; tube 3: RBC 50/microL BTube 1: WBC 7/microL, RBC 4,000/microL; tube 2: protein 75 mg/dL, glucose 60 mg/dL; tube 3: RBC 3,200/microL CTube 1: WBC 80/microL, RBC 3/microL; tube 2: protein 60 mg/dL, glucose 60 mg/dL; tube 3: RBC 0 /microL DTube 1: WBC 900/microL, RBC 10/microL; tube 2: protein 200 mg/dL, glucose 15 mg/dL; tube 3: RBC 1/microL

A 70-year-old woman with hypertension and COPD presents with shortness of breath. On evaluation, she appears tachypneic with increased work of breathing. Her breath sounds are notable for diffuse wheezing. She reports no fevers, productive cough, headache, nausea, or vomiting. She is started on ipratropium and albuterol. Which of the following would be expected on an initial ABG?

pH 7.25, PaCO₂ 80 mm Hg, HCO₃ 30 mmol/L acute exacerbation of COPD. in acute respiratory acidosis, we expect the bicarbonate to increase by 1 for each 10 mm Hg of PaCO₂, while in chronic we expect the bicarbonate to increase by 4 for each 10 mm Hg of PaCO₂. If we apply this to the above vignette, an acute PaCO₂ of 80 mm Hg should lead to a bicarbonate of 28 mmol/L, but it is 30 mmol/L, which indicates that there is some degree of renal compensation. chronic respiratory acidosis with metabolic compensation.

A 51-year-old woman with a history of hypertension, rheumatoid arthritis, migraine headaches, and hypertriglyceridemia presents to the ED for acute, nonradiating chest pain associated with nausea and diaphoresis. Which of the following would contribute to her HEART (history, ECG, age, risk factors, and troponin) score? ACousin with a history of myocardial infarction BFirst-degree relative with peripheral arterial diseasz CHistory of coronary revascularization procedurzz DSmoker with cessation 6 months agz

zHistory of coronary revascularization procedure What are the components of the HEART score? Answer: History, ECG, age, risk factors, and troponin (HEART) score.