Deck 1: Emergency Department

Question 1

A 72-year-old man is seen in the emergency department due to chest pain.  He reports 2 days of mid-sternal chest pain, left shoulder pain, fatigue, and occasional sweating.  He sleeps on his right side because sleeping on his back "hurts too much."  He has a known history of coronary artery disease and underwent coronary artery bypass grafting (CABG) 4 weeks ago.  The post-operative course was complicated by new-onset temporary atrial fibrillation and several days of post-operative fever.
His temperature is 38.2 C (100.8 F), blood pressure is 120/75 mmHg, pulse is 89/min, and pulse oximetry is 96% on room air.  His cardiac and pulmonary examinations are within normal limits.  His chest examination reveals a well-healing sternotomy site with mild erythema, but no tenderness to palpation.
ECG shows sinus rhythm with left bundle branch block, which was present on his ECG three weeks ago.  Chest x-ray reveals cardiomegaly with sternotomy wires present and a small left-sided pleural effusion.
Which of the following best explains this patient's current complaints?

A)Acute mediastinitis
B)Acute pericarditis
C)Coronary graft occlusion
D)Hospital acquired pneumonia
E)Pulmonary embolism

Answer 1

B
Explanation:
This patient's clinical presentation is consistent with postpericardiotomy syndrome (PCIS) after recent CABG.  PCIS is likely due to surgical damage of the mesothelial pericardial cells with resultant blood in the pericardial space, which causes an autoimmune response against the released cardiac antigens.  The immune complexes deposit and cause inflammation in the pericardium, pleura, and lung.
PCIS presents similar to acute pericarditis with typical pleuritic chest pain, pericardial friction rub, ECG changes, and/or new or worsening pericardial effusion.  Most patients after cardiac surgery have some baseline ECG changes (such as LBBB in this patient), making it difficult to interpret the ECG for evidence of pericarditis.  Patients who develop PCIS usually respond to NSAIDs; steroids maybe used for refractory cases.  Giving colchicine after cardiac surgery significantly decreases the incidence of PCIS.
(Choice A)  Postoperative mediastinitis typically occurs within the first 2 weeks after surgery and presents with fever, tachycardia, chest pain, and signs of sternal wound infection, such as purulent discharge.  This patient's normal appearing sternotomy site makes this less likely.
(Choice C)  Graft occlusion usually occurs within the first 30 days after CABG and typically presents with postoperative ischemic symptoms, significant ECG abnormalities, ventricular arrhythmias, and hemodynamic instability.  This patient is > 4 weeks post-surgery, has fever, and appears clinically stable, making this less likely.  His pain is more consistent with pericarditis (ie, worse with laying back), and the pain can sometimes radiate to the shoulder.
(Choice D)  Hospital acquired pneumonia would be less likely in this patient 4 weeks after hospitalization with a normal pulse oximetry and pulmonary examination.  A small left-sided pleural effusion is commonly seen after cardiac surgery, but there are no infiltrates on the chest x-ray to suggest pneumonia.
(Choice E)  Pulmonary embolism (PE) may occur after cardiac surgery and typically presents with pleuritic chest pain and hypoxia.  This patient's normal pulse oximetry and clinical presentation is less consistent with PE.
Educational objective:
Post-cardiac injury syndrome (PCIS) is commonly seen after cardiac surgery and is likely an autoimmune reaction, causing inflammation and presenting with the typical symptoms of pericarditis.  Treatment includes NSAIDs or steroids.  Prophylactic colchicine after cardiac surgery significantly decreases the incidence of PCIS.
__________
References:
The postcardiac injury syndrome: case report and review of the literature.
(http://www.ncbi.nlm.nih.gov/pubmed/16553111)

Question 2

A 72-year-old man is brought to the emergency department due to severe, tearing pain in the anterior and posterior areas of his chest for the last 2 hours.  The pain is accompanied by diaphoresis and mild shortness of breath.  The patient has never experienced similar pain.  Stress testing 6 months ago showed mild ischemia in the inferior wall, which was treated medically.  Other medical problems include hypertension, hyperlipidemia, gout, and chronic constipation.  The patient is a lifelong nonsmoker.
Blood pressure is 80/60 mm Hg in the right arm and 76/47 mm Hg in the left arm, and pulse is 102/min.  The jugular veins are distended when the patient is sitting.  Heart sounds are distant and no murmurs are heard on cardiac auscultation.  The lungs are clear to auscultation.  There is no peripheral edema.  The extremities are cold, and peripheral pulses are markedly diminished.
ECG performed in the emergency department is shown in the exhibit.
Which of the following is the best next step in management of this patient?

A)Bedside transthoracic echocardiography followed by pericardiocentesis
B)Bedside transthoracic echocardiography followed by transfer to the operating room
C)Cardiac catheterization
D)Conscious sedation followed by transesophageal echocardiography
E)CT scan of the chest with contrast

Answer 2

Bedside transthoracic echocardiography followed by transfer to the operating room

Question 3

A 34-year-old man with history of type 1 diabetes mellitus comes to the emergency department because of retrosternal chest pain for the past 12 hours.  His symptoms started last night and woke him up several times because he could not find a comfortable position.  He also describes pain in his left shoulder on deep inspiration.  His father died of a heart attack at the age of 46.  He quit smoking 8 years ago.
His temperature is 37.8 C (100.2 F), blood pressure is 110/70 mm Hg, and pulse is 100/min.  No murmurs are heard on cardiac auscultation.  Fine crackles are heard at the left lung base that clear with coughing.  An ECG is obtained and shown in this exhibit.
Which of the following changes would be expected on repeat ECG one week later?

A)Diffuse T wave inversion
B)First degree atrioventricular block
C)Left axis deviation
D)Pathologic Q waves in precordial leads
E)ST segment depression in anterolateral leads

Answer 3

Diffuse T wave inversion

Question 4

A 60-year-old woman is brought to the emergency department after an episode of syncope.  She also has generalized weakness and mild nausea.  The patient was recently hospitalized for acute decompensated heart failure, and her left ventricular ejection fraction was estimated at 35% by echocardiography.  Her discharge medications include furosemide, carvedilol, lisinopril, aspirin, and atorvastatin.  At her outpatient visit a week ago, her lisinopril dose was increased and she was started on spironolactone.
Her temperature is 36.8 C (98.2 F), blood pressure is 120/82 mm Hg, pulse is 74/min, and respirations are 16/min.  Pulse oximetry is 95% on room air.  Jugular venous pressure is 8 cm H₂O.  Scattered bibasilar crackles are present.  The patient has a grade 2/6 systolic ejection murmur along the right sternal border without radiation.  She has 1+ pedal edema to the knees bilaterally.
Her ECG shows no P waves and a wide complex regular rhythm at 74/min.  ECG done a week ago showed normal sinus rhythm, narrow QRS complexes (90 msec), and non-specific T wave abnormalities.
The patient would most likely benefit from which of the following?

A)Amiodarone
B)Atropine
C)Calcium gluconate
D)Furosemide
E)Metoprolol

Question 5

A 56-year-old man comes to the physician because of a chest and epigastric discomfort since this morning.  While sitting in the waiting area, he suddenly becomes unresponsive.  He has scarce respiratory efforts and there is no palpable pulse over the carotid arteries.
Which of the following is the most appropriate next step in managing this patient?

A)Airway opening and rescue breathing
B)Attachment of cardiac and oxygen monitors
C)Attachment of defibrillation pads
D)Chest compressions
E)Intravenous access

Question 6

A 62-year-old man comes to the emergency department because of nausea and abdominal pain.  He describes the pain as a pressure located in the epigastric area which feels like it is "pushing up" into his chest.  It began approximately 30 minutes before his arrival and he thinks it is related to having eaten some spicy food the night before.  The pain initially improved while leaning forward, but it is now present in any position.  The patient has no shortness of breath or palpitations.  He has a history of benign prostatic hyperplasia that is well-controlled with tamsulosin.  He does not smoke or use illicit drugs but drinks 4-5 alcoholic beverages daily, and occasionally consumes more.
His blood pressure is 135/75 mm Hg in the right arm and 130/75 mm Hg in left arm, pulse is 70/min, and respirations are 14/min.  Pulse oximetry shows 98% oxygen saturation on room air.  The patient is in moderate pain and is diaphoretic.  There is a 2/6 systolic murmur at the apex which radiates to the axillae.  The lungs are clear to auscultation.  The remainder of the physical examination is within normal limits.
Laboratory results are as follows:

A 12-lead electrocardiogram is shown in this exhibit.

Which of the following is the most appropriate next step in the management of this patient?

A)Coronary angiography
B)CT scan of the aorta
C)Exercise nuclear stress test
D)Ibuprofen and colchicine
E)Proton-pump inhibitor

Question 7

A 47-year-old man is brought to the emergency department by his wife due to a 2-day history of lightheadedness and generalized weakness.  The patient nearly lost consciousness on 2 occasions and has been unable to get out of bed since this morning.  He has no chest pain, headaches, or nausea.  Other medical problems include chronic low back pain, type 2 diabetes mellitus with evidence of retinopathy and proteinuria, and hypertension for which he was recently started on losartan.  His other medications include ibuprofen, amitriptyline, and low-dose aspirin.
On examination, he appears lethargic with mild muscle weakness in both lower extremities.  Initial blood pressure is 105/80 mm Hg.
His rhythm strip is shown here.
Which of the following is the most likely cause of this patient's symptoms?

A)Amitriptyline overdose
B)Electrolyte abnormalities
C)Ischemic stroke
D)Myocardial infarction
E)Sick sinus syndrome

Question 8

A 56-year-old woman comes to the emergency department with a two-day history of substernal chest pain and mild shortness of breath.  She takes levothyroxine for hypothyroidism and alendronate for osteoporosis.  She has been under a great deal of stress at her job lately because many of her co-workers were recently terminated.  Her mother died from a stroke at the age of 65 and her father had a heart attack at the age of 67.  She smokes a half-pack of cigarettes per day and drinks alcohol socially.  She denies any illicit drug abuse.
Her blood pressure is 122/70 mm Hg and pulse is 100/min and regular.  Her oxygen saturation is 98% on room air.  Lungs are clear on auscultation.
An EKG shows deep T wave inversions in the anterior precordial leads.  Her troponin I level is 2.2 ng/ml (normal < 0.012).
The patient is taken to cardiac catheterization, which shows no evidence of coronary artery disease.  On left ventriculogram, the apex is non-contractile while the base is hypercontractile.  
Which of the following is the most likely prognosis for this patient?

A)Expected average survival of one year
B)Persistent left ventricular systolic dysfunction despite medical therapy
C)Progression to end-stage heart failure in 6-8 months
D)Recovery of the left ventricular systolic function in 8-12 weeks

Question 9

A 32-year-old woman, gravida 1 para 0, at 32 weeks gestation is brought to the emergency department due to anterior chest and neck pain that began 3 hours ago.  The pain was severe at onset but has decreased to moderate discomfort.  She also has had mild nausea and epigastric discomfort.  After the onset of the chest pain, the patient experienced tingling and weakness of her right arm accompanied by blurry vision and headache that lasted approximately 20-30 minutes.  She has had a healthy pregnancy except for development of gestational diabetes mellitus at 24 weeks gestation.  The patient's blood pressure was elevated during her last prenatal visit, and she was started on an antihypertensive medication.  She has no other significant medical history.  She does not use tobacco, alcohol, or illicit drugs.
On physical examination, the patient appears comfortable.  Blood pressure is 176/104 mm Hg in the right arm and 180/99 mm Hg in the left arm, and pulse is 96/min.  Oxygen saturation is 94% on room air.  Her right pupil measures 4 mm and her left pupil measures 2 mm.  There is slight ptosis on the left side.  Lung fields are clear to auscultation with equal air entry on both sides.  Cardiac examination reveals regular heart sounds with normal S1 and S2.  The neurologic examination is otherwise unremarkable.  Peripheral pulses are equal in all extremities.  There is 2+ pitting peripheral edema of both lower extremities with some engorged varicose veins.  There are normal deep tendon reflexes without clonus.
ECG shows sinus rhythm and a 1-mm downsloping ST-segment depression in leads aVL, V5, and V6.  Urinalysis shows 1+ ketones, no protein, and no glucose.
Which of the following is the best next step in management of this patient?

A)Cardiac catheterization
B)Intravenous magnesium infusion
C)Intravenous nitroprusside infusion
D)MRI of the head
E)Transesophageal echocardiography

Question 10

A 34-year-old man is brought to the emergency department with central chest pain and nausea that started two hours ago.  He looks anxious and admits to using cocaine before his chest pain started.  He says that he uses cocaine once or twice per month, but has never had similar symptoms.  He denies any past medical history and exercises regularly at a gym.  He smokes cigarettes and drinks beer on the weekends.  He has no family history of coronary artery disease or sudden death.
On physical examination, he is mildly diaphoretic.  His blood pressure is 165/85 mm Hg and pulse is 105/min.  His oxygen saturation is 98% on room air.  Lungs are clear to auscultation.  There are no murmurs.  Peripheral pulses are brisk and symmetric.
ECG shows sinus tachycardia and a 2 mm ST segment elevation in leads II, III, and avF; a 1 mm ST segment depression is seen in lead I.  Telemetry monitoring shows occasional premature ventricular beats.  Portable chest X-ray is unremarkable.
He is immediately treated with sublingual nitroglycerin, aspirin, and benzodiazepines.  Shortly thereafter, he reports improvement of his symptoms and now rates his chest pain as 3/10, down from the initial 8/10.
Which of the following is the best next step in managing this patient?

A)Cardiac catheterization followed by observation in the coronary care unit
B)Clopidogrel, heparin drip, morphine, and observation in the coronary care unit
C)Esmolol drip, morphine, and observation in the coronary care unit
D)Nitroglycerin as needed, diltiazem, and observation on a telemetry floor
E)Nitroglycerine drip, morphine, and observation in the coronary care unit

Question 11

A 66-year-old retired police officer is brought to the emergency department due to abrupt-onset sharp anterior chest pain.  The pain started approximately 2 hours ago while he was working on his car in the garage.  The patient describes the pain, which radiates to his neck and lower jaw, as "the worst pain of my life."  He also has epigastric discomfort.  Medical problems include hypertension, hyperlipidemia, and benign prostatic hyperplasia.  Medications include hydrochlorothiazide, losartan, tamsulosin, atorvastatin, and daily aspirin.  The patient has a 30-pack-year smoking history but quit approximately 5 years ago.  He is physically active and jogs 2-3 miles on most days.
Temperature is 37.2 C (99 F), blood pressure is 201/104 mm Hg in the right upper arm and 198/94 mm Hg in the left upper arm, pulse is 90/min, and respirations are 22/min.  Pulse oximetry is 95% on room air.  The patient appears very uncomfortable due to pain.  There is a faint early diastolic murmur at the left sternal border and an S4 at the apex.  The lungs are clear to auscultation.  Mild epigastric tenderness is present on deep palpation without rebound.  There is no peripheral edema, and lower extremity pulses are symmetric.
ECG shows high-voltage QRS complexes in the precordial leads and nonspecific ST-segment and T-wave changes.
Which of the following is the most appropriate initial treatment for this patient?

A)Clopidogrel
B)Intravenous hydralazine
C)Intravenous labetalol
D)Intravenous nitroprusside
E)Unfractionated heparin

Question 12

A 36-year-old man comes to the emergency department due to a sudden onset of chest fluttering, dizziness, and weakness that started after breakfast an hour ago.  He has had no chest pain or shortness of breath.  The patient had a similar episode a month ago that woke him up from sleep, after which he went to the emergency department and was diagnosed with atrial fibrillation.  The episode terminated spontaneously, and he was discharged with metoprolol and low-dose aspirin.  Since then, the patient had been feeling well until today's symptoms began.  Medical history is otherwise insignificant, and he has no family history of heart disease.  The patient jogs 2 miles daily and tries to eat "healthy."  He used to drink beer on the weekends, but he has abstained from alcohol for the past month.  He is a lifelong nonsmoker.
Blood pressure is 118/67 mm Hg and pulse is 144/min and irregular.  BMI is 26 kg/m².  The lungs are clear to auscultation.
ECG shows atrial fibrillation with rapid ventricular response.  Transthoracic echocardiogram shows normal left ventricular size and function.  Complete blood count and metabolic panel are unremarkable.  TSH is 2.5 µU/mL.
After initial evaluation, electrical cardioversion is performed, which successfully restores normal sinus rhythm.
Which of the following is the best next step in management of this patient?

A)Coronary angiography
B)Start amiodarone
C)Start digoxin
D)Start flecainide
E)Transesophageal echocardiogram

Question 13

A 78-year-old man is brought to the emergency department after experiencing 2 episodes of syncope.  The first episode occurred yesterday while he sat reading a magazine after a heavy dinner.  The second happened today in the bathroom after urination.  The patient felt lightheaded and nauseated and had to sit down on the toilet seat before he briefly lost consciousness.  He has never had similar episodes before, but he has experienced some lightheadedness during brisk uphill walking.
Over the last several days, the patient has had lower abdominal cramps accompanied by 2 episodes of diarrhea.  He was diagnosed with aortic stenosis a year ago after a physical examination showed a murmur, but he refused to see a cardiologist for further evaluation.  In the emergency department, he says that he feels "weak but okay."
His blood pressure is 124/60 mm Hg.  Jugular venous pressure is estimated at 10 cm H₂O.  There is a harsh 4/6 systolic mid-peaking murmur at the base of the heart that radiates to both carotids.  The second heart sound is soft, and the carotid upstrokes are delayed after the first heart sound.  His lungs are clear on auscultation.  There is no peripheral edema.
An electrocardiogram is obtained in the emergency department.
Which of the following is the most likely cause of this patient's symptoms?

A)Conduction system disease
B)Left main coronary artery stenosis
C)Severe narrowing of the aortic valve
D)Vasovagal syncope
E)Volume depletion

Question 14

A 72-year-old woman with diet-controlled type 2 diabetes mellitus is brought to the emergency department for chest pain and shortness of breath.  Her initial blood pressure is 132/72 mm Hg and pulse is 102/min.  ECG shows sinus tachycardia and a 2 mm horizontal ST segment depression in the anterior precordial leads.  A chest x-ray shows bilateral patchy opacities most consistent with congestive heart failure.
She is treated with aspirin, clopidogrel, furosemide, nitroglycerin infusion, and heparin infusion.  Non-invasive positive pressure ventilation is initiated.  She is taken to the cardiac catheterization lab, and coronary angiography is performed which shows extensive triple vessel coronary artery disease.  Pulmonary artery catheter is placed and no coronary artery intervention is performed.
The patient is transferred to the cardiac care unit.  Four hours later, her blood pressure is 84/46 mm Hg and pulse is 116/min.  Hemodynamic readings from the pulmonary artery catheter are shown below.

Which of the following is the most likely cause of this patient's hypotension?

A)Cardiogenic Shock
B)Early sepsis
C)Pericardial tamponade
D)Pulmonary embolism
E)Volume depletion

Question 15

A 52-year-old construction worker is brought to the emergency department due to the sudden onset of severe substernal chest pain.  His initial ECG in the emergency department shows sinus rhythm with left bundle branch block.  There is no previous ECG available for comparison.
On physical examination, the patient appears to be in significant distress.  Temperature is 37.2 C (99 F), blood pressure is 122/75 mm Hg, pulse is 102/min, and respirations are 22/min.  Pulse oximetry is 86% on room air.  Lung examination reveals minimal bibasilar rales.  Cardiac examination reveals regular rhythm with no significant audible murmurs or pericardial rub.
An emergency cardiac catheterization shows an occluded proximal left anterior descending artery (LAD).  The left circumflex and right coronary arteries have mild luminal irregularities.  An intra-aortic balloon counterpulsation (IABP) device is inserted, and the patient undergoes successful primary angioplasty of the proximal LAD with drug-eluting stent placement.
Over the next 36 hours, the patient's hemodynamics improve, and IABP support is weaned and eventually removed.  He experiences several episodes of asymptomatic monomorphic ventricular ectopy.  He feels well and he is able to ambulate with no symptoms.  Current medications include low-dose aspirin, clopidogrel, atorvastatin, and lisinopril.  The patient is started on low-dose metoprolol succinate and does well over the next 2 days.
ECG shows sinus rhythm with a persistent left bundle branch block pattern.  A transthoracic echocardiogram shows a large area of akinesis in the mid- to distal anterior, anterolateral, and anteroapical segments, with a left ventricular ejection fraction of 25%.  There is trace mitral and tricuspid regurgitation.
Which of the following is the most appropriate next step in management of this patient?

A)Add amiodarone to the medical regimen
B)Continue current medical therapy and discharge home
C)Offer cardiac resynchronization therapy
D)Perform submaximal exercise stress testing
E)Place implantable cardioverter-defibrillator

Question 16

A 72-year-old man comes to the emergency department after a brief episode of loss of consciousness.  The patient was waiting in line to purchase a movie ticket when he felt warmth and nausea and started sweating.  He then collapsed to the ground and was unconscious for 1 to 2 minutes.  According to his wife, who witnessed the episode, he had 2 or 3 jerking movements of his arms.  He had no tongue biting or urinary incontinence.
The patient was briefly hospitalized after a similar episode 1 year ago and work-up including blood tests, ECG, and telemetry were normal.  His medical problems include hypertension, hyperlipidemia, diet-controlled type 2 diabetes mellitus, and diverticulosis.
Blood pressure is 130/84 mm Hg and pulse is 72/min with no orthostatic changes.  The patient is alert and interactive.  There are no cardiac murmurs or focal neurologic findings.
ECG shows sinus rhythm with normal intervals.  Blood cell counts, serum chemistry studies, and initial cardiac troponin I level are within normal limits.
Which of the following is the best next step in management of this patient?

A)Admit for 48-hour telemetry monitoring
B)Reassure and advise primary care provider follow-up
C)Recommend 48-hour ambulatory ECG monitoring
D)Obtain brain imaging and electroencephalography
E)Perform tilt-table testing

Question 17

A 39-year-old woman comes to the emergency department due to mild shortness of breath and right-sided pleuritic chest pain that began this morning.  The patient underwent a mastectomy for left-sided breast cancer 2 weeks ago.  She has a history of hives after eating seafood.
Blood pressure is 148/96 mm Hg, pulse is 114/min, and respirations are 21/min.  Oxygen saturation is 91% on room air.
Chest x-ray is unremarkable and urine pregnancy test is negative.  Creatinine is 0.8 mg/dL.
Which of the following is the most appropriate diagnostic approach?

A)CT pulmonary angiography after pretreatment with glucocorticoids and antihistamines
B)CT pulmonary angiography using a high-osmolar radiocontrast material
C)CT pulmonary angiography without specific precautions
D)Lower extremity compression ultrasonography
E)Ventilation-perfusion scan

Question 18

A 68-year-old man comes to the emergency department due to lightheadedness that occurs mainly upon standing.  This has gotten worse today.  He has fallen on 2 occasions, but he has not sustained any injuries.  He has not had any chest pain or pressure, palpitations, or shortness of breath at rest.  He has a history of coronary artery disease with a bare metal stent placed in the right coronary artery 2 years ago.  His other medical problems include chronic obstructive lung disease, osteoarthritis, benign prostatic hyperplasia, and hypertension.
His medications include clopidogrel, aspirin, metoprolol, atorvastatin, ramipril, and a tiotropium inhaler.  The dose of ramipril was increased recently and he was also started on tamsulosin for urinary symptoms.  He quit smoking at the time of his stent placement after a 50 pack-year smoking history.  He does not drink alcohol.
He does not appear to be in acute respiratory distress.  His blood pressure is 97/70 mm Hg, pulse is 112/min and regular, and respirations are 16/min.  His oxygen saturation is 98% on room air.  His BMI is 20 kg/m².  His mucous membranes are moist.  The neck veins appear distended while sitting and demonstrate a rapid "x" descent.  There is a 4 cm left supraclavicular lymph node which is hard and mobile on palpation.  The lungs have scattered expiratory wheezes.  There are occasional heart beats that are auscultated at the apex but not felt in the radial pulse.  There is 2+ lower extremity edema, more on the right compared to the left.
ECG shows sinus tachycardia, right bundle branch block, low-voltage QRS complexes, and nonspecific ST segment and T wave changes.
Which of the following is the most likely cause of this patient's current symptoms?

A)Ischemic cardiomyopathy
B)Medication side effect
C)Pericardial disease
D)Pulmonary embolism
E)Superior vena cava syndrome

Question 19

A 73-year-old woman comes to the emergency department because of chest discomfort.  She was involved in a low velocity motor vehicle accident earlier in the day in which she backed into another car in the parking lot.  She was wearing a seatbelt at the time and suffered no injuries.  This is her second accident in the last three months, and she is very worried that her children will take away her car as a result.
Approximately one hour after returning home, she noted the onset of substernal chest pressure, described as a "heaviness" which radiates to the jaw bilaterally and shortness of breath.  She has never experienced these symptoms before.  Her other medical problems include hypertension and hypothyroidism.  Her medications include lisinopril, hydrochlorothiazide, levothyroxine, and aspirin.
Her temperature is 36.7 C (98 F), blood pressure is 145/75 mm Hg, and pulse is 104/min.  Her BMI is 24 kg/m².  The patient is in mild distress.  The estimated jugular venous pressure is 8 mm H₂O.  There is a 2/6 systolic ejection murmur at the right upper sternal border, which radiates to the carotids bilaterally.  Her lungs are clear on auscultation.  Her peripheral pulses are 2+ and no peripheral edema is present.
An electrocardiogram demonstrates sinus tachycardia and 2 mm of ST elevation in leads V1 to V4 with T wave inversions.  No prior EKG is available for comparison.

Emergent coronary angiography is performed, which demonstrates no obstructive coronary artery disease.  Echocardiogram shows dyskinesis of the mid and apical left ventricle with hyperkinesis of the base and an overall left ventricular ejection fraction of 25%.
Which of the following best explains this patient's symptoms?

A)Aortic stenosis
B)Cardiac contusion
C)Demand ischemia
D)ST segment elevation myocardial infarction
E)Stress cardiomyopathy

Question 20

An 83-year-old woman is brought to the emergency department due to chest pressure accompanied by nausea and vomiting.  She felt well until 3 days ago when she was watching television and experienced substernal chest discomfort that radiated to her back.  The pain lasted nearly an hour before resolving spontaneously; she also had nausea and vomiting at that time.  The patient has never had chest pain before and has had no further discomfort since.  She attributes the entire experience to drinking expired milk.  The patient is currently without symptoms but is seen in the emergency department at the insistence of her daughter, who is a physician.  Other medical problems include overactive bladder and osteoarthritis.  Medications include oxybutynin and ibuprofen as needed.
Blood pressure is 110/75 mm Hg, pulse is 61/min, and respirations are 12/min.  The patient is in no acute distress.  Jugular venous pulsations are normal.  Lungs are clear to auscultation bilaterally.  Apical impulse is normal.  No heart murmurs are heard.  Pulses are 2+ and symmetrical.  There is no edema.
ECG shows normal sinus rhythm with 2-mm Q waves in leads II, III, and aVF.  Laboratory results are as follows:
The patient is admitted to the intensive care unit and scheduled for coronary angiography.  Shortly after arriving on the floor, she is noted to be markedly dyspneic.  Repeat blood pressure is 90/45 mm Hg, pulse is 125/min, and respirations are 20/min.  Lung examination reveals bilateral diffuse crackles.  A pulmonary arterial catheter is placed, with the results shown below.
Which of the following is the most likely diagnosis in this patient?

A)Left ventricular aneurysm
B)Papillary muscle rupture
C)Pulmonary embolism
D)Right ventricular infarction
E)Ruptured ventricular septum

Question 21

A 45-year-old man with known HIV infection comes to the emergency department due to a rash that began on his hands 4-5 weeks ago but then spread to involve his upper arms, shoulders, and ears.  He has no fever, trauma, recent travel, or insect bites.  He lives in a shelter and has poor medical follow-up.  The patient was treated in the past for Candida esophagitis and Pneumocystis jirovecii pneumonia.  His CD4⁺ cell count 6 months ago was 50/µL.  His temperature is 36.7 C (98 F), blood pressure is 126/80 mm Hg, and pulse is 80/min.  Photographs of the patient's skin examination are shown below.
   
Which of the following is the most likely diagnosis?

A)Crusted scabies
B)Eczema
C)Psoriasis
D)Seborrheic dermatitis
E)Tinea corporis

Question 22

A 78-year-old woman is brought to the emergency department with left hip pain after a mechanical fall at home.  Her medical history includes knee osteoarthritis, hypertension, hyperlipidemia, and a myocardial infarction requiring bare-metal stent placement 14 months earlier.  Her medications include acetaminophen, low-dose aspirin, and simvastatin.  She had previously been prescribed a beta blocker but stopped taking it a couple months ago due to fatigue.  At baseline, she is able to eat, dress, and use the bathroom without assistance.  The patient is able to walk up only half a flight of stairs before stopping due to knee pain.  She has no chest pain, shortness of breath, or palpitations.  She is a lifetime nonsmoker.
The patient appears comfortable after intravenous morphine injection.  Blood pressure is 154/80 mm Hg and pulse is 64/min.  Oxygen saturation is 96% on room air.  Physical examination shows an externally rotated and shortened left leg.  No murmurs are heard on cardiac auscultation.  Lungs are clear to auscultation.
Laboratory results are as follows:
ECG demonstrates normal sinus rhythm with Q waves in the inferior leads.  X-ray of the left hip and pelvis demonstrates a displaced intertrochanteric fracture.  Transthoracic echocardiogram obtained 6 months earlier reveals inferior wall hypokinesis, a left ventricular ejection fraction of 50%, evidence of mild diastolic dysfunction, and no major valvular abnormalities.
Which of the following is the most appropriate next step in management of this patient?

A)Order pharmacologic stress testing
B)Proceed directly with surgical repair of hip fracture
C)Repeat transthoracic echocardiogram
D)Start ACE inhibitor therapy
E)Start beta blocker therapy

Question 23

A 65-year-old woman is brought to the hospital for severe chest pain that started 7 hours ago.  She was hospitalized 6 weeks ago with ischemic stroke and treated with aspirin and rosuvastatin.  During that hospitalization, the patient had paroxysmal atrial fibrillation and was started on warfarin therapy.  Her last INR 2 days ago was 2.1.  The patient has mild, residual left-sided weakness.  Her past medical history is also significant for hypertension.
Blood pressure is 165/90 mm Hg and heart rate is 98/min and regular.  Chest examination shows crackles at the lung bases.
Electrocardiogram (ECG) shows normal sinus rhythm with 2 mm ST-segment elevation in leads V1-V4.
Which of the following is an absolute contraindication to fibrinolytic therapy in this patient?

A)Aspirin therapy
B)Blood pressure on presentation
C)Ischemic stroke
D)Time from onset of symptoms
E)Warfarin therapy

Question 24

A 43-year-old man comes to the emergency department with a 3-day history of fever, malaise, and chills.  He was hospitalized a year ago for alcohol withdrawal symptoms but otherwise no medical history is available.  He admits to using intravenous drugs.
The patient's temperature is 38.4 C (101.1 F), blood pressure is 144/90 mm Hg, and pulse is 102/min.  He has poor oral dentition.  A small white plaque is seen on the buccal mucosa.  Cervical lymph nodes are palpable bilaterally but are small and nontender.  Lungs are clear on auscultation.  There is a short 2/6 early diastolic murmur heard at the right upper sternal border.  The abdomen is soft and nontender.  Extremity pulses are full and symmetric, and there is no edema.
Laboratory results are as follows:

Blood cultures are sent.
Which of the following tests is most important for making treatment decisions at this point?

A)Blood smear
B)Bone marrow biopsy
C)CT scan of the chest
D)Echocardiography
E)Rapid HIV testing

Question 25

A 76-year-old man is brought to the emergency department after having 6 hours of shortness of breath and chest pain.  His initial blood pressure is 102/72 mm Hg and pulse is 102/min.  His oxygen saturation is 82% on 15 liters of oxygen via face mask.  Bilateral rales are heard over the lower to middle lung fields.  His initial ECG shows sinus tachycardia and a left bundle branch block.  He is intubated and rushed to the cardiac catheterization lab.
He is found to have an occluded proximal left anterior descending artery and mild atherosclerosis involving the other coronary arteries.  He has successful percutaneous revascularization with restoration of coronary flow.  A pulmonary artery catheter is placed at the end of the procedure for hemodynamic monitoring and he is transferred to the coronary care unit.  His current medications include aspirin, clopidogrel, intravenous unfractionated heparin, eptifibatide, furosemide, and propofol.  Six hours after the procedure, his blood pressure is 78/48 mm Hg, and his pulse is 120/min and regular.  His ECG shows sinus tachycardia and left bundle branch block pattern.
Hemodynamic readings from the pulmonary artery catheter show the following:

Which of the following is the most likely cause of this patient's hypotension?

A)Cardiogenic shock
B)Early sepsis
C)Hypovolemia
D)Pericardial tamponade
E)Pulmonary embolism

Question 26

A 72-year-old man comes to the emergency department because of palpitations and shortness of breath for the past 24 hours.  His medical problems include hypertension, hyperlipidemia, type 2 diabetes mellitus, obstructive sleep apnea, and emphysema.  He uses 2 liters of oxygen only during the night.  He cannot recall his medications, but uses an unknown daily inhaler for his "lung disease."  He quit smoking 12 years ago.
His blood pressure is 132/54 mm Hg and pulse is 155/min.  There is faint end expiratory wheezing noted over both lungs.  No murmurs are appreciated.  There is bilateral 1+ edema in his lower extremities.
An ECG is performed in the emergency department and is shown in this exhibit.
He is admitted to the hospital and started on a diltiazem infusion.  The next morning, he continues to have a rapid pulse at 155/min.  Transthoracic echocardiogram shows left atrial dilation, normal left ventricular systolic function, and an estimated pulmonary artery systolic pressure of 50 mm Hg.
Which of the following is the best management option for this patient?

A)Adenosine
B)Digoxin
C)Flecainide
D)Radiofrequency ablation
E)Sotalol

Question 27

A 38-year-old man comes to the emergency department due to 1 day of left-sided chest and neck pain.  He could not get comfortable the night before and eventually fell asleep in a semi-recumbent position.  He had a sore throat a week ago.  Medical history is also significant for acid reflux disease.
Temperature is 37.2 C (99 F), blood pressure is 132/80 mm Hg, and pulse is 90/min.  Heart sounds are normal, and lungs are clear to auscultation.  There are no skin rashes.
Laboratory results are as follows:
ECG shows sinus rhythm with 1- to 2-mm diffuse ST-segment elevation, except for a 2-mm ST-segment depression in lead aVR.  Chest x-ray reveals normal cardiac size and clear lung fields.
Which of the following initial therapies is most likely to cause recurrent symptomatic episodes in this patient?

A)Aspirin
B)Colchicine
C)Immune globulin
D)Indomethacin
E)Prednisone

Question 28

A 47-year-old man is brought to the emergency department due to lightheadedness and palpitations.  He denies chest pain, shortness of breath, or nausea.  He reports a history of palpitations since he was a teenager and says he can usually stop them by bearing down.  However, this maneuver did not work this time so he decided to come to the hospital.  His other medical problems include type 1 diabetes mellitus and hypertension.  He had a myocardial infarction 5 years ago, but has not had chest pain since then.  His exercise tolerance is good.
Blood pressure is 80/40 mm Hg and his pulse is 150/min.  Lungs are clear on auscultation.  No heart murmurs are appreciated.
ECG is shown in the exhibit.
Which of the following is the best next step in managing this patient?

A)Bedside transthoracic echocardiogram
B)Carotid sinus massage
C)Intravenous adenosine
D)Intravenous amiodarone
E)Intravenous sedation and cardioversion

Question 29

A 72-year-old man is brought to the emergency department due to 3 days of worsening cough and shortness of breath.  The cough is productive of a small amount of white sputum.  The patient has no chest pain.  He has a history of hypertension, gout, chronic obstructive pulmonary disease, and coronary artery disease for which he underwent coronary artery bypass grafting.  He also had mitral valve repair 6 years ago.  The patient has a 40-pack-year smoking history and continues to smoke a pack of cigarettes a day.
Blood pressure is 136/72 mm Hg, pulse is 132/min, and respirations are 26/min.  Oxygen saturation is 92% on room air.  The patient appears to be in moderate respiratory distress.  Jugular venous pulse is difficult to measure due to use of accessory muscles.  Lung auscultation shows decreased air entry in both lung fields.  There is diffuse and scattered wheezing heard throughout the lung zones.  Heart sounds are irregular with a faint holosystolic murmur heard over the cardiac apex.  There is 1+ bilateral pitting ankle edema.
Laboratory results are as follows:
ECG is shown in the exhibit.
Which of the following is the best treatment for this patient's cardiac condition?

A)Cardiac glycoside
B)Corticosteroids and inhaled bronchodilators
C)Electrical cardioversion
D)Intravenous amiodarone
E)Intravenous ibutilide

Question 30

A 76-year-old man is seen in the emergency department with cough and worsening dyspnea over the last 2 days.  He awoke suddenly last night gasping for air and could not get comfortable in any position.  He has no fever or chills.  The patient's other medical problems include hypertension and type 2 diabetes mellitus.  He has a 40-pack-year smoking history and drinks beer occasionally.
His temperature is 37.2° C (99° F), blood pressure is 150/90 mm Hg, pulse is 106/min, and respirations are 25/min.  Pulse oximetry is 94% on 2 L O₂.  Body mass index is 35 kg/m².  Jugular venous pressure is measured at 12 cm H₂O.  He appears in mild respiratory distress.  Heart sounds are distant but no murmurs are heard.  Lung examination shows bibasilar crackles and scattered bilateral wheezes.  There is 1+ pitting ankle edema seen bilaterally.
Laboratory results are as follows:

Chest x-ray reveals prominent vascular markings and blunting of costophrenic angles.  Echocardiogram shows a diffusely hypokinetic left ventricle with ejection fraction of 35%.
Which of the following best explains the normal brain natriuretic peptide value?

A)High body mass index
B)Hypertension
C)Hyponatremia
D)Noncardiac cause of dyspnea
E)Older age

Question 31

A 73-year-old woman comes to the emergency department due to vision changes.  Over the last few days, she has noticed blurred vision and scattered blind spots while watching television.  She reports poor appetite and fatigue since an episode of gastroenteritis 2 weeks ago.  She has no fever, headache, or muscle weakness but admits feeling unsteady.
Her past medical history is significant for hypertension, type 2 diabetes mellitus, heart failure with reduced ejection fraction (ejection fraction of 15%), and mild chronic obstructive lung disease.  Her medications include tiotropium, torsemide, ramipril, carvedilol, spironolactone, digoxin, and empagliflozin.  The patient is adherent with her medications and clinic visits.  She is a former smoker with a 35-pack-year history.
Her blood pressure is 144/90 mm Hg supine and 140/90 mm Hg standing.  Pulse is 52/min in both positions.  BMI is 19 kg/m².  The mucous membranes appear dry.  Lungs are clear to auscultation and no murmurs are heard on cardiac examination.  There is mild epigastric tenderness on deep palpation.  There is no peripheral edema.  Neurologic examination is unremarkable except for mild unsteady gait.
Fingerstick glucose is 109 mg/dL.
Which of the following is the most likely diagnosis?

A)Acute angle-closure glaucoma
B)Cardiac cachexia
C)Cerebellar stroke
D)Diabetic retinopathy
E)Medication toxicity

Question 32

A 67-year-old woman comes to the emergency department with swelling of her right eyelid and lips.  The swelling started an hour earlier and increased slowly until she became alarmed.  She reports no trouble breathing and has had no abdominal pain.  There is no associated itching or rash.  Her past medical history includes congestive heart failure due to nonischemic cardiomyopathy, hypertension, hyperlipidemia, and osteoporosis.  The patient's last left ventricular ejection fraction was 38%.  She is able to walk 3-4 blocks without shortness of breath.  Her current medications include furosemide, ramipril, simvastatin, and metoprolol succinate.  There is no family history of similar occurrences.
The patient's blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 14/min.  Pulse oximetry is 98% on room air.  There is non-pitting edema of her right eyelid and upper and lower lips.  Cardiac examination reveals a 2/6 holosystolic murmur at the apex.  There is no stridor and lung examination is normal.  The remainder of the examination is within normal limits.
After observation and recovery, which of the following would be the best therapeutic option for this patient?

A)Continue current medications with careful outpatient follow-up
B)Decrease the dose of ramipril
C)Stop ramipril and start aliskiren
D)Stop ramipril and start enalapril
E)Stop ramipril and start losartan

Question 33

A 61-year-old man comes to the emergency department complaining of nausea and right upper-quadrant abdominal discomfort for 3 days.  His other medical problems include hypertension, type 2 diabetes, hypercholesterolemia, and hypothyroidism.  His medications include low-dose aspirin, metformin, glipizide, hydrochlorothiazide, lisinopril, atorvastatin, and levothyroxine.  He is an active smoker with a 60-pack-year history and drinks 1-2 glasses of wine daily.
His blood pressure is 155/90 mm Hg and pulse is 80/min.  Examination shows no abnormalities.
Laboratory results are as follows:

Ultrasound examination shows several small gallstones without cholecystitis and a 3.8-cm abdominal aortic aneurysm.
Which of the following is associated with the highest rate of aneurysm expansion and rupture in this patient?

A)Active smoking
B)Chronic kidney disease
C)Daily alcohol consumption
D)LDL cholesterol > 130 mg/dL
E)Uncontrolled diabetes mellitus

Question 34

A 42-year-old woman comes to the emergency department with fever and a skin rash.  She was diagnosed with trigeminal neuralgia and started on carbamazepine 3 weeks ago.
The patient's temperature is 38.9 C (102 F).  There is diffuse confluent erythema involving 60% of the body, palpable generalized lymphadenopathy, and symmetrical facial swelling.  There are no mucosal lesions.
Her aspartate aminotransferase level is 150 U/L, eosinophil count is 800/mm³, and serum creatinine is 0.9 mg/dL.
Which of the following is the most likely diagnosis?

A)Drug-induced hypersensitivity vasculitis
B)Drug reaction with eosinophilia and systemic symptoms
C)Hypereosinophilic syndrome
D)Serum sickness-like syndrome
E)Stevens-Johnson syndrome

Question 35

A 62-year-old man comes to the emergency department due to sudden-onset chest pain.  The patient is diagnosed with unstable angina.  He undergoes cardiac catheterization and receives a drug-eluting stent to the left circumflex artery.  Medical issues include hypertension, hypercholesterolemia, osteoarthritis, and chronic kidney disease.  The patient was hospitalized 6 months earlier for upper gastrointestinal bleeding related to ibuprofen use.  He is treated with aspirin, prasugrel, lisinopril, atorvastatin, and metoprolol.
Laboratory results are as follows:
Echocardiogram shows a left ventricular ejection fraction of 55%.  Which of the following additional therapies is indicated in this patient?

A)Angiotensin II receptor blocker
B)Niacin
C)Proton pump inhibitor
D)Ranolazine
E)Spironolactone

Question 36

A 42-year-old man comes to the emergency department due to fatigue, chest pain, and shortness of breath for the past 5 days.  He has had difficulty falling asleep at night due to chest discomfort.  The patient had a "bad case of the flu" 3 weeks ago and still has a persistent cough.  He is otherwise healthy and has no other medical problems.  He has a 20-pack-year smoking history and drinks 3 or 4 beers on weekends.
Blood pressure is 92/54 mm Hg and pulse is 112/min.  Blood pressure decreases to 75/42 mm Hg during inspiration.  Jugular venous pressure is estimated at 16 cm H₂O.  There are minimal crackles present at both lung bases.  Heart sounds are faint on cardiac auscultation.  Lower extremities are cool with feeble pulses.
Chest x-ray is shown in the exhibit.
An echocardiogram in this patient would most likely show which of the following?

A)Dynamic left ventricular outflow obstruction
B)Global left ventricular hypokinesis
C)Left ventricular diastolic collapse
D)Right atrial diastolic collapse
E)Right ventricular dilation

Question 37

A 62-year-old man comes to the emergency department with 2 episodes of retrosternal pressure-like chest pain over the last 6 hours.  Medical history is significant for type 2 diabetes mellitus, hypertension, and end-stage renal disease.  He undergoes hemodialysis 3 times a week through a left arm arteriovenous fistula.
Blood pressure is 152/89 mm Hg and pulse is 88/min.  The chest is clear on auscultation.  There are no heart murmurs.
Bedside finger-stick glucose level is 134 mg/dL.  ECG shows normal sinus rhythm with 1-mm horizontal ST-segment depressions in leads II, III, aVF, and V4-V6.  The initial troponin I level is 1.5 ng/mL (normal: <0.01).
He is treated with aspirin.
Which of the following is the most appropriate additional treatment for this patient?

A)Amlodipine
B)Enoxaparin
C)Eptifibatide
D)Metoprolol
E)Spironolactone

Question 38

A 54-year-old man comes to the emergency department with severe chest and neck pain that started 2 hours ago.  His past medical history is significant for hypertension treated with amlodipine and irbesartan.  His father died suddenly at the age of 43 years.  He does not smoke or use illicit drugs.
His blood pressure is 162/100 mmHg and pulse is 101/min.  He appears mildly uncomfortable due to pain.
EKG shows sinus tachycardia, voltage criteria for left ventricular hypertrophy, and T wave inversions in leads V5 and V6.  Chest x-ray findings are shown below.

He is initially treated with nitroglycerin.
What is the best next step in managing this patient?

A)Aspirin and clopidogrel
B)Cardiac catheterization
C)Chest tube
D)CT angiogram
E)Repeat EKG in 30 min and cardiac enzymes

Question 39

A 54-year-old man comes to the emergency department due to several hours of left upper quadrant pain, which is constant and worsens with deep inspiration.  The patient came to the emergency department a week ago due to fatigue and low-grade fevers for the past month.  Blood cell counts, chest x-ray, and urinalysis were within normal limits, and the patient was discharged home with symptomatic treatment.  He has had no cough, shortness of breath, vomiting, or diarrhea but reports a 4.5-kg (10-lb) weight loss over the past month.  Medical history includes hypertension, osteoarthritis, and a "heart murmur."  The patient is a smoker with a 30-pack-year history, drinks alcohol occasionally, and does not use illicit drugs.  He is a livestock farmer in rural Pennsylvania and recently returned from a hunting trip.
Temperature is 38.4 C (101.1 F), blood pressure is 136/72 mm Hg, pulse is 90/min, and respirations are 16/min.  The lungs are clear on auscultation.  Heart sounds are normal, and a 2/6 early diastolic murmur is present at the right upper sternal border.  The abdomen is tender in the left upper quadrant with no guarding or rebound tenderness.
Laboratory results are as follows:
ECG shows sinus rhythm with nonspecific ST- and T-wave changes.  CT scan of the abdomen reveals multiple splenic infarcts.  Three sets of blood cultures obtained during the previous emergency department visit reveal no growth.  Which of the following is the best next step in management of this patient?

A)Antinuclear antibody and complement levels
B)Blood microscopy for intracytoplasmic inclusions
C)Echocardiographic examination
D)Imaging and endoscopic cancer screenings
E)Testing for inherited thrombophilia

Question 40

A 62-year-old man comes to the emergency department due to 2 hours of chest discomfort.  He was eating a light dinner when he developed rapidly worsening mid-chest discomfort associated with nausea and weakness.  For the last few days, the patient has also experienced "stomach flu" symptoms with episodic nausea and vomiting and decreased oral intake.  Two weeks ago, he was diagnosed with an acute inferior wall myocardial infarction and received a bare metal stent to the right coronary artery.  His hospital course was uncomplicated.  Pre-discharge echocardiogram showed inferior and posterior wall hypokinesis and a left ventricular ejection fraction of 50%.
Temperature is 37.2 C (99 F), blood pressure is 98/64 mm Hg, and pulse is 55/min.  Oxygen saturation is 99% on room air.  BMI is 23 kg/m².  The patient appears uncomfortable.  There is no jugular venous distention and the lungs are clear.  A grade 2/6 holosystolic murmur is heard at the apex.  The abdomen is nontender with no hepatomegaly.  Peripheral pulses are symmetric.
ECG shows sinus bradycardia with 2-mm ST-segment elevation in leads II, III, and aVF.
Which of the following is the most likely diagnosis?

A)Left ventricular aneurysm
B)Noncardiac chest pain
C)Papillary muscle rupture
D)Peri-infarction pericarditis
E)Stent thrombosis

Question 41

A 25-year-old man is brought to the emergency department due to acute-onset dizziness, weakness, sweating, and confusion.  The patient has a blood glucose level of 36 mg/dL, and his symptoms resolve with intravenous dextrose.  He has no medical conditions and takes no medications.  The patient has smoked intermittently for the last 5 years but does not use alcohol or illicit drugs.  He is unemployed and lives with his parents.  His father has type 2 diabetes mellitus and takes metformin and glyburide.  His mother has hypertension treated with lisinopril.
Physical examination is unremarkable.  The patient is hospitalized for observation.  On the second day, he develops similar symptoms with a blood glucose level of 34 mg/dL; intravenous dextrose is again administered and his symptoms improve.
Laboratory results drawn during the second episode of hypoglycemia are as follows:
Which of the following is the best next step in evaluation of this patient?

A)CT scan of the abdomen
B)Glucagon challenge
C)Insulin autoantibody levels
D)Oral hypoglycemic drug screen
E)Prolonged fasting hypoglycemia test

Question 42

A 57-year-old man with known liver cirrhosis comes to the physician because of progressive shortness of breath and fatigue for the last few months that has recently worsened.  He now becomes short of breath even at rest, particularly in the morning when getting out of bed.  He was diagnosed with chronic hepatitis C ten years ago and liver cirrhosis three years ago.  He quit using alcohol and IV drugs upon being diagnosed with hepatitis C.  He is currently disabled and usually comes to the emergency department for abdominal paracentesis once every 6 to 8 weeks.  He has been non-compliant with his outpatient medications.  He had a large volume paracentesis 3 days ago.
His temperature is 36.7 C (98 F), blood pressure is 100/70 mm Hg, pulse is 94/min, and respirations are 16/min.  The patient's pulse oximetry shows 88% saturation on room air while sitting.  After resting supine in a quiet room for 15 min, his blood pressure is 95/68 mm Hg, pulse is 88/min, and oxygen saturation is 93% on room air.  He is fully alert and has no asterixis.  Breath sounds are mildly decreased at the right base.  A moderate amount of ascites is present on abdominal examination.  There is no rebound tenderness or rigidity.  He has 1+ peripheral edema, a few spider nevi on his chest, and a slight bluish discoloration of his toes and digits.
His platelet count is 50,000 cells/µL and serum creatinine is 1.4 mg/dL.  Chest x-ray shows normal heart size and a small right-sided pleural effusion, but is otherwise unremarkable.
Which of the following is most likely to diagnose the cause of this patient's shortness of breath?

A)AFP level and liver ultrasound
B)Contrast echocardiography
C)CT scan of the chest
D)Right heart catheterization
E)Ventilation-perfusion scan

Question 43

A 70-year-old man is brought to the emergency department by his nephew after being found poorly responsive at home.  The patient lives alone and had not been seen for 2 weeks.  His family has noticed that he has been confused and less active over the past few months.  Medical history is unknown, and family members report only that the patient takes several pills a day for "heart issues," blood pressure, and headaches.  Emergency department records show a recent visit for back pain, which was treated with opioid analgesics and centrally acting muscle relaxants.
Temperature is 35 C (95 F), blood pressure is 120/100 mm Hg, pulse is 55/min, and respirations are 10/min.  The patient is lethargic and oriented only to person.  He has a puffy face and hands and an enlarged tongue.  Pupils are normal and reactive.  The neck is supple.  Cranial nerve, cardiac, pulmonary, and abdominal examinations are unremarkable.  The patient moves all extremities on command.
Laboratory results are as follows:
Chest x-ray shows a mildly enlarged cardiac silhouette and no infiltrates.  ECG shows sinus bradycardia, a QTc interval of 450 msec, and T-wave flattening.  Additional laboratory testing is pending.
Which of the following is the most appropriate next step in management of this patient?

A)Abdominal fat pad biopsy
B)Intravenous corticosteroids and thyroid hormone
C)Intravenous dextrose
D)Intravenous naltrexone
E)Intravenous thiamine

Question 44

A 22-year-old man is brought to the emergency department by paramedics after his mother found him lying on the bathroom floor.  Paramedics found him barely conscious with an empty bottle of bleach lying next to him.  His mother states that he drank the entire bottle.  He had mentioned to his mother that he wanted to end his life after his recent break-up with his girlfriend.  He is lethargic, but complains of severe pain and a burning sensation in his throat.
His other medical problems include major depression and post-traumatic stress disorder.  His sister also suffers from depression.  His medications include nortriptyline and fluoxetine, which he had not been taking for the past several days.  He has no known drug allergies.
His temperature is 37.2 C (99.0 F), blood pressure is 90/60 mm Hg, pulse is 104/min, and respirations are 22/min.  Examination shows severe pharyngeal erythema/exudates, clear lungs, and normal first and second heart sounds.  His abdomen is soft and tender with decreased bowel sounds.  There is no rebound tenderness or rigidity.
Intravenous fluids were started.  Chest and abdominal x-rays showed no evidence of free air or pleural effusions and were essentially unremarkable.
Which of the following would be the most appropriate next step in management?

A)Barium swallow
B)Intravenous glucocorticoids
C)Nasogastric lavage with cold saline
D)Oral weak acid solution
E)Upper GI endoscopy

Question 45

A 68-year-old woman is brought to the emergency department due to worsening diarrhea and abdominal pain.  The patient has had watery diarrhea every 3-4 hours for the past 2 days, and today she also had mild nausea but has been tolerating oral fluids.  The patient was discharged from the hospital 10 days ago after treatment for an Escherichia coli urinary tract infection.  Other medical conditions include hypertension, type 2 diabetes mellitus, hyperlipidemia, and chronic kidney disease.
Temperature is 39.3 C (102.7 F), blood pressure is 90/60 mm Hg, and pulse is 120/min.  On examination, the patient appears lethargic.  There is moderate abdominal distension and diffuse tenderness but no rebound tenderness or rigidity.
Laboratory results are as follows:
CT scan of the abdomen reveals an 8-cm dilation of the ascending and transverse colon with mucosal thickening.  Stool samples for analysis are obtained.
In addition to IV fluids, which of the following is the most appropriate next step in management of this patient?

A)High-dose oral vancomycin, IV metronidazole, and urgent surgical evaluation
B)High-dose oral vancomycin, rectal tube, and admission to the intensive care unit
C)IV corticosteroids, oral vancomycin, and serial abdominal radiographs
D)IV metronidazole, oral fidaxomicin, and monitoring in the intensive care unit
E)Vancomycin enema, IV metronidazole, and serial examinations

Question 46

A 44-year-old man comes to the emergency department due to a diffuse, painful skin rash that began abruptly 2 days ago.  He has also had fever and malaise but no cough, shortness of breath, abdominal pain, diarrhea, dysuria, or joint pains.  Three years ago, the patient was diagnosed with plaque psoriasis involving the scalp, elbows, and knees.  He was treated with a high-potency topical corticosteroid ointment, which has improved his symptoms.  He stopped using the ointment a week ago.  He also has a history of untreated chronic hepatitis C.  The patient is sexually active and uses condoms inconsistently.
Temperature is 38.7 C (101.8 F), blood pressure is 130/70 mm Hg, and pulse is 98/min.  There is no scleral icterus or lymphadenopathy.  Oropharyngeal mucous membranes are normal.  Skin examination reveals erythema and lesions as shown below involving his trunk, neck, and extremities.

Which of the following is the most likely diagnosis?

A)Acute pustular psoriasis
B)Disseminated gonococcal infection
C)Generalized herpes simplex virus infection
D)Staphylococcal skin infection
E)Toxic epidermal necrolysis

Question 47

A 35-year-old woman comes to the emergency department with fever, chills, and sore throat for the past 4 days.  Except for a temperature of 38.3 C (101.0 F), her other vital signs are within normal limits.  Examination shows pharyngeal and tonsillar erythema without exudates and bilateral tender cervical lymphadenopathy.  The remainder of the examination is normal.  Point-of-care testing for group A streptococcus is negative.  The patient is diagnosed with viral pharyngitis and prescribed symptomatic therapy.  She returns 3 days later due to a persistent fever, sore throat, and progressive dysphagia.
Her temperature now is 38.9 C (102.0 F), blood pressure is 118/78 mm Hg, pulse is 90 /min, and respirations are 16 /min.  Physical examination remains unchanged from 3 days ago except that she appears more ill.  Point-of-care testing for the Epstein-Barr virus is negative.
Which of the following is the most appropriate next step in management?

A)Epstein-Barr virus serology
B)Group A streptococcus throat culture
C)HIV ELISA testing
D)Lateral neck x-ray
E)Upper GI endoscopy

Question 48

A 54-year-old man with a history of alcohol abuse is brought to the emergency department after an episode of tonic-clonic seizures.  He has a history of recurrent seizures and has been treated intermittently with phenytoin.  Other medical issues include a mood disorder and anxiety.  The patient lives in a homeless shelter.  He has a 30-pack-year smoking history.  He is treated with lorazepam and phenytoin in the emergency department.
Blood pressure is 122/70 mm Hg and pulse is 112/min and regular.  BMI is 17 kg/m².  Dentition is poor and the gums are swollen with some evidence of bleeding.  Small, mobile lymph nodes are palpated in the submandibular region.  The lungs are clear to auscultation.  The liver is palpated 2 cm below the subcostal margin.  No ascites is present.  Multiple scattered petechiae are seen on both the upper and lower extremities.
Laboratory results are as follows:
Serum free phenytoin level is markedly low.
Which of the following best explains this patient's findings?

A)Leukocytoclastic vasculitis
B)Platelet dysfunction
C)Side effect of phenytoin
D)Vitamin C deficiency
E)von Willebrand factor deficiency

Question 49

A 26-year-old man is brought to the emergency department due to a severe headache that started 2 hours ago and has steadily become worse.  The patient says the pain is dull, diffuse, and associated with nausea, vomiting, lightheadedness, and blurred vision.  Medical history is unremarkable, although he is currently being evaluated for loss of libido and erectile dysfunction.  A week ago, laboratory results showed low testosterone, low gonadotropins, and high prolactin levels; TSH and free T4 were normal.  The patient does not use tobacco, alcohol, or illicit drugs.
Temperature is 36.7 C (98 F), blood pressure is 80/50 mm Hg, and pulse is 114/min.  He is diaphoretic and appears to be in significant distress, although he is awake and oriented to time, place, and person.  Pupils are 4 mm, symmetric, and reactive to light.  There is ptosis of the right eyelid and decreased adduction of the right eyeball on left gaze.  Visual field examination on confrontation shows bitemporal visual field defects.  There is no nuchal rigidity.  The remainder of the examination is unremarkable.
Laboratory results are as follows:
What is the most appropriate immediate next step in management of this patient?

A)CT scan of the head without contrast
B)Dopamine agonist therapy
C)High-dose glucocorticoid therapy
D)MRI of brain
E)Neurosurgical consultation

Question 50

A 22-year-old man comes to the emergency department due to dysphagia for the past 3 hours.  He was eating steak with his friends when he suddenly noticed a catching sensation in his throat.  He tried to drink a few sips of beer, but the sensation continued to worsen.  The patient has also had a hoarse voice for the last hour and difficulty swallowing his saliva.  He has never had similar problems before.
Medical history includes seasonal allergic rhinitis, bronchial asthma, and gastroesophageal reflux disease.  Current medications include albuterol metered-dose inhaler as needed and over-the-counter omeprazole.  The patient has consumed 5 or 6 beers daily for the past 4 years but does not use tobacco or illicit drugs.  His mother has atopic dermatitis.
Temperature is 37.5 C (99.5 F), blood pressure is 100/60 mm Hg, pulse is 92/min, and respirations are 14/min.  Examination shows no abnormalities except for a lethargic young man who is drooling and speaking in broken sentences.  An emergency endoscopy is planned.
In addition to a food bolus, which of the following would be the most likely endoscopic finding?

A)Abnormal peristaltic waves and a hiatal hernia
B)Grossly dilated esophagus with distal tapering
C)Large irregular mass in the lower esophagus
D)Multiple esophageal rings, and furrows
E)Smooth tight stricture in the upper esophagus

Question 51

A 57-year-old woman comes to the emergency department due to black stools and 2 episodes of hematemesis over the last 24 hours.  Her other medical problems include hypertension, type 2 diabetes mellitus, hypercholesterolemia, and migraine headaches.  Current medications include metformin, glyburide, simvastatin, ramipril, and low-dose aspirin.  The patient has also been taking naproxen for frequent headaches over the last week.  She has smoked a pack of cigarettes per day for 20 years and drinks 1 or 2 cans of beer daily.
Temperature is 36.7 C (98.1 F), blood pressure is 122/70 mm Hg, pulse is 96/min, and respirations are 16/min.  Examination reveals a soft abdomen that is mildly tender over the epigastrium.  There is no rebound tenderness or rigidity.
Laboratory results are as follows:
After initial fluid resuscitation, the patient undergoes upper gastrointestinal endoscopy in the emergency department; it reveals a 1.5-cm ulcer in the gastric antrum.  There is no active bleeding and the ulcer is covered with an adherent clot.  Endoscopic hemostatic therapy is performed.
Which of the following is the most appropriate course of action for this patient?

A)Advise the patient to stop naproxen; discharge on oral lansoprazole with close follow-up
B)Admit the patient, order a regular diet, and observe overnight
C)Admit the patient to the intensive care unit for octreotide infusion
D)Admit the patient to the regular medical ward and order a clear liquid diet
E)Order a blood transfusion and schedule follow-up endoscopy in 24-48 hours

Question 52

A 52-year-old man comes to the emergency department after 1 day of melena and 2 episodes of coffee-ground emesis.  Over the past several months he has had episodic epigastric discomfort, especially several hours after a meal and at night.  The patient has had no dysphagia, back pain, or weight loss, and has not used aspirin or nonsteroidal anti-inflammatory drugs.  Chronic medical problems include hypertension and hypercholesterolemia.  He does not use tobacco, alcohol, or illicit drugs.
Blood pressure is 126/70 mm Hg, and pulse is 86/min with no orthostatic changes.  The abdomen is soft and nontender, and rectal examination reveals occult blood-positive black stool.
Laboratory results are as follows:
Intravenous proton pump inhibitor therapy is started.  Upper gastrointestinal endoscopy shows a 2-cm duodenal ulcer with a visible vessel at the base.  Endoscopic treatment is performed; the patient has no recurrent hematemesis, and his hemoglobin level remains stable.  Gastric mucosal biopsies are negative for Helicobacter pylori.
Which of the following is the most appropriate next step regarding evaluation and treatment for H pylori infection in this patient?

A)Empiric anti-H pylori therapy
B)No additional testing or treatment
C)Outpatient urea breath testing
D)Repeat endoscopy and biopsy now
E)Repeat endoscopy in 4 to 6 weeks

Question 53

A 16-year-old girl is evaluated in the emergency department for syncope.  She has no other medical conditions and does not use tobacco, alcohol, or illicit drugs.  Her blood pressure is 95/65 mm Hg and pulse is 106/min.  The remainder of the physical examination is within normal limits.  Laboratory values are as follows.

The patient's urine chloride is low at 8 mEq/L.
Which of the following is the most likely diagnosis?

A)Anxiety disorder
B)Diuretic abuse
C)Ecstasy intoxication
D)Primary hyperaldosteronism
E)Surreptitious vomiting

Question 54

A 72-year-old man with end-stage renal disease comes to the emergency department due to abdominal pain for the past 6 hours.  The pain started in the lower left abdomen at the end of the hemodialysis session and has remained steady in intensity.  The pain does not radiate and is unchanged with movement.  The patient rushed to the hospital after noticing bright red blood in the bowel movement 30 minutes ago.  He has had mild nausea but no vomiting, back pain, fever, or urinary symptoms.  Medical problems include hypertension, type 2 diabetes mellitus, hyperlipidemia, depression, and gastritis.  The patient developed anuric end-stage renal disease due to hypertensive and diabetic nephropathy and has been receiving maintenance hemodialysis for the past several years.  He reports no recent antibiotic use or travel and has not eaten anything out of the ordinary.  The patient is a former smoker with a 30-pack-year history and does not use alcohol or illicit drugs.
Temperature is 37.4 C (99.3 F), blood pressure is 110/80 mm Hg, pulse is 88/min and regular, and respirations are 16/min.  Abdominal examination shows tenderness in the left lower quadrant with decreased bowel sounds, but there is no rebound tenderness or rigidity.  Rectal examination reveals stool mixed with bright red blood.
Laboratory results are as follows:
Which of the following is the best next step in management of this patient?

A)Bowel preparation followed by colonoscopy
B)Contrast-enhanced CT scan of the abdomen and pelvis
C)MR angiography of the abdomen with gadolinium
D)Stool culture and Clostridium difficile PCR
E)Upper gastrointestinal endoscopy

Question 55

A 55-year-old woman is brought to the emergency department due to severe dizziness and unsteadiness.  Two days ago, she awoke with a spinning sensation accompanied by severe nausea and vomiting and a feeling of pressure in the right ear.  The episode lasted an hour.  Over the next 48 hours, the patient had similar events while in bed.  She had no tinnitus, headache, blurry or double vision, dysphasia, dysarthria, falls, or focal weakness during the episodes.  The patient has no history of neck or head trauma.  She was evaluated for similar symptoms 2 months ago, and no medication was prescribed.
Medical history is notable for type 2 diabetes mellitus, which was diagnosed 15 years ago and is complicated by peripheral neuropathy and gastroparesis.  The patient also has hypertension, hypothyroidism, and hyperlipidemia.  Family history is notable for stroke and heart disease.
Temperature is 37 C (98.6 F), supine blood pressure is 130/85 mm Hg, and supine pulse is 88/min and regular.  Weber test shows lateralization to the left ear.  Rinne test shows diminished air and bone conduction on the right and normal findings on the left.  Sensory examination reveals a length-dependent reduction in pain, temperature, vibratory, and proprioceptive perception in the lower extremities up to the knees and in the upper extremities up to the elbows.  Reflexes are absent in the lower extremities and 1+ in the upper extremities, with mute plantar responses.  Coordination testing is normal.  A bedside Dix-Hallpike maneuver does not elicit nystagmus.
Which of the following is most likely to prevent further symptoms in this patient?

A)Canalith repositioning maneuvers
B)Low-dose aspirin
C)Midodrine
D)Oral methylprednisolone
E)Salt-restricted diet and diuretics

Question 56

A 34-year-old woman comes to the emergency department for vaginal bleeding.  The patient initially had vaginal spotting yesterday, but the bleeding has become increasingly heavy.  She also has had lower abdominal pain with nausea for the past hour.  Her last menstrual period was 7 weeks ago.  She is sexually active and does not use contraception due to a history of infertility.  The patient has had no surgeries and takes no daily medications.
Blood pressure is 100/50 mm Hg and pulse is 92/min.  BMI is 41 kg/m².  The abdomen is tender in bilateral lower quadrants with involuntary guarding.  Pelvic examination reveals a closed cervix with active bleeding from the cervical os.  Bimanual examination reveals a small, mobile uterus and right adnexal tenderness.
Hemoglobin is 9.8 g/dL and quantitative β-hCG is 7,135 IU/L.  Transvaginal ultrasound shows a thickened endometrial stripe, a 4-cm complex right adnexal mass, and a small amount of free fluid in the posterior cul-de-sac.
Which of the following is the most likely diagnosis in this patient?

A)Abruptio placentae
B)Complete hydatidiform mole
C)Ectopic pregnancy
D)Incomplete abortion
E)Pelvic endometriosis

Question 57

A 72-year-old woman undergoes parathyroidectomy for primary hyperparathyroidism.  Prior to surgery she complained of bone pain and had a compression fracture of the T11 vertebra.
Laboratory results from the day before surgery are as follows:

The patient had normal serum calcium on the first postoperative day.  She was discharged with a prescription for calcium and vitamin D.  Two days after surgery, she comes to the emergency department complaining of perioral numbness and spasms of both hands.  On examination, she appears anxious.  Her vital signs are normal except for a respiratory rate of 24/min.  Chvostek's sign is positive.
Which of the following laboratory results would be expected from blood drawn at this time?

A)High calcium, low phosphorus, and high PTH
B)Low calcium, high phosphorus, and high PTH
C)Low calcium, low phosphorus, and normal PTH
D)Normal total calcium, low ionized calcium, normal phosphorus, and normal PTH

Question 58

A 65-year-old woman comes to the emergency department due to abdominal pain.  The pain subsequently subsides, but a 3.5-cm left adrenal mass is seen on abdominal CT scan.  No other abnormalities are noted.  The mass appears rounded and vascular, and has a high attenuation (25 Hounsfield units).  The patient has experienced no headaches, palpitations, mood swings, or recent weight gain.  Medical history is notable for hypertension that is well controlled with amlodipine.  She has a current 40-pack-year smoking history.  Family history is unremarkable.
Blood pressure is 138/90 mm Hg and pulse is 76/min.  BMI is 26 kg/m².
Fasting laboratory results are as follows:
Which of the following is the most appropriate next step in evaluating this patient?

A)24-hour blood pressure monitoring
B)CT-guided fine-needle aspiration of the adrenal mass
C)CT scan of the chest to rule out malignancy
D)Follow-up CT scan of the abdomen in 6 months
E)Testing for adrenal hormonal hypersecretion

Question 59

A 38-year-old woman comes to the physician with the complaint of severe abdominal pain for 8 hours.  The pain is crampy and periumbilical and occurs every 4 to 5 minutes.  It is not improved with positional changes, and there is no radiation to the back.  She has vomited 3 times since the pain began.  Her last bowel movement was 18 hours ago.  She denies any reflux symptoms, hematemesis, melena, or hematochezia.  The patient's medical problems include depression, fibromyalgia, and hypothyroidism.  Her surgical history includes appendectomy for a ruptured appendix 20 years ago, tonsillectomy, and breast lumpectomy.  She does not use tobacco, alcohol, or illicit drugs.
Her temperature is 37.3 C (99.1 F), blood pressure is 110/80 mm Hg, pulse is 92/min, and respirations are 16/min.  The abdomen is tender in the periumbilical area.  There is no significant abdominal distension, rebound tenderness, or rigidity.  Rectal examination shows an empty rectal vault, and test for occult blood is negative.
Laboratory results are as follows:
Urine pregnancy test is negative.
Which of the following is the most appropriate next step in this patient's management?

A)Contrast-enhanced abdominal CT
B)NPO and repeat physical examinations
C)Pain management consult
D)Plain upright chest and abdominal radiographs
E)Small-bowel follow-through series

Question 60

A 56-year-old woman is brought to the emergency department after several hours of severe nausea, vomiting, palpitations, and altered mental status.  She was diagnosed with Graves' hyperthyroidism 6 months ago and received methimazole, which was stopped 2 months ago due to a skin rash.  The patient was treated with radioactive iodine (RAI) 3 days ago.  She was not taking any medications before this admission.  She does not use tobacco or alcohol.
On examination, the patient is agitated and confused.  Temperature is 39.4 C (103 F), blood pressure is 160/90 mm Hg, pulse is 160/min, and respirations are 24/min.  Pulse oximetry is 98% on room air.  The thyroid is diffusely enlarged but nontender.  The patient has a fine hand tremor and mild lid lag.  The lungs are clear to auscultation.  Her abdomen is soft and nontender.  She has no muscle rigidity, and deep tendon reflexes are 2+ bilaterally throughout.  Laboratory results are as follows:

/_
Which of the following is the best next step in management of this patient?

A)Blood cultures and empiric antibiotics
B)Dantrolene
C)Dexamethasone
D)Lorazepam
E)Propranolol and propylthiouracil

Question 61

A 43-year-old man comes to the emergency department with severe abdominal pain and vomiting for the last several days.  He has been drinking wine heavily since separating from his wife recently.  He was admitted to the hospital for alcohol-related seizures a year ago and left against medical advice.  The patient's medical problems also include chronic low back pain and nephrolithiasis.  He takes over-the-counter painkillers.  His temperature is 38.3 C (101 F), blood pressure is 112/70 mm Hg, pulse is 105/min, and respirations are 18/min.  Physical examination is significant for jaundice in the eyes and skin.  Breath sounds are normal.  The abdomen is distended, with significant tenderness in the right upper quadrant to palpation.  There is dullness to percussion in bilateral flank regions.
Laboratory results are as follows:

Which of the following is the most likely diagnosis?

A)Acute cholecystitis
B)Alcoholic hepatitis
C)Hemochromatosis
D)Hepatic abscess
E)Tylenol (acetaminophen) toxicity

Question 62

A 60-year-old woman comes to the emergency department because of progressive fatigue and low grade fever for the last 2 weeks.  She is from Mexico and is currently visiting her children in the United States.  She has never been diagnosed with any chronic medical problems.  However, she did receive a blood transfusion 20 years ago when she underwent right femur fracture repair after a motor vehicle accident.  She denies tobacco, alcohol, or illicit drug use.
Her temperature is 37.7 C (99.9 F), blood pressure is 130/76 mm Hg, and pulse is 90/min and regular.  Her BMI is 27 kg/m².  Physical examination reveals scleral icterus and non-tender rubbery lymph nodes bilaterally in the submandibular, anterior cervical, and axillary areas.  Cardiopulmonary examination reveals a 2/6 ejection-type murmur at the left sternal border, and clear lungs.  The liver edge is palpated 3 cm below the right costal margin, and the spleen tip is palpated on deep inspiration.  There is no skin rash or peripheral edema.
Laboratory results are as follows:

Which of the following would most likely be present in this patient's peripheral blood smear?

A)Bite cells
B)Fragmented red cells
C)Red blood cell inclusions
D)Spherocytes
E)Tear drop cells

Question 63

A 40-year-old man comes to the emergency department after 2 episodes of coffee-ground vomiting.  He reports black, tarry stools for 1 day.  He has had no previous episodes and has no history of liver disease, jaundice, weight loss, ascites, edema, dysphagia, or illicit drug use.  He has been taking ibuprofen for lower back pain for the past 2 weeks.  He is otherwise in good general health and takes no prescription medications.
His supine blood pressure is 120/80 mm Hg and pulse is 84/min; after 1 minute of standing they are 118/76 mm Hg and 90/min.  There is no jaundice or scleral icterus.  Cardiopulmonary examination is normal.  There is mild epigastric tenderness on palpation.  There is no hepatomegaly or stigmata of chronic liver disease.  The remainder of the examination is within normal limits.
A nasogastric tube is inserted, with return of coffee ground material and some bright red blood with clots.
Laboratory results are as follows:

Urgent gastrointestinal endoscopy is scheduled.
Which of the following values for hemoglobin represents the optimal threshold for initiating blood transfusion in this patient?

A)< 11 g/dL
B)< 10 g/dL
C)< 9 g/dL
D)< 8 g/dL
E)< 7 g/dL

Question 64

A 45-year-old man comes to the emergency department after an episode of coffee-ground emesis.  During the past 6 months, he has had intermittent abdominal pain and heartburn partially relieved by over-the-counter antacids.  The patient also complains of explosive diarrhea that has not responded to dietary modifications.  Two months ago, he stopped consuming milk without relief.  He is a lifetime nonsmoker.
His blood pressure is 133/70 mm Hg and pulse is 89/min.  There are no orthostatic changes.  He has moderate epigastric tenderness without rebound.
Laboratory results are as follows:

Upper gastrointestinal endoscopy shows 2 small ulcers in the duodenal bulb with clean bases and a 1.2-cm ulcer in the very proximal jejunum.
Which of the following is most likely to establish the diagnosis in this patient?

A)Jejunal ulcer biopsy
B)Response to triple therapy
C)Serum 5-hydroxyindoleacetic acid level
D)Serum gastrin level
E)Serum tryptase level

Question 65

A 68-year-old man is brought to the emergency department with hypoxemic respiratory failure.  He has had worsening shortness of breath associated with fevers and a cough productive of yellowish sputum for the past 2 days.  The patient has a past medical history of stable angina, hypertension, severe chronic obstructive pulmonary disease, and peptic ulcer disease.  His trachea is intubated and mechanical ventilation is initiated.
Which of the following is most likely to decrease the risk of stress ulcers associated with gastrointestinal bleeding in this patient?

A)Avoidance of vasopressors
B)Broad-spectrum antibiotics
C)Corticosteroid use
D)Enteral feeding
E)Platelet transfusion

Question 66

A 49-year-old woman comes to the emergency department with acute-onset hematemesis.  She has vomited blood 3 times over the past 3 hours and feels weak and light-headed.  She has a history of alcoholic cirrhosis with grade 1 esophageal varices, depression, and prior opiate abuse that is now in remission.  The patient takes sertraline, methadone, a multivitamin, folate, and thiamine daily.  She does not use tobacco or illicit drugs but drinks 10 ounces of vodka every night.
Temperature is 37.2 C (99 F), blood pressure is 90/50 mm Hg, pulse is 104/min, and respirations are 20/min.  The patient appears anxious and uncomfortable.  Her abdomen is distended and a fluid wave is present.  There is mild asterixis.  Rectal examination reveals guaiac-positive brown stools.  Skin examination is notable for multiple telangiectasias and palmar erythema.
Laboratory results are as follows:
Intravenous fluids and octreotide are started, and urgent esophagogastroduodenoscopy is planned.
Which of the following is the best next step in management of this patient?

A)Abdominal ultrasound
B)Antibiotics
C)Lactulose
D)Packed red blood cell transfusion
E)Platelet transfusion

Question 67

A 70-year-old woman is brought to the emergency department after she tripped and fell at home while getting out of a bathtub.  She did not lose consciousness but does have headache and mild right arm pain.  Her medical history is significant for advanced breast cancer treated with radical mastectomy and chemotherapy a year ago.
CT of the head is unremarkable.  Radiographs of the upper extremities show bone lesions consistent with metastases, but no evidence of fracture.  Her serum creatinine level is 1.4 mg/dL (creatinine clearance 30 mL/min), serum calcium level is 9.6 mg/dL, and alkaline phosphatase level is 220 U/L.
The patient is most likely to benefit from which of the following?

A)Alendronate
B)Calcium and vitamin D
C)Calcitonin
D)Denosumab
E)Local radiation therapy

Question 68

A 78-year-old man is brought to the emergency department with abdominal pain.  According to his wife, he has had epigastric discomfort for the past 2 days; this morning he refused to get out of bed and appeared confused.  Past medical history is significant for diet-controlled diabetes mellitus, coronary artery disease with stable angina, hypertension, and gastroesophageal reflux disease.
On examination, the patient is lethargic.  His temperature is 38 C (100.4 F), blood pressure is 144/90 mm Hg, pulse is 112/min and irregular, and respirations are 20/min.  Chest is clear on auscultation.  There are no heart murmurs.  The abdomen is tender to palpation in the epigastric and right upper quadrant areas.  His skin is warm and there are no rashes.
Laboratory results are as follows:

ECG reveals atrial fibrillation with no significant ST segment or T wave changes.  Abdominal ultrasound shows several small gallstones without wall thickening or edema around the gallbladder.  Common bile duct size is normal.
Which of the following is the best next step in managing this patient?

A)Cholecystostomy
B)Cholescintigraphy
C)CT angiography of the abdomen
D)Direct current cardioversion
E)Transesophageal echocardiogram

Question 69

A 20-year-old woman comes to the emergency department complaining of nausea and vomiting.  She awoke that morning with the sudden onset of nausea and vomiting.  She vomited about 10 times and became concerned when she noticed blood in the vomitus.  The patient has no dysphagia or odynophagia.  Her other medical problems include a history of menorrhagia and bulimia.  She takes naproxen daily for chronic low back pain and does not use tobacco, alcohol, or illicit drugs.
Her blood pressure is 109/60 mm Hg, pulse is 106/min, and respirations are 14/min.  Examination shows dry mucous membranes.  The abdomen is soft and nontender.  There is no hepatomegaly or splenomegaly.
Laboratory results are as follows:

Test for stool occult blood is negative.
Which of the following is the most appropriate next step in management?

A)Angiographic arterial embolization
B)Barium swallow
C)Esophagogastroduodenoscopy
D)Fresh frozen plasma
E)Intravenous octreotide

Question 70

A 66-year-old man comes to the emergency department due to abdominal pain and nausea.  He has had no vomiting or bloody stools.  Yesterday he underwent a screening colonoscopy, which revealed scattered diverticulosis and 2 polyps that were then removed.  The patient's other medical conditions include hypertension and gastroesophageal reflux disease.
Temperature is 38.1 C (100.6 F), blood pressure is 110/70 mm Hg, and pulse is 98/min.  Mucous membranes are moist.  The abdomen is tender in the periumbilical and left lower quadrants with no rebound tenderness.
Laboratory results are as follows:
Upright abdominal radiographs show no free air under the diaphragm.
Which of the following is the best next step in management of this patient?

A)Obtain CT scan of the abdomen with water-soluble contrast
B)Order noncontrast CT scan of the abdomen
C)Perform flexible sigmoidoscopy
D)Prescribe oral antibiotics and follow-up in 2 days
E)Provide reassurance for discomfort from procedural air insufflation

Question 71

An 82-year-old woman is brought to the emergency department after 2 episodes of large bloody bowel movements.  She has no abdominal pain or vomiting.  Her past medical history is significant for paroxysmal atrial fibrillation and hypertension.  She takes daily low-dose aspirin.
Her blood pressure is 130/80 mm Hg, pulse is 88/min, and respirations are 14/min.  Abdominal examination reveals no tenderness or organomegaly.
Laboratory results are as follows:

While in the emergency department, the patient has another bloody bowel movement accompanied by transient dizziness and diaphoresis.  Upper gastrointestinal endoscopy and colonoscopy reveal no source of bleeding.
Which of the following is the most likely additional physical finding on chest examination?

A)Ejection-type mid-systolic murmur
B)Holosystolic murmur
C)Late diastolic decrescendo murmur
D)Low-pitched mid-diastolic rumble
E)Pericardial knock

Question 72

An 18-year-old man comes to the emergency department due to retrosternal chest pain and pain with swallowing.  The patient has a burning pain that began abruptly the previous morning and then gradually worsened.  He has been limiting himself to soft foods as the pain is much worse with swallowing solids.  The patient has a history of tension headaches that have become more frequent lately, which he attributes to long hours of studying for exams.  His only medication is ibuprofen as needed for headaches, and he has no drug allergies.  The patient's mother has Crohn disease.  He drinks alcohol socially, smokes a half pack of cigarettes daily, and does not use illicit drugs.  The patient is sexually active and uses condoms inconsistently.
Temperature is 36.7 C (98.1 F), blood pressure is 118/76 mm Hg, pulse is 88/min, and respirations are 14/min.  There are no oropharyngeal lesions or palpable lymphadenopathy.  The lung auscultation and cardiac examination are normal.  The abdomen is soft without rebound or guarding.
Which of the following is the most appropriate next step in management of this patient's symptoms?

A)Obtain barium esophagram
B)Perform HIV testing
C)Prescribe swallowed fluticasone spray
D)Recommend ibuprofen discontinuation
E)Schedule upper gastrointestinal endoscopy

Question 73

A 44-year-old construction worker comes to the emergency department with nausea and fatigue over the last 2 days.  He strained his back at work 7 days ago.  He could not move for several days and took over-the-counter painkillers and applied hot packs.  The patient still has significant back pain and limited mobility.  He smokes 1 pack of cigarettes a day.  He drinks alcohol daily and heavily on weekends.  In addition, he also admits to using intravenous heroin on occasion.
He was hospitalized for pneumonia 6 months ago and treated with intravenous antibiotics.  The echocardiogram during that admission showed normal left ventricular systolic function, mildly dilated right ventricle, and mild pulmonary hypertension.
His temperature is 37.2° C (99° F), blood pressure is 94/50 mm Hg, and pulse is 112/min.  There is mild scleral icterus.  Several needle tracks are seen on both forearms.  No heart murmurs are present.  The lungs are clear.  There is no abdominal distention.  Moderate right upper-quadrant tenderness is present.  The spleen is not palpable.  There is no peripheral edema.
Laboratory results are as follows:

Which of the following is the most likely cause of this patient's current condition?

A)Alcoholic hepatitis
B)Bacteremia with liver abscess
C)Hepatitis C infection
D)Medication toxicity
E)Pulmonary hypertension

Question 74

A 64-year-old man comes to the emergency department with sudden onset of epigastric abdominal pain and vomiting.  He attended a colleague's retirement party the night before and admits that he had "a little too much to drink."  The patient vomited twice when he got home and noticed abdominal pain after the second vomiting episode.  He thought the pain was related to "heartburn" and took extra-strength calcium carbonate antacids with little relief.  He tried to sleep, but the severe pain kept him awake.  The patient has a history of hypertension and takes amlodipine.  He is a current smoker with a 40-pack-year history.
His temperature is 38.0° C (100.4° F), blood pressure is 108/64 mm Hg, pulse is 110/min, and respirations are 18/min.  Pulse oximetry is 96% on room air.  Examination shows a man in moderate distress.  There are normal first and second heart sounds.  Decreased breath sounds are heard on the left lower lung field with dullness to percussion.  There is both right upper-quadrant and epigastric tenderness without rebound or guarding.
Chest x-ray reveals pneumomediastinum and a moderate-sized left pleural effusion.
Which of the following is the best next step in managing this patient?

A)Abdominal ultrasound
B)Chest tube placement
C)Contrast esophagography
D)Esophagogastroduodenoscopy
E)Serum amylase and lipase

Question 75

A 58-year-old woman comes to the emergency department with 5 days of progressive headaches and dizziness.  She is a business executive who is very active in her spare time.  She takes no medications.
Her vital signs are within normal limits.  Examination shows bilateral normal reflexes and sensation and no neck stiffness.  Pupils are equal and reactive to light.  Gag reflex is intact.  There is no peripheral lymphadenopathy.
Laboratory results are as follows:

CT scan of the head with contrast shows a solitary frontal 2x3 cm lesion at the gray-white matter junction with vasogenic edema confirmed on magnetic resonance imaging.  CT scan of the chest, abdomen, and pelvis reveals a spiculated 2.5 cm right upper-lung mass with ipsilateral bronchial lymphadenopathy but no other evidence of metastatic disease.
Which of the following is the most appropriate next step in management of this patient's brain lesion?

A)Brain surgery
B)Combination chemotherapy
C)Hospice care
D)Sunitinib
E)Whole-brain radiation

Question 76

A 65-year-old man comes to the emergency department because of worsening generalized itching for 7 days.  He has experienced abdominal discomfort, bloating, and decreased appetite for several weeks.  He states that he has lost 10-12 lbs (4.5-5.4 kg) during this time, which he attributes to excessive stress at work.  He denies nausea, vomiting, diarrhea, easy bleeding, or bruising.
His temperature is 36.9 C (98.4 F), blood pressure is 123/70 mm Hg, and pulse is 78/min and regular.  On examination, he has icteric conjunctivae and skin.  He has bilateral diffuse scratch marks.  There is mild tenderness on palpation of his right upper abdominal quadrant.  The tip of the spleen is not palpable.
Laboratory results are as follows:

Abdominal ultrasound reveals an enlarged liver with dilated intrahepatic bile ducts.  A CT scan of the abdomen reveals an ill-defined 3.5 cm pancreatic mass and several low-attenuating foci in the liver consistent with metastasis.
Which of the following would be the best next step in managing this patient?

A)Biliary decompression surgery
B)Combination chemotherapy
C)Endoscopic stenting
D)Narcotic pain medication
E)Ursodeoxycholic acid

Question 77

A 72-year-old man is brought to the emergency department because of sudden onset shortness of breath and sharp left-sided chest pain.  He denies fever, loss of consciousness, or orthopnea.  He was diagnosed with metastatic pancreatic cancer three months ago.
Examination reveals clear lungs with normal first and second heart sounds.  The abdomen is soft and non-tender.  There is trace edema involving the right leg.  Neurologic examination is within normal limits.
Laboratory results are as follows:

His chest-x ray is clear.  Ultrasound of the right leg shows a thrombus in the popliteal vein.  CT angiogram of the chest reveals bilateral pulmonary emboli.
Which of the following would be the most effective long-term treatment to prevent recurrent thromboembolism in this patient?

A)Enoxaparin
B)Unfractionated heparin
C)Warfarin
D)Warfarin and IVC filter

Question 78

A 36-year-old woman comes to the emergency department with abdominal pain and distention that started 5 days earlier and has become progressively worse.  She initially thought she was experiencing bloating but the symptoms persisted despite poor appetite.  The patient has a history of migraines.  She underwent ovarian cyst resection 5 years ago.  Her medications include over-the-counter analgesics, oral contraceptive pills, and daily multivitamins.  She does not use tobacco, alcohol, or illicit drugs.
Her temperature is 37.2° C (99° F), blood pressure is 110/70 mm Hg, and pulse is 98/min.  BMI is 25 kg/m².  The estimated jugular venous pressure is 7 mm H₂O.  Lungs are clear to auscultation.  No murmurs are heard.  The abdomen is distended and there is positive fluid shift test.  The liver edge is tender and is palpated 4 cm below the right costal margin.  The spleen is not palpable.  There is trace lower-extremity edema.
Liver function test results are as follows:

Ultrasound-guided paracentesis yields 1.5 L of clear fluid.  Fluid analysis shows a white cell count of 120/mm³ and albumin of 2.4 g/L.  Cytology is pending.
Which of the following is the most likely diagnosis?

A)Acetaminophen overdose
B)Acute hepatitis B
C)Hepatic vein thrombosis
D)Peritoneal carcinomatosis
E)Primary biliary cirrhosis

Question 79

A 20-year-old African American woman with sickle cell disease comes to the emergency department with complaints of severe generalized body pain for 1 day.  She has been hospitalized for similar episodes in the past.  Her medications include folic acid, hydroxyurea, and hydrocodone as needed for pain.
After initial evaluation, including pertinent laboratory studies and chest x-ray, she is started on 1/2 normal saline at 125 mL/hr and hydromorphone every 3 hours.  Over the next 36 hours, the patient complains of worsening chest pain and mild shortness of breath.  Her temperature is 38.9 C (102 F), pulse is 112/min, and respirations are 23/min.  Oxygen saturation is 93% on 2 L O₂.  Lung examination shows bilateral crackles.  Lower-extremity examination shows tenderness with palpation.
Laboratory results are as follows:

She has good urine output.  Her chest x-ray on admission (Image 1) and repeat x-ray after 36 hours (Image 2) are shown below.


Which of the following, if instituted on initial presentation, may have helped prevent the clinical worsening that occurred in this patient?

A)Antibiotic prophylaxis
B)Hydromorphone PCA pump
C)Incentive spirometry
D)Inhaled bronchodilators
E)Stringent use of intravenous hydration

Question 80

A 19-year-old man comes to the emergency department with penile pain.  He started to get an erection about 2 hours ago, and it has not subsided.  He took pain medications without relief.  The patient has had no manipulation or trauma to his genitourinary tract.  His only medical problem is sickle cell disease (Hb SS), with his usual vasoocclusive crisis being joint and bone pain.  His last pain crisis was about 4 months ago.  His medications include hydroxyurea, folate, oxycodone, and acetaminophen.
His temperature is 37.8 C (100 F), blood pressure is 140/90 mm Hg, pulse is 120/min, and respirations are 32/min.  Pulse oximetry is 95% on room air.  Examination shows a very uncomfortable man with an erect penis.
Laboratory results are as follows:

His chest x-ray shows no infiltrates.
Which of the following is the most appropriate next step in management?

A)Corpus cavernosum aspiration
B)Epidural pain control
C)Exchange transfusion
D)Loading dose hydroxyurea
E)Shunt (glans-cavernosum) procedure