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Medical-Eval-MedBullets_op4

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A 44-year-old man presents to the emergency department acutely confused. The patient’s wife states she found him lethargic at home. He has been sick the past week with diarrhea and has been staying home from work. He is otherwise healthy and does not take any medications. His temperature is 97.5°F (36.4°C), blood pressure is 62/32 mmHg, pulse is 185/min, respirations are 25/min, and oxygen saturation is 98% on room air. The patient has profuse, bloody diarrhea while in the emergency department. The patient is given 3L of ringer lactate and subsequently appears less confused, with a blood pressure of 100/70 mmHg. He is able to drink oral fluids and protect his airway. An ECG is performed as seen in Figure A. He continues to have diarrhea while in the emergency department. Which of the following is contraindicated in the management of this patient?
{ "A": "Loperamide", "B": "Norepinephrine", "C": "Ceftriaxone", "D": "Normal saline" }
Loperamide
A
A 55-year-old man presents to the emergency department after fainting while moving furniture. He states that he has been working in a hot, humid attic all day and forgot his water bottle. He felt dizzy when standing up and then fainted and was unconscious for roughly 1 minute. He awoke at his neurologic baseline afterwards. The patient has a history of hypertension being managed by his primary care doctor. His temperature is 98.7°F (37.1°C), blood pressure is 149/82 mmHg, pulse is 86/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam reveals a diaphoretic man. He demonstrates an unremarkable cardiopulmonary exam. The patient walks with a steady gait and his neurologic exam is non-focal. An ECG is performed as seen in Figure A. The patient is given 2 liters of oral fluids and feels back to his baseline. Which of the following conditions is most likely to occur in this patient based on his current history and ECG?
{ "A": "Atrial fibrillation", "B": "Torsades des pointes", "C": "Stroke", "D": "Complete heart block" }
Complete heart block
D
A 55-year-old man with a history of polysubstance abuse is found down in his home acutely obtunded. Emergency medical services administered naloxone which immediately woke the patient up and improved his oxygen saturation from 40% to 90%. However, they noted subsequently that the patient demonstrated increased work of breathing and had crackles and wheezing on pulmonary exam. The patient arrives alert and oriented claiming he feels short of breath. He denies any chest pain or other symptoms aside from shortness of breath. He has a history of cocaine-induced cardiomyopathy and myocardial infarction from cocaine use 2 years ago. The patient has a 40 pack-year smoking history. His temperature is 96.0°F (35.6°C), blood pressure is 120/68 mmHg, pulse is 102/min, respirations are 26/min, and oxygen saturation is 88% on room air. Physical exam reveals increased work of breathing, pulmonary crackles, and wheezing. A chest radiograph is performed as seen in Figure A. Which of the following is the most likely etiology of this patient's current symptoms?
{ "A": "Medication administration", "B": "Community acquired pneumonia", "C": "Atypical pneumonia", "D": "Poor cardiac function" }
Medication administration
A
A 42-year-old man presents to the urgent care clinic with low back pain. He was working on a home improvement project the day prior to presentation when the pain started. He describes the pain as "achy and sore." It is not positional and does not radiate. He denies fevers, chills, paresthesias, and bowel or bladder incontinence. He has a history of a distal radius fracture 2 years ago from falling off a ladder. He drinks 3 alcoholic beverages weekly and denies illicit drug use. The patient’s temperature is 98.4°F (36.9°C), blood pressure is 124/80 mmHg, pulse is 90/min, and respirations are 16/min. His body mass index (BMI) is 22.4 kg/m^2. There is tenderness to palpation of his paravertebral lumbar region bilaterally. Perineal and dermatomal sensation is symmetric and intact. Strength is 5/5 to knee flexion/extension and ankle dorsiflexion/plantarflexion. Patellar and Achilles reflexes are 2+ bilaterally. Raising either leg while the patient is in the supine position does not elicit any pain. Which of the following is the most likely diagnosis?
{ "A": "Osteoarthritis", "B": "Vertebral compression fracture", "C": "Lumbar strain", "D": "Disc herniation" }
Lumbar strain
C
A 77-year-old man presents to the emergency department acutely obtunded. The patient lives alone and was found unresponsive by his son. Generally, the patient manages his own finances, medications, and works part-time. He has not been responding to phone calls for the past 3 days. The patient is unable to offer a history. He has a past medical history of hypothyroidism, depression, and diabetes. His temperature is 88.0°F (31.1°C), blood pressure is 92/62 mmHg, pulse is 35/min, respirations are 9/min, and oxygen saturation is 92% on room air. The patient is cold to the touch and moves all extremities to painful stimuli. His pupils are reactive and sluggish, and he does not follow commands. There are no signs of trauma or skin infections. The patient is started on IV fluids and hydrocortisone, is externally warmed, and is started on a norepinephrine drip. An ECG is performed as seen in Figure A. Which of the following is the most appropriate next step in management?
{ "A": "Levothyroxine administration", "B": "Free T4 level", "C": "Thyroid stimulating hormone and free T4 level", "D": "Triiodothyronine administration" }
Levothyroxine administration
A
A 52-year-old G3P3 woman presents to clinic with a 2-year history of urinary incontinence. She has had frequent, involuntary loss of urine over the last 2 years but presented today because of 10 days of dysuria. She has been treated for 2 urinary tract infections over the past 6 months. She does not endorse any loss of urine with coughing or laughter. She has no chronic medical illnesses and no surgical history. Her temperature is 99.5°F (37.5°C), blood pressure is 120/80 mmHg, pulse is 92/min, and respirations are 15/min. Her BMI is 30 kg/m^2. On pelvic examination, the vagina is dry and atrophic with a 2-cm tender, palpable anterior vaginal mass. The mass does not change with Valsava maneuver. Her postvoid residual volume is 60 mL. Which of the following is the most likely diagnosis?
{ "A": "Urethral diverticulum", "B": "Overflow incontinence", "C": "Stress urinary incontinence", "D": "Pelvic organ prolapse" }
Urethral diverticulum
A
A 48-year-old man presents to the emergency room with a 2-hour history of severe abdominal pain, nausea, and vomiting. He states that he has not passed gas or had a bowel movement in 4 days and his pain has worsened and become constant over the past 2 hours. His only medical history includes an appendectomy that he underwent as a child, and he takes no daily medications. His temperature is 38.5°C (101.3°F), blood pressure is 92/60 mmHg, pulse is 138/min, and respirations are 25/min. His pulse oximetry is 99% on room air.There are no cardiopulmonary abnormalities on auscultation. His abdomen is distended and tender in all quadrants, with guarding and rebound present. He also has increased bowel sounds throughout. Laboratory results are as follows: Hemoglobin: 11 g/dL Leukocyte count: 16,500/mm^3 with normal differential Platelets: 250,000/mm^3 Serum: Creatinine: 1.0 mg/dL Glucose: 95 mg/dL Lipase: 45 U/L Total bilirubin: 0.8 mg/dL Alkaline phosphatase: 74 U/L Aspartate aminotransferase (AST, GOT): 32 U/L Alanine aminotransferase (ALT, GPT): 45 U/L Lactate: 7.0 mmol/L Which of the following is the most appropriate next step in management?
{ "A": "Supportive care, NPO, and intravenous fluids", "B": "Urgent surgical intervention", "C": "Nasogastric tube placement", "D": "CT angiography of the abdomen and pelvis" }
Urgent surgical intervention
B
A 26-year-old woman presents to the emergency department because she feels as though her heart is "beating out of her chest." She states that she feels well apart from the discomfort of that sensation. Her temperature is 97.9°F (36.6°C), blood pressure is 124/84 mmHg, pulse is 180/min, respirations are 22/min, and oxygen saturation is 98% on room air. An ECG is obtained as seen in Figure A. After unsuccessful attempts at vagal maneuvers, the emergency physician administers an IV medication. The effect of the medication wears off in seconds. Which of the following is a potential side effect of this medication?
{ "A": "Tachycardia", "B": "Photosensitivity", "C": "Flushing", "D": "Seizure" }
Flushing
C