A 54-year-old woman comes to the emergency department due to 12 hours of constant upper abdominal discomfort, nausea, and vomiting.  The patient had a large dinner, went to bed feeling well, and was awakened by severe pain.  In the past year, she has had brief similar episodes, but the pain was never this persistent.  She has had no diarrhea or dysuria.  Medical history includes gastroesophageal reflux, hyperlipidemia, and type 2 diabetes mellitus.  The patient does not use alcohol, tobacco, or illicit drugs.  Temperature is 38.3 C (100.9 F), blood pressure is 140/90 mm Hg, pulse is 110/min, and respirations are 20/min.  BMI is 33.2 kg/m².  The lungs are clear to auscultation and heart sounds are normal.  Abdominal examination reveals moderate tenderness in the right upper quadrant with voluntary guarding.  There is no rebound tenderness.  Laboratory results are as follows:

Ultrasound of the abdomen reveals several small gallstones without gallbladder wall edema or sonographic Murphy sign.  The common bile duct is not enlarged.  Which of the following is the best next step in management of this patient?

A 50-year-old man comes to the emergency department due to unremitting pain in his left buttock near the anus.  He also has fever and malaise.  Although he is uncertain when the discomfort first began, he notes that the pain has increased significantly over the past 24 hours and he has been unable to pass stool because of it.  He has never experienced symptoms like this.  Ten years ago, he was diagnosed with type 2 diabetes mellitus, and he currently takes insulin.  Temperature is 38.7 C (101.7 F), blood pressure is 128/86 mm Hg, and pulse is 95/min.  On digital rectal examination, sphincter tone is intact, but there is tenderness and fluctuance along the left rectal wall that are palpable 5 cm above the external sphincter.  There is no crepitus in the perineum.

Item 1 of 2
What is the most appropriate next step in management of this patient?

Item 2 of 2
The patient is treated appropriately.  To minimize risk for complications, he is advised to promptly schedule a follow-up visit with his primary care physician.  Patients with anorectal abscesses are at greatest risk for which of the following conditions?

A 65-year-old man is brought to the emergency department by his wife due to severe upper-abdominal pain.  The pain began suddenly 4 hours ago while he was watching television; it radiates to the back and is exacerbated by any movement.  The patient has had gastroesophageal reflux disease for many years and has been taking over-the-counter antacids for symptom control.  He also has hypertension, which is controlled with a thiazide diuretic.  He walks 5 miles daily.  The patient has been consuming large amounts of milk and other dairy products to relieve “burning” symptoms in his stomach.  His temperature is 37.8 C (100 F), blood pressure is 110/62 mm Hg, pulse is 110/min, and respirations are 22/min.  He lies flat and motionless on the bed.  His mucous membranes are dry.  Abdominal examination shows marked tenderness on superficial palpation.  The patient does not allow any further palpation of the abdomen.  Electrocardiogram shows sinus tachycardia.

Item 1 of 3

Which of the following is the best initial test for this patient?

Item 2 of 3

Further evaluation shows pneumoperitoneum on the upright chest x-ray.  The patient’s white blood cell count is 11,300/μL, creatinine is 1.1 mg/dL, and lactic acid level is 2.1 mg/dL.  Which of the following is the most appropriate next step in management of this patient?

Item 3 of 3

The patient was managed operatively, and he recovers well.  Three years later, he comes to the emergency department with a 1-day history of nausea, vomiting, upper-abdominal pain, and distension.  An abdominal radiograph reveals the presence of multiple air-fluid levels in the small intestine consistent with intestinal obstruction.  Which of the following is the most likely mechanism of his intestinal obstruction?

A 63-year-old man comes to the emergency department due to worsening pain in the right upper quadrant, nausea, and vomiting since last night.  He woke up at midnight with abdominal discomfort and nausea.  He could not fall back to sleep due to the increasing pain as well as malaise and shaking chills.  The patient had 2 episodes of vomiting this morning.  He has gastroesophageal reflux disease and takes esomeprazole occasionally.  He also has a history of hypertension and osteoarthritis.  The patient drinks a glass of wine daily with dinner but does not use tobacco or illicit drugs.  On initial evaluation, he appears uncomfortable due to pain.  Temperature is 38.3 C (101 F), blood pressure is 96/65 mm Hg, pulse is 102/min and regular, and respirations are 18/min.  Physical examination shows mild scleral icterus.  Mucous membranes are dry.  The abdomen is soft and nondistended, with moderate tenderness in the right upper quadrant.  There is no rebound tenderness.  Bowel sounds are active.  Laboratory results are as follows:

Serum creatinine is 0.9 mg/dL.  Abdominal ultrasonography reveals increased liver echotexture consistent with fatty infiltration, several small gallstones, and dilated biliary ducts.  Intravenous fluids and empiric antibiotics are administered, and the blood pressure and tachycardia improve.  Which of the following is the best management strategy for this patient?

A 43-year-old woman comes to the emergency department due to midepigastric abdominal pain.  The pain is sharp, radiates to her back, and is accompanied by nausea, vomiting, and malaise.  Her symptoms started approximately 24 hours earlier.  For the past 6 months she has had intermittent, colicky abdominal pain that occurs after meals.  The patient’s medical problems include hypertension, depression, and recurrent urinary tract infections.  Medications include lisinopril, amlodipine, and fluoxetine.  She has no known drug allergies and does not use tobacco, alcohol, or illicit drugs.  Family history is notable for ovarian cancer in her mother.  Temperature is 37.1 C (98.8 F), blood pressure is 146/92 mm Hg, pulse is 85/min, and respirations are 14/min.  Physical examination reveals moist mucous membranes, no lymphadenopathy, clear lung fields, and normal S1 and S2.  The abdomen is soft and tender in the midepigastrium without rigidity or rebound tenderness.  Bowel sounds are normoactive.  The remainder of the examination is normal.  Laboratory results are as follows:

The patient is hospitalized and treated with supportive care.  Abdominal ultrasound reveals multiple gallstones that are 3-5 mm in diameter, but no abnormalities are seen in the common bile duct.  Lipid panel shows triglycerides of 150 mg/dL.  On the third day of hospitalization, the patient is symptom-free, she tolerates oral feeding, and liver enzymes have normalized.  Which of the following treatment options is most appropriate to prevent further episodes of pancreatitis?

A 44-year-old man with a medical history of food allergy to peanuts is brought to the emergency department for an allergic reaction.  The patient developed the acute onset of dyspnea and wheezing shortly after ingesting a cookie.  His symptoms progressed to difficulty swallowing and swelling of the face and tongue.  On arrival, temperature is 36.9 C (98.4 F), pulse is 115/min, blood pressure is 85/74 mm Hg, and respirations are 28/min.  Oxygen saturation is 93% on a nonrebreather face mask.  He is anxious and pale with swollen lips, swollen tongue, and inspiratory stridor.  On lung auscultation, bilateral wheezing is present.  Intramuscular epinephrine, intravenous fluids, and racemic epinephrine via nebulizer are administered without improvement.  The patient’s distress is increasing, and he is becoming more agitated.  The decision to intubate using awake fiberoptic nasotracheal intubation is made.

Item 1 of 2

Which of the following medications would be the best choice to aid in awake fiberoptic nasotracheal intubation in this patient?

Item 2 of 2

Severe swelling of the upper airway is seen on laryngoscopy, and 3 attempts to pass the endotracheal tube are unsuccessful.  The patient’s blood pressure is 70/40 mm Hg, pulse is 75/min, and respirations are 40/min.  Oxygen saturation is 72% on a nonrebreather face mask.  What is the best next step in management of this patient?

A previously healthy 40-year-old man is evaluated in the burn intensive care unit for decreasing urine output.  He had no medical history until 3 days ago when he was involved in a motor vehicle collision and car fire.  The patient suffered severe burns to >60% of his body as well as multiple long bone fractures, but no internal injuries to his chest or abdomen.  He has been receiving intravenous fluids and wound care.  Urine output was initially 0.5 mL/kg/hr but has decreased significantly over the last 8 hours, despite additional crystalloid boluses.  Temperature is 37 C (98.5 F), blood pressure is 88/65 mm Hg, and pulse is 125/min.  Oxygen saturation is 92% on 40% FiO₂.  The patient is intubated, sedated, and mechanically ventilated.  Burn dressings are present on his abdomen, back, and all 4 extremities.  Jugular venous distension is present.  Mild basilar crackles are present with normal inspiratory and expiratory air movement.  Heart sounds are normal.  The abdomen is distended and tense.  A urinary catheter is draining a small amount of yellow urine.  Bilateral lower extremities have 3+ pitting edema.  During the examination, the peak pressure alarm on the ventilator sounds multiple times.  Chest x-ray reveals low lung volumes with elevated hemidiaphragms.  The patient’s routine laboratory results from 2 hours earlier include the following:

Item 1 of 2

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

Item 2 of 2

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

A 72-year-old woman is found to be severely short of breath at her skilled nursing facility.  The patient was recently hospitalized for vertebral osteomyelitis and discharged 2 weeks ago to complete a 6-week course of piperacillin-tazobactam via a peripherally inserted central venous catheter.  Her dyspnea began only with exertion but is now also present at rest.  Medical history includes coronary artery disease with ischemic cardiomyopathy, chronic obstructive pulmonary disease, and chronic kidney disease.  She has had 2 hospitalizations for heart failure over the last year; noninvasive positive-pressure ventilation was required.  Paramedics observe the patient to be obtunded with agonal respirations and rales throughout the bilateral lung fields.  Oxygen saturation is 72% on room air.  She is intubated and transferred to the emergency department.  On arrival, the patient is minimally responsive to stimuli.  Temperature is 36.7 C (98 F), blood pressure is 115/65 mm Hg, and pulse is 110/min and regular.  The patient’s oxygen saturation is 88% on 100% inspired oxygen.  BMI is 19 kg/m².  The trachea is midline.  On physical examination, rales are heard on the right side and markedly decreased breath sounds on the left side of the chest.  S3 is heard.  There is 2+ bilateral peripheral edema.  A chest x-ray reveals the following:

Item 1 of 2

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

Item 2 of 2

After the intervention is performed, the patient’s oxygenation improves.  She is transferred to the medical intensive care unit and treated with diuretics and bronchodilators.  Two days later, her ventilation requirements have improved to 50% inspired oxygen and 5 cm of positive end-expiratory pressure.  The patient’s respirations suddenly become dys-synchronous with the ventilator, and her oxygen saturation drops to 85%.  Tidal volume spontaneously decreases from 350 to 200 mL.  Temperature is 37.2 C (99 F), blood pressure is 125/60 mm Hg, pulse is 110/min, and respirations are 25/min.  Physical examination shows that the trachea is midline and the endotracheal tube is in place.  No jugular venous distension is present.  Breath sounds are markedly decreased on the right side.  A portable chest x-ray reveals the following:

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

A 60-year-old man is taken to the post-anesthesia care unit less than an hour after an elective laparoscopic cholecystectomy.  The surgery was uneventful and the patient was extubated in the recovery room.  Medical history is significant for hypertension, hyperlipidemia, chronic kidney disease, and obstructive sleep apnea.  The patient has no history of alcohol, tobacco, or recreational drug use.  Temperature is 100 F (37.8 C), blood pressure is 125/65 mm Hg, pulse is 75/min, and respirations are 7/min.  Oxygen saturation is 100% on 4 L of oxygen via nasal cannula.  When the nurse attempts to wean the patient from the oxygen, pulse oximetry drops to 87%.  The patient is somnolent but arousable when his name is called.  Auscultation reveals shallow respirations with no rales, wheezing, or rhonchi.  Abdominal examination shows a surgical wound with mild distension and tympany.  There is no lower extremity edema.  Chest x-ray reveals mild hypoinflation.  Arterial blood gas analysis on 36% FiO₂ is as follows:

Which of the following is the most likely cause of this patient’s requirement of supplemental oxygen?

A 14-year-old boy is brought to the emergency department for evaluation of severe scrotal pain.  Half an hour ago, the patient was accidentally hit in the scrotum during wrestling practice.  He applied ice and took acetaminophen, neither of which relieved the pain.  He has not tried urinating due to fear of the pain.  The patient underwent a right orchiopexy as an infant due to unilateral cryptorchidism but has no chronic medical conditions.  Temperature is 36.7 C (98.1 F), blood pressure is 114/76 mm Hg, and pulse is 108/min.  Abdominal examination is unremarkable.  There is moderate bruising on the right hemiscrotum but not on the medial thigh or perineum.  The right testis is exquisitely tender to palpation but has normal contours.  Bilateral testes retract with stroking of the medial thigh.  The penis has no blood at the meatus or open wounds.  Intravenous morphine provides significant pain relief, and the patient is able to urinate spontaneously.  Urinalysis results are as follows:

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