Toxicology

(M2.PH.4733) A 65-year-old man arrives to the emergency department (ED) complaining of pain and swelling in his right leg. The patient reports he recently underwent a total hip replacement. His past medical history is significant for hypertension and diabetes. His current medications include aspirin, lisinopril, metformin, and atorvastatin. On arrival, his temperature is 99°F (37.2°C), blood pressure is 135/82 mmHg, pulse is 88/minute, and oxygen saturation is 99% O2. He denies chest pain or shortness of breath. On physical exam, his right leg appears moderately erythematous, swollen, and is tender to palpation. Other physical exam findings are negative.

A complete blood count (CBC) was performed with the following findings:

Hemoglobin: 13.0 g/dL
Leukocyte count: 6500/mm^3
Platelet count: 150,000/mm^3

The appropriate anti-coagulation therapy is started. Seven days later the patient arrives back to the ED complaining of crushing substernal chest pain. An electrocardiogram is performed and is shown in Figure A.

A CBC was performed with the following findings:

Hemoglobin: 13.5 g/dL
Leukocyte count: 8500/mm^3
Platelet count: 58,000/mm^3
INR: 2.5
aPTT: 34 seconds
Fibrinogen level: 200 mg/dL
Troponin T: 0.2 ng/mL

On physical exam, the right leg is again swollen and tender to palpation. However, a new lesion has also formed, as shown in Figure B. In addition to sending the patient for cardiac catherization, what is the most appropriate next step in management? Review Topic

(M2.PH.4817) A 32-year-old female is brought to the emergency department by her boyfriend for confusion. He reports that the patient had told him that she was staying home from work because of her allergies, which had been bothering her all week. When the patient’s boyfriend arrived home, he found the patient agitated and disoriented. He reports that when he tried to talk to her, she was "out of it" and kept asking for water. The boyfriend also reports that the patient recently received a negative evaluation at work and that she has been stressed. The patient’s past medical history is otherwise significant for ADHD, depression, and seasonal allergies. Her medications include amphetamine, desipramine, intranasal ipratropium, and diphenhydramine as needed. Her temperature is 102°F (38.9°C), blood pressure is 122/82 mmHg, pulse is 132/min, and respirations are 18/min with an oxygen saturation of 98% O2 on room air. Upon physical exam, the patient is agitated and grabbing at the air. She also appears flushed, her pupils are dilated, and she has scattered urticaria. The patient's EKG can be seen in Figure A. Which of the following is the most appropriate treatment for this patient? Review Topic

(M2.PH.4678) A 66-year-old man presents to his primary care physician with abdominal pain in the setting of progressively worsening constipation. He complains of epigastric pain that waxes and wanes, and expressed concern that he has not defecated for the past 5 days. Upon further questioning, he relates that he has been taking three of his wife's multivitamins each day for the past three weeks to "combat a cold." Vital signs are within normal limits. Physical exam reveals an abdomen with nonspecific tenderness to deep palpation without rebound tenderness, hyperpercussion, or flank tenderness. What is the most likely cause of his symptoms? Review Topic

(M2.PH.146) A mother presents to the family physician with her 16-year-old son. She explains, "There's something wrong with him doc. His grades are getting worse, he's cutting class, he's gaining weight, and his eyes are often bloodshot." Upon interviewing the patient apart from his mother, he seems withdrawn and angry at times when probed about his social history. The patient denies abuse and sexual history. What initial test should be sent to rule out the most likely culprit of this patient's behavior? Review Topic

(M2.PH.4689) A 45-year-old with a past history of being admitted for alcohol withdrawal and acute alcohol toxicity presents to the emergency department with ataxia. He is stuporous and does not respond to questions appropriately, often yelling and falling down. On exam, the patient has visual impairment and cannot read the Snellen chart correctly. Figure A shows his retina on ophthalmologic exam. His electrolytes are Na 140, K 3.0, Cl 95, HCO3 15, BUN 27, Cr 1.2. Which of the following can be administered intravenously to treat this patient in addition to intravenous fluids, thiamine, vitamin B12 and folate? Review Topic

(M3.PH.35) A man is brought into the emergency department by the police department. The officer state that the man has been arrested multiple times for public alcohol intoxication, but recently became homeless. On exam, the man is behaving erratically. His vitals are all within normal limits. He appears confused and has a slurred speech. On gait exam, the patient is ataxic and cannot stand without support for more than a few seconds. Labs return with the following values: Na 140, K 4, Cl 106, BUN 8, Cr 2. His ABG has pH 7.3, PaCO2 13mm, PaO2 130mm, HCO3 7. His urinalysis is shown in Figure 1. Blood salicylate levels return as normal. While you await other diagnostic tests, which of the following should be administered next to treat this patient? Review Topic

(M2.PH.11) A 34-year-old male is brought to the emergency department by paramedics after being found down on the sidewalk. The paramedics are unable to provide any further history and the patient in unresponsive. On exam, the patient's vitals are: T: 36 deg C, HR: 65 bpm, BP: 100/66, RR: 4, SaO2: 96%. The emergency physician also observes the findings demonstrated in figures A and B. This patient most likely overdosed on which of the following? Review Topic

(M2.PH.8) A 4-year-old boy is brought to the emergency department by his mother with stomach pain and vomiting for the last 7 hours. His mother is pregnant and states that she is taking nutritional supplements prescribed by her doctor. She mentions that her son ingested some supplements after confusing them for candy. Arterial blood gas was drawn, and he is found to have a pH of 7.2. Abdominal X-ray is shown in Figure A. After starting IV fluids, what other treatments should this patient receive? Review Topic

(M2.PH.16) A 46-year-old homeless male presented to the emergency department intoxicated, but a serum ethanol level is normal. Results from a urine study are shown in Figure A. Which of the following findings would you most likely expect in this patient?

I: elevated serum anion gap
II: elevated serum osmolar gap
III: decreased serum pH Review Topic