studies show a serum CK of 50,000 IU/L. CSF fluid analysis shows a total white blood cell count of 5/microL. Which of the following is the most appropriate next step in management?
A. Risperidone
B. Dantrolene@
C. L-Dopa
D. Prednisone
E. Antibiotics
5. A 38-year-old homeless man is brought ...
XII. Emergency
1. A 40-year-old man is brought to the emergency room after his wife found him alone in a confused
state. He admits to overdosing in a suicide attempt, but does not specify the drug taken. En route to
the hospital, he is drowsy and ataxic with blurred vision. His past medical history is significant for
asthma, insomnia, depression, and substance abuse. His temperature is 38.3C (100F), blood pressure
is 130/80mm Hg, pulse is 100/min, and respirations are 22/min. Examination shows dry mucus
membranes and skin; pupils are 8mm bilaterally. There is no neck stiffness. Lungs are clear to
auscultation. Heart sounds are within normal limits. Abdominal examination shows reduced bowel
sounds with no tenderness. A Foley catheter is placed in the ER and 600 ml of urine is collected over
one hour. Which of the following is the most likely diagnosis?
A. Salicylate intoxication
B. Serotonin syndrome
C. Cocaine intoxication
D. Diphenhydramine poisoning@
E. Phencyclidine poisoning
2. A 46-year-old male is admitted to the hospital because of right hand cellulitis. He has a history of
intravenous drug use, hepatitis C infection and septic arthritis of the knee. He smokes one pack of
cigarettes and drinks one pint of vodka daily. He is started on vancomycin. On the following day,
the swelling and redness of his arm decreases. However, he complains of bugs crawling on his skin.
His temperature is 38.3C (100.9 F), blood pressure is 160/90 mm Hg, pulse is 110/min, and
respirations are 18/min. Examination shows mild hand tremors and diaphoresis Which of the
following is the most appropriate next step in management?
A. Start chlordiazepoxide@
B. Give haloperidol
C. Start propranolol
D. Stop vancomycin
E. Start methadone
3. A 35-year-old woman is brought to the emergency room after an apparent suicide attempt. Her
current prescription of imipramine was found at her bedside along with a suicide note. En route to
the hospital, she suffered a seizure. She has been treated with many different anti-depressants over
the past several years without improvement. Her temperature is 38.3C (101F), blood pressure is
90/50 mm Hg, pulse is 120/min and respirations are 24/min. EKG shows QRS widening (0.18sec).
She is given sodium bicarbonate along with supportive treatment. Which of the following is the most
likely mechanism that explains the beneficial effects of sodium bicarbonate?
A. Alkalinization of urine will promote diuresis of the antidepressants
B. Acidification of urine will promote diuresis of the antidepressants
C. Sodium load of sodium bicarbonate will alleviate depressant action on sodium channels@
D. Sodium load of sodium bicarbonate will alleviate depressant action on potassium channels
E. Sodium load of sodium bicarbonate will alleviate depressant action on calcium channels
4. A 32-year-old male is admitted to the hospital because of confusion. He was recently diagnosed with
schizophrenia His temperature is 38.6C (101.6F), blood pressure is 160/100 mm Hg, pulse is
116/min, and respirations are 22/min. He is not oriented to time, place or person. Mucus membranes
are dry. Profuse diaphoresis is present. Lungs are clear to auscultation. Abdominal, neck and
extremity muscles are rigid. Muscle tone is increased. Deep tendon reflexes are 2+. Laboratory
, studies show a serum CK of 50,000 IU/L. CSF fluid analysis shows a total white blood cell count of
5/microL. Which of the following is the most appropriate next step in management?
A. Risperidone
B. Dantrolene@
C. L-Dopa
D. Prednisone
E. Antibiotics
5. A 38-year-old homeless man is brought to the emergency room. He is obtunded and unable to speak.
No previous medical history is known. His temperature is 34.0C (93.2F), blood pressure is 90/60 mm
Hg, pulse is 60/min and respirations are 6/min. Oxygen saturation is 86% on room air. Pupils are 5
mm in size, bilaterally. Oropharynx is dry. Lungs are clear to auscultation. Abdomen is soft; bowel
sounds are decreased; there is no organomegaly. Extremities reveal several needle marks. Babinski
sign is negative. Deep tendon reflexes are 2+ throughout. Which of the following is the most
appropriate next step in management?
A. CT scan of the head
B. Glucagon
C. Methadone
D. Naloxone@
E. Flumazenil
6. A mother brings her 16-year-old daughter to the ER after she had two episodes of coffee ground
emesis. The mother reports that for the past two weeks, the teen has not been acting like herself;
she has been especially isolated and has had a poor appetite and poor sleep. Her medical history is
significant for anemia, for which she takes iron sulfate and folic acid. She also takes acetaminophen
for occasional back pain. Presently, the patient's blood pressure is 110/70 mmHg and heart rate is
120/min. Which of the following is most likely to establish the diagnosis?
A. Liver function tests
B. Upper Gl endoscopy
C. Serum iron level@
D. CT scan of the head
E. Serum acetaminophen level
7. A 47-year-old man is brought to the ED by EMS after being found wandering in the street
mumbling. His BP is 150/75 mm Hg, HR is 110 beats per minute, temperature is 100.5°F, RR is 16
breaths per minute, oxygen saturation is 99% on room air, and fingerstick glucose is 98 mg/dL. On
examination, the patient is confused with mumbling speech. His pupils are dilated and face is
flushed. His mucous membranes and skin are dry. Which of the following toxic syndromes is this
patient exhibiting?
a. Sympathomimetic syndrome
b. Anticholinergic syndrome@
c. Cholinergic syndrome
d. Opioid syndrome
e. Ethanol syndrome
8. A 25-year-old man is carried into the ED by two of his friends who state that he is not breathing. The
patient has a history of heroin abuse. His vital signs are BP 115/70 mm Hg, HR 99 beats per minute,
temperature 98.9°F, RR 3 breaths per minute, and oxygen saturation 87% on room air. You notice
fresh needle marks and miotic pupils. You begin bag-valve mask ventilation and his oxygen
saturation increases to 99%. Which of the following is the most appropriate next step in
management?
a. Continue bag-valve-mask ventilation until he breathes on his own.
b. Perform endotracheal intubation of the patient.
,c. Evaluate response to administration of naloxone.@
d. Put the patient on supplemental oxygen.
e. Place a nasogastric tube and administer activated charcoal.
9. A 42-year-old man who is actively seizing is brought to the ED by EMS after a massive ingestion of
an unknown substance. The man is known to have a history of acquired immunodeficiency syndrome
(AIDS). An intravenous (IV) line is established and anticonvulsant therapy is administered. After
high doses of diazepam, phenobarbital, and phenytoin, it is determined that the seizures are
refractory to standard anticonvulsant therapy. Which of the following substances did this patient
most likely ingest?
a. Cocaine
b. Diphenhydramine
c. Tricyclic antidepressant (TCA)
d. Haloperidol
e. Isoniazid (INH)@
10. A 26-year-old man is brought to the emergency room by police with depressed mental status. Out of
fear of arrest, he swallowed a handful of pills as the police officers approached him. On examination,
he responds to painful stimuli but is somnolent. His respiratory rate is 8/min and after naloxone
bolus infusion increases to 12/min. Lungs are clear to auscultation. Which of the following
additional findings is most likely to be present in this patient?
A. Miosis, bradycardia, hypertension
B. Miosis, tachycardia, hypotension
C. Miosis, bradycardia, hypotension@
D. Miosis, tachycardia, hypertension
E. Mydriasis, tachycardia, hypertension
11. A 29-year-old male is brought to the emergency room because of sudden onset confusion and fever.
He was recently admitted to the hospital for hallucinations and was discharged in stable condition.
His temperature is 38.6C (101.6 F), blood pressure is 150/100 mm Hg, pulse is 112/min, and
respirations are 24/min. Mucus membranes are dry. Profuse diaphoresis is present. Lungs are clear to
auscultation. Abdominal muscles are rigid. Muscle tone is increased; "lead pipe rigidity" is noted in
all four extremities. Deep tendon reflexes are 2+. Tremor is noted. Which of the following is the
most likely diagnosis?
A. Tetanus
B. Meningitis
C. Drug induced idiosyncratic reaction@
D. Cocaine intoxication
E. Lithium intoxication
12. A 26-year-old man is brought to the emergency room after an attempted suicide by medication
overdose. For the past hour, he has suffered two seizures. His temperature is 38.8C (102F), blood
pressure is 110/85 mmHg, pulse is 90/min, and respirations are 22/min. He is not oriented to time,
place, and person. Pupils are dilated, but reactive to light and accommodation; skin is flushed and
dry. Abdominal examination shows reduced bowel sounds. EKG shows prolonged QRS complexes
(0.19 sec). Toxicology studies are pending. Which of the following is the most appropriate indicator
of severity of intoxication?
A. Serum drug levels
B. Urine drug levels
C. Duration of QRS complex@
D. Pupillary size
, E. Bowel sounds
13. A 42-year-old male is admitted to the hospital with fever and shortness of breath. He has HIV
infection, hepatitis C infection, and alcohol induced cardiomyopathy. His temperature is 38.6 C
(101.5 F). Thrush is noted in the oropharynx. Chest x-ray reveals right lower lobe consolidation. He is
started on fluconazole and moxifloxacin. His pneumonia and thrush improve over the next 2 days.
However, on the third day, he develops palpitations. His EKG strip is shown below:
Which of the following is the most appropriate next step in management?
A. Calcium gluconate
B. Magnesium sulphate@
C. Sotalol
D. Amiodarone
E. Adenosine
14. A 34-year-old homeless man is brought to the emergency room in a confused state. He complains of
epigastric pain, vomiting and blurred vision. His temperature is 36.8C (98.2F), blood pressure is
110/60 mm Hg, pulse is 110/min and respirations are 22/min. Physical examination shows poor oral
hygiene and dry mucous membranes. Lungs are clear to auscultation. Abdominal exam shows mild
epigastric discomfort. Funduscopic examination reveals optic disc hyperemia. Laboratory studies
show:
Which of the following is the most likely cause of his symptoms?
A. Ethylene glycol poisoning
B. Mesenteric ischemia
C. Septic shock
D. Diabetic ketoacidosis
E. Methanol poisoning@
15. You receive notification from EMS that they are bringing in a 17-yearold adolescent boy who was
found unconscious by a police officer. The police officer at the scene states that he snuck up on a
group of kids that he thought were using drugs. Two of them got away and one just fell to the ground
seconds after standing up. Lying on the ground next to the adolescent were plastic bags. The
emergency medical technician (EMT) states that the patient was in ventricular fibrillation. He was
shocked in the field and is now in a sinus rhythm. The EMT also administered IV dextrose,
thiamine,
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