A 75-year-old man is brought to the emergency department from home after being found unresponsive by his son.  His medical history is significant for coronary artery disease with coronary stenting 2 years ago, diabetes mellitus, hypertension, and stroke.  He was hospitalized 2 months ago with pneumonia and upper gastrointestinal bleeding, during which time he received intravenous antibiotics and a transfusion of 4 units of packed red blood cells.  In the emergency department today, temperature is 39.1 C (102.4 F), blood pressure is 70/40 mm Hg, pulse is 120/min, respiratory rate is 32/min, and oxygen saturation is 79% on room air.  Laboratory results are notable for leukocytosis but are otherwise unremarkable.  Chest x-ray reveals a new right upper lobe infiltrate.  He is treated with normal saline, antibiotics, vasopressors, and mechanical ventilation.  The next day, laboratory analyses reveal the following:Hemoglobin 9.5 mg/dLLeukocytes 15,000/mm3Platelet 120,000/mm3Sodium 137 mEq/LPotassium 4.1 mEq/LChloride 100 mEq/LBicarbonate 19 mEq/LBlood urea nitrogen 51 mg/dLCreatinine 2.1 mg/dLBilirubin, total 1.2 mg/dLAspartate aminotransferase 3,720 units/LAlanine aminotransferase 3,250 units/LAlkaline phosphatase 162 mEq/LWhich of the following most likely accounts for the abnormal liver function panel? A.Acute viral hepatitis B.Alcoholic liver disease C.Granulomatous liver disease D.Ischemic hepatic injury E.Acalculous cholecystitis F.Iron overload G.Autoimmune hepatitis

A 45-year-old man comes to the emergency department due to a 1-day history of constant upper abdominal pain, nausea, and several episodes of vomiting.  The pain is partially relieved by sitting up or bending forward.  He has also had mild shortness of breath.  The patient's other medical history includes hyperlipidemia and hypertension.  He uses tobacco and alcohol.  There is a family history of coronary artery disease and hypertension.  Temperature is 38.1 C (100.6 F), blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 22/min.  There is dullness to percussion and decreased breath sounds at the left lung base.  Abdominal examination shows epigastric tenderness.  Laboratory results are as follows:Hematocrit 44%Leukocytes 16,000/mm3Calcium 7.8 mg/dLGlucose 250 mg/dLWhich of the following plays a principal role in initial management of this patient's current condition? A.Antiplatelet agents B.Broad-spectrum antibiotics C.Calcium gluconate D.Exploratory laparotomy E.Insulin infusion F.Isotonic crystalloids G.Proton pump inhibitors

A 64-year-old woman is brought to the emergency department due to fever, chills, flank pain, and lethargy for the past 2 days.  Temperature is 38.9 C (102 F), blood pressure is 100/60 mm Hg, and pulse is 120/min.  The patient has right costovertebral angle tenderness.  Leukocytes are 16,000/mm3 and urinalysis shows pyuria, many bacteria, and positive nitrites.  ECG shows sinus tachycardia.  A central venous catheter placement is planned for intravenous therapy and hemodynamic monitoring.  After the patient's chest is appropriately prepared and draped, a needle is inserted just lateral to the angle of the left clavicle and a triple lumen catheter is placed into the left subclavian vein.  Each lumen is flushed with sterile saline after obtaining blood return.  The catheter is sutured in place to the skin and a sterile dressing is applied.  Which of the following is the best next step in management of this patient?

A 58-year-old man comes to the emergency department due to sudden onset of severe right leg pain several hours ago; the leg has since become numb.  He has never had similar symptoms and has no history of trauma, fever, or chills.  The patient recently had an acute anterior wall myocardial infarction that resulted in cardiogenic shock; he is undergoing cardiac rehabilitation.  Temperature is 36.7 C (98.1 F), blood pressure is 120/70 mm Hg, pulse is 90/min and regular, and respirations are 16/min.  Cardiopulmonary examination is unremarkable.  Compared with the left leg, the right leg appears pale and is cool to the touch.  In the right lower extremity, the popliteal pulse is normal, but more distal pulses are not palpable.  Pulses in the other extremities are normal.  Neurologic examination shows loss of sensation over the dorsum of the right foot and mild weakness with dorsiflexion.  Which of the following is the most likely cause of this patient's symptoms?

A 54-year-old man is brought to the emergency department after his family found him on the floor and unresponsive at home.  The patient has a history of hypertension but is not adherent with medical treatment.  He smokes cigarettes and uses cocaine.  Temperature is 36.6 C (97.9 F), blood pressure is 176/98 mm Hg, pulse is 58/min, and respirations are 12/min and irregular.  The patient is unresponsive to deep sternal rub.  The right pupil is widely dilated and unresponsive to light.  There is intermittent extended posturing of the left arm and leg.  Deep tendon reflexes are 4+ in the left extremities, and Babinski sign is present on the left side.  Which of the following is the most likely cause of this patient's current condition? A.Basal ganglia hemorrhage B.Cerebellar hemorrhage C.Medullary ischemic infarction D.Midbrain ischemic infarction E.Occipital cortex ischemic infarctionProceed To Next Item

A 66-year-old man comes to the emergency department with significant pain in the right leg.  He says, "The pain started yesterday; I tried resting and taking acetaminophen, but it did not go away."  Medical history includes coronary artery disease with a previous anterior wall myocardial infarction, heart failure with reduced ejection fraction, hypertension, and hyperlipidemia.  The patient does not adhere regularly to prescribed medications.  He does not smoke cigarettes or consume alcohol.  The patient appears to be in moderate discomfort due to pain.  Temperature is 36.7 C (98.1 F), blood pressure is 150/90 mm Hg, pulse is 102/min and regular, and respirations are 14/min.  On physical examination, the right lower extremity appears pale and cooler than the left.  On palpation, no pulses can be appreciated at the right popliteal and dorsalis pedis arteries, but they are detected on Doppler examination.  Sensory and motor examination is unremarkable.  Intravenous heparin infusion is initiated.  Which of the following is the best next step in management of this patient?