A 29-year-old concert pianist with severe chronic kidney disease presents with a 6-month history of loss of appetite and pruritus. Although the issue of initiating dialysis has been discussed with him and his questions answered, he has declined dialysis thus far. You understand his concerns that it will interfere with his concert tour and recording schedule. Which one of the following is the best next step?
A 58-year-old woman presents to your office with refractory bipolar I disorder. She is on the following medications: lithium carbonate, valproic acid, and olanzapine. She also takes acetaminophen for osteoarthritis and pantoprazole for gastroesophageal reflux. Lately, she has noticed she bruises very easily. Laboratory work displays a platelet count of 70 × 10⁹/L (normal 130–400). Which one of the following is most likely to induce this side effect?
A 42-year-old man presents to your office with acute left knee pain and difficulty walking. He denies any trauma. He reports 2 painful episodes involving his right great toe in the last year. He smokes half a pack of cigarettes a day and drinks at least 3 beers daily. He has a temperature of 38.2°C and has a red, swollen and warm left knee. Which one of the following is the best next step?
A 25-year-old woman, gravida 1, para 1, aborta 0, gave birth to a newborn who is hypotonic with a large protruding tongue and brachycephaly. The newborn has a single palmar crease bilaterally and short, broad hands with a curved fifth digit. These features best support a clinical diagnosis of which one of the following?
A 55-year-old man presents with vague abdominal pain and general weakness. His mother had colon cancer and died at age 60 years. His physical examination findings and complete blood count results are normal. Which one of the following tests should be ordered first?
Your colleague's receptionist asks you to assess her 4-year-old daughter who has had 2 episodesof acute otitis media in the last month. The mother wants you to arrange a consultation with an ear, nose and throat (ENT) specialist to get a tympanostomy before her daughter starts school. You do not believe there is a surgical indication at this time. Which one of the following is the best next step?
You are the emergency physician on duty in a rural hospital when heavy rains in the community cause a large landslide. There are multiple casualties expected to arrive in the emergency department. Your colleague has heard about the incident and arrives to help. Which one of the following is the best next step?
An 18-year-old woman comes to the office because of fatigue. She tells you she is struggling in her first year of university. She mentions that she spends much of her time rewriting her notes and filing and organizing her study materials. She is doing all the work in her group assignments because she feels others cannot do the work to a high enough standard. She has abandoned all enjoyable activities and seems to be constantly working and worrying about her grades. Which one of the following is the most likely diagnosis?
A 22-year-old woman is brought to the Emergency Department by her boyfriend, who says that she is experiencing a fentanyl overdose. She is unresponsive and cyanotic. She regains consciousness after naloxone is injected intravenously and demonstrates no further respiratory depression during 8 hours of observation. She states that she is 22 weeks' pregnant and wants to stop using opioids. Which one of the following is the best next step?
A 24-year-old woman with chronic anorexia nervosa presents to the Emergency Department with diarrhea, chest pain and palpitations. She is noted to have a BMI of 13, a heart rate of 48/min, significant orthostatic hypotension and a temperature of 35.9 °C. Her electrocardiogram shows frequent premature ventricular contractions. Her blood work indicates elevated liver transaminases and evidence of acute kidney injury from dehydration. She agrees to admission for medical stabilization only if she does not receive fluids either orally or intravenously, as they will cause her to gain weight and to feel bloated. Which one of the following is the best next step?
