A 74-year-old Caucasian male presents to the emergency room with complaints of shortness of breath during exertion and while lying flat. He underwent mitral, aortic, and tricuspid valve replacement one month ago. Vital Signs: Temperature: 99 °F (37.2 °C) Heart rate: 89 beats/min Blood pressure: 148/105 mm Hg Respirations: 19 breaths/min Oxygen saturation: 89% on room air Physical Examination: Anxious elderly male with scleral icterus (jaundice). Cardiac auscultation: Normal S1, S2 with a holosystolic murmur heard best at the apex in the left lateral decubitus position. Laboratory Findings: Low hemoglobin Elevated LDH Elevated indirect bilirubin Decreased haptoglobin What is the most likely diagnosis in this patient?
A 24-year-old man presents to the emergency department after being the victim of a gunshot wound during a fight. On arrival, the paramedics report that the patient is breathing spontaneously and saturating well on a non-rebreather mask. During the primary survey, the patient is found to have equal bilateral breath sounds and stable vital signs. On secondary survey, a single gunshot wound is identified in the left fourth intercostal space, 1 cm to the left of the left sternal border. Which of the following cardiac structures is most likely injured in this patient?
A 24-year-old woman presents to your office for a refill of her combination oral contraceptive medication. She reports that four months ago, her hemoglobin A1c was 6.1%, and her endocrinologist advised her to take precautions for her prediabetes. Two months ago, she was diagnosed with a hepatoma. She smokes one pack of cigarettes per day. Her blood pressure today is 130/85 mm Hg, and physical examination is otherwise unremarkable. What is the next step in the management of this patient?
Migratory, recurrent superficial thrombophlebitis is most commonly associated with which of the following diseases?
A 44 year-old obese female reports pain in the right lower leg and thigh for the last few days. She reports a dull pain on the medial side of her right thigh (figure 1) and along the lateral surface of her right knee joint (figure 2). She has a history of varicose veins in both lower extremities. Her temperature is 99 °F (37.2 °C), heart rate is 78 beats/min, blood pressure is 140/92 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 97% on room air. On examination, she is an obese woman. Physical examination is significant for induration, redness, and tenderness along the course of the local veins. The veins are erythematous, close to the surface, and palpable. There is erythema of the surrounding skin. Duplex ultrasound of the involved extremity reveals no deep venous thrombosis (figure 3). Figure 1 Which of the following is a true statement regarding this disorder?
A 58-year-old man comes to the emergency department complaining of severe pain in the right leg. He returned from Hawaii last night. The pain started mid flight without any notice. The patient has a history of IgA nephropathy and chronic kidney disease. His vital signs are given below: Height 6 ‘2; weight 342 lb; temperature is 98.4 ⁰ F, heart rate is 62 beats per minute, respiratory rate is 17 breaths per minute, and blood pressure is 145/88 mm Hg. Physical examination is significant for some tenderness over the right lower leg. Laboratory tests reveal the following: Test Result Reference range Erythrocyte count (RBC) 4.9 million/mm³ Male: 4.3 – 5.9 million/mm³ Female: 3.5 – 5.5 million/mm³ Erythrocyte sedimentation rate (Westergren) Male: 8 mm/h Male: 0-15 mm/h Female:0-20 mm/h Hematocrit 47% Male:41% – 53% Female: 36% – 46% Hemoglobin, blood 13.7 g/dL Male:13.5-17.5 g/dL Female 12.0 – 16.0 g/dL Creatinine 4.8 mg/dL 0.6 – 1.2 mg/dL Urea nitrogen 44 mg/dL 7-18 mg/dL Creatinine clearance 27 ml/min Male: 97 – 137 mL/min Female: 88 – 128 mL/min Sodium (Na⁺) 140 mEq/L 136 – 146 mEq/L Potassium (K⁺) 3.8 mEq/L 3.5 – 5.0 mEq/L Chloride (Cl⁻) 99 mEq/L 95 – 105 mEq/L Bicarbonate (HCO₃⁻) 26 mEq/L 22 – 28 mEq/L A duplex ultrasound of the right lower extremity shows a deep venous thrombosis. What is the most appropriate next step in the management of this patient?
Which of the following scores is used to determine pretest probability when deep vein thrombosis (DVT) is suspected?
A 32-year-old woman presents to the emergency room with chest pain localized under her right breast for the past two days. She also reports severe pain in her right lower leg, a constant headache, and blurry vision lasting over 12 hours. She denies fever, nausea, vomiting, or diarrhea. Her medications include a combination oral contraceptive for birth control and acetaminophen for headaches. Which of the following is a warning sign associated with her use of a combination oral contraceptive?
You are treating a 44-year-old woman admitted to the hospital for deep vein thrombosis (DVT). As she is being discharged, you recommend treatment with warfarin. However, the patient refuses, citing concerns about frequent blood tests required for monitoring warfarin therapy. She mentions seeing a television commercial about a newer medication that does not require frequent blood monitoring. Using her phone, she finds information about a drug that works by directly inhibiting factor Xa. Which of the following medications fits her description and is appropriate for treating DVT?
