A 42 year-old male presents to the emergency room with severe unrelenting colicky abdominal pain, urinary frequency and pain with urination for the last 3 hours. He denies any chest pain, lightheadedness and palpitations. A plain abdominal radiography showed a 4 mm stone in the right ureter.. His medical history is significant for taking methadone 100 mg a day for opioid dependence. He reports taking methadone for over 14 years with ‘no issues’. His ECG is significant for the QTc interval of 470 ms. His other lab values are given below: Sodium 138 mEq/L Potassium 3.7 mEq/L Chloride 98 mEq/L Bicarbonate 24 mEq/L Calcium 8.9 mg/dl Alanine aminotransferase 34 U/L Aspartate aminotransferase 22 U/L Urinalysis….Positive for blood After 3 hours in the emergency room, the patient spontaneously passed the stone and got tremendous relief. What is the next best step in the management of this patient?

A 20 year-old man is brought into the emergency department by his girlfriend. The patient has been unconscious for over twenty minutes. The patient went to a rave party last night and came home in a drunken state. His girlfriend was not able to give any details on what he drank or what he ate at the party. Now, the patient is not communicating. He barely opens his eyes upon painful stimuli. His temperature is 97 ⁰ F, heart rate is 58 beats per minute, respiratory rate is 7 breaths per minute, and blood pressure is 80/55 mm Hg. His heart and lung examinations are unremarkable. Abdomen is nontender with hypoactive bowel sounds. Pupils react to light but constricted and sluggish. Which of the following is the next best step in the management of this patient, after you checked his airway, breathing and circulation?

A 24 year-old HIV patient is brought to the emergency room for nausea, vomiting, diarrhea, abdominal cramps, goosebumps, muscle aches for the last 3 days. His sickness started a week ago with ‘flu’ like symptoms such as watery eyes, sweating, runny nose, tiredness and trouble sleeping. Physical examination is significant for pupillary dilation and piloerection. Patient opened his medication bag and showed you bottles of methadone, rifampin, and ibuprofen. On further questioning he reports that he has been taking methadone for opioid dependence, rifampin for tuberculosis and ibuprofen for headaches. What is the next best step in the management of this patient?

A 45 year-old HIV positive male is brought to the emergency room for confusion, disorientation, slow speech, chest tightness, labored breathing, shortness of breath, abdominal pain and severe constipation. Physical examination is significant for low blood pressure, a weak pulse, blue lips, constricted pupils, slow respirations. He reports that he has been taking methadone for the last 6 years for opioid addiction with ‘no issues’. Two weeks ago he was started on ibuprofen 800 mg three times a day for his knee pains and a week ago he was started on fluconazole 200 mg on the first day, followed by 100 mg once daily for oropharyngeal candidiasis. What is the most likely reason for this patient’s current distress?

Tanya is a 22 year-old female who got convicted of two felonies for drug distribution and for possessing drug related paraphernalia. She was sentenced to two years in prison and was released last week. She was actively abusing opioids and alcohol for over 4 years before she was sentenced to prison. In the prison, she attended an inhouse drug rehabilitation program. And she was started on buspirone for anxiety disorder. Today, she came to your office to continue her treatment for substance abuse and anxiety disorder. Her boyfriend, Dave is no longer interested to meet her.Her two year old daughter has been in the care of her dad, Terence since she went to prison. As of now, she is homeless because her dad told her not to come back to his home because she would become a ‘bad influence’ on his granddaughter. Patient denies any suicidal or homicidal ideations. She reports that most of her friends are drug-dependent ‘junkies’ and she should like to stay away from them as much as she can. She reports ‘I’ve not touched any stuff’ since her release. Of the following, which would be the most appropriate level of care for this patient?