NBME 15- Block 2 (Duplicate 1)

A 54-year-old woman with primary biliary cholangitis comes to the emergency department because of a 1-hour history of vomiting blood. Her medications are ursodiol, furosemide, spironolactone, and propranolol. She is awake and fully oriented. Her pulse is 80/min, and blood pressure is 100/60 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and distended with ascites. There is mild edema of the lower extremities. Laboratory studies show:

In addition to administration of intravenous fluids, which of the following is the most appropriate next step in management?

A 68-year-old man with chronic obstructive pulmonary disease is brought to the emergency department by his wife because of a 1-day history of severe shortness of breath and nonproductive cough. His wife reports that her husband has had increasing confusion and lethargy during this time. She says he also has had a 3-day history of fever and cough and a 1-day history of chills. On arrival, the patient is somnolent and difficult to arouse. He appears acutely ill. His temperature is 38.1°C (100.6°F), pulse is 110/min, respirations are 18/min, and blood pressure is 95/50 mm Hg. Pulse oximetry on 2 L/min of oxygen shows an oxygen saturation of 91%. He is using accessory muscles of respiration. Crackles are heard at the right lung base; there are scattered wheezes bilaterally. On cardiac examination, S1 and S2 are normal. The abdomen is soft. On mental status examination, he is drowsy and oriented to person but not to place or time. Laboratory studies show:

Arterial blood gas analysis on 2 L/min of oxygen by nasal cannula shows:

The patient is intubated and mechanically ventilated, and intravenous administration of fluids is begun. Which of the following is the most likely cause of the arterial blood gas findings?

A 72-year-old man comes to the emergency department because of a 4-month history of leg swelling and increasing abdominal girth. He also has a 2-year history of progressive shortness of breath. During the past 3 months, he has needed two pillows to breathe while sleeping. He has no history of serious illness and takes no medications. He has never smoked cigarettes. He worked as a sandblaster in a foundry for 40 years. His pulse is 110/min, respirations are 20/min, and blood pressure is 120/80 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Jugular venous pressure is 12 cm H2O (N=5–9). Dry crackles are heard diffusely. Cardiac examination shows a normal S1 and a split S2 with a pronounced P2; no murmurs are heard. Abdominal examination shows distention with bulging flanks. The liver is mildly tender; the span is 16 cm. There is 2+ pitting edema to the knee. A chest x-ray is shown. Which of the following is the most appropriate immediate step in management?

A 56-year-old man comes to the office because of a 3-month history of an enlarging painful ulcer on his left ankle. The ulcer occasionally exudes a clear, yellow fluid. He has cleaned the ulcer daily with soap and lukewarm water and applied an over-the-counter topical antibiotic to the area, with minimal relief. He has not had fever or chills or sustained any recent trauma. He has type 2 diabetes mellitus, coronary artery disease, hypertension, and hyperlipidemia. His medications are metformin, glipizide, atorvastatin, enalapril, hydrochlorothiazide, metoprolol, isosorbide mononitrate, and aspirin. He has no known drug allergies. He smoked one and one-half packs of cigarettes daily for 33 years but quit 5 years ago. He is 180 cm (5 ft 11 in) tall and weighs 90 kg (198 lb); BMI is 28 kg/m2. Vital signs are within normal limits. He does not appear to be in acute distress. A photograph of the left lower extremity is shown. Dorsalis pedis pulses are 2+ bilaterally; posterior tibial pulses cannot be palpated. Monofilament testing shows decreased sensation over the feet; proprioception is intact. Which of the following is the most likely diagnosis?