A 50-year-old woman presents with acute onset fever and chills for the past hour. She mentions earlier in the day she felt blue, so she took some St. John’s wort because she was told by a friend that it helps with depression. Past medical history is significant for hypertension, diabetes mellitus, and depression managed medically with captopril, metformin, and fluoxetine. She has no history of allergies. Her pulse is 130/min, the respiratory rate is 18/min, the blood pressure is 176/92 mm Hg, and the temperature is 38.5°C (101.3°F). On physical examination, the patient is profusely diaphoretic and extremely irritable when asked questions. Oriented x 3. The abdomen is soft and nontender with no hepatosplenomegaly. Increased bowel sounds are heard in the abdomen. Deep tendon reflexes are 3+ bilaterally and clonus is elicited. The sensation is decreased in the feet bilaterally. Mydriasis is present. Fingerstick glucose is 140 mg/dL. An ECG shows sinus tachycardia but is otherwise normal. Which of the following is the most likely cause of this patient’s condition?
ASepsis
BAnaphylactic reaction
CDiabetic ketoacidosis
DNeuroleptic malignant syndrome
ESerotonin syndrome
A 63-year-old man with high blood pressure, dyslipidemia, and diabetes presents to the clinic for routine follow-up. He has no current complaints and has been compliant with his chronic medications. His blood pressure is 132/87 mm Hg and his pulse is 75/min and regular. On physical examination, you notice that he has xanthelasmas on both of his eyelids. He currently uses a statin to lower his LDL but has not reached the LDL goal you have set for him. You would like to add an additional medication for LDL control. Of the following, which statement regarding fibrates is true?
AFibrates inhibit the rate-limiting step in cholesterol synthesis
BFibrates can potentiate the risk of myositis when given with statins
CFibrates can cause significant skin flushing and pruritus
DFibrates can increase the risk of cataracts
EThe primary effect of fibrates is to lower LDL
A 45-year-old man presents to the emergency department with difficulties swallowing food. He states that he experiences pain when he attempts to swallow his medications or when he drinks water. He reveals that he was diagnosed with HIV infection five years ago. He asserts that he has been taking his antiretroviral regimen, including emtricitabine, rilpivirine, and tenofovir. His temperature is 98°F (37°C), blood pressure is 100/60 mmHg, pulse is 90/min, respirations are 22/min, and oxygen saturation is 99% on room air. His physical exam is notable for a clear oropharynx, no lymphadenopathy, and a normal cardiac and pulmonary exam. No rashes are noted throughout his body. His laboratory results are displayed below: Hemoglobin: 12 g/dL Hematocrit: 37 % Leukocyte count: 8,000/mm^3 with normal differential Platelet count: 160,000/mm^3 Serum: Na+: 138 mEq/L Cl-: 108 mEq/L K+: 3.5 mEq/L HCO3-: 26 mEq/L BUN: 35 mg/dL Glucose: 108 mg/dL Creatinine: 1.1 mg/dL CD4+ count: 90/mm^3 HIV viral load: 59,000 copies/mL What is the best next step in management?
AFluconazole
BNystatin
COral swab and microscopy
DMethylprednisolone
EEsophageal endoscopy and biopsy
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