Two hours after undergoing laparoscopic roux-en-Y gastric bypass surgery, a 44-year-old man complains of pain in the site of surgery and nausea. He has vomited twice in the past hour. He has hypertension, type 2 diabetes mellitus, and hypercholesterolemia. Current medications include insulin, atorvastatin, hydrochlorothiazide, acetaminophen, and prophylactic subcutaneous heparin. He drinks two to three beers daily and occasionally more on weekends. He is 177 cm (5 ft 10 in) tall and weighs 130 kg (286 lb); BMI is 41.5 kg/m2. His temperature is 37.3°C (99.1°F), pulse is 103/min, and blood pressure is 122/82 mm Hg. Examination shows five laparoscopic incisions with no erythema or discharge. The abdomen is soft and non-distended. There is slight diffuse tenderness to palpation. Bowel sounds are reduced. Laboratory studies show: Hematocrit 45% Serum Na+ 136 mEq/L K+ 3.5 mEq/L Cl- 98 mEq/L Urea nitrogen 31 mg/dL Glucose 88 mg/dL Creatinine 1.1 mg/dL Arterial blood gas analysis on room air shows: pH 7.28 pCO2 32 mm Hg pO2 74 mm Hg HCO3- 14.4 mEq/L Which of the following is the most likely cause for the acid-base status of this patient?
AHypoxia
BUremia
CLate dumping syndrome
DVomiting
EEarly dumping syndrome
A 31-year-old obese Caucasian female presents to the Emergency Department late in the evening for left lower quadrant pain that has progressively worsened over the last several hours. She describes the pain as sharp and shooting, coming and going. Her last bowel movement was this morning. She has also had dysuria and urgency. Her surgical history is notable for gastric bypass surgery 2 years prior and an appendectomy at age 9. She is sexually active with her boyfriend and uses condoms. Her temperature is 99.5 deg F (37.5 deg C), blood pressure is 151/83 mmHg, pulse is 86/min, respirations are 14/minute, BMI 32. On physical exam, she has left lower quadrant tenderness to palpation with pain radiating to the left groin and left flank tenderness on palpation. Her urinalysis shows 324 red blood cells/high power field. Her pregnancy test is negative. What is the next best step in management?
AA KUB (kidneys, ureters and bladder) plain film
BNoncontrast CT scan
CExploratory laparoscopy
DTransvaginal ultrasound
EIntravenous pyelogram
A 79-year-old man with a history of prostate cancer is brought to the emergency department because of lower abdominal pain for 1 hour. He has not urinated for 24 hours. Abdominal examination shows a palpable bladder that is tender to palpation. A pelvic ultrasound performed by the emergency department resident confirms the diagnosis of acute urinary retention. An attempt to perform transurethral catheterization is unsuccessful. A urology consultation is ordered and the urologist plans to attempt suprapubic catheterization. As the urologist is called to see a different emergency patient, she asks the emergency department resident to obtain informed consent for the procedure. The resident recalls a lecture about the different modes of catheterization, but he has never seen or performed a suprapubic catheterization himself. Which of the following statements by the emergency department resident is the most appropriate?
A“I would prefer that you obtain informed consent when you become available again.”
B“Suprapubic catheterization is not the treatment of choice for this patient.”
C“I would be happy to obtain informed consent on your behalf, but I'm not legally allowed to do so during my residency.”
D“I will make sure the patient reads and signs the informed consent form.”
E“I will ask the patient to waive informed consent because this is an urgent procedure.”
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