A 20-year-old woman is brought to the emergency department because of severe muscle soreness, nausea, and darkened urine for 2 days. The patient is on the college track team and has been training intensively for an upcoming event. One month ago, she had a urinary tract infection and was treated with nitrofurantoin. She appears healthy. Her temperature is 37°C (98.6°F), pulse is 64/min, and blood pressure is 110/70 mm Hg. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and non-tender. There is diffuse muscle tenderness over the arms, legs, and back. Laboratory studies show: Hemoglobin 12.8 g/dL Leukocyte count 7,000/mm3 Platelet count 265,000/mm3 Serum Creatine kinase 22,000 U/L Lactate dehydrogenase 380 U/L Urine Blood 3+ Protein 1+ RBC negative WBC 1–2/hpf This patient is at increased risk for which of the following complications?
AMyocarditis
BMetabolic alkalosis
CCompartment syndrome
DAcute kidney injury
EHemolytic anemia
A 32-year-old man is brought to the emergency department after a car accident; he was extricated after 4 hours. He did not lose consciousness and does not have headache or nausea. He is in severe pain. He sustained severe injuries to both arms and the trauma team determines that surgical intervention is needed. Urinary catheterization shows dark colored urine. His temperature is 38°C (100.4°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. The patient is alert and oriented. Examination shows multiple injuries to the upper extremities, contusions on the trunk, and abdominal tenderness. Laboratory studies show: Hemoglobin 9.2 g/dL Leukocyte count 10,900/mm3 Platelet count 310,000/mm3 Serum Na+ 137 mEq/L K+ 6.8 mEq/L Cl- 97 mEq/L Glucose 168 mg/dL Creatinine 1.7 mg/dL Calcium 7.7 mg/dL Arterial blood gas analysis on room air shows a pH of 7.30 and a serum bicarbonate of 14 mEq/L. An ECG shows peaked T waves. A FAST scan of the abdomen is negative. Two large bore cannulas are inserted and intravenous fluids are administered. Which of the following is the most appropriate next step in management?
AIntravenous mannitol
BIntravenous sodium bicarbonate
CPacked red blood cell transfusion
DIntravenous calcium gluconate
EIntravenous insulin
Five days after undergoing a pancreaticoduodenectomy for pancreatic cancer, a 46-year-old woman has 2 episodes of non-bilious vomiting and mild epigastric pain. She has a patient-controlled analgesia pump. She has a history of hypertension. She has smoked one pack of cigarettes daily for 25 years. She drinks 3–4 beers daily. Prior to admission to the hospital, her only medications were amlodipine and hydrochlorothiazide. Her temperature is 37.8°C (100°F), pulse is 98/min, and blood pressure is 116/82 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows a midline surgical incision over the abdomen with minimal serous discharge and no erythema. The abdomen is soft with mild tenderness to palpation in the epigastrium. The remainder of the examination shows no abnormalities. Laboratory studies show: Hemoglobin 11.6 g/dL Leukocyte count 16,000/mm3 Serum Na+ 133 mEq/L K+ 3.4 mEq/L Cl- 115 mEq/L Glucose 77 mg/dL Creatinine 1.2 mg/dL Arterial blood gas on room air shows: pH 7.20 pCO2 23 mm Hg pO2 91 mm Hg HCO3- 10 mEq/L Which of the following is the most likely cause of this patient's acid-base status?
AExcessive alcohol intake
BAdrenal insufficiency
CRhabdomyolysis
DAdverse effect of medication
EFistula
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