A 50-year-old male presents to the emergency with abdominal pain. He reports he has had abdominal pain associated with meals for several months and has been taking over the counter antacids as needed, but experienced significant worsening pain one hour ago in the epigastric region. The patient reports the pain radiating to his shoulders. Vital signs are T 38, HR 120, BP 100/60, RR 18, SpO2 98%. Physical exam reveals diffuse abdominal rigidity with rebound tenderness. Auscultation reveals hypoactive bowel sounds. Which of the following is the next best step in management?
AAdmission and observation
BChest radiograph
C12 lead electrocardiogram
DAbdominal CT scan
EAbdominal ultrasound
A 15-year-old boy is brought to the emergency department one hour after sustaining an injury during football practice. He collided head-on into another player while wearing a mouthguard and helmet. Immediately after the collision he was confused but able to use appropriate words. He opened his eyes spontaneously and followed commands. There was no loss of consciousness. He also had a headache with dizziness and nausea. He is no longer confused upon arrival. He feels well. Vital signs are within normal limits. He is fully alert and oriented. His speech is organized and he is able to perform tasks demonstrating full attention, memory, and balance. Neurological examination shows no abnormalities. There is mild tenderness to palpation over the crown of his head but no signs of skin break or fracture. Which of the following is the most appropriate next step?
ADischarge without activity restrictions
BDischarge and refrain from all physical activity for one week
CObserve for 6 hours in the ED and refrain from contact sports for one week
DAdminister prophylactic levetiracetam and observe for 24 hours
EAdminister prophylactic phenytoin and observe for 24 hours
A 71-year-old man develops worsening chest pressure while shoveling snow in the morning. He tells his wife that he has a squeezing pain that is radiating to his jaw and left arm. His wife calls for an ambulance. On the way, he received chewable aspirin and 3 doses of sublingual nitroglycerin with little relief of pain. He has borderline diabetes and essential hypertension. He has smoked 15–20 cigarettes daily for the past 37 years. His blood pressure is 172/91 mm Hg, the heart rate is 111/min and the temperature is 36.7°C (98.0°F). On physical examination in the emergency department, he looks pale, very anxious and diaphoretic. His ECG is shown in the image. Troponin levels are elevated. Which of the following is the best next step in the management of this patient condition?
ACT scan of the chest with contrast
BEchocardiography
CFibrinolysis
DClopidogrel, atenolol, anticoagulation and monitoring
EOral nifedipine
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