132 Emergency Medicine

158. An 87-year-old woman with a history of dementia, arthritis, and

hypertension presents to the ED for abdominal pain. Her caretaker reports
that she is having mid-epigastric pain and had one episode of nonbloody,
nonbilious vomiting prior to arrival. The patient is oriented to name only.
Temperature is 99.8°F, HR is 110 beats per minute, BP is 80/44 mm Hg,
RR is 16 breaths per minute, and oxygen saturation is 96% on room air. On
examination, the abdomen is soft, nontender, with no masses, rebound or
guarding. Stool is brown and guaiac negative. You place two IV lines and
begin fluid resuscitation. You send her blood to the laboratory and order a
radiograph of her chest that is shown below. Which of the following is the
most appropriate next step in management?

a. Start IV antibiotics.
b. Order a CT scan of her abdomen.
c. Call the surgery service.
d. Place a central venous line.
e. Discharge home with Maalox.
Fever
Questions

159. A 43-year-old man, who currently uses drugs intravenously (IV),

presents to the emergency department (ED) with 2 weeks of fever, back
pain, and progressive weakness in his legs bilaterally. He denies any history
of trauma or prior surgery. His blood pressure (BP) is 130/75 mm Hg, heart
rate (HR) is 106 beats per minute, temperature is 103°F, and respiratory
rate (RR) is 16 breaths per minute. On physical examination, he has ten-
derness to palpation in the mid-lumbar spine, increased patellar reflexes,
and decreased strength in the lower extremities bilaterally, with normal
range of motion. Laboratory results reveal a white blood cell (WBC) count
of 15,500/μL, hematocrit 40%, and platelets 225/μL. Urinalysis and spi-
nal x-rays are unremarkable. Which of the following is the most likely
diagnosis?
a. Fibromyalgia
b. Ankylosing spondylitis
c. Spinal epidural abscess
d. Vertebral compression fracture
e. Spinal metastatic lesion

171
172 Emergency Medicine

160. An 81-year-old woman is brought to the ED by her children who state

that the patient is acting more tired than usual, has had fever for the last 2
days, and is more confused. Ordinarily, the patient is high functioning: she
is ambulatory, cooks for herself, and walks on a treadmill 30 minutes a day.
Her vital signs are BP 85/60 mm Hg, HR 125, RR 20, temperature 101.3°F,
and pulse oxygenation 97% on room air. On examination, the patient has
dry mucous membranes but is otherwise unremarkable. She is oriented to
person and place but states that the year is 1925. Her laboratory results
show a WBC 14,300/μL, hematocrit 31%, and platelets 350/μL. Her elec-
trolytes are within normal limits. Blood glucose is 92 mg/dL. A chest radio-
graph does not show any infiltrates. Urinalysis reveals 2+ protein, trace
ketones, WBC > 100/hpf, red blood cell (RBC) 5 to 10/hpf, nitrite positive,
and leukocyte esterase positive. After administering a 500-cc normal saline
fluid bolus and broad-spectrum antibiotics through her peripheral IV line,
the patient’s BP is 82/60 mm Hg. You suspect that the patient is in septic
shock due to an acute urinary tract infection. Which of the following is the
next most appropriate course of action to manage this patient with early-
goal-directed therapy (EGDT)?
a. Immediately start a norepinephrine infusion to increase the blood pressure given
the low systolic blood pressure.
b. Prepare to transfuse uncrossed matched packed RBC to increase oxygen-carrying
capacity given the low hematocrit.
c. Place a central venous line into the right internal jugular vein to measure central
venous pressure (CVP).
d. Transport the patient to radiology for a stat CT scan of her head given the acute
change in mental status.
e. Place a central venous line into the right internal jugular vein to measure mixed
venous oxygen saturation (SVO2).
Fever 173

161. A 23-year-old man presents to the ED with left lower abdominal pain
and left testicular pain that started 1 to 2 weeks ago and has gradually wors-
ened. He has some nausea and vomiting. His HR is 98 beats per minute,
BP is 125/65 mm Hg, temperature is 100.9°F, and RR is 18 breaths per min-
ute. Physical examination reveals a tender left testicle with a firm nodular-
ity on the posterolateral aspect of the testicle. Pain is relieved slightly with
elevation of the testicle and the cremasteric reflex in normal. You make the
presumptive diagnosis of epididymitis. Which of the following is the next
best step?
a. Prescribe pain medications and penicillin for coverage of syphilis, the most
likely causative organism.
b. Recommend bed rest, ice, and scrotal elevation with prompt urology follow-up.
c. Give ceftriaxone 125 mg intramuscularly (IM), plus a one-time dose of azithro-
mycin 1 g orally.
d. Give ceftriaxone 250 mg intramuscularly (IM), plus a 10-day course of oral
doxycycline.
e. Confirm the diagnosis with transillumination of the testicle, and then consult
urology for surgical drainage.

162. A 40-year-old man with insulin-dependent diabetes presents to the ED

with complaints of 2 days of increasingly severe perineal pain and subjective
fevers. His HR is 118 beats per minute, BP is 95/55 mm Hg, temperature
is 103.4°F, and RR is 22 breaths per minute. The bedside sugar reading is
“high.” Physical examination demonstrates crepitus over the medial thigh
and widespread erythema and purple discoloration with sharp demarca-
tion over the scrotum. The scrotum is markedly tender, warm, and edema-
tous. Which of the following is the most likely diagnosis?
a. Cutaneous candidiasis
b. Fournier syndrome
c. Phimosis
d. Paraphimosis
e. Testicular torsion
174 Emergency Medicine

163. A 55-year-old man with a history of diabetes presents with com-

plaints of developed left knee pain several days following a fall from stand-
ing height. The patient was brought to the ED by ambulance after being
found on a park bench stating he was unable to walk because of the pain.
On physical examination, there are no rashes or external signs of trauma.
His left knee is warm, diffusely tender, and swollen with a large effusion.
He has pain on passive range of motion and is refusing to walk. His BP is
150/85 mm Hg, HR is 105 beats per minute, temperature is 102.7°F, RR is
16 breaths per minute, and fingerstick glucose is 89 mg/dL. Which of the
following is the most appropriate diagnostic test?
a. Knee radiographs
b. Magnetic resonance imaging (MRI)
c. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
d. Arthrocentesis
e. Bone scan

164. A 35-year-old woman with systemic lupus erythematosus (SLE) is

brought to the ED by her brother after he found her febrile and confused.
Physical examination reveals fever, tachycardia, a waxing and waning men-
tal status, petechiae over her oral mucosa, pallor, and mildly heme-positive
stool. Her urinalysis is positive for blood, red cell casts, and proteinuria.
Laboratory results reveal blood urea nitrogen (BUN) of 40 mg/dL and crea-
tinine of 2 mg/dL. Her bilirubin is elevated (unconjugated > conjugated)
and her international normalized ratio (INR) is 0.98. Her complete blood
count reveals WBC 12,000/μL, hematocrit 29%, and platelet count 17,000/μL
with schistocytes on the peripheral smear. Which of the following is the
most appropriate next step in management?
a. Admit to the intensive care unit (ICU) for plasmapheresis and close monitoring
for acute bleeds.
b. Admit to the ICU for platelet transfusion and monitoring for acute bleeds.
c. Admit to the ICU for corticosteroid infusion, transfusion of platelets, and prompt
surgical consultation for emergent splenectomy.
d. Admit to the ICU for dialysis and close monitoring for acute bleeds.
e. Perform a noncontrast head computed tomography (CT) to screen for intracra-
nial bleeding and mass effect followed by a lumbar puncture (LP) for analysis
of cerebrospinal fluid (CSF). If negative, admit to telemetry for hemodynamic
monitoring.
Fever 175

165. A 30-year-old woman presents to the ED with fever, headache, a

“sunburn-like” rash, and confusion. A friend states that the patient has
complained of nausea, vomiting, diarrhea, and a sore throat over the
past few days. Her last menstrual period began 4 days ago. Vital signs are
HR 110 beats per minute, BP 80/45 mm Hg, RR of 18 breaths per minute,
and temperature of 103°F. On physical examination, you note an ill-ap-
pearing woman with a diffuse blanching erythroderma. Her neck is supple
without signs of meningeal irritation. On pelvic examination, you remove
a tampon. You note a fine desquamation of her skin, especially over the
hands and feet, and hyperemia of her oropharyngeal, conjunctival, and
vaginal mucous membranes. Laboratory results reveal a creatine phospho-
kinase (CPK) of 5000, WBC 15,000/μL, platelets of 90,000/μL, BUN 40
mg/dL, creatinine 2 mg/dL, and elevated liver enzymes. You suspect the
diagnosis of toxic shock syndrome and initiate IV fluids. You target antibi-
otics at which of the following causative organism?
a. Staphylococcus aureus
b. Rickettsia rickettsii
c. Streptococcus pyogenes
d. Neisseria meningitidis
e. Neisseria gonorrhoeae

166. A 32-year-old diabetic man presents to the ED with a fever and

1 week of increasing right foot pain. He states he stepped on a nail while
running barefoot 2 weeks ago but didn’t think much of it at that time. On
physical examination, his heel is mildly erythematous and diffusely tender
to palpation, with overlying warmth and edema. There is a small amount
of purulent drainage through the puncture hole in his heel. A plain radio-
graph of his foot demonstrates a slight lucency of the calcaneus. He has
decreased range of motion, but you are able to passively dorsiflex and plan-
tarflex his ankle without difficulty. His vital signs include a temperature
of 101.4°F, HR of 98 beats per minute, BP of 130/75 mm Hg, and RR of
16 breaths per minute. Which of the following is the most common caus-
ative organism of this condition?
a. Salmonella sp
b. Pseudomonas aeruginosa
c. Staphylococcus aureus
d. Group B streptococci
e. Pasteurella multocida
176 Emergency Medicine

167. A 75-year-old woman is transferred to your ED from the local nurs-

ing home for fever, cough, and increasing lethargy. Over the past 3 days,
the nursing home staff noticed increasing yellow sputum and decreasing
urine output from the patient. Her BP is 118/75 mm Hg, RR is 20 breaths
per minute, HR is 105 beats per minute, temperature is 100.9°F, and pulse
oxygenation is 94% on room air. On examination, auscultation of the lungs
reveals bibasilar crackles. Laboratory results reveal WBC 14,500/μL, hema-
tocrit 39%, platelets 250/μL, sodium 132 mEq/L, potassium 3.5 mEq/L,
chloride 100 mEq/L, bicarbonate 18 mEq/L, BUN 27 mg/dL, creatinine
1.5 mg/dL, and glucose 85 mg/dL. Serum lactate is 4.7 mmol/dL. Chest
radiography reveals bilateral lower lobe infiltrates. Based on this patient’s
presentation, which of the following is the most likely diagnosis?
a. Hospital-acquired pneumonia (HAP)
b. Community-acquired pneumonia (CAP)
c. Health care–associated pneumonia (HCAP)
d. Ventilator-associated pneumonia (VAP)
e. Atypical pneumonia

168. A 55-year-old man presents to the ED with fever, drooling, tris-

mus, and a swollen neck. He reports a foul taste in his mouth caused by a
tooth extraction 2 days ago. On physical examination, the patient appears
anxious. He has bilateral submandibular swelling and elevation and pro-
trusion of the tongue. He appears “bull-necked” with tense and markedly
tender edema and brawny induration of the upper neck, and he is tender
over the lower second and third molars. There is no cervical lymphade-
nopathy. These lungs are clear to auscultation with good air movement. His
vital signs are HR 105 beats per minute, BP 140/85 mm Hg, RR 26 breaths
per minute, and temperature 102°F. Which of the following is the most
appropriate next step in management?
a. Obtain a sample for culture, administer a dose of IV antibiotics, and obtain a soft
tissue radiograph of the neck.
b. Obtain a sample for culture, perform a broad incision and drainage at bedside,
and administer a dose of IV antibiotics.
c. Administer a dose of IV antibiotics and obtain a CT scan of the soft tissues of
the neck.
d. Administer a dose of IV antibiotics, obtain a CT scan of the soft tissues of the
neck, and obtain an emergent ENT consult.
e. Secure his airway, administer a dose of IV antibiotics, and obtain an emergent
ENT (ear, nose, and throat) consult.
Fever 177

169. A 67-year-old woman with a history of steroid-dependent COPD,

non–insulin-dependent diabetes, and hypertension presents to the ED
with complaints of a painful, red, swollen left lower leg. She states she
noted a “bug bite” in that area 1 week ago and since then has had gradually
increasing symptoms. On examination, you note a 12 cm × 10 cm sharply
demarcated area of blanching erythema, warmth, and tenderness on the
medial thigh with ascending erythema to the groin. You also note tender
adenopathy in the left inguinal region. Her BP is 90/55 mm Hg, RR is
24 breaths per minute, HR is 105 beats per minute, temperature is 102.4°F,
and pulse oxygenation is 98% on room air. Laboratory results reveal WBC
19,500/μL, hematocrit 39%, platelets 175/μL, sodium 132 mEq/L, potas-
sium 3.5 mEq/L, chloride 100 mEq/L, bicarbonate 14 mEq/L, BUN 32 mg/dL,
creatinine 1.7 mg/dL, and glucose 455 mg/dL. Serum lactate is 4.7 mmol/dL.
Which of the following best describes her clinical state?
a. She has systemic inflammatory response syndrome (SIRS).
b. She has sepsis.
c. She has severe sepsis.
d. She is in septic shock.
e. She has multiple organ dysfunction syndrome (MODS).

170. An 84-year-old man presents to the ED with his family due to concerns
that his condition is worsening despite being placed on levofloxacin for a urinary
tract infection 5 days ago by his primary care physician. His is obtunded and
unable to give any additional history. Physical examination does not reveal the
source of infection. His BP is 84/45 mm Hg, HR is 135 beats per minute, tem-
perature is 102.8°F, and his RR is 28 breaths per minute. Laboratory results reveal
WBC 24,500/μL, hematocrit 19%, platelets 90/μL, sodium 132 mEq/L, potas-
sium 7.5 mEq/L, chloride 100 mEq/L, bicarbonate 12 mEq/L, BUN 37 mg/dL,
creatinine 6.5 mg/dL, and glucose 255 mg/dL. Serum lactate is 11.3 mmol/
dL. Cardiac enzymes and troponin are mildly elevated, and he has hyperacute
T-waves on electrocardiogram (ECG). His chest radiograph shows cardiomeg-
aly with bilateral patchy opacities and pulmonary vascular congestion. Rapid
urinalysis reveals 3+ WBCs and blood and nitrates. You secure his airway with
intubation, initiate broad-spectrum antibiotics, IV fluids, and other supportive
therapies, and emergently consult nephrology, cardiology, and pulmonology.
Which of the following best describes his clinical state?
a. He has SIRS.
b. He has sepsis.
c. He has severe sepsis.
d. He is in septic shock.
e. He has MODS.
178 Emergency Medicine

171. A 37-year-old man presents to the ED with complaints of 2 days of

a sore throat and subjective fever at home. He denies cough or vomiting.
His BP is 130/75 mm Hg, HR is 85 beats per minute, temperature is 101°F,
and his RR is 14 breaths per minute. He has diffuse tonsillar swelling and
bilateral exudates with bilaterally enlarged and tender lymph nodes of the
neck. Which of the following is the next best step in management?
a. Administer penicillin and discharge the patient without further testing.
b. Perform a rapid antigen test. If it is negative, confirm with a throat culture, and
administer penicillin if the results are positive.
c. Perform a rapid antigen test. If it is negative, administer penicillin and discharge
the patient.
d. Perform a rapid antigen test. If it is positive, administer penicillin and discharge
the patient.
e. Discharge the patient without treatment or further testing.

172. A 37-year-old man who just finished a full course of penicillin for
pharyngitis presents to the ED requesting to be checked out again. He
states he took the antibiotics exactly as prescribed and initially felt some-
what improved, but over the last 2 to 3 days has had increased pain and
progressive difficulty swallowing. His BP is 130/65 mm Hg, HR is 95 beats
per minute, temperature is 100.1°F, RR is 16 breaths per minute, and oxygen
saturation is 99%. On examination, the patient is in no acute distress but
has a fluctuant mass on the right side of his neck. You visualize a normal
soft palate with swelling of the right tonsillar arch and deviation of the
uvula to the left, but additional examination is limited because he is unable
to open his mouth fully. Review of his records reveals a throat culture that
was positive for Streptococcus. Which of the following is the most appropri-
ate next step in management?
a. Attempt needle aspiration, treat him with a new course of antibiotics (either
penicillin or clindamycin), and have him return in 24 hours.
b. Give him morphine for pain control, give him a dose of IV antibiotics, and
observe him in the ED for 6 hours.
c. Admit him for incision and drainage in the OR under general anesthesia.
d. Switch his antibiotic to clindamycin and have him return in 24 hours.
e. Order a CT scan to visualize his neck, continue the penicillin, and have him
return in 24 hours.
Fever 179

173. A 50-year-old man presents to the ED complaining of fever, headache,

and neck pain for 24 hours. He states that 1 week ago he had rhinorrhea,
nasal congestion, a sore throat, and occasional dry cough. He noted gen-
eralized weakness, myalgias, and malaise yesterday afternoon, and woke
up today “feeling terrible.” His BP is 145/75 mm Hg, HR is 102 beats per
minute, temperature is 101.2°F, and his RR is 16 breaths per minute. On
examination, he is awake, alert, and nontoxic appearing although he has
discomfort in his neck with flexion. He has a nonfocal neurologic examina-
tion without increased deep tendon reflexes or opthalmoplegia. There are
no rashes. Which of the following CSF results is most consistent with your
clinical diagnosis of viral meningitis?
a. Identification of viral particles on Gram stain with an elevated CSF-to-serum
glucose level
b. A mildly elevated total protein level with a decreased glucose level
c. A mildly elevated total protein level with a WBC count of fewer than 500 cells/mm3
d. Increased turbidity with marked xanthochromia
e. A markedly elevated lymphocyte count, often exceeding 100,000 cells/mm3
with a mildly elevated total protein level

174. A 32-year-old woman presents to the ED with 7 days of vaginal

discharge and pelvic pain. She is sexually active and admits to several
recent “one night stands.” She denies trauma/injury and does not have any
urinary or other abdominal complaints. Her HR is 85 beats per minute, BP
is 135/90 mm Hg, RR is 18 breaths per minute, and temperature is 101.4°F.
On bimanual examination, you note a copious, thin, white discharge with
mild diffuse adnexal tenderness with significant cervical motion tender-
ness. There are no rashes, skin lesions, or adenopathy. Laboratory results
are notable for a WBC of 18,000/μL. A urinalysis shows WBCs but is other-
wise within normal limits. Which of the following is the most appropriate
next step in management?
a. Prescribe her a 14-day course of levofloxacin (500 mg PO once per day) and
urgent gynecology follow-up within 1 week.
b. Give her a dose of metronidazole (2 g PO) and prescribe her a 14-day course of
cephalexin (500 mg) with urgent gynecology follow-up within 1 week.
c. Give her a one-time dose of oral metronidazole (2 g PO), azithromycin (1 g PO), and
ceftriaxone (250 mg IM) with gynecology follow-up if she is not feeling better.
d. Give her a one-time dose azithromycin (1 g PO), and ceftriaxone (250 mg IM)
with urgent gynecology follow-up within 1 week.
e. Give her a dose of ceftriaxone (250 mg IM), and prescribe her a 10-day course of
doxycycline (100 mg PO BID) with urgent gynecology follow-up within 1 week.
180 Emergency Medicine

175. A 45-year-old woman presents to the ED complaining of 3 days of

fever and worsening throat pain and painful odynophagia without cough or
coryza. She sits on a chair, leaning forward with her mouth slightly open.
She is refusing to swallow and has a cup of saliva and a box of facial tissues
at her side. Vitals are HR of 120 beats per minute, BP of 110/70 mm Hg,
RR of 22 breaths per minute, oxygen saturation of 99% on room air, and
temperature of 102.8°F. You note a slight wheezing noise coming from her
anterior neck. Her voice is hoarse and she is able to open her mouth fully,
making her examination quite difficult. From what you can visualize, her
posterior oropharynx is moderately hyperemic, without exudates or ton-
sillar enlargement. A soft tissue lateral cervical radiograph shows marked
edema of the prevertebral soft tissues and absence of the vallecular space.
Which of the following is the most likely diagnosis?
a. Retropharyngeal abscess
b. Peritonsillar abscess
c. Epiglottitis
d. Pharyngitis
e. Laryngotracheitis

176. A 19-year-old woman presents with 4 days of bilateral lower abdominal

pain right greater than left. She also complains of a fever, nausea, vomiting,
and general malaise. Her last menstrual period was 5 days ago. Vitals are
HR 98 beats per minute, BP 110/65 mm Hg, RR 18 breaths per minute, and
temperature of 102.7°F. Pelvic examination demonstrates exquisite cervical
motion tenderness and right adnexal tenderness. Laboratory reports are
notable for a WBC 15,000/μL, an ESR of 95 mm/h, and a negative urine
β-human chorionic gonadotropin (β-hCG). Transvaginal ultrasound dem-
onstrates a right complex mass with cystic and solid components. Which of
the following is the most appropriate next step in management?
a. Prescribe her a 14-day course of levofloxacin (500 mg PO once per day) and
urgent gynecology follow-up within 1 week.
b. Give her a dose of metronidazole (2 g PO) and prescribe her a 14-day course of
cephalexin (500 mg) with urgent gynecology follow-up within 1 week.
c. Give her a one-time dose of oral metronidazole (2 g PO), azithromycin (1 g PO),
and ceftriaxone (250 mg IM) with gynecology follow-up if she is not feeling
better.
d. Given her a one-time dose with emergent gynecology consultation for possible
laparoscopic drainage.
e. Give her a dose of ceftriaxone (250 mg IM), and prescribe her a 10-day course
of doxycycline (100 mg PO BID) with urgent gynecology follow-up within
1 week.
Fever 181

177. A 42-year-old IV drug user presents to the ED with fever, chills, pleuritic
chest pain, myalgias, and general malaise. The patient’s vitals include an
HR of 110 beats per minute, BP of 110/65 mm Hg, RR of 18 breaths per
minute, and temperature of 103.4°F. Physical examination is notable for
retinal hemorrhages, petechiae on the conjunctivae and mucous mem-
branes, a faint systolic ejection murmur, and splenomegaly. Which of the
following is the most likely diagnosis?
a. Disseminated gonorrhea
b. Myocarditis
c. Pericarditis
d. Infectious mononucleosis
e. Endocarditis

178. A 51-year-old diabetic man complains of intense right-ear pain and

discharge. On physical examination, his BP is 145/65 mm Hg, HR 91 beats
per minute, and temperature 101°F. He withdraws when you retract the
pinna of his ear. The external auditory canal is erythematous, edematous,
and contains what looks like friable granulation tissue in the external audi-
tory canal. The tympanic membrane is partially obstructed but appears to
be erythematous, as well. You make the presumptive diagnosis of necrotiz-
ing (malignant) otitis externa. Which of the following statements regarding
this condition is true?
a. It is an uncommon complication of otitis media in otherwise healthy patients.
b. The mainstay of treatment is outpatient with oral antibiotics.
c. Cranial nerve IX palsy is the most common complication.
d. Pseudomonas aeruginosa is the most common causative organism.
e. Hearing loss is the most common complication.
182 Emergency Medicine

179. A 26-year-old woman presents to the ED with fever, malaise, and

an evolving rash in the right axilla that she initially thought was from an
insect bite that she received while hiking 1 week earlier. She complains of
generalized fatigue, nausea, headache, and joint pain over the past several
days. Her vitals are BP of 120/75 mm Hg, HR of 75 beats per minute,
RR of 16 breaths per minute, and temperature of 101°F. On physical exami-
nation, she is awake and alert, with a nonfocal neurologic examination.
Her neck is supple, but she is diffusely tender over the shoulder, knee, and
hip joints bilaterally without any distinct effusions. Her abdomen is soft
and nontender. She has a 9-cm erythematous annular plaque with partial
central clearing and a bright red outer border and a target center under her
right axilla. Which of the following is the next best step?
a. Treat empirically with broad-spectrum antibiotics and consult dermatology
emergently for a biopsy of the rash.
b. Treat empirically for a cellulitis with cephalexin for 10 days and arrange
follow-up with her primary care doctor.
c. Treat empirically for Lyme disease with doxycycline for 21 days and arrange
follow-up with her primary-care doctor.
d. Treat empirically for an allergic dermatitis with prednisone, diphenhydramine,
and famotidine for 3 days, and arrange follow-up with her primary care doctor.
e. Perform serologic testing for Borrelia burgdorferi to confirm the diagnosis of Lyme
disease and arrange follow-up with her primary care doctor.
Fever 183

180. A 22-year-old man without medical complaints presents to the ED

with a 3-day history of fever, malaise, and myalgias. He denies chest pain,
shortness of breath, nausea or vomiting, abdominal pain, cough, sore
throat, genitourinary symptoms, or respiratory tract complaints. On exam-
ination, the patient’s BP is 100/60 mm Hg, HR is 110 beats per minute,
RR is 20 breaths per minute, and temperature is 102°F. He appears awake,
alert, and comfortable. His physical examination is normal. Which of the
following is the most appropriate next step in management?
a. Discharge him with antipyretics and follow up with his primary care doctor in 1
or 2 days for a repeat examination.
b. Order a CBC, urinalysis, and chest x-ray. If normal, discharge him with anti-
pyretics and follow up with his primary care doctor in 1 or 2 days for a repeat
examination.
c. Order a CBC, urinalysis, chest x-ray, and two sets of blood cultures. If normal,
discharge him with antipyretics and follow up with his primary care doctor in 1
or 2 days for a repeat examination.
d. Order a CBC, urinalysis, chest x-ray, two sets of blood cultures, and perform an
LP. If normal, discharge him with antipyretics and follow up with his primary
care doctor in 1 or 2 days for a repeat examination.
e. Order a CBC, urinalysis, chest x-ray, two sets of blood cultures, and perform an
LP. Start empiric IV antibiotics and admit him for observation.

181. A 54-year-old man with a history of hepatitis C, alcohol abuse, and

cirrhotic ascites presents with increasing abdominal girth and abdominal
pain. He complains of increasing difficulty breathing, especially when lying
down, caused by worsening ascites. On physical examination, the patient
is cachectic and appears older than his stated age. He has a diffusely tender
abdomen and tense ascites. The liver is palpable 4 cm below the costal
margin. Vitals include a BP of 110/65 mm Hg, HR of 110 beats per minute,
RR of 22 breaths per minute, and temperature of 102°F. Which of the follow-
ing is the most common organism seen in spontaneous bacterial peritonitis?
a. Pseudomonas aeruginosa
b. Enterococcus
c. Streptococcus pneumoniae
d. Enterobacteriaceae
e. Streptococcus viridans