Acute Care and Urgent Presentations Flashcards

A 32-year-old male with type 1 diabetes presents with blood glucose 485 mg/dL, arterial pH 7.22, bicarbonate 12 mEq/L, anion gap 22, and moderate ketonuria. The primary treatment priority is:

Answer: IV fluid resuscitation (normal saline) followed by insulin infusion with potassium replacement monitoring — hospital admission required

DKA management priority: IV fluid resuscitation first, then insulin infusion with aggressive potassium monitoring. Hypokalemia is the leading cause of DKA mortality as insulin drives K+ intracellularly.

A 55-year-old man presents with acute-onset sharp chest pain that is worse with inspiration and better when leaning forward. ECG shows diffuse ST elevation in all leads with PR depression. The most likely diagnosis is:

Answer: Acute pericarditis — treat with NSAIDs plus colchicine and restrict activity

Diffuse ST elevation in all leads (not limited to one coronary territory) plus PR depression plus positional pleuritic chest pain relieved by leaning forward is classic for acute pericarditis, not STEMI.

A 66-year-old male presents to urgent care with sudden onset painless monocular vision loss in his right eye, described as a curtain coming down. He has a history of atrial fibrillation. The most likely diagnosis is:

Answer: Central retinal artery occlusion — a vascular emergency requiring immediate ophthalmology consultation

Sudden painless monocular vision loss described as a curtain effect in a patient with atrial fibrillation is central retinal artery occlusion due to embolism — a vascular emergency requiring immediate ophthalmologic evaluation.

A 38-year-old male presents with fever, headache, photophobia, neck stiffness, and a non-blanching petechial rash. The most appropriate immediate action before lumbar puncture or CT is:

Answer: Administer IV ceftriaxone and dexamethasone immediately — do not delay treatment for imaging or LP in this clinical presentation

Non-blanching petechial rash with meningismus is meningococcal meningitis until proven otherwise. IV ceftriaxone plus dexamethasone must be given immediately. Every 30-minute delay significantly increases mortality.

A 25-year-old female presents with severe substernal dysphagia and odynophagia, hoarseness, and fever after a fish dinner the previous day. Plain neck X-ray shows air in the retropharyngeal space. The most likely diagnosis is:

Answer: Retropharyngeal abscess or esophageal perforation — a deep neck space emergency requiring emergent CT neck and IV antibiotics plus or minus surgical drainage

Air in the retropharyngeal space after a swallowing event suggests esophageal perforation or retropharyngeal abscess — a surgical emergency with potential for mediastinitis.

A 70-year-old female on warfarin with INR 3.8 presents with a fall, confusion, and headache. GCS is 14. The most important initial step after primary survey is:

Answer: Obtain emergent non-contrast CT head to evaluate for intracranial hemorrhage and prepare to reverse anticoagulation

An elderly anticoagulated patient with fall plus confusion plus headache requires emergent CT head to exclude intracranial hemorrhage. If ICH is confirmed, immediate anticoagulation reversal with 4-factor PCC is indicated.