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Heart has rapid rate with a grade 1/6 systolic murmur at the left sternal border. Complete blood count, blood culture, lumbar puncture, and catheterized urine specimen are obtained and sent for stat analysis. Acetaminophen is administered by rectal suppository.
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The patient’s cardiovascular status should be monitored by ordering repeat vital signs or by changing the patient’s location to the inpatient unit or intensive care unit. The diagnostic workup should also include arterial blood gas analysis to assess acidosis, bacterial blood culture to identify the organism before administering empiric antibiotics, and serum electrolyte measurements (ie, potassium) to assess the severity of dehydration.
Step 3 is the final examination in the USMLE sequence. The test items and cases reflect the clinical situations that a general, as-yet undifferentiated physician might encounter within the context of a specific setting. Although you already may have begun specialist training, for this examination you are expected to assume the role of a general, as-yet undifferentiated physician. You are a member of an independent group practice affiliated with a number of managed care organizations. Your office has regularly scheduled hours. You can admit patients to a 400-bed regional hospital, which provides care for both the urban and the outlying rural communities.
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The patient appears drowsy, lethargic, and acutely ill. Physical examination reveals elevated temperature, tachypnea, tachycardia, and hypotension. Cardiovascular examination shows thready central and peripheral pulses. Skin examination reveals poor turgor. HEENT/neck examination shows dry mucous membranes. Abdominal examination reveals diffuse mild tenderness without guarding, rebound, or masses.
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An optimal, efficient approach would include performing a targeted physical examination (including chest/lung, cardiovascular, abdominal, and neurologic/psychiatric examinations), and ordering a serum glucose test using a glucometer and a urinalysis or complete blood count (CBC) to check for signs of infection. Stabilizing the patient with optimal intravenous (IV) fluids (eg, Lactated Ringer solution or normal saline solution) to improve hydration, and treating the patient empirically with a broad-spectrum IV or intramuscular (IM) antibiotic to cover the most likely sources of infection are important. Once the serum glucose result is obtained, starting IV insulin to treat the hyperglycemia is critical. The patient’s cardiovascular status should be monitored by ordering repeat vital signs or by changing the patient’s location to the inpatient unit or intensive care unit. The diagnostic workup should also include arterial blood gas analysis to assess acidosis, bacterial blood culture to identify the organism before administering empiric antibiotics, and serum electrolyte measurements (ie, potassium) to assess the severity of dehydration. Serum creatinine or urea nitrogen measurements (basic metabolic profile or complete metabolic profile) to assess kidney function are indicated. Continued monitoring of the patient’s serum glucose, electrolytes, particularly potassium, and arterial blood pH after treatment is also important.