175.A 75-year-old woman is transferred to your ED from the local nursing
home for fever, cough, and increasing lethargy. Over the past 3 days, the nurs-
ing 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, the patient appears dehydrated. Ausculta-
tion of the lungs reveals bibasilar crackles. Laboratory results reveal WBC
14,500/μL, hematocrit 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, cre-
atinine 1.5 mg/dL, and glucose 85 mg/dL. Serum lactate is 4.7 mmol/dL.
Based on this patient’s presentation, how would you classify her condition?
a. Systemic inflammatory response syndrome (SIRS)
b. Severe systemic inflammatory response syndrome
c. Sepsis
d. Severe sepsis
e. Septic shock
176.A 55-year-old man presents to the ED with fever, drooling, trismus,
and a swollen neck. He reports a foul taste in his mouth since a tooth
extraction 2 days ago. On physical examination, the patient appears anx-
ious. He has bilateral submandibular swelling and elevation and protrusion
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 lymphadenopathy. 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. Administer a dose of IV antibiotics and obtain a soft-tissue radiograph of the
neck.
b. Administer a dose of IV antibiotics then perform an incision and drainage at the
bedside.
c. Begin steroids to decrease inflammation and obtain an ear, nose, and throat
(ENT) consult.
d. Discharge the patient with oral antibiotics and ENT follow-up.
e. Secure his airway, start IV antibiotics, and obtain an ENT consult.
182 Emergency Medicine