184.A 19-year-old woman presents with bilateral lower-abdominal pain,
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 ten-
derness. 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 demonstrates a right complex mass with cystic
and solid components. Which of the following is the most appropriate next
step in management?
a. Ceftriaxone IM plus a 14-day course of oral doxycycline and follow-up in the
gynecology clinic.
b. Oral ofloxacin plus metronidazole and follow-up in the gynecology clinic.
c. Analgesics for a ruptured ovarian cyst and follow-up in the gynecology clinic.
d. Admission for IV antibiotics and possible laparoscopic drainage.
e. Admission for emergent medical or surgical treatment of an ectopic pregnancy.
185.A 42-year-old IV drug user presents to the ED with fever, chills, pleu-
ritic chest pain, myalgias, and general malaise. The patient’s vitals include
a HR of 110 beats per minute, BP of 110/65 mm Hg, RR of 18 breaths per
minute, and temperature of 103°F. Physical examination is notable for reti-
nal hemorrhages, petechiae on the conjunctivae and mucus membranes,
a faint systolic ejection murmur, and splenomegaly. Which of the following
is the most likely diagnosis?
a. Sick sinus syndrome
b. Myocarditis
c. Pericarditis
d. Cardiac tamponade
e. Endocarditis
186 Emergency Medicine