A 32-Year-Old Woman Comes to the Emergency Department Due to Swelling

question 1140

Multiple Choice

A 32-year-old woman comes to the emergency department due to swelling of the left arm over the last 24 hours.  The patient drinks alcohol 2-3 times a week and uses intravenous heroin daily.  She has no other chronic medical problems and takes no medications.  Temperature is 37.8 C (100 F) , blood pressure is 105/62 mm Hg, pulse is 92/min, and respirations are 16/min.  Chest auscultation reveals clear lung fields and normal first and second heart sounds.  The abdomen is soft and nontender.  Examination of the extremities shows several needle marks.  The left arm is erythematous and swollen as well as warm and tender to the touch.  There is no joint swelling, and range of motion is normal in all joints.  The patient is started on intravenous clindamycin.  The next morning the swelling and pain are improved, but the patient reports "feeling miserable."  She has nasal congestion, nausea, and abdominal cramps in addition to multiple episodes of vomiting and loose stools.  On repeat examination, the patient is restless and reports aching muscles and joints.  Blood pressure is 132/88 mm Hg, pulse is 102/min and regular, and respirations are 16/min.  Laboratory results from time of admission (0 hours) and 24 hours later are as follows: Which of the following is the most appropriate next step in management of this patient?

• A)Administer intravenous morphine
• B)Discontinue clindamycin
• C)Initiate intravenous naloxone
• D)Initiate treatment for opioid withdrawal
• E)Start flumazenil
• F)Test for Clostridium difficile toxin

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