A 47-year-old man with CKD stage 4 from diabetes mellitus presents to the ER with acute severe left leg lower leg pain after a significant fall. He is found to have a tibial shaft fracture. He currently rates his pain a 9/10. Which of the following would be the best initial choice for acute pain management?

2. A 47-year-old woman with ESKD on hemodialysis and rheumatoid arthritis presents with worsening arthritis symptoms. She is currently on hydroxychloroquine for her rheumatoid arthritis. She is completely anuric. Which of the following complications is she most likely to have if an NSAID is added to her regimen?

3. A 63-year-old man with ESKD on in-center hemodialysis was brought in to the emergency department by his wife with increasing sedation over the last two days. He has not missed any recent hemodialysis treatments; his last treatment was 2 days ago. He has not had any other symptoms. His medications include sevelamer, carvedilol, lisinopril, and baclofen, which was started 1 week ago  for muscle spasms. He takes no over-the-counter medications and is not known to use illicit drugs. On exam his blood pressure is 110/64 mm Hg and heart rate is 59 beats per minute. He is obtunded and only responds to sternal rub. He has no facial asymmetry. His deep tendon reflexes are reduced in all extremities. His exam is otherwise unremarkable. His lab findings are unremarkable. What is the most likely cause of his altered mental status?

4. A 57-year-old woman with ESKD on hemodialysis presents complaining of worsening osteoarthritis pain in her knees and hands. She has been on a stable dose of tramadol for 2 years for her arthritis. She also takes cinacalcet 30 mg per day (started 1 month ago), sevelamer 1600 mg with meals, and lisinopril 40 mg per day. What is the most likely reason for her worsening pain?