Patient Management

Paramedics rush a 24-year-old male to the trauma and resuscitation bay due to unceasing generalized tonic-clonic convulsions. According to his partner, the seizure activity commenced abruptly at their residence 20 minutes prior and has been completely unrelenting. Vital signs cannot be fully obtained due to his violent movements, but pulse oximetry reveals an oxygen saturation of 88% on room air. The patient is deeply unresponsive, actively seizing, and pooling thick secretions in his oropharynx. Multiple attempts by the critical care nurses to place a peripheral intravenous catheter fail because of his continuous, violent thrashing.

Based on fundamental resuscitation principles, arrange the following steps in the optimal chronological sequence to manage this emergency.

An adult patient is referred to an endocrinology clinic due to progressive changes in facial features, widening of the hands, and hyperhidrosis developing over the past three years. The primary care provider obtained initial screening laboratory studies, which revealed a serum insulin-like growth factor-1 (IGF-1) concentration substantially above the upper limit of normal for the patient's age and sex. Renal and hepatic function panels are unremarkable. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 72-year-old woman is brought to the emergency department from a long-term care facility due to progressively worsening lethargy over the past 24 hours. The transport personnel report that her indwelling urinary catheter is draining dark, foul-smelling, and turbid urine. Her temperature is 39.2°C (102.6°F), blood pressure is 78/40 mm Hg, pulse is 128/min, and respirations are 24/min. Pulse oximetry shows 95% on room air. On physical examination, the patient is obtunded but groans and withdraws all four extremities in response to a sternal rub. Her mucous membranes are dry, and capillary refill time is delayed (4 seconds). Which of the following are the most critical immediate steps in the stabilization and management of this patient? (Select exactly two options)

A 65-year-old man who is a current smoker presents to the clinic for a routine wellness examination. A screening chest radiograph reveals a $1.5$-cm solitary pulmonary nodule in the right upper lobe. He recently relocated and has no previous medical records at this facility. Arrange the following diagnostic steps in the most appropriate sequential order for the evaluation of this finding, proceeding from the initial best next step to the final definitive diagnostic procedure.

A 29-year-old woman, estimated to be at 34 weeks gestation, is brought to the emergency department following a high-speed motor vehicle collision. Paramedics report she was an unrestrained driver and was found unresponsive at the scene. Upon arrival, her Glasgow Coma Scale score is 6. Vital signs include a heart rate of 148/min, blood pressure of 65/35 mm Hg, respiratory rate of 6/min with agonal gasps, and oxygen saturation of 82% on room air. There is no active external hemorrhage visible. She is currently lying supine on the resuscitation bay stretcher. Arrange the following critical management steps in the most appropriate sequential order for this patient's initial stabilization and triage.

A 42-year-old male agricultural worker is brought to the emergency department by his colleagues after collapsing in a pesticide storage facility. On arrival, he is unresponsive to verbal stimuli. He is profusely diaphoretic, vomiting, and incontinent of urine and feces. Blood pressure is 90/50 mm Hg, heart rate is 42/min, and respiratory rate is 28/min. Oxygen saturation is 84% on room air. Examination reveals bilateral pinpoint pupils and generalized muscle fasciculations. The patient has copious, frothy oral secretions and audible wheezing with poor air movement on auscultation.

Arrange the following initial stabilization and management steps in the most appropriate sequential order.

A $72$-year-old female resident of an assisted living facility is brought to the emergency department due to acute confusion and lethargy that has worsened over the past $12$ hours. Staff report that she has had a productive cough and poor appetite for the last three days. Her medical history is significant for type 2 diabetes mellitus, hypertension, and a previous ischemic stroke with mild residual left-sided weakness. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $132$/min, blood pressure is $72/40$ mm Hg, and respiratory rate is $26$/min. Pulse oximetry shows $94\%$ on room air. On physical examination, she is somnolent but arouses to verbal stimuli and appropriately withdraws all four extremities from pain. Her mucous membranes are exceedingly dry, and capillary refill is delayed at $4$ seconds. Lung auscultation reveals coarse crackles in the right lower lobe. Which of the following is the most appropriate initial step in the management of this patient?

A 62-year-old man comes to the clinic reporting a 3-week history of progressively worsening shortness of breath, particularly when walking upstairs. He also reports waking up twice at night gasping for air and has noticed swelling in his ankles. He has a 10-year history of hypertension currently managed with amlodipine. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $158/92$ mmHg, pulse $92$/min, and respirations $18$/min. Physical examination reveals elevated jugular venous pressure, bibasilar lung crackles, and 2+ bilateral pitting pedal edema. A new $S_3$ gallop is auscultated. The physician suspects new-onset heart failure.

Which of the following diagnostic tests should be included in the initial workup for this patient? (Select all that apply)

A 42-year-old woman presents to the emergency department with sudden-onset, severe right upper quadrant abdominal pain that radiates to her right shoulder. The pain began one hour ago after she consumed a large, fatty meal. She reports experiencing similar, though less severe, episodes over the past few months that usually resolved spontaneously within a few hours. Her temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 16/min, and blood pressure is 128/82 mm Hg. Physical examination reveals tenderness to palpation in the right upper quadrant, but no rebound tenderness, guarding, or jaundice. Which of the following is the most appropriate next step in the diagnostic workup?

A 25-year-old woman is brought to the emergency department by a friend due to the sudden onset of difficulty breathing, throat tightness, and a diffuse itchy rash. Her symptoms began 15 minutes ago, shortly after she ate a peanut butter cookie at a local bakery. Vital signs show a temperature of 37.0°C (98.6°F), blood pressure of 82/50 mm Hg, pulse of 128/min, and respirations of 28/min. Oxygen saturation is 92% on room air. Physical examination reveals diffuse urticaria, facial edema, and bilateral expiratory wheezing. Which of the following is the most appropriate immediate next step in management?

Match each patient presentation with the most appropriate next step in their diagnostic evaluation based on established sequential testing algorithms.

A 38-year-old woman is evaluated in the ambulatory setting for recent, unexplained weight gain and new-onset hypertension. Over the past eight months, she has gained $14$ kg despite no changes to her diet or physical activity level. She also reports increasing difficulty climbing stairs and easy bruising on her extremities. Blood pressure is $158/96$ mmHg. Physical examination reveals facial plethora, prominent dorsocervical and supraclavicular fat pads, and broad violaceous striae across the lower abdomen. Initial screening for hypercortisolism is performed using a $1$-mg overnight dexamethasone suppression test. Her serum cortisol level at 8:00 AM the following morning is $14 \mu\text{g/dL}$ (normal: $<1.8 \mu\text{g/dL}$). Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

Following a high-speed collision with a commercial delivery van, a 31-year-old male pedestrian is airlifted to the regional trauma center. His electronic health record indicates no significant past medical history. During transport, the flight medical crew placed a rigid cervical collar and secured two large-bore peripheral intravenous catheters. Upon arrival, the patient is minimally responsive, groaning, and localizing to painful stimuli. Vital signs show a temperature of 35.8°C (96.4°F), blood pressure of 74/42 mm Hg, heart rate of 142/min, and respiratory rate of 28/min. His extremities are cool with weak, thready pulses. The primary survey reveals an unobstructed airway with bilateral and equal breath sounds. Evaluation of the abdomen demonstrates marked suprapubic ecchymosis and guarding. Gentle manual compression of the iliac crests reveals mechanical instability of the pelvic ring. A focused assessment with sonography for trauma (FAST) demonstrates an absence of free fluid in the pericardial, right upper quadrant, left upper quadrant, and pelvic views. A portable chest radiograph displays no acute cardiopulmonary abnormalities. Which of the following is the most appropriate next step in the immediate stabilization of this patient?

A 65-year-old man is evaluated in the intensive care unit for recurrent large-volume hematochezia. He originally presented to the emergency department 24 hours ago with bright red blood per rectum and hypotension. His medical history includes hypertension, hyperlipidemia, and coronary artery disease. Following initial resuscitation with intravenous crystalloids and two units of packed red blood cells, his vital signs normalized. A nasogastric lavage returned clear fluid with no blood or coffee-ground material. An urgent upper gastrointestinal endoscopy demonstrated a normal esophagus, stomach, and duodenum. Following rapid bowel preparation, a colonoscopy was performed which revealed scattered diverticula and fresh blood throughout the colon, but no active bleeding site could be identified.

While in the intensive care unit, the patient passes another large, bloody stool. His blood pressure drops to 95/65 mmHg and his heart rate increases to 118/min.

Which of the following is the most appropriate next step in the diagnostic workup?

A 45-year-old man is evaluated in the outpatient clinic for a three-day history of progressive left leg swelling and pain. He recently returned from a 12-hour international flight. His past medical history is unremarkable, and he takes no medications. Vital signs are stable. Physical examination reveals pitting edema, erythema, and marked tenderness along the deep venous system of the left calf. The left calf circumference is 5 cm larger than the right calf. Based on clinical criteria, the patient has a high pretest probability for a deep vein thrombosis. Which of the following is the most appropriate initial step in the diagnostic workup?

A 29-year-old woman, G2P1, at 26 weeks gestation is brought to the emergency department due to a 2-hour history of sudden-onset shortness of breath and right-sided pleuritic chest pain. She has no significant past medical history and takes only prenatal vitamins. Her vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 118/76 mmHg, heart rate of 112/min, respiratory rate of 24/min, and oxygen saturation of 94% on ambient air. Physical examination reveals clear lungs to auscultation bilaterally. The right calf is visibly swollen, erythematous, and tender to palpation compared to the left. Which of the following diagnostic studies should be ordered as the most appropriate initial steps in this patient's evaluation? (Select exactly 2)

Emergency medical services bring a 46-year-old female to the resuscitation bay due to the sudden onset of severe dyspnea and right-sided pleuritic chest pain. Two weeks ago, she underwent an open total abdominal hysterectomy for symptomatic uterine fibroids. On arrival, she appears agitated, diaphoretic, and cyanotic. Vital signs are temperature 37.2°C (99.0°F), blood pressure 82/48 mm Hg, heart rate 132/min, and respiratory rate 32/min. Oxygen saturation is 84% despite receiving 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals distended jugular veins, a loud P2 component of the second heart sound, and a right ventricular heave. The right lower extremity is edematous with calf tenderness. The patient is receiving rapid intravenous fluid resuscitation and vasopressor support is being initiated. Which of the following diagnostic modalities are the most appropriate immediate next steps in evaluating this patient? (Select 2)

A 58-year-old man is brought to the emergency department via ambulance with a sudden onset of excruciating, tearing pain between his shoulder blades. The pain began one hour ago while he was mowing his lawn and has remained constant. He has a medical history of poorly controlled hypertension, type 2 diabetes mellitus, and a 30-pack-year smoking history. On arrival, he is extremely agitated, diaphoretic, and in obvious distress. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 215/115 mmHg in the right arm and 185/95 mmHg in the left arm, heart rate of 118/min, and respiratory rate of 22/min. Pulse oximetry is 96% on room air. A bedside electrocardiogram reveals sinus tachycardia and voltage criteria for left ventricular hypertrophy, but no ST-segment or T-wave abnormalities. Peripheral pulses are diminished in the left upper and lower extremities compared to the right. Which of the following is the most urgent initial step in the management of this patient?

During morning rounds, the medical team is urgently called to the bedside of a 58-year-old male admitted the previous day for management of tense ascites. The patient has a known history of alcohol-associated decompensated cirrhosis. The bedside nurse reports he just experienced a massive episode of hematemesis, expelling approximately a liter of bright red blood. On evaluation, the patient is obtunded, exhibiting a Glasgow Coma Scale score of 7, and continues to pool blood in his oropharynx. Heart rate is 132/min, blood pressure is 78/42 mm Hg, and respiratory rate is 24/min. Two large-bore peripheral intravenous lines are already in place and crystalloid resuscitation has been initiated. Which of the following is the most appropriate immediate next step in the management of this patient?

A 52-year-old woman comes to the emergency department with a 12-hour history of severe, constant epigastric pain that radiates to her mid-back. The pain is associated with severe nausea and three episodes of non-bilious emesis. She has no history of alcohol use and takes no medications. Vital signs are temperature 37.7°C (99.9°F), blood pressure 135/85 mmHg, pulse 110/min, and respirations 18/min. Physical examination shows pronounced epigastric tenderness without rebound or rigidity. Bowel sounds are hypoactive. To establish the diagnosis and determine the likely etiology, which of the following investigations should be ordered as part of the initial diagnostic workup? (Select all that apply.)