Patient Management

Determine the optimal diagnostic sequencing for the following diverse clinical presentations of suspected acute pulmonary embolism. Link each specific patient profile to the most appropriate next step in their diagnostic workup, factoring in hemodynamic stability, pretest probability, and comorbidities.

A 45-year-old man is brought to the emergency department actively seizing. His wife reports that he has a history of epilepsy but ran out of his medications last week. The generalized tonic-clonic seizure began 10 minutes ago and has been continuous. He is unresponsive, and his airway is currently patent. Intravenous access is established. Arrange the following pharmacologic interventions in the correct sequential order of administration for escalating management of this patient's condition.

A $62$-year-old woman presents to the outpatient cardiology office for evaluation of chest discomfort. Over the past month, she has experienced multiple episodes of a dull, left-sided chest ache that consistently occurs when climbing the two flights of stairs to her apartment. The pain reliably resolves after $5$ minutes of rest. She has a history of type 2 diabetes mellitus, hypertension, and chronic kidney disease stage 4. Her current medications include amlodipine, lisinopril, and insulin glargine.

Vital signs are temperature $36.8^\circ$ C ($98.2^\circ$ F), blood pressure $146/86$ mmHg, heart rate $74$/min, and respiratory rate $14$/min. Physical examination reveals a normal point of maximal impulse, normal $S_1$ and $S_2$, and no murmurs or gallops. Lungs are clear to auscultation. There is no lower extremity edema.

Recent laboratory studies show:

A resting $12$-lead electrocardiogram shows sinus rhythm with a QRS duration of $145$ ms, broad notched R waves in leads I, aVL, $V_5$, and $V_6$, and deep S waves in leads $V_1$ and $V_2$. No prior electrocardiograms are available for comparison.

Which of the following is the most appropriate next step in the diagnostic workup for this patient's chest pain?

A 62-year-old man comes to the clinic due to a 24-hour history of severe pain, redness, and swelling in his right great toe. The pain is so severe that he cannot tolerate the weight of a bedsheet. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, type 2 diabetes mellitus, and stage 4 chronic kidney disease. Current medications include carvedilol, sacubitril-valsartan, empagliflozin, furosemide, and insulin glargine.

Vital signs show a blood pressure of 110/70 mm Hg, heart rate of 68/min, and temperature of 37.1°C (98.8°F). Physical examination reveals an erythematous, warm, swollen, and exquisitely tender right first metatarsophalangeal joint. The jugular venous pressure is estimated at 10 cm H2O. There is 2+ bilateral lower extremity pitting edema.

Laboratory studies show:
Serum creatinine: 2.8 mg/dL (baseline 2.7 mg/dL)
Estimated glomerular filtration rate: 22 mL/min/1.73 m²
Serum uric acid: 9.4 mg/dL

Which of the following is the most appropriate pharmacologic intervention for this patient's current joint symptoms?

A 52-year-old man is admitted to the hospital with a two-week history of low-grade fever, fatigue, and generalized joint pain. He has a past medical history of a bicuspid aortic valve. He reports undergoing a root canal procedure four weeks ago without taking prophylactic antibiotics. On examination, his temperature is 38.3°C (100.9°F), pulse is 96/min, and blood pressure is 128/76 mmHg. Cardiovascular examination reveals a new grade 3/6 decrescendo diastolic murmur heard best at the right second intercostal space. Physical exam also shows small, non-tender erythematous macules on his palms. Initial laboratory studies show a mild normocytic anemia and an elevated C-reactive protein. Three sets of blood cultures obtained at admission are growing *Streptococcus mutans*. A transthoracic echocardiogram is performed and demonstrates a thickened bicuspid aortic valve but does not visualize any definite valvular vegetations or abscesses. The patient remains hemodynamically stable. Which of the following is the most appropriate next step in the diagnostic workup?

A 24-year-old woman comes to the clinic reporting a 2-day history of painful urination, increased urinary frequency, and suprapubic discomfort. She has no fever, flank pain, or vaginal discharge. Her medical history is notable for a severe anaphylactic reaction (hives and bronchospasm) to amoxicillin during childhood. Vital signs are within normal limits. Urinalysis is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate empiric pharmacologic intervention for this patient?

A 45-year-old man is brought to the emergency department after a high-speed motorcycle collision. Upon arrival, he is unresponsive with a Glasgow Coma Scale score of 7 (Eye: 1, Verbal: 2, Motor: 4). Vital signs are temperature 36.1°C (97.0°F), blood pressure 68/35 mmHg, pulse 138/min, and respirations 34/min with shallow effort. Pulse oximetry shows 84% on room air. Physical examination reveals a large scalp laceration, tracheal deviation to the left, and absent breath sounds over the right hemithorax. His pelvis crepitates upon gentle lateral compression, and his extremities are cool and mottled.

Arrange the following management steps in the most appropriate sequential order according to standard trauma resuscitation protocols.

A 42-year-old man presents to the clinic for follow-up of severe hypertension. His blood pressure is 172/102 mm Hg despite strict adherence to a daily regimen of maximum-dose extended-release verapamil, hydralazine, and doxazosin. Laboratory studies today reveal a serum potassium level of 2.8 mEq/L, a serum sodium level of 144 mEq/L, and a serum creatinine of 0.9 mg/dL. The patient is otherwise healthy and has no history of licorice ingestion. Primary aldosteronism is strongly suspected.

Assuming all sequential test results yield positive findings and the patient is a candidate for surgical cure, arrange the following diagnostic and pre-procedural steps in the most appropriate, guideline-directed sequence.

A 72-year-old man is brought to the emergency department due to the sudden onset of severe, tearing abdominal and back pain that began 30 minutes ago. He has a history of hypertension, hyperlipidemia, and a 5.5-cm abdominal aortic aneurysm (AAA) that has been monitored with annual ultrasounds. His current medications include lisinopril and atorvastatin. On arrival, he is lethargic, pale, and diaphoretic. His temperature is 37.0°C (98.6°F), blood pressure is 72/42 mmHg, heart rate is 128/min, and respiratory rate is 24/min. Physical examination reveals a tender, pulsatile periumbilical mass. Femoral pulses are weak bilaterally. Two large-bore intravenous lines are established. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old man with end-stage renal disease presents to the emergency department with profound, generalized muscle weakness that began earlier today. He missed his last two scheduled hemodialysis sessions due to transportation issues. His blood pressure is 112/68 mmHg, pulse is 54/min, and respirations are 16/min. An electrocardiogram demonstrates absent P waves, a widened QRS complex, and tall, peaked T waves. A point-of-care basic metabolic panel reveals a serum potassium concentration of 8.2 mEq/L.

Arrange the following pharmacologic interventions in the most appropriate chronological sequence of administration for the acute management of this patient's severe hyperkalemia.

Emergency medical services bring a 45-year-old female to the trauma bay following a 20-foot fall from scaffolding. Upon arrival, the patient groans in pain and points to her abdomen. Vital signs show a blood pressure of 82/50 mmHg, pulse of 122/min, and respiratory rate of 24/min. Physical evaluation demonstrates marked diffuse abdominal guarding and a visibly deformed left radius. A focused assessment with sonography for trauma (FAST) demonstrates an anechoic collection in the hepatorenal space. A portable pelvic radiograph reveals no abnormalities. Which of the following interventions are indicated immediately? (Select all that apply)

A 42-year-old woman is evaluated in the emergency department for severe palpitations, tremulousness, and anxiety that have worsened over the past week. She has a history of severe, persistent asthma that requires multiple hospitalizations each year and daily use of high-dose inhaled budesonide and formoterol. She is diaphoretic and appears anxious. Her temperature is $37.8^\circ\text{C}$ ($100^\circ\text{F}$), blood pressure is $142/78\text{ mmHg}$, pulse is $122\text{ /min}$, and respirations are $20\text{ /min}$. A fine tremor is noted in her outstretched hands. An electrocardiogram reveals sinus tachycardia at $122\text{ /min}$ with no ischemic changes. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $<0.01\text{ mIU/L}$ and a significantly elevated free T4 level. Which of the following is the most appropriate initial pharmacologic intervention to rapidly control this patient's heart rate?

An ambulatory 58-year-old female presents to her primary care physician for evaluation of a progressing soft tissue infection on her left lower extremity. Her past medical history is significant for hyperlipidemia, for which she takes simvastatin daily. The physician determines that oral antimicrobial therapy is indicated. However, the physician recalls that certain antibiotics strongly inhibit the cytochrome P450 3A4 (CYP3A4) enzyme, which would significantly increase this patient's serum simvastatin levels and elevate her risk of statin-induced myopathy. Which of the following antimicrobial agents possess this specific pharmacokinetic interaction and should either be avoided or require temporary suspension of the statin? (Select all that apply)

A 43-year-old man presents for a follow-up evaluation of hypertension. He reports strict adherence to his prescribed regimen of maximum-dose amlodipine, lisinopril, and hydrochlorothiazide, but his home blood pressure readings remain consistently elevated. Today in the clinic, his blood pressure is 165/102 mm Hg. Laboratory studies reveal a serum potassium level of 2.9 mEq/L and a normal serum creatinine. The physician suspects secondary hypertension due to primary hyperaldosteronism. Arrange the following diagnostic steps in the correct order for evaluating this patient's suspected condition, from initial screening to preoperative assessment.

A 29-year-old female, G1P0 at 34 weeks gestation, is brought to the emergency department by paramedics after being the unrestrained driver in a high-speed motor vehicle collision. The patient was extricated with a rigid cervical collar and is immobilized supine on a backboard. On arrival, she is lethargic and pale. Vital signs are temperature $36.8^\circ \text{C}$ ($98.2^\circ \text{F}$), blood pressure $68/40\text{ mmHg}$, heart rate $145\text{/min}$, and respiratory rate $28\text{/min}$. Oxygen saturation is $88\%$ on a non-rebreather mask. Physical examination reveals a gravid uterus consistent with a third-trimester pregnancy. There is severe ecchymosis over the anterior chest wall. The trachea is deviated to the left. Auscultation reveals absent breath sounds over the right hemithorax and markedly distended neck veins. Her Glasgow Coma Scale score is 11. Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select 2 options)

A 28-year-old woman is brought to the emergency department by emergency medical services after being rescued from a confined house fire. She sustained partial-thickness and full-thickness burns over her anterior torso, face, and bilateral upper extremities, estimated to cover 35% of her total body surface area. She is conscious, extremely anxious, and complains of severe pain and difficulty swallowing. Her voice is noticeably hoarse, and she is coughing up carbonaceous sputum. Audible inspiratory stridor is present.

Vital signs are:
Temperature: 37.0°C (98.6°F)
Blood pressure: 118/74 mmHg
Heart rate: 122/min
Respiratory rate: 26/min
Oxygen saturation: 97% on a 100% non-rebreather mask

Physical examination reveals singed nasal hairs, soot in the oropharynx, and significant facial edema.

Which of the following is the most urgent initial step in the management of this patient?

A 64-year-old man is brought to the emergency department by his daughter due to a 2-day history of worsening confusion, lethargy, and a reversed sleep-wake cycle. He has a history of decompensated cirrhosis secondary to non-alcoholic steatohepatitis and has had one prior episode of hepatic encephalopathy. His home medications include lactulose 30 mL three times daily, spironolactone 100 mg daily, and furosemide 40 mg daily. The daughter reports he has been highly compliant with his medications and has been having 3 to 4 soft bowel movements daily.

Vital signs are temperature 37.0°C (98.6°F), heart rate 98/min, blood pressure 100/60 mmHg, and respiratory rate 16/min. Physical examination reveals a lethargic man who is oriented only to person. Scleral icterus and spider angiomas are present. The abdomen is distended with shifting dullness. When the patient's arms are extended with wrists dorsiflexed, a coarse, flapping tremor is observed.

Laboratory studies show:
Sodium: 131 mEq/L
Potassium: 2.8 mEq/L
Chloride: 90 mEq/L
Bicarbonate: 34 mEq/L
Blood urea nitrogen: 52 mg/dL
Serum creatinine: 1.4 mg/dL (baseline 0.9 mg/dL)
Total bilirubin: 3.5 mg/dL
Albumin: 2.6 g/dL

Which of the following is the most appropriate initial pharmacologic intervention?

A 52-year-old woman is evaluated in the surgical intensive care unit for clinical deterioration. She was admitted 4 weeks ago with severe acute gallstone pancreatitis and has been managed with supportive care. Over the past 3 days, she has developed spiking fevers, chills, and increasing abdominal pain. Her temperature is 39.2°C (102.6°F), blood pressure is 95/60 mmHg, pulse is 118/min, and respirations are 22/min. She is receiving broad-spectrum intravenous antibiotics and fluid resuscitation. Physical examination reveals a distended abdomen with marked epigastric tenderness to palpation. Laboratory studies show a leukocyte count of 24,000/mm³. A contrast-enhanced computed tomography scan of the abdomen demonstrates extensive walled-off pancreatic necrosis with new locules of gas within the necrotic collection. Which of the following is the most appropriate next step in management?

A 55-year-old man is brought to the emergency department by emergency medical services 15 minutes after being stung by multiple wasps while gardening. He complains of a feeling of impending doom, difficulty breathing, and dizziness. His medical history is significant for hypertension, coronary artery disease, and heart failure with reduced ejection fraction. His current medications include lisinopril, carvedilol, aspirin, and atorvastatin. On arrival, he is in severe respiratory distress with audible stridor. His temperature is 37.0°C (98.6°F), blood pressure is $72/40$ mm Hg, pulse is $110$/min, and oxygen saturation is $88\%$ on room air. Physical examination reveals diffuse wheezing bilaterally, periorbital edema, and a widespread urticarial rash. Arrange the following pharmacologic interventions in the most appropriate sequential order for the optimal acute management of this patient's condition.

A 64-year-old man comes to the primary care clinic for a follow-up appointment. One week ago, he was hospitalized for an acute myocardial infarction and was subsequently found to have a left ventricular ejection fraction of 35% on echocardiography. His medical history is significant for severe bilateral renal artery stenosis, hyperlipidemia, and osteoarthritis. Current medications include aspirin, atorvastatin, and clopidogrel. Blood pressure is 142/88 mm Hg and pulse is 76/min. The patient is euvolemic on physical examination. The physician is planning to optimize the patient's heart failure regimen. Initiation of which of the following medications is contraindicated in this patient?