Patient Management

A $26$-year-old woman with a history of type 1 diabetes mellitus presents to the emergency department complaining of diffuse abdominal pain, nausea, and persistent vomiting over the past $24$ hours. She recently had a urinary tract infection and missed her last two subcutaneous insulin doses. Vital signs reveal a blood pressure of $90/60 \text{ mm Hg}$, a heart rate of $122 \text{/min}$, and a respiratory rate of $28 \text{/min}$ with deep, rapid breathing. Point-of-care testing shows a blood glucose level of $580 \text{ mg/dL}$. Arterial blood gas analysis demonstrates a pH of $7.12$ and a serum bicarbonate of $10 \text{ mEq/L}$. Urinalysis is strongly positive for ketones. Arrange the following therapeutic and monitoring interventions in the most appropriate chronological sequence for managing this patient's condition.

A resident physician is preparing to place a right internal jugular central venous catheter in a patient requiring vasopressor support for septic shock. The necessary equipment has been brought to the patient's bedside. Arrange the following steps of the central venous catheterization procedure in the correct chronological order.

A 42-year-old woman is evaluated in the clinic due to an 8-month history of progressively worsening shortness of breath. She initially noticed dyspnea only when climbing stairs, but now experiences it while walking on level ground. She has no significant past medical history, takes no medications, and has never smoked. Vital signs show blood pressure of 118/76 mm Hg, heart rate of 88/min, respiratory rate of 18/min, and oxygen saturation of 96% on room air. Jugular venous pulsation is visible 8 cm above the sternal angle. Chest auscultation reveals clear breath sounds bilaterally. Cardiac examination shows a parasternal heave, a loud pulmonic component of the second heart sound (P $_2$), and a faint holosystolic murmur at the lower left sternal border that augments with inspiration. There is trace lower extremity edema. Initial diagnostic testing reveals the following:

- ECG: Right axis deviation and right ventricular hypertrophy.
- Chest X-ray: Enlarged central pulmonary arteries with clear lung parenchyma.
- Transthoracic echocardiogram: Right ventricular dilation with an estimated right ventricular systolic pressure of 65 mm Hg. Left ventricular size and systolic function are normal. There is no significant mitral or aortic valvular disease.
- Pulmonary function tests: Normal spirometry and lung volumes.
- High-resolution chest CT: No evidence of interstitial lung disease.

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 29-year-old man is brought to the emergency department after a high-speed motorcycle collision. He was ejected from the vehicle and found 30 feet away. On arrival, his airway is patent. He is confused and diaphoretic. Temperature is 36.2 C (97.2 F), pulse is 135/min, blood pressure is 85/50 mmHg, and respirations are 28/min. Primary survey reveals a rigid, distended abdomen and a grossly deformed right femur. A portable chest radiograph demonstrates a widened mediastinum with loss of the aortic knob contour. A focused assessment with sonography for trauma (FAST) is positive for free fluid in the hepatorenal and splenorenal recesses. The patient receives a rapid infusion of 2 units of uncrossmatched packed red blood cells, which improves his blood pressure to 105/65 mmHg. A CT scan of the chest, abdomen, and pelvis with intravenous contrast reveals a Grade III blunt thoracic aortic injury (pseudoaneurysm) just distal to the left subclavian artery, and a Grade IV splenic laceration with active contrast extravasation. While transferring the patient from the CT scanner to the stretcher, his blood pressure precipitously drops to 65/40 mmHg and his pulse increases to 150/min. He becomes unresponsive and is immediately endotracheally intubated. Which of the following is the most appropriate next step in the surgical management of this patient?

Paramedics transport a 24-year-old male to the emergency room after he collapsed at an outdoor food festival. Bystanders witnessed him rapidly develop severe respiratory distress and facial swelling shortly after consuming a dessert. Upon arrival, the patient is profoundly agitated, diaphoretic, and grasping his neck. Vital signs include a blood pressure of 76/42 mm Hg, a heart rate of 134/min, and a respiratory rate of 28/min. Pulse oximetry indicates an oxygen saturation of 88% on room air. Clinical evaluation demonstrates marked edema of the tongue and lips, a widespread erythematous urticarial rash across the torso, and prominent inspiratory stridor with minimal bilateral air movement. Which of the following is the most appropriate initial step in the stabilization of this patient?

Paramedics transport a 24-year-old man to the emergency department after he dove headfirst into a shallow lake. Bystanders successfully pulled him from the water.

Upon arrival, the patient is awake, alert, and speaking clearly. He reports a complete inability to move his arms or legs. His breathing pattern is shallow and entirely diaphragmatic.

Vital signs are as follows:
Temperature: 36.0°C (96.8°F)
Blood pressure: 72/42 mm Hg
Heart rate: 48/min
Respiratory rate: 26/min
Oxygen saturation: 92% on room air

Physical examination reveals flaccid paralysis with 0/5 motor strength in all four extremities. Sensation to pain and temperature is absent below the clavicles. His skin is warm and flushed throughout all extremities.

Based on trauma and shock management principles, arrange the following acute resuscitation steps in the correct prioritized sequence from first to last.

A 61-year-old man with a history of poorly controlled type 2 diabetes mellitus and chronic kidney disease stage 3b (baseline estimated glomerular filtration rate of $42 \text{ mL/min/1.73 m}^2$) presents to the emergency department with severe, progressively worsening mid-back pain for the past 10 days. He reports that the pain now radiates in a band-like pattern around his lower chest. Over the past 12 hours, he has experienced progressive weakness in both legs and notes he has not urinated since the previous evening.

Vital signs:
Temperature: $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$)
Blood pressure: $148/92 \text{ mmHg}$
Heart rate: $102 \text{ /min}$
Respiratory rate: $16 \text{ /min}$

Neurologic examination reveals 3/5 strength in hip flexion and knee extension bilaterally, absent patellar reflexes, and diminished pinprick sensation below the T10 dermatome. Bedside ultrasound reveals a post-void residual bladder volume of $650 \text{ mL}$. The patient is promptly catheterized.

Given the high clinical suspicion for a critical neurological emergency, which of the following diagnostic studies should be ordered concurrently as the most appropriate initial evaluation? (Select exactly 3)

A 45-year-old woman presents to the primary care clinic for follow-up of elevated blood pressure. Over her last three visits, her blood pressure has averaged 152/94 mmHg, and a diagnosis of primary hypertension is established. Her medical history is notable for bipolar I disorder, which has been well controlled on a stable dose of lithium for the past four years. Her recent serum lithium level was within the target therapeutic range, and her comprehensive metabolic panel shows normal renal function. The physician decides to initiate pharmacologic therapy for her hypertension. Which of the following antihypertensive medications is most likely to decrease the patient's renal clearance of lithium and precipitate drug toxicity?

Match each patient's clinical presentation and calculated risk stratification score to the most appropriate initial disposition setting.

A 61-year-old man with a history of alcohol use disorder and decompensated cirrhosis is evaluated on the medical ward for increasing confusion and decreased urine output. He was admitted two days ago for management of large-volume ascites. Over the past 24 hours, he has become progressively lethargic.

Vital signs show a temperature of 38.1°C (100.6°F), blood pressure of 84/52 mmHg, heart rate of 110/min, and respiratory rate of 18/min. Physical examination reveals scleral icterus, spider angiomas, and shifting dullness. He is oriented to name only and exhibits a positive asterixis.

Laboratory studies are as follows:

A diagnostic paracentesis yields cloudy fluid with an absolute neutrophil count of 650/mm³. Urinalysis shows no casts or red blood cells. A 1.5 L intravenous normal saline bolus was administered over the last 12 hours without any improvement in his blood pressure or serum creatinine.

Which of the following pharmacologic interventions are indicated in the management of this patient? (Select all that apply.)

A 68-year-old woman is evaluated for hospital discharge. She was admitted 5 days ago for severe gastroenteritis complicated by acute kidney injury. Her diarrhea has resolved, and she is tolerating a regular diet. Vital signs are normal. Laboratory studies show a blood urea nitrogen of $24 \text{ mg/dL}$ and serum creatinine of $1.1 \text{ mg/dL}$ (baseline creatinine from one month ago was $1.0 \text{ mg/dL}$). Prior to admission, she lived independently in a single-level apartment and required no assistance with activities of daily living. Today, physical therapy evaluates her and notes significant generalized deconditioning from prolonged bed rest. She now requires moderate physical assistance to transfer from the bed to a chair and to ambulate short distances. The physical therapist recommends short-term daily rehabilitative therapy but notes that the patient fatigues rapidly, tolerating a maximum of 45 minutes of physical activity per day. Which of the following is the most appropriate disposition for this patient?

A 48-year-old man is hospitalized with severe acute gallstone pancreatitis. On hospital day 21, he develops a fever of 39.2°C (102.6°F), leukocytosis of 22,000/mm³, and worsening diffuse abdominal pain. A contrast-enhanced CT scan of the abdomen shows a 12-cm region of walled-off pancreatic necrosis containing multiple gas bubbles. Assuming the patient continues to exhibit signs of systemic toxicity and fails to clinically improve after each successive therapeutic intervention, arrange the following management steps in the correct chronological sequence according to the evidence-based 'step-up' approach for infected necrotizing pancreatitis.

An ambulance brings a 68-year-old man to the acute care bay following the abrupt onset of excruciating, diffuse abdominal pain that began 4 hours prior. He has a known medical history of paroxysmal atrial fibrillation and hypertension but recently discontinued his prescribed oral anticoagulation due to financial constraints. On arrival, his vital signs demonstrate a temperature of $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), a heart rate of $130/\text{min}$ with an irregularly irregular rhythm, a blood pressure of $82/48\text{ mmHg}$, and a respiratory rate of $24/\text{min}$. Physical examination reveals a rigid, markedly distended abdomen with severe diffuse tenderness, absent bowel sounds, and pronounced involuntary guarding. Point-of-care laboratory testing reveals a leukocyte count of $22,000/\text{mm}^3$ and a serum lactate level of $8.1\text{ mmol/L}$. After initiating aggressive intravenous fluid resuscitation and broad-spectrum antibiotics, which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man comes to the primary care clinic reporting a 9-month history of excessive sweating, fatigue, and bilateral knee pain. He also mentions that his wedding ring no longer fits and he recently had to purchase shoes that are a size larger than his previous footwear. His wife reports that his snoring has worsened significantly over the past year. Vital signs are within normal limits. Physical examination reveals a prominent supraorbital ridge, an enlarged tongue, and broad, doughy hands. Given the high clinical suspicion for a specific endocrine disorder, a serum insulin-like growth factor-1 (IGF-1) level is ordered and returns significantly elevated for his age and sex. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 22-year-old man is brought to the emergency department by emergency medical services after a high-speed motor vehicle collision. He is in severe respiratory distress and is unable to speak in full sentences. His blood pressure is 80/40 mm Hg, pulse is 135/min, and respirations are 36/min. Oxygen saturation is 84% on room air. Physical examination reveals distended neck veins, absent breath sounds over the right hemithorax, and tracheal deviation to the left side. Which of the following is the most appropriate next step in management?

A $68$-year-old man is evaluated in the outpatient cardiology clinic for ongoing symptoms of heart failure. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$. He currently reports dyspnea when walking up a single flight of stairs (New York Heart Association class III). His daily medications include sacubitril-valsartan, carvedilol, and empagliflozin. He is adherent to a low-sodium diet. Vital signs show a blood pressure of $112/74$ mmHg and a pulse of $68$/min. Physical examination reveals clear lungs and trace bilateral lower extremity edema. Recent laboratory studies show:

To further reduce mortality and hospitalizations, the physician decides to initiate spironolactone at a dose of $12.5$ mg daily.

Which of the following represents the most appropriate monitoring or management strategy for this patient's new therapeutic regimen?

A primary care physician is reviewing the chart of a patient with treatment-resistant hypertension. The patient has consistently elevated blood pressure readings over 160/100 mmHg despite documented compliance with maximal doses of amlodipine, lisinopril, and chlorthalidone. Recent laboratory analysis highlights a persistent unprovoked hypokalemia (potassium 3.0 mEq/L). Suspecting an autonomous mineralocorticoid production disorder, the clinical team plans a comprehensive diagnostic workup. Arrange the following evaluations in the standard evidence-based sequence, from initial screening to final pre-surgical planning.

A 29-year-old male is brought to the trauma bay after a high-speed motorcycle collision. Upon arrival, his blood pressure is $78/40 \text{ mm Hg}$, heart rate is $142/\text{min}$, and respiratory rate is $28/\text{min}$. Intravenous crystalloid and a massive transfusion protocol are initiated. A focused assessment with sonography for trauma (FAST) reveals a large amount of free intraperitoneal fluid. The patient is immediately transported to the operating room for an exploratory laparotomy, which reveals a massive Grade V liver laceration with brisk, ongoing hemorrhage. The anesthesia team reports that the patient's core temperature has dropped to $34.1^\circ\text{C}$ ($93.4^\circ\text{F}$), and an arterial blood gas shows a pH of $7.12$ with a base deficit of $14 \text{ mEq/L}$. Diffuse microvascular bleeding is noted from all surgical surfaces. Which of the following is the most appropriate next step in surgical management?

A 19-year-old woman presents to the emergency department exactly $4$ hours after a suspected intentional ingestion of an unknown quantity of extra-strength acetaminophen tablets. She is currently asymptomatic, with stable vital signs and an unremarkable physical examination. The physician plans a comprehensive management and monitoring strategy to prevent irreversible hepatotoxicity. Arrange the following steps in the correct chronological sequence for the guideline-concordant diagnostic evaluation, clinical monitoring, and therapeutic progression for this patient.

A 78-year-old man is evaluated for hospital discharge following a 3-day admission for acute decompensated heart failure. He has severe ischemic cardiomyopathy with a documented left ventricular ejection fraction of 15%. This marks his fourth hospitalization for severe volume overload in the past six months, despite maximum tolerated guideline-directed medical therapy. The patient is currently euvolemic, resting comfortably in bed, and breathing easily on room air. During bedside rounds, he tells the physician, "I am completely exhausted from these constant hospital visits. I know my heart is failing, and I just want to go back to my house and be kept comfortable without any more aggressive treatments or readmissions." His family is highly supportive of his wishes and is continuously available to assist with his daily needs. Which of the following is the most appropriate disposition for this patient?