Patient Management

A 45-year-old man presents to the emergency department with a 2-hour history of sudden-onset, severe, and diffuse abdominal pain. He has a history of chronic lower back pain managed with high-dose daily ibuprofen. He is in severe distress and lies completely still on the examination table. His temperature is 38.2°C (100.8°F), blood pressure is 92/58 mm Hg, pulse is 122/min, and respirations are 24/min. Abdominal examination demonstrates diffuse rigidity, involuntary guarding, and severe rebound tenderness. An upright chest radiograph reveals free air under the right hemidiaphragm. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

A $66$-year-old man comes to the clinic for evaluation of a chronic cough and blood-tinged sputum over the past three months. He reports a $5$-kg ($11$-lb) unintentional weight loss during this period. The patient has a $45$-pack-year smoking history and chronic obstructive pulmonary disease. Vital signs are within normal limits. Physical examination reveals decreased breath sounds at the right lung apex. Routine laboratory testing shows a serum calcium level of $10.8$ mg/dL (reference: $8.4 - 10.2$ mg/dL). A contrast-enhanced CT scan of the chest and upper abdomen reveals a $4.5$-cm spiculated mass in the right upper lobe and a single enlarged right paratracheal lymph node measuring $1.8$ cm. The liver and adrenal glands appear normal. Which of the following is the most appropriate next step in the diagnostic sequence?

A 62-year-old woman is evaluated in the intensive care unit regarding her anticoagulation management. Seven days ago, she was admitted for a massive pulmonary embolism and was initially started on a continuous unfractionated heparin infusion. Three days into her admission, her platelet count dropped from 240,000/mm³ to 85,000/mm³. A serotonin release assay was positive, confirming heparin-induced thrombocytopenia (HIT). Heparin was immediately discontinued, and a continuous intravenous argatroban infusion was initiated.

Over the past four days, her clinical condition has stabilized, and her platelet count has recovered to 165,000/mm³. The medical team decided to transition her to oral warfarin for long-term outpatient anticoagulation, and daily warfarin therapy was initiated. Today (day 4 of combined argatroban and warfarin therapy), her vital signs are stable. Laboratory results are as follows:

Which of the following is the most appropriate next step in the monitoring and management of this patient's anticoagulation?

A 64-year-old man is currently receiving treatment in the intensive care unit for a severe exacerbation of cystic fibrosis-related bronchiectasis. Twenty minutes ago, he experienced an episode of massive hemoptysis, expectorating approximately 500 mL of bright red blood. He was immediately intubated with an 8.0-mm single-lumen endotracheal tube to secure the airway. A bedside flexible bronchoscopy performed through the endotracheal tube reveals continuous, high-volume arterial bleeding originating from the right lower lobe bronchus. Despite targeted application of cold saline and epinephrine, the bleeding remains uncontrolled and is now rapidly flooding the trachea and spilling into the left mainstem bronchus. The patient's oxygen saturation has declined from 96% to 82% despite mechanical ventilation with a fraction of inspired oxygen of 1.0. Blood pressure is 112/74 mmHg and heart rate is 118/min. Which of the following is the most appropriate immediate next step in management?

A 65-year-old man is evaluated for sudden-onset, excruciating pain in his right lower extremity. He is currently on hospital day 7 following a mechanical mitral valve replacement. His daily medications include warfarin and a continuous unfractionated heparin infusion for bridging therapy until his international normalized ratio (INR) is therapeutic. His current INR is $1.6$. Vital signs are temperature $37.1^{\circ}\text{C}$ ($98.8^{\circ}\text{F}$), blood pressure $130/80 \text{ mmHg}$, and heart rate $88/\text{min}$. Physical examination of the right lower extremity reveals a pale, cold leg. Popliteal and dorsalis pedis pulses are absent on Doppler ultrasound. Sensation to light touch is markedly diminished over the dorsum of the foot, and the patient is unable to actively dorsiflex his right toes. Laboratory studies reveal a platelet count of $65,000/\text{mm}^3$, a significant decrease from $280,000/\text{mm}^3$ on admission. Which of the following procedural and pharmacological interventions are indicated as the most appropriate next steps in this patient's management? (Select 3)

A 28-year-old woman presents to the outpatient clinic to discuss laboratory results obtained during a health screening for a new life insurance policy. She feels well and reports no bone pain, abdominal pain, nausea, polyuria, polydipsia, or mood changes. The patient has no personal history of fractures, peptic ulcer disease, or nephrolithiasis. Family history is notable for her father having a chronically elevated calcium level that "never required treatment or surgery." Vital signs are within normal limits. Physical examination reveals a non-tender neck with no palpable masses or thyromegaly.

Initial laboratory evaluation shows:
Serum calcium: $11.3\text{ mg/dL}$ (normal: $8.4-10.2\text{ mg/dL}$)
Serum albumin: $4.0\text{ g/dL}$
Serum phosphorus: $2.4\text{ mg/dL}$ (normal: $2.5-4.5\text{ mg/dL}$)
Intact parathyroid hormone: $82\text{ pg/mL}$ (normal: $10-65\text{ pg/mL}$)
25-hydroxyvitamin D: $34\text{ ng/mL}$ (normal: $20-50\text{ ng/mL}$)
Serum creatinine: $0.8\text{ mg/dL}$

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

A $69$-year-old man is brought to the emergency department by his daughter due to $3$ days of progressive nausea, vomiting, profound weakness, and visual disturbances. He reports that room lights appear to have a "yellowish halo." His medical history includes heart failure with reduced ejection fraction, persistent atrial fibrillation, and chronic kidney disease stage 3b. His daily medications are carvedilol, sacubitril-valsartan, dapagliflozin, and digoxin. Eight days ago, he was prescribed a $7$-day course of clarithromycin at an urgent care clinic for an exacerbation of chronic bronchitis.

Vital signs are temperature $37.1^\circ$ C ($98.8^\circ$ F), blood pressure $105/60$ mmHg, heart rate $46$/min, and respiratory rate $16$/min. Physical examination reveals an irregularly irregular, bradycardic rhythm.

Laboratory findings:
Serum sodium: $136$ mEq/L
Serum potassium: $6.3$ mEq/L
Blood urea nitrogen: $44$ mg/dL
Serum creatinine: $2.2$ mg/dL (baseline $1.8$ mg/dL)
Serum digoxin level: $4.8$ ng/mL (therapeutic range: $0.5-0.9$ ng/mL)

An electrocardiogram (ECG) demonstrates atrial fibrillation with a slow ventricular response and frequent, multiform premature ventricular contractions.

Which of the following is the most appropriate initial pharmacologic intervention for this patient?

A 45-year-old man presents to the outpatient clinic with a three-day history of progressively worsening perianal pain. He reports that the pain is exacerbated by sitting and during bowel movements. His temperature is 37.8°C (100.0°F), blood pressure is 125/80 mmHg, and pulse is 88/min. Physical examination reveals a 3-cm, highly tender, fluctuant, and erythematous mass located adjacent to the left posterior anal verge. There is no overlying tissue necrosis, and the patient has no signs of systemic toxicity or immunocompromise. Which of the following is the most appropriate next step in the management of this patient?

An 82-year-old man is being evaluated for hospital discharge following an 8-day admission for an acute left middle cerebral artery ischemic stroke. He is now medically stable but has residual right-sided hemiparesis and moderate oropharyngeal dysphagia. He currently participates in physical and occupational therapy but fatigues after 45 to 60 minutes of total daily activity. The multidisciplinary team is coordinating his transition to a post-acute care setting.

Arrange the following steps of this patient's disposition and care transition process in the correct chronological order to ensure a safe and appropriate handoff.

A 72-year-old male patient is currently hospitalized in the medical step-down unit for management of a severe cerebrovascular accident. He requires continuous enteral nutrition via a nasogastric tube due to profound dysphagia. His daily glycemic control is maintained using scheduled subcutaneous NPH insulin every 12 hours and regular insulin every 6 hours. An unexpected complication arises, requiring immediate transfer for an emergent procedure. Consequently, his continuous enteral feeding is abruptly halted. Arrange the following steps for metabolic monitoring and treatment evaluation in the most appropriate chronological sequence to ensure patient safety.

A 65-year-old man comes to the clinic for a follow-up evaluation. Two weeks ago, he was diagnosed with heart failure with reduced ejection fraction (left ventricular ejection fraction of $35\%$). At that time, lisinopril was added to his medication regimen, which also includes metoprolol succinate and furosemide. The patient reports feeling well, with significant improvement in his exertional dyspnea. He denies orthopnea, paroxysmal nocturnal dyspnea, or dizziness. Blood pressure is 122/78 mmHg and pulse is 68/min. Physical examination shows no jugular venous distention and clear lungs bilaterally.

Which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

A 78-year-old man is admitted to the hospital with acute decompensated heart failure. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 15% and stage 4 chronic kidney disease. This is his fourth admission for a heart failure exacerbation in the past six months. During this hospitalization, attempts to transition him from intravenous to oral diuretics resulted in symptomatic hypotension, worsening renal function, and severe dyspnea. He is currently maintained on a continuous intravenous milrinone infusion on the telemetry unit, which keeps his breathing comfortable at rest, though he experiences significant dyspnea when attempting to walk to the bathroom. The patient has been evaluated by the advanced heart failure team and is deemed ineligible for a left ventricular assist device (LVAD) or cardiac transplantation due to his advanced age and comorbidities. He is fully alert and oriented. During a family meeting, he clearly states, "I am tired of being in the hospital. I just want to go home and be comfortable. I do not want to be put on a breathing machine or shocked if my heart stops." He lives with his daughter, who is supportive and able to be present at home most of the day. Which of the following is the most appropriate disposition plan for this patient?

Following a high-speed collision with a concrete barrier, a 51-year-old female driver is extricated from her vehicle and arrives at the trauma resuscitation bay via a medical helicopter. She is fully awake but reports agonizing lower truncal pain.

Her vital signs are as follows:
Blood pressure: 64/34 mmHg
Heart rate: 144/min
Respiratory rate: 26/min
Oxygen saturation: 94% on supplemental oxygen

Physical examination reveals a mechanically unstable pelvic ring with severe crepitus elicited upon gentle bilateral compression of the iliac crests. The patient's abdomen is flat and non-tender. The focused assessment with sonography for trauma (FAST) reveals no pericardial effusion and no free fluid in the dependent abdominal recesses. Two large-bore peripheral intravenous lines are currently being established by the nursing staff.

Which of the following is the single most urgent initial step to stabilize this patient's condition?

A 38-year-old man is being treated with isoniazid, rifampin, pyrazinamide, and ethambutol for active pulmonary tuberculosis. Four weeks into his therapy, he presents to the clinic reporting new-onset nausea, right upper quadrant abdominal discomfort, and dark urine. Physical examination reveals mild scleral icterus. Arrange the following steps for the evaluation and longitudinal management of this patient's suspected drug-induced liver injury in the correct chronological sequence.

Following an emergency medical transport, a $68$-year-old male is urgently evaluated in the resuscitation bay for sudden-onset, excruciating retrosternal pain that radiates directly to his thoracic spine. The episode began one hour prior while he was resting. His medical history is notable for medication-noncompliant hypertension and tobacco use disorder. On initial assessment, the patient is overtly pale, diaphoretic, and lethargic. Vital signs reveal a blood pressure of $82/50$ mm Hg in the right arm and $60/40$ mm Hg in the left arm, a pulse of $118$/min, and a respiratory rate of $22$/min. Auscultation of the precordium demonstrates a new early diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram reveals sinus tachycardia with no ST-segment or T-wave abnormalities. A portable anteroposterior chest radiograph shows widening of the mediastinal silhouette. Which of the following is the most appropriate next step in the diagnostic workup of this patient?

Match each patient presentation and clinical risk stratification score to the most appropriate disposition or care setting.

Paramedics bring a 72-year-old woman to the emergency department after the staff at her assisted living facility noted non-bloody, bilious emesis and progressive lethargy since yesterday morning. She has a medical history significant for vascular dementia, coronary artery disease, and an open cholecystectomy a decade ago. Currently, her temperature is $38.3^\circ\text{C}$ ($101.0^\circ\text{F}$), blood pressure is $88/54 \text{ mm Hg}$, pulse is $118/\text{min}$, and respiratory rate is $22/\text{min}$. On physical examination, the abdomen is asymmetric, visibly distended, and exquisitely tender with rebound and rigidity in the right lower quadrant. Further inspection reveals a $4 \text{ cm}$, tense, erythematous mass palpable just inferior to the right inguinal ligament. Initial laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate of $4.2 \text{ mmol/L}$. Intravenous fluids and broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in the management of this patient?

A $28$-year-old man is brought directly to the operating room after sustaining multiple high-velocity gunshot wounds to the abdomen. Upon arrival, his blood pressure is $72/40\text{ mm Hg}$ and his heart rate is $145\text{/min}$. Massive transfusion protocol is initiated. A midline laparotomy is performed, revealing approximately $2.5\text{ L}$ of intraperitoneal blood, a shattered right liver lobe, and multiple destructive perforations of the small intestine. During the initial exploration, the anesthesiologist reports that the patient's core temperature has dropped to $33.8^\circ\text{C}$ ($92.8^\circ\text{F}$), his arterial pH is $7.11$, and there is diffuse microvascular oozing from all dissected tissue planes. The surgical team recognizes the onset of physiological exhaustion. Arrange the following surgical and procedural interventions in the correct chronological sequence for the optimal management of this patient.

A 74-year-old woman is brought to the emergency department with a 2-hour history of sudden, severe, and diffuse abdominal pain accompanied by nausea and one episode of non-bloody emesis. Her medical history is significant for heart failure with preserved ejection fraction and paroxysmal atrial fibrillation. She admits she stopped taking her prescribed apixaban two weeks ago due to financial constraints. On examination, she appears in significant distress, writhing on the stretcher. Her temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $102/64 \text{ mm Hg}$, heart rate is $118/\text{min}$ and irregularly irregular, respiratory rate is $22/\text{min}$, and oxygen saturation is $96\%$ on room air. Abdominal examination reveals a soft abdomen with mild, diffuse tenderness to deep palpation, but no guarding, rigidity, or rebound tenderness. Bowel sounds are hypoactive. Peripheral pulses are normal and symmetric. Which of the following diagnostic studies should be ordered concurrently as part of the immediate diagnostic sequence for this patient? (Select the THREE most appropriate options)

A 45-year-old male is brought to the emergency department after falling from a third-story balcony. On arrival, he is unresponsive with gurgling respirations and exhibits a grossly deformed right thigh. Initial vital signs include a blood pressure of 75/40 mmHg, heart rate of 135/min, and respiratory rate of 8/min.

Arrange the following initial stabilization and management steps in the most appropriate sequential order according to standard advanced trauma life support principles. Assume the patient demonstrates a transient hemodynamic response to initial resuscitation efforts.