Patient Management

An adult with end-stage renal disease is evaluated in the emergency department for severe generalized weakness after missing three consecutive hemodialysis sessions. A 12-lead electrocardiogram demonstrates widened QRS complexes and tall, peaked T waves. The care team prepares to initiate urgent medical therapy while awaiting emergency hemodialysis.

Arrange the following pharmacologic interventions in the correct chronological sequence of administration, from the most immediate therapeutic priority to the final step in management.

Emergency medical services arrive at the hospital with a 28-year-old female patient who is highly agitated and delirious. According to her family, she has a documented history of Graves disease but abandoned her prescribed medical therapy three months prior. Her temperature is 39.8°C (103.6°F), heart rate is 155/min, blood pressure is 160/70 mm Hg, and respiratory rate is 24/min. Physical examination reveals a diaphoretic patient with a diffusely enlarged, non-tender thyroid gland and a marked resting tremor. An electrocardiogram shows sinus tachycardia. Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the acute management of this patient's condition.

A triage physician evaluates a 42-year-old man who complains of severe, progressively worsening mid-back pain over the past 5 days. He states the pain wakes him from sleep and is poorly responsive to over-the-counter analgesics. The patient has a history of opioid use disorder and currently injects heroin. During the past 24 hours, he has noticed progressive weakness in both legs and an inability to urinate. Vital signs reveal a temperature of 38.3°C (100.9°F), heart rate of 105/min, blood pressure of 118/76 mm Hg, and respiratory rate of 18/min. Neurologic examination demonstrates 3/5 strength in the proximal and distal muscle groups of both lower extremities. Sensation to pinprick is decreased below the umbilicus. Patellar and Achilles reflexes are 3+ bilaterally, and a positive Babinski sign is present on the right. Point-of-care bladder ultrasound reveals 500 mL of retained urine. Which of the following diagnostic studies should be ordered concurrently as the initial workup for this patient? (Select exactly 3)

A 58-year-old postmenopausal woman presents to the clinic for evaluation of a newly identified right breast lump. She noticed the firm, painless mass in the upper outer quadrant 2 weeks ago during self-examination. Physical examination confirms a 2-centimeter, non-tender, relatively mobile mass in the right breast with no overlying skin dimpling, nipple retraction, or axillary lymphadenopathy. Her last screening mammogram was 18 months ago and was reported as normal. Arrange the following diagnostic steps in the most appropriate chronological sequence for the evaluation of this patient's new palpable mass.

A 68-year-old man presents to the ambulatory care clinic with a 1-day history of severe pain, swelling, and redness in his left knee. The pain began abruptly and is exacerbated by any movement or weight-bearing. His medical history is significant for long-standing hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease with a recent estimated glomerular filtration rate of $22 \text{ mL/min/1.73 m}^2$. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $142/85 \text{ mmHg}$, and heart rate of $82\text{/min}$. Physical examination reveals a warm, erythematous, and swollen left knee with a detectable effusion. Arthrocentesis is performed. Synovial fluid analysis reveals a leukocyte count of $35,000\text{/mm}^3$ (predominantly neutrophils). Gram stain is negative, and polarized light microscopy demonstrates numerous needle-shaped, negatively birefringent crystals. Which of the following is the most appropriate pharmacologic intervention for this patient's acute symptoms?

Following a minor fall resulting in right-sided chest wall pain, a 62-year-old male undergoes a plain radiograph of the ribs. While no fractures are identified, the radiologist notes an incidental 14-mm, well-circumscribed, noncalcified nodular opacity in the peripheral right upper lobe. The patient has a 35-pack-year smoking history but quit 5 years ago. He reports no cough, hemoptysis, or unintentional weight loss. Vital signs are within normal limits, and pulmonary auscultation reveals clear breath sounds bilaterally. Attempts to locate prior imaging studies from other institutions are unsuccessful. Which of the following is the most appropriate next step in the diagnostic workup of this incidental finding?

A 55-year-old woman is brought to the emergency department by emergency medical services due to severe, worsening respiratory distress that began earlier today. Her medical history is significant for severe persistent asthma, and she was recently hospitalized for an exacerbation. On arrival, the patient is somnolent and difficult to arouse. She is using prominent accessory muscles of respiration and exhibits paradoxical abdominal movement. Vital signs are temperature 37.2°C (99.0°F), heart rate 138/min, respirations 32/min, blood pressure 155/92 mmHg, and oxygen saturation 81% despite receiving 15 L/min of oxygen via a non-rebreather mask. Pulmonary auscultation reveals a "silent chest" with markedly diminished breath sounds and no audible wheezing bilaterally. Intravenous access is established. Which of the following is the most appropriate immediate next step in the management of this patient?

A 71-year-old man presents to an urgent care clinic with sudden-onset, severe pain in his right foot that awakened him from sleep. The patient states the pain is so intense that he cannot tolerate a bedsheet touching his foot. His medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, chronic kidney disease, and type 2 diabetes mellitus. His daily medications are sacubitril-valsartan, carvedilol, empagliflozin, and torsemide. Vital signs include a blood pressure of $108/65\text{ mm Hg}$, heart rate of $72/\text{min}$, and temperature of $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$). Physical examination reveals a visibly swollen, distinctly erythematous, warm, and exquisitely tender right first metatarsophalangeal joint. Laboratory studies show:

Leukocyte count: $11,200/\text{mm}^3$
Serum uric acid: $8.8\text{ mg/dL}$
Serum creatinine: $2.3\text{ mg/dL}$ (baseline $1.5\text{ mg/dL}$)

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

During morning rounds on the cardiology step-down unit, a physician assesses a $72$-year-old male who complains of excruciating pain in his right big toe that began overnight. The patient was hospitalized $72$ hours ago for volume overload requiring aggressive diuresis with intravenous furosemide. His respiratory status has since stabilized.

Physical examination of the right foot reveals prominent erythema, swelling, and exquisite tenderness localized to the first metatarsophalangeal joint. Arthrocentesis yields synovial fluid containing $35,000 \text{ leukocytes/mm}^3$ ($90\%$ neutrophils) and numerous negatively birefringent, needle-shaped crystals under polarized light microscopy.

His medical history is significant for ischemic cardiomyopathy (left ventricular ejection fraction $25\%$), chronic kidney disease (baseline creatinine $2.1 \text{ mg/dL}$), and a life-threatening peptic ulcer bleed $4$ months ago that required endoscopic clipping.

Today's vital signs are within normal limits. Laboratory studies show a current serum creatinine of $2.3 \text{ mg/dL}$.

Which of the following is the most appropriate targeted pharmacotherapy for this patient's acute joint pathology?

Paramedics arrive at the trauma bay with a commercial roofer who plummeted two stories onto concrete. Initial assessment reveals profound bradycardia at 48/min, marked hypotension at 76/40 mm Hg, and shallow respirations at 8/min. Pulse oximetry reads 85% on room air. He is unresponsive to verbal stimuli. Gurgling sounds are audible with each breath, and pooled blood is visible in his posterior pharynx. His extremities are unusually warm and pink despite the severe hypotension. Arrange the following initial stabilization and diagnostic steps in the most appropriate chronological order of execution for this patient.

Paramedics rush a cyanotic, gasping male patient into the resuscitation bay after he collapsed in a local park. Bystanders reported the patient was swarmed by yellow jackets approximately 15 minutes prior. The patient's spouse, who arrives shortly after, provides a medication list indicating he takes carvedilol, sacubitril-valsartan, empagliflozin, and apixaban for a history of heart failure with reduced ejection fraction. Vital signs on the monitor display a blood pressure of 68/36 mmHg, a pulse of 115/min, and an oxygen saturation of 85% on room air. Examination shows profound periorbital and labial edema, audible stridor, widespread urticaria, and poor air entry bilaterally with faint wheezing. Establish the most appropriate chronological sequence of pharmacologic interventions to stabilize this patient.

During a routine telehealth visit, a 67-year-old woman reports a two-day history of dysuria, suprapubic discomfort, and feeling the urge to urinate frequently. She feels otherwise well, with no fevers, chills, or flank pain. The patient's past medical history includes paroxysmal atrial fibrillation managed with daily warfarin. Her last international normalized ratio (INR) was therapeutic at 2.5. A urine dipstick performed at a local laboratory is positive for nitrites and leukocyte esterase. Her baseline estimated glomerular filtration rate is $88 \text{ mL/min/1.73 m}^2$. The local resistance rate of *Escherichia coli* to trimethoprim-sulfamethoxazole is approximately $10\%$. To safely treat her suspected uncomplicated cystitis without disrupting her anticoagulation status, which of the following empiric regimens are most appropriate? (Select all that apply)

A 32-year-old man is brought to the emergency department with a severe head injury and a Glasgow Coma Scale score of 6 following a motorcycle collision. He is spontaneously breathing but unable to protect his airway. His blood pressure is 110/70 mm Hg and heart rate is 115/min. The trauma team decides to proceed with rapid sequence intubation (RSI).

Arrange the following pharmacologic interventions in the correct chronological sequence of administration for this patient's airway management, from earliest to latest.

A 28-year-old woman is brought to the emergency department by her sister after collapsing at home. The sister reports that the patient complained of sudden, severe lower abdominal pain right before losing consciousness. The patient's last menstrual period was approximately 7 weeks ago. On arrival, she is lethargic, diaphoretic, and extremely pale. Vital signs are temperature 36.6°C (97.9°F), heart rate 145/min, blood pressure 68/38 mm Hg, respiratory rate 24/min, and oxygen saturation 98% on ambient air. Physical examination reveals a rigid, distended abdomen with diffuse guarding and rebound tenderness. Capillary refill is delayed at 5 seconds. Which of the following interventions should be ordered simultaneously as the most appropriate initial stabilization steps? (Select all that apply)

A $62$-year-old man comes to the clinic to establish care. His past medical history is significant for essential hypertension, hyperlipidemia, and a $30$-pack-year smoking history; he quit smoking $10$ years ago. He currently has no respiratory complaints, weight loss, night sweats, or hemoptysis. Vital signs are within normal limits. Physical examination reveals clear lung fields bilaterally and no palpable cervical or supraclavicular lymphadenopathy. A chest radiograph obtained during a recent health fair revealed a small opacity in the right mid-lung zone. He is referred for a high-resolution, non-contrast computed tomography (CT) scan of the chest, which reveals a $13$-mm solid, non-calcified pulmonary nodule with smooth margins in the right middle lobe. No hilar or mediastinal lymphadenopathy is identified. Medical records from his previous provider are requested, but no prior imaging studies are available for comparison. Which of the following is the most appropriate next step in the diagnostic workup?

A 58-year-old man presents to his primary care physician to discuss recent difficulties with erectile dysfunction. He reports an inability to maintain an erection sufficient for sexual intercourse over the past four months. His past medical history is significant for stable angina pectoris, hypertension, and hyperlipidemia. His daily medication regimen includes several drugs for his cardiovascular conditions. His blood pressure is 128/82 mmHg and heart rate is 72/min. Physical examination is unremarkable. The physician considers prescribing sildenafil. Concurrent use of which of the following medications is an absolute contraindication to initiating this therapy?

A $64$-year-old man with a history of advanced squamous cell carcinoma of the lung is brought to the emergency department by his family due to progressive lethargy, confusion, and generalized weakness over the past $3$ days. He has also been experiencing severe nausea, vomiting, and polyuria. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), heart rate of $112/\text{min}$, blood pressure of $88/58\text{ mmHg}$, and respiratory rate of $16/\text{min}$. Physical examination reveals dry mucous membranes, flat jugular veins, and delayed capillary refill. He is disoriented to time and place. Laboratory results are as follows:

Serum calcium: $14.8\text{ mg/dL}$
Serum albumin: $3.5\text{ g/dL}$
Blood urea nitrogen (BUN): $42\text{ mg/dL}$
Serum creatinine: $1.4\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$)

Electrocardiogram shows a shortened QT interval. Which of the following pharmacologic interventions are indicated in the initial management of this patient's acute metabolic derangement? (Select all that apply)

A $55$-year-old man is evaluated in the post-anesthesia care unit due to altered mental status, tachypnea, and hypotension. Two hours ago, he underwent an elective laparoscopic cholecystectomy for symptomatic cholelithiasis. His past medical history includes type 2 diabetes mellitus, hypertension, and a pulmonary embolism $4$ months ago. Home medications include metformin, empagliflozin, lisinopril, and rivaroxaban. He was instructed to hold all oral medications on the morning of surgery.

Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $78/48\text{ mmHg}$, heart rate of $128\text{/min}$, and respiratory rate of $28\text{/min}$. Physical examination reveals dry mucous membranes, clear lungs, and delayed capillary refill. The abdomen has appropriately placed, dry surgical dressings. A Foley catheter has drained $30\text{ mL}$ of urine over the last $2$ hours.

Laboratory results are as follows:

An arterial blood gas on room air reveals a pH of $7.18$, pCO $_2$ of $24\text{ mmHg}$, and pO $_2$ of $92\text{ mmHg}$.

Aggressive intravenous fluid resuscitation with isotonic crystalloid is initiated. Which of the following is the most appropriate targeted pharmacologic intervention for this patient's underlying condition?

Emergency medical services bring a 26-year-old female to the resuscitation bay after she was found obtunded in her apartment. Several empty medication bottles, including one prescribed for amitriptyline, were discovered nearby. Upon transfer to the stretcher, she exhibits generalized tonic-clonic motor activity. Her skin is warm and exceptionally dry, and her pupils measure $7$ mm bilaterally. Current vital signs are blood pressure $78/42$ mmHg, heart rate $148$/min, respiratory rate $6$/min, and oxygen saturation $84\%$ on ambient air. Cardiac monitoring reveals a regular, wide-complex tachycardia with a QRS interval of $170$ ms. Which of the following interventions must be initiated simultaneously as the immediate next steps in management? (Select all that apply)

A $48$-year-old woman is referred to the endocrinology clinic due to refractory hypertension. Her blood pressure has remained uncontrolled despite documented adherence to maximal tolerated doses of amlodipine, valsartan, and hydralazine. She reports occasional muscle weakness and severe leg cramps. Her vital signs today show a blood pressure of $165/102$ mm Hg. A basic metabolic panel reveals a serum sodium of $144$ mEq/L, a serum potassium of $2.9$ mEq/L, and a serum bicarbonate of $30$ mEq/L. The clinician strongly suspects primary hyperaldosteronism as the etiology of her presentation. Arrange the following diagnostic steps in the most appropriate sequential order to establish the diagnosis, confirm the etiology, and determine surgical candidacy.