Patient Management

A $31$-year-old man is rushed to the emergency department by his coworkers after developing sudden, severe respiratory distress while eating at a company luncheon. He is clutching his throat, visibly agitated, and speaking in one-word gasps. His past medical history is significant for mild intermittent asthma and an undocumented food allergy. Vital signs reveal a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse of $134/\text{min}$, blood pressure of $82/45\text{ mmHg}$, and respiratory rate of $32/\text{min}$. Oxygen saturation is $88\%$ on room air. Physical examination demonstrates prominent perioral swelling, diffuse wheezing in all lung fields, and a widespread erythematous rash on his chest and arms. Which of the following is the single most urgent initial step in the stabilization of this patient?

A male patient, aged $58$ years, with documented hepatic cirrhosis and portal hypertension, is evaluated in the emergency department following an episode of massive hematemesis. Upon arrival, he is obtunded, opening his eyes only to sternal rub, and actively vomiting bright red blood. His temperature is $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), blood pressure is $74/42 \text{ mm Hg}$, heart rate is $128 \text{ /min}$, and respiratory rate is $24 \text{ /min}$. Pulse oximetry demonstrates an oxygen saturation of $92\%$ on ambient air. Physical examination reveals a pale, diaphoretic patient with cool extremities and a distended abdomen with shifting dullness.

Arrange the following initial management steps in the most appropriate chronological sequence for this patient.

A 74-year-old man arrives at the emergency department reporting the sudden onset of severe, unremitting pain in his right leg that began 2 hours ago. His past medical history includes hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. He discontinued his prescribed oral anticoagulant three weeks ago due to financial constraints. Vital signs include a temperature of 37.0°C (98.6°F), heart rate of 112/min with an irregularly irregular rhythm, and blood pressure of 145/85 mm Hg. Physical examination reveals that the right lower extremity is pale and cold from the mid-thigh down. A right femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent on both palpation and continuous-wave Doppler ultrasound. The patient is unable to dorsiflex his right foot and reports profound numbness over the dorsum of the foot. The left lower extremity examination is unremarkable. Which of the following is the most appropriate next step in management?

A $42$-year-old woman comes to the clinic reporting excessive thirst and frequent urination for the past two months. She states she drinks up to $6\text{ L}$ of water daily and wakes up several times during the night to urinate. Her medical history is significant for bipolar I disorder, for which she has taken lithium for the past $8$ years. She has a history of severe manic episodes with psychotic features when she previously attempted to switch to alternative mood stabilizers. Vital signs are within normal limits.

Laboratory studies reveal:

A water deprivation test is performed. After $6$ hours of fluid restriction, her urine osmolality is $155\text{ mOsm/kg H}_2\text{O}$. Subcutaneous administration of desmopressin is given, and $2$ hours later, her urine osmolality is $160\text{ mOsm/kg H}_2\text{O}$. The patient's psychiatrist is consulted and strongly advises continuing the current lithium regimen due to the high risk of psychiatric decompensation.

Which of the following is the most appropriate pharmacologic intervention to manage this patient's polyuria?

Match each patient's clinical presentation of a severe or progressive headache with the most appropriate next diagnostic investigation in their workup algorithm.

Emergency medical services transport a primigravid patient at 26 weeks gestation to the acute care bay following the sudden onset of right-sided pleuritic chest discomfort and shortness of breath. She has no significant past medical history, and her pregnancy has been uncomplicated to date. Vital signs show a heart rate of 115/min, respiratory rate of 24/min, blood pressure of 110/70 mmHg, and oxygen saturation of 93% on room air. Physical examination reveals clear lung fields bilaterally and a normal cardiac rhythm without murmurs. Her right leg is mildly edematous compared to the left, although she denies localized calf pain. An electrocardiogram demonstrates sinus tachycardia, and a portable chest radiograph is unremarkable. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 68-year-old woman is evaluated in the preoperative clinic prior to an elective laparoscopic partial colectomy for recurrent diverticulitis. Her medical history is significant for a mechanical mitral valve replacement placed 4 years ago and a deep vein thrombosis 8 years ago. She currently takes warfarin and an angiotensin-converting enzyme (ACE) inhibitor. Her vital signs are within normal limits. Her international normalized ratio (INR) today is 2.8. The surgery is scheduled for 7 days from today. What are the mandatory perioperative management steps for this patient? (Select all that apply)

A $38$-year-old man with a history of HIV infection presents to the emergency department with a $2$-week history of progressively worsening headache, fever, and confusion. He has not taken antiretroviral therapy for the past year. Vital signs are temperature $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), pulse $105/\text{min}$, respirations $16/\text{min}$, and blood pressure $110/70\text{ mmHg}$. Physical examination shows lethargy, nuchal rigidity, and bilateral papilledema. A head CT scan without contrast reveals no focal lesions, mass effect, or hydrocephalus. Laboratory studies show a CD4 T-lymphocyte count of $45/\text{mm}^3$ and a serum sodium level of $131\text{ mEq/L}$. Lumbar puncture is performed. Cerebrospinal fluid (CSF) analysis shows an opening pressure of $360\text{ mm H}_2\text{O}$. CSF leukocyte count is $150/\text{mm}^3$ ($85\%$ lymphocytes), protein is $120\text{ mg/dL}$, and glucose is $30\text{ mg/dL}$. India ink preparation reveals encapsulated yeast cells. Which of the following pharmacologic interventions are indicated as part of this patient's immediate management? (Select all that apply)

A 68-year-old male is transported to the emergency department via ambulance with abrupt onset of excruciating, generalized abdominal pain that began 90 minutes prior to arrival. His past medical history is significant for a mechanical aortic valve replacement performed five years ago, for which he takes daily warfarin. He also has hypertension and diet-controlled type 2 diabetes. Upon arrival, he appears ashen and is diaphoretic. Temperature is 38.2°C (100.8°F), blood pressure is 82/48 mmHg, pulse is 134/min and regular, and respirations are 24/min. Abdominal examination demonstrates board-like rigidity, diffuse severe tenderness with guarding, and rebound tenderness across all four quadrants. A portable upright chest radiograph reveals a distinct crescent of radiolucency beneath the right hemidiaphragm. Point-of-care laboratory testing shows an international normalized ratio (INR) of 3.8 and a serum lactate of 5.2 mmol/L. Intravenous crystalloid resuscitation and broad-spectrum antibiotics are initiated. Which of the following interventions are mandatory immediate steps in this patient's management? (Select all that apply)

Coworkers transport a 46-year-old farmhand to the emergency department after he collapsed in an orchard. They report that he was spraying crops earlier in the day when he suddenly developed severe shortness of breath, nausea, and vomiting. On arrival, the patient is agitated, diaphoretic, and in severe respiratory distress. Vital signs are temperature 36.8°C (98.2°F), pulse 42/min, blood pressure 86/54 mmHg, respirations 28/min, and oxygen saturation 84% on room air. Physical examination reveals profound salivation, lacrimation, and frothy sputum at the mouth. The pupils are 1 mm bilaterally. Pulmonary examination shows diffuse expiratory wheezing and coarse rhonchi in all lung fields. Neurologic examination is notable for generalized muscle fasciculations. Which of the following is the most urgent initial step in the stabilization of this patient?

A 72-year-old resident of an assisted living facility is brought to the emergency department due to worsening confusion and a productive cough over the past forty-eight hours. Medical history is notable for hypertension, type 2 diabetes mellitus, and benign prostatic hyperplasia. The facility staff noted that the patient has been increasingly difficult to arouse since the morning. Upon arrival in the resuscitation bay, the patient is obtunded and responds only to deep painful stimuli. Vital signs demonstrate a temperature of 35.4°C (95.7°F), blood pressure of 72/38 mm Hg, heart rate of 128/min, and respiratory rate of 26/min. Oxygen saturation is 91% on room air. Physical examination reveals cool, mottled extremities with a prolonged capillary refill time of five seconds. Pulmonary auscultation reveals coarse rhonchi predominantly in the right lower lung field. Which of the following is the most appropriate initial step in the management of this patient?

A 28-year-old female is brought to the emergency department by her roommate due to severe agitation, palpitations, and confusion over the past 24 hours. She has a history of Graves disease but admits to discontinuing her prescribed medications three months ago. Her temperature is $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), blood pressure is $160/70$ mm Hg, pulse is $152$/min and irregular, and respirations are $24$/min. Physical examination reveals marked diaphoresis, a diffusely enlarged and non-tender thyroid gland, and a fine bilateral hand tremor. The patient is delirious and unable to cooperate with a detailed neurologic examination. An electrocardiogram demonstrates atrial fibrillation with rapid ventricular response. Which of the following pharmacologic interventions are indicated in the initial management of this patient's condition? (Select all that apply)

A 52-year-old woman is evaluated in the surgical telemetry unit 6 hours after undergoing an uncomplicated total thyroidectomy for a large multinodular goiter. Over the past 15 minutes, she has become increasingly restless and reports progressive difficulty breathing. Her voice is muffled. Temperature is 37.1°C (98.8°F), blood pressure is 155/95 mmHg, pulse is 115/min, and respirations are 26/min. Oxygen saturation is 89% on room air. Physical examination reveals audible inspiratory stridor. There is a tense, expanding, ecchymotic swelling beneath the cervical surgical incision. The lungs are clear to auscultation bilaterally. Which of the following is the most appropriate next step in management?

A 55-year-old female presents to the emergency department complaining of sudden-onset, severe epigastric pain that radiates directly to her back. The pain began abruptly two hours ago and is accompanied by multiple episodes of intractable, non-bilious emesis. She has no history of alcohol consumption and takes no routine medications. Her temperature is 37.8°C (100.0°F), pulse is 112/min, and blood pressure is 138/86 mmHg. Abdominal examination demonstrates marked epigastric tenderness with voluntary guarding, but no rebound or rigidity. Bowel sounds are hypoactive. Which of the following diagnostic investigations are the most appropriate NEXT steps in the evaluation of this patient? (Select exactly 2 options)

An established patient, a 72-year-old male with a 6-year history of Parkinson disease, presents to the outpatient neurology clinic accompanied by his wife. Over the past three weeks, he has experienced new-onset visual hallucinations, frequently reporting that strangers are standing in their living room. These episodes cause him significant distress. His motor symptoms remain well-controlled. His current daily medication regimen consists of carbidopa-levodopa, pramipexole, selegiline, and trihexyphenidyl. He takes no other medications. Vital signs include a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $134/76\text{ mmHg}$, pulse of $72\text{/min}$, and respiratory rate of $16\text{/min}$. Physical examination is remarkable for a mild resting pill-rolling tremor and slight bradykinesia, unchanged from previous visits. Laboratory results, including a complete blood count, comprehensive metabolic panel, and urinalysis, show no abnormalities.

Arrange the following pharmacologic interventions in the chronological sequence they should be implemented (from first step to last step) to appropriately manage this patient's new-onset psychosis.

Match each patient presenting with suspected stable ischemic heart disease to the most appropriate next step in their diagnostic workup.

An $82$-year-old man is evaluated in the intensive care unit for persistent fever and clinical deterioration. He was admitted $8$ days ago for severe community-acquired pneumonia and respiratory failure requiring intubation and mechanical ventilation. His hospital course has been complicated by septic shock, for which he is currently receiving continuous infusions of norepinephrine and vasopressin. Today, his temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $86/52\text{ mmHg}$, pulse is $122/\text{min}$, and respiratory rate is $18/\text{min}$ (ventilator set). Physical examination reveals a distended abdomen with guarding in the right upper quadrant upon deep palpation. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ (up from $14,000/\text{mm}^3$ yesterday). Liver function tests reveal a total bilirubin of $1.4\text{ mg/dL}$, alkaline phosphatase of $130\text{ U/L}$, aspartate aminotransferase of $45\text{ U/L}$, and alanine aminotransferase of $40\text{ U/L}$. A bedside right upper quadrant ultrasound demonstrates a markedly distended gallbladder with a thickened wall, pericholecystic fluid, and no stones or sludge. The common bile duct measures $4\text{ mm}$ in diameter. Intravenous meropenem is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 32-year-old woman with persistent asthma comes to the clinic for a preconception counseling visit. She currently uses a medium-dose fluticasone-formoterol inhaler twice daily, which provides excellent control of her symptoms. She and her husband are planning to conceive in the next few months. The patient expresses significant anxiety regarding the use of medications during pregnancy. She states, "I read on a natural parenting blog that asthma inhalers can cause severe birth defects. I have decided to stop using my inhaler immediately and will manage my asthma with breathing exercises alone." Which of the following is the most appropriate initial response by the physician?

A retired teacher visits the ambulatory care clinic for a routine wellness check. The patient's medical history includes osteoarthritis, essential hypertension, and chronic insomnia. A medication review reveals the daily use of clonazepam at bedtime, which the patient has been taking for the past two decades. The physician explains the increased risk of falls, motor vehicle accidents, and cognitive impairment associated with this medication in older adults, and recommends initiating a gradual taper. The patient becomes visibly upset, crosses their arms, and states, 'That pill is the only thing keeping me sane. If I do not get my sleep, my blood pressure goes up and my joints ache worse the next day. I am not stopping it.' Which of the following is the most appropriate initial response by the physician?

A 66-year-old female presents to the outpatient clinic for a routine wellness examination. She has no acute symptoms and feels well. Her past medical history is significant for primary hypertension, for which she takes amlodipine. She has never smoked, does not consume alcohol, and exercises by walking 30 minutes daily. Her last screening mammogram was performed 6 months ago and was unremarkable. A screening colonoscopy performed at age 61 was normal. Her medical records indicate she had negative cervical human papillomavirus (HPV) co-testing at ages 55, 60, and 64. She has never undergone bone mineral density testing. Vital signs today are within normal limits, and physical examination shows no abnormalities. Which of the following is the most appropriate next step in preventive screening for this patient?