Patient Management

A 58-year-old man with a history of adequately treated cavitary pulmonary tuberculosis presents to the emergency department coughing up copious amounts of bright red blood. He reports expectorating approximately 600 mL of blood over the past 4 hours. On presentation, his blood pressure is 90/60 mm Hg, heart rate is 118/min, respiratory rate is 28/min, and oxygen saturation is 86% on room air. He appears in severe respiratory distress and is coughing continuously, struggling to clear his airway. Coagulation studies are within normal limits. Chest radiograph demonstrates a residual cavity in the right upper lobe with new surrounding airspace opacities. Arrange the following procedural and surgical interventions in the most appropriate sequential order for managing this patient's life-threatening condition.

A 32-year-old man is evaluated by the rapid response team in the hospital due to sudden-onset severe dyspnea and lightheadedness. He was admitted two days ago for severe right-sided necrotizing pneumonia. On evaluation, he is diaphoretic, agitated, and gasping for air. His blood pressure is 74/42 mm Hg, heart rate is 142/min, and respiratory rate is 36/min. Pulse oximetry shows an oxygen saturation of 82% while receiving 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals markedly distended jugular veins and completely absent breath sounds over the entire right hemithorax. Palpation of the anterior neck demonstrates that the trachea is deviated to the left. Which of the following is the most appropriate immediate next step in the management of this patient?

During a new patient evaluation, a 34-year-old female is noted to have a blood pressure of $158/96$ mm Hg. She returns to the clinic two weeks later for a follow-up, and her blood pressure is $154/94$ mm Hg. The patient reports feeling entirely well, with no headaches, palpitations, or muscle weakness. She has no known medical conditions and takes no medications or over-the-counter supplements. She does not use tobacco or illicit substances. Her body mass index is $23$ kg/m $^2$. Physical examination reveals normal pulses in all extremities and no abdominal bruits. A comprehensive metabolic panel is obtained to assess baseline organ function, demonstrating a serum sodium of $143$ mEq/L, serum potassium of $3.1$ mEq/L, serum chloride of $103$ mEq/L, serum bicarbonate of $29$ mEq/L, and serum creatinine of $0.8$ mg/dL. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

A $72$-year-old man is brought to the emergency department complaining of sudden-onset, severe pain in his right leg that began $3$ hours ago. He has a history of atrial fibrillation but stopped taking his prescribed apixaban one month ago. On physical examination, the right leg is pale and cold to the touch. He exhibits profound motor weakness with an inability to dorsiflex the right toes. Sensation to light touch is absent over the dorsum of the right foot. Pulses are palpable in the bilateral femoral arteries but are absent in the right popliteal and pedal arteries by continuous-wave Doppler. The left leg examination is unremarkable. Which of the following are the most appropriate immediate interventions for this patient? (Select exactly two)

A 42-year-old male truck driver is evaluated in the emergency department after experiencing sudden-onset profound bilateral lower extremity weakness. Triage vital signs demonstrate a blood pressure of 205/115 mmHg and a heart rate of 92/min. Initial point-of-care laboratory testing reveals a critical serum potassium level of 1.9 mEq/L. Following acute correction of his electrolyte derangement and stabilization of his blood pressure using verapamil and doxazosin, the attending physician outlines a comprehensive diagnostic pathway to evaluate for the suspected underlying endocrine disorder.

Arrange the following diagnostic investigations in the correct clinical sequence, starting with the most immediate necessary step during his acute presentation and progressing through the definitive pre-surgical evaluation.

A 28-year-old man comes to the gastroenterology clinic for follow-up of severe, fistulizing Crohn's disease. Despite treatment with oral corticosteroids, he continues to have persistent abdominal pain and multiple draining perianal fistulas. The decision is made to initiate therapy with infliximab, a tumor necrosis factor-alpha (TNF-alpha) inhibitor. The patient has no history of cardiovascular, respiratory, or liver disease. Which of the following tests must be obtained prior to starting this medication? (Select all that apply)

An emergency medical team transports a 35-year-old man to the hospital after he suddenly lost the ability to move his legs this morning. He reports severe, unremitting mid-back pain that has progressively worsened over the past three weeks. He has a history of intravenous heroin use. He notes that he has not been able to urinate for the past 14 hours. His temperature is 38.8°C (101.8°F), pulse is 112/min, and blood pressure is 118/76 mm Hg. Neurologic examination reveals flaccid paralysis of both lower extremities with absent patellar and Achilles reflexes. Sensation to pinprick and temperature is absent below the umbilicus. Rectal examination demonstrates absent sphincter tone. Laboratory studies show a leukocyte count of 19,500/mm³ and an erythrocyte sedimentation rate of 85 mm/h. Magnetic resonance imaging of the spine reveals a large, peripherally enhancing epidural fluid collection extending from T8 to T11 with severe compression of the spinal cord. Blood cultures are drawn, and empiric broad-spectrum intravenous antibiotics are initiated. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old man presents to the ambulatory clinic after noticing a painless lump in his right scrotum during a shower three days ago. He reports no local trauma, dysuria, urethral discharge, or systemic symptoms such as weight loss or night sweats. He has no significant past medical history. Vital signs are within normal limits. Physical examination reveals a 2.5-cm, firm, non-tender nodule palpable on the anterolateral aspect of the right testicle. The mass does not transilluminate. There is no inguinal lymphadenopathy, and the contralateral testicle is normal. Which of the following tests represent the most appropriate immediate next steps in the diagnostic workup? (Select exactly two options)

Paramedics arrive at the emergency department with a 55-year-old male patient who experienced a massive episode of hematemesis at home. His medical history is significant for alcohol use disorder and biopsy-proven cirrhosis. On initial assessment in the resuscitation bay, the patient appears pale, diaphoretic, and confused. Vital signs show a blood pressure of 82/50 mmHg, a heart rate of 122/min, and an oxygen saturation of 95% on ambient air. Physical examination demonstrates scleral icterus, a distended abdomen with shifting dullness, and cutaneous spider telangiectasias. Intravenous access is established with two 16-gauge peripheral catheters, and rapid volume expansion with isotonic crystalloids is underway. The gastroenterology service is notified for an emergent upper endoscopy.

Which of the following pharmacologic therapies should be initiated concurrently? (Select all that apply)

An emergency medical team evaluates a $65$-year-old male who presents with the abrupt onset of severe, sharp chest pain that radiates to his interscapular region. He describes the pain as a "tearing" sensation. His medical history is significant for poorly controlled essential hypertension and stage $4$ chronic kidney disease with a baseline serum creatinine of $3.4$ mg/dL. His temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $192/114$ mm Hg in the right arm and $154/96$ mm Hg in the left arm, and heart rate is $105$/min. Physical examination reveals a new diastolic decrescendo murmur at the right upper sternal border. An electrocardiogram shows left ventricular hypertrophy but no acute ST-segment changes. A chest radiograph demonstrates a widened mediastinum. Which of the following is the most appropriate next step in the diagnostic workup?

A 45-year-old man is brought to the emergency department by ambulance after being rescued from a closed-space house fire. Paramedics report the patient was trapped in a smoke-filled room for approximately 10 minutes. His past medical history is significant for hypertension. On arrival, the patient is awake but severely agitated. He has full-thickness and deep partial-thickness burns over his anterior chest, abdomen, and bilateral upper extremities. Physical examination reveals singed nasal hair, soot in the oropharynx, carbonaceous sputum, and a hoarse voice. Breath sounds are present bilaterally with diffuse expiratory wheezes. Vital signs are temperature 37.1°C (98.8°F), pulse 122/min, blood pressure 118/76 mmHg, respiratory rate 28/min, and oxygen saturation 93% on a non-rebreather mask at 15 L/min. Which of the following is the most appropriate initial step in the stabilization of this patient?

A 68-year-old woman is evaluated in the emergency department for severe abdominal pain, high fever, and confusion that began earlier today. Her family reports she has had intermittent mild right-sided abdominal pain for the past few weeks. Temperature is 39.4°C (102.9°F), blood pressure is 82/50 mm Hg, pulse is 122/min, and respirations are 24/min. Physical examination reveals scleral icterus and marked tenderness to palpation in the right upper quadrant with involuntary guarding. Laboratory studies show a leukocyte count of 22,000/mm³, total bilirubin of 6.2 mg/dL, and alkaline phosphatase of 450 U/L. Arrange the following management steps in the most appropriate chronological order.

A 62-year-old woman is evaluated in the hospital for new-onset right lower extremity swelling. She was admitted 7 days ago for a non-ST-segment elevation myocardial infarction and has been receiving a continuous intravenous unfractionated heparin infusion. Her vital signs are stable. Physical examination reveals a swollen, erythematous, and tender right calf. Laboratory studies show a platelet count of $95,000/\mu L$ (down from $260,000/\mu L$ on admission). A lower extremity venous duplex ultrasound confirms an acute deep vein thrombosis in the right popliteal vein. Heparin-induced thrombocytopenia is highly suspected. Arrange the following pharmacologic management steps in the correct chronological sequence to appropriately treat this patient and safely transition her to long-term outpatient anticoagulation.

A 19-year-old male university student is carried into the triage area by his roommates because he became profoundly confused and lethargic over the last several hours. They state he complained of severe muscle aches and a headache earlier in the day. Vital signs reveal a temperature of 39.5°C (103.1°F), blood pressure of 72/38 mmHg, heart rate of 142/min, respiratory rate of 24/min, and oxygen saturation of 95% on ambient air. Physical examination demonstrates marked nuchal rigidity and a diffuse, non-blanching purpuric rash spreading across his lower extremities and trunk. He only groans in response to sternal rub. Which of the following represents the most urgent initial step in this patient's care?

An inpatient with ischemic cardiomyopathy and a left ventricular ejection fraction of 22% is preparing for hospital discharge following treatment for an acute decompensation. Over the past 72 hours, his volume status has been optimized with intravenous furosemide, and he was successfully transitioned to an oral diuretic regimen yesterday. His pre-admission medication list, which the care team is reviewing, includes carvedilol 25 mg twice daily, spironolactone 25 mg daily, and lisinopril 40 mg daily. To further reduce mortality risk, the attending physician decides to discontinue lisinopril and initiate sacubitril-valsartan therapy. The patient's most recent basic metabolic panel reveals a serum creatinine of 1.1 mg/dL and a serum potassium level of 4.6 mEq/L. Which of the following principles must be integrated into this patient's treatment transition and ongoing monitoring plan? (Select 2)

During an evaluation in the obstetric triage unit, a physician examines a woman at 29 weeks gestation who complains of the sudden onset of difficulty breathing and sharp right-sided chest pain that worsens with deep inspiration. Her pregnancy has been uncomplicated to date, and she has no significant past medical history. Vital signs reveal a heart rate of 118/min, a respiratory rate of 22/min, a blood pressure of 112/68 mmHg, and an oxygen saturation of 94% on room air. Physical examination demonstrates clear breath sounds bilaterally and normal cardiac auscultation. Evaluation of the lower extremities reveals asymmetric pitting edema and localized tenderness in the right calf. Which of the following is the most appropriate next step in evaluating this patient's condition?

Paramedics transport a 68-year-old male to the emergency room due to progressive, profound weakness over the past 24 hours. The patient has a background of ischemic cardiomyopathy and stage IV chronic kidney disease. Current outpatient medications comprise lisinopril, spironolactone, and carvedilol. Initial triage vital signs demonstrate a pulse of 42/min and a blood pressure of 105/60 mmHg. A 12-lead electrocardiogram displays a sine wave pattern with widened QRS complexes and prominently peaked T waves. A point-of-care basic metabolic panel is notable for a potassium concentration of 8.2 mEq/L. Arrange the following pharmacologic therapies in the correct chronological order for the acute management of this presentation.

A 32-year-old man is brought to the trauma bay via ambulance after losing control of his motorcycle at highway speeds. He was wearing a helmet. On arrival, he is pale and diaphoretic. He is groaning and protecting his airway. His temperature is 36.2°C (97.2°F), blood pressure is 74/40 mm Hg, heart rate is 142/min, and respiratory rate is 24/min. Oxygen saturation is 96% on room air. Breath sounds are equal and clear bilaterally. His abdomen is visibly distended, tense, and diffusely tender with guarding. The pelvis is mechanically stable to anteroposterior and lateral compression. A focused assessment with sonography for trauma (FAST) demonstrates a large amount of anechoic fluid in the hepatorenal and splenorenal recesses. Two large-bore peripheral intravenous catheters have been established. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select all that apply)

A 61-year-old female patient is evaluated in the intensive care unit due to deteriorating hemodynamics. She underwent a complex open ventral hernia repair with myofascial advancement flaps 24 hours ago. Over the past four hours, her urine output has steadily declined to a total of 15 mL. She is currently intubated and mechanically ventilated. Her temperature is 37.2°C (99.0°F), blood pressure is 82/48 mmHg, and pulse is 126/min. The patient is receiving a continuous infusion of norepinephrine, and her blood pressure remains low despite two 1-L boluses of intravenous lactated Ringer solution. The respiratory therapist reports that the peak airway pressures have gradually increased from 22 cm H2O to 45 cm H2O over the same time period. Physical examination reveals an extremely tense and distended abdomen with diffuse firmness to palpation. A transducer attached to the indwelling urinary catheter displays a pressure of 26 mmHg. Laboratory studies obtained 30 minutes ago show a hemoglobin of 10.4 g/dL and a lactate of 4.2 mmol/L. Which of the following is the most appropriate next step in the management of this patient?

A 72-year-old woman comes to the clinic reporting a 4-week history of worsening insomnia, profound fatigue, and a 4.5-kg (10-lb) weight loss despite a normal appetite. Her past medical history is significant for hypertension and recurrent highly symptomatic atrial fibrillation. Her current medications include amiodarone, apixaban, and lisinopril. She has been taking amiodarone for the past three years with good control of her arrhythmias. Her blood pressure is 138/85 mm Hg and heart rate is 108/min and irregular. Physical examination reveals a fine tremor of the outstretched hands, warm and moist skin, and a normal-sized, non-tender thyroid gland without palpable nodules.

Laboratory results are as follows:

Which of the following is the most appropriate next step in the evaluation to guide treatment for this patient's current condition?