Patient Management

A 42-year-old woman is brought to the emergency department after falling from a 15-foot ladder. She is confused, pale, and diaphoretic. Vital signs show a blood pressure of 85/50 mm Hg, heart rate of 122/min, respiratory rate of 26/min, and oxygen saturation of 91% on room air. She has evident facial swelling, a visibly deformed mandible, and blood pooling in her oropharynx causing stridorous breathing. Arrange the following initial management steps in the most appropriate chronological order according to standard trauma resuscitation protocols.

A 24-year-old female is rushed to the resuscitation bay by her college roommate, who discovered her in a highly lethargic state in their dormitory. An empty bottle of amitriptyline was found on her bedside table. Upon evaluation, the patient is somnolent and disoriented but spontaneously maintains a patent airway and localizes to painful stimuli. Her past medical history is notable for recurrent major depressive disorder and generalized anxiety. Current vital signs show a temperature of 38.2°C (100.8°F), heart rate of 138/min, blood pressure of 78/48 mm Hg, respirations of 14/min, and pulse oximetry of 96% on ambient air. Physical examination reveals mydriasis, dry oral mucosa, and a complete absence of bowel sounds. A stat electrocardiogram displays a wide-complex sinus tachycardia with a QRS duration of 145 ms and a prominent terminal R wave in lead aVR. Which of the following represents the most urgent initial step in the stabilization of this patient?

A 68-year-old woman presents to the emergency department with sudden-onset, severe pain in her right lower extremity that began 2 hours ago. On physical examination, the right foot is pale, cold, and pulseless. She is unable to wiggle her toes, and sensation to light touch is absent over the dorsum of the foot. Her blood pressure is 145/90 mmHg, and her heart rate is 110/min with an irregularly irregular rhythm. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

Review the following clinical profiles of patients presenting for ambulatory care visits. For each patient, match their presentation with the single most appropriate, guideline-concordant preventive care intervention to order next.

A 64-year-old woman with a history of rheumatic mitral stenosis and atrial fibrillation presents to the emergency department reporting sudden, severe right leg pain that began 2 hours ago. She admits to running out of her prescribed anticoagulant medication three weeks ago. Vital signs include a blood pressure of $142/88 \text{ mm Hg}$ and a heart rate of $112/\text{min}$ with an irregularly irregular rhythm. Physical examination of the right lower extremity reveals a cold, pale leg with visible mottling. There is complete loss of light touch sensation over the dorsum of the foot, and the patient is unable to dorsiflex her toes. Palpation reveals a strong right femoral pulse, but popliteal, dorsalis pedis, and posterior tibial pulses are absent. Bedside continuous-wave Doppler ultrasound demonstrates absent arterial signals but audible venous signals in the right foot. Which of the following interventions are indicated in the immediate management of this patient? (Select all that apply)

A 52-year-old agricultural worker is brought to the emergency department by his coworkers. He collapsed 30 minutes ago while mixing chemicals in an enclosed, poorly ventilated greenhouse. Coworkers report he complained of severe abdominal cramps and blurred vision before losing consciousness. On arrival, the patient is unresponsive to painful stimuli. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $85/50\text{ mm Hg}$, heart rate $42/\text{min}$, respiratory rate $10/\text{min}$, and oxygen saturation $84\%$ on room air. Examination reveals profuse diaphoresis and copious, frothy secretions emanating from his mouth. Pupils are $1\text{ mm}$ bilaterally and poorly reactive to light. Pulmonary auscultation reveals diffuse wheezing and bilateral rhonchi. Widespread muscle fasciculations are visible across his chest and extremities. Which of the following is the most appropriate initial step in the stabilization of this patient?

A 62-year-old woman is preparing for discharge to her home after a 4-day hospitalization for an exacerbation of chronic obstructive pulmonary disease. The physician is initiating the discharge medication reconciliation process to ensure a safe care transition. Arrange the standard steps of the discharge medication reconciliation process in the correct chronological sequence from first to last.

A 55-year-old man is evaluated for hospital discharge. He was admitted 3 weeks ago for severe acute necrotizing pancreatitis complicated by acute respiratory distress syndrome, requiring 14 days of mechanical ventilation in the intensive care unit. He was transferred to the general medical ward 7 days ago. His current medications include subcutaneous insulin and oral pancreatic enzyme replacement therapy. Vital signs are within normal limits, and laboratory studies show resolution of his acute kidney injury and leukocytosis. The patient is tolerating a regular diet. However, he has generalized muscle weakness and requires moderate physical assistance from two people to transfer from the bed to a chair. He cannot ambulate independently. During physical therapy evaluation, he demonstrates high motivation and successfully participates in 3.5 hours of combined physical and occupational therapy without excessive fatigue. He lives in a single-story home with his wife, who works full-time during the day. Which of the following is the most appropriate disposition for this patient?

A 62-year-old man is hospitalized for the management of acute diverticulitis. He has been receiving intravenous ceftriaxone and metronidazole for $48$ hours, but his clinical condition has deteriorated. He continues to have a fever of $39.0^\circ\text{C}$ ($102.2^\circ\text{F}$) and complains of worsening severe left lower quadrant abdominal pain. Physical examination reveals focal rebound tenderness in the left lower quadrant without diffuse abdominal rigidity. His leukocyte count has increased from $14,000/\text{mm}^3$ to $18,500/\text{mm}^3$. A repeat computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast demonstrates a new $5.5\text{-cm}$ rim-enhancing fluid collection adjacent to the sigmoid colon.

Which of the following are appropriate procedural and management steps at this time? (Select all that apply)

A 72-year-old man is evaluated in the clinic following a recent hospital admission for symptomatic ventricular tachycardia. During his hospitalization, he was initiated on oral amiodarone therapy to suppress further arrhythmias. His past medical history is significant for a mechanical aortic valve replacement, hypertension, and hyperlipidemia. His current home medications include warfarin, lisinopril, and atorvastatin. The patient is currently asymptomatic, and his vital signs are within normal limits. Which of the following are appropriate components of the monitoring and treatment evaluation plan for this patient? (Select all that apply)

A 61-year-old woman is brought to the emergency department due to a 24-hour history of severe left-sided flank pain, shaking chills, and confusion. Her temperature is 39.4°C (102.9°F), blood pressure is 86/50 mm Hg, pulse is 124/min, and respirations are 24/min. Physical examination reveals dry mucous membranes and marked left costovertebral angle tenderness. Laboratory studies demonstrate a leukocyte count of 21,000/mm³ with 15% bands. Serum creatinine is 1.8 mg/dL (baseline 0.9 mg/dL). A non-contrast computed tomography scan of the abdomen and pelvis reveals a 9-mm radiopaque calculus in the proximal left ureter with moderate proximal hydroureteronephrosis and surrounding perinephric fat stranding.

Arrange the following interventions in the most appropriate chronological sequence for the management of this patient.

A patient with end-stage renal disease presents to the emergency department with profound, progressive lower extremity weakness after missing two scheduled hemodialysis sessions. An immediate electrocardiogram reveals peaked T waves and a widened QRS complex. Rapid laboratory testing confirms a serum potassium level of $7.8$ mEq/L.

Arrange the following pharmacologic interventions in the correct, priority-based sequential order for the acute management of this patient's life-threatening condition.

A 72-year-old man is preparing for discharge home after a 4-day hospitalization for community-acquired pneumonia. His vital signs are stable, he is tolerating oral intake, and his oxygen saturation is 96% on room air. Arrange the following fundamental steps of the discharge process in the most appropriate chronological sequence to ensure a safe transition of care.

Match each patient clinical scenario with the most appropriate post-acute care disposition setting.

A resident of a skilled nursing facility is transferred to the intensive care unit due to two days of progressive right upper quadrant pain, high fevers, and profound lethargy. Medical history is notable for severe ischemic cardiomyopathy with a left ventricular ejection fraction of 20%, as well as severe chronic obstructive pulmonary disease requiring home oxygen. On evaluation, blood pressure is 76/42 mm Hg, heart rate is 128/min, and temperature is 39.4°C (102.9°F). Physical examination reveals a rigid, exquisitely tender right subcostal region with localized guarding. Bedside ultrasonography demonstrates a distended gallbladder with an 8-mm thickened wall, significant pericholecystic fluid, and a large stone impacted in the infundibulum. Laboratory studies show a leukocyte count of 22,000/mm³ and an elevated serum lactate. The anesthesiology service determines the patient is currently a prohibitive risk for general anesthesia. Arrange the following management steps in the most appropriate chronological order for this patient's definitive care.

A 48-year-old man is brought to the emergency department via ambulance for continuous seizure activity. His wife witnessed the onset of a generalized tonic-clonic seizure 10 minutes prior to arrival. He has a history of epilepsy but has not taken his medications for the past week. On evaluation, he is unresponsive with continuous generalized rhythmic motor activity. His blood pressure is 145/85 mmHg, pulse is 118/min, and oxygen saturation is 94% on a non-rebreather mask. Intravenous access is rapidly established.

Arrange the following pharmacologic interventions in the correct sequential order according to standard algorithmic management of status epilepticus, starting with initial therapy and progressing to treatment for super-refractory cases.

A 71-year-old man is evaluated in the surgical intensive care unit three hours after an uncomplicated right carotid endarterectomy. The nursing staff alerts the physician because the patient has become increasingly restless and reports sudden, severe difficulty swallowing along with a sensation of choking. His blood pressure is 185/105 mmHg, pulse is 118/min, and respirations are 26/min. Pulse oximetry shows an oxygen saturation of 92% on a 4-liter nasal cannula. On physical examination, the patient is diaphoretic and in moderate respiratory distress with audible inspiratory stridor. The right neck exhibits a tense, rapidly expanding, plum-colored swelling beneath the closed surgical incision. The trachea is palpably deviated to the left. Which of the following is the most appropriate next step in the management of this patient?

A $62$-year-old man presents to the outpatient clinic reporting a $4$-month history of right calf pain. He describes the pain as a severe, cramping ache that consistently begins after walking approximately two blocks. The pain forces him to stop and rest, and it completely resolves within $5$ minutes of standing still. His medical history is significant for type 2 diabetes mellitus, hypertension, hyperlipidemia, and a $40$-pack-year smoking history. His current medications include metformin, lisinopril, and atorvastatin. Vital signs show a blood pressure of $145/88$ mmHg and a heart rate of $78$/min. On physical examination, the skin of the bilateral lower extremities is thin, shiny, and lacks hair distally. The right dorsalis pedis and posterior tibial pulses are palpable but significantly diminished compared to the left. No ulcerations or gangrene are noted. Which of the following is the most appropriate next step in the diagnostic workup?

A 54-year-old woman comes to the oncology clinic for a routine follow-up visit. Six months ago, she underwent a lumpectomy and adjuvant radiation therapy for early-stage right breast cancer. Surgical pathology revealed a tumor that was positive for human epidermal growth factor receptor 2 (HER2) and negative for estrogen and progesterone receptors. She recently completed a course of paclitaxel and is currently receiving maintenance therapy with trastuzumab. She has a history of well-controlled essential hypertension and type 2 diabetes mellitus. Her current medications include lisinopril, metformin, and trastuzumab. She reports feeling well, has resumed her normal daily activities, and exercises for 30 minutes daily without difficulty. She denies chest pain, shortness of breath, orthopnea, or lower extremity edema. Her blood pressure is 124/76 mm Hg, and pulse is 72/min. Physical examination reveals clear lungs, a regular heart rhythm with no murmurs, and no jugular venous distention or peripheral edema. Which of the following is the most appropriate next step in the management of this patient?

A $58$-year-old woman with metastatic breast cancer is evaluated on hospital day $3$. She was initially admitted for acute confusion, severe constipation, and profound lethargy. Laboratory studies on admission showed a corrected serum calcium level of $14.8$ mg/dL. She was promptly treated with aggressive intravenous normal saline, subcutaneous calcitonin, and a single dose of intravenous pamidronate.

Today, her mental status is markedly improved, and she is alert and oriented. Vital signs are temperature $37.0^{\circ}$ C ($98.6^{\circ}$ F), blood pressure $122/78$ mmHg, heart rate $84$/min, and respiratory rate $16$/min.

Current laboratory studies show:
Blood urea nitrogen: $18$ mg/dL
Serum creatinine: $1.1$ mg/dL
Corrected serum calcium: $11.2$ mg/dL

Which of the following is the most appropriate next step in the pharmacologic management of this patient?