Patient Management

Paramedics transport a 74-year-old male resident of an assisted living facility to the acute care triage area. The facility staff reported that he has been complaining of worsening lower abdominal discomfort and has had three episodes of bilious vomiting since yesterday evening. His medical history includes hypertension, benign prostatic hyperplasia, and mild vascular dementia. On arrival, his temperature is 38.3°C (100.9°F), blood pressure is 102/60 mmHg, heart rate is 118/min, and respiratory rate is 20/min. Physical examination reveals a $4 \times 5$ cm firm mass in the right inguinal region. The mass is exquisitely tender to palpation and cannot be reduced into the peritoneal cavity. The skin overlying the mass is warm and displays a dark purplish discoloration. Laboratory testing shows a leukocyte count of $16,500/\mu L$. Which of the following is the most appropriate next step in the management of this patient?

A $32$-year-old woman is brought to the emergency department by her family due to profound confusion, agitation, and a high fever. She has a history of Graves disease but stopped taking her prescribed medications three months ago. On presentation, her temperature is $39.8^\circ \text{C}$ ($103.6^\circ \text{F}$), blood pressure is $160/70$ mm Hg, heart rate is $155$/min and irregular, and respiratory rate is $24$/min. Physical examination reveals a restless, diaphoretic patient with prominent exophthalmos, a diffusely enlarged and non-tender thyroid gland, a fine tremor in her outstretched hands, and a faint yellowing of her sclerae. An electrocardiogram confirms atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is made. Arrange the following pharmacologic agents in the correct chronological sequence for the protocolized management of this patient's endocrine emergency.

An $82$-year-old woman is brought to the emergency department due to unrelenting right lower extremity pain. She was found by her neighbor on the floor of her apartment. The patient states the pain began abruptly $16$ hours ago. Her medical history includes type $2$ diabetes mellitus, hypertension, and paroxysmal atrial fibrillation. She is not taking oral anticoagulants. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $158/92\text{ mm Hg}$, pulse $115/\text{min}$ and irregularly irregular, and respirations $18/\text{min}$. On physical examination, the right lower extremity is cyanotic, mottled, and cold to the touch from the mid-thigh down. Capillary refill is absent. The patient has complete loss of sensation to pinprick and light touch below the knee. She is unable to move her toes or ankle, and the calf muscles are rigid and tender to palpation. Bedside Doppler ultrasonography reveals absent arterial and venous signals in the right foot. Which of the following is the most appropriate next step in the management of this patient's right lower extremity?

A 58-year-old man is brought to the emergency department by his family due to confusion, fever, and worsening abdominal swelling over the past 48 hours. His medical history is significant for alcohol-associated cirrhosis, portal hypertension, and prior esophageal variceal banding. Current home medications include spironolactone, furosemide, and nadolol. Vital signs show a temperature of 38.3°C (100.9°F), blood pressure of 96/58 mmHg, and heart rate of 105/min. Physical examination reveals scleral icterus, a distended abdomen with shifting dullness, and diffuse abdominal tenderness to palpation without rebound or guarding. The patient is disoriented to time and place, and asterixis is present on wrist extension.

Pertinent laboratory results are as follows:

Diagnostic paracentesis is performed, yielding cloudy ascitic fluid with a polymorphonuclear (PMN) cell count of 650/mm³.

Which of the following pharmacologic interventions are appropriate to initiate simultaneously in this patient? (Select all that apply)

An internal medicine physician is evaluating a 72-year-old man for worsening renal function discovered on routine laboratory monitoring. The patient has a history of resistant hypertension that has been difficult to control despite maximum tolerated doses of amlodipine, metoprolol, and chlorthalidone. Three weeks ago, lisinopril was added to his medication regimen to achieve better blood pressure control. The patient currently feels well and denies any headache, chest pain, shortness of breath, or changes in urination.

Vital signs today show a blood pressure of 182/98 mmHg and a heart rate of 74/min. Physical examination is notable for a high-pitched holosystolic murmur heard best over the right upper quadrant of the abdomen.

Current laboratory studies are compared to baseline from three weeks ago:

Urinalysis reveals no red blood cells, white blood cells, or casts.

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's hypertension?

A 42-year-old previously healthy woman arrives at the emergency department reporting the sudden onset of severe, continuous pain in her upper abdomen that radiates directly to her mid-back. She has vomited three times since the pain started four hours ago. She reports no recent alcohol use or new medications. Her temperature is 37.8°C (100.0°F), blood pressure is 135/85 mm Hg, pulse is 110/min, and respiratory rate is 18/min. Examination reveals significant tenderness in the epigastric region with voluntary guarding, but no rebound tenderness or rigidity. Bowel sounds are hypoactive. Which of the following diagnostic studies should be ordered concurrently as part of this patient's initial evaluation? (Select all that apply)

A 28-year-old man is brought to the emergency department by emergency medical services after being rescued from a residential house fire. Firefighters report that he was trapped in a closed, smoke-filled bedroom for approximately 10 minutes before being extracted. On arrival, the patient is agitated and speaking in a hoarse voice. He is coughing up dark, carbonaceous sputum. Physical examination reveals partial-thickness burns over his anterior chest and bilateral upper extremities, estimated to involve 18% of his total body surface area. Examination of the face reveals singed nasal hairs, soot in the oropharynx, and mild facial erythema. Lung auscultation demonstrates diffuse bilateral wheezing. Vital signs are: temperature 37.1°C (98.8°F), pulse 122/min, blood pressure 114/72 mm Hg, respiratory rate 26/min, and oxygen saturation 96% on a 15 L/min non-rebreather mask. Which of the following is the most appropriate immediate next step in the management of this patient?

A 68-year-old man comes to the outpatient clinic for a follow-up examination regarding his heart failure. He was diagnosed with New York Heart Association (NYHA) class III heart failure with a reduced ejection fraction (HFrEF) six months ago. An echocardiogram at that time showed a left ventricular ejection fraction of $25\%$. His past medical history is significant for hypertension, type 2 diabetes mellitus, and severe bilateral renal artery stenosis that was diagnosed via magnetic resonance angiography two years ago. His current medications include carvedilol, furosemide, and atorvastatin. The patient reports stable dyspnea on exertion but denies orthopnea, paroxysmal nocturnal dyspnea, or recent weight gain. Vital signs include a blood pressure of $142/86 \text{ mmHg}$ and a regular heart rate of $62 \text{ /min}$. Physical examination reveals a jugular venous pressure of $6 \text{ cm H}_2\text{O}$. The lungs are clear to auscultation bilaterally, and there is no lower extremity edema. Laboratory studies show:

Serum sodium: $138 \text{ mEq/L}$
Serum potassium: $5.6 \text{ mEq/L}$
Blood urea nitrogen: $34 \text{ mg/dL}$
Serum creatinine: $2.2 \text{ mg/dL}$

Which of the following is the most appropriate next step in pharmacologic management to reduce this patient's long-term mortality?

A $34$-year-old man is brought to the emergency department via ambulance after being struck by a high-speed vehicle as a pedestrian. On arrival, he is confused and visibly diaphoretic. His blood pressure is $72/40 \text{ mmHg}$, heart rate is $142 \text{ /min}$, and respiratory rate is $28 \text{ /min}$. Pulse oximetry shows $94\%$ on a non-rebreather mask. The airway is patent, and breath sounds are equal bilaterally. The abdomen is tense and distended. Physical examination reveals an unstable pelvic ring upon gentle medial compression of the iliac crests. Two large-bore peripheral intravenous lines are established, and balanced blood product resuscitation is initiated.

Arrange the following procedural and diagnostic steps in the most appropriate chronological sequence for managing this patient's condition:

A $45$-year-old male is evaluated in the surgical intensive care unit due to worsening respiratory mechanics and hemodynamic instability. He was admitted yesterday after sustaining major trauma in a motor vehicle collision, which necessitated an emergent damage-control laparotomy with perihepatic packing for a severe liver laceration. A temporary abdominal closure device was placed at the conclusion of the surgery. Over the past two hours, the patient's urine output has decreased to $15$ mL/hour. Current vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $80/48$ mm Hg, and a heart rate of $132$/min. The mechanical ventilator is alarming frequently for high peak inspiratory pressures. Physical examination reveals an extremely tense and distended abdomen. Bladder pressure measurement reveals an intra-abdominal pressure of $29$ mm Hg. Which of the following is the most appropriate next step in the management of this patient?

A 46-year-old male patient presents to the internal medicine clinic due to poorly controlled hypertension. His current medication regimen consists of maximally tolerated doses of amlodipine, olmesartan, and chlorthalidone. Today, his resting blood pressure is 168/94 mm Hg. Physical examination is unremarkable with no abdominal bruits, edema, or cushingoid features. Laboratory studies reveal a serum potassium level of 2.8 mEq/L and a serum bicarbonate level of 30 mEq/L. Given the presence of severe hypertension and spontaneous hypokalemia, there is strong suspicion for a specific secondary etiology. The patient's antihypertensive regimen is transitioned to doxazosin and verapamil for several weeks to prevent assay interference, and a stepwise diagnostic evaluation is planned. Arrange the following diagnostic studies in the most appropriate, guideline-directed sequence to evaluate this patient's condition, from the initial diagnostic step to definitive pre-surgical planning.

A $22$-year-old male is transported to the trauma center by police officers following a physical altercation. He sustained a stab wound to the left anterior neck. On arrival, the patient is highly agitated and holding a blood-soaked garment to his neck. Blood is actively oozing from the wound site. His voice is noticeably hoarse, and he is coughing up bright red blood. Vital signs reveal a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $105/65\text{ mmHg}$, pulse of $118/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is $89\%$ on room air. Physical examination demonstrates an expanding, pulsatile hematoma on the left side of the neck and audible biphasic stridor. Which of the following is the most appropriate immediate next step in the management of this patient?

A $72$-year-old man is brought to the emergency department from a skilled nursing facility due to altered mental status, fever, and purulent sputum production over the past $24$ hours. His medical history is significant for severe chronic obstructive pulmonary disease (COPD), type $2$ diabetes mellitus, and chronic kidney disease stage $3$. Three weeks ago, he was treated with a $10$-day course of oral levofloxacin for a COPD exacerbation.

On arrival, his temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $82/50\text{ mm Hg}$, pulse is $122/\text{min}$, and respirations are $28/\text{min}$. Oxygen saturation is $86\%$ on room air.

Physical examination reveals coarse crackles in the right lung base and decreased breath sounds globally.

Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ with $15\%$ bands, blood urea nitrogen of $42\text{ mg/dL}$, and a serum creatinine of $2.1\text{ mg/dL}$ (baseline $1.4\text{ mg/dL}$).

Chest radiograph demonstrates a dense consolidation in the right lower lobe.

After securing the airway and administering a rapid intravenous fluid bolus, vasopressor therapy is initiated.

Which of the following antimicrobial agents should be included in this patient's empiric regimen? (Select all that apply)

A 45-year-old construction worker is brought to the emergency department after a trench collapsed, trapping his right lower extremity under heavy debris for 4 hours. On arrival, he is in significant distress due to excruciating pain in his right calf, which he describes as "10 out of 10." The pain is markedly exacerbated by passive dorsiflexion of his toes. Vital signs show a blood pressure of 135/85 mm Hg, heart rate of 110/min, and respiratory rate of 18/min. Physical examination reveals a tense, swollen right calf with tight, shiny overlying skin. Both dorsalis pedis and posterior tibial pulses are palpable and symmetric to the contralateral side. Capillary refill is 4 seconds in the right foot. A urinary catheter is placed, yielding dark reddish-brown urine. Direct manometry of the right anterior compartment demonstrates a pressure of 45 mm Hg. Based on these findings, which of the following interventions are indicated in the immediate management of this patient? (Select all that apply.)

A 74-year-old woman is brought to the emergency department by her family due to sudden, severe abdominal pain that began 8 hours ago. She has a history of heart failure with reduced ejection fraction and paroxysmal atrial fibrillation. She was previously taking apixaban but discontinued it one month ago after sustaining a traumatic subdural hematoma from a mechanical fall. On arrival, the patient is lethargic and moaning in pain. Her temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $78/48 \text{ mmHg}$, pulse is $132/\text{min}$ and irregularly irregular, and respirations are $24/\text{min}$. Physical examination reveals a distended abdomen that is rigidly tense. There is diffuse rebound tenderness, involuntary guarding, and absent bowel sounds. Laboratory studies show a leukocyte count of $22,000/\mu\text{L}$ and a serum lactate of $7.8 \text{ mmol/L}$. Which of the following is the most appropriate next step in management?

A 42-year-old woman is evaluated in the ambulatory clinic for an 8-month history of progressively worsening exertional dyspnea and fatigue. She has no prior medical conditions, takes no medications, and has never smoked. Vital signs include a blood pressure of 118/76 mmHg, heart rate of 88/min, and respiratory rate of 16/min. Pulse oximetry is 96% on room air.

Cardiovascular examination reveals a regular rate and rhythm, a prominently loud pulmonic component of the second heart sound, and a grade 2/6 holosystolic murmur at the left lower sternal border that increases in intensity with inspiration. The lungs are clear to auscultation bilaterally. There is no jugular venous distention or peripheral edema.

An electrocardiogram demonstrates right axis deviation and right ventricular hypertrophy. A transthoracic echocardiogram reveals an estimated pulmonary artery systolic pressure of 62 mmHg, right ventricular enlargement, and normal left ventricular size and systolic function with no left-sided valvular abnormalities.

Subsequent pulmonary function testing, including spirometry and diffusing capacity of the lungs for carbon monoxide (DLCO), is within normal limits. High-resolution computed tomography of the chest reveals clear lung fields without interstitial lung disease or emphysema.

Which of the following is the most appropriate next step in the diagnostic workup of this patient's condition?

While conducting rounds in the intensive care unit, a physician is urgently called to the bedside of a 72-year-old man who suddenly developed aphasia and right-sided hemiparesis. The patient was admitted five days earlier for the management of a massive saddle pulmonary embolism and has been receiving a continuous intravenous infusion of unfractionated heparin since admission. His medical history includes hypertension, diet-controlled type 2 diabetes, and a mechanical mitral valve replacement performed four years ago.

Vital signs currently show a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $110/65\text{ mmHg}$, heart rate of $118/\text{min}$, and respiratory rate of $22/\text{min}$. Physical examination is notable for a new grade 3/6 holosystolic murmur radiating to the axilla. Neurological assessment confirms global aphasia and dense right hemiplegia.

Immediate laboratory analysis reveals:
Leukocyte count: $19,500/\text{mm}^3$
Hemoglobin: $10.4\text{ g/dL}$
Platelet count: $42,000/\text{mm}^3$ (baseline on admission was $215,000/\text{mm}^3$)
Serum creatinine: $2.1\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$)

An emergent non-contrast CT scan of the head reveals a large acute ischemic infarction in the left middle cerebral artery territory, complicated by scattered petechial hemorrhages. A subsequent bedside transthoracic echocardiogram demonstrates a $1.2\text{ cm}$ highly mobile vegetation attached to the mechanical mitral valve. Blood cultures have been obtained.

Which of the following pharmacologic interventions are appropriate in the immediate management of this patient? (Select all that apply)

A 59-year-old man is admitted to the hospital with a 3-week history of severe fatigue, night sweats, and intermittent chills. His past medical history is significant for benign prostatic hyperplasia with recurrent urinary tract infections, as well as chronic kidney disease stage 4 secondary to hypertensive nephrosclerosis. His baseline estimated glomerular filtration rate is 22 mL/min/1.73 m². Current home medications include amlodipine, tamsulosin, and sodium bicarbonate. On examination, temperature is 38.3°C (100.9°F), blood pressure is 138/85 mm Hg, and pulse is 96/min. Cardiovascular examination reveals a new 3/6 holosystolic murmur loudest at the cardiac apex. Dermatologic examination shows several painful, violaceous nodules on the palmar aspects of the fingers. Transesophageal echocardiography demonstrates a 1.2-cm oscillating vegetation on the mitral valve. Blood cultures are drawn, and all four bottles grow *Enterococcus faecalis*. Antimicrobial susceptibility testing reveals the isolate is susceptible to ampicillin, vancomycin, and linezolid, with no high-level aminoglycoside resistance detected. Which of the following is the most appropriate definitive intravenous pharmacotherapy for this patient's infection?

A 34-year-old female is evaluated in the post-anesthesia care unit 45 minutes after undergoing a total thyroidectomy for Graves disease. The nursing staff urgently calls the physician because the patient has become extremely agitated, is grasping at her neck, and is struggling to breathe. Vital signs are temperature 37.1°C (98.8°F), blood pressure 168/96 mmHg, heart rate 124/min, and respiratory rate 28/min. Oxygen saturation is 86% on a non-rebreather mask. Physical examination reveals audible biphasic stridor, a tense and rapidly expanding swelling of the anterior neck, and fresh ecchymosis extending toward the sternal notch. The surgical dressing is saturated with bright red blood. Arrange the following interventions in the most appropriate chronological order for managing this patient's acute complication.

A 55-year-old male with a history of alcohol-associated cirrhosis arrives at the emergency department via ambulance after vomiting a large volume of bright red blood. He is confused and lethargic. Vital signs show a temperature of 36.8°C (98.2°F), blood pressure of 82/45 mm Hg, heart rate of 128/min, and respiratory rate of 22/min. Physical examination reveals scleral icterus, spider angiomas on the chest, and a distended abdomen with a positive fluid wave. The patient continues to have active hematemesis in the trauma bay.

Arrange the following management steps and procedural interventions in the most appropriate chronological sequence for this patient, assuming each successive intervention fails to achieve definitive hemostasis.