Patient Management

A 42-year-old man is diagnosed with a 5-cm right adrenal pheochromocytoma after presenting with episodic palpitations, diaphoresis, and severe hypertension. He is scheduled for a laparoscopic adrenalectomy in 14 days. His current blood pressure is 185/110 mmHg, and his heart rate is 98/min. To ensure optimal surgical outcomes and minimize perioperative complications, an escalating protocol of hemodynamic management is required.

Arrange the following pharmacologic interventions in the correct chronological sequence of administration, from 14 days preoperatively through to the intraoperative period.

A 28-year-old man is brought to the trauma bay via helicopter following a high-speed motorcycle collision where he was thrown approximately 30 feet. Upon arrival, he is pale and diaphoretic. His blood pressure is 82/50 mm Hg, pulse is 135/min, and respirations are 32/min. Oxygen saturation is 89% on 15 L/min via a non-rebreather mask. Physical examination reveals a midline trachea, absent breath sounds over the right hemithorax, and dullness to percussion on the right side. Large-bore intravenous access is established, and a massive transfusion protocol is initiated. A 36-French right-sided tube thoracostomy is performed, yielding an immediate return of 1,650 mL of gross blood. Five minutes later, an additional 200 mL of blood drains into the collection system, and the patient's blood pressure remains 84/52 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

An urgent evaluation is requested in the emergency department for a 54-year-old woman presenting with a 3-day history of progressively worsening, painful oral sores, severe fatigue, and fever. She has a history of seropositive rheumatoid arthritis, for which she has taken weekly methotrexate and daily folic acid for the past 4 years with excellent disease control. One week ago, she was evaluated at an urgent care clinic for a purulent spider bite on her right thigh and was prescribed a 10-day course of trimethoprim-sulfamethoxazole.

Vital signs are temperature 39.2°C (102.6°F), blood pressure 105/65 mm Hg, pulse 112/min, and respirations 18/min. Physical examination reveals pale conjunctivae, diffuse petechiae on the lower extremities, and severe, ulcerated stomatitis with hemorrhagic crusting of the lips. The right thigh skin lesion is healing well with no erythema or fluctuance.

Blood and urine cultures are drawn. In addition to immediate discontinuation of her current home medications and initiation of empiric broad-spectrum intravenous antibiotics, which of the following is the most appropriate targeted pharmacologic intervention?

A 64-year-old man presents to the clinic with a 3-day history of productive cough, fever, and progressive shortness of breath. He has a history of persistent atrial fibrillation, heart failure with preserved ejection fraction, and major depressive disorder. His home medications include sotalol, apixaban, escitalopram, and lisinopril. His temperature is 38.2°C (100.8°F), blood pressure is 130/80 mm Hg, heart rate is 72/min, and respiratory rate is 20/min. Oxygen saturation is 94% on room air. Physical examination reveals bronchial breath sounds and crackles over the right lower lung field. A chest radiograph demonstrates a right lower lobe consolidation. The patient is diagnosed with community-acquired pneumonia, and a decision is made to manage him in the outpatient setting. Which of the following is the most appropriate empiric antibiotic regimen for this patient?

A 42-year-old man comes to the primary care clinic complaining of a 3-day history of fever, chills, productive cough with rust-colored sputum, and shortness of breath. His medical history includes type 2 diabetes mellitus and severe opioid use disorder, for which he has been successfully maintained on a high dose of methadone (100 mg daily) for the past three years. Vital signs are temperature 38.6°C (101.5°F), blood pressure 122/78 mmHg, pulse 94/min, and respiratory rate 22/min. Oxygen saturation is 95% on room air. Physical examination reveals bronchial breath sounds and egophony over the left lower posterior lung fields. A chest radiograph demonstrates a dense left lower lobe consolidation. A recent electrocardiogram obtained for routine screening showed a heart rate of 78/min and a QTc interval of $485 \text{ ms}$ (normal $\leq 440 \text{ ms}$ in males). The physician determines that the patient is clinically stable for outpatient management of community-acquired pneumonia. Which of the following is the most appropriate empiric pharmacologic intervention for this patient?

Emergency medical services bring a 72-year-old male to the emergency department with sudden-onset, agonizing abdominal pain that started 4 hours ago. His past medical history is significant for nonvalvular atrial fibrillation, for which he takes apixaban, as well as hypertension and osteoarthritis. On arrival, his temperature is 38.4°C (101.1°F), blood pressure is 88/50 mm Hg, pulse is 124/min, and respiratory rate is 22/min. He appears diaphoretic and is lying completely still on the gurney. Abdominal examination reveals a rigid, board-like abdomen with severe diffuse tenderness, rebound tenderness, guarding, and absent bowel sounds. An upright chest radiograph demonstrates a crescent of radiolucency beneath the right hemidiaphragm. Laboratory results reveal a leukocyte count of 17,500/mm³ and a hemoglobin of 13.2 g/dL. Which of the following interventions are indicated in the immediate management of this patient? (Select all that apply)

A 38-year-old female presents to the outpatient clinic with a chief complaint of rapid weight gain and easy bruising over the past year. She notes that her menstrual cycles have become irregular, occurring every 6 to 8 weeks. Her medical history includes well-controlled hypertension and polycystic ovary syndrome. Her current medications consist of lisinopril and a combined oral contraceptive pill. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 154/96 mmHg, heart rate of 82/min, and respiratory rate of 14/min. Her body mass index is 34 kg/m $^2$. Physical examination demonstrates a plethoric face, prominent supraclavicular fat accumulation, and wide, purplish striae across the bilateral flanks and lower abdomen. She has trace pitting edema in the lower extremities and exhibits 4/5 strength in the proximal leg muscles. Fasting plasma glucose is 114 mg/dL. Due to strong clinical suspicion for hypercortisolism, a 1-mg overnight dexamethasone suppression test is performed. The 8:00 AM serum cortisol level the following morning is 12.4 $\mu$ g/dL (normal: $< 1.8 \mu$ g/dL).

Which of the following is the most appropriate next step in the diagnostic workup?

A 45-year-old man comes to the clinic for a routine follow-up visit. Four weeks ago, he was diagnosed with active pulmonary tuberculosis and started on a daily regimen of isoniazid, rifampin, pyrazinamide, ethambutol, and pyridoxine. The patient reports that his persistent cough and night sweats have significantly improved since starting therapy. He feels well and specifically denies any nausea, vomiting, abdominal pain, fatigue, or dark urine. Vital signs are within normal limits. Physical examination reveals no scleral icterus, and the abdomen is soft and non-tender without hepatomegaly. Routine follow-up laboratory studies are obtained and show the following results:

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

During morning rounds on the surgical ward, the team is urgently called to evaluate a patient recovering from a sigmoid colectomy performed four days prior. The patient, a 64-year-old retired teacher, reports an abrupt onset of excruciating, diffuse abdominal pain that started two hours ago. His vital signs show a temperature of 39.1°C (102.4°F), blood pressure of 82/48 mm Hg, and a heart rate of 132/min. On physical examination, the patient lies completely still in bed. Palpation of the abdomen reveals board-like rigidity, diffuse guarding, and pronounced rebound tenderness in all quadrants. Bowel sounds are absent. Following the placement of two large-bore intravenous lines, aggressive crystalloid resuscitation and broad-spectrum antibiotics are initiated. What is the most appropriate next step in the procedural management of this patient?

A 35-year-old woman is evaluated in the clinic due to a six-month history of episodic, severe headaches accompanied by profound diaphoresis and a sensation of a racing heart. She reports that these episodes occur spontaneously and last for 15 to 20 minutes. In the clinic, her blood pressure is 172/104 mmHg, and her heart rate is 98/min. The remainder of her physical examination is unremarkable. Given the high clinical suspicion for a catecholamine-secreting tumor, arrange the following diagnostic steps in the most appropriate standard sequence, progressing from initial screening to comprehensive preoperative staging and risk stratification.

A $64$-year-old man with a $15$-year history of poorly controlled type 2 diabetes mellitus and peripheral arterial disease is brought to the emergency department due to altered mental status and severe right foot pain. His temperature is $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, heart rate is $122/\text{min}$, and respiratory rate is $22/\text{min}$. Examination reveals a black, malodorous ulcer over the right first metatarsal head. There is surrounding erythema, significant edema, and palpable crepitus extending to the midfoot. Right dorsalis pedis and posterior tibial pulses are not palpable by manual examination or Doppler ultrasound. Laboratory studies show a leukocyte count of $24,000/\text{mm}^3$ and serum lactate of $4.8\text{ mmol/L}$. Arrange the following procedural and management steps in the most appropriate chronological order.

A 68-year-old retired architect is brought to the clinic by his husband due to a 14-month history of progressive cognitive changes. The husband reports that the patient frequently misplaces household items, repeats questions in conversation, and recently struggled to complete their annual tax return—a task he previously managed with ease. The patient has a medical history of essential hypertension and hyperlipidemia, both well-controlled on lisinopril and atorvastatin. Vital signs are within normal limits. A complete blood count and comprehensive metabolic panel obtained during a health fair one month ago were completely normal, with no evidence of anemia or electrolyte derangements. Neurological examination shows normal cranial nerves, strength, and reflexes, and his gait is steady. A Montreal Cognitive Assessment (MoCA) is performed, and the patient scores 21/30, losing points primarily on delayed recall and visuospatial tasks. Along with a comprehensive history and physical examination, which of the following tests should be ordered as part of the complete set of initial concurrent diagnostic workup? (Select 3)

A 21-year-old woman is brought to the emergency department by her roommate due to progressive confusion, nausea, vomiting, and ringing in her ears for the past 4 hours. The roommate reports finding several empty bottles of over-the-counter pain relievers in their shared bathroom. On arrival, her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $118/74\text{ mmHg}$, pulse is $122/\text{min}$, and respirations are $28/\text{min}$. Physical examination reveals a diaphoretic, mildly agitated patient. Cardiopulmonary examination is unremarkable except for tachycardia and tachypnea.

Laboratory results are as follows:

Serum chemistry:
Sodium: $141\text{ mEq/L}$
Potassium: $3.2\text{ mEq/L}$
Chloride: $101\text{ mEq/L}$
Bicarbonate: $14\text{ mEq/L}$
BUN: $14\text{ mg/dL}$
Creatinine: $0.9\text{ mg/dL}$
Glucose: $88\text{ mg/dL}$

Arterial blood gas (room air):
pH: $7.45$
pCO2: $19\text{ mmHg}$
pO2: $98\text{ mmHg}$

Serum salicylate level is $65\text{ mg/dL}$ (therapeutic $15-30\text{ mg/dL}$). Acetaminophen level is undetectable.

The physician plans to initiate therapy to enhance the systemic elimination of the ingested toxin. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 52-year-old woman is evaluated in the ambulatory clinic for a routine wellness examination. She reports feeling generally well but mentions experiencing mild, intermittent palpitations over the last three months. She denies heat intolerance, unintentional weight loss, or changes in bowel habits. She has no history of neck radiation or family history of thyroid disease. Her heart rate is $88 \text{ /min}$ and blood pressure is $126/78 \text{ mm Hg}$. On physical examination, a $2.2 \text{ cm}$, firm, mobile, and non-tender nodule is palpated in the right lobe of her thyroid gland. There is no cervical lymphadenopathy. Initial laboratory testing reveals a serum thyroid-stimulating hormone (TSH) level of $0.05 \text{ mU/L}$ (normal: $0.4 - 4.0 \text{ mU/L}$). A subsequent ultrasound of the neck confirms a $2.2 \text{ cm}$ solid, isoechoic nodule in the right thyroid lobe without suspicious sonographic features such as microcalcifications or irregular margins. Which of the following is the most appropriate next step in the diagnostic workup of this patient's nodule?

A 54-year-old man is brought to the emergency department by his wife after he vomited a large amount of bright red blood at home. His medical history is significant for chronic hepatitis C infection and alcohol use disorder. Upon arrival, the patient is lethargic and moans incomprehensibly, opening his eyes only to a sternal rub. Vital signs are temperature 36.2°C (97.2°F), pulse 132/min, blood pressure 78/45 mmHg, respiratory rate 26/min, and oxygen saturation 93% on room air. Physical examination reveals scleral icterus, palmar erythema, and a distended, non-tender abdomen with shifting dullness. Large-bore peripheral intravenous access is obtained, and aggressive volume resuscitation with crystalloids and blood products is initiated. Which of the following is the most appropriate next step in the management of this patient?

A $61$-year-old woman presents to the emergency department with a $1$-day history of sharp right-sided chest pain that worsens with deep inspiration, accompanied by progressive shortness of breath. She has a history of type 2 diabetes mellitus, hypertension, and stage 4 chronic kidney disease. Her current medications include amlodipine, insulin glargine, and atorvastatin. Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $138/82\text{ mmHg}$, pulse is $114/\text{min}$, and respirations are $22/\text{min}$. Pulse oximetry shows $92\%$ on room air. BMI is $34\text{ kg/m}^2$. Physical examination is notable for mild swelling and tenderness in the right calf. Laboratory testing shows a serum creatinine of $2.9\text{ mg/dL}$ (baseline $2.7\text{ mg/dL}$) and an estimated creatinine clearance of $17\text{ mL/min}$. Computed tomography pulmonary angiography demonstrates a filling defect in the right lower lobe pulmonary artery. Transthoracic echocardiography reveals normal right ventricular size and function. Which of the following is the most appropriate initial pharmacologic intervention?

A 31-year-old man is brought to the trauma bay by helicopter emergency medical services following a motorcycle crash. He was thrown approximately 30 feet into a ditch. On arrival, he is confused, agitated, and diaphoretic. His airway is intact, and breath sounds are present and equal bilaterally. Vital signs show a temperature of 36.2°C (97.2°F), heart rate of 148/min, blood pressure of 68/38 mm Hg, respiratory rate of 28/min, and oxygen saturation of 95% on 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals extensive ecchymosis over the lower abdomen and perineum, a mechanically unstable pelvis to lateral compression, and a visibly deformed right thigh. Two 16-gauge peripheral intravenous catheters are rapidly established. Which of the following interventions should be ordered simultaneously as the immediate next steps in the patient's stabilization? (Select 3)

A $28$-year-old woman is rushed to the emergency resuscitation bay after collapsing at a local shopping center. Emergency medical technicians report that she was initially responsive but became confused and profoundly lethargic during transport. According to her partner, she had been complaining of escalating, sharp right-sided pelvic pain over the past $24$ hours. Her last menstrual period was approximately eight weeks ago. Upon arrival, her temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $72/40\text{ mmHg}$, heart rate is $142\text{/min}$, and respiratory rate is $24\text{/min}$. Physical examination demonstrates marked pallor, diaphoresis, and a rigid, distended abdomen with diffuse guarding. A rapid point-of-care urine pregnancy test is positive. Bedside focused assessment with sonography for trauma (FAST) reveals a massive amount of free fluid in the hepatorenal recess and the rectouterine pouch. Aggressive intravenous fluid resuscitation with crystalloids and uncrossmatched type O-negative packed red blood cells is immediately initiated through two large-bore peripheral catheters. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and fever. She has a history of Graves disease but stopped taking her antithyroid medications three months ago. Her temperature is 39.4°C (103.0°F), blood pressure is 158/72 mmHg, and pulse is 152/min and irregular. Physical examination reveals a diffuse, non-tender goiter, marked diaphoresis, and a fine tremor. An electrocardiogram demonstrates atrial fibrillation with rapid ventricular response. A clinical diagnosis of thyroid storm is made. While multiple therapies are required for comprehensive management, they must be administered in a highly specific physiological sequence to prevent the paradoxical worsening of the thyrotoxicosis. Arrange the following pharmacologic interventions in the correct chronological order of administration.

Emergency medical services transport a 42-year-old man to the emergency department for an ongoing seizure. Paramedics report the patient's wife witnessed the onset of generalized tonic-clonic activity 12 minutes prior to arrival. He has a known history of epilepsy and recently missed several doses of his home medications. Upon arrival, the patient remains unresponsive with continuous, rhythmic jerking of all four extremities. Vital signs show a blood pressure of 160/95 mmHg, a heart rate of 132/min, and an oxygen saturation of 94% on a non-rebreather mask. A point-of-care blood glucose level is 115 mg/dL. Intravenous access is rapidly secured. Arrange the following pharmacologic interventions in the correct chronological sequence for the stepwise management of this patient's status epilepticus, starting with the most appropriate immediate therapy and escalating to treatments for refractory and super-refractory cases.