Patient Management

A $78$-year-old woman is brought to the emergency department from a skilled nursing facility due to severe abdominal pain and altered mental status. Staff report that she has had progressive abdominal distention, nausea, and no bowel movements for the past $3$ days. Her past medical history is significant for Parkinson disease, chronic constipation, and moderate Alzheimer dementia. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse is $122/\text{min}$, blood pressure is $85/55\text{ mmHg}$, and respirations are $24/\text{min}$. Physical examination reveals a massively distended abdomen that is diffusely tender to palpation, with severe rigidity and involuntary guarding. Bowel sounds are absent. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$ and a serum lactate level of $4.8\text{ mmol/L}$. An upright abdominal radiograph demonstrates a markedly dilated loop of colon extending from the pelvis to the right upper quadrant in an inverted U-shape, lacking haustra. Which of the following is the most appropriate next step in management?

A 52-year-old man comes to the clinic due to a new-onset tremor and headaches over the past 3 days. He underwent a deceased-donor renal transplantation 8 months ago for end-stage renal disease secondary to hypertensive nephrosclerosis. His maintenance immunosuppression regimen consists of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Two weeks ago, he was diagnosed with esophageal candidiasis by his primary care physician and was started on a 14-day course of oral fluconazole. His temperature is 37.1°C (98.8°F), blood pressure is 168/95 mmHg (baseline 125/80 mmHg), and heart rate is 82/min. Physical examination reveals a fine resting tremor in both hands. The renal allograft is non-tender to palpation.

Laboratory studies show:
Blood urea nitrogen: 42 mg/dL
Serum creatinine: 2.7 mg/dL (baseline 1.3 mg/dL)
Serum potassium: 5.2 mEq/L
Urinalysis: Trace protein, no red blood cells, no white blood cells

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

A 64-year-old woman is evaluated in the surgical intensive care unit for a rapidly declining platelet count. Seven days ago, she underwent a complex coronary artery bypass grafting procedure. Her postoperative course was initially uncomplicated, and she has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. Today, her platelet count is 55,000/μL, representing a 65% drop from her baseline of 180,000/μL. Examination reveals a new, painful, swollen right lower extremity. Venous duplex ultrasonography confirms an acute right popliteal deep vein thrombosis. A clinical diagnosis of heparin-induced thrombocytopenia (HIT) is suspected based on a 4T score of 6 (high probability). Arrange the following management and monitoring steps in the most appropriate chronological sequence for this patient.

A 67-year-old woman is evaluated in the cardiology clinic for a three-month history of episodic chest heaviness. She reports that the discomfort occurs when she performs upper body exertion, such as vacuuming or carrying groceries, and resolves completely after approximately five minutes of rest. Her medical history is significant for type 2 diabetes mellitus, hypertension, hyperlipidemia, advanced bilateral knee osteoarthritis, and severe persistent asthma. She relies on a motorized scooter for mobility due to debilitating joint pain. Her respiratory regimen includes a daily high-dose fluticasone-salmeterol inhaler and oral montelukast, but she still requires albuterol rescue therapy three to four times a week. Vital signs include a blood pressure of $146/88$ mm Hg and a heart rate of $76$/min. Physical examination reveals bilateral end-expiratory wheezes and pronounced crepitus in both knees. The cardiac examination is unremarkable. Her baseline electrocardiogram displays normal sinus rhythm without ischemic changes or conduction delays. Which of the following is the most appropriate next step in diagnostic workup?

A 76-year-old woman is admitted to the hospital from the emergency department due to a 3-day history of a productive cough, fever, and worsening shortness of breath. Her past medical history is significant for hypertension, type 2 diabetes mellitus, and major depressive disorder. Her current medications include lisinopril, metformin, and citalopram. She has a documented allergy to amoxicillin, which caused a maculopapular rash on her trunk when she was a teenager; she has never experienced anaphylaxis, wheezing, or lip swelling.

Vital signs include a temperature of $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure of $118/74\text{ mmHg}$, pulse of $102/\text{min}$, and respiratory rate of $26/\text{min}$. Pulse oximetry shows $91\%$ on room air. Physical examination reveals bronchial breath sounds and crackles in the right lower lung field. Laboratory studies show a leukocyte count of $14,500/\mu\text{L}$ with $85\%$ neutrophils. Chest radiograph demonstrates a right lower lobe consolidation. An electrocardiogram obtained on admission shows normal sinus rhythm with a QTc interval of $495\text{ ms}$.

Which of the following is the most appropriate empiric pharmacologic intervention for this patient?

Correlate the following specific clinical risk profiles and functional assessments with their optimal disposition or care transition setting according to standard medical guidelines.

A 48-year-old male presents to the clinic complaining of excessive sweating, diffuse joint pain, and a gradual increase in his shoe size over the past three years. He also mentions that he recently had to have his wedding ring resized because it would no longer fit over his knuckle. On physical examination, his blood pressure is 148/92 mm Hg. He is noted to have coarse facial features, a prominent mandible, macroglossia, and enlarged, doughy hands. The physician strongly suspects an underlying endocrine disorder characterized by hormonal hypersecretion.

Assuming each step confirms the progression of the diagnostic pathway, arrange the following clinical evaluations in the most appropriate sequential order to screen for, confirm, localize, and assess the local complications of this patient's suspected condition.

A 45-year-old man comes to the clinic for a routine follow-up. He has a 5-year history of bipolar I disorder, which has been well-controlled on lithium monotherapy. He has not experienced a manic or depressive episode since starting this medication. Over his last three clinic visits, his blood pressure has been consistently elevated, averaging $154/92$ mm Hg. He has strictly adhered to a low-sodium diet and a regular aerobic exercise program for the past 6 months without significant improvement in his blood pressure. His body mass index is $26$ kg/m $^2$. The remainder of his physical examination is unremarkable. Laboratory studies reveal a serum creatinine of $0.9$ mg/dL and a serum lithium level of $0.8$ mEq/L (therapeutic range: $0.6-1.2$ mEq/L). A decision is made to initiate pharmacologic therapy for his essential hypertension. Which of the following is the most appropriate initial antihypertensive medication for this patient?

An emergency physician evaluates a 62-year-old man who reports three days of progressively worsening left lower abdominal pain accompanied by fever and chills. His medical history is significant for hypertension and hyperlipidemia, both well-controlled with medications. His temperature is 38.7°C (101.7°F), blood pressure is 134/82 mm Hg, pulse is 105/min, and respiratory rate is 16/min. Physical examination demonstrates marked tenderness and guarding over the left lower quadrant, but the abdomen is otherwise soft without diffuse rigidity or generalized rebound tenderness. Laboratory studies show a leukocyte count of 16,500/mm³ with 82% neutrophils. A contrast-enhanced computed tomography scan of the abdomen and pelvis reveals inflammatory changes adjacent to the sigmoid colon, complicated by a well-defined, 5.2-cm unilocular pericolic fluid collection with an enhancing rim. There is no evidence of free intraperitoneal air. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old woman with a history of diffuse large B-cell lymphoma presents to the emergency department with chills and a temperature of $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$). She received her last cycle of cytotoxic chemotherapy 8 days ago. Laboratory studies show a white blood cell count of $700/\text{mm}^3$ with $30\%$ neutrophils (absolute neutrophil count: $210/\text{mm}^3$). She is hemodynamically stable, has a central venous port in place, and has no localizing signs of infection on physical examination. Arrange the following steps in the optimal sequence for the evaluation, monitoring, and therapeutic de-escalation of this patient's condition.

For each of the described post-acute recovery profiles, determine the most appropriate transition of care destination based on facility admission criteria and patient functional capacity.

Paramedics bring a $62$-year-old male to the emergency department after he experienced sudden-onset right-sided pleuritic chest pain and dyspnea. He currently resides in a local homeless shelter and has a history of essential hypertension. Upon arrival, his vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $135/85\text{ mm Hg}$, heart rate of $92\text{/min}$, and respiratory rate of $18\text{/min}$. Pulse oximetry is $96\%$ on room air. Physical examination reveals mild right calf swelling and tenderness. Laboratory analysis demonstrates normal high-sensitivity troponin I and NT-proBNP levels, alongside normal renal function. A CT pulmonary angiogram confirms a small acute segmental pulmonary embolism in the right lower lobe. Transthoracic echocardiography reveals a normal right ventricle without evidence of strain. The patient's calculated Pulmonary Embolism Severity Index (PESI) score is $55$ (Class I, very low risk). Which of the following is the most appropriate disposition for this patient?

A 72-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, tearing back pain and dizziness that began 30 minutes ago. His medical history is significant for hypertension, hyperlipidemia, and a 40-pack-year smoking history. Upon arrival, he appears pale, diaphoretic, and lethargic. His temperature is 36.5°C (97.7°F), blood pressure is 78/45 mm Hg, heart rate is 122/min, and respiratory rate is 22/min. Physical examination reveals a large, pulsatile mid-abdominal mass. Bedside ultrasonography demonstrates a 7.5-cm abdominal aortic aneurysm with adjacent free intra-abdominal fluid. Two large-bore peripheral intravenous lines are established. Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

A 62-year-old man with a history of a mechanical mitral valve replacement comes to the outpatient clinic for routine coagulation monitoring. Five days ago, he was evaluated at an urgent care center for a purulent skin infection and was started on oral trimethoprim-sulfamethoxazole. His current medications include warfarin, metoprolol, and lisinopril. The patient reports feeling well and denies any epistaxis, hematuria, melena, or easy bruising. Vital signs are within normal limits. Physical examination reveals a healing area of cellulitis on the right lower extremity, with no evidence of petechiae or ecchymoses.

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

An ambulatory care appointment is scheduled for a 64-year-old male patient who is being managed for chronic heart failure with reduced ejection fraction (HFrEF). Over the past three months, he has noticed a progressive decline in his exercise tolerance and now experiences shortness of breath when walking up a single flight of stairs, consistent with New York Heart Association (NYHA) class III symptoms. His current daily medication regimen comprises lisinopril 40 mg, metoprolol succinate 100 mg, and spironolactone 25 mg. In the clinic, his blood pressure measures $128/82 \text{ mmHg}$ and heart rate is $68 \text{/min}$. The physical examination is notable for mild jugular venous distention and trace bilateral lower extremity edema. A recent echocardiogram confirms a left ventricular ejection fraction of $32\%$. Serum laboratory analysis reveals a potassium level of $4.6 \text{ mEq/L}$ and an estimated glomerular filtration rate of $58 \text{ mL/min/1.73 m}^2$. The treating physician plans to escalate his heart failure pharmacotherapy by replacing his current renin-angiotensin system inhibitor with sacubitril-valsartan. Which of the following is the most appropriate strategy for executing this pharmacologic transition?

Match each patient's clinical presentation with the most appropriate next step in their diagnostic workup.

A 72-year-old woman is preparing for discharge after a 4-day hospitalization for community-acquired pneumonia. She is clinically stable but has new-onset weakness and requires assistance with activities of daily living. Arrange the following steps of the discharge planning and care transition process in the most appropriate chronological sequence to ensure safe disposition and minimize readmission risk.

A 34-year-old woman is brought to the emergency department by paramedics following a high-speed motor vehicle collision. On arrival, she is unresponsive and has a Glasgow Coma Scale score of 6 (E1, V1, M4). She has obvious blunt trauma to her abdomen with extensive ecchymosis across her lower quadrants.

Vital signs are:
* Temperature: 35.8°C (96.4°F)
* Heart rate: 142/min
* Blood pressure: 68/38 mm Hg
* Respiratory rate: 8/min and shallow
* Oxygen saturation: 84% on room air

Arrange the following initial stabilization and management steps in the most appropriate sequential order.

A 58-year-old man comes to the cardiology clinic for a routine follow-up visit. He was diagnosed with ischemic cardiomyopathy and heart failure with reduced ejection fraction two years ago. Over the last two months, the patient reports increasing exertional dyspnea; he now becomes short of breath after walking up a single flight of stairs. His current medications include enalapril, carvedilol, spironolactone, and dapagliflozin. He is compliant with his medication regimen and a low-sodium diet. His blood pressure is 118/76 mmHg, and his heart rate is 68/min. Physical examination reveals clear lungs to auscultation bilaterally, no jugular venous distention, and trace bilateral pedal edema. Laboratory studies show a serum sodium of 138 mEq/L, potassium of 4.6 mEq/L, and creatinine of 1.2 mg/dL. The physician decides to replace the patient's angiotensin-converting enzyme (ACE) inhibitor with an angiotensin receptor-neprilysin inhibitor (ARNI) to further reduce morbidity and mortality. Which of the following is the most appropriate next step in modifying this patient's pharmacologic regimen?

A 33-year-old female schoolteacher schedules a visit at a primary care office due to recurrent, frightening episodes of a racing heart and intense sweating over the last $4$ months. During these spells, which typically last $15$ to $20$ minutes before subsiding spontaneously, she also experiences severe, throbbing headaches. She reports having four such distinct episodes in the past $30$ days. Her medical history is unremarkable, and she does not take any prescription or over-the-counter medications. She denies the use of illicit substances, tobacco, or alcohol. During today's visit, she is asymptomatic. Vital signs show a blood pressure of $154/96$ mmHg and a heart rate of $92$/min. Physical examination, including a comprehensive cardiovascular and neurologic assessment, reveals no abnormalities. Routine blood work, including a comprehensive metabolic panel and complete blood count, is within normal limits. Which of the following is the most appropriate next step in the diagnostic evaluation?