Patient Management

A 68-year-old man is brought to the emergency department by his daughter due to worsening shortness of breath and progressive lethargy over the past 6 hours. He has a medical history of severe chronic obstructive pulmonary disease and heart failure with preserved ejection fraction. On arrival, the patient is somnolent, only minimally responsive to loud verbal stimuli, and is noted to have a weak gag reflex. His temperature is 37.4°C (99.3°F), heart rate is 118/min, blood pressure is 152/88 mmHg, respiratory rate is 34/min with shallow efforts, and oxygen saturation is 76% on room air. Physical examination reveals profound use of accessory muscles of respiration, diaphoresis, and diminished breath sounds bilaterally with faint expiratory wheezes. Which of the following is the most urgent initial step in the management of this patient?

A $28$-year-old male is rushed to the resuscitation bay by emergency medical services following a ballistic injury to the left upper abdominal quadrant. On primary survey, his airway is secured, blood pressure is $65/35$ mmHg, and heart rate is $142$/min. A massive transfusion protocol is initiated, and he is transferred immediately to the operating room for an exploratory laparotomy. Upon entering the abdomen, massive hemoperitoneum, a shattered spleen, a deep hepatic laceration, and multiple small bowel perforations are identified. The surgeon decides to proceed with a damage control approach due to the patient's profound hypothermia and developing coagulopathy. Arrange the following procedural and management steps in the correct chronological sequence for damage control surgery.

A 48-year-old man is brought to the emergency department by his wife due to sudden, excruciating retrosternal chest pain that began 2 hours ago. He reports the pain started immediately after an episode of forceful retching and vomiting following a large meal with alcohol. His temperature is 38.3°C (100.9°F), blood pressure is 105/65 mmHg, heart rate is 118/min, and respiratory rate is 24/min. Physical examination reveals diaphoresis and a crunching sound synchronized with the heartbeat on cardiac auscultation. Subcutaneous crepitus is palpable in the suprasternal notch. Arrange the following steps in the most appropriate sequence for the management of this patient.

An internal medicine physician is coordinating the transfer of a patient with end-stage liver disease and recent hepatic encephalopathy from a hospital step-down unit to a long-term care facility. To prevent adverse drug events during this care transition, the physician must strictly follow the standardized medication reconciliation process. Arrange the following steps of care transition medication reconciliation in the correct chronological sequence according to established patient safety guidelines.

A 38-year-old woman is evaluated in the outpatient clinic for progressive weight gain, persistent fatigue, and easy bruising over the past six months. She has also noted irregular, infrequent menstrual cycles. Her blood pressure is $156/94$ mmHg, heart rate is $82$/min, and BMI is $32 \text{ kg/m}^2$. Physical examination reveals facial plethora, accumulation of dorsocervical and supraclavicular fat, and wide, violaceous striae across her lower abdomen. She takes no medications and has no history of exogenous glucocorticoid use. The physician suspects an endocrine abnormality and plans to initiate a diagnostic workup. Which of the following diagnostic tests are the most appropriate initial screening steps to establish the diagnosis in this patient? (Select exactly 2 tests)

A 55-year-old woman is evaluated in the intensive care unit for refractory hematemesis. She has a history of decompensated cirrhosis secondary to nonalcoholic steatohepatitis. Two hours ago, she was admitted with large-volume hematemesis, hypotension, and tachycardia. She was promptly intubated for airway protection, started on intravenous octreotide and ceftriaxone, and resuscitated with packed red blood cells, fresh frozen plasma, and platelets using a massive transfusion protocol. An emergent upper endoscopy was performed, revealing actively bleeding esophageal varices. The gastroenterologist deployed multiple bands, but brisk, spurting hemorrhage continues from a defect that cannot be controlled endoscopically. The patient's current blood pressure is 70/40 mmHg, and her heart rate is 135/min. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old man is evaluated in the cardiac intensive care unit for acute-onset, severe right knee pain and swelling. He was admitted 2 days ago for a non-ST-segment elevation myocardial infarction (NSTEMI). His medical history is significant for chronic kidney disease stage 4 (baseline serum creatinine 2.4 mg/dL), hypertension, and a history of a bleeding gastric ulcer 1 year ago. His current medications include aspirin, ticagrelor, fondaparinux, metoprolol, and a high-intensity statin.

Vital signs show a temperature of 37.8°C (100.0°F), blood pressure 135/85 mm Hg, and pulse 88/min.

Physical examination reveals a markedly swollen, erythematous, warm, and exquisitely tender right knee. There is a large effusion, and range of motion is severely limited by pain.

Arthrocentesis is performed. Synovial fluid analysis shows a leukocyte count of 45,000/mm³ with 85% neutrophils. Polarized light microscopy reveals strongly negatively birefringent, needle-shaped crystals. Gram stain of the fluid is negative.

Which of the following is the most appropriate pharmacologic intervention for this patient's acute joint condition?

A 72-year-old resident of a long-term care facility is rushed to the acute care bay because of sudden unresponsiveness and an elevated temperature. The transporting crew reports that the patient was found in bed, difficult to rouse, and exhibiting shallow breathing. On assessment, the patient's temperature is 39.6°C (103.3°F), blood pressure is 68/34 mmHg, heart rate is 132/min, and respirations are 26/min. The skin displays a reticular, purplish discoloration over the lower extremities, and capillary refill is substantially delayed. Which of the following are the most appropriate simultaneous initial stabilization steps for this patient? (Select exactly 2 options)

A 48-year-old woman comes to the clinic for evaluation of a newly noticed lump in her anterior neck, which she discovered while applying lotion two weeks ago. Over the past two months, she has experienced a $3\text{-kg}$ ($6.6\text{-lb}$) unintentional weight loss, increased sweating, and intermittent palpitations. She denies dysphagia, hoarseness, or dyspnea. Vital signs show a blood pressure of $132/78 \text{ mm Hg}$, a heart rate of $104\text{/min}$, and a respiratory rate of $16\text{/min}$. Physical examination reveals a $2.5\text{-cm}$, firm, mobile, non-tender nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is appreciated.

Initial laboratory and imaging studies are obtained. The serum thyroid-stimulating hormone (TSH) level is $0.05 \text{ mU/L}$ (normal: $0.4-4.0 \text{ mU/L}$). A targeted neck ultrasound confirms a $2.5\text{-cm}$ solid, primarily hypoechoic nodule in the right thyroid lobe with regular margins and no suspicious microcalcifications.

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

A 65-year-old woman presents to the clinic for a routine wellness visit. She has a history of primary hypertension and osteoarthritis, for which she takes amlodipine and acetaminophen. She does not smoke or consume alcohol. Her family history is notable for a mother who experienced a hip fracture at age 75. Her vital signs and physical examination are unremarkable. A review of her medical records reveals the following preventive care history:

- Mammography: Normal results 3 years ago
- Colonoscopy: Normal results 11 years ago
- Pap smear with human papillomavirus (HPV) co-testing: Negative 4 years ago. She has a documented history of two additional consecutive negative co-tests over the prior decade, with no history of cervical intraepithelial neoplasia.
- Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine: Administered 6 years ago

Which of the following combinations of screening tests is most appropriate to order for this patient today?

Review the clinical scenarios of the following four patients presenting to the emergency department. Match each patient with their most appropriate initial disposition and care setting based on validated clinical risk stratification tools.

A 28-year-old woman is brought to the emergency department by paramedics due to continuous generalized shaking of her arms and legs. Her roommate states she found her seizing 20 minutes ago. The patient has a history of epilepsy but has not taken her medications recently due to insurance issues. On arrival, she is unresponsive to verbal commands and has continuous, rhythmic, bilateral extremity jerking. Her blood pressure is 142/88 mm Hg, heart rate is 118/min, respiratory rate is 22/min, and oxygen saturation is 96% on a non-rebreather mask. Fingerstick blood glucose is 98 mg/dL. Two large-bore intravenous lines are established.

Arrange the following pharmacologic interventions in the most appropriate chronological sequence for managing this patient's condition, assuming she continues to seize despite each successive therapy.

A 68-year-old man presents to the emergency department complaining of sudden, severe pain in his right leg that began 2 hours ago. He describes the leg as feeling "numb and heavy." His medical history is significant for hypertension, type 2 diabetes mellitus, and atrial fibrillation. He states he ran out of his prescribed apixaban two weeks ago. His vital signs are temperature 37.1°C (98.8°F), blood pressure 156/92 mm Hg, pulse 118/min and irregularly irregular, and respirations 16/min. Physical examination of the right lower extremity reveals pallor and coolness to the touch from the mid-calf down. The right dorsalis pedis and posterior tibial pulses are absent on both palpation and continuous-wave Doppler ultrasound. He has decreased sensation to light touch over the dorsum of the right foot and exhibits mild weakness when asked to dorsiflex his toes. The left lower extremity is warm with normal pulses. Which of the following is the most appropriate next step in the management of this patient?

A $41$-year-old woman is brought to the emergency department by her husband due to a two-day history of progressively worsening right-sided abdominal pain, fevers, and confusion. Her past medical history is significant for morbid obesity, for which she underwent a laparoscopic Roux-en-Y gastric bypass and a cholecystectomy four years ago. Her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), pulse is $128/\text{min}$, blood pressure is $78/48\text{ mm Hg}$, and respirations are $26/\text{min}$. Physical examination reveals scleral icterus and significant tenderness to palpation in the right upper quadrant with involuntary guarding. The patient is oriented only to her own name. Laboratory studies show a leukocyte count of $21,000/\text{mm}^3$, a total bilirubin of $7.2\text{ mg/dL}$, a direct bilirubin of $5.5\text{ mg/dL}$, and an alkaline phosphatase of $510\text{ U/L}$. Aspartate aminotransferase (AST) is $180\text{ U/L}$ and alanine aminotransferase (ALT) is $210\text{ U/L}$. A bedside right upper quadrant ultrasound reveals a dilated common bile duct measuring $1.5\text{ cm}$ with internal echogenic foci and posterior acoustic shadowing. The patient receives $3\text{ L}$ of intravenous crystalloids and broad-spectrum antibiotics. Despite these measures, her blood pressure remains $80/50\text{ mm Hg}$, and a continuous norepinephrine infusion is initiated. Which of the following is the most appropriate next step in the management of this patient?

An outpatient clinic physician is preparing to disclose a diagnosis of Alzheimer disease to a 64-year-old former mechanic and his wife, following a recent comprehensive neurocognitive evaluation and brain MRI. The physician intends to follow the SPIKES protocol for delivering difficult medical news. Arrange the following physician actions in the correct chronological sequence according to this communication framework.

A 78-year-old woman with advanced Alzheimer dementia is admitted to the medical intensive care unit with aspiration pneumonia and septic shock. She requires vasopressor support and noninvasive positive pressure ventilation. Despite broad-spectrum antibiotics and fluid resuscitation, her respiratory status continues to decline, and the care team considers endotracheal intubation. The patient is profoundly encephalopathic and lacks decision-making capacity. She does not have a designated healthcare proxy or an advance directive. The patient's family includes her 80-year-old husband and two adult daughters. The husband has a documented history of mild cognitive impairment. However, upon evaluation by the intensive care physician, the husband demonstrates a clear understanding of his wife's prognosis and the risks and benefits of intubation. He consistently expresses his rationale for choosing comfort-focused measures, citing his wife's previously expressed wishes to avoid mechanical ventilation. The two adult daughters strongly disagree with the husband and demand that their mother be intubated and fully resuscitated, arguing that their father's cognitive impairment invalidates his decision. Which of the following is the most appropriate next step in the management of this patient?

A 66-year-old man with a history of progressive glioblastoma is evaluated during a routine home hospice visit. He has been bedbound for the past month and became entirely unresponsive 24 hours ago. His daughter, who is his primary caregiver, is highly distressed. She reports that her father has developed very noisy, gurgling breathing over the past several hours. She states, 'It sounds like he is choking on his own fluid. Please suction it out so he can breathe.'

Vital signs are temperature 37.1°C (98.8°F), pulse 98/min, and respirations 18/min. Physical examination reveals an unresponsive patient. There is prominent gurgling heard during both inspiration and expiration. The patient's face is relaxed, and he shows no signs of grimacing, accessory muscle use, or restlessness. Lung auscultation reveals transmitted upper airway sounds bilaterally without focal crackles or wheezes. Which of the following is the most appropriate next step in management?

Review the following patient clinical profiles encountered during primary care wellness visits. For each patient, identify the single most appropriate, guideline-concordant preventive screening intervention and interval based on current evidence-based recommendations.

A 54-year-old man presents to the clinic for a routine health maintenance examination. He has no significant past medical history and takes no medications. He has a 35-pack-year smoking history and continues to smoke one pack of cigarettes daily. During the visit, the physician recommends an annual low-dose chest CT for lung cancer screening. The patient immediately crosses his arms and says, "I don't see the point of doing that. If I have lung cancer, it's a death sentence anyway, so I would rather just live my life without knowing."

Which of the following is the most appropriate initial response by the physician?

A 48-year-old man presents to the clinic to establish primary care. The physician intends to implement a structured, evidence-based behavioral intervention for smoking cessation during the visit. Arrange the following physician actions in the correct chronological sequence according to standard clinical guidelines for tobacco cessation (the 5 A's model).