Patient Management

A 35-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and uncontrollable shivering that began abruptly earlier today. She has a history of treatment-resistant major depressive disorder. Ten days ago, her psychiatrist discontinued her fluoxetine regimen due to lack of efficacy. Three days ago, she was started on tranylcypromine. Her temperature is $39.2^\circ \text{C}$ ($102.6^\circ \text{F}$), blood pressure is $168/98 \text{ mm Hg}$, pulse is $128/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals profuse diaphoresis, mydriasis, and hyperactive bowel sounds. Neurologic examination demonstrates severe lower extremity hyperreflexia and spontaneous clonus. Intravenous fluids and lorazepam are administered, but the patient remains highly agitated and her temperature increases to $39.8^\circ \text{C}$ ($103.6^\circ \text{F}$). Which of the following is the most appropriate next pharmacologic intervention?

A 29-year-old male is brought to the trauma center following a severe crush injury at a construction site. He is confused and pale. Vital signs are HR 142/min, BP 70/40 mm Hg, and RR 26/min. The airway is intact, and breath sounds are equal bilaterally. A focused assessment with sonography for trauma (FAST) exam shows no pericardial or intraperitoneal fluid. A portable chest radiograph is normal. A portable pelvic radiograph reveals a severe diastasis of the pubic symphysis and disruption of the right sacroiliac joint. A pelvic binder is immediately applied, and a massive transfusion protocol is initiated. After receiving 4 units of packed red blood cells, 4 units of fresh frozen plasma, and 1 unit of platelets over the next 20 minutes, the patient's blood pressure remains 72/42 mm Hg. The interventional radiology suite is currently occupied with another emergency, and the team will not be available for at least an hour. Which of the following is the most appropriate next step in the management of this patient?

A 66-year-old man is brought to the emergency department by his wife due to a 3-day history of progressively worsening shortness of breath, increased cough, and a change in his sputum from clear to thick, dark yellow. He has a 40-pack-year smoking history and was diagnosed with chronic obstructive pulmonary disease (COPD) five years ago. His home medications include a once-daily umeclidinium-vilanterol inhaler and an albuterol rescue inhaler, which he has used eight times today with minimal relief. He has no other major medical conditions. Temperature is 37.8°C (100.0°F), blood pressure is 146/88 mmHg, pulse is 114/min, and respiratory rate is 26/min. Pulse oximetry shows 88% on room air. The patient is using accessory muscles of respiration. Physical examination reveals a barrel-shaped chest, a prolonged expiratory phase, and diffuse bilateral wheezing. There is no jugular venous distention or lower extremity edema. A chest radiograph reveals hyperinflation without focal consolidation, pneumothorax, or pleural effusion.

Which of the following pharmacologic interventions should be included in the immediate management of this patient? (Select all that apply, indicating hangileri doğrudur)

An 82-year-old woman is evaluated for discharge planning. She was admitted to the hospital 11 days ago for severe community-acquired pneumonia. Upon admission, she had a CURB-65 score of 4, requiring intubation and a 7-day stay in the intensive care unit. She was successfully extubated 4 days ago and transferred to the general medical ward.

Currently, she is awake, alert, and oriented. She reports feeling much better but is profoundly fatigued. Temperature is 37.1°C (98.8°F), blood pressure is 128/76 mm Hg, pulse is 78/min, and respirations are 16/min. Pulse oximetry is 96% on room air. Lungs are clear to auscultation bilaterally.

Laboratory studies show a leukocyte count of 11,200/mm³, decreased from a peak of 24,000/mm³ on admission. Her renal function and electrolytes are within normal limits. She is currently completing a 14-day course of oral antibiotics.

Prior to admission, the patient lived at home with her 84-year-old husband and was independent with all activities of daily living. Currently, she has profound generalized muscle weakness consistent with ICU-acquired weakness. She requires the maximal assistance of two people to transfer from the bed to a chair and cannot feed herself or perform basic grooming. Physical and occupational therapy evaluate her and note that she has excellent potential for functional recovery; however, she completely exhausts after 30 minutes of mild therapeutic exercise and is unable to participate in more intensive therapy sessions at this time.

Her husband, who uses a wheelchair due to severe osteoarthritis, is unable to assist with her physical care. They have no other family members nearby.

Which of the following is the most appropriate disposition for this patient?

Following a heavy dinner, a 41-year-old female is brought to the emergency department by her partner due to sudden, unremitting right upper abdominal pain radiating to the right scapula. She reports intense nausea and has vomited twice over the past few hours. She is a non-smoker with a BMI of 34 kg/m² and a history of hypertriglyceridemia. Upon triage, her temperature is 38.5°C (101.3°F), pulse is 112/min, blood pressure is 135/85 mm Hg, and respiratory rate is 18/min. Abdominal examination demonstrates focal tenderness below the right costal margin, which sharply worsens on deep inspiration, causing her to abruptly halt her breath. There are no signs of clinical jaundice. To properly evaluate this patient's acute presentation, which of the following are the most appropriate initial diagnostic tests to order? (Select exactly 3 options)

An urgent urology consultation is requested for a 55-year-old female admitted to the intensive care unit with worsening distributive shock. She initially sought care at an outpatient clinic three days prior for left-sided back pain and dysuria, where she was prescribed oral nitrofurantoin. Her clinical status has deteriorated significantly over the past 12 hours.

Current vital signs reveal a temperature of $39.6^\circ\text{C}$ ($103.3^\circ\text{F}$), heart rate of $128\text{/min}$, blood pressure of $80/48\text{ mm Hg}$ despite a $3\text{-L}$ intravenous crystalloid bolus and initiation of norepinephrine, and respiratory rate of $24\text{/min}$. Physical examination demonstrates a lethargic, diaphoretic patient with pronounced left costovertebral angle tenderness.

Laboratory analysis reveals:

A non-contrast computed tomography scan of the abdomen and pelvis shows severe left hydroureteronephrosis secondary to an $11\text{-mm}$ radiopaque calculus lodged at the ureteropelvic junction, accompanied by significant perinephric fat stranding. Broad-spectrum intravenous antibiotics are currently being administered.

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

An 82-year-old man is evaluated for discharge planning. He was admitted to the hospital one week ago for urosepsis complicated by acute kidney injury. During the first few days of his admission, he required temporary hemodialysis and intensive care monitoring. His clinical status has since improved significantly; his renal function has recovered, dialysis has been discontinued, and he was transitioned to oral antibiotics yesterday. Current vital signs are temperature 37.0°C (98.6°F), blood pressure 130/80 mmHg, pulse 72/min, and respiratory rate 14/min. Prior to admission, he was fully independent and served as the primary caregiver for his 80-year-old wife, who has severe osteoarthritis and is bound to a motorized wheelchair. They live in a ground-floor apartment. Today, physical and occupational therapy evaluations reveal profound generalized weakness. The patient requires maximum physical assistance to transition from sitting to standing and can only take a few steps using a rolling walker. He fatigues quickly, tolerating approximately 60 minutes of physical therapy per day. Which of the following is the most appropriate discharge disposition for this patient?

A 29-year-old female patient is evaluated in the surgical intensive care unit on postoperative day two following an uncomplicated open cholecystectomy. Over the past four hours, she has become profoundly delirious and agitated. Her husband notes she has a history of "mild hyperthyroidism" for which she had been taking medication intermittently, but she completely discontinued all medical therapy one month ago.

Vital signs demonstrate a temperature of $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), pulse of $158/\text{min}$, blood pressure of $152/68\text{ mmHg}$, and respirations of $28/\text{min}$.

Physical examination reveals an actively hallucinating and diaphoretic patient. Ophthalmic examination shows bilateral proptosis and lid retraction. The thyroid gland is diffusely enlarged, firm, and a continuous bruit is audible over the lateral lobes. Cardiovascular examination reveals a regular, rapid rhythm with a hyperdynamic precordium. A fine tremor is present in the upper extremities. Laboratory studies reveal a TSH of $<0.01\text{ }\mu\text{U/mL}$ and free T4 of $5.8\text{ ng/dL}$.

Arrange the following pharmacologic interventions in the strictly correct chronological sequence to maximize therapeutic efficacy and prevent an acute exacerbation of this patient's underlying condition.

A 74-year-old female patient with a history of severe chronic obstructive pulmonary disease is preparing for transfer to a post-acute rehabilitation facility following a prolonged hospitalization for acute hypoxic respiratory failure. Her clinical status has stabilized, and the hospital team is initiating the discharge process. To ensure a safe transition of care and adhere to established discharge protocols, arrange the following transitional care steps in the most appropriate chronological sequence.

A 24-year-old male is transported to the emergency department by ambulance after being found unresponsive in his apartment. Paramedics report finding empty bottles of amitriptyline and alprazolam on his nightstand.

Upon arrival, the patient responds only with incomprehensible sounds to a deep sternal rub. His respirations are shallow and sonorous. Vital signs demonstrate a blood pressure of 82/48 mmHg, heart rate of 138/min, and respiratory rate of 8/min with an oxygen saturation of 88% on room air. The bedside cardiac monitor displays a wide-complex regular rhythm with a QRS duration of 155 ms.

Arrange the following management steps in the most appropriate sequential order to stabilize and evaluate this patient.

A 54-year-old man is brought to the emergency department after coughing up approximately 700 mL of bright red blood over the past two hours. He has a history of treated pulmonary tuberculosis with known residual cavitary disease in the right upper lobe. Upon arrival, he continues to expectorate large volumes of blood and appears in moderate respiratory distress. Vital signs are temperature 37.1°C (98.8°F), blood pressure 112/68 mmHg, pulse 118/min, and respiratory rate 28/min. Oxygen saturation is 87% on room air.

Arrange the following management and procedural interventions in the most appropriate chronological sequence for this patient's presentation.

A 57-year-old woman comes to the clinic reporting severe, generalized muscle aches and profound fatigue that began two days ago. She also notes that her urine has become unusually dark, resembling the color of tea. Five days ago, she was diagnosed with Helicobacter pylori infection and was started on a 14-day eradication regimen consisting of pantoprazole, amoxicillin, and clarithromycin. Her past medical history is significant for hyperlipidemia and hypertension, for which she takes simvastatin and lisinopril daily. Her temperature is 37.1°C (98.8°F), blood pressure is 126/82 mmHg, and pulse is 78/min. Physical examination reveals tenderness to palpation over the bilateral deltoid and quadriceps muscles. Neurologic examination shows 4/5 strength in the proximal upper and lower extremities with normal deep tendon reflexes. A urine dipstick performed in the clinic is positive for 3+ blood, but the microscopic examination reveals 0 to 1 red blood cells per high-power field. Which of the following is the most appropriate next step in the management of this patient?

A 71-year-old man visits his primary care physician for an annual health maintenance examination. He feels well and reports no new symptoms. His medical history includes essential hypertension and hyperlipidemia. He is a former smoker with a 30-pack-year history, having quit entirely 12 years ago. Medical records confirm he underwent a screening colonoscopy at age 63, which was normal. An abdominal aortic ultrasound performed at age 67 revealed no aneurysm. His only vaccinations over the past decade have been annual influenza shots and appropriate COVID-19 boosters. He takes lisinopril and atorvastatin. Vital signs today are within normal limits. Which of the following preventive interventions are currently indicated for this patient? (Select all that apply)

A triage nurse calls the physician to immediately evaluate a patient who just arrived with profound muscle weakness. The patient is a 57-year-old male with a history of hypertension, type 2 diabetes mellitus, and end-stage renal disease who reports missing his last two scheduled hemodialysis sessions due to severe regional weather. He complains of a heavy sensation in his limbs and perioral numbness that began earlier today. His blood pressure is 150/88 mmHg, heart rate is 52/min, and respiratory rate is 18/min. Cardiopulmonary auscultation is unremarkable, but neurologic examination reveals symmetric 3/5 weakness in the proximal and distal muscles of all four limbs. An urgent 12-lead electrocardiogram is obtained and displays significantly peaked T waves, flattened P waves, and a widened QRS complex. A venous blood gas analysis indicates a serum potassium concentration of 7.9 mEq/L.

Arrange the following pharmacologic therapies in the correct chronological sequence for the acute management of this life-threatening presentation.

A 43-year-old previously healthy female is evaluated in the outpatient clinic for a six-month history of progressive fatigue and breathlessness upon exertion. She has no chronic medical conditions, takes no medications, and has never smoked. Vital signs include a heart rate of 92/min, blood pressure of 110/70 mm Hg, and oxygen saturation of 97% on room air. Jugular venous pressure is estimated at 8 cm H2O. Auscultation reveals a prominently accentuated pulmonary component of the second heart sound and a faint holosystolic murmur at the lower left sternal border. Lungs are clear. Arrange the following diagnostic studies in the most appropriate, guideline-recommended stepwise sequence for evaluating this patient's suspected condition.

A 47-year-old woman is evaluated on the surgical ward for acute respiratory distress. Four hours ago, she underwent an uncomplicated total thyroidectomy for a large, symptomatic multinodular goiter. The cross-covering physician is called to the bedside because the patient is highly anxious and complaining of severe difficulty breathing. Her temperature is 37.2°C (99.0°F), blood pressure is 158/92 mmHg, heart rate is 116/min, and oxygen saturation is 86% on room air. Physical examination reveals a diaphoretic woman using accessory muscles of respiration. High-pitched inspiratory stridor is audible. There is a tense, rapidly expanding, ecchymotic swelling beneath the surgical incision, which is closed with surgical clips. Which of the following is the most appropriate next step in the management of this patient?

A $74$-year-old woman is evaluated in the clinic following a recent non-traumatic T12 vertebral compression fracture. A dual-energy x-ray absorptiometry (DEXA) scan reveals a T-score of $-3.2$ at the lumbar spine and $-2.9$ at the femoral neck. Her medical history includes type 2 diabetes mellitus, hypertension, and chronic kidney disease. Five years ago, she developed a provoked deep vein thrombosis following orthopedic surgery. Twelve years ago, she underwent lumpectomy followed by localized external beam radiation therapy for early-stage right breast cancer. Current medications include amlodipine, metformin, and cholecalciferol.

Vital signs are within normal limits. Laboratory studies are as follows:

Which of the following is the most appropriate pharmacologic intervention to reduce this patient's risk of future fractures?

A 68-year-old woman is brought to the emergency department by emergency medical services after experiencing two episodes of massive hematemesis at home. She has a history of severe osteoarthritis, for which she takes high-dose ibuprofen daily. On arrival, she is alert, oriented, and very anxious, but able to speak in full sentences. Her temperature is 36.8°C (98.2°F), blood pressure is 75/40 mm Hg, pulse is 132/min and thready, respirations are 20/min, and oxygen saturation is 98% on room air. Physical examination reveals pale conjunctivae, cold and diaphoretic extremities, and a soft, non-tender abdomen. Rectal examination demonstrates black, tarry stool. Which of the following initial stabilization steps are indicated simultaneously? (Select all that apply)

A 78-year-old man is evaluated for discharge planning. He was admitted 4 days ago for uncomplicated cellulitis of the right lower extremity. He was initially treated with intravenous cefazolin and has since transitioned to oral cephalexin. His erythema has significantly improved, he is afebrile, and his vital signs are within normal limits.

The patient has a 4-year history of vascular dementia. He is independently ambulatory without an assistive device and is able to feed himself. However, he is incontinent of urine and requires prompting for grooming. He lives with his 76-year-old wife in a single-story home. During a family meeting, his wife tearfully reports that over the past month, the patient has begun wandering outside the house at night. Two weeks ago, local police found him walking along a busy road at 2:00 AM and brought him home. His wife states she is physically exhausted, unable to stay awake to monitor him, and can no longer guarantee his safety at home.

During hospitalization, the patient has been intermittently agitated at night, attempting to leave the ward, which necessitated a 1:1 safety sitter. He does not have any ongoing intravenous medication requirements or complex wound care needs.

Which of the following is the most appropriate disposition plan for this patient?

Match each ambulatory patient's clinical risk profile with the most appropriate next step in preventive care and screening based on current guidelines.