Patient Management

A 62-year-old man is brought to the emergency department with sudden-onset, severe, "tearing" chest pain that radiates to his interscapular region. His blood pressure is 210/115 mm Hg, and his heart rate is 118/min. A bedside transesophageal echocardiogram demonstrates an intimal flap in the descending aorta. The clinical team prepares to initiate aggressive medical management prior to definitive vascular surgery evaluation. Arrange the following pharmacologic interventions in the most appropriate sequential order for managing this patient's acute presentation.

A retired construction worker, aged 69, establishes care at a new primary care facility following his previous provider's relocation. He currently feels well, walks three miles daily, and denies any cardiopulmonary or gastrointestinal symptoms. He consumed two packs of cigarettes daily starting in high school but completely abstained from all tobacco products starting at age 52 after a friend developed emphysema. His records document a colonoscopy with no abnormal findings performed four years ago. His body mass index is 26 kg/m^2, and his blood pressure is 122/76 mmHg. He asks which cancer and vascular screening tests are indicated for him today. According to evidence-based recommendations, what is the most appropriate imaging or laboratory test to order?

A 45-year-old man visits his primary care provider due to worsening joint pain, generalized fatigue, and excessive sweating over the past three years. He mentions having to buy larger shoes and a new wedding band recently because his old ones no longer fit. His wife notes that his snoring has become exceptionally loud and he occasionally gasps for air during sleep. Vital signs show a blood pressure of 158/96 mmHg. Physical examination reveals a prominent brow ridge, a widened jaw, an enlarged tongue, and broad, fleshy hands. The physician suspects a specific hypersecretory endocrine disorder.

Arrange the following diagnostic steps in the most appropriate sequence to properly evaluate this patient's suspected condition, proceeding from the initial screening test to final anatomical localization.

A 34-year-old woman is evaluated in the outpatient clinic for follow-up of a deep vein thrombosis (DVT). Three days ago, she presented to the emergency department with left leg swelling and was diagnosed with an unprovoked left popliteal DVT. She was discharged with a prescription for rivaroxaban. Her past medical history is significant for systemic lupus erythematosus (SLE) with polyarthritis, well-controlled on hydroxychloroquine. She also has a history of two consecutive spontaneous abortions at 10 and 12 weeks of gestation. Current medications are rivaroxaban and hydroxychloroquine. Vital signs are within normal limits. Physical examination shows mild left lower extremity pitting edema.

Laboratory studies obtained during the emergency department visit are reviewed:
Hemoglobin: 12.2 g/dL
Platelet count: 130,000/mm³
Prothrombin time (PT): 13 seconds (normal: 11-15 seconds)
Activated partial thromboplastin time (aPTT): 62 seconds (normal: 25-40 seconds)

A 1:1 mixing study with normal plasma yields an aPTT of 58 seconds.

Which of the following is the most appropriate pharmacologic intervention for this patient's deep vein thrombosis?

An oncology team evaluates a 59-year-old male with metastatic melanoma before administering his next scheduled dose of pembrolizumab. He reports feeling unusually anxious and sweaty over the past two weeks, along with experiencing mild hand tremors. He has no other medical history. Vital signs show a blood pressure of $135/82 \text{ mm Hg}$ and a regular pulse of $110 \text{ /min}$. Physical examination reveals a fine action tremor and warm, moist skin, but no focal abdominal or pulmonary findings. Laboratory results demonstrate a thyroid-stimulating hormone (TSH) level of $<0.01 \mu\text{U/mL}$ (normal: $0.5-5.0 \mu\text{U/mL}$) and a free T4 of $2.8 \text{ ng/dL}$ (normal: $0.8-1.8 \text{ ng/dL}$). His hepatic and renal function panels are within normal limits. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old male patient presents to his primary care provider for an annual wellness visit. His medical history is notable for type 2 diabetes mellitus, which is currently well-controlled on metformin monotherapy. He has a remote smoking history, having consumed 1 pack of cigarettes daily for 25 years before successfully quitting 18 years ago. His last comprehensive physical examination was five years ago. He is up to date on colorectal cancer screening, having undergone a normal colonoscopy two years ago. He received a tetanus-diphtheria (Td) booster 2 years ago following a minor hand laceration. He has no prior history of receiving pneumococcal, zoster, or human papillomavirus (HPV) vaccines. Which of the following preventive interventions are indicated for this patient at today's visit? (Select all that apply)

Emergency medical services arrive at the trauma center with a 29-year-old man who sustained a stab wound during a physical altercation. The patient is awake but extremely agitated, frequently grasping at his throat. His blood pressure is 90/50 mm Hg, heart rate is 124/min, respiratory rate is 26/min, and oxygen saturation is 92% on a non-rebreather mask. Physical examination reveals a 3-cm linear laceration in the right anterior neck, located in the area between the cricoid cartilage and the angle of the mandible. There is a rapidly enlarging, pulsatile hematoma deep to the laceration. The patient's voice is muffled, he exhibits audible biphasic stridor, and copious bloody secretions are pooling in his oropharynx. Which of the following are the most appropriate immediate procedural and surgical interventions for this patient? (Select all that apply.)

Evaluate the following emergency department patient presentations. Match each clinical scenario to the most appropriate initial disposition and care setting based on current clinical guidelines and risk stratification scores.

While climbing a flight of stairs at a shopping mall, a $72$-year-old man experiences a sudden loss of consciousness. Bystanders report that he collapsed without warning but regained full orientation within a minute of falling. He arrives at the emergency department via private vehicle thirty minutes later. His past medical history is significant for essential hypertension and hyperlipidemia. Current medications include lisinopril and atorvastatin. On arrival, he is asymptomatic and alert. Vital signs show a temperature of $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure of $138/82\text{ mmHg}$, heart rate of $78\text{/min}$, and respiratory rate of $14\text{/min}$. Physical examination reveals a late-peaking, harsh systolic murmur heard best at the right second intercostal space with radiation to the neck. The lungs are clear to auscultation. A 12-lead electrocardiogram demonstrates voltage criteria for left ventricular hypertrophy and normal sinus rhythm with no ST-segment or T-wave abnormalities. Which of the following is the most appropriate next diagnostic study for this patient?

Paramedics arrive at the emergency department with a $66$-year-old female patient who developed acute confusion, fever, and right-sided abdominal pain over the last $24$ hours. Her medical history includes an aortic valve replacement with a mechanical prosthesis requiring chronic warfarin therapy, as well as an episode of penicillin-induced anaphylaxis requiring mechanical ventilation $10$ years ago.

Vital signs on arrival are:
Temperature: $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$)
Blood pressure: $82/50\text{ mmHg}$
Heart rate: $118\text{ /min}$
Respiratory rate: $22\text{ /min}$
Oxygen saturation: $95\%$ on room air

Physical assessment shows marked scleral icterus, a crisp mechanical heart click, and severe tenderness with voluntary guarding in the right upper abdominal quadrant.

Initial laboratory panel:
Leukocyte count: $18,500\text{ /mm}^{3}$
Total bilirubin: $4.5\text{ mg/dL}$
Alkaline phosphatase: $380\text{ U/L}$
Aspartate aminotransferase (AST): $145\text{ U/L}$
Alanine aminotransferase (ALT): $160\text{ U/L}$
Lactate: $4.8\text{ mmol/L}$
International Normalized Ratio (INR): $2.6$ (patient's therapeutic target is $2.5$ to $3.5$)

Abdominal ultrasound demonstrates a $1.2\text{ cm}$ radiopaque stone in the common bile duct with proximal biliary dilation. Two sets of peripheral blood cultures are obtained. The clinical team diagnoses acute ascending cholangitis with resultant septic shock.

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

An 84-year-old man is evaluated on postoperative day 4 following a right hip hemiarthroplasty for a femoral neck fracture. His postoperative course has been uncomplicated, and his pain is well-controlled with oral acetaminophen. His past medical history includes hypertension, diet-controlled type 2 diabetes mellitus, and mild osteoarthritis. Vital signs are within normal limits. The surgical incision is clean and intact. Before the fall, the patient lived in a single-story home with his 82-year-old wife, who uses a wheeled walker for mobility. Prior to hospitalization, he ambulated independently. He currently requires maximum assistance for transfers and can only take a few steps with a walker. Physical and occupational therapy evaluate him and note that while he is highly motivated, he fatigues rapidly, participating in only 45 minutes of therapy per session before requiring a prolonged rest. The therapy team recommends continued daily rehabilitation. Which of the following is the most appropriate disposition for this patient?

A 68-year-old woman is brought to the emergency department reporting sudden, severe pain in her left leg that began 4 hours ago. She has a history of rheumatic mitral stenosis and atrial fibrillation, but she has not taken her prescribed warfarin for the past two weeks. Her temperature is 37.1°C (98.8°F), blood pressure is 142/86 mmHg, and pulse is 110/min and irregularly irregular. Physical examination of the left lower extremity reveals absent popliteal and pedal pulses using a handheld Doppler ultrasound. The left leg is cold, pale, and exhibits livedo reticularis extending up to the mid-thigh. The patient has profound loss of light touch sensation over the foot and is unable to actively dorsiflex her toes. Venous Doppler signals in the left foot are audible. Which of the following is the most appropriate next step in management?

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

A 72-year-old man is evaluated in the hospital on day 4 of an admission for a severe exacerbation of chronic obstructive pulmonary disease (COPD). He originally presented with dyspnea, wheezing, and a productive cough. His home medications include inhaled tiotropium, as-needed albuterol, and warfarin for a mechanical mitral valve (target INR 2.5-3.5). Upon admission, he was started on intravenous methylprednisolone, nebulized ipratropium-albuterol, and oral levofloxacin. Today, his dyspnea has completely resolved, and he is breathing comfortably on room air. He reports no chest pain, palpitations, or signs of bleeding. Vital signs are temperature 37.1°C (98.8°F), pulse 82/min, respirations 14/min, and blood pressure 128/78 mm Hg. Laboratory studies obtained this morning show:

Hemoglobin: 13.5 g/dL
Platelet count: 210,000/mm³
Serum creatinine: 1.1 mg/dL
Prothrombin time (PT): 48 seconds
International normalized ratio (INR): 6.2

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

A 62-year-old woman is brought to the emergency department after being found unresponsive by her family. She is diagnosed with a large left middle cerebral artery (MCA) ischemic stroke. She undergoes successful mechanical thrombectomy but is left with right-sided hemiplegia and expressive aphasia. She is expected to make a gradual but significant recovery over the next few months. Arrange the following care settings in the most appropriate chronological sequence for this patient's anticipated recovery and rehabilitation pathway, starting immediately after her acute intervention.

Evaluate the following asymptomatic adult patients presenting to a general internal medicine clinic for their annual wellness visits. For each patient profile, identify the single most appropriate, guideline-concordant preventive care intervention to recommend today.

An obstetric rapid response team is managing a 34-year-old G3P3 patient who developed massive, life-threatening hemorrhage shortly after the uncomplicated vaginal delivery of a 4.2-kg infant. The placenta delivered intact. Initial evaluation revealed severe uterine atony. Despite vigorous bimanual massage and the administration of intravenous oxytocin, intramuscular methylergonovine, intramuscular carboprost, and rectal misoprostol, the patient continues to experience profuse bleeding. Her current blood pressure is 82/45 mm Hg with a heart rate of 130/min. A massive transfusion protocol has been initiated. Bedside ultrasound shows an empty uterine cavity, and speculum examination reveals no vaginal or cervical lacerations.

Arrange the following procedural and surgical interventions in the most appropriate sequential order for escalating the management of this patient's refractory postpartum hemorrhage, proceeding from the initial next step to the definitive intervention of last resort.

A $62$-year-old man is evaluated prior to hospital discharge following an admission for acute decompensated heart failure. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$. His home medications prior to admission included lisinopril, carvedilol, and furosemide. During the hospital stay, he was appropriately diuresed to euvolemia. The medical team plans to optimize his guideline-directed medical therapy by discontinuing lisinopril, initiating sacubitril-valsartan, and adding spironolactone. His vital signs are currently stable. Laboratory results obtained this morning show a serum potassium of $4.2$ mEq/L and an estimated glomerular filtration rate (eGFR) of $55$ mL/min/1.73 m $^2$. Which of the following statements regarding the monitoring and modification of this patient's pharmacotherapy are correct? (Select all that apply)

An internal medicine physician evaluates a 41-year-old male patient during a routine follow-up visit. The patient reports a 4-day history of profound exhaustion, nausea without vomiting, and noticing his urine has become dark brown. Thirty days prior, he was diagnosed with active pulmonary tuberculosis and commenced on a four-drug regimen consisting of isoniazid, rifampin, pyrazinamide, and ethambutol. He does not consume alcohol and has no prior history of liver disease. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $118/76\text{ mmHg}$, and heart rate of $82/\text{min}$. Physical examination is notable for mild scleral icterus and moderate tenderness to palpation in the right upper abdominal quadrant. No hepatosplenomegaly is appreciated.

Which of the following are the most appropriate immediate steps in the management of this patient? (Select exactly two)

A 48-year-old woman is evaluated during a routine health maintenance visit. She has no current medical complaints and feels well. Her surgical history is significant for a total abdominal hysterectomy with bilateral salpingectomy performed three years ago for symptomatic uterine fibroids. Her ovaries were preserved. Review of her medical records shows that her most recent cervical cancer screening, performed four years ago prior to her surgery, revealed atypical squamous cells of undetermined significance (ASC-US) with a negative high-risk human papillomavirus (hrHPV) test. She has no prior history of cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer, and she has not undergone any screening tests since her operation. She is in a monogamous relationship and does not smoke. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in screening for this patient?