Patient Management

A $58$-year-old woman is brought to the emergency department by her husband due to progressive confusion, lethargy, and a witnessed generalized tonic-clonic seizure at home. She has a history of small cell lung cancer and is currently undergoing chemotherapy. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $134/82 \text{ mmHg}$, pulse is $88/\text{min}$, and respiratory rate is $16/\text{min}$. She is somnolent but arousable to painful stimuli. Laboratory testing reveals a serum sodium concentration of $110 \text{ mEq/L}$, serum osmolality of $240 \text{ mOsm/kg}$, and urine osmolality of $650 \text{ mOsm/kg}$. A diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) causing severe, symptomatic hyponatremia is made.

Arrange the following monitoring and therapeutic evaluation steps in the most appropriate chronological sequence for managing this patient's acute presentation.

A 67-year-old man is admitted to the hospital with a 3-day history of productive cough, fever, shortness of breath, and right-sided pleuritic chest pain. His past medical history is significant for symptomatic atrial fibrillation, heart failure with preserved ejection fraction, and type 2 diabetes mellitus. His current medications include sotalol, apixaban, metformin, and empagliflozin. He has no known drug allergies.

Vital signs are:
Temperature: $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$)
Blood pressure: $118/74 \text{ mmHg}$
Pulse: $88/\text{min}$
Respirations: $28/\text{min}$
Oxygen saturation: $91\%$ on room air

Physical examination reveals bronchial breath sounds and crackles over the right lower lung field.

Laboratory results are as follows:
Leukocyte count: $14,500/\text{mm}^3$ ($85\%$ neutrophils)
Blood urea nitrogen: $28 \text{ mg/dL}$
Creatinine: $1.2 \text{ mg/dL}$

Chest radiography demonstrates a dense consolidation in the right lower lobe. An electrocardiogram shows normal sinus rhythm with a heart rate of $88/\text{min}$ and a QTc interval of $490 \text{ ms}$ (normal: $\leq 440 \text{ ms}$ in men).

The patient is diagnosed with community-acquired pneumonia. Which of the following is the most appropriate empiric pharmacologic intervention for this patient?

An occupational health physician evaluates a 28-year-old woman who is preparing to begin employment as a clinical laboratory technician, a role that involves handling human blood samples. She has a medical history of severe plaque psoriasis, which has been well controlled since initiating treatment with subcutaneous adalimumab six months ago. She has no other medical conditions. She has never smoked cigarettes and consumes alcohol occasionally. Her last cervical cancer screening with cytology was one year ago and was normal. Physical examination today reveals normal vital signs and clear skin with faint residual hyperpigmentation on the extensor surfaces. A review of her childhood immunization records confirms completion of the standard pediatric series, including two doses of the measles, mumps, and rubella vaccine. Pre-employment serological testing indicates a negative varicella-zoster virus IgG antibody and a negative hepatitis B surface antibody (anti-HBs). The patient states she never had chickenpox as a child. Which of the following is the most appropriate immunization strategy for this patient?

A 62-year-old man is evaluated in the intensive care unit for acute-onset dyspnea, right-sided pleuritic chest pain, and altered mental status. He is currently on postoperative day 4 following an open left hemicolectomy for a perforated diverticulum. Vital signs are temperature 37.2°C (99.0°F), blood pressure 76/42 mmHg, pulse 135/min, and respiratory rate 28/min. Oxygen saturation is 84% on a non-rebreather mask. Physical examination reveals jugular venous distension and a right ventricular heave. An urgent computed tomography pulmonary angiogram demonstrates a massive saddle pulmonary embolism extending into the bilateral main pulmonary arteries. Bedside transthoracic echocardiography shows severe right ventricular dilation with hypokinesis. Which of the following is the most appropriate next step in the management of this patient?

A 68-year-old woman is brought to the emergency department via ambulance after a witnessed generalized tonic-clonic seizure. Her husband reports that she recently started taking hydrochlorothiazide for hypertension and has been drinking large volumes of water due to medication-induced dry mouth. On presentation, she is unresponsive, and shortly after arrival, she develops a recurrent generalized tonic-clonic seizure. A point-of-care basic metabolic panel reveals a serum sodium concentration of 114 mEq/L. The physician immediately initiates management for severe symptomatic hyponatremia.

Arrange the following steps for the treatment and ongoing monitoring of this patient's condition in the most appropriate chronological sequence.

A 68-year-old woman is brought to the emergency department by her family due to progressive confusion, fever, and severe right upper quadrant abdominal pain that began 24 hours ago. On presentation, her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $82/50\text{ mmHg}$, pulse is $124/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals scleral icterus, severe right upper quadrant tenderness with involuntary guarding, and lethargy. Laboratory studies show a leukocyte count of $18,500/\text{mm}^3$, total bilirubin of $6.2\text{ mg/dL}$, direct bilirubin of $4.8\text{ mg/dL}$, and alkaline phosphatase of $450\text{ U/L}$. A bedside right upper quadrant ultrasound demonstrates a dilated common bile duct measuring $12\text{ mm}$ and gallstones within the gallbladder. Arrange the following management steps in the most appropriate chronological sequence for this patient.

For each patient presenting to the primary care clinic, select the single most appropriate, guideline-concordant preventive care intervention from the available choices.

A 62-year-old female presents to the emergency department complaining of severe, crushing substernal chest pain radiating to her left arm, which started $2$ hours ago while resting. She also reports progressive shortness of breath over the same period. Her past medical history is significant for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Vital signs show a blood pressure of $155/92$ mmHg, heart rate of $112$/min, respiratory rate of $24$/min, and oxygen saturation of $89\%$ on room air. Physical examination reveals prominent jugular venous distention. Cardiac auscultation reveals an S3 gallop, and pulmonary auscultation demonstrates bilateral crackles extending to the mid-lung fields. An electrocardiogram shows $2$ mm ST-segment depressions in leads V2-V5 and T-wave inversions in leads I and aVL. There are no ST-segment elevations. Laboratory studies reveal a markedly elevated high-sensitivity cardiac troponin T. In addition to supplemental oxygen and sublingual nitroglycerin, which of the following pharmacologic interventions should be ordered for this patient at this time? (Select all that apply)

A $58$-year-old man is evaluated in the hospital for worsening renal function. He was admitted $3$ days ago for fever, confusion, and abdominal pain. He has a history of alcohol-associated cirrhosis. On admission, diagnostic paracentesis revealed an ascitic fluid absolute neutrophil count of $600/\text{mm}^3$. He was appropriately started on intravenous cefotaxime, and his home regimen of spironolactone and furosemide was discontinued.

Despite resolving fever and improving mental status over the past $48$ hours, his urine output has decreased to $300$ mL/day. Vital signs today show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure of $88/52$ mmHg, and heart rate of $94/\text{min}$. Physical examination reveals scleral icterus, spider angiomas, and tense ascites without peripheral edema.

Laboratory results:
Sodium: $130$ mEq/L
Potassium: $4.8$ mEq/L
Blood urea nitrogen: $68$ mg/dL (was $22$ mg/dL on admission)
Creatinine: $3.2$ mg/dL (was $1.1$ mg/dL on admission)
Urine sodium: $8$ mEq/L
Urinalysis: No red blood cells, white blood cells, or casts.

A volume expansion trial with intravenous albumin ($1$ g/kg/day for $2$ days) was completed, but his repeat serum creatinine today is $3.4$ mg/dL. Renal ultrasound reveals normal-sized kidneys with no hydronephrosis.

Which of the following is the most appropriate next pharmacologic intervention for this patient's renal failure?

A hematology consultation is requested for a 61-year-old man hospitalized with a massive left popliteal deep vein thrombosis. He was initially managed with a continuous intravenous infusion of unfractionated heparin. On hospital day 6, his platelet count fell precipitously from an admission baseline of $260,000/\mu L$ to $75,000/\mu L$. Suspecting a drug-induced complication, the medical team obtained a serotonin release assay, which returned positive. All heparin products were immediately withdrawn, and an intravenous argatroban infusion was initiated. Now, on hospital day 10, the patient's lower extremity edema has significantly improved, and his platelet count has steadily recovered to $155,000/\mu L$. The clinical team is preparing for discharge and plans to transition his antithrombotic therapy to oral warfarin. Which of the following outlines the most appropriate strategy for monitoring and adapting his pharmacotherapy?

A $68$-year-old man presents to the clinic for a routine diabetes follow-up. He has a $12$-year history of type 2 diabetes mellitus, hypertension, and hyperlipidemia. His current medications include metformin $1000\text{ mg}$ twice daily, amlodipine $5\text{ mg}$ daily, atorvastatin $40\text{ mg}$ daily, and aspirin $81\text{ mg}$ daily. He feels well and reports no polyuria, polydipsia, or peripheral edema.

Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $132/80\text{ mmHg}$, and heart rate $72/\text{min}$. Physical examination reveals diminished vibratory sensation in both feet but is otherwise unremarkable.

Laboratory results are as follows:

Urinalysis shows microalbuminuria but no hematuria or cellular casts.

Based on the laboratory findings, which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

A 72-year-old man comes to the clinic for a routine health maintenance examination. His medical history includes type 2 diabetes mellitus, hypertension, and hyperlipidemia. He does not use tobacco. Current medications are metformin, lisinopril, and atorvastatin. He has no history of myocardial infarction, angina, stroke, or transient ischemic attack. Vital signs include a blood pressure of 132/80 mmHg and a heart rate of 74/min. Physical examination is unremarkable. His most recent hemoglobin A1c is 7.2%. The patient recently read an article about cardiovascular health and asks if he should start taking a daily low-dose aspirin to prevent a heart attack. According to current preventive care guidelines, which of the following is the most appropriate recommendation regarding aspirin therapy for this patient?

A 42-year-old woman is evaluated in the clinic for severe, seropositive rheumatoid arthritis that remains highly active despite six months of maximally tolerated methotrexate and folic acid therapy. The physician plans to add adalimumab to her current regimen. She has a past medical history of mild intermittent asthma. Current medications include methotrexate, folic acid, and an as-needed albuterol inhaler. Vital signs are within normal limits. Physical examination reveals active synovitis with swelling and tenderness in the bilateral metacarpophalangeal and proximal interphalangeal joints. Which of the following baseline and ongoing monitoring parameters are required for this patient's new pharmacological regimen? (Select 3)

A 71-year-old woman is evaluated via telehealth for dysuria, suprapubic discomfort, and urinary urgency that began 2 days ago. She has a history of a mechanical mitral valve replacement performed 3 years ago, for which she takes chronic warfarin. Her most recent international normalized ratio (INR) checked one week ago was 2.9, which is within her target range of 2.5 to 3.5. She reports no fever, chills, back pain, or gross hematuria. A clean-catch urinalysis obtained at a local laboratory demonstrates positive nitrites, positive leukocyte esterase, and >50 white blood cells per high-power field. The physician diagnoses acute uncomplicated cystitis and plans to prescribe a 3-day course of trimethoprim-sulfamethoxazole.

Which of the following are necessary monitoring and treatment adjustments for this patient? (Select 2 options)

A 28-year-old woman is brought to the emergency department after being stung by a bee while hiking. She is profusely sweating and reports difficulty breathing along with a feeling of impending doom. On physical examination, she has diffuse coalescing urticaria, marked facial angioedema, and audible biphasic wheezing. Her blood pressure is $78/40$ mmHg, heart rate is $135$/min, and oxygen saturation is $88\%$ on room air. Large-bore intravenous access is rapidly established.

Assuming her hemodynamic instability and symptoms persist despite each successive intervention, arrange the following pharmacologic therapies in the correct sequential order of administration according to anaphylaxis resuscitation guidelines.

While recovering in the intensive care unit from a severe exacerbation of chronic obstructive pulmonary disease requiring mechanical ventilation, a 74-year-old male develops a new-onset fever of 38.9°C (102.0°F) and increasing vasopressor requirements. His medical history includes coronary artery disease, chronic obstructive pulmonary disease, and heart failure with preserved ejection fraction. Physical examination reveals a distended abdomen with focal guarding in the right upper quadrant. Laboratory studies show a leukocyte count of 18,500/mm³ and mild elevations in aspartate aminotransferase and alanine aminotransferase, with a normal total bilirubin level. A bedside right upper quadrant ultrasound demonstrates gallbladder wall thickening to 6 mm, pericholecystic fluid, and a sonographic Murphy sign, without intrahepatic or extrahepatic biliary ductal dilation. Which of the following is the most appropriate procedural intervention for this patient's current abdominal condition?

A 54-year-old woman comes to the clinic for a routine health maintenance examination. She feels well and has no acute complaints. Her medical history is significant for hypertension and stage 3a chronic kidney disease secondary to hypertensive nephrosclerosis. Her current medications include lisinopril and amlodipine. She smoked 1 pack of cigarettes daily for 25 years but successfully quit 10 years ago. Her most recent screening colonoscopy was performed 9 years ago and revealed no polyps. She underwent a screening mammogram 1 year ago, which was normal. She received the two-dose recombinant zoster vaccine series 2 years ago, the annual influenza vaccine last month, and a Tdap booster 3 years ago. She has not received any other immunizations in adulthood. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following interventions are indicated for this patient today? (Select all that apply)

A 24-year-old man is evaluated in the emergency department for severe right lower leg pain. Two hours ago, he sustained a closed mid-shaft tibial fracture during a soccer game and was subsequently placed in a circumferential long-leg cast. He now reports excruciating, throbbing pain in the right leg that is rapidly worsening and completely unrelieved by intravenous morphine. Vital signs are temperature 37.1°C (98.8°F), blood pressure 138/86 mm Hg, heart rate 112/min, and respiratory rate 18/min. On examination, the leg feels intensely tight, and passive extension of the toes elicits agonizing pain. Paresthesias are noted over the dorsum of the foot. Distal dorsalis pedis and posterior tibial pulses are palpable. What is the most appropriate sequential order of management steps for this patient?

An asymptomatic 24-year-old female presents to her primary care provider to establish care and undergo a health maintenance visit. She reports feeling well overall. Her only regular medication is a combined oral contraceptive pill. She reports becoming sexually active with a new male partner three months ago, noting inconsistent use of barrier protection. She has a lifetime history of three sexual partners. She has never smoked cigarettes or used illicit drugs. She denies abnormal vaginal discharge, dyspareunia, or genital lesions. A review of her electronic medical record indicates that she underwent a normal cervical cytology (Pap smear) at age 21, but has not had any other preventive screenings since that time. Physical examination reveals a normal cervix with no cervical motion tenderness or adnexal masses. Based on current guidelines, which of the following is the most appropriate screening strategy for this patient today?

A 62-year-old man is evaluated in the outpatient clinic for new-onset muscle pain and weakness. Two weeks ago, he was discharged from the hospital to complete a 6-week course of outpatient intravenous daptomycin for methicillin-resistant *Staphylococcus aureus* (MRSA) osteomyelitis of the right first metatarsal. He reports diffuse aching in his thighs, shoulders, and lower back that began 3 days ago and has progressively worsened. He now has difficulty climbing stairs. He has no chest pain, shortness of breath, or new focal neurologic deficits. His right foot wound is healing well with no erythema or purulent drainage.

Vital signs are within normal limits. Physical examination reveals diffuse proximal muscle tenderness and $4/5$ strength in the bilateral hip flexors and shoulder abductors.

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