Patient Management

An otherwise healthy 24-year-old female visits her physician complaining of a new lump in her left breast that she noticed two weeks ago while showering. She has no personal or family history of breast cancer and reports no nipple discharge, overlying skin changes, or systemic symptoms. Her menstrual cycles are regular. Vital signs are within normal limits. On physical examination, a 2-cm, firm, mobile, well-circumscribed, non-tender mass is palpated in the upper outer quadrant of the left breast. There is no axillary lymphadenopathy, and examination of the right breast is unremarkable. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

A previously healthy $42$-year-old man visits a new primary care provider to establish medical care. He reports feeling unusually fatigued over the last few months, accompanied by frequent muscle cramps in his legs and an increase in nighttime urination. He has not seen a physician in five years and currently takes no medications. His blood pressure is $172/104$ mmHg, and his heart rate is $78$/min. Physical examination reveals normal heart sounds, clear lungs, and no abdominal bruits. Laboratory testing shows the following:

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

A 71-year-old female resident of a skilled nursing facility is brought to the emergency department due to profound lethargy. Staff report she has been increasingly confused since yesterday. Her temperature is 39.5°C (103.1°F), blood pressure is 78/42 mm Hg, heart rate is 134/min, and respiratory rate is 24/min. Pulse oximetry shows 95% on room air. Physical examination reveals warm, flushed extremities, dry mucous membranes, and cloudy, malodorous urine in her collection bag. Which of the following simultaneous initial emergency orders are most appropriate? (Select all that apply)

A 64-year-old man is evaluated in the emergency department for a 5-day history of progressively worsening, severe mid-back pain. He describes the pain as a dull, constant ache that is not relieved by position changes or over-the-counter analgesics. Over the past 12 hours, he has developed bilateral leg heaviness and difficulty initiating micturition. His medical history is significant for type 2 diabetes mellitus, hypertension, and a recent episode of methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia secondary to a peripheral intravenous catheter infection 3 weeks ago. He completed a 14-day course of oral cephalexin for the bacteremia. His temperature is 38.2°C (100.8°F), blood pressure is 145/88 mmHg, and pulse is 98/min. Physical examination reveals focal tenderness to percussion over the T8-T10 spinous processes. Neurological examination demonstrates 4/5 strength in the bilateral lower extremities, diminished deep tendon reflexes at the knees and ankles, and decreased sensation to pinprick below the umbilicus. A bladder scan shows a post-void residual volume of 450 mL.

Which of the following diagnostic steps should be prioritized and performed concurrently in this patient's initial evaluation? (Select 2)

An evaluation is requested for a 49-year-old male who reports a 6-month history of voluminous, watery diarrhea and persistent epigastric pain. The patient notes that his symptoms have barely improved despite strict adherence to a high-dose oral omeprazole regimen. His medical history is notable for a duodenal ulcer that perforated and required surgical patch repair one year ago. His vital signs today are within normal limits. Following instructions to discontinue his proton pump inhibitor for seven days, the patient underwent an upper gastrointestinal endoscopy, which demonstrated unusually thickened gastric folds and the presence of two distinct ulcers in the postbulbar duodenum. Subsequent laboratory analysis reveals a fasting serum gastrin concentration of $580 \text{ pg/mL}$ (normal: $< 100 \text{ pg/mL}$) and a basal gastric pH of $1.4$. Which of the following is the most appropriate next step in the diagnostic workup?

A 62-year-old woman is brought to the emergency department by her daughter due to profound generalized weakness and near-syncope that started earlier this morning. The patient has a history of type 2 diabetes mellitus, hypertension, and end-stage renal disease for which she receives hemodialysis three days a week. She missed her last two dialysis sessions due to transportation issues. On physical examination, she appears lethargic and pale. Vital signs are temperature 36.8°C (98.2°F), blood pressure 82/48 mm Hg, pulse 38/min, and respiratory rate 22/min. Oxygen saturation is 97% on ambient air. Cardiac auscultation reveals severe bradycardia without murmurs. A stat 12-lead electrocardiogram is obtained immediately upon arrival, demonstrating absent P waves and markedly widened QRS complexes that merge seamlessly with the T waves. Which of the following is the most appropriate immediate next step in the management of this patient?

A 62-year-old man is brought to the emergency department by ambulance due to the sudden onset of severe, "tearing" chest pain that radiates to his back, between the shoulder blades. The pain began $30$ minutes ago while he was resting. He has a medical history of poorly controlled hypertension, hyperlipidemia, and a $40$-pack-year smoking history. On presentation, he appears in acute distress, anxious, and diaphoretic. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $215/115$ mm Hg in the right arm and $205/110$ mm Hg in the left arm, heart rate $118$/min, and respiratory rate $22$/min. Oxygen saturation is $97\%$ on room air. Cardiovascular examination reveals a regular tachycardia and a new, faint decrescendo diastolic murmur heard best at the right upper sternal border. The lungs are clear to auscultation bilaterally. An electrocardiogram shows sinus tachycardia and voltage criteria for left ventricular hypertrophy, but no acute ischemic changes. Which of the following is the most appropriate immediate next step in management?

A $38$-year-old woman presents to the clinic with progressive weight gain, facial fullness, and proximal muscle weakness over the past $8$ months. She also reports irregular menstrual periods and easy bruising. Blood pressure is $155/95$ mmHg, and BMI is $32$ kg/m $^2$. Physical examination reveals facial plethora, supraclavicular fat pads, and wide violaceous striae on her abdomen. There is trace peripheral edema. The physician suspects an endogenous endocrine etiology for her symptoms.

Arrange the following diagnostic steps in the most appropriate sequential order for the comprehensive workup of this patient's suspected condition, from initial biochemical screening to final definitive localization.

Emergency medical services transport a 55-year-old male to the resuscitation bay after he vomited approximately one liter of bright red blood at a local restaurant. The patient's wife notes he has a history of decompensated liver cirrhosis due to chronic alcohol use and has been hospitalized previously for ascites. Upon arrival, the patient is lethargic, responds only to painful stimuli, and is actively coughing up blood clots. Vital signs reveal a temperature of 36.5°C (97.7°F), heart rate of 128/min, blood pressure of 82/45 mm Hg, respiratory rate of 26/min, and oxygen saturation of 91% on room air. Examination shows scleral icterus, spider angiomas on the chest, and a distended, non-tender abdomen. Peripheral intravenous access is established by the nursing staff. Which of the following is the most appropriate immediate next step in management?

A rapid response team is called to the bedside of a 45-year-old hospitalized man who developed sudden-onset respiratory distress. The patient was admitted yesterday for community-acquired pneumonia and was receiving his second dose of intravenous piperacillin-tazobactam. Ten minutes into the infusion, he began complaining of severe throat tightness, shortness of breath, and feeling dizzy. The bedside nurse immediately stopped the antibiotic infusion and applied supplemental oxygen via a non-rebreather mask.

Vital signs reveal a blood pressure of 78/42 mm Hg, a heart rate of 138/min, a respiratory rate of 28/min, and an oxygen saturation of 91% on the non-rebreather mask. Physical examination shows diffuse urticaria over the trunk and extremities, periorbital edema, and audible inspiratory stridor with widespread expiratory wheezing.

Which of the following are the most appropriate immediate next steps in the management of this patient? (Select exactly 2 options)

A 29-year-old woman, G2P1, at 24 weeks gestation presents to the emergency department with sudden-onset shortness of breath and right-sided pleuritic chest pain. Her heart rate is 112/min, respiratory rate is 22/min, blood pressure is 110/70 mmHg, and oxygen saturation is 94% on room air. Physical examination reveals clear lungs bilaterally, normal heart sounds, and no asymmetric lower extremity edema, erythema, or tenderness. An electrocardiogram shows sinus tachycardia. You are planning the diagnostic pathway to evaluate for a suspected pulmonary embolism while minimizing fetal and maternal radiation exposure.

Arrange the following diagnostic modalities in the correct sequential order as recommended by current clinical guidelines, proceeding to the next step only if the preceding test is negative, normal, or non-diagnostic.

Match each acute clinical presentation with the most appropriate and urgent next diagnostic step.

A 26-year-old woman is brought to the emergency department by paramedics after being found unresponsive in her apartment. Her roommate reports finding empty bottles of amitriptyline and diphenhydramine on her nightstand. En route to the hospital, the patient had a 3-minute generalized tonic-clonic seizure. Upon arrival, she is actively seizing. Vital signs are temperature 38.2°C (100.8°F), blood pressure 82/50 mm Hg, pulse 138/min, and respirations 8/min. Pulse oximetry shows 88% on room air. Pupils are 7 mm bilaterally and sluggishly reactive. Mucous membranes are dry. An immediate electrocardiogram reveals sinus tachycardia with a QRS duration of 165 msec and a prominent terminal R wave in lead aVR. Which of the following are the most appropriate immediate simultaneous steps in the stabilization of this patient? (Select 3)

A university student is rushed to the resuscitation bay after being discovered seizing in a dormitory. Scattered empty bottles of amitriptyline and diphenhydramine were located nearby. The patient is currently exhibiting continuous generalized tonic-clonic movements. Physical examination reveals flushed, dry skin and symmetrically dilated pupils. Continuous monitoring displays a pulse of 142/min, blood pressure of 76/40 mm Hg, and oxygen saturation of 92% on room air. An electrocardiogram rhythm strip shows a wide-complex sinus tachycardia with a QRS duration of $165$ msec and a prominent terminal R wave in lead aVR.

Which of the following are the MOST appropriate simultaneous initial stabilization steps? (Select 2)

A 45-year-old woman presents to the clinic with a 6-month history of progressive shortness of breath on exertion. She has no significant past medical history and takes no medications. Vital signs are within normal limits, with an oxygen saturation of 96% on room air. Physical examination reveals a loud pulmonic component of the second heart sound (P2), a right-sided S3 gallop, and trace bilateral lower extremity edema. Lungs are clear to auscultation bilaterally. Electrocardiography demonstrates right axis deviation and right ventricular hypertrophy. The physician suspects pulmonary hypertension and plans a stepwise diagnostic evaluation to confirm the diagnosis and determine the specific etiology.

Arrange the following diagnostic modalities in the correct sequential order for the comprehensive workup of this patient's suspected pulmonary hypertension, from the most appropriate initial evaluation to definitive hemodynamic confirmation.

Emergency medical services bring a 33-year-old male construction worker to the trauma bay after he fell approximately 6 meters (20 feet) from a scaffold. The prehospital crew reports that he has been progressively struggling to breathe during transport. According to a coworker who accompanied him, the patient has a past medical history of asthma and uses an albuterol inhaler occasionally. On arrival, the patient is highly agitated, diaphoretic, and gasping for air. Vital signs include a temperature of 36.8°C (98.2°F), heart rate of 142/min, blood pressure of 74/42 mm Hg, respiratory rate of 36/min, and oxygen saturation of 86% despite receiving oxygen via a non-rebreather mask. Physical examination reveals distended jugular veins and a trachea that is palpably shifted toward the right side. Auscultation demonstrates completely absent breath sounds over the entire left lung field. The abdomen is non-distended, and the pelvis is clinically stable. Two large-bore peripheral intravenous lines have been established. Which of the following is the most appropriate immediate next step in the management of this patient?

A 68-year-old man is brought to the emergency department complaining of a sudden onset of excruciating, tearing pain in his chest that radiates directly to his back. The pain began 45 minutes ago while he was eating dinner. His medical history is significant for long-standing hypertension, type 2 diabetes mellitus, and stage 4 chronic kidney disease with a baseline serum creatinine of 2.6 mg/dL. His current medications include amlodipine, lisinopril, aspirin, and insulin. On physical examination, he appears in severe distress and is diaphoretic. His blood pressure is 185/105 mmHg in the right arm and 140/90 mmHg in the left arm. His heart rate is 105/min. Cardiac auscultation reveals a faint, decrescendo diastolic murmur at the right upper sternal border. The lungs are clear to auscultation bilaterally. Neurologic examination is unremarkable. An electrocardiogram shows sinus tachycardia with voltage criteria for left ventricular hypertrophy, but no acute ST-segment or T-wave abnormalities. A portable chest radiograph demonstrates a widened mediastinum. Laboratory studies reveal a current serum creatinine of 2.9 mg/dL. Which of the following is the most appropriate next step in the diagnostic workup?

A 26-year-old woman comes to the clinic after noticing a small lump in her left breast while showering two days ago. She has no significant past medical history and takes no medications. There is no family history of breast or ovarian cancer. Vital signs are within normal limits. Physical examination reveals a $2$-cm, firm, mobile, well-circumscribed mass in the upper outer quadrant of the left breast. There are no skin changes, nipple retraction, or axillary lymphadenopathy. Which of the following is the most appropriate next step in the diagnostic workup?

A 54-year-old man is brought to the emergency department by his partner after vomiting a large amount of bright red blood at home. He has a known history of alcohol use disorder and cirrhosis. On arrival, he is lethargic and visibly pale. Vital signs reveal a heart rate of 134/min, a blood pressure of 78/46 mm Hg, a respiratory rate of 22/min, and an oxygen saturation of 96% on ambient air. His abdomen is distended but non-tender. Which of the following is the most appropriate initial step in the stabilization of this patient?

Ten minutes after successful endotracheal intubation for refractory status asthmaticus, a 28-year-old man's mechanical ventilator begins continuously sounding the high peak airway pressure alarm. The patient's blood pressure, previously 122/78 mm Hg, abruptly drops to 62/40 mm Hg, and his heart rate increases from 110/min to 148/min. Physical examination reveals prominent jugular venous distention. The trachea is midline. Chest auscultation demonstrates markedly diminished breath sounds symmetrically across both lung fields with very little chest wall excursion. There is no subcutaneous emphysema. Which of the following is the most appropriate immediate next step in the stabilization of this patient?