Patient Management

A 68-year-old man is brought to the emergency department via ambulance due to the sudden onset of severe, tearing chest pain that radiates to his back between his shoulder blades. The pain began abruptly 45 minutes ago while he was sitting at his desk. His medical history includes poorly controlled hypertension, type 2 diabetes mellitus, and stage IV chronic kidney disease. Current medications include amlodipine, lisinopril, insulin glargine, and aspirin.

Upon arrival, his temperature is 37.0°C (98.6°F), blood pressure is 185/105 mmHg in the right arm and 145/85 mmHg in the left arm. Pulse is 110/min, and respirations are 22/min. Oxygen saturation is 96% on room air. The patient appears distressed and diaphoretic. Cardiopulmonary examination reveals a regular tachycardia and a faint early diastolic murmur at the right upper sternal border. Lungs are clear to auscultation bilaterally. There is a noticeable discrepancy in radial pulse volume between the right and left arms.

Electrocardiography (ECG) shows sinus tachycardia with left ventricular hypertrophy but no acute ST-segment or T-wave changes. Initial laboratory studies reveal a serum creatinine of 2.8 mg/dL (baseline 2.5 mg/dL) and high-sensitivity troponin T within normal limits. Intravenous labetalol is initiated for blood pressure and heart rate control.

Which of the following is the most appropriate next step in the diagnostic workup?

A 62-year-old man with a history of decompensated alcoholic cirrhosis arrives at the emergency department accompanied by his daughter. She explains that he recently vomited a large quantity of dark red blood and clots at home. On assessment, the patient is lethargic, diaphoretic, and his extremities are cool to the touch. Vital signs reveal a blood pressure of 78/48 mm Hg, a heart rate of 132/min, a respiratory rate of 22/min, and an oxygen saturation of 95% on room air. Which of the following are the most appropriate immediate next steps in the stabilization of this patient? (Select exactly 2 options)

A 42-year-old woman is brought to the emergency department by her husband due to a sudden-onset, severe headache that began 3 hours ago. She describes it as the "worst headache of my life." Her medical history is unremarkable, and she takes no daily medications. Vital signs show a blood pressure of 150/90 mm Hg, heart rate of 92/min, and respiratory rate of 16/min. Neurological examination reveals no focal deficits, but she reports mild photophobia and neck stiffness. A non-contrast computed tomography (CT) scan of the head reveals no evidence of acute hemorrhage or mass effect. Which of the following is the most appropriate next step in the diagnostic workup?

A 23-year-old university student is brought to the emergency department by paramedics following an altercation outside a local restaurant. He sustained a single stab wound to the left anterior neck with a pocketknife. Upon arrival, the patient is highly agitated, diaphoretic, and exhibits audible high-pitched inspiratory sounds. Vital signs include a temperature of 37.0°C (98.6°F), blood pressure of 105/65 mm Hg, heart rate of 122/min, and respiratory rate of 28/min. Oxygen saturation is 94% on a 15 L/min non-rebreather mask. Physical examination reveals a 2-cm laceration positioned vertically between the cricoid cartilage and the angle of the mandible. There is a rapidly enlarging, pulsatile swelling beneath the wound, and the trachea is palpably deviated to the right. The patient speaks in a hoarse, whispering voice and is coughing up bright red blood. Which of the following is the single most urgent initial stabilization step for this patient?

A 61-year-old man is evaluated in the hospital for 3 days of fever, dry cough, pleuritic chest pain, and mild hemoptysis. His medical history is significant for an orthotopic heart transplant 3 years ago for nonischemic cardiomyopathy and a history of recurrent unprovoked deep venous thrombosis. His current medications include tacrolimus, mycophenolate mofetil, prednisone, and warfarin.

Vital signs are temperature $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse $102/\text{min}$, blood pressure $118/74\text{ mmHg}$, and respirations $20/\text{min}$. Pulse oximetry shows $94\%$ on room air.

A serum galactomannan assay is markedly elevated. A non-contrast CT of the chest reveals a $3\text{ cm}$ macronodule in the right upper lobe surrounded by a halo of ground-glass attenuation.

The infectious disease service diagnoses invasive pulmonary aspergillosis and recommends initiating intravenous voriconazole.

Which of the following simultaneous pharmacologic interventions are indicated for this patient? (Select all that apply)

A 22-year-old college student is brought to the emergency department by his roommates because he is unarousable. He had complained of a severe headache and fever for the past 24 hours. Vital signs show temperature $39.5^\circ\text{C}$ ($103.1^\circ\text{F}$), blood pressure 80/40 mm Hg, pulse 135/min, and respirations 28/min. Oxygen saturation is 88% on room air. Physical examination reveals a petechial rash on the lower extremities and nuchal rigidity. The patient only withdraws to pain and does not open his eyes or make any sounds (Glasgow Coma Scale score of 6).

Arrange the following management steps in the most appropriate sequential order for this patient's initial stabilization and diagnostic workup.

A 56-year-old man is evaluated in the clinic for persistent hypertension. He has a 4-year history of elevated blood pressure that remains poorly controlled despite adherence to maximum tolerated doses of amlodipine, lisinopril, and hydrochlorothiazide. His blood pressure today is 162/98 mm Hg. Laboratory studies show a serum potassium level of 3.2 mEq/L and a serum sodium level of 145 mEq/L. The physician suspects primary aldosteronism.

Arrange the following diagnostic interventions in the most appropriate chronological order to establish the diagnosis, localize the pathology, and guide surgical management, assuming each successive test yields abnormal findings that necessitate further workup.

During a routine primary care visit, a 42-year-old man is evaluated for persistently elevated blood pressure. He was diagnosed with hypertension four years ago. Despite documented adherence to a daily regimen containing maximal doses of amlodipine, olmesartan, and chlorthalidone, his home blood pressure readings consistently remain above $150/90 \text{ mm Hg}$. He reports no headaches, palpitations, or episodic sweating. Today, his blood pressure is $162/98 \text{ mm Hg}$, and his pulse is $76/\text{min}$. His body mass index is $26 \text{ kg/m}^2$. Physical examination is unremarkable. Laboratory studies from last week demonstrate a serum potassium level of $2.9 \text{ mEq/L}$ and a sodium level of $144 \text{ mEq/L}$. A plasma aldosterone-to-renin ratio is significantly elevated, and primary aldosteronism is subsequently confirmed via a lack of aldosterone suppression following an intravenous saline infusion test. An unenhanced computed tomography (CT) scan of the abdomen reveals a $1.4\text{-cm}$, lipid-rich, low-density nodule in the right adrenal gland. The left adrenal gland appears morphologically normal. The patient is otherwise healthy, has a good baseline functional status, and expresses a strong preference for definitive surgical management over lifelong medical therapy. Which of the following is the most appropriate next step in management?

A 62-year-old man is brought to the emergency department due to sudden-onset, severe substernal chest pain that radiates to his left jaw. The pain started 45 minutes ago. His blood pressure is 120/80 mmHg, and his heart rate is 90/min. An electrocardiogram shows ST-segment elevations in leads V1 through V4. His medical history includes type 2 diabetes mellitus, hyperlipidemia, and erectile dysfunction. He reports taking sildenafil 12 hours ago for erectile dysfunction. Which of the following medications is absolutely contraindicated in the initial management of this patient's acute presentation?

Match each clinical presentation of a patient with a thyroid abnormality to the most appropriate guideline-indicated next step in their diagnostic workup.

A 52-year-old woman is evaluated in the hospital for sudden-onset, severe shortness of breath. She was admitted earlier today for management of osteomyelitis and recently underwent placement of a right internal jugular central venous catheter. Her blood pressure is 78/40 mmHg, pulse is 134/min, and oxygen saturation is 82% on room air. On physical examination, she is in severe respiratory distress and is diaphoretic. The trachea is deviated to the left. The neck veins are visibly distended. Breath sounds are completely absent over the right hemithorax, and the right chest is hyperresonant to percussion. Which of the following is the most appropriate next step in management of this patient?

A 32-year-old man with a known history of epilepsy is brought to the emergency department by ambulance. His roommate reports that the patient has been experiencing continuous generalized tonic-clonic movements for the past 20 minutes without regaining consciousness. Upon arrival, the patient is actively seizing. The airway is secured, and peripheral intravenous access is immediately established. Arrange the following pharmacologic interventions in the correct sequential order of escalation for the management of status epilepticus, from first-line therapy to refractory management.

A 52-year-old man undergoes an unenhanced computed tomography (CT) scan of the abdomen and pelvis to evaluate suspected nephrolithiasis after recently passing a calcium oxalate stone. The scan reveals an incidental 4.6-cm, well-circumscribed left adrenal mass with an unenhanced attenuation of 28 Hounsfield units. The right adrenal gland is normal. The patient is completely asymptomatic. He has no history of hypertension, palpitations, headaches, or weight changes. He takes no medications. Vital signs are temperature 37.1°C (98.8°F), blood pressure 118/76 mm Hg, heart rate 72/min, and respiratory rate 14/min. Physical examination reveals no abdominal bruits, purple striae, central adiposity, or abnormal fat distribution. Serum potassium is 4.3 mEq/L and serum creatinine is 0.9 mg/dL. Which of the following is the most appropriate next step in the diagnostic workup?

Emergency medical services arrive at the trauma bay with a 35-year-old construction worker who fell approximately 20 feet from scaffolding. On presentation, the patient is obtunded with gurgling respirations and profound maxillofacial bleeding. The cardiac monitor displays a sinus tachycardia of 138/min. Noninvasive blood pressure is 75/40 mm Hg, and respiratory rate is 28/min.

According to standard trauma resuscitation protocols, arrange the following initial stabilization steps in the most appropriate chronological sequence.

During a routine health maintenance examination, a physician detects an asymmetric neck swelling in a previously healthy 48-year-old female. The patient reports a 3-kg (6.6-lb) unintentional weight loss over the past two months and describes intermittent episodes of a 'racing heart.' Vital signs show a heart rate of 98/min and a blood pressure of 128/82 mmHg. Physical examination reveals a firm, mobile, 2.5-cm mass in the right anterior neck that moves with swallowing. No cervical lymphadenopathy is appreciated. Laboratory evaluation demonstrates a thyroid-stimulating hormone (TSH) level of 0.08 µU/mL (normal: 0.4–4.0 µU/mL) and a free thyroxine (T4) level of 2.1 ng/dL (normal: 0.8–1.8 ng/dL). A comprehensive neck ultrasound identifies a 2.6-cm solid, mildly hypoechoic nodule in the right thyroid lobe with increased central vascularity. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's condition?

A 45-year-old man presents to the clinic complaining of increasing ring and shoe size over the past three years. He also reports excessive sweating, worsening snoring, and joint pain. Physical examination reveals coarse facial features, a prominent jaw, and enlarged, doughy hands. The physician strongly suspects a condition caused by a hyperfunctioning anterior pituitary adenoma. What is the correct sequence of the following diagnostic steps to evaluate this patient's condition? Arrange the items from the initial screening test to the final localization study.

Paramedics transport a 19-year-old man to the trauma bay following a headfirst diving accident in a shallow lake. On arrival, he is apneic and completely unresponsive to noxious stimuli. Emergency medical personnel are actively providing assisted ventilation via a bag-valve-mask device. His temperature is $35.2^\circ\text{C}$ ($95.4^\circ\text{F}$), blood pressure is $72/40\text{ mmHg}$, heart rate is $44\text{/min}$, and oxygen saturation is $94\%$ on $100\%$ oxygen. Physical examination reveals flaccid paralysis and absent deep tendon reflexes in all four extremities. A $6\text{-cm}$ scalp laceration over the vertex is actively oozing blood.

Arrange the following initial management steps in the most appropriate chronological order.

A 64-year-old man with a history of hypertension and hyperlipidemia is brought to the emergency department by ambulance due to severe, crushing substernal chest pain that began 45 minutes ago while shoveling snow. The patient is pale, profusely diaphoretic, and appears in acute distress. Vital signs are temperature 36.6°C (97.9°F), heart rate 42/min, blood pressure 72/40 mm Hg, respiratory rate 22/min, and oxygen saturation 96% on room air. Physical examination reveals marked jugular venous distention. Auscultation of the chest demonstrates clear lung fields bilaterally with no murmurs or gallops. An immediate 12-lead electrocardiogram shows 3-mm ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL. Which of the following is the most appropriate next step in the management of this patient?

A 55-year-old man is evaluated in the emergency department for left leg pain and swelling that began 24 hours ago. He has a history of colon cancer and is currently undergoing active chemotherapy. His temperature is 37.1 C (98.8 F), blood pressure is 130/80 mm Hg, heart rate is 88/min, and respiratory rate is 14/min. Physical examination reveals a visibly swollen, tense, and erythematous left lower extremity. The left calf circumference is 5 cm larger than the right calf. There is no chest pain or shortness of breath. Which of the following is the most appropriate next step in the diagnostic workup for this patient?

A 61-year-old man arrives at the emergency department reporting severe, crushing substernal chest pain that radiates to his jaw, accompanied by profound diaphoresis and nausea. The symptoms began abruptly 45 minutes prior. His past medical history is notable for hypertension, type 2 diabetes mellitus, and hyperlipidemia. Vital signs are temperature 36.8°C (98.2°F), heart rate 112/min, blood pressure 74/48 mm Hg, respiratory rate 22/min, and oxygen saturation 96% on room air. Physical examination reveals elevated jugular venous pressure with prominent a-waves. Pulmonary auscultation reveals clear breath sounds bilaterally without crackles or wheezes. A 12-lead electrocardiogram demonstrates 3-mm ST-segment elevations in leads II, III, and aVF, with reciprocal ST-segment depressions in leads I and aVL. Which of the following is the most urgent initial step in the management of this patient?