Patient Management

A 47-year-old female pedestrian is struck by a commercial delivery truck and brought directly to the trauma resuscitation bay. On arrival, she is lethargic, diaphoretic, and pale. Vital signs include a heart rate of 145/min, blood pressure of 65/35 mmHg, and respiratory rate of 28/min. Pulse oximetry is currently unreadable due to poor peripheral perfusion. The primary survey reveals clear, equal breath sounds bilaterally and no obvious source of external hemorrhage. The pelvis is highly unstable to gentle anteroposterior compression, and the right thigh is significantly swollen and deformed. Two large-bore peripheral intravenous lines are immediately established. Which of the following are the most appropriate immediate next steps in the stabilization of this patient? (Select all that apply)

Emergency Medical Services arrives at the trauma bay with a 28-year-old construction worker who fell approximately 30 feet from scaffolding. Upon transfer to the resuscitation stretcher, the patient demonstrates decerebrate posturing, absent vocalizations, and no eye opening to sternal rub.

Initial assessment reveals the following vital parameters:
- Temperature: 36.2°C (97.2°F)
- Heart rate: 138/min
- Blood pressure: 78/42 mm Hg
- Respiratory rate: 8/min (shallow and irregular)
- Oxygen saturation: 88% on ambient air

A rapid physical survey identifies a large, actively bleeding avulsion of the right parietal scalp. Neurologic evaluation shows anisocoria, with the right pupil fixed and dilated at 7 mm while the left is 3 mm and reactive. The left thigh exhibits massive swelling and a noticeable angular deformity.

Arrange the following management steps in the most appropriate chronological sequence of execution to stabilize this critically ill patient.

Evaluate the following patients presenting with upper gastrointestinal symptoms. Match each clinical presentation to the most appropriate next step in their diagnostic workup.

Match each clinical presentation of gastrointestinal bleeding with the most appropriate next step in the diagnostic workup.

A 36-year-old woman presents to the clinic with progressive weight gain, fatigue, and easy bruising over the past 8 months. She also reports irregular menstrual periods and new-onset facial hair growth. Blood pressure is 158/98 mmHg, pulse is 82/min, and BMI is 34 kg/m². Physical examination reveals facial plethora, prominent dorsocervical and supraclavicular fat pads, wide purple abdominal striae, and significant weakness when rising from a seated position. A baseline metabolic panel demonstrates a fasting blood glucose of 145 mg/dL and a serum potassium of 3.3 mEq/L. The physician suspects a specific endocrine disorder. Assuming positive or equivocal findings at each step that require further investigation, arrange the following diagnostic tests in the most appropriate chronological order to establish the diagnosis and definitive etiology, from initial screening to final preoperative localization.

A 68-year-old woman presents to the outpatient clinic reporting a burning sensation during urination and increased urinary frequency for the past 3 days. She reports no fever, chills, flank pain, or vaginal discharge. Her medical history is significant for atrial fibrillation, for which she takes warfarin, and stage 4 chronic kidney disease. Her current medications include warfarin, metoprolol, and a daily multivitamin. Vital signs are within normal limits. Physical examination reveals mild suprapubic tenderness but no costovertebral angle tenderness.

Which of the following is the most appropriate pharmacologic intervention for this patient's current condition?

A 38-year-old female presents to the clinic for evaluation of progressive weight gain, irregular menstrual periods, and worsening facial hair growth over the past year. She also reports new-onset proximal muscle weakness, noting difficulty rising from a seated position. Physical examination reveals a blood pressure of $155/95 \text{ mmHg}$, a body mass index of $32 \text{ kg/m}^2$, central adiposity, facial plethora, and wide purple abdominal striae.

Initial laboratory screening for hypercortisolism is performed. A 24-hour urinary free cortisol excretion is significantly elevated. An overnight $1 \text{ mg}$ dexamethasone suppression test reveals a morning serum cortisol level of $14 \text{ \mu g/dL}$ (reference range: $< 1.8 \text{ \mu g/dL}$).

Which of the following is the most appropriate next step in this patient's diagnostic workup?

A 62-year-old man comes to the clinic to review imaging results. He originally presented to an urgent care center two days ago with left-sided flank pain, and an unenhanced computed tomography (CT) scan of the abdomen and pelvis was performed to evaluate for suspected nephrolithiasis. The scan revealed a 4-mm non-obstructing stone in the left kidney, but it also incidentally demonstrated a 4.5-cm, solid, heterogeneous mass in the upper pole of the right kidney. The patient has a 30-pack-year smoking history but denies gross hematuria, fever, bone pain, or unintentional weight loss. Vital signs are temperature 37.0 C (98.6 F), blood pressure 138/86 mm Hg, heart rate 78/min, and respiratory rate 14/min. Physical examination reveals a soft, non-tender abdomen with no palpable masses. Which of the following represent the most appropriate concurrent next steps in this patient's diagnostic workup? (Select all that apply)

During a routine follow-up appointment, a 28-year-old female patient reports experiencing persistently low mood, anhedonia, and severe fatigue over the past two months. She recently lost her job and has been struggling to fall asleep. Psychiatric evaluation confirms a new diagnosis of major depressive disorder. Her medical history is notable for a seizure disorder that has been stably managed with carbamazepine for the past five years. When designing a pharmacologic treatment plan, which of the following agents are appropriate and safe choices for this patient? (Select all that apply)

A 19-year-old college student is rushed to the emergency department by his roommates. They report he accidentally consumed a cookie containing macadamia nuts 15 minutes prior to arrival. He has a past medical history of mild intermittent asthma but no known food allergies. He is now clutching his throat and struggling to breathe. Physical examination reveals a widespread urticarial rash, significant swelling of the lips and tongue, and audible stridor. He is visibly agitated and using accessory muscles of respiration. Vital signs show a blood pressure of 82/40 mmHg, a heart rate of 138/min, a respiratory rate of 28/min, and an oxygen saturation of 88% on room air. Which of the following are the most appropriate immediate stabilization steps for this patient? (Select all that apply)

A 62-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 intrascapular region. His wife reports the pain began abruptly 45 minutes ago while he was watching television. His past medical history is significant for poorly controlled hypertension and tobacco use. On arrival, he appears ashen, diaphoretic, and lethargic. His temperature is 36.8°C (98.2°F), blood pressure is 82/50 mmHg in the right arm and 74/46 mmHg in the left arm, pulse is 122/min, and respirations are 22/min. Physical examination reveals a new early diastolic decrescendo murmur heard best at the right upper sternal border. Radial pulses are diminished bilaterally, more pronounced on the left. An electrocardiogram shows sinus tachycardia with non-specific ST-segment and T-wave changes. A portable bedside chest radiograph reveals a widened mediastinum. Which of the following is the most appropriate next step in the diagnostic workup?

A 71-year-old woman is brought to the emergency department from an assisted living facility due to a progressively declining level of consciousness over the past 24 hours. Her medical history is notable for type 2 diabetes mellitus, hypertension, and advanced Alzheimer dementia. On presentation, she is lethargic, responds only to painful stimuli, and appears mottled. Vital signs are temperature 39.4°C (102.9°F), blood pressure 70/38 mm Hg, heart rate 132/min, and respiratory rate 26/min. Oxygen saturation is 95% on room air. Physical examination reveals dry mucous membranes and a cloudy, foul-smelling effluent in her indwelling urinary catheter. Which of the following is the most urgent initial step in the management of this patient?

A 67-year-old male presents to the outpatient clinic for preoperative medical clearance prior to an elective right total knee arthroplasty. He has a 45-pack-year smoking history and currently smokes one pack of cigarettes per day. He denies any cough, hemoptysis, dyspnea, or unintentional weight loss. A screening posterior-anterior and lateral chest radiograph performed earlier today demonstrates a new 1.6-cm, noncalcified, irregularly marginated solitary nodule in the left upper lobe. The patient mentions that he had some lung x-rays taken at a different hospital about four years ago for a minor respiratory infection, but he does not have the results with him. Which of the following are the most appropriate immediate next steps in the diagnostic workup for this patient? (Select all that apply.)

A 27-year-old male is brought to the emergency department by paramedics after being struck by a commercial delivery truck while riding his bicycle. According to emergency medical services, he was thrown approximately 15 feet upon impact. Upon arrival, the patient is restless, diaphoretic, and confused.

Vital signs are:
- Temperature: 36.1°C (97.0°F)
- Blood pressure: 62/34 mmHg
- Heart rate: 148/min
- Respiratory rate: 36/min
- SpO2: 82% on high-flow oxygen via non-rebreather mask

Physical examination reveals a patient in severe respiratory distress with prominent jugular venous distention. The trachea is visibly deviated to the left. Auscultation demonstrates absent breath sounds and hyperresonance to percussion over the right hemithorax. Abdominal examination shows generalized guarding. Gentle anteroposterior pressure on the iliac crests reveals mechanical instability of the pelvic ring. Bilateral lower extremity pulses are faint and thready. Intravenous access is established with two large-bore peripheral catheters.

Which of the following simultaneous initial stabilization steps are indicated in this patient's immediate management? (Select the 3 most appropriate steps)

Emergency medical personnel transport a 55-year-old man to the acute care bay following an episode of voluminous hematemesis at his home. The patient's wife notes he has a long-standing history of alcohol-associated cirrhosis. Upon transfer to the stretcher, the patient is obtunded, pale, and has audible gurgling during inspiration. Vital signs include a temperature of 36.5 C (97.7 F), a blood pressure of 72/42 mm Hg, a heart rate of 144/min, and a respiratory rate of 28/min. Oxygen saturation cannot be reliably obtained due to poor peripheral perfusion.

Arrange the following management steps in the most appropriate chronological sequence for this patient's initial stabilization and triage.

A 54-year-old woman is brought to the emergency department via ambulance due to sudden-onset difficulty breathing, lightheadedness, and a diffuse rash. Her symptoms began 20 minutes after eating a meal containing shellfish at a local restaurant. En route and upon arrival, she received a total of 2 L of intravenous normal saline and two separate doses of 0.3 mg intramuscular epinephrine, spaced 5 minutes apart. The patient is lethargic but arousable and complains of a "tight throat" and severe nausea. Her medical history is significant for essential hypertension, generalized anxiety disorder, and migraine headaches. Her daily medications include lisinopril, propranolol, and sertraline. Her temperature is 37.0°C (98.6°F), blood pressure is 76/42 mm Hg, pulse is 62/min, and respirations are 26/min. Oxygen saturation is 94% on 4 L/min via nasal cannula. Physical examination reveals diffuse, intensely pruritic erythematous plaques over the trunk and extremities, along with mild facial and lip swelling. Lung auscultation demonstrates diffuse bilateral expiratory wheezing. She is speaking in short phrases without stridor. Which of the following is the most appropriate immediate next step in the stabilization of this patient?

Match each patient presentation evaluating for suspected coronary artery disease with the most appropriate next step in diagnostic test sequencing.

A 74-year-old man is brought to the emergency department from a long-term care facility due to worsening confusion and fever over the past 24 hours. He has a history of benign prostatic hyperplasia and relies on an indwelling Foley catheter.

On arrival, the patient is obtunded. His skin is warm and flushed.

Vital signs are:
Temperature: 39.4°C (102.9°F)
Blood pressure: 74/42 mm Hg
Pulse: 124/min
Respirations: 24/min
Oxygen saturation: 95% on room air.

The urinary catheter bag contains cloudy, dark urine.

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

A 29-year-old G1P0 woman is evaluated in the emergency department for a one-day history of lower abdominal cramping and mild vaginal spotting. She reports that her last menstrual period was approximately 6 weeks ago. Her medical history is unremarkable, and she takes no medications. Vital signs are within normal limits, including a heart rate of 78/min and a blood pressure of 116/74 mm Hg. Physical examination demonstrates a closed, non-tender cervical os. There is mild right-sided adnexal tenderness, but no palpable masses, guarding, or rebound tenderness are appreciated. A point-of-care urine pregnancy test is positive. Subsequent transvaginal ultrasonography reveals a thickened endometrial stripe measuring $14 \text{ mm}$, no evidence of an intrauterine gestational sac, and normal-appearing ovaries bilaterally with no free fluid in the cul-de-sac. Laboratory testing shows a quantitative serum $\beta$-hCG level of $1,100 \text{ mIU/mL}$. Which of the following is the most appropriate next step in the diagnostic workup?

A 42-year-old man presents to the primary care clinic for a follow-up visit regarding elevated blood pressure. Over the past three months, his blood pressure measurements have consistently ranged from 145/92 mmHg to 152/96 mmHg despite strict lifestyle modifications. His past medical history is significant for asthma, which is well-controlled with an as-needed albuterol inhaler. The physician decides to initiate pharmacologic antihypertensive therapy. Which of the following medications should be avoided in this patient due to the risk of exacerbating his underlying respiratory condition?