Patient Management

A 74-year-old woman is brought to the clinic by her son for a progressive decline in her memory over the past 12 months. The son notes that she frequently repeats questions, forgets recently discussed topics, and recently became disoriented while walking in her own neighborhood. She previously managed her own finances but now struggles to pay bills on time. She has a history of essential hypertension, osteoarthritis, and occasional urinary incontinence over the past 2 years. Her current medications include lisinopril and acetaminophen. Vital signs are Temp 36.8°C (98.2°F), BP 132/82 mmHg, HR 72/min, and RR 14/min. Neurological examination shows normal cranial nerves, normal motor strength and sensation, and a normal, steady gait. She scores 21/30 on the Montreal Cognitive Assessment (MoCA), losing points primarily on delayed recall, orientation, and visuospatial tasks. Which of the following are indicated as the most appropriate concurrent steps in the initial diagnostic workup of this patient? (Select 2)

A 72-year-old man is transferred to the intensive care unit with septic shock secondary to a severe intra-abdominal infection. Blood cultures have been drawn and broad-spectrum antimicrobial therapy has been initiated. However, his mean arterial pressure remains below 65 mmHg, and he exhibits signs of poor tissue perfusion. The clinical team proceeds to manage his hemodynamic instability according to standard sepsis resuscitation guidelines. Arrange the following pharmacologic interventions in the correct sequential order of escalation for the treatment of his persistent hypotension.

A 35-year-old woman comes to the clinic for evaluation of a painless lump in her neck that she noticed two weeks ago while applying moisturizer. She reports no changes in weight, bowel habits, energy levels, or temperature tolerance. She has no significant past medical history and takes no medications. Vital signs are within normal limits. Physical examination reveals a 1.5-cm, firm, mobile, non-tender nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is appreciated. Laboratory testing shows a serum thyroid-stimulating hormone (TSH) level of 2.8 µU/mL (reference range: 0.5–5.0 µU/mL). Which of the following is the most appropriate next step in the diagnostic workup?

Following a high-speed frontal vehicular collision, a gravid $30$-year-old patient (estimated $34$ weeks gestation) is evaluated in the trauma resuscitation area. She was an unrestrained driver. Paramedics deliver her immobilized in a strict supine position on a spine board. She is extremely pale, restless, and describes a constant, tearing pain in her abdomen.

Vital signs demonstrate:
- Temperature: $36.2^\circ\text{C}$ ($97.2^\circ\text{F}$)
- Blood pressure: $72/40\text{ mmHg}$
- Heart rate: $138/\text{min}$
- Respiratory rate: $28/\text{min}$
- SpO2: $91\%$ on room air

Clinical evaluation shows collapsed neck veins and a midline trachea. Pulmonary auscultation reveals clear, symmetric breath sounds. Her abdomen is enlarged, hypertonic, and board-like with diffuse tenderness to palpation. A moderate amount of dark red blood is present at the vaginal introitus. Pelvic compression testing shows no mechanical instability.

Which of the following interventions should be implemented SIMULTANEOUSLY as part of the immediate initial stabilization for this patient? (Select 3)

A 54-year-old man undergoes evaluation for a 1-week history of progressively worsening pain with swallowing and retrosternal burning. His medical history is notable for a deceased-donor renal transplantation 3 years ago. His daily maintenance immunosuppressive regimen consists of tacrolimus, mycophenolate mofetil, and prednisone. Temperature is 37.2°C (99.0°F), blood pressure is 128/78 mm Hg, and pulse is 76/min. Physical examination reveals easily removable white plaques on the buccal mucosa and soft palate. Upper gastrointestinal endoscopy demonstrates adherent, whitish plaques throughout the middle and distal esophagus. The physician decides to initiate targeted therapy with oral fluconazole. Which of the following is the most appropriate concurrent pharmacologic management step for this patient?

A 35-year-old woman is brought to the emergency department by ambulance due to the sudden onset of severe palpitations, shortness of breath, and lightheadedness. Her symptoms began approximately 30 minutes ago while she was watching television. She has no significant past medical history and takes no medications. On physical examination, the patient is lethargic, pale, and profusely diaphoretic. Her temperature is 37.1°C (98.8°F), blood pressure is 74/42 mmHg, heart rate is 185/min and regular, respiratory rate is 26/min, and oxygen saturation is 95% on room air. Cardiac auscultation reveals a rapid, regular rhythm with no murmurs. Pulmonary auscultation is clear bilaterally. An electrocardiogram obtained immediately upon arrival shows a regular, narrow-complex tachycardia at a rate of 185/min without discernible P waves. Two large-bore peripheral intravenous lines are placed.

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

An otherwise healthy 42-year-old male is evaluated in the emergency department for sudden, severe head pain. He states the pain began abruptly 2 hours ago during a high-intensity workout and describes it as unlike any headache he has ever experienced. Associated symptoms include marked nausea and sensitivity to light. Vital signs show a blood pressure of 165/95 mmHg, a heart rate of 92/min, and a temperature of 37.1°C (98.8°F). Neurologic examination is nonfocal, but there is noticeable resistance to neck flexion. Arrange the following diagnostic interventions in the correct chronological sequence for working up this patient's likely diagnosis, from first to last.

During a routine health maintenance visit, a 54-year-old man describes a gradual increase in his shoe and ring size over the last four years. He also reports excessive sweating, deepening of his voice, and daytime somnolence. His wife notes that his snoring has worsened significantly. On examination, he has prominent supraorbital ridges, a widened jaw with increased dental spacing, and coarse facial features. Blood pressure is 158/96 mmHg. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's suspected condition, progressing from the initial screening test to the pre-surgical anatomical assessment.

An ambulatory $42$-year-old man is evaluated in the hypertension specialty clinic due to persistently elevated blood pressure. He was diagnosed with essential hypertension $5$ years ago, but his readings remain consistently above $150/90$ mm Hg despite strict adherence to a daily regimen of amlodipine, olmesartan, and indapamide. The patient reports occasional episodes of proximal muscle weakness and nocturnal polyuria, but is otherwise asymptomatic. Vital signs today show a blood pressure of $158/96$ mm Hg and a heart rate of $76$/min. Physical examination is unremarkable, with no abdominal bruits, cushingoid features, or radiofemoral delay.

Basic metabolic panel reveals the following:

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

Paramedics bring a 19-year-old college student to the emergency department resuscitation bay due to sudden and severe right-sided chest pain accompanied by extreme shortness of breath. The symptoms began abruptly while he was playing basketball. On arrival, the patient is deeply cyanotic, diaphoretic, and in severe respiratory distress. Vital signs show a blood pressure of 78/46 mmHg, heart rate of 142/min, respiratory rate of 38/min, and oxygen saturation of 82% on 15 L/min of oxygen via a nonrebreather mask. Physical examination reveals distended jugular veins and a trachea that is visibly shifted to the left. Auscultation demonstrates completely absent breath sounds over the entire right hemithorax with hyperresonance on percussion. Which of the following is the most appropriate immediate next step in management?

A 34-year-old woman is evaluated in the hospital after experiencing a generalized tonic-clonic seizure lasting approximately 2 minutes. She was admitted 2 days ago for a perforated appendix and underwent an emergent laparoscopic appendectomy. Postoperatively, she has been receiving intravenous fluids and empiric intravenous ertapenem. She has a 12-year history of focal epilepsy with secondary generalization, which had been well-controlled without any seizures for the past 4 years on a stable daily dose of valproic acid. She also uses a levonorgestrel-releasing intrauterine device.

The patient is currently post-ictal but is slowly returning to her baseline mental status. She denies any preceding aura, headache, or focal weakness. Her temperature is 37.6°C (99.7°F), blood pressure is 112/70 mm Hg, heart rate is 84/min, and respiratory rate is 14/min. Physical examination reveals a well-healing abdominal incision with mild right lower quadrant tenderness. Neurologic examination shows no focal deficits.

Laboratory studies obtained immediately after the seizure show:

Review of her electronic medical record shows an outpatient valproic acid level of 88 mcg/mL drawn 3 weeks ago.

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

A 42-year-old woman is evaluated in the clinic for a 1-year history of progressive weight gain, new-onset facial hair growth, and easy bruising. Her blood pressure is 155/95 mmHg, and her BMI is 34 kg/m^2. Physical examination reveals facial plethora, supraclavicular fat pads, and broad violaceous striae across her abdomen. Proximal muscle weakness is noted on neurologic examination. Initial laboratory evaluation shows a 24-hour urine free cortisol level that is 4 times the upper limit of normal. A low-dose (1 mg) overnight dexamethasone suppression test demonstrates a morning serum cortisol of 14 µg/dL (normal: < 1.8 µg/dL). Subsequent testing reveals a plasma adrenocorticotropic hormone (ACTH) level of 85 pg/mL (normal: 10-60 pg/mL). An MRI of the pituitary gland is performed and demonstrates a 4-mm hypoenhancing lesion in the right anterior pituitary gland. Which of the following is the most appropriate next step in the diagnostic workup?

A 62-year-old man with chronic kidney disease stage 4 presents to the emergency department reporting progressive, severe muscle weakness over the past 24 hours. He recently started taking lisinopril and spironolactone for hypertension and heart failure. His pulse is 48/min, and blood pressure is 105/65 mm Hg. An electrocardiogram reveals peaked T waves and a widened QRS complex. Stat laboratory results show a serum potassium level of 7.6 mEq/L. Arrange the following pharmacologic interventions in the most appropriate chronological order of administration for the acute management of this patient's condition.

A 34-year-old man comes to the clinic for a follow-up examination of poorly controlled hypertension. He was diagnosed with hypertension two years ago and is currently taking amlodipine, lisinopril, and hydrochlorothiazide at maximally tolerated doses. He reports no headaches, chest pain, palpitations, or abnormal sweating. His blood pressure is $162/100$ mm Hg, and his pulse is $78$/min. His BMI is $24$ kg/m $^2$. Physical examination shows no abdominal bruits, delayed femoral pulses, or cushingoid features. Laboratory studies reveal:

Sodium: $142$ mEq/L
Potassium: $2.9$ mEq/L
Chloride: $104$ mEq/L
Bicarbonate: $28$ mEq/L
Creatinine: $0.9$ mg/dL

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

A 68-year-old male with a history of hypertension and heavy tobacco use collapses during a family gathering and is rapidly transported to the acute care bay. He is lethargic, moaning in pain, and complains of sudden, excruciating pain tearing through his abdomen and lower back. Initial assessment reveals a pale, diaphoretic patient with cool extremities and delayed capillary refill.

Vital signs:
- Temperature: 36.2°C (97.2°F)
- Heart rate: 132/min
- Blood pressure: 65/40 mmHg
- Respirations: 22/min
- Oxygen saturation: 94% on room air

Physical examination is notable for a distended abdomen with a prominent, pulsatile mass palpated just above the umbilicus. Bedside focused assessment with sonography for trauma (FAST) demonstrates free intra-abdominal fluid.

Based on the clinical presentation, which of the following simultaneous initial management steps are most urgently indicated? (Select exactly two options)

A $68$-year-old man with a history of severe chronic obstructive pulmonary disease is brought to the emergency department for severe respiratory distress and altered mental status. He is subsequently intubated for acute hypercapnic respiratory failure and placed on volume-controlled mechanical ventilation. Ten minutes later, the ventilator's high-pressure alarm begins to sound continuously. His blood pressure precipitously drops from $142/88 \text{ mm Hg}$ to $70/40 \text{ mm Hg}$, and his heart rate increases from $98\text{/min}$ to $135\text{/min}$. Pulse oximetry shows an oxygen saturation of $86\%$. Physical examination reveals new-onset jugular venous distension. The trachea is midline. Auscultation of the chest reveals markedly diminished breath sounds bilaterally. Which of the following is the most appropriate immediate next step in management?

A 26-year-old primigravid woman at 8 weeks gestation presents to the clinic for a routine prenatal visit. Over the past three weeks, she has experienced frequent palpitations, heat intolerance, excessive sweating, and a 2.3-kg (5-lb) weight loss despite an increased appetite. Her blood pressure is 128/78 mmHg, pulse is 112/min, and respirations are 16/min. Physical examination reveals mild exophthalmos and a diffusely enlarged, non-tender thyroid gland. A fine bilateral hand tremor is noted when her arms are outstretched. Laboratory studies show:

Thyroid-stimulating hormone (TSH): 0.01 µU/mL (normal: 0.1-2.5 µU/mL)
Free thyroxine (T4): 2.9 ng/dL (normal: 0.8-1.5 ng/dL)
Thyroid-stimulating immunoglobulin: Elevated

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

A 38-year-old woman is evaluated in the clinic for progressive central obesity, severe fatigue, facial plethora, and easy bruising over the past eight months. She has newly diagnosed hypertension and type 2 diabetes mellitus. Physical examination is notable for wide, violaceous abdominal striae and proximal muscle weakness. To definitively evaluate the etiology of this patient's suspected condition, arrange the following diagnostic steps in the most appropriate chronological sequence, progressing from initial screening to definitive pre-surgical localization. Assume the condition is ultimately driven by a functional microadenoma that measures 3 mm on imaging.

Determine the most appropriate next step in the diagnostic workup for each of the following patients presenting with gastrointestinal symptoms.

A 34-year-old woman is evaluated in the endocrinology clinic for a 6-month history of secondary amenorrhea, milky nipple discharge, and new-onset headaches. She has no significant past medical history and takes no medications. On physical examination, vital signs are within normal limits. Neurologic examination reveals a bitemporal hemianopsia on confrontation visual field testing. A urine pregnancy test is negative. Initial laboratory studies show a serum prolactin concentration of 65 ng/mL (reference range: 4-25 ng/mL) and a thyroid-stimulating hormone level of 1.4 µU/mL. A magnetic resonance imaging scan of the brain with sellar sequences demonstrates a 2.8-cm pituitary mass with suprasellar extension and compression of the optic chiasm. Which of the following are the most appropriate next steps in the diagnostic workup for this patient? (Select all that apply)