Patient Management

A 29-year-old woman is brought to the emergency department by her sister due to profound confusion, agitation, and vomiting for the past 24 hours. The sister reports the patient was diagnosed with Graves disease two years ago but has not taken any medications for the last five months. Vital signs show a temperature of 40.2°C (104.4°F), blood pressure of 158/68 mmHg, pulse of 155/min, and respirations of 26/min. Physical examination reveals a diaphoretic, delirious patient with a diffuse, smooth, non-tender goiter, bilateral proptosis, and a fine resting tremor. Electrocardiogram demonstrates atrial fibrillation with a rapid ventricular response. A clinical diagnosis of thyroid storm is established.

Arrange the following pharmacologic interventions in the correct chronological sequence required to safely and effectively manage this patient's endocrine emergency.

Match each classic patient presentation with the most appropriate initial diagnostic imaging study.

Emergency medical services bring a 22-year-old man to the resuscitation bay for severe shortness of breath. He is a college student who has suffered from an upper respiratory tract infection over the past three days. According to his roommate, he has a known background of severe persistent asthma but ran out of his rescue inhaler yesterday. Upon arrival, the patient is extremely agitated, profusely diaphoretic, and using accessory muscles of respiration. He is unable to speak more than a single word at a time. Initial evaluation reveals a temperature of 37.4°C (99.3°F), a blood pressure of 152/94 mm Hg, a heart rate of 142/min, a respiratory rate of 38/min, and an oxygen saturation of 84% on room air. Physical examination reveals paradoxical abdominal wall movement. Auscultation demonstrates a "silent chest" with no audible wheezing or breath sounds bilaterally. Which of the following is the most appropriate initial step in the management of this patient?

A 42-year-old woman is brought to the emergency department due to profound weakness, vomiting, and confusion. She has a history of systemic lupus erythematosus and has taken daily oral prednisone for the past 5 years. However, she ran out of her medication one week ago. Two days ago, she developed nausea, vomiting, and diarrhea. Her temperature is 37.8°C (100°F), heart rate is 125/min, respiratory rate is 22/min, and blood pressure is 70/40 mmHg. Physical examination reveals a lethargic and diaphoretic patient. Laboratory results show:

Which of the following are the most appropriate immediate stabilization steps for this patient? (Select 2)

A 28-year-old male is brought to the emergency department by paramedics after sustaining a single stab wound to the left parasternal border of his chest. Paramedics report that en route, the patient was obtunded with a palpable carotid pulse, a systolic blood pressure of 70 mm Hg, and distended neck veins. Upon transfer to the trauma bay stretcher, he becomes completely unresponsive, apneic, and loses his central pulses. The cardiac monitor demonstrates pulseless electrical activity (PEA). Cardiopulmonary resuscitation is immediately initiated by the trauma team. Arrange the following initial stabilization and procedural steps in the most appropriate chronological order for managing this patient's traumatic cardiac arrest.

Emergency medical services personnel arrive at the trauma bay with a 32-year-old male who suffered a high-velocity fall from a fourth-story balcony. He is unresponsive and producing incomprehensible sounds. Vital signs obtained immediately upon transfer to the resuscitation stretcher are temperature 35.8°C (96.4°F), pulse 148/min, blood pressure 64/35 mmHg, respiratory rate 38/min, and oxygen saturation 82% on room air. The patient localizes to painful stimuli but does not open his eyes. Physical examination reveals marked jugular venous distention. The trachea is shifted to the left, and there is no air movement auscultated over the right chest wall. Gentle anteroposterior pressure on the iliac crests demonstrates significant mechanical instability. Multiple large-bore intravenous lines are currently being obtained by the nursing staff.

Which of the following interventions must be initiated immediately and simultaneously to stabilize this patient? (Select 3)

A 42-year-old man is brought to the emergency department by emergency medical services after being rescued from a residential house fire. He was found trapped in a small, smoke-filled basement for approximately 20 minutes before firefighters could extricate him. He has a past medical history of poorly controlled asthma. On arrival, the patient is extremely agitated, coughing vigorously, and speaking with a noticeably hoarse voice. Physical examination reveals soot in the oropharynx, singed eyebrows, and partial-thickness burns over his anterior forearms, which account for approximately 4% of his total body surface area. Bilateral expiratory wheezes are heard on lung auscultation. Vital signs are temperature 37.3°C (99.1°F), blood pressure 135/85 mmHg, heart rate 112/min, respiratory rate 26/min, and oxygen saturation 95% on a 15 L/min non-rebreather mask. Which of the following is the single most urgent initial step in the management of this patient?

A 68-year-old man comes to the clinic for a routine follow-up. He feels well but reports he recently recovered from a severe bout of gastroenteritis that lasted for 4 days. His blood pressure is 135/85 mm Hg and his pulse is 78/min. Physical examination is unremarkable. Laboratory studies show a serum creatinine level of 2.4 mg/dL, up from a baseline of 1.1 mg/dL three months ago. His current home medications include metformin, lisinopril, acetaminophen, amlodipine, and atorvastatin. The physician decides to hold certain medications while the patient's renal function recovers. Which of the following home medications should be temporarily held in the setting of this patient's acute kidney injury? (Select all that apply)

A 68-year-old man is hospitalized for an acute right lower extremity deep vein thrombosis. His medical history is significant for hypertension, type 2 diabetes mellitus, and end-stage renal disease on hemodialysis. On admission, he was started on a continuous intravenous unfractionated heparin infusion. On hospital day 4, routine morning laboratory studies reveal a platelet count of $85,000/mm^3$, representing a significant decline from his baseline of $210,000/mm^3$ on admission. He is hemodynamically stable, his right leg swelling is unchanged, and there is no evidence of active bleeding. A serotonin release assay is ordered, but the clinical suspicion for heparin-induced thrombocytopenia is high. The heparin infusion is immediately discontinued. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 38-year-old man is evaluated in the preoperative clinic prior to a scheduled open reduction and internal fixation of a severely displaced tibial plateau fracture. The procedure is planned for 3 days from today. His medical history is notable for severe opioid use disorder, which has been in sustained remission for 4 years. He is maintained on a stable daily dose of sublingual buprenorphine-naloxone (16 mg / 4 mg). He has no other chronic medical conditions and takes no other medications. Vital signs are within normal limits. The patient expresses significant anxiety regarding postoperative pain control and fears that his current medication will interfere with his pain management. Which of the following is the most appropriate pharmacologic strategy regarding his opioid use disorder therapy in the perioperative period?

A 54-year-old man is rushed to the emergency department after his wife found him collapsed on the bathroom floor surrounded by a large amount of bright red vomit. He has a known history of alcohol-associated cirrhosis. Upon arrival, he is lethargic, obtunded, and only withdrawing from painful stimuli. Vital signs are temperature 36.5°C (97.7°F), blood pressure 75/40 mmHg, pulse 138/min, and respirations 28/min. Pulse oximetry shows 88% on room air. Physical examination reveals cool, diaphoretic skin, profound scleral icterus, and a distended abdomen with a palpable fluid wave. The physician notes audible gurgling in his upper airway, and there is active, ongoing hematemesis from the patient's mouth.

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

A 68-year-old man is brought to the emergency department by ambulance 30 minutes after his wife noticed him slurring his words and unable to move his right arm and leg. He has a medical history of hypertension and type 2 diabetes mellitus. His blood pressure is 180/100 mm Hg, pulse is 92/min, and respirations are 16/min. Neurologic examination reveals right-sided facial droop, right-sided hemiparesis, and expressive aphasia. Which of the following are the most appropriate immediate next steps in the diagnostic workup? (Select two)

A 48-year-old man comes to the emergency department with a 12-hour history of severe, constant epigastric pain that radiates to his back. The pain is accompanied by intractable nausea and non-bilious vomiting. He has a 10-year history of heavy alcohol use but states his last drink was 2 days ago. His medical history is otherwise unremarkable. Temperature is 37.8°C (100.0°F), blood pressure is 142/88 mmHg, pulse is 115/min, and respirations are 20/min. Physical examination reveals a distressed patient leaning forward on the stretcher. Abdominal examination shows marked epigastric tenderness to deep palpation with guarding, but no rebound tenderness or rigidity. Bowel sounds are hypoactive. Which of the following are the most appropriate initial steps in the diagnostic workup for this patient? (Select the 2 correct answers)

Emergency medical services bring a 64-year-old man to the emergency department after he collapsed at his workplace. Prior to losing consciousness, he complained of an agonizing, tearing pain radiating to his interscapular region. Upon arrival, he is lethargic and pale. Vital signs are temperature 36.8°C (98.2°F), blood pressure 75/40 mmHg in the right arm and 60/35 mmHg in the left arm, heart rate 132/min, and respiratory rate 26/min. Oxygen saturation is 96% on room air. Physical examination reveals prominently distended neck veins. The lungs are clear to auscultation bilaterally. Cardiac auscultation reveals distant heart sounds and a high-pitched, decrescendo diastolic murmur heard most loudly at the right upper sternal border. Radial pulses are markedly weaker on the left compared to the right. A point-of-care ultrasound of the heart demonstrates a large pericardial effusion with right ventricular collapse during diastole. Which of the following is the most appropriate immediate next step in the management of this patient?

A 28-year-old man comes to the clinic for evaluation of a painless ulcer on his penis that appeared one week ago. He has no other symptoms and feels well. He is sexually active with multiple partners. His medical history is significant for an episode of severe anaphylaxis, including throat swelling and hypotension, after receiving amoxicillin at age 12. He takes no daily medications. Vital signs are within normal limits. Physical examination reveals a 1.5-cm, indurated, painless ulcer with a clean base on the glans penis. There is bilateral, non-tender inguinal lymphadenopathy. Dark-field microscopy of a sample from the ulcer exudate shows motile spirochetes. Which of the following is the most appropriate pharmacologic intervention for this patient?

A 19-year-old male college student is transported to the emergency department after suddenly developing severe difficulty breathing and facial swelling while at a local seafood restaurant. He states that his throat feels tight. He has no known past medical history and takes no daily medications. On presentation, the patient is visibly anxious and using accessory muscles of respiration. Temperature is $37.0^\circ$ C ($98.6^\circ$ F), blood pressure is $86/50$ mmHg, pulse is $128$/min, respirations are $28$/min, and oxygen saturation is $94\%$ on room air. Physical examination reveals audible stridor, diffuse bilateral wheezing, and raised, erythematous plaques on his anterior chest. Which of the following is the most appropriate initial step in the management of this patient?

A 74-year-old woman is evaluated in the intensive care unit for a new-onset fever and increased oxygen requirement. She was admitted 5 days ago for a severe ischemic stroke and currently requires mechanical ventilation. Her temperature is 39.1°C (102.4°F), blood pressure is 88/54 mmHg, and heart rate is 118/min. She has a documented history of a severe anaphylactic reaction to penicillin, characterized by hives and airway edema. A portable chest radiograph shows a new right lower lobe consolidation. A tracheal aspirate is sent for Gram stain and culture. Which of the following medications are most appropriate to include in this patient's initial empiric pharmacologic regimen? (Select all that apply)

A 42-year-old woman comes to the clinic for a routine follow-up. Eighteen months ago, she underwent a lumpectomy and adjuvant radiation therapy for an estrogen receptor-positive, progesterone receptor-positive, HER2-negative invasive ductal carcinoma of the right breast. She has been taking tamoxifen since completing radiation therapy. Three weeks ago, she visited an urgent care clinic for new-onset anhedonia, persistent low mood, and severe hot flashes that frequently interrupted her sleep. She was diagnosed with major depressive disorder and prescribed fluoxetine. Today, the patient reports a mild improvement in her mood but states the hot flashes remain highly bothersome. Additionally, she expresses concern after reading an article online about potential interactions between her medications. Vital signs are within normal limits. Physical examination is unremarkable. Which of the following is the most appropriate pharmacologic intervention for this patient?

An otherwise healthy 45-year-old female teacher establishes care at a new primary care office. She reports feeling well with no recent changes in weight, bowel habits, temperature tolerance, or energy levels. Vital signs are within normal limits. During the physical examination, the physician palpates a 1.5-cm, firm, mobile, non-tender nodule in the right lobe of the thyroid gland. There is no palpable cervical lymphadenopathy, and the remainder of the examination is unremarkable. Which of the following is the most appropriate next step in the diagnostic workup?

Accompanied by her spouse, a 26-year-old woman arrives at the emergency department complaining of agonizing right-sided lower abdominal pain and severe lightheadedness that commenced roughly two hours prior. Upon initial assessment, she is lethargic and visibly diaphoretic with marked conjunctival pallor. Her last menstrual cycle occurred 7 weeks ago, and she noted a small amount of vaginal bleeding this morning. Vital signs are notable for a temperature of 37.1°C (98.8°F), a blood pressure of 72/40 mm Hg, a heart rate of 138/min, a respiratory rate of 24/min, and an oxygen saturation of 98% breathing ambient air. Abdominal examination demonstrates a rigid, distended contour with generalized tenderness to palpation and involuntary guarding. Her capillary refill time is prolonged at 4 seconds. Which of the following represents the most appropriate initial step in the management of this patient?