Patient Management

A 58-year-old man with a history of alcohol-related cirrhosis is brought to the emergency department by his family due to increasing confusion and lethargy over the past 24 hours. His family reports that he has not had any recent falls, head trauma, vomiting, or dark stools. He has been compliant with his home medications, which include furosemide, spironolactone, and nadolol.

Temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), blood pressure is 105/65 mmHg, heart rate is 102/min, and respiratory rate is 16/min. Physical examination reveals a lethargic man who is oriented only to person. Scleral icterus is present. He has prominent abdominal distention with a positive fluid wave and shifting dullness. No focal neurologic deficits are present, but he exhibits a coarse, flapping tremor of the hands when his wrists are actively extended. Digital rectal examination reveals brown, guaiac-negative stool.

Which of the following diagnostic steps are indicated to determine the precipitating cause of this patient's acute decompensation? (Select 2)

A 58-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 interscapular region. The pain began 45 minutes ago. His medical history is notable for essential hypertension, but he admits he has not taken his prescribed amlodipine for the past month. Upon arrival, he appears distressed, pale, and diaphoretic. His temperature is 36.8°C (98.2°F), blood pressure is 82/50 mm Hg, pulse is 124/min, and respirations are 24/min. Pulse oximetry shows 96% on room air. Physical examination reveals markedly distended jugular veins. Cardiac auscultation shows muffled heart sounds and a new early diastolic decrescendo murmur heard best at the right upper sternal border. The lungs are clear to auscultation bilaterally. Pulses in the upper and lower extremities are equal. An electrocardiogram shows sinus tachycardia and low-voltage QRS complexes without acute ST-segment or T-wave abnormalities. A portable chest radiograph demonstrates a widened mediastinum. Which of the following is the most appropriate next step in the diagnostic workup?

A rapid response team is activated for a patient on the medical ward who has experienced an acute clinical deterioration. The patient is a 22-year-old man who was admitted 24 hours ago for a severe asthma exacerbation. Over the past 15 minutes, he has become extremely agitated, diaphoretic, and severely dyspneic. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $76/40\text{ mm Hg}$, heart rate $146/\text{min}$, respiratory rate $36/\text{min}$, and oxygen saturation $82\%$ despite receiving oxygen via a non-rebreather mask. Physical examination reveals absent breath sounds over the right hemithorax with hyperresonance to percussion. The neck veins are visibly distended, and the trachea is deviated to the left. The patient's extremities are cool to the touch with delayed capillary refill. Which of the following is the most appropriate initial step in the management of this patient?

A 72-year-old man presents to the clinic with progressive exertional dyspnea, fatigue, and bilateral lower extremity swelling over the past 6 months. He also reports waking up frequently at night due to numbness and a "pins and needles" sensation in both hands, predominantly affecting the thumbs, index, and middle fingers. His medical history is notable for hypertension, for which he takes lisinopril. Blood pressure is 112/70 mm Hg, and pulse is 84/min. Physical examination reveals jugular venous distention to 9 cm $H_2O$. Lungs are clear to auscultation. Cardiac examination shows a regular rhythm with a prominent S4 gallop; no murmurs are appreciated. Bilateral 2+ pitting edema is present up to the mid-calves.

Electrocardiography demonstrates normal sinus rhythm with first-degree atrioventricular block, low QRS voltage in the limb leads, and QS waves in leads V1 to V3.

Transthoracic echocardiography reveals a left ventricular ejection fraction of 55%, severe concentric left ventricular hypertrophy (interventricular septum thickness of 1.7 cm) with a "sparkling" granular appearance of the myocardium, and severe biatrial enlargement. Doppler evaluation shows a restrictive filling pattern.

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

A 34-year-old woman establishes care at an outpatient clinic for evaluation of progressive weight gain, new-onset irregular menses, and proximal muscle weakness over the past eight months. Physical examination reveals facial plethora, prominent supraclavicular fat pads, and broad purple abdominal striae. Her blood pressure is 155/95 mmHg. The physician suspects a specific endocrine disorder. Arrange the following diagnostic steps in the most appropriate sequential order for the workup of this patient's suspected condition, from initial confirmation to definitive localization.

A 62-year-old man with metastatic prostate cancer is being evaluated in the palliative care clinic. He is currently experiencing poorly controlled bone pain and dose-limiting neurotoxicity, manifesting as myoclonus and hyperalgesia, on his high-dose oral morphine regimen. The physician decides to transition the patient to oral hydromorphone to improve pain control and resolve the neurotoxicity. Arrange the following steps of opioid rotation in the correct clinical sequence to safely and effectively transition the patient to the new regimen.

A 64-year-old woman with advanced breast cancer metastatic to the liver and axial skeleton is evaluated in the inpatient palliative care unit. She was admitted two days ago for intractable bone pain. Her home pain regimen consisted of extended-release morphine 90 mg every 12 hours and immediate-release morphine 30 mg every 4 hours as needed. Over the past 48 hours, her required frequency of breakthrough morphine has doubled. Today, she is profoundly agitated and complains of severe, diffuse pain, crying out even when the bedsheets lightly brush her skin. Her husband, who is her designated healthcare proxy, is distressed and states, "The cancer is spreading rapidly and she is in agony! You must increase her morphine dose immediately."

On physical examination, the patient is disoriented to time and place. She exhibits frequent, brief, shock-like involuntary muscle contractions in her upper and lower extremities. Vital signs are temperature 37.1°C (98.8°F), heart rate 92/min, blood pressure 110/70 mm Hg, and respiratory rate 16/min. Laboratory studies show a serum creatinine level of 3.4 mg/dL (baseline 0.9 mg/dL).

When approached by the care team, the patient intermittently yells, "I just want my normal pain pills, don't change them!"

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

A 65-year-old man with advanced amyotrophic lateral sclerosis (ALS) is admitted to the hospital with severe aspiration pneumonia and acute hypercapnic respiratory failure. He is obtunded and unable to communicate. The palliative care team is consulted regarding the potential withdrawal of non-invasive ventilation. The medical team determines the patient lacks decision-making capacity. Several individuals are present and offer conflicting opinions on what the patient would want.

According to standard default surrogate consent statutes and medical ethics principles in the majority of US jurisdictions, arrange the following individuals in the correct legally recognized hierarchy for surrogate decision-making, from highest priority (first to be consulted) to lowest priority.

A 58-year-old woman is admitted to the hospital with intractable vomiting and severe, diffuse abdominal pain. She has stage IV ovarian cancer with extensive peritoneal carcinomatosis. Laboratory studies are significant for a serum creatinine of 3.8 mg/dL (baseline 0.9 mg/dL). On examination, the patient is lethargic, oriented only to her name, and unable to participate in medical decision-making.

A legally binding living will, signed by the patient one year ago, is present in her electronic medical record. The document explicitly refuses artificial nutrition, hydration, and surgical interventions in the event of an incurable, terminal condition, requesting only symptom-directed comfort care. She did not formally designate a healthcare power of attorney.

The patient is accompanied by her adult son, who has been her sole caregiver. Shortly after admission, the patient's legal husband arrives. The patient and her husband have been informally separated for four years, with no legal separation or divorce filed. The husband demands that the medical team place a percutaneous feeding tube and perform a palliative venting gastrostomy. He states, "I am still her legal husband and highest-ranking decision-maker. I am officially revoking her living will right now." The son strongly objects, demanding the team follow the living will and administer intravenous morphine for her severe pain.

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

A $28$-year-old man is evaluated in the outpatient psychiatry clinic during a routine follow-up. He has a history of treatment-resistant schizophrenia and was started on clozapine $4$ weeks ago. The patient reports a significant reduction in auditory hallucinations and feels that his mood has stabilized. He currently has no somatic complaints, including no fever, sore throat, cough, or dysuria. His vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $118/76\text{ mmHg}$, heart rate $82/\text{min}$, and respiratory rate $14/\text{min}$. Physical examination is unremarkable.

A complete blood count drawn today reveals:
White blood cell count: $4,500/\text{mm}^3$
Absolute neutrophil count: $1,200/\text{mm}^3$

His baseline absolute neutrophil count prior to initiating therapy was $3,800/\text{mm}^3$. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old woman is evaluated in the post-anesthesia care unit 3 hours after undergoing an uncomplicated total thyroidectomy for a multinodular goiter. The nursing staff calls the physician because the patient has become highly agitated, is complaining of worsening neck fullness, and is experiencing progressive difficulty breathing. Her temperature is 37.1°C (98.8°F), blood pressure is 158/92 mm Hg, pulse is 114/min, and respiratory rate is 28/min with audible inspiratory stridor. Oxygen saturation is 92% on room air. Physical examination reveals a tense, rapidly expanding swelling deep to the anterior neck incision. Removing the outer surgical dressing exposes a taut, bulging, and bluish surgical site. Which of the following is the most appropriate next step in management?

A 55-year-old man comes to the clinic for a routine follow-up. Three months ago, he was diagnosed with primary hyperlipidemia and was started on rosuvastatin. He reports taking his medication daily and has no current complaints. He specifically denies experiencing any muscle weakness, dark urine, abdominal pain, or jaundice. Physical examination reveals no abnormalities. Routine laboratory testing shows the following results:

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

A 52-year-old man is hospitalized for a proximal right lower extremity deep vein thrombosis. He is initially managed with a continuous intravenous unfractionated heparin infusion. On admission, his laboratory evaluation was unremarkable, including a platelet count of 240,000/mm³. On day 5 of hospitalization, routine morning laboratory testing reveals a platelet count of 110,000/mm³. He reports feeling well and is hemodynamically stable. Physical examination shows no new signs of bleeding, petechiae, or expanding edema. Which of the following is the most appropriate next step in the management of this patient?

An established clinic patient with ischemic heart disease schedules a visit to discuss new-onset erectile dysfunction. He reports achieving partial erections that are insufficient for intercourse and desires pharmacological assistance. His past medical history includes a myocardial infarction three years prior, hypertension, and hyperlipidemia. His daily medication regimen consists of low-dose aspirin, lisinopril, carvedilol, atorvastatin, and isosorbide mononitrate. He specifically asks for a prescription for sildenafil. The physician explains that this medication cannot be safely prescribed due to an absolute contraindication with his current regimen. Which of the following home medications precludes the use of sildenafil in this patient?

During a routine oncology clinic visit, a 71-year-old male complains of progressive right calf pain and swelling over the past three days. He was diagnosed with advanced gastric adenocarcinoma three months ago and is currently receiving palliative chemotherapy. He has no history of recent trauma, surgery, or prolonged immobilization. His temperature is 37.1°C (98.8°F), blood pressure is 128/78 mmHg, pulse is 88/min, and respiratory rate is 14/min. Physical examination reveals an erythematous and edematous right lower leg that is tender to palpation. A lower extremity venous Doppler ultrasound confirms an acute deep venous thrombosis in the right popliteal and femoral veins. Laboratory studies show a hemoglobin of 10.2 g/dL, platelet count of 185,000/mm³, and creatinine of 1.0 mg/dL (estimated glomerular filtration rate: 72 mL/min). Which of the following is the most appropriate pharmacologic intervention for this patient's acute thrombosis?

A 48-year-old man is brought to the emergency department by his partner after vomiting a large volume of bright red blood at home. He continues to have massive hematemesis upon arrival in the resuscitation bay. The patient has a history of decompensated cirrhosis secondary to chronic alcohol use disorder. He appears agitated, diaphoretic, and confused. Temperature is $36.5^\circ\text{C}$ ($97.7^\circ\text{F}$), blood pressure is $72/38\text{ mmHg}$, pulse is $134/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows $93\%$ on room air. Physical examination reveals scleral icterus, a distended abdomen with a fluid wave, and cool, clammy extremities with delayed capillary refill. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select exactly 2 options)

A 68-year-old man is evaluated in the intensive care unit on day 4 of treatment for ventilator-associated pneumonia. He was extubated yesterday and is currently breathing comfortably on room air. His empiric antibiotic regimen consists of intravenous vancomycin and cefepime. Sputum cultures are pending. On admission, his serum creatinine was $0.9 \text{ mg/dL}$. Today, laboratory studies show:

A vancomycin trough level drawn 30 minutes prior to the 7th scheduled dose is $28 \text{ \mu g/mL}$ (therapeutic range for severe infections: $15$-$20 \text{ \mu g/mL}$). The patient's vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $120/75 \text{ mmHg}$, and heart rate $82\text{/min}$. Physical examination reveals clear lungs bilaterally and no peripheral edema.

Which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

Match each patient presenting for evaluation of suspected stable ischemic heart disease with the most appropriate guideline-directed initial noninvasive diagnostic stress test.

Progressive shortness of breath over three days prompted the family of a 71-year-old male to transport him to the hospital. He has a documented history of severe chronic obstructive pulmonary disease. According to his relatives, his cough has worsened, producing purulent sputum, and his mentation has significantly declined since the morning. Upon initial triage evaluation, the patient is somnolent and withdraws only from painful stimuli. He displays shallow, rapid respiratory efforts with profound utilization of the sternocleidomastoid and scalene muscles. Vital signs are recorded as follows: temperature $38.1^\circ \text{C}$ ($100.6^\circ \text{F}$), blood pressure $152/95 \text{ mmHg}$, heart rate $118/\text{min}$, respiratory rate $32/\text{min}$, and pulse oximetry $81\%$ while breathing ambient air. Auscultation of the thorax demonstrates markedly decreased air entry globally with faint end-expiratory wheezes. Which of the following represents the most appropriate immediate next step in management?

A 24-year-old female is rushed to the emergency department by her roommates due to profound lethargy and confusion. Her roommates report that she has type 1 diabetes mellitus and recently experienced a severe gastrointestinal illness that prevented her from eating or taking her usual insulin doses for the past 48 hours. On arrival, she is stuporous and responds only to deep pain. Vital signs reveal a blood pressure of $78/40 \text{ mmHg}$, heart rate of $118 \text{ /min}$, respiratory rate of $32 \text{ /min}$ with deep, sighing respirations, and a temperature of $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$). Oxygen saturation is $98\%$ on ambient air. Fingerstick blood glucose measurement indicates a value greater than $600 \text{ mg/dL}$. A stat 12-lead electrocardiogram demonstrates absent P waves, significantly widened QRS complexes, and tall, peaked T waves. Two large-bore peripheral intravenous lines are immediately established. Which of the following is the single most urgent next step in the management of this patient?