Patient Management

A 64-year-old man is brought to the emergency department by emergency medical services after collapsing at home. His wife reports that he complained of sudden, severe, "tearing" chest pain radiating to his back shortly before losing consciousness. He has a history of poorly controlled hypertension and type 2 diabetes mellitus. Upon arrival, the patient is lethargic and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 74/40 mmHg, pulse is 128/min, and respirations are 24/min. Physical examination reveals distended jugular veins and distant heart sounds. Radial pulses are diminished symmetrically. A bedside point-of-care ultrasound demonstrates a large anechoic space surrounding the heart with diastolic collapse of the right ventricular free wall. Additionally, a thin, mobile, echogenic linear structure is visualized within the lumen of the proximal ascending aorta. Which of the following is the most appropriate next step in the procedural management of this patient?

A 65-year-old man is urgently evaluated by the rapid response team due to sudden-onset hypotension and altered mental status. Two days ago, he underwent an open right hemicolectomy for colon adenocarcinoma. Earlier this morning, he developed acute dyspnea; a computed tomography pulmonary angiogram confirmed a segmental pulmonary embolism, and a therapeutic continuous intravenous heparin infusion was initiated. He now appears lethargic, pale, and diaphoretic. His temperature is 37.0°C (98.6°F), blood pressure is 76/45 mm Hg, pulse is 134/min, and respirations are 24/min. Physical examination reveals a newly distended, firm, and diffusely tender abdomen. The surgical wound is intact with no external bleeding. Laboratory testing shows a hemoglobin level of 6.2 g/dL, representing a significant drop from 11.4 g/dL drawn 8 hours prior. Which of the following is the most appropriate next step in the management of this patient?

An intensive care unit team evaluates a $62$-year-old man who complains of sudden, intense pain and swelling in his left lower extremity. He was admitted $6$ days prior for a massive right-sided pulmonary embolism and has been receiving a continuous intravenous unfractionated heparin infusion since admission. His medical history is significant for hypertension, type 2 diabetes mellitus, and end-stage renal disease requiring hemodialysis three times weekly.

Temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, pulse is $98/\text{min}$, and respirations are $18/\text{min}$. Physical examination shows a remarkably swollen, erythematous, and tender left lower extremity extending from the calf to the mid-thigh. Peripheral pulses are palpable bilaterally.

Laboratory studies obtained today (Hospital Day $6$) compared to admission (Hospital Day $1$) are as follows:

A duplex ultrasonography of the left lower extremity demonstrates a new acute deep vein thrombosis in the left femoral and popliteal veins. Unfractionated heparin is immediately discontinued.

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

A $65$-year-old man is evaluated in the intensive care unit for transition of his anticoagulation therapy. He was admitted $10$ days ago for a massive unprovoked pulmonary embolism and was initially treated with a continuous intravenous unfractionated heparin infusion. On hospital day $5$, his platelet count dropped from an admission value of $260,000/\text{mm}^3$ to $85,000/\text{mm}^3$. A serotonin release assay was positive, confirming heparin-induced thrombocytopenia (HIT). Heparin was immediately discontinued, and a continuous infusion of argatroban was initiated. The patient is now clinically stable, and his platelet count has recovered to $165,000/\text{mm}^3$. His renal and hepatic functions are within normal limits. The critical care team plans to transition him to warfarin for long-term anticoagulation with a target International Normalized Ratio (INR) of $2.0$ to $3.0$. Current morning laboratory studies reveal an activated partial thromboplastin time (aPTT) of $68$ seconds (target: $60$ to $80$ seconds) and an INR of $3.6$. The patient has not yet received any doses of warfarin. Which of the following is the most appropriate next step in the monitoring and treatment evaluation for this patient's anticoagulation?

An $81$-year-old male is evaluated in the acute care ward after being transferred from an assisted living facility. Over the past $48$ hours, he has experienced progressive abdominal swelling, recurrent bilious emesis, and an absolute inability to pass stool or flatus. His medical history is notable for an open appendectomy performed three decades ago. On evaluation, he appears lethargic and is in significant distress. Temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), pulse is $128/\text{min}$, respirations are $26/\text{min}$, and blood pressure is $86/50\text{ mm Hg}$. Physical examination reveals a tympanitic and markedly distended abdomen with absent bowel sounds. Palpation elicits diffuse rigidity, involuntary guarding, and severe rebound tenderness across all four quadrants. Laboratory studies demonstrate a leukocyte count of $22,000/\text{mm}^3$ with $18\%$ bands, and a serum lactate level of $6.1\text{ mmol/L}$. Intravenous crystalloid fluid resuscitation and broad-spectrum antibiotics are actively being infused. Which of the following interventions represent the most appropriate next steps in this patient's procedural and surgical management? (Select all that apply)

Match each patient presenting with a suspected or confirmed thyroid nodule to the most appropriate next step in their diagnostic evaluation sequence.

A 34-year-old woman with a history of Graves disease is brought to the emergency department by her family due to fever, severe agitation, and palpitations over the past 24 hours. She recently had an upper respiratory tract infection. Temperature is 39.8°C (103.6°F), pulse is 152/min, respirations are 24/min, and blood pressure is 150/90 mm Hg. She appears delirious and is profusely diaphoretic. Physical examination reveals a symmetrically enlarged, non-tender thyroid gland and a fine resting tremor. Electrocardiogram demonstrates marked sinus tachycardia. A presumptive diagnosis of thyroid storm is made. Supportive care with intravenous fluids and external cooling is initiated.

Arrange the following targeted pharmacologic interventions in the correct chronological sequence to safely and effectively manage this patient's condition, starting with the most immediate intervention.

Match each patient scenario with the most appropriate disposition or care setting transition upon hospital discharge.

A 34-year-old woman is evaluated in the rheumatology clinic for a follow-up visit. She was diagnosed with severe rheumatoid arthritis 2 years ago and has been managed with weekly oral methotrexate and daily folic acid. Over the past three months, she has experienced worsening morning stiffness lasting up to 2 hours and increasing pain in her wrists and hands. Physical examination reveals active, boggy synovitis in the bilateral metacarpophalangeal and proximal interphalangeal joints. She has no significant past medical history other than rheumatoid arthritis, and a comprehensive review of systems is negative. Her vital signs are within normal limits. Recent laboratory studies show a hemoglobin of 11.4 g/dL, an aspartate aminotransferase of 36 U/L (normal: 8-40 U/L), and an alanine aminotransferase of 44 U/L (normal: 7-35 U/L). Given the inadequate response to her current regimen, the physician plans to add etanercept to her treatment. Before starting this new medication, which of the following screening tests are required? (Select all that apply)

A 45-year-old man presents to the emergency department with a 2-day history of productive cough, chills, and right-sided chest pain that worsens with deep inspiration. He has no significant past medical history and takes no medications. His vital signs are temperature 38.5°C (101.3°F), blood pressure 128/78 mmHg, pulse 88/min, and respiratory rate 16/min. Oxygen saturation is 97% on room air. On examination, he is alert and fully oriented. Auscultation reveals crackles over the right lower lung field. Laboratory studies show a blood urea nitrogen (BUN) level of 12 mg/dL. A chest radiograph demonstrates a right lower lobe consolidation. Which of the following is the most appropriate disposition for this patient?

A 62-year-old woman is brought to the emergency department due to a 4-hour history of severe, sudden-onset, diffuse abdominal pain. Her medical history is significant for heart failure with preserved ejection fraction, atrial fibrillation, and a mechanical mitral valve replacement for which she takes daily warfarin. On physical examination, the patient appears agitated and diaphoretic. Her abdomen is rigidly distended with diffuse rebound tenderness and involuntary guarding.

Vital signs are:
Blood pressure: 82/50 mm Hg
Heart rate: 125/min and irregularly irregular
Respiratory rate: 24/min
Temperature: 38.7°C (101.7°F)

Laboratory studies reveal:
Leukocyte count: 18,200/mm³
Hemoglobin: 11.4 g/dL
Platelet count: 155,000/mm³
Creatinine: 1.6 mg/dL
Lactate: 5.2 mmol/L
INR: 3.4

An upright chest radiograph reveals free subdiaphragmatic radiolucency. The surgical team is consulted.

Which of the following are mandatory components of the immediate management plan for this patient? (Select all that apply)

A $26$-year-old woman, who is $9$ weeks pregnant, is evaluated in the emergency department for a $24$-hour history of right-sided flank pain, fever, and severe nausea with vomiting. Her temperature is $38.9^{\circ}\text{C}$ ($102.0^{\circ}\text{F}$), blood pressure is $110/70\text{ mmHg}$, and heart rate is $112/\text{min}$. Physical examination reveals marked right-sided costovertebral angle tenderness. She is currently unable to tolerate any oral intake. Laboratory evaluation shows a leukocyte count of $16,000/\text{mm}^3$ with a left shift. Urinalysis is positive for leukocyte esterase, nitrites, and $>50$ white blood cells per high-power field. Which of the following is the most appropriate initial pharmacologic intervention?

Emergency medical services transport a 28-year-old female patient to the resuscitation bay due to an uninterrupted generalized tonic-clonic seizure. According to paramedic transport records, the active seizing started 15 minutes prior to arrival and has not abated. The patient remains unresponsive. Point-of-care blood glucose testing is 95 mg/dL. Bilateral large-bore intravenous catheters are secured.

Arrange the following pharmacologic interventions in the standard, guideline-concordant sequence for escalating the management of this patient's condition.

During an outpatient psychiatric evaluation, a physician is planning the long-term management of a 35-year-old male patient with bipolar I disorder. The patient has been unmedicated for over a year but recently experienced a severe manic episode that disrupted his employment. He is now stabilized and agrees to begin maintenance pharmacotherapy with lithium carbonate. Prior to writing the prescription, which of the following baseline investigations must be ordered? (Select all that apply)

A 68-year-old man presents to the clinic for a follow-up visit. Four days ago, he was evaluated in the emergency department for acute left flank pain and hematuria. A noncontrast computed tomography (CT) scan of the abdomen and pelvis demonstrated a 4-mm stone in the left ureter, which he has since passed. The radiologist's report also noted an incidental 14-mm, solitary, solid, noncalcified nodule in the posterior basal segment of the right lower lobe. The patient currently feels well and reports no chest pain, dyspnea, chronic cough, hemoptysis, or unintentional weight loss. His medical history is significant for hypertension and hyperlipidemia. He smoked one pack of cigarettes daily for 40 years but quit 3 years ago. There are no prior imaging studies available for comparison. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following is the most appropriate next step in the diagnostic workup?

A 30-year-old man with a history of severe, treatment-resistant schizophrenia is brought to the clinic by his family for a follow-up appointment. His psychiatrist recently transitioned him to clozapine after trials of multiple other antipsychotic medications failed to control his auditory hallucinations and severe paranoia. The patient is currently doing well, reports significant improvement in his symptoms, and denies any fever, sore throat, or fatigue. As part of the mandatory surveillance protocol for this medication, which of the following parameters must be evaluated weekly during his first six months of therapy?

Carefully match each patient's clinical presentation, functional status, and medical needs with the most appropriate post-hospitalization disposition setting.

A 58-year-old man is brought to the emergency department via ambulance after coughing up approximately 800 mL of bright red blood over the past two hours. The patient is visibly anxious, diaphoretic, and struggling to clear his airway of ongoing bleeding. His wife reports he had cavitary pulmonary tuberculosis 15 years ago but has been otherwise healthy. Vital signs show a temperature of 37.2°C (99.0°F), blood pressure of 102/64 mmHg, heart rate of 128/min, and respiratory rate of 28/min. Pulse oximetry is 84% on room air. Auscultation of the chest reveals coarse gurgling sounds and diminished air entry exclusively over the right middle and lower lung fields, while the left lung fields are clear. Which of the following is the most appropriate initial step in the stabilization of this patient?

A 67-year-old male is brought to the emergency department by ambulance due to the sudden onset of excruciating, diffuse abdominal pain that began one hour ago. He has a medical history of a mechanical aortic valve replacement for which he takes warfarin. Upon arrival, he appears pale, diaphoretic, and in severe distress. Temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $82/48 \text{ mmHg}$, heart rate is $128/\text{min}$, and respiratory rate is $26/\text{min}$. Physical examination reveals a rigid, board-like abdomen with severe diffuse tenderness and rebound guarding. Bowel sounds are absent. An upright chest radiograph demonstrates crescent-shaped radiolucencies under both hemidiaphragms. Point-of-care laboratory testing reveals an international normalized ratio (INR) of $3.6$ and a serum lactate of $4.2 \text{ mmol/L}$. The surgical team is immediately consulted for an emergency exploratory laparotomy. Which of the following are mandatory concurrent steps in the immediate management of this patient? (Select all that apply)

Emergency extraction teams airlift a 31-year-old construction worker to the regional trauma center after he was buried under a collapsed concrete retaining wall for over four hours. On presentation, the patient is minimally responsive and pale.

Vital signs show a blood pressure of 72/40 mmHg, a pulse of 134/min, and a respiratory rate of 26/min. Oxygen saturation is 94% on a non-rebreather mask.

Primary survey demonstrates a patent airway and equal bilateral breath sounds. The pelvis is mechanically stable to applied pressure. Point-of-care ultrasound shows a hyperdynamic heart with a completely collapsible inferior vena cava and no free intraperitoneal fluid. Both lower extremities are exquisitely tense, visibly swollen, and cold to the touch. Dorsalis pedis pulses are absent bilaterally via Doppler.

A bedside electrocardiogram demonstrates a regular rhythm with widened QRS complexes and prominent, peaked T waves.

Which of the following initial stabilization steps should be ordered simultaneously? (Select two)