Patient Management

A 54-year-old man with a history of alcohol-associated cirrhosis is brought to the emergency department by emergency medical services after vomiting large amounts of bright red blood at home. Upon arrival, he is lethargic, confused, and actively vomiting blood. His Glasgow Coma Scale score is 8. Vital signs are temperature 36.8°C (98.2°F), blood pressure 82/48 mmHg, heart rate 128/min, and respiratory rate 24/min. Physical examination reveals scleral icterus, palmar erythema, and a distended abdomen with a positive fluid wave. Arrange the following procedural and medical interventions in the most appropriate chronological sequence for managing this patient's acute presentation.

A 55-year-old man with a history of alcohol use disorder and cirrhosis is brought to the emergency department by ambulance after vomiting a large volume of bright red blood at home. Upon arrival, he is lethargic and minimally responsive to verbal stimuli. While being transferred to the stretcher, he has another large episode of hematemesis. Vital signs are temperature 36.5°C (97.7°F), blood pressure 78/40 mmHg, pulse 128/min, and respirations 24/min. Pulse oximetry is 93% on room air. Examination reveals a somnolent patient with cool, clammy extremities, scleral icterus, and a distended abdomen with a positive fluid wave. Arrange the following management steps in the most appropriate chronological sequence for this patient's initial stabilization and care.

A 28-year-old primigravida at 14 weeks gestation is evaluated in the emergency department for a newly developed, painful swelling in her left lower extremity that began two days ago. She has no significant past medical history and takes only a daily prenatal vitamin. Her vital signs are: blood pressure $112/70\text{ mmHg}$, heart rate $88/\text{min}$, respiratory rate $16/\text{min}$, and pulse oximetry $99\%$ on room air. Physical examination reveals pitting edema, erythema, and tenderness localized to the left calf and thigh. A complete blood count and comprehensive metabolic panel are within normal limits. Compression ultrasonography of the left lower extremity reveals a non-compressible left femoral vein, confirming the presence of an acute deep vein thrombosis (DVT). Which of the following is the most appropriate pharmacologic intervention for this patient?

Emergency medical services bring a 71-year-old man to the resuscitation bay after he experienced agonizing, sudden-onset pain in his lower back and abdomen while doing yard work. His past medical history includes hypertension, hyperlipidemia, and a 40-pack-year smoking history. On arrival, he appears ashen and diaphoretic, and he is lethargic but arousable to painful stimuli.

Physical examination reveals a prominent, expansile, pulsatile mass in the periumbilical region. The bilateral femoral pulses are weak and thready. Two large-bore peripheral intravenous catheters are rapidly secured.

Which of the following interventions are indicated in the immediate management of this patient? (Select all that apply)

A 24-year-old woman is evaluated in the outpatient psychiatric clinic following a recent hospitalization for an acute manic episode. The physician and patient agree to initiate pharmacotherapy with lithium carbonate for mood stabilization.

Arrange the following steps regarding the baseline evaluation, therapeutic drug monitoring, and long-term surveillance of this patient in the correct chronological sequence.

A young adult is brought to the emergency department with severe agitation, palpitations, and fever. Vital signs reveal a temperature of $39.8^\circ C$ ($103.6^\circ F$), a heart rate of $145$/min, and a blood pressure of $160/70$ mmHg. Physical examination shows a diffusely enlarged, non-tender thyroid gland, a fine resting tremor, and marked diaphoresis. An emergent laboratory panel confirms profound hyperthyroidism. The clinical picture is highly consistent with thyroid storm.

Arrange the following pharmacologic interventions in the required chronological sequence for the acute management of this patient's condition.

A 32-year-old woman is brought to the emergency department by paramedics after being found unresponsive in her apartment. Her medical history is significant for major depressive disorder, generalized anxiety disorder, and chronic migraine headaches. Her roommate reports that the patient recently lost her job and had been expressing feelings of hopelessness over the past two weeks. Several empty, unlabeled prescription medication bottles were found on her nightstand.

Vital signs upon arrival are:
Temperature: 38.6°C (101.5°F)
Blood pressure: 82/48 mm Hg
Pulse: 128/min
Respiratory rate: 12/min
SpO2: 95% on room air

Physical examination reveals dry mucous membranes, sluggishly reactive mydriasis, and flushed, warm skin. Bowel sounds are hypoactive. Neurologic examination shows symmetric hyperreflexia and continuous clonus in the lower extremities.

An electrocardiogram demonstrates sinus tachycardia with a QRS complex duration of 152 ms and a prominent terminal R wave in lead aVR measuring 4 mm.

Intravenous fluids and an intravenous bolus of sodium bicarbonate are immediately administered. Ten minutes later, the patient develops a generalized tonic-clonic seizure.

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

An 82-year-old male resident of a skilled nursing facility is transported to the emergency department after experiencing progressive abdominal distention, nausea, and an inability to pass flatus or stool for the past 48 hours. He has a past medical history of advanced Parkinson disease, chronic constipation, and hypertension. Current vital signs include a temperature of 37.1°C (98.8°F), blood pressure of 135/85 mmHg, pulse of 88/min, and respirations of 16/min. Physical examination reveals a massively distended and tympanitic abdomen. There is mild diffuse discomfort to palpation, but no guarding, rigidity, or rebound tenderness is appreciated. A plain upright abdominal radiograph is obtained and demonstrates a markedly dilated loop of large bowel forming a characteristic 'coffee bean' appearance extending from the pelvis toward the upper abdomen, without pneumoperitoneum. Which of the following is the most appropriate next step in the procedural management of this patient?

A 52-year-old woman is brought to the emergency department by her husband after the sudden onset of an excruciating headache that began 10 hours ago while she was lifting heavy boxes. She describes it as the "worst headache of my life" and reports associated photophobia, nausea, and two episodes of vomiting. She has a history of well-controlled hypertension. Her temperature is 37.1°C (98.8°F), blood pressure is 165/95 mm Hg, pulse is 98/min, and respirations are 16/min. Physical examination reveals a mildly lethargic patient who prefers to keep her eyes closed in the darkened room. She exhibits significant resistance and pain with passive neck flexion. No focal motor or sensory deficits are noted. Laboratory studies show a serum sodium level of 132 mEq/L and a leukocyte count of 11,000/mm³. A non-contrast computed tomography (CT) scan of the head is performed and shows no evidence of acute intracranial hemorrhage, mass effect, or midline shift. Which of the following is the most appropriate next step in the diagnostic workup?

A 58-year-old man comes to the clinic for a routine follow-up. He was diagnosed with hyperlipidemia 4 weeks ago and was started on moderate-intensity atorvastatin. At his initial visit, his calculated 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 12%, and his baseline liver function tests and creatine kinase levels were within normal limits. Today, he is asymptomatic and reports no muscle aches, dark urine, unusual fatigue, or abdominal pain. He asks the physician how frequently he needs to return to have his liver enzymes checked while taking this medication. Which of the following is the most appropriate recommendation regarding liver function monitoring for this patient?

A 32-year-old woman with relapsing-remitting multiple sclerosis is evaluated in the neurology clinic. She has experienced two clinical relapses over the past year, and her latest magnetic resonance imaging reveals three new gadolinium-enhancing periventricular lesions despite full adherence to interferon beta-1a therapy. The physician and patient agree to transition her disease-modifying therapy to oral fingolimod. Her past medical history is otherwise unremarkable. She takes no other medications. Vital signs are within normal limits. Physical examination demonstrates mild residual weakness in the right lower extremity. Which of the following baseline evaluations or monitoring parameters are explicitly required prior to or during the initiation of this specific medication? (Select all that apply)

During a routine wellness examination, a physician evaluates a $65$-year-old female patient with a history of postmenopausal osteoporosis. The patient reports strict adherence to her medication regimen, which consists of alendronate, calcium carbonate, and cholecalciferol, over the preceding $60$ months. She exercises regularly by participating in a local walking group and denies any recent falls, bone pain, or historical fractures. A dual-energy x-ray absorptiometry (DEXA) scan performed prior to this visit demonstrates a T-score of $-2.1$ at the lumbar spine and $-1.9$ at the femoral neck. A comparison with her initial DEXA scan from $5$ years ago shows significant improvement from baseline T-scores of $-2.6$ and $-2.4$ at the respective sites. Physical examination reveals a well-appearing individual with no spinal tenderness or kyphosis. Which of the following is the most appropriate next step in managing this patient's pharmacotherapy?

A 46-year-old man is evaluated in the emergency department for the abrupt onset of severe shortness of breath and right-sided chest pain that worsens with deep inspiration. The symptoms began 2 hours ago. He recently returned from a 14-hour cross-country road trip. His medical history is notable for severe persistent asthma, which has been poorly controlled over the last month, and a well-documented anaphylactic reaction to iodinated contrast media that previously required intubation. Vital signs show a temperature of 37.3°C (99.1°F), blood pressure of 135/85 mmHg, pulse of 118/min, and respirations of 26/min. Pulse oximetry is 91% on room air. Physical examination reveals mild expiratory wheezing bilaterally. The right lower extremity is visibly swollen, erythematous, and tender to palpation, with a 4-cm increase in calf circumference compared to the left. An electrocardiogram reveals sinus tachycardia. A portable chest radiograph shows mild hyperinflation but no focal consolidations or pleural effusions. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

An attending physician is rounding on the general medical ward to finalize the discharge plan for an 84-year-old woman. She was admitted one week ago with urosepsis and hyperactive delirium. Her hospital course included a 48-hour stay in the intensive care unit for fluid resuscitation and transient vasopressor support. She has now been afebrile for 72 hours, her white blood cell count has normalized, and her delirium has completely resolved. She is alert, oriented, and cognitively at her baseline.

Prior to admission, she lived alone in a two-story home, managed her own finances, and walked independently without assistive devices. Currently, she is hemodynamically stable and completing a course of oral antibiotics. A physical therapy evaluation notes profound generalized deconditioning. She requires moderate physical assistance from two staff members to transition from sitting to standing. She can ambulate a maximum of 10 feet using a rolling walker with continuous physical support. During her therapy session today, she became physically exhausted after 40 minutes and required a prolonged rest period in bed. Her daughter lives 2 hours away, works full-time, and cannot provide daily hands-on care.

Based on these clinical findings, which of the following is the most appropriate disposition for this patient?

Match each patient's clinical status and rehabilitation capacity to the most appropriate post-acute care disposition setting.

A 22-year-old man is brought to the emergency department after a high-speed motor vehicle collision. He is in severe respiratory distress. Vital signs show a blood pressure of 82/50 mm Hg, heart rate of 138/min, and respiratory rate of 34/min. Oxygen saturation is 84% on a nonrebreather mask. Physical examination reveals distended neck veins, absent breath sounds over the right hemithorax, and deviation of the trachea to the left side. Which of the following procedural interventions are indicated in the initial emergency management of this patient? (Select all that apply)

An outpatient nephrology consultation is requested for a renal transplant recipient who developed acute kidney injury and neurologic symptoms. The patient, who received a deceased-donor kidney six months prior due to IgA nephropathy, has been maintained on a regimen of tacrolimus, mycophenolate mofetil, and prednisone. Fourteen days ago, oral fluconazole therapy was initiated for persistent oropharyngeal candidiasis.

Currently, the patient complains of new-onset bilateral hand tremors and intermittent headaches. Vital signs show a blood pressure of 152/92 mmHg and a pulse of 82/min. Examination demonstrates a fine postural tremor but no allograft tenderness.

Laboratory analysis reveals a serum creatinine of 1.9 mg/dL and a blood urea nitrogen of 34 mg/dL. Baseline serum creatinine two weeks prior was 1.1 mg/dL.

Which of the following is the most appropriate next step in monitoring and adjusting this patient's treatment plan?

A primary care physician is evaluating a $52$-year-old man who presents with a productive cough, subjective fevers, and fatigue lasting for four days. The patient has no significant past medical history and takes no daily medications. On examination, he is alert and cooperative. His temperature is $38.4^{\circ}\text{C}$ ($101.1^{\circ}\text{F}$), blood pressure is $124/78\text{ mmHg}$, pulse is $88/\text{min}$, and respiratory rate is $18/\text{min}$. Oxygen saturation is $97\%$ on ambient air. Auscultation of the lungs reveals crackles in the left lower base. Point-of-care laboratory testing shows a blood urea nitrogen level of $12\text{ mg/dL}$. A chest radiograph demonstrates a left lower lobe consolidation. The patient is able to drink fluids without difficulty and lives at home with his healthy spouse. Based on clinical risk stratification, which of the following is the most appropriate disposition for this patient?

A physician is called to the bedside of a 55-year-old female on the postsurgical unit. She underwent an uncomplicated subtotal parathyroidectomy and right hemithyroidectomy 4 hours ago. Upon arrival, the patient is highly agitated, leaning forward, and exhibiting audible high-pitched inspiratory sounds. Vital signs are temperature 37.1°C (98.8°F), heart rate 124/min, respiratory rate 28/min, and blood pressure 165/95 mmHg. Pulse oximetry is 85% on 15 L/min of oxygen via a non-rebreather mask. Physical examination reveals a markedly distended, tense anterior neck with bluish discoloration extending laterally beyond the borders of the surgical dressing. The dressing itself is dry, but the underlying tissue is firmly indurated. The patient is utilizing accessory muscles for respiration. Which of the following is the most appropriate immediate next step in management?

A $74$-year-old man presents to the clinic with a $3$-day history of dysuria, increased urinary frequency, and suprapubic discomfort. His medical history is significant for a mechanical aortic valve replacement and stage $4$ chronic kidney disease. Current medications include warfarin and amlodipine. He has a history of anaphylactic shock following penicillin administration in his twenties. Vital signs include a temperature of $37.1^\circ \text{C}$ ($98.8^\circ \text{F}$), blood pressure of $138/82 \text{ mmHg}$, and heart rate of $76/\text{min}$. Laboratory evaluation reveals a serum creatinine of $2.6 \text{ mg/dL}$ (baseline $2.5 \text{ mg/dL}$) and an estimated glomerular filtration rate (eGFR) of $22 \text{ mL/min/}1.73\text{ m}^2$. His international normalized ratio (INR) is currently $2.5$. Urinalysis is positive for leukocyte esterase and nitrites, with $40$ white blood cells per high-power field. Which of the following is the most appropriate empiric pharmacologic intervention for this patient's condition?