Patient Management

A $28$-year-old woman is brought to the emergency department by emergency medical services for a severe asthma exacerbation. She has been using her albuterol inhaler multiple times at home without relief. Upon arrival, she is lethargic and extremely diaphoretic. She is seated in a tripod position, using accessory muscles of respiration. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $145/90\text{ mmHg}$, pulse $138\text{/min}$, and respirations $32\text{/min}$. Oxygen saturation is $84\%$ on high-flow oxygen. Lung auscultation reveals a "silent chest" with no audible wheezing or air movement. Which of the following is the single most urgent initial step in the stabilization of this patient?

An $82$-year-old man is evaluated in the intensive care unit for worsening oxygenation and persistent fever. He was admitted $4$ days ago for severe community-acquired pneumonia and required endotracheal intubation on hospital day $2$ due to acute respiratory failure. His empiric antimicrobial regimen includes intravenous vancomycin and cefepime. Today, his temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, and heart rate is $112\text{/min}$. Endotracheal aspirate cultures drawn on admission have grown *Staphylococcus aureus*. Susceptibility testing reveals resistance to oxacillin and a vancomycin minimum inhibitory concentration (MIC) of $4.0\text{ }\mu\text{g/mL}$.

Pertinent laboratory results:
- Leukocyte count: $18,500\text{/mm}^3$
- Serum creatinine: $2.3\text{ mg/dL}$ (baseline $1.1\text{ mg/dL}$)

His medical history is significant for major depressive disorder and atrial fibrillation, for which he takes home medications including escitalopram, metoprolol, and apixaban via an orogastric tube. A decision is made to discontinue vancomycin and initiate an alternative agent for the methicillin-resistant *Staphylococcus aureus* (MRSA) infection. Which of the following is the most appropriate targeted pharmacologic intervention?

Emergency medical personnel transport a 38-year-old female to the resuscitation bay after she was discovered unarousable in her bedroom. A partially empty bottle of prescribed amitriptyline was found on the adjacent nightstand. On initial evaluation, the patient is completely unresponsive to deep painful stimuli and produces coarse, gurgling sounds with respiration. Vital signs reveal a blood pressure of 78/48 mmHg, a heart rate of 132/min, a respiratory rate of 6/min with shallow effort, and an oxygen saturation of 82% on ambient air. A stat 12-lead electrocardiogram demonstrates sinus tachycardia with a QRS duration of 160 ms. Which of the following represents the single most urgent initial step in the stabilization of this patient?

A $62$-year-old man is brought to the emergency department with four days of progressively worsening back pain and low-grade fevers. He reports that over the past $12$ hours, he has developed weakness in both legs and has been unable to urinate. Two weeks ago, he was treated for a cutaneous abscess on his left thigh. His temperature is $38.3^\circ\text{C}$ ($100.9^\circ\text{F}$), blood pressure is $135/85 \text{ mmHg}$, and heart rate is $102 \text{ /min}$. Neurologic examination reveals $3/5$ strength in the bilateral lower extremities, decreased sensation to pinprick below the umbilicus, and decreased rectal sphincter tone. There is exquisite focal percussion tenderness over the T10 spinous process. Laboratory studies reveal a serum creatinine of $1.6 \text{ mg/dL}$ (estimated glomerular filtration rate: $45 \text{ mL/min/1.73 m}^2$). He has no implanted medical devices. Which of the following diagnostic studies are appropriate NEXT steps in the workup of this patient? (Select all that apply)

A 42-year-old woman comes to the clinic for a routine wellness evaluation. She has no acute complaints but mentions noticing a lump in the lower portion of her neck over the past month. She reports no changes in her weight, bowel habits, resting heart rate, temperature tolerance, or mood. She has no history of neck radiation or family history of thyroid cancer. Vital signs are within normal limits. Physical examination reveals a solitary, firm, non-tender, mobile $2.5$-cm nodule in the right lobe of the thyroid gland. There is no associated cervical lymphadenopathy. Which of the following tests are the most appropriate initial steps in the diagnostic workup of this patient's finding? (Select all that apply)

A 68-year-old man with symptomatic atrial fibrillation is started on oral amiodarone for rhythm control. Due to the medication's well-established toxicity profile, specific organ systems must be evaluated prior to initiation and periodically during long-term therapy. Which of the following tests are required for routine baseline and ongoing monitoring in this patient? (Select all that apply)

A 45-year-old male construction worker is brought to the emergency department by emergency medical services after a concrete pillar collapsed on him. On arrival, paramedics are applying direct manual pressure to his right lower extremity, which has sustained a mid-thigh traumatic amputation with active, pulsatile arterial bleeding. The patient is unresponsive, opens his eyes only to painful stimuli, and is making gurgling sounds. There is an expanding hematoma on the right side of his neck. His respiratory rate is 8/min and shallow. His blood pressure is 70/40 mm Hg, and his pulse is 140/min and thready. Arrange the following management steps in the most appropriate chronological order.

A 45-year-old man with bipolar disorder is admitted to the intensive care unit with profound confusion, coarse tremors, and ataxia. His home medications include lithium carbonate, lisinopril, and ibuprofen. Laboratory evaluation reveals a serum creatinine of 2.4 mg/dL (baseline 1.0 mg/dL) and a serum lithium level of 3.8 mEq/L. He is hemodynamically stable. Arrange the following steps in the optimal chronological sequence for the monitoring and management of this patient's toxicity.

A $58$-year-old man with a history of decompensated alcoholic cirrhosis is evaluated in the emergency department for a $2$-day history of worsening abdominal distension, diffuse abdominal pain, and lethargy. His temperature is $38.4^\circ \text{C}$ ($101.1^\circ \text{F}$), blood pressure is $92/58 \text{ mmHg}$, and heart rate is $106/\text{min}$. Physical examination reveals scleral icterus, severe ascites with a positive fluid wave, and diffuse mild abdominal tenderness. Laboratory studies reveal:

A diagnostic paracentesis is performed, and ascitic fluid analysis shows a total leukocyte count of $1,200/\text{mm}^3$ with $70\%$ neutrophils. Which of the following pharmacologic interventions are indicated as part of this patient's immediate management? (Select all that apply)

While covering the triage desk, a physician evaluates a 28-year-old G2P1 patient who reports the abrupt onset of excruciating right-sided pelvic pain and light vaginal bleeding. The symptoms started approximately one hour ago. She notes her last menstrual period was seven weeks prior. On evaluation, she is lethargic, pale, and actively shivering. Vital signs demonstrate a blood pressure of 76/40 mm Hg, a heart rate of 142/min, and a respiratory rate of 24/min. Abdominal examination is significant for diffuse rigidity, severe right lower quadrant tenderness, and marked guarding. A rapid bedside urine human chorionic gonadotropin test is positive. Two large-bore intravenous lines are immediately placed for crystalloid resuscitation. Which of the following is the most appropriate next procedural or management step?

A $62$-year-old man is evaluated on the cardiology floor prior to hospital discharge. Two days ago, he was admitted for a non-ST-segment elevation myocardial infarction (NSTEMI). He subsequently underwent coronary angiography and percutaneous coronary intervention with the placement of a drug-eluting stent in the right coronary artery. His past medical history includes hypertension, type $2$ diabetes mellitus, and osteoarthritis. His home medications, which included lisinopril, metformin, and ibuprofen, were temporarily held on admission. Echocardiography performed yesterday shows a left ventricular ejection fraction of $45\%$. Vital signs are temperature $37.0^\circ C$ ($98.6^\circ F$), blood pressure $126/78$ mmHg, and pulse $68$/min. Laboratory studies show a serum creatinine of $1.1$ mg/dL. Which of the following pharmacologic interventions are appropriate for this patient at discharge? (Select all that apply)

A 68-year-old man is brought to the emergency department by paramedics after collapsing in a grocery store. Bystanders report he was complaining of severe, tearing back pain just before losing consciousness. On arrival, he is lethargic and confused but opens his eyes to pain. His past medical history includes hypertension, hyperlipidemia, and a 40-pack-year smoking history. Vital signs are temperature 36.8°C (98.2°F), blood pressure 72/40 mm Hg, heart rate 118/min, respiratory rate 22/min, and oxygen saturation 95% on room air. Physical examination reveals a pale, diaphoretic man with cool extremities. The abdomen is slightly distended, and a prominent pulsatile mass is palpated in the periumbilical region. Femoral pulses are diminished bilaterally. Which of the following are the most appropriate simultaneous initial steps in the stabilization and management of this patient? (Select all that apply)

A 72-year-old man is evaluated for transition of care. He was admitted to the hospital 28 days ago for severe acute pancreatitis complicated by necrotizing fluid collections and acute respiratory distress syndrome. The patient spent 21 days in the intensive care unit and was transferred to a step-down unit one week ago. He is currently awake, alert, and able to follow basic commands. He is hemodynamically stable without vasopressor support. The patient remains dependent on mechanical ventilation via a tracheostomy. Multiple attempts to completely wean him from the ventilator have been unsuccessful, although he currently tolerates pressure support ventilation for 4 hours daily. He is receiving enteral nutrition via a percutaneous endoscopic gastrostomy tube. He has severe critical illness polyneuropathy; a physical therapy evaluation notes he can only tolerate passive range of motion and sitting at the edge of the bed for 15 minutes before experiencing severe fatigue. Laboratory studies today show a blood urea nitrogen of 34 mg/dL and a serum creatinine of 1.2 mg/dL (baseline 1.1 mg/dL). Which of the following is the most appropriate disposition or next step in management for this patient?

A 78-year-old woman is evaluated by the multidisciplinary team to determine her next site of care. She was admitted five days ago for treatment of acute pyelonephritis. Her infection has fully resolved on intravenous antibiotics, and she has been transitioned to an oral antimicrobial regimen. Her vital signs are within normal limits. Prior to admission, she lived independently in a two-story house. However, physical therapy evaluation indicates she currently requires significant assistance with transferring from bed to chair, bathing, and dressing due to profound hospital-associated deconditioning. She can actively participate in 1 to 2 hours of therapy daily but fatigues quickly. She does not require continuous physician monitoring or complex nursing care. Which of the following is the most appropriate next step in the care transition for this patient?

A 68-year-old man with a history of congestive heart failure presents with worsening dyspnea. Chest radiography reveals a new, large, right-sided pleural effusion. The physician decides to perform a diagnostic and therapeutic thoracentesis. Arrange the following steps of the thoracentesis procedure in the correct chronological order from first to last.

A 42-year-old woman comes to the clinic for a follow-up visit. One week ago, she was diagnosed with primary hypothyroidism and was started on levothyroxine 50 mcg daily. Today, she reports that her fatigue, dry skin, and cold intolerance have not improved. She asks if her medication dosage can be increased. She takes the medication every morning on an empty stomach with water. Vital signs are temperature 36.8°C (98.2°F), blood pressure 118/76 mmHg, pulse 68/min, and respirations 14/min. Physical examination reveals delayed relaxation of deep tendon reflexes but is otherwise unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Following a high-speed motorcycle collision, a 26-year-old male rider is admitted directly to the trauma bay. He is profoundly agitated, clutching his chest, and struggling to breathe. Vital signs show a blood pressure of 70/35 mmHg, a heart rate of 142/min, a respiratory rate of 32/min, and an oxygen saturation of 82% despite receiving high-flow supplemental oxygen. Clinical evaluation demonstrates marked distension of the jugular veins, a rightward shift of the trachea, and a hyperresonant left hemithorax with completely absent breath sounds. What is the most appropriate immediate step in the management of this patient?

A $52$-year-old man presents to the clinic with acute, severe pain and swelling in his right knee that began $12$ hours ago. He reports the pain is so intense that he cannot tolerate the weight of his clothing over the joint. His medical history is significant for a deceased-donor renal transplant $4$ years ago for end-stage renal disease secondary to hypertensive nephrosclerosis. His current medications include cyclosporine, mycophenolate mofetil, prednisone ($5\text{ mg}$ daily), and amlodipine. Temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $132/84\text{ mmHg}$, and pulse is $88\text{/min}$. Physical examination shows an erythematous, warm, and swollen right knee with exquisitely limited range of motion. Joint aspiration yields cloudy yellow fluid with a leukocyte count of $45,000\text{/mm}^3$ ($85\%$ neutrophils). Polarized light microscopy reveals negatively birefringent, needle-shaped crystals. Gram stain of the synovial fluid shows no organisms. Serum creatinine is $1.6\text{ mg/dL}$, which is at his baseline. Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute joint condition?

A 45-year-old man is evaluated in the emergency department for right-sided pleuritic chest pain and mild shortness of breath that began 12 hours ago. He has no past medical history. He works as a software engineer and lives with his wife. Vital signs are temperature 37.1°C (98.8°F), blood pressure 132/84 mmHg, heart rate 88/min, and respiratory rate 16/min. Pulse oximetry is 98% on room air. Physical examination reveals clear lungs, normal heart sounds, and mild swelling in the right calf. Laboratory testing shows a normal basic metabolic panel, and undetectable serum troponin I and brain natriuretic peptide (BNP). A CT pulmonary angiogram confirms a right lower lobe segmental pulmonary embolism. Bedside echocardiography demonstrates a normal-sized right ventricle with preserved systolic function. The patient's pain is well controlled. He is highly health literate and demonstrates clear understanding of his diagnosis and necessary precautions. Which of the following is the most appropriate care setting transition and disposition for this patient?

A 24-year-old pregnant woman presents to the obstetric clinic for her initial prenatal visit at 16 weeks of gestation. She feels well and has no active complaints. Physical examination shows normal vital signs, a gravid uterus appropriate for gestational age, and no mucosal lesions, chancre, or skin rashes. Prenatal screening laboratories show a reactive rapid plasma reagin (RPR) test with a titer of 1:64. Confirmatory testing with Treponema pallidum particle agglutination (TP-PA) is positive. The patient's electronic medical record indicates a history of severe anaphylaxis to amoxicillin during childhood, which was documented with an intensive care unit admission for airway compromise. Which of the following is the most appropriate pharmacologic management for this patient's infection?