Patient Management

A 36-year-old man with recently diagnosed, untreated HIV infection is admitted to the hospital due to a 3-week history of progressively worsening headaches, nausea, and intermittent confusion. His CD4 cell count is $28 \text{ cells/mm}^3$. Vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure of $118/76 \text{ mmHg}$, heart rate of $92/\text{min}$, and respiratory rate of $14/\text{min}$. Neurologic examination is notable for lethargy and mild nuchal rigidity. A lumbar puncture is performed, revealing an opening pressure of $290 \text{ mm H}_2\text{O}$. Cerebrospinal fluid analysis shows a positive cryptococcal antigen test and the presence of encapsulated yeast on India ink preparation. The patient is to be treated with a comprehensive pharmacologic regimen to manage his opportunistic infection and underlying HIV.

Arrange the following pharmacologic interventions in the most appropriate chronological order of their initiation for this patient.

A 41-year-old woman presents to the clinic with an 8-month history of progressive central weight gain, severe fatigue, and proximal muscle weakness. She also reports the onset of facial hair growth and irregular menstrual cycles. Her blood pressure is 158/96 mmHg and her BMI is 33 kg/m^2. Physical examination reveals a rounded, plethoric face, prominent supraclavicular fat pads, and wide, violaceous striae on her abdomen. Laboratory results are notable for a serum potassium level of 3.1 mEq/L and a fasting blood glucose of 138 mg/dL. The physician suspects an endogenous hormonal excess syndrome.

Assuming that each diagnostic step yields findings that necessitate progression to the next level of workup for a central, adrenocorticotropic hormone (ACTH)-dependent etiology (with non-definitive initial imaging), arrange the following investigations in the most appropriate, guideline-directed sequence from initial screening to final confirmation.

A 55-year-old man is evaluated in the medical ward on hospital day 5. He was admitted for a severe exacerbation of ulcerative colitis. His past medical history includes focal impaired awareness seizures, for which he has taken oral phenytoin 300 mg daily for the past 4 years without recent breakthrough seizures.

During the hospitalization, the following laboratory results and clinical notes were documented:

*(Reference ranges: Albumin 3.5-5.0 g/dL; Total Phenytoin 10-20 mcg/mL)*

Today, the patient is lethargic and speaks with slurred speech. Neurologic examination reveals prominent horizontal nystagmus on lateral gaze and severe truncal ataxia when he is assisted to a sitting position. Renal and hepatic function panels are within normal limits.

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

A $34$-year-old female patient presents to the primary care clinic reporting progressive weight gain, profound fatigue, and irregular menstrual cycles over the last year. On physical examination, her blood pressure is $162/98$ mm Hg. She has prominent facial adiposity, a dorsocervical fat pad, and multiple violaceous striae measuring up to $1.5$ cm in width across her lower abdomen.

The physician suspects an underlying endocrine disorder. Assuming each subsequent investigation result confirms the preceding suspicion and points toward a central etiology without definitive initial structural findings, arrange the following diagnostic steps in the correct clinical sequence to establish the diagnosis and identify the precise anatomical source.

Following a left middle cerebral artery ischemic stroke, a 71-year-old female patient is medically stabilized on the neurology ward. It is hospital day six, and her vitals are within normal limits. She exhibits residual right hemiparesis and moderate expressive aphasia. During evaluation, therapists note she needs substantial physical assistance to move from bed to chair. Despite these deficits, she follows commands well, shows strong motivation, and has demonstrated the stamina to participate in three hours of active, multimodal therapy (physical, occupational, and speech) each day. Her spouse is elderly and cannot physically lift her.

Which of the following is the most appropriate next step in care setting transition?

A 76-year-old man presents to the outpatient clinic with a 3-day history of profound nausea, generalized weakness, and decreased appetite. He also reports that his vision has acquired a "yellowish tint." His medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of 30%, chronic kidney disease stage 3a, and paroxysmal atrial fibrillation. His home medications include lisinopril, metoprolol succinate, furosemide, apixaban, and digoxin 0.25 mg daily. One week ago, amiodarone was added to his regimen for increasing episodes of symptomatic atrial fibrillation.

Vital signs show a blood pressure of 105/65 mm Hg and a heart rate of 52/min with an irregularly irregular rhythm.

Laboratory evaluation reveals:

Which of the following are the most appropriate immediate steps in the monitoring and treatment evaluation of this patient? (Select exactly 2 options)

An 82-year-old woman is brought to the emergency department from a skilled nursing facility due to a 3-day history of worsening, colicky abdominal pain and intractable vomiting. The nursing staff notes that she has not had a bowel movement or passed flatus for 48 hours. Her medical history is significant for type 2 diabetes mellitus, hypertension, severe chronic obstructive pulmonary disease, and recurrent episodes of right upper quadrant abdominal pain that she has managed conservatively for several years. Her temperature is 37.9°C (100.2°F), pulse is 112/min, blood pressure is 108/64 mm Hg, and respirations are 20/min. Physical examination reveals dry mucous membranes and decreased skin turgor. The abdomen is markedly distended and tympanitic. Auscultation demonstrates high-pitched, tinkling bowel sounds. There is mild, diffuse abdominal tenderness without rebound guarding or rigidity. Laboratory studies show a leukocyte count of 14,200/mm³, blood urea nitrogen of 42 mg/dL, and serum creatinine of 1.6 mg/dL. An upright plain radiograph of the abdomen reveals dilated loops of small bowel with multiple air-fluid levels and branching radiolucencies overlying the central hepatic shadow. Which of the following is the most appropriate definitive management for this patient?

A 72-year-old man with a history of ischemic cardiomyopathy and a left ventricular ejection fraction of 30% presents to the emergency department with severe, worsening shortness of breath over the past 3 days. He reports orthopnea and paroxysmal nocturnal dyspnea. His blood pressure is 165/95 mm Hg, heart rate is 110/min, and respiratory rate is 28/min. Oxygen saturation is 89% on room air. Physical examination reveals jugular venous distention, bibasilar crackles extending halfway up the lung fields, and 3+ bilateral pitting pedal edema. Which of the following pharmacologic interventions are appropriate for the initial management of this patient's acute presentation? (Select all that apply)

An outpatient with heart failure with reduced ejection fraction is evaluated in the cardiology clinic. Her current medication regimen includes sacubitril-valsartan, carvedilol, and furosemide. To further optimize her guideline-directed medical therapy, the physician prescribes spironolactone. The patient is instructed to complete a laboratory blood draw in one week. Measurement of which of the following serum parameters is the most critical component of this planned follow-up evaluation?

A 58-year-old female is admitted to the cardiac telemetry unit for the elective initiation of an antiarrhythmic medication. She has a history of highly symptomatic paroxysmal atrial fibrillation that has been refractory to maximum tolerated doses of metoprolol and flecainide. The patient currently feels well and denies chest pain, palpitations, or shortness of breath. Her home medications include metoprolol succinate, apixaban, and atorvastatin. Her vital signs are within normal limits. The attending physician plans to initiate dofetilide to maintain sinus rhythm.

Which of the following monitoring parameters and laboratory studies are MANDATORY to obtain prior to the first dose and at designated intervals during the initial 72 hours of this therapy? (Select 3 answers)

An elderly patient is recovering on the neurology floor following an acute middle cerebral artery ischemic stroke. The primary inpatient team has determined that the patient likely requires intensive, multidisciplinary rehabilitation before returning home. Arrange the following steps for transitioning this patient to an Inpatient Rehabilitation Facility (IRF) in the most appropriate chronological order to ensure a safe and compliant care transition.

A 34-year-old woman with a history of poorly controlled Graves disease presents to the emergency department with severe agitation, nausea, and vomiting. Her family reports she abruptly stopped taking all her medications two weeks ago. On examination, she is delirious, profusely diaphoretic, and tremulous. Her temperature is 40.2°C (104.4°F), blood pressure is 158/70 mm Hg, and heart rate is 155/min. An electrocardiogram demonstrates atrial fibrillation with a rapid ventricular response. Intravenous access is established. Arrange the following pharmacologic interventions in the required chronological sequence for the acute stabilization of this patient.

Emergency medical services arrive at the resuscitation bay with a 29-year-old male who collapsed at a local seafood restaurant. The patient's friends state he began coughing violently, complaining of a 'thick tongue', and broke out in hives shortly after eating a crab dish.

Current vital signs:
Temperature: 36.9 °C (98.4 °F)
Heart rate: 146/min
Blood pressure: 68/38 mm Hg
Respiratory rate: 32/min
Oxygen saturation: 84% on room air

On initial evaluation, the patient is obtunded. There is profound swelling of the periorbital tissues, lips, and oropharynx. Loud, high-pitched inspiratory stridor is present. The extremities are cool and mottled, with a prolonged capillary refill time.

Which of the following interventions should be ordered IMMEDIATELY and SIMULTANEOUSLY to stabilize this patient? (Select 3 options that apply)

A 54-year-old woman is evaluated in the clinic for newly diagnosed primary hypertension. Over her last three outpatient visits, her blood pressure has averaged 154/96 mmHg. She feels well and reports no headaches, visual changes, or chest pain. Her medical history is significant only for bipolar I disorder, which has been successfully maintained for the past decade with daily lithium carbonate therapy. Her most recent laboratory studies show a normal serum creatinine level and a serum lithium concentration within the narrow therapeutic range. The physician plans to initiate first-line antihypertensive pharmacotherapy. To prevent a clinically significant pharmacokinetic drug interaction that could precipitate coarse hand tremors, ataxia, and confusion, which of the following antihypertensive medications should be avoided in this patient?

A 68-year-old man is preparing for discharge after a 4-day hospitalization for community-acquired pneumonia. The care team is initiating the discharge medication reconciliation process to ensure a safe transition to the outpatient setting. Arrange the standard steps of the medication reconciliation process in the correct chronological sequence, from first to last.

A 58-year-old man is evaluated in the emergency department for worsening respiratory distress. He has a history of chronic obstructive pulmonary disease (COPD) and was brought in by ambulance after his wife found him gasping for air. On arrival, his blood pressure is 150/90 mm Hg, heart rate is 122/min, and oxygen saturation is 84% on room air. Physical examination reveals accessory muscle use, diffuse wheezing, and paradoxical abdominal breathing. Despite initiation of noninvasive positive-pressure ventilation and continuous bronchodilator therapy, the patient's mental status rapidly declines. The physician decides to proceed with rapid sequence intubation (RSI). Arrange the following procedural steps for RSI in the most appropriate chronological sequence.

During an afternoon shift at an outpatient clinic, staff hear a loud thud from a restroom and discover a $74$-year-old man collapsed on the floor. He is immediately transported via advanced life support to the adjacent hospital's resuscitation bay. Upon arrival, the patient is diaphoretic, lethargic, and complains of excruciating, tearing pain radiating to his lower back. Vital signs reveal a blood pressure of $65/40$ mm Hg, a heart rate of $128$/min, and a respiratory rate of $24$/min. Physical examination demonstrates a prominent, expansile pulsation in the epigastrium. An immediate bedside focused assessment with sonography for trauma (FAST) reveals a $7.5$ cm dilation of the infrarenal aorta surrounded by hypoechoic free fluid. Which of the following are appropriate immediate steps in the procedural and clinical management of this patient? Select all that apply.

Emergency medical services arrive at the emergency department with a 45-year-old man who has been experiencing a continuous generalized tonic-clonic seizure for the past 15 minutes. Upon evaluation, the patient remains unresponsive with rhythmic motor jerking of all four extremities. His airway is patent with spontaneous respirations, and a point-of-care capillary blood glucose is 98 mg/dL. The nursing staff has successfully secured intravenous access. Arrange the following pharmacologic interventions in the required chronological sequence for the escalating management of this patient's condition.

A 54-year-old man is admitted to the hospital with an acute, unprovoked deep vein thrombosis and a subsequent pulmonary embolism. He is hemodynamically stable and is initiated on a continuous intravenous infusion of unfractionated heparin. Which of the following laboratory parameters are essential to monitor routinely to ensure the therapeutic efficacy and safety of this specific therapy? (Select all that apply)

Emergency medical responders transport a 22-year-old male to the trauma center following a high-speed bicycle collision against a concrete wall. He is gasping for air and profoundly cyanotic. Vital signs show a blood pressure of 76/40 mmHg, pulse of 142/min, and respiratory rate of 34/min. Physical examination reveals tracheal deviation to the left, prominently distended jugular veins, and no audible breath sounds over the right hemithorax. Which of the following is the most appropriate next step in the management of this patient?