Patient Management

A 50-year-old man is treated in the intensive care unit for massive hematemesis. He has a history of severe alcohol use disorder and decompensated cirrhosis. Upon admission, he was tachycardic and hypotensive, requiring prompt endotracheal intubation for airway protection. He has been receiving aggressive resuscitation with intravenous crystalloids, matched packed red blood cells, continuous octreotide infusion, and prophylactic ceftriaxone. An urgent esophagogastroduodenoscopy was attempted but aborted; pooling blood completely obscured the visualization of the esophageal mucosa, precluding any endoscopic band ligation or sclerotherapy. Currently, his blood pressure is 78/48 mm Hg and his heart rate is 132/min. The critical care team determines that a transjugular intrahepatic portosystemic shunt (TIPS) is indicated, but the interventional radiology team states that the procedure cannot be initiated for another 90 minutes. Which of the following is the most appropriate immediate procedural intervention for this patient?

A 74-year-old woman is evaluated in the emergency department for sudden, severe, diffuse abdominal pain that began 4 hours ago. She has a history of paroxysmal atrial fibrillation, type 2 diabetes mellitus, and chronic kidney disease. She recently stopped taking her apixaban due to financial constraints. On presentation, her temperature is 38.2°C (100.8°F), blood pressure is 82/50 mm Hg, pulse is 128/min and irregularly irregular, and respirations are 24/min. Physical examination reveals a rigid, distended abdomen with diffuse rebound tenderness and involuntary guarding. Laboratory studies show a leukocyte count of 22,000/mm³ and serum lactate of 8.4 mmol/L (Normal: 0.5-2.2 mmol/L). Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are initiated.

Which of the following procedural and surgical interventions are definitively indicated in the management of this patient? (Select all that apply)

A 71-year-old man is brought to the emergency department after a sudden onset of severe headache, right-sided weakness, and expressive aphasia. He has a history of nonvalvular atrial fibrillation, hypertension, and type 2 diabetes mellitus. His daily medications include apixaban, lisinopril, and metformin. On arrival, his blood pressure is $185/105 \text{ mm Hg}$. A non-contrast CT scan of the head reveals a large left basal ganglia intracerebral hemorrhage. His blood pressure is promptly managed with an intravenous nicardipine infusion. Due to his life-threatening bleeding and confirmed recent apixaban use, an intravenous bolus followed by a 2-hour infusion of andexanet alfa is administered.

One hour after the completion of the andexanet alfa infusion, the patient's neurological examination remains unchanged from presentation. A repeat head CT shows no expansion of the hematoma. The intensive care team orders a chromogenic anti-factor Xa activity level (calibrated for apixaban) to evaluate the success of the reversal therapy. The result is $1.8 \text{ IU/mL}$ (therapeutic range for stroke prevention: $1.0 - 2.0 \text{ IU/mL}$), suggesting high residual apixaban activity.

Which of the following is the most appropriate next step in the monitoring and treatment evaluation of this patient?

A 32-year-old woman presents to the outpatient clinic with a two-day history of dysuria, increased urinary frequency, and suprapubic discomfort. She has no fever, chills, or flank pain. Her last menstrual period was 10 weeks ago, and a urine pregnancy test performed in the clinic is positive. Vital signs are within normal limits. Physical examination reveals mild suprapubic tenderness but no costovertebral angle tenderness. Urinalysis is positive for leukocyte esterase, nitrites, and bacteria. The patient has no known drug allergies. Which of the following is the most appropriate empiric pharmacologic intervention for this patient?

Match each clinical vignette describing a patient awaiting hospital discharge to the most appropriate post-acute care disposition setting.

Match each patient's clinical presentation with the most appropriate next diagnostic imaging study based on current guidelines.

A 58-year-old man with a history of treated cavitary pulmonary tuberculosis is brought to the emergency department by ambulance due to a sudden episode of massive hemoptysis. Paramedics report he expectorated approximately 600 mL of bright red blood into a basin during the 20-minute transport. On arrival, the patient is agitated, actively coughing up blood, and visibly struggling to breathe. Vital signs are temperature 37.0°C (98.6°F), blood pressure 82/48 mm Hg, pulse 134/min, and respirations 34/min. Pulse oximetry is 84% on room air. Pulmonary auscultation reveals gurgling and absent breath sounds over the right lung, while the left lung has clear breath sounds. Which of the following are the most appropriate simultaneous initial steps in the stabilization of this patient? (Select 2 answers)

A $42$-year-old woman comes to the clinic for a follow-up visit. Two weeks ago, she was evaluated for fatigue and was found to have a hemoglobin concentration of $9.8 \text{ g/dL}$, a mean corpuscular volume of $74 \text{ fL}$, and a serum ferritin level of $8 \text{ ng/mL}$. At that time, she was diagnosed with iron deficiency anemia secondary to heavy menstrual bleeding and was instructed to start oral ferrous sulfate. Today, the patient reports that she has been taking the medication consistently. She still feels somewhat tired but denies shortness of breath, chest pain, or lightheadedness. Her vital signs are within normal limits. Laboratory results today show a hemoglobin concentration of $10.1 \text{ g/dL}$ and a reticulocyte count of $5.2\%$ (normal: $0.5\%-1.5\%$). Which of the following is the most appropriate next step in management?

A 46-year-old man comes to the clinic for a routine health maintenance examination. He feels well and has no concerns. His medical history is unremarkable, and he takes no medications. He has no family history of colorectal, prostate, or lung cancer. He does not smoke, drink alcohol, or use illicit drugs. Vital signs are within normal limits. Physical examination is unremarkable. He has not had any cancer screening tests in the past. Which of the following is the most appropriate next step in preventive care for this patient?

A father brings his 3-year-old son to the outpatient pediatric clinic because the child has been refusing to move his left arm for the past hour. The father explains that they were walking in the park when the boy stumbled; to prevent him from falling to the ground, the father quickly pulled the child up by the left hand. Immediately afterward, the child began crying and holding his arm against his side. On physical examination, the boy is alert but appears anxious. He is cradling his left arm close to his body with the elbow slightly flexed and the forearm pronated. There is no visible swelling, ecchymosis, deformity, or point tenderness over the clavicle, shoulder, elbow, or wrist. The child cries and resists only when the clinician attempts to supinate the left forearm. Which of the following is the most appropriate next step in management?

A 55-year-old man is in the intensive care unit being managed for recurrent seizures secondary to viral encephalitis. His seizures have been well-controlled for the past week on a continuous intravenous infusion of valproic acid. On hospital day 8, he developed a new fever, increased respiratory secretions, and a right lower lobe consolidation on chest radiograph. Sputum and blood cultures were obtained, and he was started empirically on intravenous meropenem. On hospital day 10, the patient experiences a 3-minute generalized tonic-clonic seizure.

Relevant laboratory results are shown below:

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

An 81-year-old woman is evaluated on hospital day 5 to determine the appropriate post-acute care setting. She was initially admitted for altered mental status and hypotension secondary to a severe Escherichia coli urinary tract infection. She received intravenous fluids and targeted antibiotic therapy. Currently, her blood pressure is 128/78 mmHg, pulse is 82/min, and respirations are 16/min. She has been afebrile for 48 hours. Her leukocyte count is 8,200/mm³ and serum creatinine has improved from 2.6 mg/dL on admission to 1.0 mg/dL. Her baseline functional status before admission was independent in all activities of daily living. She resides in a single-story house with her 83-year-old husband, who uses a walker due to advanced osteoarthritis. Currently, the patient is easily fatigued, oriented only to person and place, and requires the assistance of two staff members to transfer from the bed to a chair. A physical therapy evaluation notes that she can actively participate in structured exercises for approximately 45 minutes per day before becoming exhausted. Which of the following is the most appropriate disposition for this patient?

A 68-year-old man is admitted to the general medical ward with acute-onset fever, tachypnea, and a right lower lobe infiltrate on chest radiograph. He is diagnosed with community-acquired pneumonia. Arrange the following steps in the correct chronological sequence for his initial management, ongoing monitoring, and therapeutic de-escalation.

A $58$-year-old woman is evaluated in the intensive care unit for altered mental status, severe agitation, and fever. She has a history of major depressive disorder, generalized anxiety disorder, and chronic back pain. Her home medications include fluoxetine, tramadol, and cyclobenzaprine. Two days ago, she was admitted for severe community-acquired pneumonia and was started on broad-spectrum antimicrobial therapy, including intravenous linezolid. Today, she is diaphoretic and confused. Temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $165/100$ mmHg, heart rate is $128$/min, and respiratory rate is $24$/min. Physical examination reveals mydriasis, excessive diaphoresis, hyperactive bowel sounds, and inducible myoclonus in the bilateral lower extremities. Which of the following are the most appropriate immediate pharmacologic interventions? (Select all that apply)

A 56-year-old man is evaluated in the emergency department for right upper quadrant abdominal pain, jaundice, and black, tarry stools that started 24 hours ago. Five days ago, he underwent an ultrasound-guided percutaneous liver biopsy to evaluate undiagnosed cirrhosis. His temperature is 37.1°C (98.8°F), blood pressure is 102/64 mm Hg, pulse is 112/min, and respirations are 16/min. Physical examination shows scleral icterus and right upper quadrant tenderness without guarding or rebound. Laboratory studies reveal a hemoglobin level of 8.2 g/dL (baseline 13.5 g/dL) and a total bilirubin of 4.8 mg/dL. Following the administration of intravenous fluids and packed red blood cells, the patient undergoes an esophagogastroduodenoscopy. The esophageal and gastric mucosa are normal, and no varices are identified. However, fresh blood is observed actively extruding from the ampulla of Vater. Which of the following is the most appropriate next step in management?

A 64-year-old man presents with sudden, intractable, generalized abdominal pain that began 2 hours ago. His medical history is significant for coronary artery disease, chronic obstructive pulmonary disease, and daily naproxen use for severe osteoarthritis. Vital signs show a temperature of 38.6°C (101.5°F), blood pressure of 86/52 mmHg, heart rate of 124/min, and respiratory rate of 28/min. Physical examination reveals a rigid, board-like abdomen with severe diffuse tenderness, rebound, and involuntary guarding. An upright chest radiograph demonstrates free air under the right hemidiaphragm. The surgical service is consulted, and an emergent exploratory laparotomy is planned.

Which of the following interventions are essential components of this patient's immediate preoperative management? (Select all that apply)

A 68-year-old man presents to the emergency department complaining of sudden, excruciating pain in his left leg that began 4 hours ago. He has a history of paroxysmal atrial fibrillation and recently stopped taking his prescribed rivaroxaban due to financial constraints. On physical examination, the left lower extremity is notably pale and cool to the touch from the mid-thigh distally. The left femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent. Handheld continuous-wave Doppler reveals no arterial signals in the left foot, but venous signals remain audible. Neurologic examination of the left lower extremity demonstrates profound loss of sensation extending up to the mid-calf and a new-onset inability to dorsiflex the foot. Intravenous heparin and adequate analgesia are administered immediately. Which of the following is the most appropriate next step in the management of this patient?

A 48-year-old man comes to the clinic for follow-up of treatment-resistant hypertension. His blood pressure remains 168/98 mmHg despite adherence to maximum doses of amlodipine, lisinopril, and hydrochlorothiazide. Laboratory studies two weeks ago showed a serum potassium of 3.1 mEq/L. Subsequent evaluation revealed a plasma aldosterone concentration (PAC) of 34 ng/dL and a suppressed plasma renin activity (PRA) of 0.4 ng/mL/h. A confirmatory intravenous saline infusion test demonstrated persistent elevation of aldosterone levels, confirming the diagnosis of primary aldosteronism. An abdominal computed tomography (CT) scan shows a 1.4-cm, lipid-rich adenoma in the right adrenal gland and a morphologically normal left adrenal gland. The patient is a good surgical candidate and expresses a strong desire for a definitive surgical cure. Which of the following is the most appropriate next step in management?

During an interdisciplinary rounds discussion on the psychiatric ward, the care team plans the discharge of a 35-year-old female who was recently stabilized from an acute manic episode. The patient was successfully transitioned to maintenance lithium carbonate therapy over the past ten days. Her current serum lithium trough level is within the therapeutic window. To appropriately monitor for the most common long-term adverse effects of this pharmacotherapy, which of the following laboratory parameters should be periodically evaluated in the outpatient setting? (Select all that apply)

A 71-year-old man comes to the clinic reporting a 2-month history of worsening mid-to-lower back pain. The pain is constant, does not improve with rest, and occasionally awakens him at night. Over the same period, he has experienced progressive fatigue, constipation, and increased urinary frequency. His past medical history is notable only for mild osteoarthritis, for which he takes acetaminophen as needed. He does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. Physical examination reveals tenderness to palpation over the lumbar spine but no focal neurological deficits.

Laboratory results are as follows:

Hemoglobin: $9.2 \text{ g/dL}$
Leukocyte count: $6,500/\mu\text{L}$
Platelet count: $140,000/\mu\text{L}$
Calcium: $11.8 \text{ mg/dL}$
Creatinine: $2.1 \text{ mg/dL}$
Alkaline phosphatase: $95 \text{ U/L}$

Which of the following diagnostic tests should be ordered concurrently as the most appropriate next steps in this patient's initial workup? (Select all that apply)