Patient Management

A 68-year-old man presents to the urgent care clinic with a 4-day history of productive cough, chills, and progressive shortness of breath. His past medical history is significant for hypertension, type 2 diabetes mellitus, and congenital long QT syndrome. Current medications include lisinopril, metformin, and a multivitamin. His temperature is 38.3°C (100.9°F), blood pressure is 134/82 mmHg, pulse is 92/min, and respiratory rate is 22/min. Oxygen saturation is 95% on room air. Pulmonary examination reveals focal crackles and increased tactile fremitus over the left lower lung zone. A chest radiograph demonstrates a left lower lobe consolidation. The patient is diagnosed with community-acquired pneumonia and is deemed stable for outpatient management. Which of the following antimicrobial agents are appropriate to include in his empiric treatment regimen? (Select all that apply)

Match each patient's clinical demographic and risk profile with the most appropriate indicated preventive screening modality.

A 62-year-old man is preparing for hospital discharge following an admission for a severe chronic obstructive pulmonary disease (COPD) exacerbation. During his stay, he required a brief period of noninvasive positive pressure ventilation in the intensive care unit before stabilizing on the general medical ward. His discharge plan includes a new home oxygen requirement and a transition from his previous short-acting bronchodilators to a new combination maintenance inhaler. To ensure a safe transition of care and minimize the risk of readmission, arrange the following discharge planning steps in the most appropriate chronological sequence.

During a routine follow-up evaluation, a primary care physician reviews the laboratory results of a patient who recently began antihypertensive therapy. The patient is a nulliparous female in her mid-fifties with uncomplicated type 2 diabetes mellitus. Three weeks prior, she was prescribed enalapril for blood pressure management. Today, she feels well and denies any dizziness, cough, or peripheral edema. Vital signs demonstrate a blood pressure of $132/84\text{ mmHg}$, compared to a baseline of $154/92\text{ mmHg}$.

Baseline laboratory studies (3 weeks ago):
Serum creatinine: $0.9\text{ mg/dL}$
Serum potassium: $4.2\text{ mEq/L}$

Current laboratory studies:
Serum creatinine: $1.1\text{ mg/dL}$
Serum potassium: $4.6\text{ mEq/L}$

Based on these findings, what is the most appropriate modification to this patient's treatment plan?

Disposition planning is underway in the emergency department for an 82-year-old man who presented with a 3-day history of productive cough, mild shortness of breath, and low-grade fever. He has a history of hypertension, benign prostatic hyperplasia, and severe bilateral knee osteoarthritis. Prior to this illness, he lived alone, ambulated independently with a cane, and managed his own daily activities.

Over the past 48 hours, he has become progressively weaker. He reports two near-falls today and is now unable to bear weight or walk from his bed to the bathroom without two-person assistance. His closest relative lives three hours away.

Vital signs are temperature 37.8°C (100.0°F), blood pressure 135/85 mmHg, pulse 92/min, and respirations 20/min. Pulse oximetry is 95% on room air. He is fully alert and oriented to person, place, and time.

Physical examination reveals crackles in the right lower lung base. Cardiac examination is normal. He has 4/5 motor strength in the lower extremities bilaterally, limited by fatigue, with normal reflexes.

Laboratory studies show:
Blood urea nitrogen: 16 mg/dL
Serum creatinine: 1.0 mg/dL
Leukocyte count: 11,500/mm³

Chest radiography reveals a right lower lobe consolidation.

Based on the patient's objective severity scores and functional capacity, which of the following is the most appropriate disposition?

A 68-year-old man is evaluated in the intensive care unit (ICU) to determine the most appropriate care setting transition. He was admitted 28 days ago for severe community-acquired pneumonia that progressed to acute respiratory distress syndrome. He was intubated on hospital day 2 and underwent tracheostomy placement on day 14. Currently, the patient is hemodynamically stable, has been off vasopressors for two weeks, and is alert and following commands. Renal function and electrolytes are within normal limits. However, he remains dependent on mechanical ventilation. Daily weaning trials have been attempted, but he fatigues after 2 to 3 hours on a trach collar and requires resumption of full ventilatory support. Additionally, he developed a stage 3 sacral pressure ulcer during his acute illness, which currently requires daily sharp debridement and wound vacuum-assisted closure management. Which of the following is the most appropriate disposition for this patient?

A 27-year-old man is brought to the emergency department by his roommate, who found him confused and lethargic next to several empty medication bottles. The patient has a past medical history of major depressive disorder and chronic neuropathic pain. On arrival, he is somnolent but arouses to verbal stimuli. Vital signs are temperature $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure 84/54 mm Hg, pulse 128/min, and respirations 16/min. Pulse oximetry is 97% on room air. Physical examination reveals dry mucous membranes, dilated pupils bilaterally, and warm, flushed skin. Bowel sounds are absent. A 12-lead electrocardiogram demonstrates sinus tachycardia with a QRS interval of 165 ms and a prominent terminal R wave in lead aVR. Which of the following is the most urgent initial step in the stabilization of this patient?

A $68$-year-old man presents to the cardiology clinic for a routine follow-up. He has a history of nonischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$ diagnosed two years ago, as well as chronic kidney disease. He reports experiencing dyspnea when walking approximately one block and requires two pillows to sleep comfortably at night. His current medications include carvedilol $25$ mg twice daily, dapagliflozin $10$ mg daily, and furosemide $80$ mg twice daily.

Vital signs show a blood pressure of $132/82$ mm Hg and a regular heart rate of $64$/min. The estimated jugular venous pressure is $8$ cm H $_2$ O. Lungs are clear to auscultation. Cardiac examination reveals a regular rhythm with a normal S1 and S2, and a prominent S3 gallop. There is trace bilateral pedal edema.

Laboratory studies are as follows:

His estimated glomerular filtration rate is $22$ mL/min/1.73m $^2$. The physician wishes to optimize his heart failure regimen to improve symptoms and reduce mortality. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A $47$-year-old woman with diffuse large B-cell lymphoma is currently undergoing cyclical CHOP chemotherapy. Seven days after her last cycle, she presents to the emergency department with severe chills and a temperature of $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$). Her absolute neutrophil count (ANC) is determined to be $110 \text{ cells/mm}^3$. She has a peripherally inserted central catheter (PICC) in place. Arrange the following diagnostic, monitoring, and therapeutic steps in the most appropriate chronological sequence for the management of this patient's neutropenic fever.

A 28-year-old female is brought to the emergency department triage desk by her sister after collapsing at home. The sister reports that the patient complained of sharp, sudden-onset right lower quadrant abdominal pain shortly before losing consciousness. The patient has no significant past medical history but has not had a menstrual period in seven weeks. On evaluation, the patient is somnolent but groans in response to painful stimuli. She is markedly pale and diaphoretic. Vital signs include a heart rate of 142/min, a blood pressure of 68/36 mmHg, a respiratory rate of 24/min, and an oxygen saturation of 97% on room air. Physical examination reveals a rigid, diffusely tender abdomen with involuntary guarding. Which of the following is the most appropriate immediate next step in the management of this patient?

A 66-year-old man presents to the primary care clinic with a 4-day history of a productive cough, fever, and progressive shortness of breath. His medical history is significant for type 2 diabetes mellitus, hypertension, and major depressive disorder. Current medications include metformin, lisinopril, and citalopram. His temperature is 38.4°C (101.1°F), blood pressure is 132/82 mmHg, pulse is 98/min, and respiratory rate is 22/min. Pulse oximetry shows 94% on room air. Physical examination reveals bronchial breath sounds and crackles over the left lower lung field. Laboratory studies show a leukocyte count of 14,000/mm³ with a left shift. Serum creatinine is 1.1 mg/dL. A chest radiograph demonstrates a left lower lobe consolidation. An electrocardiogram obtained in the clinic reveals a normal sinus rhythm with a QTc interval of 520 msec. Which of the following is the most appropriate outpatient pharmacologic regimen for this patient?

A 55-year-old man with poorly controlled type 2 diabetes mellitus is brought to the emergency department due to a 24-hour history of severe pain and swelling in his right lower leg. He sustained a minor abrasion to his shin three days ago. His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), heart rate is $122/\text{min}$, blood pressure is $88/56\text{ mm Hg}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a markedly swollen, erythematous right lower leg. The erythema is advancing rapidly, and there are violaceous bullae over the anterior shin. Palpation elicits palpable crepitus and pain that is out of proportion to the visual extent of the skin changes. Laboratory studies show:

Aggressive intravenous fluid resuscitation and broad-spectrum antibiotics are immediately initiated. Which of the following is the most appropriate next step in management?

An 82-year-old woman is admitted to the hospital after a mechanical fall at home resulting in a displaced right femoral neck fracture. She is evaluated by the orthopedic surgery team, who recommend urgent hemiarthroplasty to minimize morbidity. Her past medical history is significant for hypertension and atrial fibrillation, for which she takes warfarin. Her vital signs are within normal limits. Laboratory evaluation reveals an International Normalized Ratio (INR) of 3.8. The surgical team wishes to proceed with the operation as soon as it is safe. Which of the following procedural preparation steps are indicated for this patient? (Select all that apply)

An asymptomatic 68-year-old male presents to the primary care office for an annual wellness visit. He has no acute complaints and feels well. His medical history is significant for mild osteoarthritis, which is well controlled with occasional acetaminophen. He is a former smoker who smoked half a pack of cigarettes daily for 20 years, quitting 5 years ago. He drinks alcohol occasionally and exercises three times a week. Review of his records shows a normal screening colonoscopy at age 65 and a normal lipid panel 6 months ago. His blood pressure today is 122/78 mmHg, and his heart rate is 72/min. Physical examination is unremarkable. Which of the following is the most appropriate next step in preventive screening for this patient?

A 42-year-old man is evaluated in the surgical oncology clinic for the management of a recently diagnosed right adrenal mass. He initially presented to his primary care physician with a 6-month history of episodic, severe headaches, profuse sweating, and palpitations. His blood pressure during those episodes was often greater than 190/110 mm Hg. Subsequent biochemical testing revealed markedly elevated 24-hour urine fractionated metanephrines and catecholamines. A CT scan of the abdomen without contrast demonstrated a 5.5-cm, lipid-poor, right adrenal mass. The patient is scheduled to undergo a laparoscopic right adrenalectomy. His current blood pressure is 178/104 mm Hg and his heart rate is 102/min.

Arrange the following procedural and management steps in the most appropriate chronological order to safely prepare for and perform the surgical intervention.

A 33-year-old male is transported to the emergency department via ambulance after a high-speed frontal motor vehicle collision. On arrival, he is deeply unresponsive with a Glasgow Coma Scale score of 6. He has gurgling respirations at a rate of 6/min. Blood pressure is 65/40 mm Hg, and heart rate is 142/min. Paramedics have already placed a tourniquet on his right thigh, effectively controlling active hemorrhage from an open femur fracture. Arrange the following management steps in the most appropriate chronological order for this patient.

A 54-year-old man is brought to the intensive care unit with a temperature of $39.2^{\circ} \text{C}$ ($102.6^{\circ} \text{F}$), heart rate of 122/min, and blood pressure of 88/56 mm Hg. He has a history of severe gallstone pancreatitis that required an extended admission 4 weeks ago. He had been steadily improving at a rehabilitation facility until 2 days ago when he developed worsening abdominal pain, lethargy, and fever. On examination, his abdomen is distended and diffusely tender with prominent guarding in the epigastrium. Laboratory studies show a leukocyte count of $22,000/\mu\text{L}$ with 15% bands. You suspect infected walled-off pancreatic necrosis (WON) complicated by septic shock.

Arrange the following procedural and surgical management steps in the correct chronological sequence, reflecting the current evidence-based "step-up" approach for this patient's evolving condition, starting from immediate initial presentation through to the management of refractory disease.

A 42-year-old woman is hospitalized after sustaining severe multisystem trauma in an all-terrain vehicle accident. Her hospital course is complicated by acute respiratory distress syndrome (ARDS), requiring a tracheostomy and prolonged mechanical ventilation. Assuming a steady, uncomplicated clinical recovery trajectory, arrange the following healthcare settings in the most appropriate chronological sequence representing the standard step-down transition of care.

An obstetric patient at 26 weeks gestation presents to the emergency triage area with abrupt-onset right-sided pleuritic chest discomfort and dyspnea. She has no significant past medical history and takes only prenatal vitamins. Vital signs reveal a temperature of 37.1°C (98.8°F), heart rate of 118/min, respiratory rate of 26/min, blood pressure of 112/70 mmHg, and oxygen saturation of 94% on ambient air. Physical examination is notable for an asymmetrically swollen and tender left calf with palpable cord-like induration. Auscultation of the lungs is clear bilaterally, and cardiovascular examination reveals sinus tachycardia without murmurs. Which of the following represent the most appropriate concurrent initial diagnostic studies for this patient? (Select exactly 2 answers)

An unresponsive 42-year-old woman is admitted to the intensive care unit following a rapid decline in mental status at an outpatient clinic. Her family reports she complained of severe right flank pain and rigors for the past day. Current vital signs include a blood pressure of $85/50\text{ mmHg}$, a heart rate of $122\text{ beats/min}$, and a temperature of $39.4^{\circ}\text{C}$ ($102.9^{\circ}\text{F}$). Point-of-care ultrasound demonstrates significant right-sided hydronephrosis. A subsequent non-contrast computed tomography scan confirms an $8\text{-mm}$ radiopaque calculus lodged in the proximal right ureter accompanied by perinephric fluid. Arrange the clinical interventions below in the most appropriate chronological sequence for this patient.