Patient Management

During a routine outpatient visit, a $64$-year-old female patient reports a $2$-month history of recurrent chest tightness. The discomfort reliably emerges after she walks up a flight of stairs and dissipates completely within $5$ minutes of sitting down. Her established diagnoses include type $2$ diabetes mellitus, essential hypertension, and mixed dyslipidemia. She is compliant with a regimen of metformin, lisinopril, and atorvastatin. Today, her blood pressure is $135/85 \text{ mmHg}$ and her heart rate is $76/\text{min}$. Auscultation of the heart and lungs yields no abnormal findings. An in-office $12$-lead electrocardiogram reveals normal sinus rhythm, a prolonged QRS duration of $145 \text{ msec}$, broad, notched R waves in leads I, aVL, V5, and V6, alongside discordant ST-segment depression in the lateral leads. Which of the following is the most appropriate next step in the diagnostic workup?

Emergency medical services arrive at the resuscitation bay with an unresponsive adult found unconscious in an apartment. The roommate reports that multiple empty, unlabeled medication bottles were scattered on the bedside table. Initial vital signs show a blood pressure of 90/50 mmHg, a pulse of 112/min, and a respiratory rate of 6/min. Physical examination reveals miotic pupils, decreased bowel sounds, and generalized hyperreflexia. A 12-lead electrocardiogram is rapidly obtained, demonstrating sinus tachycardia with a QRS complex duration of 145 msec and a prominent terminal R wave in lead aVR. Based on the patient's presentation and diagnostic findings, which of the following pharmacologic interventions are indicated for immediate management? (Select all that apply)

A 48-year-old woman comes to the clinic for a follow-up visit. Four weeks ago, she was diagnosed with Graves disease after presenting with unintentional weight loss, heat intolerance, and palpitations. At that time, she was initiated on methimazole and propranolol. Today, the patient reports feeling significantly better. She has gained 1.5 kg (3.3 lb) and notes complete resolution of her palpitations and tremors. She denies any sore throat, fever, or abdominal discomfort. Her blood pressure is 120/78 mm Hg and pulse is 74/min. Physical examination reveals a mild, diffuse, non-tender goiter but is otherwise unremarkable. Which of the following is the most appropriate next step in monitoring this patient's treatment?

A $68$-year-old man is evaluated in the intensive care unit for new-onset swelling of his right leg. He is currently on hospital day $8$ following a mitral valve replacement and has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. On admission, his baseline platelet count was $240,000/\text{mm}^3$; today, it is $90,000/\text{mm}^3$. A lower extremity venous duplex ultrasound reveals an acute deep vein thrombosis in the right femoral vein. Heparin-induced thrombocytopenia is suspected. All heparin-containing products are immediately discontinued, a continuous intravenous infusion of argatroban is initiated, and a serotonin release assay is sent.

Three days later, the patient's leg swelling has improved. His platelet count has increased to $165,000/\text{mm}^3$, and his activated partial thromboplastin time has remained consistently in the therapeutic range. The serotonin release assay returns positive. The patient is clinically stable, and the critical care team plans to transition him to oral warfarin for long-term anticoagulation.

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

A 23-year-old primigravid woman at 14 weeks of gestation presents to the outpatient obstetric clinic for a routine prenatal visit. She has no current symptoms and reports feeling well. Physical examination reveals no genital lesions, rashes, or lymphadenopathy. Routine prenatal laboratory screening is performed, which shows a rapid plasma reagin (RPR) titer of 1:32. A confirmatory Treponema pallidum particle agglutination (TPPA) test is reactive. Her medical history is notable for a severe anaphylactic reaction to amoxicillin during childhood, which manifested as diffuse urticaria, wheezing, and hypotension. Which of the following is the most appropriate pharmacologic intervention for this patient?

During an evening shift, paramedics transport a 19-year-old female university student to the resuscitation bay. Her dormitory residents initiated the emergency call after finding her profoundly confused and feverish. She is obtunded upon arrival. Vital signs display a temperature of 39.7°C (103.5°F), blood pressure of 76/40 mm Hg, heart rate of 142/min, and respiratory rate of 24/min. Pulse oximetry shows 96% on ambient air. Physical examination reveals marked nuchal rigidity and a widespread non-blanching purpuric eruption across the trunk and bilateral lower extremities. Her Glasgow Coma Scale score is 11.

Which of the following interventions should be ordered SIMULTANEOUSLY for the immediate initial stabilization of this patient? (Select all that apply)

A 74-year-old man with an 8-year history of Parkinson disease is brought to the clinic by his daughter because he has been experiencing distressing visual hallucinations over the past three weeks. He frequently sees strangers standing in his living room, which causes him significant anxiety. His motor symptoms, including bradykinesia and rigidity, are currently well controlled. He has no fever, dysuria, or recent illnesses. A urinalysis and basic metabolic panel performed in the clinic are unremarkable. His current daily medication regimen includes carbidopa-levodopa, ropinirole, selegiline, and trihexyphenidyl. Arrange the following pharmacological interventions in the correct sequential order of implementation for the stepwise management of this patient's psychosis, proceeding from the first step to the final step if symptoms remain refractory.

A 74-year-old woman with a history of heart failure, atrial fibrillation, and diabetes mellitus is being prepared for hospital discharge. She was treated for sepsis secondary to a urinary tract infection, which was complicated by acute kidney injury (now resolving). As part of the disposition planning, the physician is completing the discharge medication reconciliation to ensure a safe transition of care. Arrange the following steps of the medication reconciliation process in the most appropriate chronological order according to standard patient safety guidelines.

A 34-year-old woman with a history of Graves disease is brought to the emergency department by her husband due to severe agitation, palpitations, and confusion. She recently stopped taking her prescribed antithyroid medications. Her temperature is 39.4°C (103°F), blood pressure is 158/72 mmHg, heart rate is 145/min, and respiratory rate is 24/min. Physical examination reveals a staring gaze, a diffusely enlarged and non-tender thyroid gland, and fine resting tremors in both hands. An electrocardiogram shows sinus tachycardia. The physician diagnoses a thyroid storm. Arrange the following pharmacologic interventions in the most appropriate sequential order for the acute management of this patient's condition.

A medical consultation is requested for an inpatient who was admitted earlier today for severe confusion and generalized weakness. The patient was recently diagnosed with a right hilar mass, and a subsequent biopsy confirmed squamous cell carcinoma of the lung. Clinical evaluation reveals profound lethargy, decreased skin turgor, and dry oral mucous membranes.

Laboratory studies demonstrate:
Serum calcium: $14.6$ mg/dL
Serum phosphorus: $2.1$ mg/dL
Blood urea nitrogen: $68$ mg/dL
Serum creatinine: $3.2$ mg/dL (baseline $0.9$ mg/dL two weeks ago)
Intact parathyroid hormone (PTH): $8$ pg/mL (normal: $10-65$ pg/mL)

Aggressive volume resuscitation with intravenous isotonic saline and administration of calcitonin have been initiated. Which of the following is the most appropriate next step in this patient's pharmacologic management?

A 49-year-old man visits a primary care provider for a general health examination. He has not sought medical care since his twenties. He reports feeling perfectly well and exercises regularly. He has never used tobacco products. His body mass index is 23 kg/m². He has no known family history of medical conditions. Vital signs and physical examination findings are within normal limits. Which of the following preventive screening tests are currently indicated for this patient? (Select all that apply)

A gastroenterology consultation is requested for a female in her mid-forties suffering from relentless burning abdominal discomfort and persistent loose, watery stools for the past eight months. The abdominal distress frequently awakens her from sleep. Outpatient medical records indicate that a recent upper endoscopy revealed markedly thickened gastric folds alongside multiple mucosal ulcerations extending deep into the postbulbar duodenum. Biopsy specimens from the gastric antrum showed no evidence of Helicobacter pylori organisms. Her current medications include high-dose esomeprazole, which was initiated two weeks ago following the endoscopy but has provided minimal symptomatic relief. To properly evaluate her condition, the proton pump inhibitor is discontinued and temporarily replaced with an H2-receptor antagonist, which is subsequently stopped $48$ hours prior to laboratory testing. A fasting serum gastrin concentration is then measured at $620$ pg/mL (normal: $< 100$ pg/mL) alongside a simultaneously recorded basal gastric pH of $1.4$. Which of the following is the most appropriate next step in the diagnostic workup?

A 56-year-old man is brought to the emergency department by ambulance after vomiting large amounts of bright red blood at home. His wife reports that he has a history of alcohol-associated cirrhosis and previously diagnosed esophageal varices. On arrival, the patient is obtunded, opens his eyes only to painful stimuli, and is actively vomiting small amounts of blood. His temperature is 36.5°C (97.7°F), blood pressure is 78/40 mm Hg, pulse is 132/min, and respirations are 26/min. Pulse oximetry shows 92% on room air. Physical examination reveals scleral icterus, prominent abdominal distension with a fluid wave, and mottled extremities. Two large-bore intravenous lines have been successfully placed by the nursing staff. Which of the following is the most appropriate immediate next step in management?

A 58-year-old man is hospitalized with an acute deep vein thrombosis in his right leg. He is promptly started on a continuous intravenous infusion of unfractionated heparin. The nursing staff is instructed to draw blood every six hours to adjust the infusion rate according to a standard hospital protocol. Which of the following laboratory parameters is the most appropriate to monitor and titrate this therapy?

While managing a 68-year-old man with refractory septic shock in the intensive care unit, a physician prepares to obtain central venous access for continuous vasopressor administration. The physician decides to place a right internal jugular central venous catheter using the standard Seldinger technique. After donning maximal sterile barriers, prepping and draping the site, and visualizing the target vessel with real-time ultrasound, the physician must perform the catheter insertion. Arrange the following procedural steps of the Seldinger technique in the correct chronological order.

Match each patient presentation in the emergency department to the most appropriate disposition and care setting transition.

Emergency medical services bring a 29-year-old man to the trauma bay 30 minutes after he fell from a 3-story scaffolding. He is confused and moaning in pain. His temperature is $36.5^{\circ}\text{C}$ ($97.7^{\circ}\text{F}$), blood pressure is 78/42 mmHg, pulse is 138/min, and respirations are 26/min. Oxygen saturation is 95% on a non-rebreather mask. The patient's airway is patent, and breath sounds are equal bilaterally. A portable chest radiograph reveals clear lung fields without evidence of pneumothorax or hemothorax. An anteroposterior pelvic radiograph demonstrates a widened pubic symphysis of 3 cm and a displaced right sacroiliac joint. A focused assessment with sonography for trauma (FAST) scan demonstrates a 2-cm anechoic stripe in the hepatorenal recess (Morison pouch). Intravenous access is established, a pelvic binder is applied, and a massive transfusion protocol is initiated. Ten minutes later, his blood pressure remains 80/40 mmHg. Which of the following is the most appropriate next step in the management of this patient?

An otherwise healthy 45-year-old woman arrives at the acute care clinic with sudden-onset, excruciating periumbilical pain and unremitting vomiting. Over the past 14 hours, her emesis has transitioned from clear fluid to bilious material. She reports no passage of flatus or stool since the symptoms commenced. Her medical and surgical histories are unremarkable. On initial triage, her temperature is 38.0°C (100.4°F), heart rate is 118/min, blood pressure is 108/65 mm Hg, and respiratory rate is 22/min. Physical examination demonstrates an asymmetrically distended abdomen featuring a prominent, tympanitic mass that spans from the right lower quadrant toward the epigastrium. Auscultation reveals high-pitched, tinkling bowel sounds. Initial laboratory analysis shows a leukocyte count of 14,200/mm³ and a serum lactate concentration of 3.1 mmol/L (Normal: 0.5-2.2 mmol/L). An urgent computed tomography scan of the abdomen and pelvis shows a massively dilated cecum flipped into the upper abdomen, accompanied by a twisting of the mesenteric vessels and a fully collapsed distal colon. Which of the following is the most appropriate next step in management?

A 45-year-old man with a history of recurrent nephrolithiasis presents with severe, medically refractory gastroesophageal reflux and chronic diarrhea. Recent esophagogastroduodenoscopy revealed prominent gastric folds and multiple ulcerations in the distal duodenum. The clinical picture is highly suspicious for Zollinger-Ellison syndrome, potentially in the setting of Multiple Endocrine Neoplasia type 1. Arrange the following diagnostic steps in the most appropriate chronological sequence to establish the biochemical diagnosis and definitively localize the responsible tumor.

A $28$-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and palpitations. She has a history of Graves disease but has been nonadherent to her medications for the past three months. One week ago, she was treated for a urinary tract infection. Her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure is $160/70\text{ mm Hg}$, and pulse is $145\text{ /min}$ and irregular. Physical examination reveals profuse diaphoresis, a fine resting tremor, and a diffusely enlarged, non-tender thyroid gland. An electrocardiogram demonstrates atrial fibrillation with a rapid ventricular response. The patient is diagnosed with thyroid storm.

Arrange the following pharmacologic interventions in the correct sequential order of administration for the safe and optimal management of this patient's condition.