Patient Management

A 62-year-old man with a history of type 2 diabetes mellitus and stage 4 chronic kidney disease presents to the emergency department with severe generalized muscle weakness and tingling in his extremities that began earlier today. His home medications include lisinopril, amlodipine, and sitagliptin. His heart rate is 54/min, blood pressure is 112/68 mmHg, and respiratory rate is 18/min. A 12-lead electrocardiogram demonstrates peaked T waves, absent P waves, and a widened QRS complex. A point-of-care basic metabolic panel reveals a serum potassium level of 7.8 mEq/L. The physician decides to immediately begin pharmacologic management.

Arrange the following pharmacologic interventions in the most appropriate sequential order of priority for this patient's acute management.

A 32-year-old woman comes to the outpatient clinic reporting a 6-week history of intermittent double vision and drooping of her right eyelid. She notes that these symptoms are usually absent in the morning but become progressively more noticeable by the late afternoon and evening. Recently, she has also experienced mild difficulty chewing tough foods like steak. She has no significant past medical history and takes no medications. Vital signs are within normal limits. Neurologic examination reveals a right-sided ptosis that becomes more pronounced after the patient is asked to maintain an upward gaze for 60 seconds. Extraocular movements are notable for asymmetric limitation in both eyes, without pupillary involvement. Strength in the proximal and distal extremities is intact, and deep tendon reflexes are normal bilaterally. Which of the following is the most appropriate next step in the diagnostic evaluation?

Determine the most appropriate post-discharge care environment for each of the following complex clinical presentations based on the patient's medical stability, rehabilitation endurance, and symptom management requirements.

An internist evaluates a 66-year-old female patient who recently relocated to the area and wants to establish primary care. She has an intact uterus and cervix. She provides comprehensive medical records from her previous provider. Review of these records shows negative cervical cytology and human papillomavirus (HPV) co-testing at ages 55, 60, and 64. She has never had an abnormal Papanicolaou test or a history of cervical dysplasia. She is currently sexually active with her husband of 40 years. Which of the following is the most appropriate next step regarding cervical cancer screening for this patient?

A 24-year-old woman is brought to the emergency department by ambulance due to severe shortness of breath, wheezing, and a tight chest that began 2 hours ago. She has a history of moderate persistent asthma but has not used her inhalers for the past week. On arrival, she appears anxious and is using accessory muscles of respiration. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $135/85\text{ mm Hg}$, pulse is $118/\text{min}$, and respiratory rate is $28/\text{min}$. Oxygen saturation is $92\%$ on room air. Physical examination reveals diffuse bilateral end-expiratory and inspiratory wheezes. Laboratory studies show a leukocyte count of $12,500/\text{mm}^3$ with a normal differential. Which of the following pharmacologic interventions should be administered as part of her immediate initial management? (Select all that apply)

A 32-year-old woman, gravida 3, para 3, is evaluated on the labor and delivery unit for excessive vaginal bleeding 20 minutes after a spontaneous vaginal delivery of a 4200-g (9.3-lb) neonate. The placenta was delivered intact 5 minutes after the neonate. Her past medical history is significant for chronic hypertension and moderate persistent asthma. Current medications include oral nifedipine and a budesonide-formoterol inhaler. Her blood pressure is 168/105 mmHg, and heart rate is 112/min. Physical examination reveals a large gush of blood from the vagina. The uterus is soft, boggy, and palpable 3 cm above the umbilicus. Careful inspection of the vagina and cervix reveals no lacerations. Bimanual uterine massage is initiated, and a continuous intravenous oxytocin infusion is started. Ten minutes later, the patient continues to have heavy vaginal bleeding, and the uterus remains boggy. Which of the following is the most appropriate next pharmacologic intervention?

A 58-year-old man is evaluated in the intensive care unit for sudden hemodynamic decompensation. He was admitted three days ago for severe community-acquired pneumonia and was subsequently intubated due to acute respiratory distress syndrome. His past medical history is significant for chronic obstructive pulmonary disease and hypertension. The patient is currently receiving mechanical ventilation with a high positive end-expiratory pressure. Over the last 5 minutes, the ventilator has been repeatedly alarming for high peak airway pressures. His temperature is 37.8°C (100.0°F), blood pressure is 72/40 mm Hg, pulse is 142/min, and respiratory rate is 28/min (set ventilator rate 18/min). Pulse oximetry shows an oxygen saturation of 83%. Physical examination reveals distended neck veins and a trachea that is deviated to the right. Auscultation demonstrates markedly diminished breath sounds over the left hemithorax with hyperresonance to percussion. Which of the following is the most urgent initial step in the management of this patient?

An executive in her late twenties visits the ambulatory care clinic reporting six months of progressively worsening shortness of breath with physical exertion. She denies chronic cough, orthopnea, daytime fatigue, or prior lung disease. She has no significant medical history and takes only oral contraceptives. Vital signs are within normal limits, with an oxygen saturation of $96\%$ on ambient air. Physical examination reveals a prominent pulmonic component of the second heart sound and a faint parasternal heave. The lung fields are clear to auscultation, and there is no peripheral edema. Electrocardiography reveals right axis deviation and an incomplete right bundle branch block. A chest radiograph demonstrates prominent central pulmonary arteries without parenchymal infiltrates. Echocardiography shows a structurally normal left ventricle with an ejection fraction of $65\%$, normal valvular function, and right ventricular enlargement with an estimated right ventricular systolic pressure of $52$ mmHg. Pulmonary function testing demonstrates a normal forced vital capacity, normal FEV1/FVC ratio, and a slightly reduced diffusion capacity for carbon monoxide (DLCO). Which of the following is the most appropriate next step in evaluating this patient's condition?

A 74-year-old woman is brought to the emergency department by emergency medical services after a witnessed generalized tonic-clonic seizure lasting 2 minutes. She is currently postictal, profoundly confused, and agitated. Her past medical history is significant for atrial fibrillation, major depressive disorder, diabetic peripheral neuropathy, and hypertension. Her home medications include apixaban, amitriptyline, fluoxetine, and metoprolol succinate. Her husband notes that she was recently prescribed tramadol for acute back pain and took her first two doses earlier today.

Vital signs are:
Temperature: 39.4°C (102.9°F)
Heart rate: 142/min
Blood pressure: 175/95 mm Hg
Respiratory rate: 22/min
SpO2: 96% on room air

Physical examination reveals a profusely diaphoretic and flushed woman. Pupils are 6 mm bilaterally and reactive to light. Bowel sounds are hyperactive. Neuromuscular examination is remarkable for significant hypertonia in the lower extremities, 4+ patellar reflexes bilaterally, and spontaneous, sustained ankle clonus.

An electrocardiogram demonstrates atrial fibrillation with a rapid ventricular response of 142/min and a QTc interval of 535 ms.

Which of the following pharmacologic interventions are indicated in the immediate management of this patient? (Select all that apply)

A 58-year-old man is evaluated on the medical-surgical ward for transition of care. He was admitted 8 days ago for a severe right diabetic foot infection complicated by osteomyelitis of the first metatarsal. He underwent a partial ray amputation on hospital day 2. The surgical site was intentionally left open and currently requires complex wet-to-dry dressing changes twice daily. He is receiving intravenous vancomycin via a peripherally inserted central catheter (PICC) for methicillin-resistant Staphylococcus aureus (MRSA); the planned antibiotic course is 6 weeks.

Vital signs are normal, and he is afebrile. Laboratory studies show a leukocyte count of $7,800/\mu L$ and a C-reactive protein (CRP) of $35 \text{ mg/L}$ (normal: $<10 \text{ mg/L}$), which has steadily decreased from $150 \text{ mg/L}$ on admission.

From a mobility standpoint, the patient is strictly non-weight-bearing on the right lower extremity. Physical therapy has trained him to be independent with wheelchair mobility on level surfaces; however, he cannot use crutches or a walker due to pre-existing severe bilateral shoulder osteoarthritis. He lives alone in a second-floor apartment accessible only by a steep flight of stairs. He is clinically stable and eager to leave the acute care hospital.

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

A $58$-year-old man is admitted to the hospital with a $4$-day history of progressively worsening left lower quadrant abdominal pain, subjective fever, and reduced appetite. His past medical history is significant for hypertension and hyperlipidemia. His temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $118/74\text{ mmHg}$, pulse is $106/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals a non-distended abdomen with marked tenderness and guarding in the left lower quadrant. There is no diffuse rebound tenderness or rigidity. Bowel sounds are hypoactive. Laboratory evaluation shows a leukocyte count of $16,500/\text{mm}^3$ with $82\%$ neutrophils. Intravenous fluid resuscitation and broad-spectrum antibiotics are initiated. Cross-sectional imaging of the abdomen and pelvis with intravenous contrast reveals severe wall thickening of the sigmoid colon with surrounding fat stranding, as well as an adjacent, well-circumscribed $6.5\text{-cm}$ fluid collection with rim enhancement. There is no evidence of free air in the peritoneal cavity.

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

Match each clinical presentation of suspected gastrointestinal bleeding with the most appropriate next diagnostic test in the sequencing algorithm.

A 65-year-old male presents to the clinic for a routine health maintenance examination. He has not seen a physician in over a decade. He feels well and has no acute complaints. His medical history is unremarkable, and he takes no medications. He has a 40-pack-year history of smoking and continues to smoke one pack of cigarettes daily. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following preventive screening tests are indicated for this patient? (Select all that apply)

A $35$-year-old woman is brought to the emergency department by paramedics after being struck by a speeding delivery truck while walking in a crosswalk. Upon arrival in the trauma bay, she is unresponsive to verbal commands and only groans in response to painful stimuli.

Her vital signs are:
Temperature: $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$)
Heart rate: $138/\text{min}$
Blood pressure: $72/40 \text{ mmHg}$
Respiratory rate: $32/\text{min}$
Oxygen saturation: $84\%$ on room air

Physical examination reveals a massive, actively spurting laceration over the right anteromedial thigh. The right lower extremity is deformed. Breath sounds are present and symmetric bilaterally. The abdomen is grossly distended and tense.

Arrange the following initial management steps in the most appropriate chronological order according to advanced trauma life support protocols.

A 35-year-old woman is brought to the emergency department immediately after accidentally ingesting a meal containing peanuts. She is in marked respiratory distress with audible stridor and diffuse urticaria. Her blood pressure is 75/40 mm Hg, heart rate is 135/min, and oxygen saturation is 91% on room air. Arrange the following pharmacologic interventions in the correct sequence of prioritization for the initial stabilization of this patient, from the most immediate life-saving intervention to adjunctive therapy.

A 24-year-old man is brought to the emergency department 15 minutes after sustaining a gunshot wound. The entrance wound is located in the left fifth intercostal space at the midclavicular line. There is no exit wound.

Vital signs on arrival:
- Blood pressure: 76/40 mm Hg
- Heart rate: 138/min
- Respiratory rate: 32/min
- Oxygen saturation: 86% on room air

Primary survey reveals flat neck veins and a midline trachea. There are absent breath sounds and dullness to percussion over the left hemithorax. The abdomen is exquisitely tender with diffuse rigidity and involuntary guarding.

Large-bore intravenous access is established, the massive transfusion protocol is activated, and the patient is rapidly intubated for airway protection. His blood pressure remains 76/40 mm Hg following intubation.

Which of the following are REQUIRED immediate procedural interventions for this patient? (Select all that apply)

A 35-year-old woman is brought to the emergency department by emergency medical services after collapsing at a local seafood restaurant. Bystanders report that shortly after she began eating, she grasped her throat, developed a hoarse voice, and subsequently lost consciousness. Her past medical history is significant for poorly controlled asthma and allergic rhinitis, for which she uses an inhaled corticosteroid and a short-acting beta-agonist as needed.

Upon arrival, she is unresponsive to verbal stimuli but withdraws from painful stimuli.

Vital signs are:
Temperature: 37.1°C (98.8°F)
Blood pressure: 72/40 mmHg
Heart rate: 138/min
Respiratory rate: 32/min
Oxygen saturation: 84% on a non-rebreather mask

Physical examination reveals significant facial and periorbital edema. Lung auscultation demonstrates poor air movement bilaterally with prominent high-pitched inspiratory stridor and diffuse expiratory wheezes. Examination of the skin shows widespread raised, erythematous, intensely pruritic plaques across her trunk and extremities.

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

A $54$-year-old woman is evaluated in the ambulatory care clinic and diagnosed with primary hypertension. Her blood pressure is $154/92\text{ mmHg}$. She has no other chronic medical conditions and takes no daily medications. Baseline laboratory studies reveal a creatinine level of $0.9\text{ mg/dL}$ and a potassium level of $4.1\text{ mEq/L}$. The physician initiates once-daily oral lisinopril. The patient is scheduled for a follow-up appointment.

Which of the following is the most appropriate next step in monitoring this patient's new pharmacotherapy?

A 32-year-old man is evaluated in the outpatient clinic for increased thirst and frequent urination over the past 3 months. He reports drinking approximately 6 to 8 liters of water daily and waking up 3 to 4 times per night to urinate. His medical history is significant for bipolar I disorder. He has had multiple severe manic episodes with psychotic features in the past, which required prolonged hospitalizations. Trials of divalproex sodium, carbamazepine, and atypical antipsychotics were ineffective in preventing relapses. For the past 4 years, he has been completely stable with no mood episodes on a regimen of lithium carbonate $900 \text{ mg}$ daily. He takes no other medications.

Vital signs are within normal limits. Physical examination reveals mild dry mucous membranes but is otherwise unremarkable.

Laboratory results are as follows:
Serum sodium: $146 \text{ mEq/L}$
Serum potassium: $4.1 \text{ mEq/L}$
Serum creatinine: $1.0 \text{ mg/dL}$
Serum lithium: $0.9 \text{ mEq/L}$ (therapeutic range: $0.6-1.2 \text{ mEq/L}$)
Serum osmolality: $298 \text{ mOsm/kg H}_2\text{O}$
Urine osmolality: $120 \text{ mOsm/kg H}_2\text{O}$

Following a formal water deprivation test, his urine osmolality remains low and does not significantly increase after the administration of subcutaneous desmopressin.

Given the patient's psychiatric history and current stability, which of the following is the most appropriate next step in the management of this patient's new symptoms?

A 42-year-old man presents to the urgent care clinic with a 3-day history of fever, productive cough, and shortness of breath. He has a history of type 2 diabetes mellitus and takes metformin. Vital signs are temperature 38.4°C (101.1°F), blood pressure 125/80 mmHg, pulse 98/min, and respiratory rate 20/min. Oxygen saturation is 96% on room air. Physical examination reveals crackles in the left lower lung base. Laboratory studies show a leukocyte count of 11,500/mm³ with 75% neutrophils. A chest x-ray reveals a left lower lobe infiltrate. The patient reports a history of severe anaphylaxis to penicillin, characterized by hives and wheezing. He has not taken any antibiotics in the past 90 days. Which of the following is the most appropriate empiric pharmacologic intervention for this patient?