Patient Management

A 32-year-old woman is brought to the emergency department via ambulance for a generalized tonic-clonic seizure. Her husband states the seizure began 15 minutes ago at home, and she has not regained consciousness or ceased convulsing since onset. She has a known history of medication-refractory focal impaired awareness seizures. Upon arrival, she is actively seizing, tachycardic to 128/min, and blood pressure is 142/88 mm Hg. She is maintaining her airway, with an oxygen saturation of 92% on room air. Two large-bore intravenous lines are immediately established.

Assuming the patient's generalized convulsive seizure activity continues unabated despite each successive intervention, arrange the following pharmacologic therapies in the correct guideline-directed escalation sequence, from initial management to treatment of super-refractory status epilepticus.

A 45-year-old woman is evaluated on the surgical ward four hours after undergoing a total thyroidectomy for a large multinodular goiter. The on-call physician is urgently summoned because the patient has become increasingly agitated and is complaining of severe difficulty breathing. She is pointing to her neck and is unable to speak in full sentences. Vital signs are temperature 37.1°C (98.8°F), blood pressure 162/94 mm Hg, pulse 118/min, and respirations 28/min. Pulse oximetry shows an oxygen saturation of 91% on room air. Physical examination reveals a high-pitched inspiratory sound audible from the doorway. The surgical dressing is intact, but there is tense, progressive swelling of the anterior neck beneath the incision line. Which of the following is the most appropriate immediate next step in management?

A 55-year-old woman is transported to the triage area by her husband after being found lethargic at home. She has a known history of decompensated cirrhosis due to chronic alcohol use. Over the past several hours, she has vomited large quantities of bright red blood. On arrival, she is somnolent, groans to painful stimuli, and continues to have episodes of active hematemesis. Vital signs show a blood pressure of 75/40 mmHg, a pulse of 135/min, and respirations of 26/min. Pulse oximetry displays 91% on room air. Which of the following is the most appropriate initial step in the management of this patient?

A 32-year-old man with no known medical history is brought to the emergency department by emergency medical services (EMS). His roommate found him unresponsive and experiencing generalized tonic-clonic movements. EMS reports that the continuous seizure activity began 25 minutes ago. Paramedics established peripheral intravenous access en route but did not administer any medications. Upon arrival, the patient remains unresponsive with ongoing rhythmic jerking of his extremities. His blood pressure is 145/88 mm Hg, heart rate is 132/min, and oxygen saturation is 94% on a non-rebreather mask. Fingerstick blood glucose is 102 mg/dL. The emergency physician initiates a protocolized escalation for status epilepticus. Assuming the patient's seizures remain completely refractory to each successive pharmacological intervention, arrange the following therapies in the correct chronological sequence of administration, progressing from initial emergent therapy to salvage therapy for super-refractory status epilepticus.

A 64-year-old man is admitted to the general medical ward for a 3-day history of productive cough, high fevers, and right-sided pleuritic chest pain. His medical history is significant for coronary artery disease, hypertension, and highly symptomatic paroxysmal atrial fibrillation. His daily medications include dofetilide, apixaban, lisinopril, and atorvastatin. His temperature is $38.7^\circ\text{C}$ ($101.7^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, pulse is $78/\text{min}$, respiratory rate is $22/\text{min}$, and oxygen saturation is $92\%$ on room air. Physical examination reveals bronchial breath sounds and crackles in the right lower lung field. Laboratory studies show a leukocyte count of $14,500/\mu\text{L}$ with $82\%$ neutrophils. Serum electrolyte levels and renal function are within normal limits. An electrocardiogram demonstrates normal sinus rhythm with a corrected QT (QTc) interval of $475\text{ ms}$. Chest radiography confirms a right lower lobe consolidation. Which of the following is the most appropriate empiric pharmacologic regimen for this patient?

A 67-year-old man presents to the clinic with a 3-month history of progressively worsening fatigue, generalized weakness, and severe, aching mid-back pain. The pain does not radiate and is not relieved by over-the-counter analgesics. He has no history of trauma, weight loss, or constitutional symptoms. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $135/85 \text{ mmHg}$, pulse is $88/\text{min}$, and respiratory rate is $14/\text{min}$.

Physical examination reveals conjunctival pallor and point tenderness to percussion over the T10 and T11 spinous processes. Neurologic examination of the lower extremities shows $5/5$ motor strength, intact sensation to light touch and pinprick, and $2+$ bilateral patellar and Achilles reflexes.

Initial laboratory studies obtained yesterday reveal:

The physician suspects a plasma cell dyscrasia. Which of the following diagnostic investigations should be ordered concurrently as the most appropriate next steps in this patient's diagnostic workup? (Select exactly two)

A 42-year-old male construction worker is brought to the emergency department by paramedics after being extricated from beneath a collapsed concrete retaining wall, where he was trapped for approximately seven hours. Upon arrival, the patient is somnolent and weakly responsive to painful stimuli. His bilateral lower extremities are severely swollen, ecchymotic, and tense to palpation, with absent pedal pulses. Vital signs reveal a blood pressure of 82/48 mm Hg, a heart rate of 52/min, a respiratory rate of 22/min, and an oxygen saturation of 95% on supplemental oxygen. A stat 12-lead electrocardiogram demonstrates absent P waves, markedly widened QRS complexes, and tall, peaked T waves. Which of the following is the single most urgent initial step in the stabilization of this patient?

A 48-year-old man presents to the emergency department reporting severe, constant epigastric pain that radiates to his back, which began 6 hours ago. The pain is associated with nausea and two episodes of non-bilious vomiting. He has no significant past medical history and takes no medications. He reports drinking 1 to 2 beers on occasional weekends. Vital signs show a temperature of 37.8°C (100.0°F), heart rate of 105/min, blood pressure of 135/85 mmHg, and respiratory rate of 18/min. Physical examination reveals diminished bowel sounds and marked epigastric tenderness to deep palpation, without guarding or rebound tenderness. Laboratory studies show:

Leukocyte count: 12,500/mm³
Serum lipase: 2,500 U/L
Aspartate aminotransferase (AST): 180 U/L
Alanine aminotransferase (ALT): 310 U/L
Alkaline phosphatase: 150 U/L
Total bilirubin: 1.8 mg/dL

Following initial fluid resuscitation and pain management, which of the following is the most appropriate next step in the diagnostic workup?

Emergency medical services transport a 29-year-old female to the resuscitation bay following an intentional pharmaceutical ingestion. Empty pill bottles for amitriptyline and sustained-release diltiazem were found beside her. On arrival, she is lethargic and responds only to painful stimuli. Vital signs include a temperature of 36.8°C (98.2°F), blood pressure of 78/40 mm Hg, heart rate of 52/min, and respiratory rate of 14/min. Physical examination is notable for dry mucous membranes, mydriasis, and delayed capillary refill. An electrocardiogram reveals sinus bradycardia with a PR interval of 240 ms, a QRS duration of 145 ms, and a QTc interval of 510 ms. Bedside capillary blood glucose is 142 mg/dL. Intravenous fluid resuscitation is commenced. Which of the following pharmacologic interventions are most appropriate to initiate next? (Select all that apply)

A 56-year-old woman is evaluated in the clinic for follow-up of major depressive disorder. Two months ago, she was started on sertraline. She reports that her mood has minimally improved, but she has developed new-onset progressive fatigue, frequent nausea, and mild muscle cramps over the past two weeks. Her medical history is also significant for partial complex seizures, which have been well controlled on levetiracetam for the past five years. Her blood pressure is $128/82 \text{ mmHg}$, pulse is $76/\text{min}$, and respirations are $14/\text{min}$. Physical examination reveals mild lethargy and sluggish deep tendon reflexes, but no focal neurologic deficits. Laboratory studies show:

A review of her records shows a normal basic metabolic panel three months ago. Sertraline is discontinued, and fluid restriction is initiated for the management of syndrome of inappropriate antidiuretic hormone (SIADH) secretion. The patient continues to experience severe depressive symptoms and requests an alternative treatment.

Which of the following is the most appropriate medication to treat this patient's depression?

A 45-year-old woman is hospitalized due to a 3-day history of high fever, dry cough, and right-sided pleuritic chest pain. She underwent a living-donor renal transplant 6 months ago for end-stage renal disease secondary to IgA nephropathy. Her current medications include tacrolimus, mycophenolate mofetil, and prednisone. Temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, pulse is $105/\text{min}$, and respirations are $20/\text{min}$. Oxygen saturation is $94\%$ on room air. Physical examination reveals crackles over the right upper lung field. Laboratory studies show:

A non-contrast CT scan of the chest demonstrates a 3-cm dense nodule with surrounding ground-glass opacity (halo sign) in the right upper lobe. Serum *Aspergillus* galactomannan antigen testing is markedly positive. Blood cultures are pending. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A 72-year-old man is evaluated on the orthopedic ward for new-onset agitation and lower abdominal discomfort. He underwent an uncomplicated right total hip arthroplasty 8 hours ago under spinal anesthesia. His medical history includes hypertension, type 2 diabetes mellitus, and benign prostatic hyperplasia. Current medications include amlodipine, metformin, and as-needed oxycodone. Vital signs are temperature 37.1°C (98.8°F), blood pressure 158/92 mmHg, pulse 108/min, and respirations 18/min. Physical examination reveals a palpable, tender mass in the suprapubic region. A bedside bladder ultrasound demonstrates a fluid volume of 650 mL. A nurse attempts to place a standard 16-French urethral catheter but encounters firm resistance in the prostatic urethra and is unable to advance the catheter further. Which of the following is the most appropriate next step in the procedural management of this patient?

Emergency medical services bring a 19-year-old college student to the emergency department after he fell approximately 15 feet from a balcony. Paramedics report he was briefly conscious at the scene but rapidly became unresponsive during transport.

On arrival, his eyes are closed, he makes no vocal sounds, and he extends his upper extremities in response to painful stimuli.

Vital signs include a blood pressure of 190/100 mmHg, a heart rate of 48/min, a respiratory rate of 8/min with an irregular pattern, and an oxygen saturation of 89% despite a non-rebreather mask.

Primary survey reveals a boggy swelling over the right parietal area. Neurologic examination shows a right pupil measuring 7 mm and unreactive to light, while the left pupil is 3 mm and reactive.

Arrange the following patient management steps in the most appropriate chronological sequence.

A 29-year-old man is brought to the trauma resuscitation bay following a high-speed motor vehicle collision. Emergency medical services report a prolonged extrication time. Upon arrival, the patient is unresponsive. Vital signs show a pulse of 135/min, blood pressure of 82/50 mm Hg, and a respiratory rate of 35/min. Pulse oximetry indicates an oxygen saturation of 85% despite high-flow supplemental oxygen. Physical examination reveals significant maxillofacial trauma with active bleeding pooling in the oropharynx. The right hemithorax is hyperresonant to percussion with absent breath sounds. The abdomen is distended and rigid. Arrange the following management steps in the most appropriate sequential order according to standardized trauma resuscitation protocols.

A 65-year-old man is evaluated in the clinic after a routine preoperative chest radiograph for an elective inguinal hernia repair reveals a 15-mm solid nodule in the periphery of the right upper lung lobe. He has a 40-pack-year smoking history and quit 2 years ago. He reports no cough, hemoptysis, or weight loss. Vital signs are normal, and physical examination is unremarkable. Arrange the following diagnostic steps in the most appropriate sequential order for evaluating this patient's pulmonary nodule, from the immediate next step to the definitive diagnostic procedure.

A 71-year-old male is evaluated in the hospital prior to discharge. He was admitted 3 days ago for acute decompensated heart failure presenting as sudden-onset pulmonary edema. He was successfully treated with intravenous furosemide and noninvasive positive pressure ventilation. He had a similar episode of flash pulmonary edema two months ago, despite having a normal left ventricular ejection fraction on a recent echocardiogram. Medical history includes hypertension, hyperlipidemia, and coronary artery disease. Two weeks prior to this admission, his primary care physician discontinued amlodipine and started valsartan due to poorly controlled blood pressure. Current medications include aspirin, atorvastatin, metoprolol, valsartan, and furosemide.

Vital signs today show a blood pressure of 178/96 mm Hg and a heart rate of 78/min. Physical examination reveals clear lungs bilaterally. Cardiac examination shows a regular rate and rhythm with an S4 gallop. Abdominal examination reveals a systolic-diastolic bruit heard in the periumbilical region.

Laboratory studies obtained this morning show:
Sodium: 139 mEq/L
Potassium: 4.8 mEq/L
Blood urea nitrogen: 44 mg/dL
Creatinine: 2.8 mg/dL (baseline was 1.2 mg/dL one month ago)

Which of the following is the most appropriate next step in the diagnostic workup?

A 54-year-old man presents to the emergency department with a 4-day history of fever, pleuritic chest pain, and hemoptysis. He underwent an orthotopic heart transplant 8 months ago for nonischemic cardiomyopathy. His current daily medications include tacrolimus, mycophenolate mofetil, prednisone, and prophylactic valganciclovir. His temperature is 38.6°C (101.5°F), blood pressure is 118/74 mm Hg, pulse is 96/min, and respiratory rate is 20/min. Pulse oximetry shows 94% on room air. Physical examination reveals bronchial breath sounds and inspiratory crackles over the right upper lung field. High-resolution computed tomography of the chest demonstrates a dense right upper lobe consolidation surrounded by a ground-glass opacity (halo sign). Serum galactomannan assay is markedly elevated. Which of the following is the most appropriate pharmacologic management for this patient?

A $55$-year-old man with a history of alcohol-associated cirrhosis and esophageal varices is evaluated in the intensive care unit. He was admitted $3$ days ago for worsening ascites, confusion, and abdominal pain. Upon admission, diagnostic paracentesis revealed an absolute neutrophil count of $650 \text{ cells/mm}^3$. Intravenous ceftriaxone was initiated for spontaneous bacterial peritonitis. His home medications include oral lactulose, spironolactone, furosemide, and nadolol. Upon admission, his diuretics were held, but nadolol was continued for primary prophylaxis of variceal bleeding.

Over the past $48$ hours, he has received volume expansion with intravenous albumin ($1 \text{ g/kg/day}$). Despite these measures, his urine output has decreased to $300 \text{ mL/day}$ over the last $24$ hours.

Current vital signs:
Blood pressure: $86/52 \text{ mmHg}$
Heart rate: $105\text{/min}$
Temperature: $37.8^\circ\text{C}$ ($100.0^\circ\text{F}$)

Microscopic urinalysis is normal with no red blood cells, casts, or protein. Renal ultrasound demonstrates normal kidneys without hydronephrosis.

Which of the following pharmacologic interventions are indicated at this time? (Select all that apply)

Match each clinical presentation of suspected pulmonary embolism with the most appropriate next step in diagnostic testing according to current guidelines.

A 59-year-old man presents to the urgent care clinic with excruciating pain and swelling in his right great toe that began abruptly last night. He reports that the pain is so severe he cannot tolerate even the weight of a bedsheet on his foot. Medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, type 2 diabetes mellitus with a recent hemoglobin A1c of 9.2%, stage 4 chronic kidney disease with an estimated glomerular filtration rate of 22 mL/min/1.73 m², and a bleeding gastric ulcer that was treated endoscopically one month ago. Vital signs are temperature 37.1°C (98.8°F), blood pressure 118/75 mmHg, and heart rate 82/min. Examination reveals a markedly erythematous, swollen, and exquisitely tender right first metatarsophalangeal joint. Arthrocentesis yields synovial fluid with a leukocyte count of 45,000/mm³ and negatively birefringent, needle-shaped crystals. Which of the following is the most appropriate pharmacologic intervention for this patient's acute symptoms?