Patient Management

A $45$-year-old woman presents to the emergency department reporting the sudden onset of a severe, diffuse headache that began $18$ hours ago. She describes it as the "worst headache of my life." The headache was accompanied by two episodes of vomiting and sensitivity to light. Her past medical history is significant for hypertension and tobacco use. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), pulse is $92$/min, blood pressure is $168/95$ mmHg, and respirations are $16$/min. On physical examination, the patient appears uncomfortable and prefers to keep the room lights off. Neurologic examination shows intact cranial nerves, $5/5$ motor strength in all extremities, and normal deep tendon reflexes. Neck flexion produces mild discomfort. A non-contrast computed tomography (CT) scan of the head reveals no evidence of intracranial hemorrhage, mass effect, or midline shift. Which of the following is the most appropriate next step in the diagnostic workup?

A 25-year-old man is brought to the emergency department by paramedics following a witnessed generalized tonic-clonic seizure that lasted approximately 3 minutes. His roommate reports finding an empty prescription bottle of amitriptyline, which had been refilled the previous day, next to the patient. The patient has a history of major depressive disorder. Upon arrival, he is postictal, lethargic, and mumbling incomprehensibly, but he localizes to pain and his airway is currently patent. His skin is flushed, warm, and dry. Pupils are 6 mm bilaterally and sluggishly reactive to light. Mucous membranes are markedly dry. Vital signs show a temperature of 38.2°C (100.8°F), blood pressure of 82/45 mmHg, heart rate of 138/min, respiratory rate of 18/min, and oxygen saturation of 97% on room air. An electrocardiogram reveals sinus tachycardia with a QRS duration of 165 msec and a prominent terminal R wave measuring 4 mm in lead aVR. Which of the following is the most urgent initial step in the management of this patient?

A 54-year-old male is evaluated in the emergency department for a severe episode of coughing accompanied by the expectoration of a large volume of bright red blood. According to his wife, he has coughed up at least 600 mL of blood over the past hour. His past medical history is notable for cavitary pulmonary tuberculosis that was successfully treated five years ago, as well as chronic obstructive pulmonary disease. While being triaged, the patient continues to experience massive hemoptysis and begins to exhibit prominent accessory muscle use, diaphoresis, and paradoxical abdominal breathing. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 88/54 mmHg, pulse of 128/min, and respiratory rate of 34/min. Pulse oximetry indicates an oxygen saturation of 82% on room air. Auscultation reveals prominent gurgling sounds predominantly over the right hemithorax. Which of the following is the most appropriate immediate next step in the management of this patient?

Match each clinical scenario with the most appropriate next step in the diagnostic and management sequence.

A 34-year-old man is evaluated in the surgical telemetry unit $12$ hours after undergoing intramedullary nailing of a closed midshaft tibial fracture. He complains of rapidly worsening left leg pain that is no longer relieved by his prescribed intravenous morphine. He describes the pain as a severe, deep aching sensation. On examination, the patient appears uncomfortable and diaphoretic. Vital signs show a temperature of $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure of $138/85 \text{ mmHg}$, heart rate of $105/\text{min}$, and respiratory rate of $18/\text{min}$. The left lower leg is significantly swollen, tense, and exquisitely tender to palpation. Passive dorsiflexion and plantar flexion of the toes elicit excruciating pain. Dorsalis pedis and posterior tibial pulses are palpable and symmetric bilaterally. Capillary refill is less than $2$ seconds. Which of the following is the most appropriate next step in management?

A 42-year-old man is brought to the emergency department by paramedics after being rescued from a residential fire. He was trapped in a closed room for an unknown duration. On arrival, he is agitated and reports severe pain. Physical examination reveals full-thickness burns over his anterior torso and bilateral upper extremities. He has singed eyebrows, facial erythema, and carbonaceous sputum in his oropharynx. His voice is noticeably hoarse when he speaks. Vital signs include a heart rate of 128/min, blood pressure of 110/65 mm Hg, respiratory rate of 28/min, and an oxygen saturation of 99% on a 15 L/min non-rebreather mask. Breath sounds are clear and symmetric bilaterally. Which of the following is the single most urgent initial step in the stabilization of this patient?

A $71$-year-old man is brought to the emergency department via ambulance due to sudden-onset, severe abdominal and lower back pain accompanied by a brief episode of syncope at home. His medical history is significant for hypertension, hyperlipidemia, and a $5.2\text{-cm}$ infrarenal abdominal aortic aneurysm that has been managed conservatively. Upon arrival, he is diaphoretic and confused. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure $68/42\text{ mmHg}$, pulse $135\text{/min}$, and respirations $22\text{/min}$. Physical examination reveals a distended abdomen with an exquisitely tender, pulsatile midline mass. Intravenous access is rapidly established with two large-bore peripheral catheters. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

A 68-year-old man comes to the clinic for a routine follow-up regarding his heart failure. Two months ago, he was hospitalized for an acute heart failure exacerbation. During that admission, his lisinopril was discontinued after his serum creatinine acutely worsened from a baseline of $1.9 \text{ mg/dL}$ to $3.8 \text{ mg/dL}$ and his serum potassium peaked at $6.1 \text{ mEq/L}$. Since discharge, he has adhered to a low-sodium diet and his weight has remained stable. He currently has no orthopnea or lower extremity edema but reports dyspnea when walking up one flight of stairs or carrying groceries. His past medical history includes heart failure with reduced ejection fraction (most recent echocardiogram 1 month ago showed a left ventricular ejection fraction of $25\%$), type 2 diabetes mellitus, chronic kidney disease, and coronary artery disease.

Current medications include carvedilol $25 \text{ mg}$ twice daily, dapagliflozin $10 \text{ mg}$ daily, furosemide $40 \text{ mg}$ daily, atorvastatin $40 \text{ mg}$ daily, and aspirin $81 \text{ mg}$ daily.

Vital signs are:
Temperature: $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$)
Blood pressure: $118/75 \text{ mm Hg}$
Pulse: $66/\text{min}$ and regular
Respirations: $16/\text{min}$

Physical examination shows a jugular venous pressure of $7 \text{ cm H}_2\text{O}$. The lungs are clear to auscultation bilaterally. Cardiac examination reveals a regular rate and rhythm with normal S1 and S2; no murmurs, rubs, or gallops are heard. The extremities have trace, bilateral, non-pitting edema.

Laboratory studies show:
Sodium: $138 \text{ mEq/L}$
Potassium: $5.2 \text{ mEq/L}$
Bicarbonate: $24 \text{ mEq/L}$
Creatinine: $2.7 \text{ mg/dL}$ (estimated glomerular filtration rate: $24 \text{ mL/min/1.73 m}^2$)

Which of the following is the most appropriate pharmacologic intervention to further reduce this patient's risk of all-cause mortality?

A 72-year-old man is evaluated in the emergency department for worsening shortness of breath, orthopnea, and lower extremity swelling over the past week. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$. Blood pressure is $112/72$ mmHg, heart rate is $138$/min, and respiratory rate is $22$/min. Oxygen saturation is $92\%$ on room air. Cardiac examination reveals an irregularly irregular rhythm and a third heart sound ($S_3$). Pulmonary examination shows bibasilar crackles extending midway up the lung fields. Bilateral $2+$ lower extremity pitting edema is present. Electrocardiogram demonstrates atrial fibrillation with a rapid ventricular response. Intravenous furosemide is administered. Which of the following is the most appropriate additional pharmacologic intervention?

A $55$-year-old man is evaluated in the neurointensive care unit for right lower extremity swelling. Five days ago, he was admitted for a spontaneous subarachnoid hemorrhage. His past medical history is significant for a mechanical aortic valve replacement performed three years ago, for which he takes daily warfarin. Upon admission, his international normalized ratio (INR) was $3.2$, and his coagulopathy was appropriately reversed with four-factor prothrombin complex concentrate and intravenous vitamin K. A follow-up non-contrast computed tomography scan of the head obtained yesterday showed a stable hemorrhage with no expansion.

Today, physical examination reveals new-onset, non-pitting edema and tenderness of the right calf and thigh. Venous duplex ultrasonography of the right lower extremity demonstrates a non-compressible thrombus extending from the popliteal vein into the right superficial femoral vein. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $140/85$ mm Hg, heart rate $88$/min, and respiratory rate $16$/min. Oxygen saturation is $98\%$ on room air.

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

A $28$-year-old woman is brought to the emergency department via ambulance after being the unrestrained driver in a high-speed motor vehicle collision. Upon arrival, her blood pressure is $78/45$ mmHg, heart rate is $135$/min, and respiratory rate is $28$/min. Pulse oximetry shows $88\%$ on room air. Primary survey reveals a patent airway, and the trachea is midline. Chest examination demonstrates severely decreased breath sounds and dullness to percussion over the right hemithorax. The remainder of the examination shows no obvious external bleeding or pelvic instability.

Place the following surgical and procedural interventions in the most appropriate chronological order for the optimal management of this patient.

An 84-year-old man who resides in a nursing care facility is transferred to the hospital due to progressively worsening abdominal swelling and failure to pass any gas or stool over the past three days. His medical history includes Parkinson disease, type 2 diabetes mellitus, and chronic constipation requiring daily laxatives. The patient complains of crampy abdominal discomfort but denies nausea, vomiting, or chills. On arrival, his temperature is $37.1^\circ$ C ($98.8^\circ$ F), blood pressure is $138/84$ mmHg, pulse is $86$/min, and respiratory rate is $16$/min. Physical examination demonstrates a markedly distended, tympanic abdomen. The abdomen is diffusely and mildly tender to palpation, but there is no rigidity, guarding, or rebound tenderness. Digital rectal examination reveals an empty rectal vault. Laboratory studies show a leukocyte count of $7,600/\mu L$ and a serum lactate level of $1.0$ mmol/L. An upright abdominal radiograph displays a massive, dilated loop of large bowel arising from the pelvis and projecting toward the right upper quadrant, characterized by an absence of haustral markings and a central double-wall thickness. Which of the following is the most appropriate next step in management?

A 45-year-old man is evaluated for treatment-resistant hypertension, episodic severe headaches, and diaphoresis. Laboratory testing reveals markedly elevated plasma fractionated metanephrines. Magnetic resonance imaging of the abdomen demonstrates a 5-cm right adrenal mass. The patient is scheduled for a laparoscopic adrenalectomy in 14 days.

Arrange the following interventions in the correct chronological sequence for this patient's perioperative pharmacologic management.

A $56$-year-old man is brought to the emergency department by his spouse due to progressive lethargy, confusion, and abdominal swelling over the past $48$ hours. The patient has a history of alcohol-associated cirrhosis and esophageal varices. His last variceal banding was six months ago. He takes furosemide and spironolactone but has been nonadherent for the past week. His temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $92/58\text{ mmHg}$, pulse is $112/\text{min}$, and respirations are $20/\text{min}$. Physical examination reveals scleral icterus, spider angiomas, and asterixis. The abdomen is tense and distended with shifting dullness and diffuse mild tenderness to palpation. There is no rebound tenderness or guarding. Rectal examination shows brown, guaiac-negative stool. Which of the following diagnostic studies are the most appropriate initial steps in the concurrent diagnostic workup of this patient? (Select all that apply)

A 58-year-old man with a history of stage 5 chronic kidney disease is brought to the emergency department due to profound generalized weakness. He reports missing his last two scheduled hemodialysis sessions due to transportation issues. His blood pressure is 110/70 mmHg, and his pulse is 42/min. Physical examination shows flaccid muscle weakness in all four extremities. An electrocardiogram (ECG) reveals a heart rate of 42/min, absent P waves, a markedly widened QRS complex, and tall, peaked T waves. Point-of-care testing shows a serum potassium level of 8.6 mEq/L. Arrange the following pharmacologic interventions in the correct chronological sequence for the acute management of this patient, ordered from the most immediate priority to the subsequent steps.

A 48-year-old agricultural worker is brought to the emergency department triage area by his coworkers in a private truck after he accidentally spilled a concentrated organophosphate pesticide on his clothing 20 minutes ago. He is confused, profusely sweating, and vomiting. Vital signs are temperature 36.5°C (97.7°F), heart rate 42/min, blood pressure 88/55 mm Hg, respiratory rate 28/min, and oxygen saturation 86% on room air. Physical examination reveals pinpoint pupils, excessive salivation, and diffuse wheezing with copious crackles. Widespread muscle fasciculations are noted.

Arrange the following initial stabilization and management steps in the most appropriate chronological order, from first to last.

An intensive care unit team is called to evaluate a female patient, aged $67$, due to profound hypotension and worsening mentation. She was admitted through the emergency department earlier today after her family found her difficult to arouse. Her medical history includes a mechanical mitral valve replacement performed $5$ years ago (managed with chronic warfarin therapy) and frequent urinary tract infections. Of note, she finished a $7$-day regimen of oral ciprofloxacin $2$ weeks prior for acute cystitis.

Initial assessment in the emergency department revealed a core temperature of $39.2^\circ\text{C}$ ($102.5^\circ\text{F}$). Urinalysis was markedly abnormal, showing positive nitrites, leukocyte esterase, and $>50$ leukocytes per high-power field. She was given $30$ mL/kg of intravenous balanced crystalloid solution over a $2$-hour window.

Current parameters in the ICU show:
Temperature: $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$)
Blood pressure: $76/44$ mm Hg
Heart rate: $142$/min with an irregularly irregular rhythm
Respiratory rate: $24$/min
Oxygen saturation: $95\%$ on room air

A 12-lead electrocardiogram confirms atrial fibrillation with rapid ventricular response.

Pertinent laboratory data include:
Leukocytes: $18,500$/mm $^3$
Hemoglobin: $11.2$ g/dL
Platelets: $165,000$/mm $^3$
Serum creatinine: $2.1$ mg/dL (recent baseline was $0.9$ mg/dL)
Serum lactate: $4.8$ mmol/L
INR: $1.7$ (established target range for her valve prosthesis is $2.5$-$3.5$)

Blood and urine cultures are incubating.

Which of the following intravenous pharmacologic interventions are appropriate to administer at this time? (Select all that apply)

A 62-year-old man with a history of severe alcohol use disorder and hepatic cirrhosis is brought to the emergency department by paramedics after vomiting copious amounts of bright red blood at home. The EMS crew reports that he became progressively less responsive during transport.

Upon arrival in the resuscitation bay, the patient is obtunded and responds only to deep sternal pressure. There is ongoing pooling of dark bloody secretions in his oropharynx with audible gurgling on inspiration.

Vital signs are:
* Blood pressure: 65/35 mmHg
* Heart rate: 142/min and thready
* Respiratory rate: 8/min and shallow
* Oxygen saturation: 84% on room air

His capillary refill time is prolonged at 5 seconds, and his extremities are cool and mottled.

Which of the following are the most appropriate immediate, simultaneous next steps in the management of this patient? (Select 2)

A 45-year-old male construction worker is brought to the emergency department by emergency medical services after falling approximately 6 meters (20 feet) from a scaffold. On arrival, he is unresponsive to verbal commands but moans in response to deep pain. He has a large, actively bleeding scalp laceration and an obvious deformity of his right thigh. His respirations are sonorous and shallow. Vital signs are temperature 36.2°C (97.2°F), blood pressure 75/40 mm Hg, heart rate 135/min, respiratory rate 8/min, and oxygen saturation 86% on room air. Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select 2)

While at work, a $48$-year-old construction worker experiences an abrupt onset of excruciating abdominal pain. He arrives at the emergency department shortly after via emergency medical services. His past medical history is significant for chronic knee osteoarthritis managed with frequent use of over-the-counter naproxen. Current vital signs show a temperature of $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure of $96/58\text{ mm Hg}$, pulse of $118/\text{min}$, and respiratory rate of $24/\text{min}$. The patient appears diaphoretic and refuses to change position on the stretcher. Abdominal examination demonstrates diffuse, involuntary muscle spasm, marked rebound tenderness, and absent bowel sounds. An upright portable chest radiograph displays free subdiaphragmatic radiolucency. Fluid resuscitation and intravenous broad-spectrum antibiotics are immediately started.

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