Patient Management

A 28-year-old woman is brought to the emergency department by her roommate due to severe agitation, confusion, and muscle twitching that began earlier today. She has a history of major depressive disorder, for which she takes citalopram. Two days ago, she was evaluated at an urgent care clinic for a severe migraine and was prescribed sumatriptan. Today, she also consumed multiple doses of over-the-counter dextromethorphan for a new-onset cough.

On arrival, her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $168/98\text{ mmHg}$, pulse is $128/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals a diaphoretic, flushed, and restless patient. Pupils are $6\text{ mm}$ and reactive to light bilaterally. Bowel sounds are hyperactive. Neurologic examination is notable for spontaneous myoclonus, hyperreflexia that is more pronounced in the lower extremities, and ocular clonus.

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

A 34-year-old male with treatment-resistant schizophrenia is admitted to a strictly smoke-free inpatient psychiatric unit following a severe exacerbation of psychosis at a group home. He was started on clozapine three weeks ago in the outpatient setting, and his dosage was gradually titrated to $400\text{ mg}$ daily. The patient has a history of smoking two packs of cigarettes daily for the past ten years. Upon admission, he is provided with a transdermal nicotine patch to manage withdrawal symptoms.

Vital signs show a blood pressure of $110/70\text{ mm Hg}$, heart rate of $105/\text{min}$, respiratory rate of $16/\text{min}$, and temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$). Physical examination is unremarkable except for mild resting tachycardia. A complete blood count obtained upon admission shows an absolute neutrophil count (ANC) of $1,600/\mu\text{L}$.

Which of the following are appropriate next steps in the monitoring and treatment evaluation of this patient? (Select all that apply)

A 23-year-old woman presents to the outpatient clinic reporting a 3-day history of lower abdominal pain and increased vaginal discharge. She has a new male sexual partner and notes inconsistent condom use. Her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $112/72\text{ mm Hg}$, and pulse is $88\text{/min}$. She denies nausea or vomiting and is tolerating an oral diet well. Pelvic examination reveals a friable cervix with yellow mucopurulent discharge, pronounced cervical motion tenderness, and bilateral adnexal tenderness. A point-of-care urine pregnancy test is negative. Which of the following pharmacologic interventions should be included in the initial empiric treatment regimen for this patient? (Select all that apply)

A 28-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision. He was the unrestrained driver of a vehicle that struck a concrete barrier. On arrival, he is confused and diaphoretic. His temperature is $36.5^{\circ}\text{C}$ ($97.7^{\circ}\text{F}$), blood pressure is $78/52\text{ mm Hg}$, pulse is $135/\text{min}$, and respirations are $24/\text{min}$. Oxygen saturation is 96% on high-flow oxygen via a non-rebreather mask. The airway is patent. Breath sounds are equal bilaterally. The abdomen is distended and diffusely tender to palpation. The pelvis is stable to anteroposterior and lateral compression. A portable chest radiograph reveals a widened mediastinum with obliteration of the aortic knob but no pneumothorax or hemothorax. A focused assessment with sonography for trauma (FAST) examination demonstrates a large amount of free fluid in the hepatorenal recess (Morison's pouch) and the splenorenal recess. Two large-bore intravenous lines are placed, and balanced blood product transfusion is initiated. Which of the following is the most appropriate next step in the management of this patient?

A 41-year-old woman is evaluated in the oncology clinic to discuss adjuvant endocrine therapy for breast cancer. She recently underwent a lumpectomy and sentinel lymph node biopsy for a stage I, estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative invasive ductal carcinoma. Radiation therapy was completed two weeks ago. Her medical history is significant for major depressive disorder, which has been well controlled on fluoxetine for the past four years. She also reports experiencing new-onset, disruptive hot flashes that disturb her sleep. Her menstrual cycles are regular, occurring every $28$ days. Her body mass index is $24 \text{ kg/m}^2$. Vital signs and physical examination are within normal limits. The oncologist plans to initiate tamoxifen. Which of the following is the most appropriate pharmacologic adjustment for this patient?

A $68$-year-old man is evaluated in the clinic for a $3$-month history of progressively worsening lower back pain, generalized fatigue, and recent-onset constipation. He has no prior history of malignancy or significant chronic medical conditions. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $138/86\text{ mmHg}$, pulse is $84/\text{min}$, and respiratory rate is $14/\text{min}$. Physical examination reveals midline tenderness over the lower lumbar spine with no focal neurologic deficits. Muscle strength and deep tendon reflexes are symmetric and intact in both lower extremities.

Laboratory studies show:

Based on these findings, which of the following diagnostic studies are the most appropriate concurrent next steps in this patient's evaluation? (Select two)

A 72-year-old man with a history of severe ischemic cardiomyopathy is brought to the emergency department with progressive dyspnea, orthopnea, and worsening confusion over the past 24 hours. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 74/50 mm Hg, heart rate of 118/min, and respiratory rate of 28/min. Physical examination reveals cool, mottled extremities, significant jugular venous distention, and coarse bilateral crackles extending to the mid-lung fields. Urine output since arrival has been minimal. A bedside echocardiogram demonstrates a left ventricular ejection fraction of 20% with severe global hypokinesis and a dilated, non-collapsible inferior vena cava. Arrange the following pharmacologic interventions in the most appropriate sequential order for the management of this patient, starting with the most immediate stabilizing action.

A 27-year-old man is brought to the emergency department by paramedics following a high-speed motorcycle collision without a helmet. Upon arrival, the patient is unresponsive with massive facial crush injuries and copious bleeding into his oropharynx. He exhibits gurgling respiratory efforts. Vital signs reveal a blood pressure of 72/40 mm Hg, a pulse of 135/min, and a respiratory rate of 8/min. Oxygen saturation is 81% on high-flow oxygen. Physical examination is notable for absent breath sounds on the right hemithorax and distended neck veins. His pelvis is stable to palpation, and paramedics have effectively placed a tourniquet on a mangled left lower extremity. Arrange the following steps in the most appropriate sequential order for the initial stabilization and management of this patient.

A gastroenterology consultation is requested for a 42-year-old male who has developed severe, recurrent peptic ulcer disease despite strict adherence to maximal high-dose proton pump inhibitor therapy. He additionally reports a six-month history of high-volume, watery diarrhea that improves only slightly with fasting. A recent esophagogastroduodenoscopy demonstrated markedly hypertrophic gastric folds and multiple atypical ulcerations extending into the distal duodenum and proximal jejunum. Vital signs are stable: temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 74/min, and respiratory rate 14/min. Laboratory results reveal a normal basic metabolic panel, intact parathyroid hormone, and a serum calcium level of 9.2 mg/dL. The clinical team strongly suspects a functional neuroendocrine tumor and plans a comprehensive evaluation. Arrange the following diagnostic modalities in the correct, guideline-directed sequence, progressing from initial biochemical screening to precise anatomic localization.

A 72-year-old man is brought to the emergency department from a skilled nursing facility with altered mental status, fever, and a productive cough. His temperature is $39.2^{\circ} \text{C}$ ($102.6^{\circ} \text{F}$), heart rate is $124/\text{min}$, respiratory rate is $26/\text{min}$, and blood pressure is $72/40 \text{ mmHg}$. His oxygen saturation is $88\%$ on room air. The patient is diagnosed with severe community-acquired pneumonia complicated by septic shock. After securing the airway and obtaining appropriate cultures, empirical broad-spectrum antimicrobial therapy is prescribed.

Arrange the following hemodynamic interventions in the correct sequential order according to standard protocolized management of septic shock, starting from the initial intervention to salvage therapy for refractory hypotension.

A 42-year-old man presents to the clinic complaining of worsening headaches and excessive sweating over the past 14 months. He mentions that his wedding ring has become too tight to wear and his shoe size has recently increased. His blood pressure is 148/92 mm Hg, and his heart rate is 78/min. Physical examination reveals coarse facial features, macroglossia, and widened hands with thickened fingers. Visual field testing by confrontation is normal. Due to high clinical suspicion for acromegaly, a serum insulin-like growth factor-1 (IGF-1) level is obtained and returns markedly elevated for his age and sex. Which of the following is the most appropriate next step in the diagnostic workup?

A 64-year-old man comes to the urgent care clinic due to the sudden onset of severe pain, swelling, and redness in his left knee that awoke him from sleep. He has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of $30\%$, chronic kidney disease with a baseline serum creatinine of $2.7 \text{ mg/dL}$, and a recent diagnosis of atypical community-acquired pneumonia for which he began taking clarithromycin $3$ days ago. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $118/76 \text{ mm Hg}$, and pulse is $82/\text{min}$. Physical examination shows a warm, erythematous, and exquisitely tender left knee with a moderate effusion. Arthrocentesis is performed, yielding synovial fluid with a leukocyte count of $35,000/\mu\text{L}$ ($90\%$ neutrophils). Polarized light microscopy reveals needle-shaped, negatively birefringent crystals. Gram stain shows no organisms. Which of the following is the most appropriate pharmacologic intervention for this patient's current joint condition?

Emergency medical personnel arrive at the resuscitation bay with a 58-year-old male experiencing high-volume hematemesis. His spouse reports that he has a history of alcohol use disorder and hepatic cirrhosis. During transfer to the hospital bed, the patient has another large episode of vomiting bright red blood. He appears profoundly lethargic, pale, and diaphoretic. Vital signs demonstrate a heart rate of 138/min, blood pressure of 74/42 mm Hg, respiratory rate of 28/min, and oxygen saturation of 88% on ambient air. Physical examination reveals pooled blood in the posterior oropharynx, a diminished gag reflex, and gurgling respirations. Intravenous access is established with two large-bore peripheral catheters. Which of the following is the single most urgent initial step in the management of this patient?

A $55$-year-old man is evaluated in the surgical ward $3$ hours after undergoing an anterior cervical discectomy and fusion for severe cervical radiculopathy. The nursing staff requested an urgent evaluation because the patient developed sudden-onset severe anterior neck pressure, difficulty swallowing, and shortness of breath. On arrival, the patient is visibly agitated, diaphoretic, and has audible inspiratory stridor. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $165/95\text{ mm Hg}$, pulse is $118/\text{min}$, and respirations are $28/\text{min}$. Pulse oximetry shows an oxygen saturation of $87\%$ on room air. Physical examination reveals a tense, rapidly expanding, and ecchymotic swelling beneath the surgical incision on the anterior neck. Which of the following are the most appropriate immediate steps in management? (Select all that apply)

A 64-year-old woman arrives at the emergency department with a 24-hour history of severe right-sided flank pain, intense chills, and acute confusion. Vital signs reveal a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure of 88/54 mmHg, and a heart rate of 118/min. Physical examination is notable for exquisite right costovertebral angle tenderness. Initial laboratory evaluation demonstrates a leukocyte count of $18,500/\text{mm}^3$ and a serum creatinine level of $1.9 \text{ mg/dL}$. A non-contrast CT scan of the abdomen and pelvis shows a 9-mm calculus in the proximal right ureter accompanied by severe hydronephrosis and perinephric fat stranding.

Arrange the following patient management and procedural interventions in the most appropriate chronological sequence for this patient.

A 67-year-old woman is brought to the emergency department from a skilled nursing facility due to a 2-day history of progressively worsening abdominal pain, distension, and obstipation. She has a medical history significant for Parkinson disease, chronic constipation, and severe osteoarthritis. Her current medications include carbidopa-levodopa, polyethylene glycol, and acetaminophen. Vital signs show a temperature of 37.6°C (99.7°F), blood pressure of 105/65 mmHg, heart rate of 115/min, and respiratory rate of 20/min. Physical examination reveals a markedly distended and tympanitic abdomen with diffuse tenderness. There is no rebound tenderness or guarding. Laboratory studies show a leukocyte count of 11,500/mm³ and normal serum electrolyte levels. An abdominal plain radiograph demonstrates a massively dilated, comma-shaped loop of bowel projecting from the right lower quadrant toward the left upper quadrant. A subsequent computed tomography scan of the abdomen shows a markedly distended cecum with mesenteric twisting and a transition point in the right colon. Which of the following is the most appropriate next step in management?

A $45$-year-old woman is evaluated in the intensive care unit for fever and hypotension. She was admitted $12$ days ago for induction chemotherapy for acute myeloid leukemia. Over the past $24$ hours, her temperature has spiked to $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), and her blood pressure has dropped to $85/50\text{ mmHg}$, remaining hypotensive despite a $2\text{ L}$ intravenous normal saline bolus. She has a central venous catheter in her right internal jugular vein. She currently complains of severe perianal pain. Physical examination reveals an indurated, exquisitely tender, and erythematous perianal region without fluctuance. Laboratory studies show an absolute neutrophil count of $100/\mu\text{L}$. The patient's medical record documents a history of severe anaphylaxis (laryngeal edema and hypotension) to amoxicillin. Blood and perianal tissue cultures are obtained.

Which of the following intravenous pharmacologic agents should be included in this patient's empiric antimicrobial regimen? (Select all that apply)

A 29-year-old G1P0 woman at 22 weeks gestation presents to the emergency department complaining of sudden-onset shortness of breath and right-sided chest pain that worsens with deep inspiration. The symptoms started 3 hours ago. She has no significant past medical history. Vital signs show a temperature of 37.1°C (98.8°F), heart rate of 118/min, blood pressure of 112/72 mmHg, respiratory rate of 24/min, and oxygen saturation of 94% on room air. Physical examination reveals clear lung fields bilaterally. Cardiac auscultation reveals tachycardia with a regular rhythm and no murmurs. Examination of the lower extremities demonstrates mild, asymmetric swelling of the left calf with localized tenderness. An electrocardiogram shows sinus tachycardia. A chest radiograph is unremarkable. Which of the following is the most appropriate next diagnostic test?

Emergency medical responders bring a 42-year-old man to the trauma center following a fall from a 6-meter (20-foot) scaffold. The patient is confused and visibly diaphoretic. Vital signs upon arrival include a heart rate of 138/min, blood pressure of 76/40 mm Hg, and respiratory rate of 28/min. Oxygen saturation is 91% on high-flow oxygen. Primary survey demonstrates tracheal deviation to the left, absent breath sounds on the right, and severe dullness to percussion over the right hemithorax. Bilateral large-bore intravenous access is established, and the institutional massive transfusion protocol is activated. A 36-French thoracostomy tube is promptly inserted into the right pleural space, which immediately drains 1,650 mL of frank blood. Despite the ongoing administration of blood products, the patient's blood pressure remains 82/45 mm Hg five minutes later. Which of the following is the most appropriate next step in the management of this patient?

A 54-year-old female teacher is brought to the emergency department by her spouse due to the sudden onset of a severe, diffuse headache that began roughly 8 hours ago. She describes it as unlike any headache she has ever experienced, reaching maximum intensity within seconds. The patient also reports significant nausea and sensitivity to light. Her past medical history is notable for well-controlled essential hypertension and hypothyroidism. Current medications include lisinopril and levothyroxine. On arrival, her temperature is 37.2°C (99.0°F), blood pressure is 162/94 mmHg, pulse is 92/min, and respiratory rate is 16/min. Physical examination demonstrates moderate resistance to passive neck flexion, but cranial nerves, motor strength, and sensory functions are fully intact. A non-contrast computed tomography (CT) scan of the head is obtained immediately and 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?