Patient Management

A 72-year-old man presents to the emergency department with sudden, severe pain in his left lower leg that began 2 hours ago. He has a history of permanent atrial fibrillation but reports running out of his prescribed oral anticoagulant medication three weeks ago. On physical examination, his left foot and calf are pale and cool to the touch. The left femoral pulse is palpable, but the popliteal, dorsalis pedis, and posterior tibial pulses are absent to palpation and inaudible on continuous-wave Doppler ultrasound. Sensation is markedly decreased over the dorsum of the foot, and the patient is unable to move his toes. The right lower extremity is warm with strong distal pulses. Which of the following interventions are indicated for the immediate management of this patient? (Select all that apply)

A $62$-year-old woman is evaluated in the hospital for new-onset swelling and pain in her right lower extremity. She was admitted $6$ days ago for an acute pulmonary embolism and was immediately started on a continuous intravenous infusion of unfractionated heparin. Her respiratory status has significantly improved, but today she reports severe calf pain. Vital signs are within normal limits. Physical examination shows a right calf that is swollen, erythematous, and tender to palpation. Duplex ultrasonography confirms a new deep vein thrombosis in the right popliteal vein. Laboratory studies show a platelet count of $95,000/\mu L$, a significant decline from her admission platelet count of $260,000/\mu L$. Renal and hepatic function tests are within normal limits. Which of the following is the most appropriate next step in the pharmacologic management of this patient?

A $72$-year-old woman is brought to the emergency department from a skilled nursing facility due to severe lethargy and confusion over the past $12$ hours. Transport personnel report that she had a productive cough and foul-smelling urine for $3$ days prior to this acute decline. On arrival, she is unarousable to verbal stimuli but moans in response to painful stimuli. Vital signs include a temperature of $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure of $76/40\text{ mm Hg}$, pulse of $128/\text{min}$, and respiratory rate of $28/\text{min}$. Oxygen saturation is $86\%$ on room air. Capillary refill time is $5$ seconds. Arrange the following initial stabilization and management steps in the most appropriate chronological sequence for this patient.

A 45-year-old woman is evaluated in the surgical recovery unit two hours after an uncomplicated total thyroidectomy. The nursing staff urgently requests a physician assessment because the patient has become increasingly restless and reports severe neck tightness along with difficulty breathing. Physical examination reveals audible inspiratory stridor. Her surgical dressing is saturated with blood, and palpation reveals a tense, rapidly expanding swelling extending unilaterally beneath the incision line. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 160/95 mm Hg, heart rate 118/min, and respiratory rate 28/min. Pulse oximetry demonstrates an oxygen saturation of 91% on room air. Which of the following is the most appropriate immediate next step in the management of this patient?

Seeking evaluation for a predictable pattern of chest discomfort, a 62-year-old male executive visits his primary care physician. Over the last six weeks, he has experienced a squeezing sensation in the center of his chest whenever he walks the two blocks from his commuter train to his office. The discomfort consistently subsides within five minutes of resting or sitting down. He has a history of type 2 diabetes mellitus, hypertension, and advanced osteoarthritis of both knees requiring the use of a mobility aid. Current medications include metformin, lisinopril, and as-needed acetaminophen. Vital signs show a blood pressure of 138/86 mmHg and a heart rate of 72/min. Cardiac auscultation reveals a regular rhythm with no murmurs, rubs, or gallops. Lungs are clear to auscultation bilaterally. A resting 12-lead electrocardiogram demonstrates sinus rhythm, left axis deviation, and a left bundle branch block. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's symptoms?

A 74-year-old woman presents to her primary care clinic to discuss progressive right knee pain that has been worsening over the past 6 months. She describes the pain as a deep, dull ache that worsens when climbing stairs and improves with rest. She experiences approximately 15 minutes of stiffness in the right knee upon waking in the morning. Her medical history includes hypertension, type 2 diabetes mellitus, stage 4 chronic kidney disease (baseline creatinine 2.4 mg/dL), and a remote history of a bleeding gastric ulcer that required endoscopic intervention. Her current medications are amlodipine, insulin glargine, and acetaminophen 1,000 mg three times daily. She reports that the acetaminophen no longer provides adequate pain relief. Vital signs are within normal limits. Physical examination reveals bony enlargement of the right knee with palpable crepitus during active range of motion. There is no significant warmth, erythema, or joint effusion. A recent radiograph of the right knee shows asymmetric joint space narrowing and subchondral sclerosis.

Which of the following is the most appropriate next step in the pharmacologic management of this patient's knee pain?

A 54-year-old man presents to the emergency department with a 3-hour history of sudden, severe, and diffuse abdominal pain. He has a history of chronic knee osteoarthritis and takes high-dose naproxen daily. He appears in acute distress and lies completely still on the stretcher. His temperature is 38.2°C (100.8°F), blood pressure is 102/64 mm Hg, pulse is 118/min, and respirations are 22/min. Abdominal examination reveals a rigid, board-like abdomen with diffuse guarding and rebound tenderness. Arrange the following steps in the most appropriate sequence for the management of this patient.

A 65-year-old man is evaluated in the surgical intensive care unit for acute right lower extremity pain and swelling. He underwent a coronary artery bypass graft 7 days ago. Since his surgery, he has been receiving subcutaneous unfractionated heparin for deep venous thrombosis (DVT) prophylaxis. Vital signs are stable. Physical examination reveals a swollen, erythematous, and tender right calf. Laboratory studies show a platelet count of $55,000/\mu L$, a significant decline from his baseline of $260,000/\mu L$ immediately post-operation. A compression Doppler ultrasound of the right lower extremity confirms a new occlusive DVT in the popliteal vein. A serotonin release assay is strongly positive. Arrange the following pharmacologic management steps in the correct chronological sequence to optimally treat this patient's acute thrombosis and safely transition him to long-term oral anticoagulation.

A 34-year-old woman is brought to the emergency department by paramedics after collapsing at a seafood restaurant. Her partner states she began complaining of an itchy throat and difficulty breathing shortly after eating a shrimp appetizer. Her past medical history is significant for asthma and a known shellfish allergy, but she did not have her epinephrine autoinjector with her. Upon arrival, she is lethargic and gasping for air. Physical examination reveals diffuse erythematous hives, marked periorbital edema, and audible inspiratory stridor. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 72/42 mm Hg, pulse of 142/min, respiratory rate of 32/min, and oxygen saturation of 86% on room air. Which of the following interventions should be ordered simultaneously as the immediate next steps in management? (Select all that apply)

A 48-year-old man is evaluated in the primary care clinic after noticing a lump in his lower anterior neck while shaving. He reports a recent onset of increased sweating, frequent bowel movements, and an unintended weight loss of 3 kg (6.6 lbs) over the past two months. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 134/86 mm Hg, and heart rate of 104/min. Physical examination reveals a 2.5-cm, firm, mobile, non-tender nodule in the left thyroid lobe. There is no cervical lymphadenopathy. Laboratory testing reveals a serum thyroid-stimulating hormone (TSH) level of 0.05 µU/mL (normal: 0.4–4.0 µU/mL) and a free thyroxine (T4) level of 2.6 ng/dL (normal: 0.8–1.8 ng/dL). A subsequent neck ultrasound confirms a 2.5-cm solid nodule in the left thyroid lobe without any suspicious sonographic features (e.g., no microcalcifications or irregular margins). Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 35-year-old man is brought to the emergency department by emergency medical services due to ongoing generalized shaking of his extremities. The paramedics report that the seizure activity began 20 minutes ago and has been continuous without any periods of responsiveness. His past medical history is significant for a traumatic brain injury two years ago. His blood pressure is 142/88 mmHg, heart rate is 118/min, and oxygen saturation is 95% on a non-rebreather mask. Intravenous access is established, and fingerstick blood glucose is 108 mg/dL (6.0 mmol/L).

Arrange the following pharmacologic interventions in the most appropriate escalating sequence for managing this patient's condition, assuming the seizure activity remains refractory to each preceding step.

A 45-year-old woman is evaluated in the clinic for follow-up of difficult-to-control hypertension. Her blood pressure today is 168/102 mmHg despite documented adherence to maximal doses of amlodipine, lisinopril, and hydrochlorothiazide. She reports occasional muscle weakness but is otherwise asymptomatic. Fundoscopy shows no papilledema, and her neurological examination is normal. Laboratory studies reveal a serum potassium of 3.1 mEq/L and a serum sodium of 142 mEq/L. The physician suspects a specific secondary cause of her hypertension. Arrange the following diagnostic steps in the correct sequential order from initial screening to definitive pre-surgical evaluation.

A 62-year-old woman presents to the preoperative clinic for evaluation ahead of an elective right hemicolectomy scheduled in seven days. The surgery is indicated for a large, flat cecal adenoma that was unamenable to endoscopic resection. Her medical history includes a mechanical mitral valve replacement performed five years ago, type 2 diabetes mellitus, hypertension, and stage 3 chronic kidney disease. She leads an active lifestyle and reports walking at least two miles daily without experiencing chest pain, shortness of breath, or fatigue. Current medications include warfarin, metformin, and lisinopril. Vital signs are within normal limits. Laboratory studies reveal a serum creatinine of 1.5 mg/dL, an INR of 2.8, and an HbA1c of 7.1%. Which of the following procedural and perioperative management steps are indicated for this patient? (Select all that apply)

A 58-year-old woman is brought to the emergency department by her family due to progressively worsening shortness of breath, inability to lie flat, and generalized weakness over the past three days. She has a history of ischemic cardiomyopathy with a left ventricular ejection fraction of 25%. Her home medications include sacubitril-valsartan, carvedilol, spironolactone, and dapagliflozin. Temperature is 36.8°C (98.2°F), blood pressure is 86/56 mmHg, pulse is 112/min, and respiratory rate is 24/min. Oxygen saturation is 88% on room air. The patient appears lethargic. Extremities are cool to the touch with faint peripheral pulses and 2+ pitting edema up to the knees. Jugular venous pulsation is visible at the angle of the mandible while sitting upright. Chest auscultation reveals diffuse bilateral crackles extending to the mid-lung fields. Laboratory studies show:

An electrocardiogram shows sinus tachycardia with a left bundle branch block, unchanged from prior tracings. Which of the following is the most appropriate initial pharmacologic intervention for this patient?

A 65-year-old man with a history of type 2 diabetes mellitus and peripheral neuropathy is brought to the emergency department due to rapidly worsening right leg pain, swelling, and fever over the past 12 hours. The patient reports the pain is excruciating and much worse than the visible skin changes would suggest. He is confused and lethargic. Vital signs are temperature $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure $82/50\text{ mmHg}$, heart rate $128/\text{min}$, and respiratory rate $24/\text{min}$. Physical examination reveals a swollen, tense right lower extremity with poorly demarcated erythema advancing proximally toward the knee. Several violaceous bullae are present on the calf, and palpable crepitus is noted over the anterior tibia. Laboratory results show a leukocyte count of $24,000/\text{mm}^3$, serum sodium of $130\text{ mEq/L}$, and serum creatinine of $1.9\text{ mg/dL}$. Vigorous intravenous fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

A 26-year-old man is brought to the emergency department via ambulance after being ejected from a motorcycle at highway speeds. He was not wearing a helmet. On arrival, the patient is unresponsive with a Glasgow Coma Scale score of 6. He has massive midface crush injuries with active, brisk hemorrhage into the oropharynx. He is making gurgling respiratory sounds with poor chest rise. Vital signs are temperature $36.1^\circ\text{C}$ ($97.0^\circ\text{F}$), blood pressure 78/48 mm Hg, heart rate 135/min, and respiratory rate 8/min. Oxygen saturation is 84% on room air. The bilateral radial pulses are weak and thready. An attempt at bag-valve-mask ventilation is unsuccessful due to severe facial deformity and continuous bleeding.

Arrange the following management steps in the most appropriate chronological sequence for this patient's initial stabilization and triage.

A 48-year-old man is brought to the emergency department by emergency medical services after being found wandering near a bus station. He is agitated, diaphoretic, and yelling at unseen individuals. He has a known history of severe alcohol use disorder and has been hospitalized multiple times for intoxication. Vital signs show a heart rate of 122/min, blood pressure of 168/100 mm Hg, respiratory rate of 20/min, and oxygen saturation of 97% on room air. Fingerstick blood glucose is 82 mg/dL. Physical examination reveals coarse, bilateral hand tremors, bilateral horizontal nystagmus, and a broad-based, unsteady gait. He is disoriented to place and time. Which of the following pharmacologic interventions are appropriate in the immediate management of this patient? (Select all that apply)

An unresponsive 68-year-old man with a known history of severe chronic obstructive pulmonary disease is rushed to the resuscitation bay by his family. His wife reports that his breathing became progressively more labored over the previous 6 hours before he became unarousable at home. Currently, the patient only groans and minimally withdraws in response to a sternal rub. His temperature is 37.2°C (99.0°F), blood pressure is 145/88 mmHg, pulse is 118/min, and respiratory rate is 30/min. Pulse oximetry reveals an oxygen saturation of 81% on room air. The physical examination is notable for shallow, rapid respirations with marked intercostal retractions and poor bilateral air movement. Which of the following is the most appropriate initial step in this patient's management?

A 58-year-old man is evaluated in the intensive care unit for new-onset severe abdominal pain. He was admitted 6 hours ago after presenting with sudden, tearing interscapular pain. At the time of admission, computed tomography angiography revealed a Stanford Type B aortic dissection originating just distal to the left subclavian artery and extending to the aortic bifurcation. He was appropriately managed with intravenous esmolol and nicardipine infusions, which reduced his heart rate to 62/min and blood pressure to 112/68 mmHg, resulting in the resolution of his back pain. Currently, he reports diffuse, constant abdominal pain that is out of proportion to the physical examination findings. The abdomen is soft and non-distended, with no rebound tenderness or guarding. His current blood pressure is 115/70 mmHg, and heart rate is 64/min. Laboratory studies show a serum lactic acid level of 5.2 mmol/L, up from 1.1 mmol/L on admission. Which of the following is the most appropriate next step in management?

Emergency medical services transport a 68-year-old female to the resuscitation bay due to sudden-onset, crushing substernal chest discomfort and severe shortness of breath that awoke her from sleep 45 minutes prior. Her past medical history includes type 2 diabetes mellitus, hypertension, and a 40-pack-year smoking history. Initial vital signs obtained by the triage nursing staff show a temperature of 36.8°C (98.2°F), a heart rate of 122/min, a blood pressure of 78/50 mmHg, and a respiratory rate of 34/min. Pulse oximetry indicates an oxygen saturation of 80% on room air. On physical examination, the patient is diaphoretic, agitated, and communicating only in one-to-two word phrases due to severe respiratory distress. Prominent jugular venous distention is noted. Pulmonary auscultation reveals diffuse, coarse crackles throughout all lung fields bilaterally. Cardiac auscultation reveals a regular tachycardia and an audible S3 gallop, without murmurs. An immediate 12-lead electrocardiogram obtained upon arrival shows 4-mm ST-segment elevations in leads V1 through V6 with reciprocal changes in the inferior leads. Two large-bore intravenous lines are established. Which of the following represents the single most urgent priority in the initial stabilization of this patient?