Patient Management

Pulmonary embolism (PE) is a potentially life-threatening condition, but its diagnostic workup must be tailored to patient stability, pre-test probability, and comorbidities to avoid unnecessary risk. Match each patient presentation with the most appropriate guideline-indicated next diagnostic step in their evaluation.

A 64-year-old man presents to the clinic for an initial visit to establish primary care. He has a history of chronic obstructive pulmonary disease and a 40 pack-year smoking history. Two weeks ago, he was evaluated at an urgent care center for an exacerbation of his chronic cough, which was successfully treated with a short course of oral corticosteroids. A chest radiograph performed during that visit revealed a 14-millimeter, noncalcified, peripheral nodule in the right upper lobe. Medical records indicate that a previous chest radiograph obtained four years ago showed no evidence of this nodule. The patient currently feels well and reports his cough has returned to baseline. Vital signs are within normal limits. Physical examination reveals distant breath sounds and mild end-expiratory wheezing, but is otherwise unremarkable.

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's lung nodule?

A $65$-year-old man presents to the urgent care clinic with a $1$-day history of excruciating pain in his right big toe. The pain awoke him from sleep and is so severe that he cannot tolerate the weight of his bedsheets. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$, chronic kidney disease stage 4, type 2 diabetes mellitus, and hyperlipidemia. His current medications include carvedilol, sacubitril-valsartan, empagliflozin, furosemide, and atorvastatin. Vital signs show a blood pressure of $118/76$ mm Hg, heart rate of $72$/min, and temperature of $37.1^\circ$ C. Physical examination reveals a markedly erythematous, swollen, and exquisitely tender right first metatarsophalangeal joint. The remainder of the joint examination is unremarkable. Laboratory studies from one week ago showed a serum creatinine of $2.6$ mg/dL (estimated glomerular filtration rate $24$ mL/min/$1.73$ m $^2$) and a hemoglobin A1c of $7.8\%$. Joint aspiration is deferred as the clinical presentation is highly classic for podagra. Which of the following is the most appropriate initial pharmacologic therapy for this patient's acute joint condition?

A 52-year-old man is brought to the emergency department by coworkers after collapsing in an agricultural field where he was spraying pesticides. On arrival, he is confused, agitated, and incontinent of urine and feces. Physical examination reveals profuse diaphoresis, copious salivation, and diffuse wheezing on lung auscultation. His pupils are 1 mm bilaterally. Vital signs show a temperature of 37.1 C (98.8 F), heart rate of 42/min, blood pressure of 85/55 mmHg, respiratory rate of 28/min, and oxygen saturation of 87% on room air. He is actively coughing up large amounts of clear, frothy secretions. Which of the following are the most appropriate simultaneous initial steps in the management of this patient? (Select all that apply)

Match each clinical presentation with the most appropriate next diagnostic test.

A 68-year-old woman with highly symptomatic paroxysmal atrial fibrillation is admitted to the cardiology service for initiation of dofetilide therapy. Her past medical history is significant for hypertension and heart failure with preserved ejection fraction. Her home medications include metoprolol succinate, losartan, and apixaban. Which of the following parameters must be strictly monitored during the initial inpatient phase of therapy with this medication? (Select all that apply)

A $72$-year-old woman is brought to the emergency department by her family due to a $3$-day history of worsening abdominal distension, severe crampy abdominal pain, and an inability to pass flatus or stool. Her past medical history is significant for hypertension and osteoarthritis. Her temperature is $37.4^{\circ}\text{C}$ ($99.3^{\circ}\text{F}$), blood pressure is $135/85\text{ mmHg}$, pulse is $98/\text{min}$, and respiratory rate is $16/\text{min}$. Physical examination reveals a markedly distended, tympanic abdomen with diffuse mild tenderness but no rebound or guarding. Computed tomography (CT) of the abdomen and pelvis with intravenous contrast reveals an obstructing mass in the sigmoid colon with severe proximal large bowel dilation. The cecum measures $11.5\text{ cm}$ in diameter. There is no free intraperitoneal air. Intravenous fluids and nasogastric decompression are initiated. Which of the following are appropriate next steps in the procedural management of this patient? (Select all that apply)

During a routine follow-up visit, a retired construction worker with a 15-year history of poorly controlled type 2 diabetes mellitus asks the physician to evaluate a wound on the bottom of his right foot. He noticed a foul-smelling discharge on his sock earlier this week but denies any pain, fever, or chills. Vital signs are within normal limits. Examination of the right plantar aspect reveals a 3 cm by 2 cm deep ulceration under the first metatarsal head. The ulcer is surrounded by a 2-cm rim of erythema and warmth. Dorsalis pedis and posterior tibial pulses are 2+ bilaterally. Probing the base of the ulcer with a sterile blunt instrument reveals a hard, gritty surface. Which of the following diagnostic steps are indicated as the most appropriate initial evaluation for this patient's current condition? (Select 2)

An emergency department evaluates a 68-year-old man who reports progressive generalized weakness and perioral numbness over the past 48 hours. He recently began taking lisinopril and spironolactone for newly diagnosed heart failure with reduced ejection fraction. His blood pressure is 118/72 mm Hg, heart rate is 54/min, and respiratory rate is 16/min. He continues to produce adequate urine.

Laboratory studies show:
Serum sodium: 136 mEq/L
Serum potassium: 7.8 mEq/L
Serum chloride: 104 mEq/L
Serum bicarbonate: 18 mEq/L
Blood urea nitrogen: 48 mg/dL
Serum creatinine: 2.9 mg/dL (baseline 1.8 mg/dL)

An electrocardiogram demonstrates absent P waves, widening of the QRS complex, and tall, peaked T waves.

Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the acute management of this patient's condition.

A 79-year-old man residing in a skilled nursing facility is brought to the emergency department due to progressively worsening abdominal distension, severe pain, and failure to pass stool or flatus over the past 48 hours. His medical history includes Parkinson disease, chronic constipation, and mild cognitive impairment. His temperature is $38.6^\circ\text{C}$, blood pressure is $86/54\text{ mm Hg}$, heart rate is $126\text{/min}$, and respiratory rate is $24\text{/min}$. He appears distressed and diaphoretic. Abdominal examination reveals profound distension with diffuse rigidity, marked tenderness to palpation, and rebound tenderness. Bowel sounds are absent. An upright plain radiograph of the abdomen displays a massive, dilated, inverted U-shaped loop of large bowel extending from the pelvis toward the right upper quadrant, with no free air under the diaphragm. Laboratory studies demonstrate a leukocyte count of $18,500/\mu\text{L}$ and serum lactate of $5.1\text{ mmol/L}$. Following initial intravenous fluid resuscitation and broad-spectrum antibiotic administration, which of the following is the most appropriate next step in management?

A 67-year-old woman with end-stage renal disease on hemodialysis is admitted for a severe diabetic foot infection. She is treated with intravenous vancomycin and prophylactic subcutaneous unfractionated heparin. On hospital day 7, she develops sudden-onset dyspnea and pleuritic chest pain. Vital signs show a heart rate of 112/min, blood pressure of 130/80 mmHg, and oxygen saturation of 89% on room air. Computed tomography pulmonary angiography confirms a new segmental pulmonary embolism. Laboratory studies reveal a platelet count of 65,000/mm³, which has fallen from a baseline of 240,000/mm³ on admission. The 4Ts score is calculated as 7, indicating a high probability of heparin-induced thrombocytopenia (HIT). The clinical team decides to manage her acute thrombosis and bridge her to long-term oral anticoagulation with a vitamin K antagonist.

Arrange the following pharmacologic orders in the strict chronological sequence required to safely manage this patient's coagulopathy from the acute phase through the transition to outpatient therapy.

A 19-year-old male university student is transported to the trauma bay after falling approximately 15 feet from a balcony. Paramedics note that he was initially conversing and complaining of a severe headache, but his mental status rapidly deteriorated en route. Upon arrival, he is deeply obtunded and withdraws only to painful stimuli. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $185/105\text{ mmHg}$, pulse $42/\text{min}$, and respirations $6/\text{min}$ and irregular. Physical examination reveals a right pupil that is $7\text{ mm}$ and unreactive to light; the left pupil is $3\text{ mm}$ and briskly reactive. Intravenous access was established in the field. Arrange the following patient management steps in the most appropriate chronological order.

A 48-year-old man presents to the ambulatory clinic complaining of excessive sweating, diffuse joint pain, and an increase in his shoe size over the past two years. He notes that he recently had to have his wedding ring resized because it no longer fit his finger. He has no significant past medical history and takes no medications. Vital signs show a blood pressure of 158/96 mm Hg, pulse of 76/min, and respiratory rate of 14/min. Physical examination reveals coarse facial features, a prominent forehead, and macroglossia. There is a 'doughy' consistency to the skin on his hands. Laboratory testing reveals a serum insulin-like growth factor-1 (IGF-1) concentration of 780 ng/mL (reference range: 90-250 ng/mL). Which of the following is the most appropriate next step in this patient's diagnostic workup?

A 72-year-old woman is admitted to the hospital due to progressively worsening shortness of breath, orthopnea, and lower extremity swelling over the past four days. Her medical history is significant for ischemic cardiomyopathy with a documented left ventricular ejection fraction of 25%, type 2 diabetes mellitus, and chronic kidney disease. On triage, her temperature is 37.1°C (98.8°F), blood pressure is 102/68 mm Hg, heart rate is 148/min and irregular, respiratory rate is 24/min, and oxygen saturation is 91% on room air. Physical examination reveals elevated jugular venous pressure to 11 cm $H_2O$, bibasilar crackles extending to the mid-lung fields, and 3+ bilateral pitting edema. An electrocardiogram is obtained and demonstrates a narrow-complex, irregularly irregular tachycardia lacking distinct P waves. She is placed on supplemental oxygen and intravenous bumetanide is prescribed. Which of the following pharmacologic agents are appropriate for immediate intravenous rate control of this patient's arrhythmia? (Select all that apply)

A 65-year-old man is brought to the emergency department by emergency medical services after vomiting bright red blood at home. He has a history of osteoarthritis for which he takes daily naproxen. Upon arrival, he appears pale, anxious, and diaphoretic. His temperature is 37.1°C (98.8°F), blood pressure is 92/58 mmHg, pulse is 118/min, and respiratory rate is 18/min. Physical examination reveals conjunctival pallor and mild epigastric tenderness. Digital rectal examination shows melena. Arrange the following procedural and management steps in the most appropriate chronological sequence for this patient.

An internal medicine physician is providing follow-up care for a 61-year-old patient with nonischemic cardiomyopathy in the outpatient clinic. The patient's most recent echocardiogram demonstrates a left ventricular ejection fraction of 28%. The patient's current medication regimen consists of carvedilol, spironolactone, dapagliflozin, and sacubitril-valsartan.

On physical examination, blood pressure is 118/74 mmHg, pulse is 68/min, and respiratory rate is 14/min. Jugular venous pressure is estimated at 6 cm H2O. Lungs are clear to auscultation bilaterally, and there is no lower extremity edema. Pertinent laboratory studies reveal a serum sodium of 139 mEq/L, potassium of 4.6 mEq/L, and creatinine of 1.1 mg/dL.

During the visit, the patient expresses concern regarding a recent loss of prescription drug coverage, stating that the sacubitril-valsartan has become financially prohibitive. After discussing alternatives, the physician and patient agree to discontinue the sacubitril-valsartan and initiate oral lisinopril to maintain optimal guideline-directed medical therapy. The patient confirms taking the final dose of sacubitril-valsartan this morning at 8:00 AM.

Based on pharmacologic safety guidelines, which of the following is the most appropriate instruction for initiating lisinopril in this patient?

A 58-year-old man with a history of decompensated alcoholic cirrhosis is evaluated in the emergency department for worsening abdominal distension, fever, and confusion over the past 24 hours. His current outpatient medications include propranolol, spironolactone, furosemide, and lactulose. His temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), blood pressure is $92/58\text{ mmHg}$, and heart rate is $108/\text{min}$. Physical examination reveals a lethargic man with a distended, diffusely tender abdomen, shifting dullness, and mild asterixis. Laboratory studies show:

Diagnostic paracentesis yields cloudy fluid with a nucleated cell count of $600/\text{mm}^3$ and $80\%$ polymorphonuclear leukocytes.

Which of the following pharmacologic interventions are appropriate for this patient's acute management? (Select all that apply.)

A 24-year-old woman with type 1 diabetes mellitus is admitted to the intensive care unit with diabetic ketoacidosis. Initial laboratory studies show a blood glucose of $520$ mg/dL, an arterial pH of $7.12$, an anion gap of $22$, and a serum potassium of $2.9$ mEq/L. Arrange the following steps regarding her ongoing management, monitoring, and therapeutic transition in the correct chronological sequence.

A 52-year-old man is evaluated on hospital day 18 for worsening fever and abdominal pain. He was initially admitted for severe acute gallstone pancreatitis. Over the first week of his hospitalization, he required aggressive intravenous fluid resuscitation and intensive care monitoring, but his condition had steadily improved until two days ago. Currently, his temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $105/65$ mm Hg, pulse is $118$/min, and respiratory rate is $22$/min. Physical examination reveals a distended abdomen with marked epigastric tenderness but no rebound or guarding. Laboratory studies show a leukocyte count of $22,000/\mu\text{L}$. A contrast-enhanced computed tomography scan of the abdomen demonstrates a $12 \times 10$ cm heterogeneous fluid collection replacing the body and tail of the pancreas, containing multiple distinct gas bubbles. Intravenous meropenem is initiated. What is the most appropriate next step in the management of this patient?

A physician is reviewing the charts of four patients presenting with different manifestations of suspected gastrointestinal blood loss. Match each clinical presentation with the most appropriate next diagnostic test in their evaluation sequence.