Patient Management

A routine health maintenance evaluation is conducted for a 63-year-old female patient with a complex medical history. She is currently managed for seropositive rheumatoid arthritis with weekly methotrexate and subcutaneous etanercept. She also has type 2 diabetes mellitus, maintained on metformin. The patient reports feeling well with no new complaints. She is a lifelong nonsmoker and exercises moderately three times a week.

A review of her preventive care timeline reveals the following:
- Screening colonoscopy at age 54 showed no abnormalities.
- Mammography 8 months ago was reported as normal.
- Bone mineral density testing via DEXA scan at age 59 demonstrated a T-score of -1.1 at the femoral neck.
- She successfully completed the two-dose recombinant zoster vaccination protocol at age 52.
- Her primary care provider administered the 15-valent pneumococcal conjugate vaccine (PCV15) exactly three months ago during a flare of her arthritis.
- Her tetanus-diphtheria-acellular pertussis (Tdap) booster was administered 5 years ago.

Physical examination today demonstrates stable joint findings with no active synovitis. Hemoglobin A1c is 6.8%.

Based on current guidelines, which of the following is the most appropriate next step in this patient's preventive care?

A 42-year-old construction worker is brought to the emergency department by paramedics after falling approximately 25 feet from a scaffold. The patient is immobilized on a backboard with a rigid cervical collar in place. He is obtunded, and pooling of blood and secretions is visible in his oropharynx. Vital signs are temperature 36.2°C (97.2°F), blood pressure 72/40 mmHg, pulse 142/min, and respirations 36/min. Pulse oximetry shows 84% on a 15-L nonrebreather mask. Physical examination reveals a Glasgow Coma Scale score of 7 (E2, V2, M3). His trachea is deviated to the right. There are absent breath sounds over the left hemithorax and hyperresonance to percussion. Jugular venous distention is present. His abdomen is distended and firm. Bilateral large-bore peripheral intravenous access is immediately established by nurses. Arrange the following management steps in the most appropriate chronological order.

A 38-year-old male presents to the outpatient clinic for a blood pressure recheck. He has a history of hypertension that remains poorly controlled despite adherence to a regimen of amlodipine, lisinopril, and chlorthalidone at maximal therapeutic doses. His blood pressure today is 162/100 mmHg. Laboratory studies reveal a serum potassium level of 3.0 mEq/L. His chlorthalidone is discontinued, and his potassium is repleted to normal levels over the next two weeks. The physician strongly suspects an underlying endocrine etiology for his resistant hypertension. Arrange the following diagnostic steps in the most appropriate sequential order for working up this patient's suspected condition, from initial screening to definitive pre-surgical evaluation.

A 68-year-old man is evaluated on the surgical ward for decreased urine output. He underwent an open cholecystectomy for acute gangrenous cholecystitis two days ago. Over the past 12 hours, his urine output has been 150 mL via the urethra after his indwelling urinary catheter was removed earlier in the day. His preoperative serum creatinine was 1.1 mg/dL, and his current serum creatinine is 2.8 mg/dL. His medical history includes hypertension, benign prostatic hyperplasia, and osteoarthritis. His perioperative medications include lisinopril, ketorolac, and piperacillin-tazobactam. Vital signs are temperature 37.1°C (98.8°F), blood pressure 135/82 mmHg, and heart rate 88/min. Physical examination shows normal skin turgor, a healing right upper quadrant incision, and dullness to percussion in the suprapubic region. Which of the following studies comprise the most appropriate initial diagnostic workup for this patient's acute kidney injury? (Select exactly 3 answers)

A 34-year-old woman is evaluated in the emergency department for a two-day history of progressive left leg swelling and pain. She has a known medical history of an ischemic stroke at age 28 and three spontaneous consecutive first-trimester abortions, for which she was extensively evaluated. Outpatient serologic testing at that time confirmed high titers of anti-cardiolipin IgG, anti-beta-2-glycoprotein I IgG, and a repeatedly positive lupus anticoagulant. Her only current medication is low-dose aspirin. Vital signs are within normal limits. Physical examination reveals an erythematous, edematous left lower extremity with tenderness to palpation along the popliteal fossa. Her leg is warm, and distal pulses are palpable. Venous duplex ultrasonography confirms an occlusive thrombus in the left popliteal vein. Laboratory testing shows a normal complete blood count, normal serum creatinine, and a normal hepatic panel. Which of the following is the most appropriate pharmacologic intervention for managing this patient's acute thrombosis?

An ambulatory evaluation is conducted for a patient who reports a five-day history of nonproductive cough, low-grade fevers, and profound fatigue. Medical history is significant for paroxysmal atrial fibrillation, which is currently managed with sotalol and rivaroxaban. Vital signs show a temperature of 37.9°C (100.2°F), pulse of 64/min, and blood pressure of 128/82 mmHg. Pulmonary examination is notable for bilateral scattered crackles. A chest radiograph demonstrates diffuse interstitial opacities. A rapid respiratory panel returns positive for Mycoplasma pneumoniae. A 12-lead electrocardiogram performed during the visit shows normal sinus rhythm with a corrected QT (QTc) interval of 490 milliseconds. Which of the following is the most appropriate antimicrobial intervention to prescribe for this patient?

A 71-year-old male resident of a long-term care facility is transferred to the intensive care unit due to profound hypotension and altered sensorium. He has a known history of complicated nephrolithiasis and recurrent pyelonephritis. Upon arrival, his blood pressure is 74/42 mmHg, heart rate is 126/min, and respiratory rate is 26/min. His core temperature is 39.4°C (102.9°F). Initial laboratory evaluation reveals a serum lactate of 5.1 mmol/L and a marked leukocytosis. Blood and urine cultures are obtained, and broad-spectrum intravenous antimicrobial therapy is initiated without delay.

Arrange the following hemodynamic and pharmacologic interventions in the correct evidence-based sequence according to standard septic shock management guidelines. Assume the patient's mean arterial pressure (MAP) remains below 65 mmHg despite the completion of each preceding intervention.

A 54-year-old man arrives at the emergency department via ambulance with sudden-onset, severe, tearing chest pain that radiates to his interscapular region. He has a history of poorly controlled hypertension, hyperlipidemia, and a 30-pack-year smoking history. On examination, he appears diaphoretic and in severe distress. Blood pressure is 218/116 mmHg in the right arm and 224/114 mmHg in the left arm. Heart rate is 118/min and regular. A bedside focused assessment with sonography for trauma (FAST) shows no pericardial effusion. Computed tomography (CT) angiography of the chest and abdomen reveals an intimal flap originating distal to the left subclavian artery and extending to the renal arteries. Both true and false lumens are visualized, with no evidence of end-organ malperfusion.

Arrange the following pharmacologic interventions in the definitive physiological sequence required to safely stabilize this patient's condition.

A 26-year-old woman arrives at the emergency department via private vehicle complaining of sudden, severe right lower abdominal pain that began one hour ago. She reports severe dizziness and states she nearly lost consciousness while walking from the parking lot. She is 7 weeks pregnant according to her last menstrual period and has a past medical history significant for pelvic inflammatory disease. On physical examination, she is lethargic, pale, and diaphoretic. Vital signs include a temperature of 37.2 C (99.0 F), blood pressure of 74/42 mm Hg, heart rate of 140/min, respiratory rate of 24/min, and oxygen saturation of 97% on room air. Her abdomen is rigidly distended with diffuse tenderness and rebound, most prominent in the right lower quadrant. Which of the following is the most appropriate immediate next step in the stabilization and management of this patient?

A 71-year-old man presents to the clinic reporting a three-week history of progressively worsening generalized pruritus, dark urine, and pale-colored stools. He has also noticed a 5-kg (11-lb) weight loss over the past two months. He has a medical history of hypertension and osteoarthritis. He smoked one pack of cigarettes daily for 35 years but quit five years ago. Vital signs are stable. Physical examination demonstrates diffuse scleral icterus and jaundice. Abdominal examination reveals a soft, non-tender, palpable mass in the right upper quadrant.

Laboratory findings are as follows:

A transabdominal ultrasound shows marked dilation of the common bile duct and intrahepatic bile ducts, along with a markedly distended gallbladder without gallstones. The distal common bile duct and pancreas are obscured by overlying bowel gas.

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

Match each clinical presentation with the most appropriate next step in the diagnostic sequence.

A 68-year-old male is in the intensive care unit receiving invasive mechanical ventilation for severe acute respiratory distress syndrome secondary to influenza pneumonia. Over the past 10 minutes, the ventilator alarms for persistently high peak airway pressures. His blood pressure drops precipitously to 68/40 mm Hg, and his heart rate increases to 142/min. Oxygen saturation decreases from 94% to 81%. On physical examination, the trachea is visibly deviated to the left. Auscultation reveals completely absent breath sounds over the right hemithorax, with hyperresonance to percussion. The neck veins are severely distended.

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

A 42-year-old woman is evaluated for progressive weight gain, easy bruising, and proximal muscle weakness over the past 8 months. Blood pressure is 158/96 mmHg. Physical examination reveals central adiposity, facial plethora, and broad violaceous striae on her abdomen. Initial laboratory testing confirms endogenous hypercortisolism with a 24-hour urine free cortisol of 145 mcg/24h (normal: 4-50 mcg/24h) and a 1-mg overnight dexamethasone suppression test demonstrating a morning serum cortisol of 12 mcg/dL (normal: <1.8 mcg/dL). Which of the following is the most appropriate next step in the diagnostic workup?

A 38-year-old woman is evaluated in the outpatient clinic for a 2-month history of palpitations, increased sweating, and an unintended weight loss of 4 kg (8.8 lb). She has no significant past medical history and takes no medications. Vital signs include a blood pressure of 135/85 mm Hg and a heart rate of 112/min. Physical examination reveals a mild fine tremor of the outstretched hands and a palpable, firm, non-tender nodule in the right lobe of the thyroid gland. There is no cervical lymphadenopathy. A targeted ultrasound of the neck demonstrates a 2.2-cm solid, markedly hypoechoic nodule in the right thyroid lobe with microcalcifications and irregular margins. Laboratory studies show:

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

An established 51-year-old male patient comes to the clinic for follow-up of medication-resistant hypertension. His blood pressure remains consistently above 150/90 mmHg despite documented adherence to a daily regimen consisting of maximally tolerated doses of amlodipine, lisinopril, and chlorthalidone. A routine comprehensive metabolic panel reveals a serum potassium concentration of 2.8 mEq/L. The clinical picture is highly suspicious for primary hyperaldosteronism. Arrange the following diagnostic and evaluative steps in the most appropriate evidence-based sequence, progressing from initial investigation to definitive pre-surgical assessment.

A 62-year-old woman is evaluated in the intensive care unit for new-onset toe pain. She was admitted 5 days ago for a massive pulmonary embolism and has been receiving a continuous intravenous unfractionated heparin infusion. Her temperature is 37.2°C (99.0°F), blood pressure is 138/86 mm Hg, and pulse is 98/min. Physical examination reveals dark purple discoloration and ischemic changes in the toes of her left foot. Laboratory studies show a platelet count of 88,000/mm³, a significant decrease from her admission platelet count of 250,000/mm³. A presumptive diagnosis of heparin-induced thrombocytopenia (HIT) with arterial thrombosis is made, and anti-platelet factor 4 (PF4) antibody testing is ordered.

Arrange the following pharmacologic management steps in the required chronological sequence according to standard treatment protocols for this condition.

A 31-year-old woman is rushed to the emergency department triage desk by her colleagues. They report she suddenly developed severe throat tightness, shortness of breath, and dizziness approximately ten minutes after consuming a pastry at a local café. The patient has a past medical history of poorly controlled asthma and a severe peanut allergy. On arrival, she is visibly lethargic, diaphoretic, and grasping at her neck. Her vital signs are temperature 36.9°C (98.4°F), heart rate 148/min, blood pressure 72/42 mm Hg, respiratory rate 34/min, and oxygen saturation 84% on room air. Physical examination reveals audible inspiratory stridor, widespread erythematous urticaria, and perioral cyanosis. Her level of consciousness continues to rapidly decline while in the resuscitation bay. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

A $48$-year-old woman comes to the clinic reporting a $6$-month history of severe, generalized pruritus that is worse at night. She also reports worsening fatigue during this period but denies abdominal pain, weight changes, dark urine, or changes in bowel habits. Her medical history is unremarkable, and she takes no medications. She consumes alcohol on rare social occasions and has no history of illicit drug use. Vital signs are within normal limits. Physical examination demonstrates extensive excoriations over her arms and legs. There is no scleral icterus, spider angiomata, or palmar erythema. The abdomen is soft and non-tender, with no palpable hepatosplenomegaly.

Laboratory results are as follows:
Total bilirubin: $1.0$ mg/dL
Aspartate aminotransferase (AST): $42$ U/L
Alanine aminotransferase (ALT): $46$ U/L
Alkaline phosphatase: $610$ U/L
Gamma-glutamyl transferase (GGT): $420$ U/L

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

An $81$-year-old woman is brought to the emergency department from an assisted living facility due to the passage of $3$ large, dark maroon bowel movements mixed with clots over the past two hours. Her medical history includes hypertension, osteoarthritis, and permanent atrial fibrillation, for which she takes apixaban, lisinopril, and as-needed acetaminophen. On arrival, her temperature is $36.8^{\circ}\text{C}$ ($98.2^{\circ}\text{F}$), blood pressure is $82/50$ mm Hg, pulse is $118$/min, and respirations are $18$/min. Physical examination reveals a pale, lethargic patient. Her abdomen is soft and non-tender without guarding. Digital rectal examination demonstrates gross maroon blood. Intravenous access is rapidly established. Initial laboratory studies show a hemoglobin level of $7.2$ g/dL (baseline $11.5$ g/dL six months ago).

Arrange the following procedural and management steps in the most appropriate chronological order for evaluating and treating this patient's condition.

An adult female patient is evaluated in the outpatient clinic for a recent history of progressive weight gain, easy bruising, and proximal muscle weakness. Physical examination reveals facial plethora, supraclavicular fat pads, and violaceous striae on the lower abdomen. Her blood pressure is 154/96 mm Hg. The physician strongly suspects endogenous hypercortisolism (Cushing syndrome) and plans a stepwise evaluation to confirm the diagnosis and localize the etiology. Arrange the following diagnostic steps in the most appropriate sequential order, from initial screening to final invasive localization.