Patient Management

A 34-year-old woman is evaluated in the outpatient clinic for progressive weight gain, generalized weakness, and easy bruising over the past eight months. She notes her face has become "rounder" and she has developed dark hair on her chin. Medical history is notable for newly diagnosed hypertension and type 2 diabetes mellitus, which are poorly controlled despite escalating therapy. She does not take any prescription, over-the-counter, or herbal medications, and specifically denies using exogenous corticosteroids. On physical examination, blood pressure is 158/96 mmHg and heart rate is 82/min. She has facial plethora, a prominent dorsocervical fat pad, central adiposity with thin extremities, and wide violaceous striae on her abdomen. Proximal muscle weakness is noted in the lower extremities.

Arrange the following diagnostic investigations in the correct sequential order for the comprehensive evaluation of this patient's condition, starting from the initial diagnostic screening to the final localization procedure.

A $31$-year-old woman, gravida 2, para 1, at $9$ weeks gestation presents to the emergency department with a $2$-day history of severe agitation, palpitations, vomiting, and diarrhea. She has a history of Graves disease, for which she stopped taking her medications when she discovered she was pregnant. She also has a history of severe persistent asthma requiring daily fluticasone and salmeterol inhalers, with her last exacerbation requiring endotracheal intubation three years ago.

On physical examination, her temperature is $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure is $152/68\text{ mmHg}$, heart rate is $158/\text{min}$ and regular, and respiratory rate is $26/\text{min}$. She is delirious, markedly tremulous, and diaphoretic. A diffusely enlarged, non-tender thyroid gland is palpable. Lung auscultation reveals diffuse bilateral end-expiratory wheezing.

Laboratory testing shows:
Thyroid-stimulating hormone (TSH): $<0.01\text{ \mu U/mL}$
Free thyroxine (T4): $5.4\text{ ng/dL}$ (Reference: $0.8-1.8\text{ ng/dL}$)

An electrocardiogram shows sinus tachycardia.

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

A 41-year-old woman is evaluated in the rheumatology clinic for a follow-up visit. Two weeks ago, she was diagnosed with highly active, seropositive rheumatoid arthritis after presenting with persistent symmetric polyarthritis of her wrists, metacarpophalangeal, and proximal interphalangeal joints. She has no other medical conditions and takes no medications other than ibuprofen as needed. Physical examination shows active synovitis in both hands. Recent laboratory studies from her initial diagnostic workup demonstrate a normal complete blood count, normal comprehensive metabolic panel, positive rheumatoid factor, and positive anti-cyclic citrullinated peptide antibodies. After a discussion of treatment goals, the physician and patient agree to initiate systemic therapy with once-weekly oral methotrexate and daily folic acid supplementation. Which of the following additional tests must be obtained to establish safety baselines and rule out absolute contraindications prior to initiating this specific pharmacotherapy? (Select 2)

A $42$-year-old woman is evaluated in the hospital for persistent fever. She was admitted two days ago with right-sided flank pain, dysuria, and a temperature of $39.1^\circ\text{C}$ ($102.4^\circ\text{F}$). Her medical history is significant for complex partial seizures, which have been well-controlled on valproic acid for the past five years, and type $2$ diabetes mellitus. Upon admission, she was started on empiric intravenous ceftriaxone for severe pyelonephritis.

Today, her temperature is $38.9^\circ\text{C}$ ($102.0^\circ\text{F}$), blood pressure is $105/65 \text{ mmHg}$, heart rate is $112 \text{ bpm}$, and respiratory rate is $18/\text{min}$. Laboratory studies show a serum creatinine of $1.9 \text{ mg/dL}$ (baseline $0.8 \text{ mg/dL}$).

Blood and urine cultures drawn on admission are both growing *Escherichia coli*. The microbiology laboratory confirms that the isolate is an extended-spectrum beta-lactamase (ESBL) producer. The susceptibility profile is as follows:

Ceftriaxone: Resistant
Cefepime: Resistant
Piperacillin-tazobactam: Susceptible
Meropenem: Susceptible
Amikacin: Susceptible

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

A 64-year-old man is evaluated in the intensive care unit for sudden-onset hemodynamic instability. The patient was admitted three days ago for severe community-acquired pneumonia complicated by acute respiratory distress syndrome (ARDS) and has been receiving mechanical ventilation with high positive end-expiratory pressure (PEEP). Two minutes ago, the ventilator's high-pressure alarm began sounding continuously. His temperature is 37.8°C (100.0°F), blood pressure is 65/40 mm Hg, pulse is 138/min, and respirations are set at 18/min but the patient is dyssynchronous. Oxygen saturation is 78% on a fraction of inspired oxygen (FiO2) of 0.80. Physical examination reveals distended neck veins, tracheal deviation to the left, and absent breath sounds over the right hemithorax. Which of the following is the single most urgent initial stabilization step?

A $56$-year-old woman is brought to the emergency department by her husband due to rapidly progressive pain, swelling, and redness of her left lower leg over the past $24$ hours. She has a history of type 2 diabetes mellitus and peripheral neuropathy. She felt feverish earlier today and experienced a single episode of vomiting. On triage, her temperature is $39.2^{\circ}\mathrm{C}$ ($102.6^{\circ}\mathrm{F}$), blood pressure is $88/54\mathrm{\ mmHg}$, pulse is $122/\mathrm{min}$, and respirations are $24/\mathrm{min}$. Physical examination reveals an ill-appearing patient. The left lower extremity demonstrates diffuse, poorly demarcated erythema and tense edema extending from the ankle to the proximal calf. There are distinct violaceous bullae present on the anterior shin. Palpation of the leg elicits exquisite pain out of proportion to the visible skin changes, and faint crepitus is noted. Laboratory studies show a leukocyte count of $24,500/\mathrm{mm}^3$ with $18\%$ bandemia, a serum sodium level of $130\mathrm{\ mEq/L}$, and a serum creatinine of $2.1\mathrm{\ mg/dL}$. Which of the following are the most appropriate immediate steps in the management of this patient? (Select all that apply)

A 48-year-old man is evaluated in the clinic for persistently elevated blood pressure. He was diagnosed with hypertension three years ago. His current medications include maximally tolerated doses of amlodipine, lisinopril, and doxazosin. He reports no headaches, palpitations, or diaphoresis. Vital signs are significant for a blood pressure of 168/98 mm Hg and a heart rate of 76/min. Physical examination is unremarkable, and no abdominal bruits are auscultated.

Current laboratory studies:
Sodium: 144 mEq/L
Potassium: 2.8 mEq/L
Chloride: 102 mEq/L
Bicarbonate: 29 mEq/L
Creatinine: 0.9 mg/dL

A review of his medical records indicates that his potassium was 3.1 mEq/L prior to the initiation of any antihypertensive therapy. Due to high clinical suspicion for secondary hypertension, hormonal screening is obtained:

Plasma renin activity (PRA): 0.2 ng/mL/h (Normal: 0.6 - 4.3 ng/mL/h)
Plasma aldosterone concentration (PAC): 28 ng/dL (Normal: 4 - 21 ng/dL)

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

A 34-year-old woman is evaluated in the medical ward for severe community-acquired pneumonia. Over the past 24 hours, her clinical status has deteriorated, necessitating the initiation of vasopressors. While a physician is attempting to place a right internal jugular central venous catheter, the patient suddenly exhibits profound respiratory distress and her level of consciousness rapidly declines. Vital signs show a temperature of 38.8°C (101.8°F), blood pressure of 64/34 mmHg, heart rate of 148/min, and respiratory rate of 36/min. Oxygen saturation is 76% despite a non-rebreather mask. On physical examination, the trachea is visibly deviated to the left, and the jugular veins are markedly distended. Auscultation reveals absent breath sounds over the entire right hemithorax, with associated hyperresonance to percussion.

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

An 82-year-old man is evaluated in the intensive care unit for new-onset fever and abdominal distension. He was admitted 8 days ago for severe community-acquired pneumonia requiring endotracheal intubation and mechanical ventilation. His medical history is significant for coronary artery disease and heart failure with preserved ejection fraction. Current medications include propofol, fentanyl, and intravenous broad-spectrum antibiotics. Temperature is 38.9°C (102.0°F), blood pressure is 88/54 mm Hg (currently requiring a norepinephrine infusion), pulse is 118/min, and respirations are 18/min on the ventilator. Physical examination reveals a distended abdomen with guarding in the right upper quadrant. Laboratory studies show a leukocyte count of 22,000/mm³ and serum lactate of 4.1 mmol/L. Liver function tests show a normal total bilirubin and mildly elevated transaminases. A bedside right upper quadrant ultrasound reveals a thickened gallbladder wall measuring 6 mm, significant pericholecystic fluid, and absence of gallstones. The common bile duct is not dilated. Which of the following is the most appropriate next step in the procedural management of this patient?

A $58$-year-old man presents to the emergency department with a $12$-hour history of severe right knee pain and swelling. He reports the pain woke him up from sleep and is exacerbated by the weight of his bedsheets. His medical history is significant for HIV, hypertension, and chronic kidney disease stage 3a. His current medications include darunavir, cobicistat, emtricitabine, tenofovir alafenamide, lisinopril, and amlodipine. His viral load is undetectable, and his CD4 count is $620/\text{mm}^3$. Temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $142/88\text{ mmHg}$, and pulse is $92/\text{min}$. Physical examination reveals a warm, erythematous, and exquisitely tender right knee with a noticeable effusion. Laboratory studies show a serum creatinine of $1.9\text{ mg/dL}$ (baseline $1.8\text{ mg/dL}$) and a serum uric acid level of $9.4\text{ mg/dL}$. Arthrocentesis yields cloudy yellow synovial fluid with a leukocyte count of $62,000/\text{mm}^3$ ($88\%$ neutrophils). Gram stain reveals no organisms. Polarized light microscopy of the fluid demonstrates needle-shaped, negatively birefringent crystals. Which of the following is the most appropriate initial pharmacologic intervention for this patient's acute joint condition?

During a routine annual physical examination, a physician identifies a neck mass in a 45-year-old female patient. The patient reports she has felt completely well and has not noticed the lump herself. A detailed review of systems is negative for unintentional weight changes, heat or cold intolerance, resting tremors, dysphagia, or hoarseness. Her past medical history is notable only for mild primary hypertension well-controlled on amlodipine. She has no personal or family history of radiation exposure or endocrine malignancies. On palpation of the neck, there is a discrete, 1.5-cm, firm, and freely mobile nodule located in the right lobe of the thyroid gland. The gland is otherwise normal in size and consistency, and there is no palpable cervical lymphadenopathy. Vital signs are within normal limits.

Which of the following diagnostic studies are indicated as the most appropriate immediate next steps in the evaluation of this patient? (Select exactly 2)

A 34-year-old woman is brought to the emergency department by paramedics after being struck by a commercial delivery truck while in a crosswalk. She was thrown approximately 8 meters. Upon arrival, she is obtunded with gurgling, inadequate respirations. Vital signs are temperature 35.8°C (96.4°F), blood pressure 70/30 mmHg, pulse 148/min, and respirations 36/min. Physical examination reveals marked tracheal deviation to the left and hyperresonance with completely absent breath sounds over the right hemithorax. Her extremities are cold, and her pelvis feels mechanically unstable on gentle palpation.

Arrange the following initial stabilization steps in the correct chronological sequence according to the Advanced Trauma Life Support (ATLS) primary survey protocol.

An internal medicine physician is urgently called to the medical admission unit to evaluate a patient with acute right-sided flank pain and rigors. The patient, a 64-year-old female, reports that her symptoms started abruptly yesterday. Initial vitals demonstrate a temperature of $39.4^\circ\text{C}$ ($102.9^\circ\text{F}$), blood pressure of $86/54\text{ mm Hg}$, heart rate of $122/\text{min}$, and respiratory rate of $22/\text{min}$. On examination, exquisite tenderness is elicited over the right costovertebral angle. Laboratory analysis reveals a leukocytosis of $18,500/\text{mm}^3$ and a serum creatinine of $1.8\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$). A catheterized urine specimen yields positive results for leukocyte esterase, nitrites, and abundant bacteria. Intravenous fluid resuscitation with 2 liters of crystalloid is immediately administered, yielding a blood pressure improvement to $110/70\text{ mm Hg}$. Clinical suspicion is high for an infected obstructing ureteral calculus.

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

A 52-year-old woman presents to the outpatient clinic with a 2-day history of dysuria, urinary frequency, and suprapubic discomfort. She has a history of a mechanical mitral valve replacement for which she takes warfarin. Her most recent international normalized ratio (INR), checked 2 days ago, was 2.8. She has no fever, chills, vaginal discharge, or flank pain. Vital signs are temperature 37.1°C (98.8°F), heart rate 82/min, blood pressure 124/78 mm Hg, and respiratory rate 14/min. Physical examination reveals mild suprapubic tenderness but no costovertebral angle tenderness. Urinalysis shows positive leukocyte esterase, positive nitrites, and $>50$ white blood cells/hpf. She has no known drug allergies and her renal function is normal. Which of the following is the most appropriate pharmacologic management for this patient?

A 62-year-old man with a 40-pack-year smoking history is evaluated in the clinic after a routine pre-operative chest radiograph reveals an incidental 14-mm solitary pulmonary nodule in the right upper lobe. He is entirely asymptomatic. Vital signs are within normal limits, and physical examination is unremarkable. Arrange the following steps in the most appropriate standard clinical sequence for the diagnostic workup of this patient's pulmonary finding.

A $28$-year-old man with a history of type $1$ diabetes mellitus is brought to the emergency department complaining of severe nausea, vomiting, and diffuse abdominal pain for the past $24$ hours. He reports missing several doses of his basal insulin due to a recent gastrointestinal illness. Vital signs show a temperature of $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), heart rate of $124$/min, blood pressure of $96/58$ mmHg, and respiratory rate of $24$/min with deep, rapid breaths. Laboratory studies reveal:

Serum glucose: $580$ mg/dL
Serum sodium: $134$ mEq/L
Serum potassium: $4.6$ mEq/L
Serum chloride: $98$ mEq/L
Serum bicarbonate: $12$ mEq/L
Arterial pH: $7.22$
Urinalysis: $3+$ ketones

Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the management of this patient, from initial presentation to clinical resolution.

A 68-year-old woman is admitted to the hospital with a 3-day history of fever, productive cough, and progressive shortness of breath. Medical history is significant for nonvalvular atrial fibrillation, essential hypertension, and major depressive disorder. Her current home medications include apixaban, sotalol, lisinopril, and escitalopram. Her temperature is 38.4°C (101.1°F), blood pressure is 132/82 mmHg, pulse is 88/min, and respirations are 22/min. Pulse oximetry shows 93% on room air. Physical examination reveals bronchial breath sounds and crackles in the right lower lung field. Laboratory studies show a leukocyte count of 14,500/mm³. Serum creatinine is 0.9 mg/dL and electrolytes are within normal limits. A chest radiograph demonstrates a right lower lobe consolidation. An electrocardiogram shows normal sinus rhythm with a QTc interval of 520 ms. The patient is diagnosed with non-severe community-acquired pneumonia requiring inpatient management. Which of the following is the most appropriate empiric pharmacotherapy for this patient's infection?

Paramedics transport a 29-year-old female to the acute care bay after she collapsed at a grocery store. En route, the patient regained partial consciousness but remained confused and complained of excruciating lower abdominal cramping. She has no known chronic medical conditions. Upon arrival, the patient appears ashen and is actively sweating. Vital signs show a temperature of 36.7°C (98.0°F), blood pressure of 74/42 mm Hg, heart rate of 138/min, and respiratory rate of 26/min. Oxygen saturation is 99% on ambient air. The abdomen is distended, with significant guarding and rigidity noted across all quadrants. A rapid bedside urine human chorionic gonadotropin test is positive. Which of the following are the most appropriate simultaneous initial steps in the stabilization of this patient? (Select 2 options)

A 45-year-old man is brought to the emergency department by his family due to altered mental status, severe muscle stiffness, and high fever that began 24 hours ago. His medical history is significant for schizoaffective disorder, for which he has been taking clozapine and lithium for several years. Two days ago, he was prescribed oral haloperidol at an urgent care clinic for an acute exacerbation of severe agitation.

Vital signs are temperature 39.4°C (102.9°F), pulse 122/min, respirations 22/min, and blood pressure 168/100 mmHg. Physical examination reveals a diaphoretic, confused man. Neurologic examination is notable for severe, generalized "lead-pipe" muscle rigidity and decreased bowel sounds. Hyperreflexia and clonus are absent.

Laboratory studies show:
Leukocyte count: 16,500/mm³
Serum creatine kinase: 15,400 U/L
Serum creatinine: 2.1 mg/dL (baseline 0.9 mg/dL)

Which of the following pharmacologic interventions are appropriate in the management of this patient's current condition? (Select all that apply)

Match the following clinical presentations of suspected gastrointestinal bleeding with the most appropriate next step in their diagnostic sequencing.