Patient Management

A 20-year-old male college student is brought to the emergency department by his roommates due to a 12-hour history of severe generalized headache, subjective fever, and increasing confusion. He vomited three times prior to arrival. His past medical history is unremarkable, and he takes no medications. On presentation, his temperature is 39.5°C (103.1°F), blood pressure is 95/60 mmHg, heart rate is 122/min, and respiratory rate is 22/min. Physical examination reveals a lethargic patient who opens his eyes to pain and is oriented only to his name. Nuchal rigidity is present. A non-blanching, purpuric rash is noted on his lower extremities. Pupils are equal and reactive to light. There are no focal motor deficits.

Along with the immediate administration of empiric intravenous antibiotics and dexamethasone, which of the following are the most appropriate initial diagnostic studies to perform at this time? (Select the TWO most appropriate options)

A 48-year-old woman comes to the clinic for a routine health maintenance examination. She has a history of systemic lupus erythematosus (SLE) that is well-controlled. Her daily medications include mycophenolate mofetil and 15 mg of prednisone, which she has been taking for the past three years. She is a former smoker with a 22-pack-year history, having quit 4 years ago. She has no new complaints today and feels well. Her last screening mammogram was performed 3 years ago and was normal. A screening colonoscopy was performed at age 45 and revealed no polyps or abnormalities. Cervical cytology with human papillomavirus (HPV) co-testing was performed 2 years ago and was normal. She received an inactivated influenza vaccine at a local pharmacy two weeks ago and has completed all routine childhood immunizations. She has never received a pneumococcal or herpes zoster vaccine.

Which of the following preventive interventions are indicated for this patient at today's visit? (Select all that apply)

A 48-year-old woman presents to her primary care physician for a routine health maintenance examination. She reports feeling generally well but mentions experiencing occasional episodes of a racing heartbeat over the past two months. She has no significant past medical history and takes no medications. Vital signs show a blood pressure of 130/80 mm Hg, heart rate of 98/min, and respiratory rate of 14/min. Physical examination reveals a palpable, mobile, non-tender mass in the right anterior neck. No cervical lymphadenopathy is appreciated. A targeted ultrasound of the neck demonstrates a 2.4-cm solid, isoechoic nodule in the right lobe of the thyroid gland with no microcalcifications. Laboratory studies are ordered, which reveal a serum thyroid-stimulating hormone (TSH) level of 0.08 mU/L (normal: 0.4-4.0 mU/L) and a free thyroxine (T4) level of 2.2 ng/dL (normal: 0.9-1.7 ng/dL). Which of the following is the most appropriate next step in the diagnostic workup of this patient?

An emergent surgical consultation is requested for a 62-year-old male with acute-onset, severe left lower quadrant abdominal pain. The pain began roughly 24 hours prior and is now unrelenting. Vital signs reveal a temperature of 38.6°C (101.5°F), blood pressure of 105/65 mmHg, heart rate of 110/min, and respiratory rate of 18/min. The abdomen is exquisitely tender in the left lower quadrant with involuntary guarding and rebound tenderness. Laboratory analysis is notable for a leukocyte count of 16,500/mm³ with 85% neutrophils. A contrast-enhanced computed tomography scan of the abdomen and pelvis shows marked diverticular inflammation, a 3-cm pericolic fluid collection, and locules of extraluminal air. The patient is being prepared for the operating room. He has no known medication allergies. In addition to intravenous fluid resuscitation, which of the following antimicrobial regimens are appropriate for empiric management in this patient? (Select all that apply)

Match the following clinical presentations and risk stratification scores to their most appropriate initial care setting and disposition plan.

A 42-year-old female patient is evaluated in the outpatient clinic for progressive weight gain, proximal muscle weakness, and easy bruising developing over the past 14 months. Physical examination reveals central adiposity, facial plethora, and wide violaceous abdominal striae. Her blood pressure is 158/96 mmHg. A diagnosis of endogenous hypercortisolism (Cushing syndrome) is suspected. Arrange the following diagnostic steps in the most appropriate sequential order to establish the diagnosis and identify its underlying etiology.

A 68-year-old woman comes to the clinic for an annual health maintenance examination. She has a history of primary hypertension and osteoarthritis. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy at age 48 for symptomatic uterine fibroids. Pathological examination of the uterus and cervix at that time was benign, and her prior cervical cancer screening tests were consistently normal. She recently became sexually active with a new male partner.

Her most recent colonoscopy was performed at age 62 and revealed no polyps or abnormalities. She underwent a screening mammogram and a dual-energy x-ray absorptiometry (DXA) scan three months ago, both of which were within normal limits. She has a 40-pack-year history of smoking but successfully quit 10 years ago. She currently takes lisinopril and acetaminophen as needed. Vital signs are within normal limits.

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

A 68-year-old man comes to the clinic for a routine follow-up examination. He has a history of nonvalvular atrial fibrillation, heart failure with reduced ejection fraction (LVEF 35%), and hyperlipidemia. One month ago, he was diagnosed with active pulmonary tuberculosis and was started on a standard four-drug regimen consisting of rifampin, isoniazid, pyrazinamide, and ethambutol. His other daily medications include apixaban, lisinopril, carvedilol, and atorvastatin. Vital signs today are temperature 37.0°C (98.6°F), blood pressure 122/80 mmHg, heart rate 72/min, and respiratory rate 16/min. Physical examination is unremarkable. Laboratory studies, including renal and hepatic function panels, are within normal limits. Which of the following is the most appropriate modification to this patient's pharmacologic regimen?

A 54-year-old man with a history of alcohol use disorder and cirrhosis is brought to the emergency department by his daughter after he vomited a large amount of bright red blood at home. In the triage area, he has another massive episode of hematemesis. He appears lethargic and is difficult to arouse. His temperature is 37.1°C (98.8°F), blood pressure is 78/40 mmHg, pulse is 134/min, and respirations are 24/min. Pulse oximetry shows 92% on room air. The patient's skin is cool and clammy. His abdomen is distended with a positive fluid wave.

Which of the following are the most appropriate simultaneous initial steps in the stabilization of this patient? (Select 2 answers)

For each of the following ambulatory clinical encounters, identify the most appropriate next step in preventive care based on the patient's specific risk factors and demographic profile.

A $68$-year-old man returns to the outpatient clinic for evaluation of persistently elevated blood pressure. He has a history of severe coronary artery disease, for which he underwent coronary artery bypass grafting five years ago, and sick sinus syndrome requiring placement of a dual-chamber permanent pacemaker. His current medications include aspirin, atorvastatin, metoprolol, amlodipine, and lisinopril. The lisinopril was added to his regimen three weeks ago due to uncontrolled hypertension. Today, his blood pressure is $176/98$ mm Hg, and his heart rate is $72$/min. Physical examination reveals a soft, high-pitched systolic bruit auscultated just to the right of the umbilicus. Laboratory studies obtained this morning show a serum creatinine level of $2.6$ mg/dL, an increase from a baseline of $1.4$ mg/dL recorded one month ago. The estimated glomerular filtration rate (eGFR) is $24$ mL/min/$1.73$ m $^2$. Urinalysis shows no red blood cells or casts. Which of the following is the most appropriate next step in this patient's diagnostic workup?

Following a high-speed motor vehicle collision, a 29-year-old woman is brought to the emergency department by paramedics. Upon arrival, she is unresponsive and has mottled, cool extremities. Vital signs include a heart rate of 145/min, blood pressure of 65/35 mm Hg, and respiratory rate of 36/min. Physical examination reveals that the trachea is markedly deviated to the left. The right hemithorax is expanded, hyperresonant to percussion, and completely lacks audible breath sounds. The jugular veins are significantly distended. Which of the following is the most appropriate immediate next step in management?

Match each patient presentation of gastrointestinal bleeding or anemia with the most appropriate next step in diagnostic workup.

A 71-year-old man is brought to the emergency department from a skilled nursing facility with profound lethargy and fever. His temperature is 39.4°C (102.9°F), heart rate is 128/min, respiratory rate is 24/min, and blood pressure is 74/38 mmHg. Oxygen saturation is 95% on ambient air. Physical examination reveals dry mucous membranes, delayed capillary refill, and suprapubic tenderness. Laboratory studies show a white blood cell count of 19,000/mm³ and a serum lactate of 4.8 mmol/L. Blood and urine cultures are obtained, and broad-spectrum intravenous antibiotics are initiated for suspected urosepsis. The clinical team anticipates a prolonged resuscitation course and outlines a step-wise treatment pathway to maintain a mean arterial pressure (MAP) greater than 65 mmHg. Arrange the following pharmacologic interventions in the correct sequential order of administration according to guideline-directed therapy for septic shock.

A 59-year-old woman comes to the clinic for a routine health maintenance examination. She has a history of type 2 diabetes mellitus and primary hypertension, which are well-controlled on metformin and lisinopril. She smoked 1.5 packs of cigarettes daily for 20 years but successfully quit at age 43. Her past medical history is otherwise unremarkable. Her last screening colonoscopy was at age 49 and revealed no polyps. She had a normal screening mammogram 1 year ago, and a normal Papanicolaou (Pap) smear with negative human papillomavirus (HPV) co-testing 3 years ago. She has received all age- and risk-appropriate vaccinations, including a Tdap booster 4 years ago and a 20-valent pneumococcal conjugate vaccine (PCV20) at age 55. She currently feels well and has no complaints. Vital signs and physical examination are unremarkable. Which of the following is the most appropriate next step in preventive care for this patient?

A 45-year-old woman is evaluated in an urgent care clinic for a painful skin lesion on her left lower extremity. She states that she noticed a small "spider bite" three days ago that has progressively enlarged and become exquisitely tender. Her past medical history is notable for major depressive disorder, which is well-controlled on fluoxetine. She was also hospitalized six months ago for severe *Clostridioides difficile* colitis after receiving a course of antibiotics for sinusitis. Her temperature is 37.8°C (100.0°F), blood pressure is 122/78 mm Hg, and pulse is 88/min. Physical examination of the left calf reveals a 4-cm fluctuant nodule surrounded by a 6-cm area of intense erythema, induration, and warmth. Bedside ultrasound confirms a localized fluid collection. An incision and drainage procedure is performed, yielding 20 mL of purulent exudate. Given the significant surrounding cellulitis and the high local prevalence of community-acquired methicillin-resistant *Staphylococcus aureus* (MRSA), the physician decides to initiate empiric oral antibiotic therapy. Which of the following is the most appropriate pharmacologic intervention?

A 31-year-old male is transported to the trauma center via ambulance following an assault with a sharp object. He sustained a single stab wound to the left anterolateral neck, horizontally aligned with the cricoid cartilage. He appears severely distressed, diaphoretic, and is clutching his neck. His temperature is $36.6^\circ\text{C}$ ($97.9^\circ\text{F}$), pulse is $142\text{/min}$, blood pressure is $78/42\text{ mm Hg}$, and respirations are $32\text{/min}$. Oxygen saturation is $90\%$ on ambient air. Physical examination demonstrates a $4\text{-cm}$ laceration with pulsatile hemorrhage that is only partially controlled with direct pressure by the emergency responders. A prominent, tense hematoma is visibly enlarging and deviating the larynx to the contralateral side, accompanied by biphasic stridor. Which of the following interventions are mandatory immediate next steps in this patient's procedural management? (Select all that apply.)

An $81$-year-old male resident of a memory care facility is transported to the hospital due to progressive abdominal distension and failure to pass stool or flatus for the past three days. He has a history of vascular dementia, Parkinson disease, and chronic constipation. His daily medications include carbidopa-levodopa, donepezil, and scheduled senna. Vital signs show a temperature of $37.1^\circ$ C ($98.8^\circ$ F), blood pressure of $134/82$ mm Hg, pulse of $94$/min, and respiratory rate of $18$/min. On physical examination, the abdomen is markedly distended and tympanic to percussion. There is generalized mild tenderness to deep palpation, but no guarding, rebound tenderness, or rigidity is noted. Bowel sounds are high-pitched and infrequent. Laboratory testing reveals a leukocyte count of $9,500$/mm $^3$ and a serum lactate of $1.1$ mmol/L. An unenhanced abdominal computed tomography scan demonstrates a massively dilated loop of large bowel forming a U-shape in the pelvis, converging toward the left lower quadrant, accompanied by a mesenteric "whirl sign". No free intraperitoneal air or bowel wall pneumatosis is visualized. Which of the following is the most appropriate next step in management?

An office worker in his late 60s is evaluated in the clinic for three months of non-radiating, deep lower back pain and progressive generalized fatigue. He reports that his pain is worse with movement and has not responded to escalating doses of over-the-counter ibuprofen. He denies fevers, weight loss, or urinary incontinence. His past medical history is notable only for mild osteoarthritis. Vital signs are within normal limits. Physical examination demonstrates marked conjunctival pallor and localized tenderness to palpation over the L3 and L4 spinous processes. Neurological examination, including strength, sensation, and deep tendon reflexes in the lower extremities, is unremarkable. Initial laboratory analysis reveals the following:

* Hemoglobin: 9.4 g/dL
* Mean corpuscular volume: 89 fL
* Leukocyte count: 5,500/mm³
* Platelet count: 165,000/mm³
* Creatinine: 1.8 mg/dL
* Calcium: 11.4 mg/dL

Which of the following diagnostic studies should be ordered concurrently as the most appropriate next steps in this patient's evaluation? (Select three)

Identify the most appropriate initial admission location or post-acute care transition setting for the following clinical scenarios.