Patient Management

Match each patient scenario to the most appropriate discharge disposition or care transition service.

A $68$-year-old woman is admitted to the intensive care unit with profound lethargy, confusion, and a generalized tonic-clonic seizure. She has a history of hypertension for which chlorthalidone was prescribed two weeks ago. On admission (Hour 0), her serum sodium concentration is $111$ mEq/L. A 3% sodium chloride infusion is initiated. Six hours later, her mental status improves, and the infusion rate is reduced by half. The following morning (Hour 12), the patient is alert and oriented. The nurse notes a significant increase in urine output to approximately $400$ mL/hr over the past three hours.

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

A 54-year-old man with a history of alcoholic cirrhosis and esophageal varices is brought to the emergency department by his wife due to worsening confusion, subjective fever, and increasing abdominal distension over the past 48 hours. His home medications include spironolactone, furosemide, propranolol, and lactulose, though his wife reports he has refused to take them for the last three days. His temperature is $38.2^\circ\text{C}$ ($100.8^\circ\text{F}$), blood pressure is $88/54\text{ mmHg}$, heart rate is $112/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination reveals scleral icterus, marked ascites with shifting dullness, and diffuse mild abdominal tenderness without rebound. He is lethargic and exhibits asterixis.

Laboratory results are as follows:

Baseline serum creatinine from three weeks ago was $0.9\text{ mg/dL}$. Diagnostic paracentesis yields cloudy ascitic fluid with a total leukocyte count of $850/\mu\text{L}$ and a neutrophil count of $520/\mu\text{L}$.

In addition to judicious fluid resuscitation, which of the following pharmacologic interventions should be included in this patient's immediate management plan? (Select all that apply)

During an outpatient rheumatology consultation, a $42$-year-old woman receives a new diagnosis of highly active, erosive rheumatoid arthritis. She has a past medical history of type $2$ diabetes mellitus and mild intermittent asthma, currently managed with metformin and as-needed albuterol. Due to rapidly progressive joint destruction and elevated inflammatory markers, the physician plans to initiate aggressive combination therapy with methotrexate and infliximab. Physical examination reveals symmetric synovitis in the metacarpophalangeal and proximal interphalangeal joints bilaterally. The cardiovascular and pulmonary examinations are completely unremarkable, with no jugular venous distention, crackles, or edema. The patient has no history of international travel or known infectious exposures.

Which of the following baseline screening evaluations MUST be obtained prior to initiating this specific pharmacologic regimen? (Select the 2 correct answers.)

Determine the optimal post-evaluation care setting or discharge disposition for each of the following clinical presentations by synthesizing their risk stratification scores, functional capacities, and therapeutic requirements.

During a routine employee wellness check, a 35-year-old female teacher is noted to have an asymmetric neck. She reports feeling entirely well, with no recent weight changes, palpitations, heat intolerance, or changes in bowel habits. Her medical history includes only mild seasonal allergies, for which she takes an over-the-counter antihistamine as needed. Her blood pressure is 118/76 mmHg and heart rate is 72/min. On palpation, a 2.0-cm, firm, non-tender mass is identified in the right thyroid lobe. The mass moves upward when the patient swallows. No adjacent cervical lymphadenopathy is appreciated. Which of the following represents the most appropriate initial step in the diagnostic workup for this patient?

Match each of the following ambulatory patient profiles with the single most appropriate guideline-concordant preventive care intervention.

A 42-year-old woman comes to the clinic for an annual health maintenance examination. She has a history of generalized anxiety disorder, which is well controlled with sertraline. She has no family history of breast, colon, ovarian, or other malignancies. She underwent cervical cancer screening with cytology and human papillomavirus (HPV) co-testing 3 years ago, which yielded negative results. She does not smoke and drinks one glass of wine on weekends. Her body mass index is 23 kg/m2, and her blood pressure is 118/76 mmHg. Physical examination, including a clinical breast examination, reveals no abnormalities. Which of the following cancer screening recommendations is most appropriate for this patient at this time?

A multidisciplinary care team is formulating a transition plan for a 71-year-old woman who has been hospitalized for 28 days following a complex coronary artery bypass grafting procedure. Her postoperative course was complicated by a deep sternal wound infection requiring surgical debridement and severe acute respiratory distress syndrome.

She currently has a tracheostomy in place and remains dependent on mechanical ventilation via pressure support for 16 hours daily. The respiratory therapy team is conducting ongoing weaning trials, but she experiences significant respiratory muscle fatigue during prolonged trials. She is hemodynamically stable, afebrile, and has not required vasoactive medications for 12 days. She requires a six-week course of intravenous antibiotics and negative pressure wound therapy with dressing changes every 48 hours.

On neurologic examination, she is alert, interactive, and correctly follows multi-step commands. However, physical and occupational therapy assessments reveal profound critical illness polyneuropathy. She requires maximum assistance to sit at the edge of the bed and can only participate in active rehabilitation exercises for 15 to 20 minutes per day before becoming exhausted.

Which of the following is the most appropriate care setting transition for this patient?

A $61$-year-old man with end-stage renal disease presents to the emergency department with profound generalized weakness. He missed his last two scheduled hemodialysis sessions due to transportation issues. His pulse is $52$/min, blood pressure is $110/70$ mmHg, and respiratory rate is $16$/min. An electrocardiogram reveals prolonged PR intervals, widened QRS complexes, and tall, peaked T waves. Laboratory studies show a serum potassium level of $8.1$ mEq/L.

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

A 64-year-old female is brought to the emergency department after the sudden onset of excruciating abdominal pain that began 3 hours ago. She has a history of nonvalvular atrial fibrillation but stopped taking her prescribed rivaroxaban one month ago. On physical examination, the patient appears distressed and is writhing on the stretcher. Her abdomen is soft and mildly tender to deep palpation, without guarding, rigidity, or rebound tenderness. Her temperature is $37.4^\circ\text{C}$ ($99.3^\circ\text{F}$), blood pressure is $135/82\text{ mmHg}$, heart rate is $112\text{/min}$ and irregular, and respiratory rate is $22\text{/min}$. Laboratory studies show a leukocyte count of $17,200\text{/mm}^3$ and a serum lactate level of $5.4\text{ mmol/L}$. Based on the suspected diagnosis, arrange the following procedural and management steps in the most appropriate chronological sequence for this patient.

A 68-year-old man is nearing the end of his hospital stay following an admission for severe sepsis secondary to pneumonia. He has completed a course of intravenous antibiotics and is now hemodynamically stable. Due to significant generalized deconditioning, the multidisciplinary team has recommended a transition to a skilled nursing facility (SNF) for physical rehabilitation. As the attending physician, you are leading the transition of care process to minimize the risk of readmission and ensure patient safety.

Arrange the following essential steps of this patient's care transition in the most appropriate chronological sequence according to standard safe discharge practices.

A 58-year-old woman comes to the physician's office due to increasingly difficult breathing over the past four weeks. She reports that her symptoms worsen when walking up a flight of stairs, and she has recently started sleeping with three pillows at night to avoid feeling "smothered." Her medical history is notable for type 2 diabetes mellitus and essential hypertension. Current medications include metformin and lisinopril. Blood pressure is 148/92 mm Hg, pulse is 88/min, and respirations are 18/min. Pulse oximetry shows 95% on room air. Physical examination reveals elevated jugular venous pressure, fine bibasilar crackles on lung auscultation, a regular heart rhythm with a prominent S3 gallop, and 2+ bilateral lower extremity pitting edema. Which of the following diagnostic tests should be ordered as part of the initial workup for this patient's condition? (Select all that apply)

A 45-year-old woman is brought to the emergency department by her husband due to severe agitation, confusion, and shivering that began earlier today. She has a history of major depressive disorder and was recently diagnosed with a soft tissue infection. Her daily home medications include citalopram. Three days ago, she was started on oral linezolid. Her temperature is 39.1°C (102.4°F), blood pressure is 165/95 mmHg, pulse is 122/min, and respiratory rate is 22/min. Physical examination reveals profuse diaphoresis, dilated pupils, and hyperreflexia with inducible myoclonus in the bilateral lower extremities. Intravenous fluids and lorazepam are administered, but her symptoms persist. Which of the following pharmacologic interventions is the most appropriate next step in management?

An industrial worker is brought to the emergency department after a heavy steel pipe rolled onto his lower torso. Upon arrival, he is pale, diaphoretic, and confused. His temperature is 36.5°C (97.7°F), blood pressure is 78/42 mm Hg, pulse is 138/min, and respirations are 24/min. The airway is patent, and breath sounds are equal bilaterally. Inspection reveals extensive ecchymosis over the suprapubic and perineal areas. There is gross blood visible at the urethral meatus. Gentle anteroposterior pressure on the iliac crests reveals mechanical instability. Intravenous access is established, a pelvic binder is applied immediately, and a massive transfusion protocol is initiated. A focused assessment with sonography for trauma (FAST) shows no fluid in the pericardial sac or peritoneal cavity. Despite the administration of 2 units of uncrossmatched packed red blood cells and 1 liter of crystalloid, his blood pressure remains 80/45 mm Hg. Which of the following is the most appropriate next step in management?

An executive visits a primary care provider to discuss recurrent chest tightness. The 54-year-old male patient reports that the central chest sensation is predictably triggered by brisk walking and consistently subsides following a few minutes of rest. His medical history includes type 2 diabetes mellitus and dyslipidemia, which are managed with metformin and rosuvastatin. Office vital signs show a pulse of 74/min and a blood pressure of 136/82 mm Hg. Cardiopulmonary auscultation yields no murmurs, gallops, or abnormal breath sounds. The patient is functionally active, has a normal gait, and exercises recreationally. A baseline resting electrocardiogram demonstrates normal sinus rhythm with no ST-segment or T-wave alterations. Which of the following is the most appropriate next step in the diagnostic workup?

A 55-year-old woman comes to the clinic for a routine health maintenance examination. Her past medical history is notable for hypertension, which is well controlled on lisinopril. She currently smokes 1 pack of cigarettes daily and has a 35 pack-year smoking history. Her surgical history includes a total abdominal hysterectomy for symptomatic uterine fibroids at age 42. She has not seen a physician in 6 years and does not remember her previous health screening dates, except for a normal screening mammogram at age 49. Her blood pressure is 126/78 mm Hg, heart rate is 72/min, and BMI is 24 kg/m². She is asymptomatic. Which of the following preventive care interventions are indicated for this patient at this visit? (Select all that apply.)

A $67$-year-old woman is evaluated in the intensive care unit for worsening clinical status. She was admitted $4$ days ago after undergoing an elective partial colectomy for diverticular disease. Over the last $4$ hours, she has become increasingly lethargic. Her temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $76/42\text{ mmHg}$, heart rate is $132\text{/min}$, and respiratory rate is $24\text{/min}$. Her urine output has been $15\text{ mL}$ over the past $2$ hours. Physical examination reveals a rigid, distended abdomen with diffuse rebound tenderness.

The patient has received $3\text{ L}$ of intravenous lactated Ringer solution over the past $3$ hours, but her blood pressure remains $78/44\text{ mmHg}$.

Laboratory studies show:
Leukocyte count: $18,500\text{/mm}^3$
Lactate: $5.8\text{ mmol/L}$
Creatinine: $1.9\text{ mg/dL}$ (baseline $0.8\text{ mg/dL}$)
INR: $1.5$ (normal: $0.8-1.1$)

There is no evidence of active bleeding from the surgical site or other orifices. Blood cultures and abdominal imaging have been ordered.

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

A $58$-year-old man presents to the emergency department with a $2$-hour history of sudden-onset, severe, diffuse abdominal pain. His medical history is significant for a mechanical mitral valve replacement performed $3$ years ago, for which he takes daily warfarin.

On physical examination, his temperature is $38.4^\circ\text{C}$ ($101.1^\circ\text{F}$), blood pressure is $92/58\text{ mmHg}$, heart rate is $115/\text{min}$, and respiratory rate is $22/\text{min}$. The patient lies completely still on the stretcher. His abdomen is rigid with diffuse rebound tenderness and involuntary guarding.

Laboratory studies show:
- Hemoglobin: $13.2\text{ g/dL}$
- Leukocyte count: $16,500/\text{mm}^3$
- Platelet count: $210,000/\text{mm}^3$
- International normalized ratio (INR): $3.2$

An upright chest radiograph demonstrates free air under the right hemidiaphragm.

Which of the following are the most appropriate immediate steps in management? (Select all that apply)

A $66$-year-old male comes to the clinic for follow-up of recent fatigue, severe heat intolerance, and an unintentional weight loss of $4.5\text{ kg}$ ($10\text{ lb}$) over the last month. His medical history is significant for ischemic cardiomyopathy with a reduced ejection fraction and recurrent sustained ventricular tachycardia. His medications include sacubitril-valsartan, metoprolol succinate, spironolactone, and amiodarone, which he has taken for two years. Vital signs show a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), a blood pressure of $118/76\text{ mmHg}$, and an irregular pulse of $112/\text{min}$. Physical examination reveals warm, moist skin and a fine bilateral hand tremor. No goiter or exophthalmos is noted.

Laboratory results are as follows:
Thyroid-stimulating hormone (TSH): $<0.01\text{ }\mu\text{U/mL}$ (Normal: $0.4-4.0\text{ }\mu\text{U/mL}$)
Free T4: $4.1\text{ ng/dL}$ (Normal: $0.8-1.8\text{ ng/dL}$)
Free T3: $2.8\text{ pg/mL}$ (Normal: $2.3-4.2\text{ pg/mL}$)

Color flow Doppler ultrasonography of the thyroid gland demonstrates severely decreased vascularity.

Which of the following is the most appropriate next step in the management of this patient's thyroid dysfunction?