Patient Management

A 42-year-old woman presents to the clinic for evaluation of progressive weight gain and easy bruising over the past 8 months. She also reports new-onset facial hair growth and difficulty climbing stairs due to muscle weakness. Her blood pressure is 155/95 mmHg. Physical examination reveals central obesity, facial plethora, prominent supraclavicular fat pads, and wide, purplish striae on her abdomen. Laboratory evaluation shows a fasting blood glucose of 128 mg/dL. The physician suspects a syndrome of cortisol excess. Assuming each subsequent test is indicated based on the results of the preceding evaluation and is necessary to reach a definitive diagnosis, arrange the following diagnostic steps in the most appropriate sequential order from initial screening to definitive confirmation of the source.

A $68$-year-old woman is brought to the emergency department from a skilled nursing facility due to fever and altered mental status. For the past $48$ hours, she has had right upper quadrant abdominal pain and nausea. Her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure is $78/46 \text{ mm Hg}$, pulse is $128/\text{min}$, and respirations are $26/\text{min}$. Physical examination reveals scleral icterus and right upper quadrant tenderness without rebound or guarding. She is lethargic and oriented only to person. Laboratory studies show:

Leukocyte count: $22,000/\text{mm}^3$
Total bilirubin: $8.6 \text{ mg/dL}$
Direct bilirubin: $6.4 \text{ mg/dL}$
Alkaline phosphatase: $650 \text{ U/L}$
Aspartate aminotransferase (AST): $210 \text{ U/L}$
Alanine aminotransferase (ALT): $235 \text{ U/L}$
Lactic acid: $5.2 \text{ mmol/L}$

A right upper quadrant ultrasound demonstrates a dilated common bile duct measuring $15 \text{ mm}$ with an echogenic focus casting a posterior acoustic shadow in the distal duct. The gallbladder contains multiple stones but lacks wall thickening or pericholecystic fluid. She is given $3 \text{ L}$ of intravenous crystalloid and broad-spectrum antibiotics, but her blood pressure remains $80/50 \text{ mm Hg}$, necessitating the initiation of a norepinephrine infusion. Which of the following is the most appropriate next step in management?

During a routine health maintenance visit, a 51-year-old transgender man discusses his preventive care needs. He has been receiving continuous gender-affirming testosterone therapy for the past six years. His surgical history includes a bilateral mastectomy with chest reconstruction performed five years ago; he has not undergone a hysterectomy or oophorectomy. He is a lifelong non-smoker and consumes one alcoholic beverage per week. His last preventive screening was a normal Papanicolaou (Pap) test with negative high-risk human papillomavirus (HPV) co-testing seven years ago. He has no significant family history of malignancy. His body mass index is 26 kg/m². Vital signs are within normal limits. Which of the following is the most appropriate next step in preventive care for this patient?

Evaluate the following hospitalized patients who have achieved medical stability but require continued care. Pair each patient's clinical profile with the most appropriate post-acute care transition setting based on their medical acuity, therapy tolerance, and care goals.

A $54$-year-old man is brought to the emergency department by emergency medical services after coughing up approximately $600$ mL of bright red blood over the past two hours. He has a history of treated pulmonary tuberculosis and residual cavitary disease in the left upper lobe. On arrival, he continues to cough up copious amounts of blood. His temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $105/65$ mmHg, heart rate is $122$/min, and respiratory rate is $28$/min. Pulse oximetry shows an oxygen saturation of $86\%$ on room air. Auscultation reveals coarse rhonchi over the left hemithorax and clear breath sounds on the right. Intravenous access is established. Which of the following procedural interventions are immediately indicated? (Select all that apply)

A 32-year-old woman is evaluated in the neurology clinic to discuss ongoing management of relapsing-remitting multiple sclerosis. Over the past 14 months, she has experienced two disabling clinical relapses while on daily subcutaneous glatiramer acetate. Recent magnetic resonance imaging of the brain and cervical spine reveals three new gadolinium-enhancing lesions. After discussing treatment options, the physician and patient agree to discontinue glatiramer acetate and initiate oral fingolimod. Her past medical history is notable only for mild asthma that is well-controlled with an as-needed albuterol inhaler. She takes no other medications. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 72/min, and respirations 14/min. Which of the following monitoring or baseline assessment steps are required for this patient prior to or during the initiation of this new pharmacotherapy? (Select all that apply)

A nurse urgently calls the on-duty physician to the post-anesthesia care unit to evaluate a patient who underwent an uncomplicated total thyroidectomy for a multinodular goiter three hours ago. The patient is a 48-year-old female who is now exhibiting severe agitation, high-pitched inspiratory stridor, and progressive dyspnea. Her oxygen saturation is 86% on room air. Physical examination reveals a tense, rapidly expanding swelling beneath the surgical incision on her anterior neck. Which of the following procedural and management steps are indicated IMMEDIATELY for this patient? (Select all that apply)

A hospital medicine physician is finalizing transition plans for an 84-year-old woman recovering from a severe urinary tract infection complicated by bacteremia and acute encephalopathy. After 5 days of inpatient treatment, her infection is controlled on oral antibiotics, and her mental status has returned to her baseline of mild neurocognitive disorder. Prior to this acute illness, she lived with her son and was independent in basic activities of daily living. Currently, profound deconditioning limits her mobility; she requires maximal assistance of two staff members for bed-to-chair transfers and cannot participate in physical therapy for more than 15 minutes at a time due to severe fatigue. Her son works outside the home during the day. Which of the following is the most appropriate next step in care setting transition for this patient?

A 34-year-old woman is brought to the emergency department by her husband due to severe agitation, palpitations, and confusion. She has a history of Graves disease but stopped taking her medications three months ago. Her temperature is $39.8^\circ\text{C}$ ($103.6^\circ\text{F}$), blood pressure is $168/76\text{ mmHg}$, pulse is $152/\text{min}$ and irregular, and respirations are $24/\text{min}$. Physical examination reveals a diaphoretic, delirious patient with a fine tremor, lid lag, and a diffusely enlarged, non-tender thyroid gland. An electrocardiogram shows atrial fibrillation with rapid ventricular response. Arrange the following pharmacologic interventions in the required chronological sequence for the acute management of this patient's condition to prevent exacerbation of her thyrotoxic state.

A 32-year-old woman is brought to the intensive care unit by emergency medical services due to severe agitation, delirium, and a temperature of 39.8°C (103.6°F). Her blood pressure is 158/72 mm Hg, and her pulse is 165/min and irregular. Physical examination reveals profuse diaphoresis, a diffusely enlarged and non-tender thyroid gland, bilateral proptosis, and a pronounced bilateral resting tremor. An electrocardiogram shows atrial fibrillation with a rapid ventricular response. She has a history of Graves disease but has been nonadherent to her medications for the past four months. Laboratory studies confirm a diagnosis of thyroid storm.

Arrange the following therapeutic interventions in the correct chronological order, from the most immediate initial action to the final definitive management step.

A $62$-year-old man is hospitalized for the management of a right lower extremity deep vein thrombosis and a pulmonary embolism. He was admitted $5$ days ago and immediately started on a continuous intravenous unfractionated heparin infusion. His symptoms of dyspnea and leg swelling have significantly improved. He has no active bleeding, and physical examination is unremarkable except for mild residual edema in the right calf. Today, his vital signs are stable.

Serial laboratory results are as follows:

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

A 29-year-old man comes to the clinic reporting episodic palpitations, severe throbbing headaches, and profuse sweating that have occurred roughly twice a week for the past three months. Each episode lasts approximately 20 to 30 minutes and resolves spontaneously. He has no significant past medical history and takes no medications. On physical examination in the office, his blood pressure is 182/105 mmHg and his heart rate is 112/min. The remainder of his physical examination is unremarkable. The physician strongly suspects a catecholamine-secreting tumor.

Arrange the following diagnostic steps in the most appropriate chronological sequence for the evaluation of this patient's suspected condition, from initial screening to post-diagnostic management.

A $65$-year-old woman comes to the clinic for a routine follow-up. $5$ years ago, a dual-energy x-ray absorptiometry (DEXA) scan revealed a T-score of $-2.7$ at the lumbar spine and $-2.6$ at the femoral neck. At that time, she was diagnosed with osteoporosis and was prescribed oral alendronate, along with daily calcium and vitamin D supplementation. She has been fully compliant with her regimen and has not experienced any clinical fractures. She does not smoke or consume alcohol, and she takes no other prescription medications.

Today, a repeat DEXA scan demonstrates a T-score of $-1.9$ at the lumbar spine and $-2.0$ at the femoral neck. A Fracture Risk Assessment Tool (FRAX) calculation indicates a low $10$-year probability of major osteoporotic and hip fractures. The patient inquires about the necessity of continuing her current osteoporosis pharmacotherapy.

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

A 28-year-old man is evaluated in the orthopedic trauma unit 14 hours after undergoing closed reduction and casting for a displaced midshaft tibial fracture. He reports excruciating right leg pain that is rapidly worsening and no longer relieved by intravenous opioid analgesia. On physical examination, the right calf is tense and swollen. The pain is dramatically exacerbated by passive dorsiflexion of the right toes. Capillary refill is 2 seconds, and the dorsalis pedis pulse is palpable.

Arrange the following procedural and surgical steps in the most appropriate chronological order for the definitive management of this patient's acute complication.

A 68-year-old man comes to the clinic for a follow-up visit. Two weeks ago, he was hospitalized for a mild heart failure exacerbation and was discharged in stable condition. His medical history includes ischemic cardiomyopathy with a left ventricular ejection fraction of 35%, type 2 diabetes mellitus, and hypertension. His home medications include lisinopril, carvedilol, and furosemide $40$ mg twice daily. At the time of discharge, empagliflozin was added to his regimen. Today, the patient reports feeling lightheaded when standing up from a seated position and complains of increased thirst.

Blood pressure is $110/70$ mm Hg while supine and $92/58$ mm Hg while standing. Heart rate is $72$/min while supine and $90$/min while standing. Physical examination reveals flat jugular veins while sitting and dry oral mucosa. Lungs are clear to auscultation.

Current laboratory results are as follows:

(Note: Discharge serum creatinine was $1.1$ mg/dL and BUN was $16$ mg/dL.)

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

A 54-year-old man is evaluated in the outpatient clinic for a 6-month history of episodic facial flushing, intermittent severe diarrhea, and abdominal cramping. He reports that the flushing episodes are frequently triggered by emotional stress or consuming alcohol. He has lost 4 kg (8.8 lb) over this period. Medical history is unremarkable, and he takes no daily medications. Vital signs are temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 82/min, and respiratory rate 14/min. Physical examination reveals telangiectasias over the cheeks and nose. Cardiac auscultation reveals a grade 2/6 holosystolic murmur at the left lower sternal border that becomes louder with inspiration. Abdominal examination shows mild diffuse tenderness but no hepatosplenomegaly or palpable masses. Which of the following is the most appropriate next step in the diagnostic workup?

A 74-year-old woman is evaluated in the emergency department after a sudden, brief loss of consciousness. The episode occurred while she was walking to her mailbox. She reports no preceding nausea, diaphoresis, lightheadedness, or palpitations. She regained consciousness within seconds and had no post-event confusion. Her medical history includes hypertension and osteoarthritis. Vital signs show a blood pressure of 138/82 mm Hg, heart rate of 68/min, and respiratory rate of 14/min. Orthostatic vital signs show no significant changes. Physical examination, including a comprehensive neurologic assessment, reveals no abnormalities. An electrocardiogram demonstrates normal sinus rhythm, a PR interval of 240 ms, a QRS duration of 130 ms with an rSR' pattern in lead V1, and left axis deviation. High-sensitivity cardiac troponin levels are undetectable. Based on the patient's presentation and diagnostic findings, which of the following is the most appropriate disposition for this patient?

A 62-year-old woman is brought to the emergency department by her daughter due to progressive, severe lower abdominal pain and repeated episodes of bilious vomiting over the past 12 hours. The patient has been increasingly confused since this morning. She has a history of hypertension and osteoarthritis. Her temperature is 38.9°C (102.0°F), pulse is 126/min, blood pressure is 86/54 mmHg, and respirations are 24/min. Physical examination reveals dry mucous membranes and a diaphoretic, lethargic patient. Abdominal examination is notable for a tense, erythematous, and exquisitely tender 4-cm mass in the right groin, located below the inguinal ligament. The abdomen is diffusely distended with guarding and rebound tenderness. Laboratory studies show a leukocyte count of 18,500/mm³ with 15% bands and a serum lactate level of 4.2 mmol/L. Intravenous fluid resuscitation is immediately initiated. Which of the following are the most appropriate next steps in the management of this patient? (Select all that apply)

A 72-year-old retired accountant is brought to the outpatient clinic by his son due to progressive memory decline over the past 14 months. The son reports that the patient frequently forgets recent conversations, misplaces household items, and recently struggled to balance his checkbook, a task he previously managed with ease. The patient has a medical history of essential hypertension and benign prostatic hyperplasia. Current medications include lisinopril and tamsulosin. Vital signs are within normal limits. On physical examination, there are no focal neurological deficits, and his gait is normal. The patient scores 22/30 on a standardized cognitive assessment.

According to current guidelines, which of the following investigations are indicated as part of the initial concurrent diagnostic workup to evaluate for reversible causes of this patient's cognitive decline? (Select all that apply)

A $54$-year-old man is evaluated on the inpatient medical ward $12$ hours after being admitted for increased abdominal girth, low-grade fever, and mild confusion. He has a history of decompensated cirrhosis due to chronic hepatitis C infection and alcohol use disorder. Temperature is $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse is $98/\text{min}$, and blood pressure is $105/65 \text{ mmHg}$. Physical examination reveals scleral icterus, spider angiomas, and tense ascites with shifting dullness. Asterixis is present.

Laboratory studies show:
Leukocyte count: $11,500/\text{mm}^3$
Platelet count: $85,000/\text{mm}^3$
Blood urea nitrogen: $42 \text{ mg/dL}$
Serum creatinine: $2.3 \text{ mg/dL}$ (Baseline $3$ months ago was $1.1 \text{ mg/dL}$)
Total bilirubin: $4.5 \text{ mg/dL}$
Serum albumin: $2.4 \text{ g/dL}$

Diagnostic paracentesis is performed, and ascitic fluid analysis reveals an absolute neutrophil count of $650/\text{mm}^3$ and total protein of $1.2 \text{ g/dL}$. The patient is immediately started on intravenous cefotaxime and oral lactulose.

Which of the following is the most appropriate additional pharmacologic intervention at this time?