Patient Management

A 24-year-old woman with a history of type 1 diabetes mellitus is admitted to the intensive care unit for the management of diabetic ketoacidosis (DKA). On presentation, she has a serum glucose of $580 \text{ mg/dL}$, an anion gap of $24 \text{ mEq/L}$, and a serum potassium of $4.8 \text{ mEq/L}$. She has received an initial intravenous fluid bolus of 0.9% sodium chloride.

Arrange the following monitoring and therapeutic steps in the correct chronological sequence required for the safe resolution of her DKA and transition to maintenance therapy.

An emergency physician evaluates a patient who was brought in by ambulance for severe, worsening shortness of breath.

The patient is a 52-year-old female who reports progressive chest tightness, wheezing, and a sensation of her heart racing that began early this morning. Her medical history is notable for severe persistent asthma, hypertension, and recently diagnosed hyperthyroidism for which she is awaiting endocrinology follow-up. She states that she ran out of her methimazole prescription two weeks ago. Current medications include high-dose inhaled fluticasone-salmeterol, an albuterol rescue inhaler, and oral amlodipine.

Vital signs are: Temperature 37.0°C (98.6°F), blood pressure 118/76 mmHg, pulse 148/min, respirations 26/min, and oxygen saturation 90% on room air.

Physical examination reveals a patient in visible respiratory distress using accessory muscles of respiration. Lung auscultation demonstrates diffuse, bilateral expiratory wheezing with a markedly prolonged expiratory phase.

A 12-lead electrocardiogram shows a narrow-complex, irregularly irregular tachycardia at a rate of 148/min with absent P waves. There are no ischemic ST-segment changes.

The patient is immediately placed on supplemental oxygen and started on continuous nebulized albuterol, ipratropium, and intravenous methylprednisolone. Thirty minutes later, her respiratory status improves slightly (oxygen saturation now 94%), but her heart rate remains elevated at 145/min, and she complains of ongoing uncomfortable palpitations.

Which of the following is the most appropriate pharmacologic intervention to manage her heart rate?

Paramedics bring a 42-year-old man to the trauma bay following a high-velocity motor vehicle crash. On arrival, the patient is highly agitated and gasping for air. Physical examination demonstrates severe maxillofacial crush injuries with massive ongoing hemorrhage from the nose and mouth. Vital signs show a blood pressure of 110/70 mm Hg, heart rate of 128/min, and respiratory rate of 28/min. Oxygen saturation is 81% on a high-flow non-rebreather mask. Marked intercostal retractions and audible stridor are present. Because of the distorted anatomy and copious blood pooling in the oropharynx, an experienced physician is unable to visualize the vocal cords after two attempts at direct orotracheal intubation. Subsequent attempts to oxygenate the patient using a bag-valve-mask device are ineffective. Which of the following is the most appropriate next step in management?

Match the following ambulatory patient profiles with their most critical, guideline-indicated preventive screening or immunization step.

During a busy morning in the primary care clinic, a physician evaluates four different adult patients for their routine health maintenance visits. For each patient presentation, identify the single most appropriate, guideline-concordant preventive screening or immunization intervention.

A 35-year-old man is brought to the emergency department by emergency medical services following a high-speed motorcycle collision. On arrival, he is confused and diaphoretic. His temperature is 36.5°C (97.7°F), blood pressure is 78/45 mm Hg, pulse is 135/min, and respiratory rate is 28/min. Pulse oximetry shows 88% on room air. Primary survey reveals a patent airway but absent breath sounds over the right hemithorax and dullness to percussion. An extended focused assessment with sonography in trauma (eFAST) scan reveals a large fluid collection in the right pleural space and no pericardial effusion. A right-sided tube thoracostomy is promptly placed, which immediately drains 1,600 mL of bright red blood. The patient's blood pressure transiently improves to 88/50 mm Hg after the administration of 1 liter of intravenous crystalloid fluid, but then drops back to 76/40 mm Hg. Which of the following are the most appropriate immediate next steps in the management of this patient? (Select all that apply)

A 22-year-old woman is brought to the emergency department by her roommate due to progressive lethargy, confusion, and recurrent vomiting over the last 48 hours. The patient has a history of bipolar I disorder and generalized tonic-clonic seizures. Her home medications include valproic acid, which was initiated six weeks ago, and a daily multivitamin. She does not use alcohol, tobacco, or illicit drugs.

On presentation, her temperature is 36.8°C (98.2°F), blood pressure is 118/74 mm Hg, pulse is 88/min, and respiratory rate is 14/min. Physical examination shows a somnolent woman who is oriented only to her name. A bilateral flapping tremor of the hands is elicited upon wrist extension. No jaundice, scleral icterus, or abdominal distension is noted.

Laboratory studies are obtained:

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

A 24-year-old man comes to the emergency department due to sudden-onset severe dyspnea, palpitations, and lightheadedness that began while playing basketball. He reports no chest pain but feels as though he might pass out. His medical history is significant for a heart murmur identified during adolescence, though he was lost to follow-up. Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $92/60\text{ mmHg}$, pulse $132\text{/min}$ and regular, and respirations $24\text{/min}$. Pulse oximetry is $91\%$ on room air. Physical examination reveals a harsh, crescendo-decrescendo systolic murmur at the left lower sternal border; the murmur's intensity increases when the patient transitions from a squatting to a standing position. Pulmonary auscultation reveals fine crackles at both lung bases. An electrocardiogram demonstrates sinus tachycardia with marked left ventricular hypertrophy and deep, narrow Q waves in the lateral leads. Which of the following is the most appropriate initial pharmacologic intervention?

A 72-year-old man is evaluated in the primary care clinic to discuss stroke prevention. He was recently diagnosed with nonvalvular atrial fibrillation after presenting with intermittent palpitations. He has a history of hypertension, benign prostatic hyperplasia, and osteoarthritis. Current medications include lisinopril, tamsulosin, and acetaminophen as needed. His heart rate is currently 78/min and regular. After a shared decision-making discussion regarding his CHA2DS2-VASc score and bleeding risks, the physician decides to initiate rivaroxaban.

Which of the following laboratory evaluations are essential for baseline assessment and routine ongoing monitoring of this specific pharmacotherapy? (Select all that apply)

A dermatologist refers a 58-year-old woman to the primary care clinic to optimize her preventive health measures. She has a 10-year history of severe plaque psoriasis that is currently well controlled with adalimumab monotherapy. She has no other medical conditions and does not use tobacco or alcohol. Her surgical history is notable for an uncomplicated appendectomy in her twenties. She reports having a painful episode of shingles on her right flank three years ago. Review of her records shows that a screening mammogram and a co-testing cervical cancer screening (Pap smear and HPV testing) were both performed one year ago with normal results. Her last screening colonoscopy was at age 50 and was entirely normal. Her immunizations are up to date for annual influenza, and a tetanus-diphtheria-acellular pertussis (Tdap) booster was given four years ago. She has not received any pneumococcal or zoster vaccinations. Which of the following is the most appropriate next step in this patient's preventive management?

A $68$-year-old woman presents to the cardiology clinic for a routine follow-up. She has a history of heart failure with reduced ejection fraction (left ventricular ejection fraction of $30\%$). Her current daily medication regimen includes lisinopril, carvedilol, spironolactone, and digoxin. She has been stable on these medications for the past two years, with her most recent serum digoxin concentration measuring $0.8 \text{ ng/mL}$ (therapeutic range for heart failure: $0.5 - 0.9 \text{ ng/mL}$). During today's visit, an electrocardiogram reveals new-onset paroxysmal atrial fibrillation with a ventricular rate of $110/\text{min}$. The physician decides to initiate amiodarone therapy for rhythm control and suppression of the atrial fibrillation. Which of the following is the most appropriate next step regarding her current medication regimen?

A 45-year-old man with a history of poorly controlled type 2 diabetes mellitus presents to the emergency department with a 24-hour history of severe left knee pain, swelling, and subjective fevers. He reports no recent trauma to the area. Vital signs show a temperature of 39.1°C (102.4°F), blood pressure of 110/70 mm Hg, heart rate of 112/min, and respiratory rate of 18/min. On physical examination, the left knee is markedly swollen, erythematous, and warm to the touch. Severe pain is elicited with minimal passive range of motion, and the patient refuses to bear weight on the affected limb. Arrange the following surgical and medical management steps in the most appropriate chronological order for this patient.

A $72$-year-old man with a history of small cell lung cancer is brought to the emergency department after a witnessed generalized tonic-clonic seizure. His family reports that he has been progressively confused and lethargic over the past $3$ days. On arrival, he is postictal but protecting his airway. His vital signs are within normal limits. Laboratory studies reveal:

* Serum sodium: $112$ mEq/L
* Serum potassium: $4.0$ mEq/L
* Serum osmolality: $240$ mOsm/kg
* Urine osmolality: $600$ mOsm/kg
* Urine sodium: $50$ mEq/L

Arrange the following steps in the correct chronological sequence for the acute management and ongoing monitoring of this patient's condition.

A 48-year-old woman comes to the clinic reporting persistently low mood, anhedonia, fatigue, and difficulty concentrating for the past three months. She states she has been struggling emotionally since completing local radiation therapy for early-stage, estrogen receptor-positive breast cancer six months ago. She has been taking tamoxifen daily since that time. In addition to her mood symptoms, she complains of severe, frequent hot flashes that wake her up multiple times a night, resulting in significant daytime sleepiness. Her vital signs are temperature 37.0°C (98.6°F), blood pressure 122/78 mm Hg, and pulse 74/min. Physical examination is unremarkable. The physician diagnoses her with major depressive disorder and discusses treatment options to manage her current symptoms. Which of the following is the most appropriate pharmacologic intervention?

A 56-year-old woman comes to the clinic for a routine wellness examination. She feels well and has no specific concerns today. Her past medical history is notable for hypertension, which is well controlled with lisinopril. She has never smoked cigarettes, consumes alcohol occasionally, and exercises three times a week. Her family history is negative for cancer or osteoporotic fractures.

A review of her electronic medical record reveals the following recent screening results:
- Screening mammography performed 12 months ago showed no evidence of malignancy (BI-RADS category 1).
- Fecal immunochemical test (FIT) performed 12 months ago was negative.
- Cervical cytology with high-risk human papillomavirus (hrHPV) co-testing performed 3 years ago was negative for intraepithelial lesion or malignancy and negative for hrHPV.
- Fasting lipid panel and hemoglobin A1c performed 6 months ago were within normal limits.

She is up to date on all recommended vaccinations. Her body mass index is 24 kg/m².

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

A 61-year-old male is currently in the medical intensive care unit undergoing treatment for a severe exacerbation of chronic obstructive pulmonary disease. He was placed on prophylactic subcutaneous unfractionated heparin upon admission. On day 6 of hospitalization, routine complete blood count reveals a platelet count of $85,000/\mu L$, a significant decline from his admission baseline of $210,000/\mu L$. Concurrently, he complains of new-onset right calf pain, and venous duplex ultrasonography confirms a new deep vein thrombosis. A presumptive diagnosis of heparin-induced thrombocytopenia (HIT) with thrombosis is made.

Arrange the following steps for the immediate management, subsequent monitoring, and treatment evaluation of this patient in the correct chronological sequence.

A 71-year-old man arrives at the emergency department complaining of sudden, agonizing pain in his left leg that started 3 hours ago. He has a medical history of essential hypertension and paroxysmal atrial fibrillation, but he stopped taking his prescribed apixaban two months ago. Vital signs are temperature 37.1°C (98.8°F), blood pressure 148/88 mm Hg, heart rate 118/min and irregularly irregular, and respiratory rate 18/min. On physical examination, the left lower extremity is pale, mottled, and cold to the touch from the mid-thigh distally. The patient reports severe numbness over the dorsal aspect of his left foot and demonstrates mild weakness when asked to actively dorsiflex his toes. Handheld Doppler ultrasound evaluation of the left lower extremity reveals absent arterial signals in the dorsalis pedis and posterior tibial arteries, but venous signals remain audible.

Which of the following are the most appropriate immediate next steps in the management of this patient? (Select exactly 2 options)

A 32-year-old man comes to the emergency department complaining of right lower quadrant abdominal pain that has been progressively worsening over the past 5 days. He also reports nausea, decreased appetite, and subjective fever. His temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $110/70\text{ mmHg}$, pulse is $105/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals focal tenderness and a palpable fullness in the right lower quadrant, with localized guarding. Laboratory studies show a leukocyte count of $18,000/\text{mm}^3$ with a left shift. Intravenous fluids and broad-spectrum antibiotics are initiated. A computed tomography scan of the abdomen and pelvis with intravenous contrast reveals a ruptured appendix with an adjacent $6.5\text{-cm}$ fluid collection demonstrating an enhancing rim. Which of the following is the most appropriate next step in the management of this patient?

An internal medicine team is evaluating a 67-year-old female who was directly admitted to the hospital with a 24-hour history of high fever, profound weakness, and new-onset gingival bleeding. Her past medical history is notable for seropositive rheumatoid arthritis, essential hypertension, and type 2 diabetes mellitus. Her home medications include weekly oral methotrexate, daily folic acid, lisinopril, and metformin. Review of her recent outpatient records reveals a visit to an urgent care clinic three days prior for dysuria, during which she was prescribed a 7-day course of trimethoprim-sulfamethoxazole.

Upon evaluation, her temperature is 38.2 °C (100.8 °F), blood pressure is 110/70 mmHg, and heart rate is 105/min. Physical examination demonstrates pale conjunctivae and scattered non-blanching petechiae across her lower extremities.

Initial laboratory studies show:

Blood and urine cultures have been obtained. Which of the following pharmacologic interventions are immediately indicated for this patient? (Select all that apply)

An emergency medical services unit brings a 36-year-old male to the trauma center following prolonged extraction from a burning residential building. On primary survey, the patient is highly agitated and in severe respiratory distress, demonstrating vigorous accessory muscle use and audible biphasic stridor. His voice is notably hoarse, and there is visible carbonaceous material within the oropharynx. Physical examination reveals leathery, contracted, and painless full-thickness burns circumferentially involving his entire anterior and posterior chest wall, as well as both upper extremities. Vital signs are temperature 37.1°C (98.8°F), heart rate 132/min, blood pressure 88/58 mm Hg, and respiratory rate 36/min. Pulse oximetry shows 91% on a 15 L/min non-rebreather mask. Radial pulses are absent on the left and evaluated only by Doppler ultrasound on the right. His chest excursion is severely limited during maximal inspiratory effort, resulting in shallow tidal volumes. Which of the following procedural interventions are emergently indicated? (Select all that apply)