Patient Management

A 66-year-old man presents to the clinic for an annual health maintenance examination. His past medical history is notable for diet-controlled type 2 diabetes mellitus, essential hypertension, and mild osteoarthritis of the right knee. He is a former smoker, having smoked one pack of cigarettes daily for 25 years before quitting exactly 17 years ago. His current medications include lisinopril and acetaminophen as needed.

Review of his preventive health record reveals:
- A screening colonoscopy at age 62 was unremarkable.
- An abdominal aortic aneurysm screening ultrasound at age 65 showed a normal aorta.
- He completed a primary hepatitis B vaccination series at age 55.
- He received the two-dose recombinant zoster vaccine series at age 50.
- He received his annual influenza vaccine last month.
- He has never received any pneumococcal vaccines.

Physical examination today is unremarkable. His blood pressure is 126/78 mm Hg, and his body mass index is 26 kg/m². Which of the following is the most appropriate next step in this patient's preventive care?

Targeted antimicrobial therapy is being planned for a 62-year-old female currently receiving mechanical ventilation for severe pneumonia. She was transferred from a skilled nursing facility 3 days ago. Endotracheal aspirate cultures collected on admission have finalized, demonstrating heavy growth of methicillin-resistant Staphylococcus aureus (MRSA). The patient's past medical history is notable for major depressive disorder, generalized anxiety disorder, and osteoarthritis. Her routine home medications, which are currently being administered via an orogastric tube, include citalopram, buspirone, and scheduled acetaminophen. Current laboratory studies show a serum creatinine of 0.8 mg/dL and normal hepatic transaminases. Which of the following intravenous medications is the most appropriate targeted pharmacologic intervention for this patient?

Review the following patient profiles from an outpatient primary care clinic. Match each patient with the most critical, guideline-concordant preventive care intervention required during their visit today.

A 64-year-old man is brought to the emergency department by his family due to progressive lethargy, confusion, and worsening constipation over the past week. He has a history of advanced squamous cell carcinoma of the lung. On physical examination, his temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $105/65\text{ mmHg}$, heart rate is $112\text{/min}$, and respiratory rate is $16\text{/min}$. The patient is somnolent but arousable to tactile stimuli. The mucous membranes are exceptionally dry, and skin turgor is diminished. There is no jugular venous distention, and lung fields are clear to auscultation.

Laboratory studies show:
Serum calcium: $15.6\text{ mg/dL}$
Serum phosphorus: $2.1\text{ mg/dL}$
Serum creatinine: $1.2\text{ mg/dL}$ (baseline $0.9\text{ mg/dL}$)
Intact parathyroid hormone (PTH): $8\text{ pg/mL}$ (Normal: $10-65\text{ pg/mL}$)

Aggressive intravenous fluid resuscitation with 0.9% sodium chloride is initiated. In addition to continued intravenous fluids, which of the following is the most appropriate pharmacologic intervention?

An ambulatory patient in her late sixties presents to the clinic to discuss her bone health after recent screening tests. Her dual-energy x-ray absorptiometry (DEXA) demonstrates a lumbar spine T-score of $-2.8$ and a femoral neck T-score of $-2.4$. She has a history of hypertension but no prior fragility fractures. The physician and patient agree to initiate weekly oral alendronate. Arrange the following interventions in the most appropriate chronological order to safely initiate, monitor, and manage this patient's therapeutic course.

A 68-year-old man is admitted to the intensive care unit with worsening shortness of breath and progressive lethargy over the past 2 days. He has a history of ischemic cardiomyopathy. Upon arrival, he is obtunded, and his extremities are cold and mottled. Vital signs show a temperature of $36.8^\circ \text{C}$ ($98.2^\circ \text{F}$), blood pressure of $72/48 \text{ mm Hg}$, heart rate of $118/\text{min}$, and respiratory rate of $26/\text{min}$. Jugular venous distention is prominent. Lung auscultation reveals bilateral crackles. Cardiac examination shows a summation gallop. A pulmonary artery catheter reveals a cardiac index of $1.5 \text{ L/min/m}^2$ (normal: $2.5-4.0$) and a pulmonary capillary wedge pressure of $28 \text{ mm Hg}$ (normal: $4-12$).

Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the acute stabilization and subsequent management of this patient's condition.

A physician is reviewing the electronic health record of a male patient born in 1961 ahead of an upcoming wellness visit. The current year is 2026. The patient has a past medical history of mild persistent asthma and hypertension. He currently smokes 1.5 packs of cigarettes daily and has done so for the past 30 years. Medical records indicate that a screening colonoscopy performed 6 years ago revealed no polyps or abnormalities. Hepatitis C screening was negative 3 years ago. His immunization record documents the administration of the 20-valent pneumococcal conjugate vaccine (PCV20) at age 63 and a tetanus, diphtheria, and acellular pertussis (Tdap) booster 4 years ago. He has no history of receiving any formulation of the shingles vaccine. He has never undergone vascular or pulmonary imaging.

Which of the following preventive interventions are currently indicated for this patient? (Select all that apply)

A 56-year-old man presents to the clinic for a follow-up evaluation of gout. He has a history of three acute gouty flares in the past year, affecting his left first metatarsophalangeal joint and right knee. Five weeks ago, he was started on allopurinol $100\text{ mg}$ daily for urate-lowering therapy and colchicine $0.6\text{ mg}$ daily for flare prophylaxis. His medical history is significant for hypertension and stage 3a chronic kidney disease. His estimated glomerular filtration rate is $52\text{ mL/min/1.73 m}^2$. Today, he reports feeling well and has not experienced any joint pain since starting the medications.

Laboratory results from today are as follows:

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

A 71-year-old man presents to the primary care clinic with $24$ hours of severe, sudden-onset pain and swelling in his left big toe. He reports the pain woke him from sleep and is exacerbated by the light touch of his bedsheets. He has a medical history of ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$, chronic kidney disease stage 4 with a baseline eGFR of $22 \text{ mL/min/1.73 m}^2$, and poorly controlled type 2 diabetes mellitus with a recent HbA1c of $9.2\%$. Three weeks ago, he was hospitalized for an acute heart failure exacerbation, which required increasing his daily furosemide dose. Current medications include lisinopril, carvedilol, furosemide, empagliflozin, and aspirin. Vital signs are within normal limits. Examination reveals an erythematous, exquisitely tender, and swollen left first metatarsophalangeal joint. Arthrocentesis yields synovial fluid with $45,000 \text{ leukocytes/\mu L}$ ($85\%$ neutrophils). Polarized light microscopy demonstrates negatively birefringent, needle-shaped crystals. Gram stain is negative for organisms. Which of the following is the most appropriate next step in pharmacologic management?

A primary care physician is evaluating several patients during a busy morning clinic session. Match each patient's clinical presentation with the most appropriate, guideline-concordant next step in preventive care or screening.

An internal medicine physician in an ambulatory clinic is preparing to prescribe oral methotrexate for a patient with newly diagnosed, seropositive rheumatoid arthritis. The patient has no history of liver disease, hematologic abnormalities, or chronic kidney disease. Prior to dispensing the medication and establishing a follow-up schedule, the physician is formulating a comprehensive clinical and laboratory surveillance plan. Which of the following parameters are mandatory to assess at baseline and periodically during ongoing treatment with this pharmacotherapy? (Select all that apply)

A 32-year-old female, gravida 3, para 3, is evaluated in the labor and delivery unit for severe vaginal bleeding. She has a history of mild persistent asthma, for which she uses an inhaled corticosteroid and as-needed albuterol. Twenty minutes ago, she delivered a $4.1\text{ kg}$ ($9\text{ lb}$) infant vaginally after a prolonged second stage of labor. The placenta was delivered intact. She now has a continuous, brisk flow of vaginal blood. Her temperature is $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure is $98/60\text{ mm Hg}$, and heart rate is $112/\text{min}$. The uterus is soft, boggy, and palpated $2\text{ cm}$ above the umbilicus. Intravenous oxytocin is running, and bimanual uterine massage is being performed, but the bleeding persists. Estimated blood loss is approximately $1050\text{ mL}$.

Which of the following pharmacologic agents are appropriate to administer to this patient to control the hemorrhage? (Select 3)

A 34-year-old man is evaluated in the outpatient psychiatric clinic for a routine follow-up. He has a history of treatment-resistant schizophrenia and was started on clozapine 6 weeks ago after failing trials of risperidone and olanzapine. His psychiatric symptoms have significantly improved, and he reports no auditory hallucinations for the past two weeks. He currently smokes one pack of cigarettes daily. He feels well and denies fever, chills, sore throat, or fatigue. His vital signs are within normal limits. Baseline laboratory studies prior to initiating clozapine showed a total leukocyte count of $7,200/\mu\text{L}$ and an absolute neutrophil count (ANC) of $4,500/\mu\text{L}$. Today, his total leukocyte count is $3,800/\mu\text{L}$ and his ANC is $1,300/\mu\text{L}$. The patient is not of an ethnicity typically associated with benign ethnic neutropenia. Based on the current monitoring parameters, which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

An adult patient is admitted to the cardiac telemetry unit with acute decompensated heart failure, presenting with severe bilateral lower extremity edema, jugular venous distention, and orthopnea. The patient has an established history of heart failure with reduced ejection fraction and routinely takes 40 mg of oral furosemide daily at home. The inpatient medical team plans a structured, stepwise diuretic strategy to safely achieve euvolemia while preserving renal function. Arrange the following steps in the most appropriate chronological sequence for monitoring diuretic response and sequentially adapting treatment in this patient.

A $68$-year-old woman is evaluated in the emergency department for a $2$-day history of fever, chills, right-sided flank pain, and nausea. Her medical history is significant for a mechanical mitral valve replacement $4$ years ago, paroxysmal atrial fibrillation, and recurrent urinary tract infections. Her medications include warfarin and metoprolol. Two months ago, she was hospitalized for pyelonephritis, and blood and urine cultures at that time grew Klebsiella pneumoniae confirmed to be an extended-spectrum beta-lactamase (ESBL) producer.

Upon arrival, her temperature is $39.2^{\circ}\text{C}$ ($102.6^{\circ}\text{F}$), blood pressure is $88/54\text{ mmHg}$, pulse is $118/\text{min}$ and irregularly irregular, and respiratory rate is $22/\text{min}$. Physical examination reveals marked right costovertebral angle tenderness.

Laboratory results:
Leukocyte count: $18,500/\text{mm}^3$
Serum creatinine: $2.4\text{ mg/dL}$ (baseline $0.8\text{ mg/dL}$)
INR: $3.2$
Urinalysis: $3+$ leukocyte esterase, positive nitrites, $>50\text{ WBCs/hpf}$

The patient receives a $30\text{ mL/kg}$ intravenous bolus of lactated Ringer solution. Repeat blood pressure is $112/68\text{ mmHg}$. Blood and urine cultures are obtained. Which of the following is the most appropriate next pharmacologic intervention?

A 43-year-old male arrives at the internal medicine clinic for a routine wellness evaluation. He has no acute symptoms and generally feels well. His past medical history is notable only for mild hyperlipidemia, for which he takes rosuvastatin and follows a heart-healthy diet. He exercises regularly, drinks alcohol on social occasions, and has never smoked or used illicit substances. His family history is significant for a father who was diagnosed with colon cancer at age 51. The patient has never undergone any gastrointestinal endoscopic procedures or noninvasive colorectal cancer screening. His vital signs are within normal limits, and his physical examination is unremarkable. Which of the following is the most appropriate next step regarding colorectal cancer screening for this patient?

A 19-year-old male is evaluated in the dermatology clinic for severe, scarring nodulocystic acne on his face, chest, and back. He has not experienced meaningful improvement despite a 4-month trial of oral doxycycline and topical tretinoin. The physician decides to initiate therapy with oral isotretinoin. The patient has no other medical history and takes no other medications. Which of the following evaluations are essential to perform prior to initiating and periodically during this specific pharmacotherapy? (Select 2)

A 32-year-old woman is admitted to the hospital with acute-onset right leg pain and swelling. Venous duplex ultrasonography reveals a deep vein thrombosis in the right femoral and popliteal veins. Her medical history is significant for systemic lupus erythematosus and antiphospholipid syndrome. She previously experienced a deep vein thrombosis three years ago and was treated with warfarin, but she discontinued all medications one year ago. Her vital signs are stable, and physical examination is notable only for right lower extremity pitting edema and erythema. She has no active bleeding.

Baseline laboratory studies obtained prior to treatment show:

The physician orders a continuous intravenous infusion of unfractionated heparin for acute anticoagulation. Six hours after the initiation of the heparin infusion, a repeat aPTT is reported as >150 seconds. The patient continues to have no signs of bleeding.

Which of the following is the best next step in monitoring and evaluating this patient's anticoagulant therapy?

A 53-year-old man is brought to the emergency department after falling from a 20-foot scaffolding. He is unresponsive and has a Glasgow Coma Scale score of 6 (Eye 1, Verbal 1, Motor 4). His pupils are equal and reactive, but he has a large right frontal hematoma. Vital signs are temperature 36.5°C (97.7°F), heart rate 108/min, blood pressure 172/98 mmHg, and respiratory rate 22/min. The trauma team decides to secure the airway via rapid sequence intubation (RSI) using a neuroprotective strategy to mitigate potential spikes in intracranial pressure. Pre-oxygenation with 100% oxygen is initiated.

Arrange the following pharmacologic agents in the correct chronological sequence of administration according to standard rapid sequence intubation protocols for this patient.

A male patient in his late seventies is evaluated in the emergency department for profound weakness, lightheadedness, and multiple episodes of large-volume melena that began 12 hours ago. Four days prior, he was evaluated at an urgent care clinic for a mild exacerbation of chronic obstructive pulmonary disease characterized by increased dyspnea and purulent sputum. At that time, his chronic medications—apixaban, lisinopril, tiotropium, and formoterol—were continued without dosage adjustments. He was additionally prescribed a five-day course of oral prednisone and an empiric oral antimicrobial. On presentation to the emergency department, his blood pressure is 88/54 mmHg and his pulse is 115/min. Laboratory studies reveal a hemoglobin concentration of 7.6 g/dL (down from a baseline of 13.8 g/dL three months ago) and a serum creatinine of 1.2 mg/dL. Which of the following antimicrobials was most likely prescribed during the urgent care visit?