Patient Management

A 68-year-old man is evaluated in the intensive care unit for sudden-onset shortness of breath and right-sided pleuritic chest pain. Three days ago, he underwent a left frontotemporal craniotomy for resection of a glioblastoma. His temperature is 37.1°C (98.8°F), blood pressure is 118/76 mm Hg, pulse is 112/min, and respirations are 24/min. Pulse oximetry shows 91% on room air. Physical examination reveals a well-healing cranial incision. The lungs are clear to auscultation bilaterally. Laboratory studies show a troponin I level of 0.8 ng/mL (normal: $<0.04$ ng/mL). A computed tomography pulmonary angiogram demonstrates a large filling defect in the right main pulmonary artery with associated right ventricular enlargement. Which of the following is the most appropriate next step in the management of this patient?

A 34-year-old woman presents to the clinic for a routine health maintenance visit. Six months ago, she was diagnosed with Crohn disease involving the terminal ileum and colon. Her disease is currently in clinical remission on a maintenance regimen of infliximab and azathioprine. She feels well and reports no abdominal pain, diarrhea, or weight loss. She works as a high school teacher. Review of her immunization records reveals she received all standard childhood vaccines but has not received any immunizations since age 18. Laboratory evaluation shows negative varicella-zoster virus IgG antibodies. Her vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in the preventive management of this patient?

A 42-year-old man is being prepared for discharge after a 28-day hospital course for severe acute necrotizing pancreatitis complicated by infected pseudocysts. He underwent multiple exploratory laparotomies and abdominal washouts. He is now afebrile, tolerating a transitional oral diet, and his open abdominal wounds are healing well via secondary intention, though they require daily complex dressing changes. The multidisciplinary team determines he is stable to be discharged to his private residence with support from a Home Health Agency (HHA) for wound care and outpatient parenteral antimicrobial therapy (OPAT).

Arrange the following steps of the hospital discharge and care transition process in the most appropriate chronological sequence to ensure patient safety and minimize the risk of readmission.

An internal medicine physician is coordinating the care transition for a 69-year-old woman on hospital day 6. She was initially hospitalized for sepsis secondary to a complicated urinary tract infection. Her clinical course included a three-day intensive care unit stay requiring vasopressor support. She has since been successfully stepped down to the general medical floor, and her infection has clinically resolved on targeted oral antibiotic therapy. She has a history of diet-controlled type 2 diabetes mellitus and moderate osteoarthritis of the knees.

Her vital signs are now stable and within normal limits. A multidisciplinary evaluation notes that she requires moderate physical assistance from one person to transfer from a bed to a chair and to walk short distances. During daily sessions with physical and occupational therapy, the patient becomes visibly exhausted and cannot participate in therapeutic exercises for more than 45 minutes total per day.

Before her illness, she lived independently in a single-story house. Her only relative is a son who lives in a neighboring state and is unable to provide physical assistance or stay with her.

Based on her clinical and functional status, which of the following is the most appropriate next step in care transition for this patient?

A 78-year-old woman is evaluated on hospital day 7 for disposition planning. She was admitted for an acute right middle cerebral artery territory ischemic stroke. Her hospital course was complicated by mild aspiration pneumonia, which has been fully treated with a 5-day course of intravenous antibiotics.

Her past medical history includes hypertension, vascular dementia, and severe oropharyngeal dysphagia. A percutaneous endoscopic gastrostomy (PEG) tube was placed two years ago, and her enteral feeding regimen is well-tolerated and stable.

Currently, she is afebrile and medically stable with vital signs within normal limits. She is breathing comfortably on room air.

Neurologic examination shows dense left-sided hemiplegia, profound left-sided neglect, and expressive aphasia. She is bedbound and requires maximal assistance from two caregivers for all activities of daily living (ADLs), including bed mobility, transfers, and personal hygiene. She is unable to follow multi-step commands and cannot actively participate in physical or occupational therapy sessions.

The patient lives with her 82-year-old husband, who has advanced Parkinson disease and relies on a motorized wheelchair. He is her designated healthcare proxy and states he can no longer physically care for her at home. He is fully cooperative with the medical team's recommendations. They have no other local family support.

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

A 48-year-old man presents to the primary care clinic reporting worsening fatigue, excessive sweating, and joint pain in his knees and hands over the past year. He mentions that his wedding ring no longer fits and he recently had to purchase shoes two sizes larger than his usual size. He has a history of newly diagnosed hypertension and obstructive sleep apnea. Vital signs show a blood pressure of 152/94 mm Hg, heart rate of 76/min, and respiratory rate of 14/min. Physical examination reveals coarse facial features, a prominent mandible, macroglossia, and enlarged, doughy hands. Visual field testing by confrontation is normal. A serum insulin-like growth factor-1 (IGF-1) level is ordered and returns markedly elevated for his age and sex. Which of the following is the most appropriate next step in the patient's diagnostic workup?

A 62-year-old woman presents to the outpatient clinic with a 4-day history of intense vulvar pruritus, dysuria, and a thick, white, odorless vaginal discharge. Her medical history is significant for a mechanical mitral valve replacement 5 years ago, for which she takes daily warfarin. Her other medications include metoprolol and low-dose aspirin. Her last international normalized ratio (INR) obtained one week ago was 2.8, which is within her target range of 2.5 to 3.5. Vital signs are within normal limits. Pelvic examination reveals significant vulvovaginal erythema and thick, adherent white plaques on the vaginal walls. A potassium hydroxide (KOH) preparation of the vaginal discharge reveals branching pseudohyphae and budding yeast. Which of the following is the most appropriate pharmacologic intervention for this patient?

A 67-year-old man is evaluated in the emergency department for sudden-onset, severe, tearing pain between his shoulder blades that began two hours ago. He has a history of poorly controlled hypertension, hyperlipidemia, and a 40-pack-year smoking history. On presentation, his blood pressure is 218/114 mmHg in the right arm and 212/110 mmHg in the left arm, and his heart rate is 112/min. Physical examination reveals a distressed, diaphoretic patient. Cardiovascular examination shows a regular rhythm with no murmurs. Abdominal examination reveals diffuse tenderness with voluntary guarding and diminished bowel sounds. The right lower extremity is cool to the touch with absent dorsalis pedis and posterior tibial pulses; left lower extremity pulses are normal. Initial laboratory studies show a serum lactate level of 5.8 mmol/L and a serum creatinine of 2.1 mg/dL (baseline 1.0 mg/dL). Intravenous esmolol and nicardipine infusions are initiated, successfully lowering his blood pressure to 118/74 mmHg and heart rate to 62/min. A computed tomography angiography of the chest, abdomen, and pelvis demonstrates an intimal flap originating just distal to the left subclavian artery and extending into the common iliac arteries. The true lumen is severely compressed by the false lumen. The superior mesenteric and right renal arteries arise from the false lumen, which exhibits delayed and sluggish contrast enhancement. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old woman schedules a telehealth consultation to establish primary care after moving to a new state. She reports feeling well and takes only a daily multivitamin. She underwent menopause at age 51. She has never used tobacco products, drinks alcohol occasionally, and walks two miles daily. Her family history is notable for hypertension in her father. She reports her last colonoscopy was at age 62 and was normal, and her last mammogram was six months ago and normal. Which of the following screening tests is most appropriate to order for this patient today?

A psychiatrist is evaluating a 31-year-old male patient who recently experienced a severe acute manic episode. The physician decides to initiate pharmacotherapy with valproate as a mood stabilizer. Before starting this medication and periodically during the initial months of treatment, specific laboratory parameters must be monitored due to the drug's known adverse effect profile. Which of the following diagnostic studies should be routinely obtained for this patient? (Select all that apply)

A physician is reviewing the laboratory results of a 64-year-old woman who had blood drawn earlier in the day for routine monitoring. The patient has a history of rheumatic heart disease and underwent a mechanical mitral valve replacement four years ago. She is maintained on chronic warfarin therapy. Three days ago, she was evaluated at an urgent care clinic for dysuria and was prescribed a short course of trimethoprim-sulfamethoxazole. During a subsequent telephone encounter, the patient reports feeling well and denies any bruising, bleeding gums, epistaxis, or dark stools. Her target international normalized ratio (INR) is 2.5 to 3.5. Today, her INR is reported as 7.2. Which of the following is the most appropriate next step in the management of this patient's anticoagulation?

A $38$-year-old man presents to the clinic for a follow-up evaluation of worsening fatigue, a $6\text{-kg}$ ($13.2\text{-lb}$) weight gain, and easy bruising over the past $3$ months. He also reports new-onset muscle weakness when climbing stairs. His medical history is significant for HIV, diagnosed $4$ years ago, and severe seasonal allergic rhinitis. His current medications include a single-tablet antiretroviral regimen consisting of elvitegravir, cobicistat, emtricitabine, and tenofovir alafenamide. Four months ago, he was prescribed a fluticasone nasal spray for his allergic rhinitis, which he uses twice daily.

Vital signs are temperature $37.0^\circ\text{C}$ ($98.6^\circ\text{F}$), blood pressure $158/96 \text{ mmHg}$, pulse $82\text{/min}$, and respirations $14\text{/min}$. BMI is $31 \text{ kg/m}^2$. Physical examination reveals a plethoric face, prominent supraclavicular fat pads, and wide violaceous striae on the lower abdomen.

Laboratory studies:
Sodium: $142 \text{ mEq/L}$
Potassium: $3.8 \text{ mEq/L}$
Fasting glucose: $135 \text{ mg/dL}$
Morning serum cortisol: $1.2 \text{ \mu g/dL}$ (Normal: $6\text{--}23 \text{ \mu g/dL}$)
Plasma ACTH: $< 5 \text{ pg/mL}$ (Normal: $10\text{--}60 \text{ pg/mL}$)
HIV viral load: Undetectable
CD4 T-lymphocyte count: $620\text{/mm}^3$

What is the most appropriate next step in the pharmacologic management of this patient?

A 48-year-old male construction worker visits a primary care clinic to establish care. He states that he feels entirely healthy and has avoided the medical system for over twenty years. He currently smokes one pack of cigarettes daily and has maintained this habit since his early twenties. He is in a monogamous relationship with a new female partner. Vital signs are within normal limits, and his body mass index is 23 kg/m². He has no family history of malignancy or premature cardiovascular disease. Based on current evidence-based guidelines, which of the following preventive screening tests should be ordered for this patient today? (Select all that apply)

A 49-year-old premenopausal female is evaluated in the medical oncology clinic to discuss adjuvant therapy following a recent lumpectomy and sentinel lymph node biopsy. Pathology demonstrated a 1.5-cm, estrogen receptor-positive, progesterone receptor-positive, and HER2-negative invasive ductal carcinoma. Margins were negative, and no lymph nodes were involved. She completed adjuvant radiation therapy last week and is now scheduled to begin endocrine therapy. Her past medical history includes major depressive disorder, which has been well-controlled on paroxetine for the past 4 years. She currently reports no depressive symptoms but complains of moderate daily hot flashes. Vital signs and physical examination are unremarkable. The oncologist plans to start tamoxifen. Which of the following is the most appropriate recommendation regarding this patient's pharmacotherapy?

Determine the most appropriate post-acute care disposition for each patient based on their clinical stability, functional status, and required level of ongoing medical intervention.

A 68-year-old man with a history of persistent atrial fibrillation presents to the emergency department complaining of sudden, severe pain in his right lower extremity that began two hours ago. On physical examination, the right leg is cold and pale distal to the knee. The patient exhibits diminished light touch sensation over the dorsum of the foot, but he can freely wiggle his toes and dorsiflex his ankle. Femoral pulses are strong bilaterally, but right popliteal and pedal pulses are nonpalpable. Handheld continuous-wave Doppler demonstrates absent arterial signals but present venous signals in the right foot. Arrange the following management steps in the most appropriate chronological sequence for this patient.

A 74-year-old woman with a history of permanent atrial fibrillation and medication nonadherence presents to the emergency department with a 2-hour history of sudden, severe, mid-abdominal pain. She is writhing in agony, but her abdomen is surprisingly soft and non-tender to palpation. Vital signs show a heart rate of $118$/min, blood pressure of $142/88$ mmHg, and respiratory rate of $22$/min. Laboratory studies reveal a leukocyte count of $18,500/mm^3$ and a serum lactate level of $4.2$ mmol/L. She is suspected of having acute superior mesenteric artery embolism.

Arrange the following interventions in the most appropriate chronological sequence for the definitive management of this patient.

A 61-year-old woman is evaluated in the clinic after an emergency department visit two days ago for a minor mechanical fall. During that visit, a non-contrast CT scan of the abdomen and pelvis was performed to evaluate for suspected rib or solid organ injury. The scan showed no traumatic injuries, but an incidental 2.8-cm mass was identified in the left adrenal gland. The mass is well-circumscribed and homogeneous, with an attenuation of 4 Hounsfield units. The patient's medical history is significant for estrogen receptor-positive breast cancer treated with a lumpectomy and radiation therapy six years ago; she has been in remission since. She currently feels well and reports no abdominal pain, palpitations, headaches, or unexplained weight changes. Blood pressure is 126/82 mmHg, and heart rate is 72/min. Physical examination reveals no abdominal tenderness, striae, or palpable masses. Which of the following is the most appropriate next step in the diagnostic workup of this patient's adrenal mass?

A 45-year-old woman is evaluated in the transplant clinic 3 months after receiving a deceased-donor renal allograft. Her maintenance immunosuppression regimen includes tacrolimus, mycophenolate mofetil, and prednisone. Routine surveillance laboratory testing reveals a new quantitative cytomegalovirus (CMV) DNA viral load of $15,000 \text{ IU/mL}$. She is currently asymptomatic and her renal allograft function is stable. The decision is made to manage this active CMV infection to prevent progression to tissue-invasive disease.

Arrange the following steps in the correct chronological sequence for the therapeutic management, monitoring, and evaluation of this patient's CMV infection.

A 67-year-old female is evaluated for transition of care from the medical intensive care unit. She was admitted 22 days ago for severe acute respiratory distress syndrome secondary to a viral pneumonitis. Her hospital course was complicated by ventilator-associated pneumonia and critical illness polyneuropathy. She was successfully extubated 4 days ago and is now breathing comfortably on 2 L/min of oxygen via nasal cannula.

Current medications include prophylactic enoxaparin, pantoprazole, and intravenous ceftriaxone (day 7 of a 14-day course for Pseudomonas pneumonia). She is receiving enteral nutrition via a newly placed percutaneous endoscopic gastrostomy (PEG) tube due to severe post-extubation dysphagia.

Vital signs are temperature 37.1 C (98.8 F), blood pressure 118/76 mm Hg, heart rate 82/min, and respiratory rate 16/min.

On examination, the patient is alert, oriented, and highly motivated to recover. She has a resolving 2 cm x 2 cm stage 2 pressure ulcer on her sacrum. Neurologic examination reveals symmetric 3/5 strength in the proximal upper and lower extremities. She requires maximal assistance to sit on the edge of the bed and cannot bear weight. Physical therapy notes indicate that she participates enthusiastically but experiences severe fatigue after 30 minutes of exertion and requires the remainder of the day to rest. She lives with her 72-year-old husband in a single-story home.

Which of the following is the most appropriate discharge disposition for this patient?