Patient Management

Match each ambulatory patient profile with the most appropriate, guideline-concordant preventive care intervention or recommendation.

A 68-year-old man presents to the clinic with severe pain, swelling, and redness in his right knee that began abruptly 18 hours ago. He has a history of poorly controlled type 2 diabetes mellitus, diabetic nephropathy, and hypertension. His current medications include insulin glargine, insulin lispro, and amlodipine. Vital signs show a temperature of 37.3°C (99.1°F), blood pressure of 145/88 mmHg, and heart rate of 88/min. Physical examination reveals an erythematous, markedly swollen, and exquisitely tender right knee with severely limited range of motion.

Laboratory studies reveal:
- Serum creatinine: 2.7 mg/dL (baseline 2.5 mg/dL)
- Estimated GFR: 24 mL/min/1.73 m²
- Serum glucose: 345 mg/dL
- Hemoglobin A1c: 10.4%

Arthrocentesis of the right knee yields 4 mL of turbid yellow fluid. Synovial fluid analysis shows a leukocyte count of 22,000/mm³ with 85% neutrophils. Polarized light microscopy demonstrates numerous needle-shaped, negatively birefringent crystals. Gram stain of the fluid shows no organisms.

Which of the following is the most appropriate pharmacologic intervention for this patient's acute joint condition?

During a routine health maintenance visit, a $42$-year-old woman reports difficulty performing fine motor tasks at work due to a bilateral hand tremor. The tremor is most prominent during voluntary movements. She is diagnosed with essential tremor and requests medical therapy. Her medical records indicate a longstanding history of moderate persistent asthma, currently managed with a daily budesonide inhaler and an as-needed albuterol inhaler. As the physician considers initiating pharmacotherapy for her tremor, which of the following agents should be avoided?

A 59-year-old man presents to the clinic for follow-up of Crohn's disease and gout. His Crohn's disease has been well-controlled for the past three years on a stable dose of azathioprine (150 mg daily). However, he has experienced three severe gout flares over the last six months. He brings a new prescription for allopurinol 100 mg daily from his rheumatologist and asks for advice regarding the safety of combining these medications before taking his first dose. His current laboratory results, including a complete blood count and comprehensive metabolic panel, are within normal limits. Which of the following is the most appropriate next step in the management of this patient's medication regimen?

A 28-year-old man is brought to the emergency department 30 minutes after falling approximately 25 feet from a scaffold. He complains of excruciating pelvic and lower back pain. He has no significant past medical history. His temperature is 36.8°C (98.2°F), blood pressure is 80/40 mmHg, heart rate is 134/min, and respiratory rate is 24/min. Physical examination reveals blood at the urethral meatus. There is marked instability of the pelvic ring in response to gentle manual compression. A cervical spine collar is in place. Intravenous access is established with two large-bore peripheral lines, and a massive transfusion protocol is initiated. A bedside Focused Assessment with Sonography for Trauma (FAST) examination shows no intraperitoneal free fluid. A portable chest radiograph is unremarkable. An anteroposterior pelvic radiograph demonstrates widening of the pubic symphysis to 4.5 cm and disruption of the right sacroiliac joint. Despite receiving 2 liters of warmed crystalloid and 2 units of uncrossmatched packed red blood cells, his blood pressure remains 82/45 mmHg and heart rate is 130/min.

Which of the following are appropriate next steps in the procedural management of this patient? (Select all that apply)

A 29-year-old pregnant woman, gravida 2, para 1, is evaluated in the outpatient clinic for a routine prenatal visit at 28 weeks gestation. She has no chronic medical conditions and takes only a daily prenatal vitamin. She has never smoked cigarettes, consumed alcohol, or used illicit drugs. Her last cervical cancer screening was at age 27 and was normal. During her previous pregnancy three years ago, she received all standard prenatal care and immunizations. Today, her blood pressure is 112/70 mm Hg and her heart rate is 78/min. Fetal heart tones are normal. Which of the following is the most appropriate immunization to administer to this patient at this visit?

A 64-year-old man is hospitalized for an acute deep vein thrombosis of the right lower extremity. He is promptly started on a continuous unfractionated heparin infusion. On admission (hospital day 1), his platelet count is 240,000/mm³. On hospital day 5, routine morning laboratory studies reveal a platelet count of 90,000/mm³. The patient remains hemodynamically stable, reports no new symptoms, and physical examination reveals no petechiae, ecchymoses, or signs of active bleeding. His right leg swelling has improved. Which of the following is the most appropriate next step in the management of this patient?

A 59-year-old man is evaluated on hospital day 28 for disposition planning. He was initially admitted for severe acute necrotizing pancreatitis complicated by infected pseudocysts, requiring multiple exploratory laparotomies. He is currently hemodynamically stable and was successfully weaned from mechanical ventilation five days ago. He now breathes room air via a tracheostomy collar. Enteral feeding is provided via a percutaneous endoscopic gastrostomy tube. He is receiving intravenous meropenem for a multidrug-resistant abdominal fluid collection, with three weeks of therapy remaining. A large, complex midline abdominal wound is being managed with negative pressure wound therapy. The patient is alert and cooperative. He exhibits profound generalized weakness and becomes exhausted after 20 minutes of physical therapy. Daily laboratory results have been stable for the past week, and his clinical condition only requires weekly physician assessments. Which of the following is the most appropriate next step in the care transition for this patient?

A 34-year-old woman is evaluated in the outpatient clinic for a 1-year history of progressive weight gain, easy bruising, and new-onset facial hair growth. She reports increased difficulty climbing stairs due to muscle weakness. She does not take any exogenous corticosteroids, over-the-counter supplements, or herbal medications. Vital signs show a blood pressure of 158/96 mmHg and a body mass index of 34 kg/m². Physical examination reveals central obesity, facial plethora, supraclavicular fat pads, and wide violaceous striae over the lower abdomen. There is high clinical suspicion for endogenous Cushing syndrome.

Assuming the diagnostic workup ultimately confirms Cushing disease (an adrenocorticotropic hormone-secreting pituitary adenoma), arrange the following diagnostic tests in the correct sequential order from initial screening to final anatomic localization.

A 68-year-old man presents to the clinic to discuss management of newly diagnosed nonvalvular atrial fibrillation. His medical history includes hypertension, type 2 diabetes mellitus, and osteoarthritis. His current medications include lisinopril, metformin, and acetaminophen. His blood pressure is 134/82 mmHg, and his pulse is 88/min and irregularly irregular. The physician and patient agree to initiate apixaban therapy for stroke prophylaxis. Which of the following parameters must be evaluated prior to initiation and monitored periodically during this specific pharmacotherapy? (Select all that apply)

An emergency medical services team brings a 64-year-old male patient to the resuscitation bay after he lost consciousness at a local fitness center. He is currently awake but complains of severe, sharp anterior chest pain that radiates to his jaw. His medical history is significant for poorly controlled hypertension.

Vital signs are temperature 37.0°C (98.6°F), blood pressure 82/45 mmHg, heart rate 118/min, and respiratory rate 24/min. Pulse oximetry shows 94% on room air.

Physical examination reveals a diaphoretic, pale man in marked distress. The jugular venous pressure is estimated at 14 cm H2O. Cardiac auscultation reveals distant heart sounds. Lungs are clear to auscultation bilaterally. Pulses are weak but symmetric in all extremities.

A bedside point-of-care ultrasound is performed immediately. The parasternal long-axis view demonstrates a large circumferential pericardial effusion with right ventricular free wall bowing inward during diastole. Additionally, an echogenic linear flap is visualized undulating within a significantly dilated aortic root.

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

A 15-year-old girl is brought to the clinic by her mother due to the absence of menstrual periods. She has never experienced a menstrual bleed. The patient reports no cyclical pelvic pain, headaches, visual changes, or loss of smell. Her past medical history is unremarkable, and she takes no medications. She plays high school volleyball but does not engage in extreme physical training. She is at the 35th percentile for height and 45th percentile for weight. Vital signs are within normal limits. Physical examination reveals Tanner stage 1 breast development and Tanner stage 1 pubic hair. There is no clitoromegaly or severe acne. A transabdominal pelvic ultrasound is performed and demonstrates a normal-appearing prepubertal uterus, cervix, and bilateral ovaries. Which of the following is the most appropriate next step in the diagnostic workup?

An emergency response team is actively resuscitating a 34-year-old individual who was found unresponsive with continuous, generalized tonic-clonic movements. Paramedics report the seizure activity has persisted without interruption for at least 20 minutes prior to arrival. Two large-bore intravenous lines are rapidly secured. Vital signs show a blood pressure of $142/88$ mmHg, heart rate of $118$/min, and oxygen saturation of $96\%$ on high-flow oxygen. A point-of-care blood glucose reading is $112$ mg/dL. Arrange the following pharmacologic therapies in the correct sequential order of administration for the escalating algorithmic management of this condition.

A 71-year-old woman is evaluated in the emergency department for a 4-day history of progressively worsening productive cough, fever, and shortness of breath. Her past medical history is notable for type 2 diabetes mellitus, hypertension, and osteoarthritis. She lives independently at home. Her temperature is 38.8°C (101.8°F), blood pressure is 88/56 mmHg, pulse is 118/min, and respiratory rate is 32/min. Oxygen saturation is 89% on room air and improves to 94% on 4 L/min via nasal cannula. She is alert and oriented to person, place, and time.

Physical examination reveals coarse crackles and bronchial breath sounds over the right middle and left lower lung fields.

Laboratory results are as follows:
Leukocyte count: 16,500/mm³
Blood urea nitrogen: 34 mg/dL
Creatinine: 1.3 mg/dL
Platelet count: 180,000/mm³

A chest radiograph demonstrates dense alveolar infiltrates in the right middle and left lower lobes. Following the administration of 1.5 L of intravenous normal saline, her blood pressure improves to 106/64 mmHg. Empiric intravenous antibiotics are initiated.

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

A 23-year-old female college student presents to the university health clinic for a routine wellness examination. She reports feeling well and has no specific complaints. Her medical history is unremarkable, and she currently takes an oral contraceptive pill daily. She mentions that she recently became sexually active with a new male partner. Review of her immunization records confirms she completed the human papillomavirus (HPV) vaccine series at age 12. According to current United States Preventive Services Task Force (USPSTF) guidelines, which of the following screening interventions are indicated for this patient during today's visit? (Select all that apply)

A 68-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) is being prepared for hospital discharge following an acute exacerbation. He initially presented with hypoxemic respiratory failure requiring noninvasive positive pressure ventilation. He has since improved and will be discharged on continuous home oxygen therapy, which is a new requirement for him. He also has a newly prescribed inhaler regimen. To ensure a safe transition of care and minimize readmission risk, arrange the following discharge planning steps in the most appropriate chronological sequence.

A 42-year-old man presents to the emergency department with sudden-onset shortness of breath and right-sided pleuritic chest pain. He has a history of focal onset seizures, which have been well controlled on carbamazepine for the past five years. Vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $132/84\text{ mm Hg}$, heart rate $105/\text{min}$, respiratory rate $20/\text{min}$, and oxygen saturation $95\%$ on room air. Physical examination reveals clear lungs and a swollen, tender right calf. A computed tomography pulmonary angiogram reveals a segmental pulmonary embolism in the right lower lobe. Laboratory studies reveal a serum creatinine of $0.9\text{ mg/dL}$ and normal hepatic function. Which of the following is the most appropriate pharmacologic intervention for this patient?

Paramedics transport an $82$-year-old female to the acute care area following a syncopal episode at her residence. Her family reports she complained of severe dizziness and chest heaviness immediately before losing consciousness. Her medical history is significant for hypertension, hyperlipidemia, and a myocardial infarction three years ago. Upon arrival, the patient is lethargic and profoundly diaphoretic. Vital signs show a temperature of $36.4^\circ\text{C}$ ($97.5^\circ\text{F}$), blood pressure of $72/40\text{ mmHg}$, pulse of $28/\text{min}$, and respiratory rate of $18/\text{min}$. Oxygen saturation is $94\%$ on room air. Physical examination reveals cool, clammy extremities with a capillary refill time of $4\text{ seconds}$. Jugular venous distention is absent, and lung fields are clear to auscultation bilaterally. A $12$-lead electrocardiogram displays regular P waves at a rate of $90/\text{min}$ and regular, broad QRS complexes ($0.16\text{ sec}$) at a rate of $28/\text{min}$ with complete dissociation between the atria and ventricles. Two large-bore intravenous lines are secured. Which of the following is the most appropriate next step in the stabilization of this patient?

A $54$-year-old man with a history of stage $4$ chronic kidney disease presents to the emergency department complaining of generalized muscle weakness and palpitations that started earlier today. His vital signs are stable, but his electrocardiogram reveals peaked T waves and widened QRS complexes. Laboratory results show a serum potassium level of $7.6$ mEq/L. Arrange the following pharmacologic interventions in the most appropriate chronological sequence for the acute stabilization and management of this patient.

A 24-year-old woman is brought to the emergency department by paramedics after being found unresponsive in her apartment. Paramedics note an empty bottle of amitriptyline on the nightstand. On arrival, she is obtunded and only withdraws her extremities from painful stimuli. Her Glasgow Coma Scale score is 8. Vital signs are temperature $36.8^\circ\text{C}$ ($98.2^\circ\text{F}$), blood pressure 80/50 mmHg, pulse 135/min, and respiratory rate 10/min. A point-of-care electrocardiogram reveals sinus tachycardia with a QRS duration of $160\text{ ms}$ and a prominent terminal R wave in lead aVR.

Arrange the following management steps in the most appropriate chronological sequence for this patient's initial stabilization and subsequent care.