Patient Management

A 52-year-old woman is brought to the emergency department due to sudden-onset, severe abdominal pain and bilious vomiting that started 12 hours ago. She reports no bowel movements or flatus during this time. Her medical history is unremarkable, and she has had no prior abdominal surgeries. Her temperature is $37.6^\circ\text{C}$ ($99.7^\circ\text{F}$), blood pressure is $115/75\text{ mmHg}$, and heart rate is $110/\text{min}$. Physical examination reveals an asymmetric, tympanic, and markedly distended abdomen. There is diffuse tenderness to palpation but no guarding or rigidity. Laboratory results are notable for a leukocyte count of $12,500/\text{mm}^3$ and a normal serum lactate level. A CT scan of the abdomen with intravenous contrast demonstrates a severely dilated cecum measuring $10.5\text{ cm}$ in diameter displaced into the left upper quadrant, with a "whirl pattern" of the mesenteric vessels and collapsed distal bowel. Which of the following is the most appropriate next step in management?

An asymptomatic 68-year-old retired teacher presents for an annual wellness assessment. He reports feeling well with no active complaints. His past medical history includes well-controlled essential hypertension and hyperlipidemia. He has a 40 pack-year smoking history but successfully quit 8 years ago. He consumes alcohol occasionally and walks briskly for 30 minutes three times a week.

His immunization history shows a tetanus, diphtheria, and acellular pertussis (Tdap) booster 3 years ago, completion of the two-dose recombinant zoster vaccine series at age 65, and a recent annual influenza vaccination. He has no history of receiving any pneumococcal vaccines. A screening colonoscopy performed 5 years ago was entirely normal. Physical examination today reveals a blood pressure of 126/78 mmHg, a heart rate of 72/min, and a body mass index of 27 kg/m².

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

A $62$-year-old woman is evaluated in the hospital for new-onset right leg swelling and pain. She was admitted $6$ days ago for an acute pulmonary embolism and was subsequently started on a continuous unfractionated heparin infusion. On admission, her platelet count was $260,000/\text{mm}^3$. Today, her vital signs are temperature $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$), blood pressure $130/80\text{ mmHg}$, pulse $92/\text{min}$, and respirations $16/\text{min}$. Physical examination reveals a visibly swollen right calf that is tender to palpation. A venous Doppler ultrasound of the right lower extremity demonstrates an acute deep venous thrombosis in the right femoral vein. Laboratory studies from this morning show a platelet count of $110,000/\text{mm}^3$ and an activated partial thromboplastin time (aPTT) of $65\text{ seconds}$ (therapeutic range: $60-80\text{ seconds}$). Which of the following is the most appropriate next step in the management of this patient?

A $45$-year-old man presents to the clinic for a routine $4$-week follow-up visit. One month ago, he was diagnosed with active pulmonary tuberculosis and was started on a daily regimen of isoniazid, rifampin, pyrazinamide, and ethambutol, supplemented with pyridoxine. Today, he reports significant improvement in his symptoms; his cough has nearly resolved, and his night sweats have ceased. He has a good appetite and explicitly denies any nausea, vomiting, abdominal pain, fatigue, or dark urine. Physical examination reveals normal vital signs, no scleral icterus, and a non-tender abdomen without hepatomegaly.

Laboratory studies obtained today show the following:

Total bilirubin: $0.8 \text{ mg/dL}$ (Reference: $0.1-1.2 \text{ mg/dL}$)
Alkaline phosphatase: $85 \text{ U/L}$ (Reference: $40-120 \text{ U/L}$)
Aspartate aminotransferase (AST): $165 \text{ U/L}$ (Reference: $10-40 \text{ U/L}$)
Alanine aminotransferase (ALT): $175 \text{ U/L}$ (Reference: $10-40 \text{ U/L}$)

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

A 79-year-old man is admitted to the intensive care unit with severe septic shock and multiorgan failure. He is currently intubated, sedated, and lacks clinical decision-making capacity. The medical team concludes that further aggressive interventions are futile and wishes to discuss transitioning to comfort-focused care. A chart review reveals no advance directive, living will, or designated durable power of attorney for healthcare. The patient is a widower and his parents are deceased. He is survived by an adult son who lives in another state, a brother who visits him daily, and a devoted neighbor who has served as his primary caregiver for the past three years. Which of the following individuals is the most appropriate legally recognized primary surrogate decision-maker for this patient?

A 32-year-old nulliparous woman arrives at the outpatient clinic to establish primary care. She reports excellent overall health and exercises regularly. She has no gastrointestinal complaints, unexplained weight changes, or evidence of bleeding. Her medical background is notable only for an appendectomy during childhood. Family history is significant for her mother, who was diagnosed with an early-stage colonic adenocarcinoma at the age of 46 and underwent a curative hemicolectomy. Medical records confirm the mother's tumor underwent mismatch repair protein analysis, demonstrating no loss of nuclear expression. Her maternal grandfather developed a similar intestinal malignancy at the age of 72. The patient expresses anxiety regarding her familial susceptibility and inquires about the optimal timing and modality for her own surveillance. Based on current evidence-based guidelines, which of the following is the most appropriate strategy for this patient?

A 42-year-old man comes to the clinic for a routine follow-up visit. He was diagnosed with hypertension and type 2 diabetes mellitus three months ago, at which time he was prescribed amlodipine and metformin. Today, his blood pressure is 154/92 mmHg and his hemoglobin A1c is 8.5%. Upon inquiry, the patient admits he stopped taking both medications after one week. He explains, "A coworker warned me that these blood pressure pills will eventually destroy my kidneys. I started taking a daily herbal detox supplement instead. I feel perfectly fine, so I do not want to put unnatural chemicals into my body." Which of the following is the most appropriate initial response by the physician?

A $55$-year-old woman is evaluated in the hospital on postoperative day $6$ following an abdominal hysterectomy. She was admitted to the general medical ward and started on an intravenous unfractionated heparin infusion $5$ days ago for a right lower extremity deep vein thrombosis. Today, she reports new pain and swelling at the site of a peripheral intravenous catheter in her left arm. Her temperature is $37.2^\circ \text{C}$ ($99.0^\circ \text{F}$), blood pressure is $128/82$ mmHg, and pulse is $88$/min. Physical examination shows induration, erythema, and tenderness along the left cephalic vein, consistent with superficial thrombophlebitis. There is no active bleeding, and no petechiae are noted.

Laboratory results are as follows:
- Hemoglobin: $12.2$ g/dL
- Platelet count: $110,000/\text{mm}^3$ (Baseline $5$ days ago: $320,000/\text{mm}^3$)
- Partial thromboplastin time (PTT): $68$ seconds

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

During a medication management visit, a 58-year-old woman asks about her current health maintenance requirements. She takes methotrexate and daily prednisone ($10 \text{ mg}$) for rheumatoid arthritis, which was diagnosed five years ago. She has never smoked cigarettes. Her body mass index is $21 \text{ kg/m}^2$. A review of her preventive care history shows a normal screening colonoscopy three years ago, a negative primary human papillomavirus test two years ago, and a normal bilateral mammogram six months ago. She completed the recombinant zoster and 20-valent pneumococcal conjugate vaccine series last year. Which of the following is the most appropriate indicated preventive service for this patient at this time?

During a comprehensive annual evaluation, a 62-year-old man is assessed at the primary care clinic. He has a past medical history of diet-controlled type 2 diabetes mellitus and essential hypertension. His current medications include amlodipine and atorvastatin. He reports feeling well overall, though he notes intermittent, mild lower back pain after heavy yard work; the pain lacks radiation and resolves rapidly with rest and acetaminophen. He denies any bowel or bladder incontinence, saddle anesthesia, or lower extremity weakness.

His substance use history reveals that he began smoking cigarettes at age 20, consuming 1.5 packs daily until he quit on his 50th birthday. He consumes alcohol occasionally but denies illicit drug use. He has been in a monogamous marriage for 35 years.

A review of his preventive health record demonstrates:
- A screening colonoscopy performed 4 years ago at age 58 revealed no polyps or abnormalities.
- Routine screening for HIV, hepatitis B, and hepatitis C conducted at age 55 was negative.
- Following his diabetes diagnosis at age 59, he received a dose of the 20-valent pneumococcal conjugate vaccine (PCV20).
- He completed the two-dose recombinant zoster vaccine series at age 56.
- He received a tetanus, diphtheria, and acellular pertussis (Tdap) booster 3 years ago.
- He received the seasonal influenza vaccine two weeks ago.

Recent laboratory studies from a separate visit two weeks ago show a hemoglobin A1c of 6.2% and an in-range lipid profile. His physical examination today, including a detailed neurologic assessment of the lower extremities, is entirely within normal limits.

Based on current clinical guidelines, which of the following is the most appropriate next step in the management of this patient?

A 62-year-old man comes to the clinic for a routine health maintenance evaluation. He recently went through a divorce and reports being sexually active with multiple new male partners over the past 6 months. He admits to inconsistent condom use. His medical history is significant for essential hypertension, for which he takes amlodipine. He smoked 1.5 packs of cigarettes daily for 20 years but quit 8 years ago. His most recent cancer screening was a colonoscopy at age 54, which was normal. His vaccination history includes the complete hepatitis B series, a tetanus-diphtheria-acellular pertussis (Tdap) booster at age 58, and an influenza vaccine 2 weeks ago. He has never received pneumococcal or zoster vaccines. Vital signs and physical examination are unremarkable. Basic metabolic panel and hepatic function panel are within normal limits. Point-of-care HIV testing is negative, and comprehensive sexually transmitted infection testing is sent to the laboratory. Assuming the pending tests are negative, which of the following is the most appropriate next step in comprehensive preventive care?

A 31-year-old woman, gravida 1, para 0, presents to the clinic for a routine prenatal visit at 13 weeks of gestation. She has a medical history of chronic hypertension that is currently well controlled. She has never smoked and consumes no alcohol. Her daily medication is nifedipine. Vital signs today demonstrate a blood pressure of $126/82 \text{ mm Hg}$, a heart rate of 78/min, and a body mass index of $28 \text{ kg/m}^2$. A urine dipstick is negative for protein. Fetal heart tones are audible via Doppler ultrasound. Which of the following is the most appropriate preventive intervention to add to this patient's management plan at this time?

Evaluate the following patient profiles during routine ambulatory visits. Match each patient with the most appropriate, guideline-concordant next step in preventive care based on current United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) recommendations.

An unhoused male patient born in $1968$ presents to a community health outreach clinic to establish primary care. He has not received any medical care in nearly a decade. Medical records indicate a history of chronic hepatitis C virus infection complicated by biopsy-proven cirrhosis; he successfully completed direct-acting antiviral therapy $6$ years ago and achieved a sustained virologic response. He reports a history of intravenous substance use, which he also ceased $6$ years ago. The patient currently smokes $1.5$ packs of cigarettes daily, a habit he began at age $18$. His medical history is notable for a severe anaphylactic reaction (hypotension and wheezing) to dietary eggs during childhood. Physical examination reveals scattered spider angiomas but no ascites, jaundice, or encephalopathy. Vital signs are within normal limits. Which of the following preventive health interventions are appropriate for this patient at today's visit? (Select all that apply)

A 64-year-old man presents to the emergency department reporting the sudden onset of agonizing, tearing pain in his anterior chest that radiates directly to his mid-back. The pain started abruptly one hour ago while he was eating dinner. His medical history is notable for essential hypertension, obstructive sleep apnea, and hyperlipidemia. The patient appears visibly distressed, agitated, and is sweating profusely. Vital signs demonstrate a temperature of 37.1°C (98.8°F), blood pressure of 220/120 mm Hg in the right arm and 175/95 mm Hg in the left arm, heart rate of 118/min, and respiratory rate of 24/min. Physical examination reveals a new early diastolic decrescendo murmur at the right upper sternal border. Radial pulses are bounding on the right but significantly diminished on the left. Electrocardiography demonstrates sinus tachycardia and criteria for left ventricular hypertrophy, but no acute ST-segment or T-wave changes. Which of the following is the most urgent initial step in the management of this patient?

Match each patient's clinical presentation and initial diagnostic findings with the most appropriate next step in their workup sequence.

A 25-year-old male driver is transported to the trauma bay following a high-speed frontal motor vehicle collision. On arrival, he is unresponsive to verbal stimuli. His breathing is shallow with audible gurgling. Vital signs include a blood pressure of 72/40 mm Hg, pulse of 138/min, and respiratory rate of 8/min. Examination shows extensive maxillofacial ecchymosis and mechanical instability of the pelvic ring. Arrange the following interventions in the most appropriate chronological sequence for this patient's acute management.

A 68-year-old man is evaluated on the medical ward for severe right knee pain and swelling that began abruptly overnight. He was admitted $3$ days ago for community-acquired pneumonia, which has been improving on empiric intravenous ceftriaxone and oral clarithromycin. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$, chronic kidney disease stage 4 (baseline serum creatinine $2.7 \text{ mg/dL}$), and poorly controlled type 2 diabetes mellitus.

Current medications include lisinopril, carvedilol, furosemide, dapagliflozin, and insulin glargine.

Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $112/68 \text{ mmHg}$, pulse $88/\text{min}$, and respirations $16/\text{min}$.
Physical examination reveals a warm, erythematous, swollen, and exquisitely tender right knee. Range of motion is severely limited by pain. The remainder of the examination is notable for trace bilateral pitting lower extremity edema.

Laboratory studies obtained this morning show:
Blood urea nitrogen: $48 \text{ mg/dL}$
Creatinine: $2.9 \text{ mg/dL}$
Glucose, fasting: $285 \text{ mg/dL}$

Right knee arthrocentesis yields $15 \text{ mL}$ of cloudy yellow fluid. Synovial fluid analysis shows a leukocyte count of $45,000/\mu\text{L}$ ($85\%$ neutrophils). Polarized light microscopy reveals negatively birefringent, needle-shaped crystals. Gram stain is negative for organisms.

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

A $62$-year-old man is brought to the emergency department via ambulance due to sudden-onset, severe, tearing chest pain radiating to his interscapular region. The pain began $45$ minutes ago while he was watching television. His past medical history is significant for hypertension, hyperlipidemia, erectile dysfunction, and severe persistent asthma. He was hospitalized two weeks ago for status asthmaticus. His current home medications include amlodipine, atorvastatin, sildenafil as needed, a fluticasone-salmeterol inhaler, and an albuterol rescue inhaler.

On physical examination, the patient appears diaphoretic and in severe distress. Blood pressure is $215/115$ mmHg in the right arm and $210/110$ mmHg in the left arm. Heart rate is $118$ beats/min, respiratory rate is $22$ breaths/min, and oxygen saturation is $94\%$ on room air. Pulmonary auscultation reveals diffuse bilateral expiratory wheezing.

Laboratory results are as follows:
Sodium: $138$ mEq/L
Potassium: $4.1$ mEq/L
Chloride: $102$ mEq/L
Calcium: $8.0$ mg/dL
Albumin: $2.8$ g/dL
Creatinine: $1.1$ mg/dL
Troponin I: $< 0.01$ ng/mL (Normal: $< 0.04$ ng/mL)

A computed tomography (CT) angiography of the chest demonstrates an intimal flap in the descending thoracic aorta, distal to the origin of the left subclavian artery.

Which of the following is the most appropriate initial pharmacologic intervention for this patient?

A 71-year-old woman with widely metastatic breast cancer is admitted to the inpatient hospice unit for end-of-life care. She is actively dying and minimally responsive. Over the past 24 hours, she has experienced episodes of severe terminal delirium with agitation, which are currently being managed with scheduled haloperidol. Her family is now highly distressed by loud, gurgling respiratory sounds originating from her upper airway. Auscultation reveals coarse upper airway transmitted sounds with clear lung bases. Her respiratory rate is 14/min, and she shows no signs of air hunger, accessory muscle use, or labored breathing during quiet intervals. Which of the following is the most appropriate next step in the management of this patient's respiratory symptom?