Patient Management

An 58-year-old male resident of an assisted living facility is evaluated in the emergency department due to a two-day history of frequent falls and worsening gait unsteadiness. Staff members also note that he has become increasingly confused. His medical history includes post-traumatic epilepsy, heart failure, and decompensated cirrhosis. His current medications are phenytoin, spironolactone, furosemide, and lactulose. He reports adhering to his regimen and has two to three soft bowel movements daily. On physical examination, he is alert but disoriented to time and place. Neurologic evaluation reveals prominent horizontal nystagmus on bilateral lateral gaze and a broad-based, unsteady gait. Asterixis is absent.

Laboratory results are as follows:

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

During morning rounds in the medical intensive care unit, a $24$-year-old man is evaluated. He was admitted $18$ hours ago with severe diabetic ketoacidosis. He has received aggressive fluid resuscitation and a continuous intravenous regular insulin infusion. Currently, he is asymptomatic, alert, and requesting breakfast. His most recent basic metabolic panel demonstrates a serum bicarbonate of $21\text{ mEq/L}$ and an anion gap of $10\text{ mEq/L}$. Venous pH is $7.34$. Point-of-care blood glucose is $175\text{ mg/dL}$. The care team decides it is time to transition him to a maintenance regimen of subcutaneous glargine and lispro insulin. Arrange the following steps in the most appropriate chronological sequence to safely accomplish this therapeutic transition.

An intensive care unit team assumes care of a 32-year-old male who was admitted overnight following an intentional overdose. Paramedics found empty prescription bottles for amitriptyline and clonazepam near him. The patient was intubated for airway protection shortly after arrival. Despite the administration of 3 liters of intravenous lactated Ringer solution over the past four hours, his blood pressure remains 76/40 mm Hg. His heart rate is 134/min. Physical examination is notable for widely dilated pupils, dry oral mucosa, and absent bowel sounds. The continuous cardiac monitor displays sinus tachycardia. A stat 12-lead electrocardiogram confirms a QRS duration of 152 ms, a prominent terminal R wave in lead aVR, and a QTc interval of 518 ms. Which of the following pharmacologic interventions are appropriate at this time? (Select all that apply)

A 68-year-old man with a history of ischemic cardiomyopathy (left ventricular ejection fraction 25%) and paroxysmal atrial fibrillation presents to the cardiology clinic for follow-up. Over the past month, he has experienced progressive fatigue and frequent palpitations. His current medications include sacubitril-valsartan, carvedilol, eplerenone, dapagliflozin, and apixaban. Vital signs today are within normal limits except for an irregular pulse of 118/min. An electrocardiogram confirms atrial fibrillation with a rapid ventricular response. Given his heavy symptomatic burden and underlying structural heart disease, the physician decides to initiate oral amiodarone for rhythm control. Which of the following baseline diagnostic studies are strictly indicated prior to or shortly after initiating this medication? (Select exactly 3 options)

A 76-year-old woman is brought to the emergency department due to the sudden onset of severe abdominal pain that started 3 hours ago. Her medical history includes hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. She stopped taking her prescribed apixaban one week ago prior to a dental extraction and did not resume it. Her temperature is 38.2°C (100.8°F), blood pressure is 82/50 mm Hg, pulse is 128/min and irregular, and respirations are 26/min. On physical examination, the abdomen is distended with board-like rigidity, diffuse tenderness to palpation, and marked rebound tenderness. Bowel sounds are absent.

The patient is immediately started on aggressive intravenous fluid resuscitation, broad-spectrum antibiotics, and an intravenous heparin infusion. Which of the following is the most appropriate next step in the management of this patient?

During an outpatient rheumatology consultation, a 47-year-old female patient is diagnosed with seropositive rheumatoid arthritis following a four-month history of bilateral symmetric swelling in her proximal interphalangeal and metacarpophalangeal joints. The physician and patient engage in shared decision-making and agree to initiate systemic disease-modifying antirheumatic drug (DMARD) therapy with weekly oral methotrexate. The patient has a history of mild essential hypertension and takes amlodipine. Which of the following baseline evaluations are necessary to safely initiate and subsequently monitor this specific pharmacotherapy? (Select the three that apply)

A 60-year-old male is evaluated in the surgical critical care unit due to rapidly worsening groin pain and hemodynamic instability. He was admitted earlier today with a presumed diagnosis of severe scrotal cellulitis. His past medical history includes long-standing, insulin-dependent diabetes mellitus. Current vital signs include a temperature of 39.1°C (102.4°F), heart rate of 128/min, blood pressure of 82/50 mm Hg, and respiratory rate of 26/min. The patient is lethargic but moans during the examination. The genitourinary exam reveals induration, violaceous discoloration, and palpable crepitus extending from the perineum into the lower anterior abdominal wall. A foul-smelling, dishwater-like fluid is seeping from a small ulceration on the scrotum. Broad-spectrum intravenous antibiotics and aggressive fluid resuscitation are currently being administered. Which of the following is the most appropriate next step in the management of this patient?

A 22-year-old man with type 1 diabetes mellitus is managed in the intensive care unit for diabetic ketoacidosis (DKA). He has been receiving a continuous intravenous regular insulin infusion, appropriate intravenous fluids, and potassium supplementation for the past $14$ hours. The most recent basic metabolic panel reveals a blood glucose of $185$ mg/dL, a serum bicarbonate of $19$ mEq/L, and a calculated anion gap of $10$ mEq/L. The patient is awake, alert, and states he is hungry. The physician decides to transition the patient from intravenous to subcutaneous insulin therapy. Arrange the following steps in the most appropriate chronological order to safely accomplish this therapeutic transition and ongoing monitoring.

A $56$-year-old man visits his primary care provider due to intense pain and swelling in his right great toe that began abruptly overnight. He reports that the pain is so severe he cannot tolerate the weight of a bedsheet on his foot. The patient underwent a deceased-donor kidney transplantation $3$ years ago for end-stage renal disease secondary to hypertensive nephrosclerosis. His maintenance immunosuppressive regimen consists of tacrolimus, mycophenolate mofetil, and prednisone ($5\text{ mg}$ daily). His other medications include amlodipine and low-dose aspirin. Vital signs show a temperature of $37.3^\circ\text{C}$ ($99.1^\circ\text{F}$), blood pressure of $134/82\text{ mmHg}$, and heart rate of $88/\text{min}$. Examination of the right lower extremity reveals marked erythema, edema, and exquisite tenderness localized to the first metatarsophalangeal joint. Recent laboratory testing demonstrates a serum creatinine of $1.6\text{ mg/dL}$, which is unchanged from his baseline over the past year. Serum uric acid is $9.2\text{ mg/dL}$. An arthrocentesis of the affected joint yields cloudy fluid with a leukocyte count of $32,000/\text{mm}^3$ ($85\%$ neutrophils). A Gram stain shows no organisms. Polarized light microscopy demonstrates numerous negatively birefringent, needle-shaped crystals. Which of the following is the most appropriate initial pharmacologic intervention for this patient's joint symptoms?

A 31-year-old pregnant woman (G2P1) at 34 weeks gestation arrives at the obstetric triage unit reporting severe right-sided back pain, nausea, and shaking chills over the past 24 hours. Her temperature is 39.1°C (102.4°F), blood pressure is 100/60 mm Hg, pulse is 112/min, and respiratory rate is 20/min. Physical examination reveals pronounced right costovertebral angle tenderness. Fetal heart rate tracing is reassuring, and there are no uterine contractions. Laboratory studies show a leukocyte count of 16,500/mm³. Urinalysis is positive for nitrites, leukocyte esterase, and >50 white blood cells per high-power field. The patient's medical history is notable for a severe anaphylactic reaction characterized by hypotension and wheezing following amoxicillin administration during childhood. Five years ago, she developed a diffuse maculopapular rash and facial swelling after taking cephalexin. Which of the following is the most appropriate empiric pharmacotherapy for this patient?

A 28-year-old primigravid patient at 28 weeks of gestation presents for a scheduled prenatal evaluation. Her pregnancy has been uncomplicated thus far. She reports normal fetal movement and denies any vaginal bleeding, leakage of fluid, or contractions. Her pre-pregnancy body mass index was 23 kg/m^2, and her weight gain has been appropriate. Her blood pressure is 110/70 mmHg. Routine laboratory results from her first-trimester evaluation, including HIV, rapid plasma reagin, and hepatitis B surface antigen tests, were negative. Her last Papanicolaou test was performed two years ago and was reported as normal. She has no acute symptoms today. Which of the following preventive care interventions are currently indicated for this patient? (Select all that apply)

A physician evaluates a 41-year-old female patient who schedules a visit to establish care and discuss her long-term health maintenance. She reports feeling perfectly well and has no physical complaints. Her medical history is unremarkable, and she takes no prescription medications. The patient's family history is significant for a maternal aunt diagnosed with melanoma at age 60; there is no family history of breast, colon, or gynecologic malignancies. She does not use tobacco products and consumes one glass of wine per week. Her blood pressure is 115/72 mmHg, and her body mass index is 22 kg/m². A review of her outside medical records indicates that her last cervical cancer screening, which utilized primary human papillomavirus (HPV) testing, was performed three years ago at age 38 and returned negative results. Based on current guidelines, which of the following screening tests should be recommended for this patient today?

A 64-year-old woman comes to the primary care clinic for a routine follow-up. Six months ago, she was diagnosed with symptomatic paroxysmal atrial fibrillation and was subsequently started on oral amiodarone. She reports that her palpitations have completely resolved and she has been able to resume her daily 2-mile walks without shortness of breath, fatigue, or cough. Her other medical history is unremarkable. Current medications include amiodarone and apixaban. Vital signs are within normal limits. Physical examination shows a regular rate and rhythm with no murmurs, and clear lungs bilaterally. Which of the following diagnostic tests are indicated for the routine ongoing monitoring of this patient's antiarrhythmic therapy? (Select all that apply)

A 46-year-old female presents to the primary care clinic for a routine health maintenance evaluation. She has a history of seropositive rheumatoid arthritis, which was diagnosed 4 years ago. Her disease is currently well controlled on a regimen of weekly methotrexate and subcutaneous etanercept. She feels well and reports no joint pain, stiffness, or systemic symptoms. She smoked one pack of cigarettes daily for 15 years but quit 5 years ago. She has no other chronic medical conditions, and her only other medication is a daily multivitamin. Her most recent screening tests include a normal colonoscopy at age 45 and a normal screening mammogram 8 months ago. Hepatitis B and C virus screening tests were negative 3 years ago. She received a tetanus-diphtheria-pertussis (Tdap) booster 4 years ago. She has not yet received an influenza vaccine this season. Vital signs are within normal limits, and physical examination is unremarkable. Which of the following is the most appropriate next step in preventive care for this patient?

An independent 68-year-old woman visits the clinic to establish care and discuss her health maintenance. Her past medical history includes well-controlled essential hypertension and primary hypothyroidism. She consumed one pack of cigarettes daily for 25 years but successfully abstained from tobacco starting 12 years ago. Family history is notable for her mother passing away from ovarian cancer at age 72. Review of her medical records reveals a normal colonoscopy at age 64, a normal bilateral mammogram 11 months ago, and negative cervical cytology with negative high-risk HPV testing at age 63. She has documented consecutive negative cervical cancer screenings over the preceding two decades. A bone mineral density evaluation performed at age 65 demonstrated a T-score of -0.4 at the lumbar spine. Which of the following is the most appropriate next step in this patient's preventive care?

A 48-year-old man presents to the primary care clinic for a routine wellness evaluation. His medical history includes type 2 diabetes mellitus and hypertension, both diagnosed three years ago. His daily medications are metformin and lisinopril. He does not smoke, drinks alcohol occasionally, and denies any illicit drug use. His family history is unremarkable for early-onset cancers. His body mass index is 31 $kg/m^2$. Blood pressure is 128/82 mmHg. His last colonoscopy, performed at age 45, was normal. A hepatitis C virus antibody screening performed three years ago was negative. His immunization records show he received all standard childhood vaccines. In adulthood, he received a tetanus, diphtheria, and pertussis (Tdap) booster four years ago and receives an annual influenza vaccination. He has not received any other vaccines since establishing adult care. Which of the following preventive interventions are indicated for this patient today? (Select all that apply)

An occupational health physician is evaluating a corporate executive who requires medical clearance prior to a long-term overseas deployment. The patient is a 50-year-old female whose past medical history is notable for essential hypertension, currently well-managed with daily amlodipine. Her body mass index is 31 kg/m². She reports a previous smoking habit of half a pack of cigarettes per day between the ages of 20 and 45, having ceased all tobacco use five years ago. A comprehensive review of her medical records reveals that she has not undergone any standardized preventive health screenings or diagnostic imaging in the past decade. Which of the following screening modalities are indicated for this patient prior to her departure? (Select all that apply)

A $39$-year-old man presents to the addiction medicine clinic complaining of severe muscle aches, abdominal cramping, diarrhea, and rhinorrhea over the past $3$ days. He has a history of opioid use disorder and has been stable on a fixed daily dose of oral methadone for the past $2$ years without any illicit drug use. Three weeks ago, he was diagnosed with a latent tuberculosis infection after a positive interferon-gamma release assay. He was subsequently started on a daily regimen of oral rifampin, which is planned for a $4$-month duration. His vital signs today include a blood pressure of $145/92$ mmHg, a heart rate of $110$/min, and a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$). Physical examination reveals diaphoresis, pupillary dilation, and hyperactive bowel sounds. A urine toxicology screen is negative for all illicit substances. Which of the following is the most appropriate pharmacologic intervention for this patient's current symptoms?

A 64-year-old man is evaluated in the clinic for a routine follow-up. Six months ago, he was diagnosed with highly symptomatic paroxysmal atrial fibrillation and was started on amiodarone for rhythm control. His other medical conditions include hypertension and type 2 diabetes mellitus. His current medications are amiodarone, lisinopril, metformin, and apixaban. He reports feeling well and denies palpitations, shortness of breath, cough, fatigue, heat intolerance, or visual changes. His pulse is 68/min, and blood pressure is 122/78 mmHg. Physical examination, including pulmonary auscultation and neurologic assessment, is unremarkable. An electrocardiogram performed today shows normal sinus rhythm with a heart rate of 66/min and a QTc interval of 440 msec. Baseline chest radiograph, pulmonary function tests, and laboratory studies were normal prior to amiodarone initiation. Which of the following is the most appropriate next step in the monitoring of this patient's pharmacotherapy?

A 48-year-old man is brought to the emergency department via ambulance due to a prolonged seizure. His wife reports that he abruptly lost consciousness and began experiencing generalized shaking while eating breakfast. The paramedics arrived 10 minutes after the onset of the episode and noted continuous, generalized tonic-clonic motor activity. En route to the hospital, his convulsions did not cease. On arrival in the emergency bay, the patient remains unresponsive with active generalized tonic-clonic movements. His estimated weight is 80 kg (176 lb). Vital signs show a blood pressure of 168/94 mmHg, heart rate of 136/min, and oxygen saturation of 92% on a non-rebreather mask. Point-of-care blood glucose is 102 mg/dL. He has no established intravenous access.

Arrange the following pharmacologic interventions in the correct sequential order for the evidence-based management of this patient's emergency, from the immediate initial step to the therapy reserved for super-refractory disease.