Patient Management

A 73-year-old man presents to the clinic for a health maintenance visit. He has not seen a healthcare provider in over a decade. His medical history is significant for ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, New York Heart Association class III heart failure, and severe chronic obstructive pulmonary disease requiring continuous home oxygen therapy. He is a current smoker with a 55 pack-year smoking history. The patient spends the majority of his day resting in a recliner due to dyspnea on minimal exertion. His medications include aspirin, metoprolol succinate, sacubitril-valsartan, empagliflozin, furosemide, and a fluticasone-umeclidinium-vilanterol inhaler.

He has never undergone screening for colon, prostate, or lung cancer. He recently read an article about the importance of early cancer detection and asks which screening tests he should undergo today.

Which of the following is the most appropriate recommendation regarding cancer screening for this patient?

Seeking to establish care after recently relocating, a 68-year-old woman presents to a new primary care provider for a wellness visit. Her past medical history is notable for human immunodeficiency virus (HIV) infection, diagnosed two decades ago, which remains well-controlled on a daily antiretroviral regimen. Her most recent CD4 T-lymphocyte count is 680 cells/mm³, and her viral load is undetectable. She smoked one pack of cigarettes daily from age 20 to age 38, completely abstaining since then.

A review of her previous medical records reveals the following preventive care history:
- A screening colonoscopy at age 60 demonstrated no polyps or masses.
- A screening mammogram performed 11 months ago was interpreted as Breast Imaging Reporting and Data System (BI-RADS) category 1.
- A dual-energy x-ray absorptiometry scan at age 65 showed a T-score of -0.8 at the lumbar spine and femoral neck.
- Cervical cancer screening via cytology and high-risk human papillomavirus (hrHPV) co-testing was performed at ages 59, 62, and 65; all results were negative for intraepithelial lesion or malignancy and negative for hrHPV.

The patient currently takes no medications other than her antiretroviral therapy. She is up to date on her recombinant zoster vaccine, pneumococcal vaccination series, and the seasonal influenza vaccine.

Based on current evidence-based guidelines, which of the following screening tests is indicated for this patient today?

A 54-year-old man is brought to the emergency department due to sudden onset of severe, "tearing" chest pain that radiates to his interscapular region. The pain started 45 minutes ago while he was moving heavy furniture. He has a history of essential hypertension and tobacco use. On presentation, he is anxious and diaphoretic. Vital signs are temperature 37.0°C (98.6°F), blood pressure 210/120 mmHg in the right arm and 170/100 mmHg in the left arm, heart rate 115/min, and respiratory rate 24/min. Pulse oximetry is 96% on room air. Neurologic examination is unremarkable. Electrocardiogram reveals sinus tachycardia with left ventricular hypertrophy but no acute ischemic changes. Which of the following is the most appropriate next step in the management of this patient?

During a routine health maintenance visit, a 58-year-old male with essential hypertension and chronic kidney disease stage 2 is prescribed lisinopril. His blood pressure in the clinic is 152/94 mmHg. Baseline laboratory studies obtained today show a serum creatinine of 1.2 mg/dL and a serum potassium of 4.3 mEq/L. The patient is instructed on how to take the medication and asked to schedule a follow-up visit. Which of the following is the most appropriate next step in monitoring this patient's new therapy?

A 78-year-old man is evaluated in the intensive care unit for right upper quadrant abdominal pain and fever. Three days ago, he was admitted for an acute anterior ST-elevation myocardial infarction complicated by cardiogenic shock. He was treated with primary percutaneous coronary intervention and placement of a drug-eluting stent. His current medications include aspirin, ticagrelor, high-intensity statin, and a continuous intravenous infusion of norepinephrine.

His temperature is $39.2^\circ\text{C}$ ($102.6^\circ\text{F}$), blood pressure is $88/54\text{ mm Hg}$, pulse is $112/\text{min}$, and respiratory rate is $22/\text{min}$. Physical examination reveals marked right upper quadrant tenderness with guarding. A bedside ultrasound demonstrates a distended gallbladder with a thickened wall measuring $8\text{ mm}$, pericholecystic fluid, and multiple echogenic gallstones. The common bile duct diameter is $5\text{ mm}$ with no stones visualized within it. Laboratory studies show a leukocyte count of $19,500/\mu\text{L}$, total bilirubin of $0.9\text{ mg/dL}$, and alkaline phosphatase of $110\text{ U/L}$. Intravenous fluid resuscitation and broad-spectrum antibiotics have been initiated.

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

Following an open reduction and internal fixation for a comminuted right tibial diaphysis fracture, a young adult patient is evaluated on the surgical ward for intractable lower extremity pain. The operative procedure was completed 14 hours ago. The overnight nursing staff reports that the patient has required multiple breakthrough doses of intravenous hydromorphone with minimal relief.

The patient describes the pain as a severe, deep burning sensation in the right calf that is significantly worse than his preoperative pain. On physical examination, the right leg is markedly swollen, and the anterior compartment feels exceptionally tight and woody to palpation. Passive plantar flexion of the right ankle elicits agonizing pain. Dorsalis pedis and posterior tibial pulses are 2+ and symmetric with the left foot. Capillary refill is less than 2 seconds in the right toes, but the patient reports decreased sensation to light touch in the first dorsal web space. All compressive dressings and bandages have already been completely removed down to the skin, with no improvement in symptoms.

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

A 63-year-old man presents to the clinic for a routine wellness evaluation. His medical history includes type 2 diabetes mellitus, hyperlipidemia, and mild osteoarthritis. He smoked one pack of cigarettes daily for 25 years but successfully quit at age 45. His family history is non-contributory.

Review of his preventive care records reveals the following:
- A screening colonoscopy performed at age 58 showed three 6-mm tubular adenomas, which were completely excised.
- He received the 20-valent pneumococcal conjugate vaccine (PCV20) at age 58 shortly after his diabetes diagnosis.
- He received a 2-dose series of recombinant zoster vaccine at age 50.
- He received a tetanus-diphtheria-acellular pertussis (Tdap) booster 4 years ago.
- He has never undergone abdominal imaging.

He currently has no symptoms, and his diabetes is well-controlled. Which of the following is the most appropriate next step in this patient's preventive care?

A 52-year-old man visits the clinic for a follow-up appointment. He has a history of chronic hepatitis C virus (HCV) infection, genotype 1a. He has just taken the final dose of a 12-week regimen of daily glecaprevir-pibrentasvir. Prior to initiating therapy, baseline testing for hepatitis B virus and HIV was negative, and liver transient elastography demonstrated a fibrosis score of F2 (moderate fibrosis). The patient reports feeling well and has experienced no adverse effects from the medication. He has no history of alcohol use disorder. Physical examination shows no jaundice, spider angiomata, or hepatosplenomegaly.

Serial laboratory results are as follows:

The patient asks how the clinical team will determine if his liver infection has been fully cured by the antiviral regimen. Which of the following is the most appropriate next step in evaluating the success of this patient's treatment?

Five patients are currently awaiting transition from an acute care hospital. The attending physician must determine the correct post-acute environment for each based on their current clinical stability, rehabilitation tolerance, and functional deficits. Match each patient scenario with the most appropriate post-acute care setting.

Match each patient's clinical presentation with the most appropriate next step in their diagnostic workup and test sequencing, according to established guidelines for pulmonary nodules and lung mass evaluation.

Emergency medical services bring a 72-year-old woman to the acute care bay because she suddenly developed right-sided weakness, right facial droop, and severe expressive aphasia exactly 45 minutes prior to arrival. Her current blood pressure is 175/95 mmHg, and her heart rate is 92/min with an irregularly irregular rhythm. Medical records indicate a history of hypertension and atrial fibrillation, for which she recently stopped taking her anticoagulant medication. The clinical presentation is highly suspicious for an acute ischemic stroke. Which of the following are the most critical initial diagnostic tests that should be ordered immediately to determine her eligibility for acute pharmacological reperfusion therapy? (Select all that apply)

A 29-year-old woman, gravida 2, para 1, at 26 weeks gestation, comes to the emergency department due to sudden-onset shortness of breath and sharp, right-sided chest pain that worsens with deep inspiration. The symptoms began 2 hours ago. She also reports progressive swelling and discomfort in her left leg over the past 3 days. Her pregnancy has been uncomplicated, and she has no significant past medical history. She takes prenatal vitamins. Her temperature is 37.1 C (98.8 F), blood pressure is 112/70 mm Hg, pulse is 118/min, and respirations are 24/min. Pulse oximetry shows 94% on room air. Examination reveals clear lungs bilaterally. The cardiovascular examination is notable for tachycardia without murmurs. The left calf is visibly swollen, erythematous, and tender to palpation, with a circumference 4 cm greater than the right calf. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A $52$-year-old woman is brought to the emergency department by her husband due to the sudden onset of an excruciating headache that began $8\text{ hours}$ ago. She describes it as the "worst headache of my life" and reports one episode of vomiting and extreme sensitivity to room lights. Her medical history is significant for a mechanical mitral valve replacement performed $3\text{ years}$ ago for severe rheumatic mitral stenosis. Her daily medications include warfarin and metoprolol.

On presentation, her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $168/94\text{ mm Hg}$, pulse is $88/\text{min}$, and respiratory rate is $16/\text{min}$. Neurologic examination reveals a fully alert and oriented patient with intact cranial nerves, normal motor strength, and normal sensory function. Mild nuchal rigidity is present.

Laboratory studies show an international normalized ratio (INR) of $3.2$.

A non-contrast computed tomography (CT) scan of the head is performed and reveals no acute intracranial hemorrhage, mass effect, or midline shift.

Which of the following is the most appropriate next step in the diagnostic workup?

During a routine morning round on the telemetry unit, a hospitalized patient suddenly loses consciousness, and the central monitor instantly displays coarse ventricular fibrillation. No carotid pulse is palpable. Arrange the following emergency interventions in the correct chronological sequence according to standard Advanced Cardiac Life Support (ACLS) protocols for this specific presentation.

Match each patient's clinical presentation and initial coagulation laboratory findings with the most appropriate next step in diagnostic test sequencing.

For each of the following patient scenarios, select the most appropriate initial diagnostic investigation from the available choices.

A 68-year-old man is brought to the emergency department by emergency medical services due to sudden-onset, severe shortness of breath. He has a history of ischemic cardiomyopathy with a known left ventricular ejection fraction of $25\%$. Upon arrival, the patient is lethargic, diaphoretic, and using accessory muscles of respiration. His blood pressure is $72/48$ mm Hg, heart rate is $122$/min, respiratory rate is $34$/min, and oxygen saturation is $82\%$ on room air. Physical examination reveals cool, mottled extremities and prominent jugular venous distention. Auscultation of the lungs demonstrates coarse crackles in all lung fields. Which of the following is the most appropriate initial step in the stabilization of this patient?

A 32-year-old rock climber is brought to the emergency department by paramedics after an estimated 30-foot fall. He arrives immobilized on a backboard with a rigid cervical collar in place. He is agitated, tachycardic, and has an obvious deformity of his right femur. Arrange the following steps of his initial trauma resuscitation in the correct chronological order according to standard Advanced Trauma Life Support (ATLS) primary survey principles.

A 24-year-old female graduate student schedules an appointment at the university health clinic after noticing a lump in her right breast while showering. She reports that the lump has been present for approximately six weeks and has not fluctuated in size or tenderness with her menstrual cycles. Her medical history is unremarkable, and she takes no medications other than a combined oral contraceptive pill. Her family history is negative for breast or ovarian malignancies. Vital signs are within normal limits. On physical examination, there is a 2.5-cm, firm, highly mobile, non-tender, and well-circumscribed mass in the upper outer quadrant of the right breast. There is no overlying skin dimpling, nipple retraction, or palpable axillary lymphadenopathy. Which of the following is the most appropriate next step in the diagnostic evaluation of this patient?

A 62-year-old man is evaluated in the intensive care unit for new-onset fever, increased purulent endotracheal secretions, and worsening oxygenation. He was intubated 6 days ago for severe blunt chest trauma following a motor vehicle collision. His medical history is significant for a severe, IgE-mediated anaphylactic allergy to penicillin, documented as causing diffuse urticaria, angioedema, and respiratory failure. Vital signs show a temperature of 39.2°C (102.6°F), heart rate of 122/min, and blood pressure of 82/45 mmHg despite the administration of 3 liters of intravenous crystalloid. He is started on a norepinephrine infusion. A chest radiograph reveals a new dense infiltrate in the right lower lobe. The patient requires prompt initiation of empiric antimicrobial therapy for suspected ventilator-associated pneumonia and septic shock. Which of the following antimicrobial agents should be included in this patient's empiric regimen? (Select all that apply)