Patient Management

A 71-year-old man presents to the clinic to establish care. He recently moved to the area to live closer to his family and has not seen a physician in six years. His medical history includes osteoarthritis of the knees and mild essential hypertension, both well-controlled with over-the-counter ibuprofen and lisinopril. He smoked 1.5 packs of cigarettes daily from age 20 to 50 but quit 21 years ago. He drinks one glass of wine on weekends. His previous medical records indicate that his last colonoscopy was performed at age 59 and revealed no polyps. A hepatitis C antibody test performed six years ago was negative. His most recent lipid panel and hemoglobin A1c, obtained during a community health fair last month, were within normal limits. His father died of a stroke at age 80, and his older brother was treated for localized prostate cancer at age 68. The patient is asymptomatic and his physical examination is unremarkable. Which of the following is the most appropriate combination of screening tests to recommend for this patient?

During a routine follow-up visit, an internal medicine physician evaluates a patient who was recently diagnosed with heart failure with reduced ejection fraction (LVEF 35%). The patient's prescribed medical regimen includes carvedilol, empagliflozin, and lisinopril. While reviewing the medication list, the patient states, "I stopped taking the lisinopril two weeks ago. A neighbor told me that those blood pressure pills destroy your kidneys. Since I feel completely fine right now, I do not want to risk kidney damage." Which of the following is the most appropriate initial response by the physician?

A 55-year-old man presents to the clinic for a routine health maintenance examination. He has not seen a physician in seven years. He feels well and has no acute complaints. His only past medical history is a surgical meniscus repair in his twenties. He takes no daily medications. He is a current smoker with a 35-pack-year smoking history, and he drinks 1 to 2 beers on weekends. His body mass index is 23 kg/m². His last health care visit was at age 48, during which he underwent a screening colonoscopy that was normal. At that time, a comprehensive metabolic panel, fasting lipid panel, and HIV screening were also unremarkable. He received a Tdap booster and an influenza vaccine at a local pharmacy last month, but he has not received any other adult immunizations. Which of the following preventive interventions are indicated for this patient at today's visit? (Select all that apply)

A 55-year-old woman presents to the clinic to review the results of a recent breast biopsy. The physician is preparing to deliver the diagnosis of invasive ductal carcinoma. According to the SPIKES protocol for delivering bad news, arrange the following physician actions and statements in the correct chronological order.

A 64-year-old man comes to the office for a routine follow-up evaluation. Three weeks ago, he was hospitalized for a non-ST-segment elevation myocardial infarction and was discharged on aspirin, ticagrelor, atorvastatin, and metoprolol. Today, his blood pressure is 128/78 mm Hg and heart rate is 68/min. During the interview, the patient states, "I stopped taking the atorvastatin and ticagrelor a few days ago. I read online that statins can completely destroy your liver. Also, my neighbor told me that a high-dose natural garlic extract thins the blood just as well as prescription drugs, without all the toxic chemicals, so I started taking that instead."

Which of the following is the most appropriate initial response by the physician?

Seeking to establish care, a 38-year-old woman arrives at the ambulatory clinic for a comprehensive wellness evaluation. She was diagnosed with systemic lupus erythematosus (SLE) complicated by class III lupus nephritis five years ago. Her disease has been clinically quiescent for the past three years on a maintenance regimen of mycophenolate mofetil and 10 mg of daily prednisone. She feels well and has no new symptoms. Her husband accompanies her, and she notes they have been mutually monogamous for the past decade.

Review of her preventive health records reveals the following:
* Dual-energy x-ray absorptiometry (DEXA) scan performed 6 months ago showed normal bone mineral density.
* Following her SLE diagnosis, she completed three consecutive normal annual cervical cytology exams. Her most recent screening, performed 2 years ago, was a negative cervical cytology with a negative high-risk HPV co-test.
* She received the 20-valent pneumococcal conjugate vaccine (PCV20) 1 year ago.
* She received the inactivated quadrivalent influenza vaccine 3 weeks ago at a community health fair.

Based on current immunization and screening guidelines, which of the following is the most appropriate next step in preventive care for this patient?

A 31-year-old G2P1 woman at 28 weeks gestation presents to the clinic for a routine prenatal visit. Her pregnancy has been uncomplicated to date. Her medical history is significant for mild intermittent asthma, which is well-controlled with an albuterol inhaler as needed. She feels well and reports normal fetal movement. Her blood type is AB-positive. Review of her immunization records shows that she received a complete series of standard childhood vaccines. She also received a tetanus-diphtheria-acellular pertussis (Tdap) vaccine two years ago during the third trimester of her first pregnancy. An inactivated influenza vaccine was administered three weeks ago. Vital signs and physical examination are unremarkable. Fundal height is 28 cm, and the fetal heart rate is 145/min. Which of the following is the most appropriate preventive intervention for this patient at today's visit?

An ambulatory care physician is evaluating a 58-year-old male who was diagnosed with primary hypertension and hyperlipidemia six months ago. At that time, he was prescribed lisinopril and atorvastatin. Today, his blood pressure is 156/94 mmHg. When asked about his daily medication routine, the patient admits he has not filled the prescriptions. He states, 'I feel completely fine, and my brother told me those cholesterol pills will destroy my liver. I prefer to let my body handle things naturally.'

Which of the following is the most appropriate initial response by the physician?

A primary care physician is managing a full schedule of adult patients presenting for health maintenance visits. Based on current United States Preventive Services Task Force (USPSTF) and Advisory Committee on Immunization Practices (ACIP) guidelines, match each patient's clinical vignette with the most appropriate next step in preventive care.

During routine outpatient clinic visits, a physician encounters several patients with varying levels of readiness to modify their health behaviors. Based on the Transtheoretical Model of Change, match each patient statement to the most appropriate physician counseling strategy.

A 24-year-old nulligravid woman presents to the clinic for a well-woman evaluation. She has no significant past medical history and takes no daily medications. She is currently sexually active with a new male partner and uses oral contraceptive pills for pregnancy prevention. Her last Papanicolaou (Pap) test was performed at age 21, and the results were normal. The physician advises the patient that she is due for a repeat cervical cancer screening today. The patient politely declines, stating, "I received the complete series of HPV vaccines when I was in high school. I read that the vaccine prevents the virus that causes cervical cancer, so I shouldn't need to undergo these uncomfortable exams anymore." Which of the following is the most appropriate response by the physician?

A 42-year-old man with a history of poorly controlled hypertension and a recent transient ischemic attack presents to the clinic for a follow-up examination. During the encounter, the physician notes a strong odor of tobacco smoke on the patient's clothing. The physician plans to implement a structured, guideline-concordant tobacco cessation intervention. According to the United States Preventive Services Task Force (USPSTF) recommended framework for counseling, arrange the following physician actions in the correct sequential order from first to last.

During a comprehensive intake evaluation at a new primary care practice, a physician assesses a 61-year-old male patient who has lacked medical follow-up for the past eight years. His past medical history includes type 2 diabetes mellitus, currently managed with diet and metformin. The patient reports a history of smoking one pack of cigarettes daily starting at age 20, but he successfully quit 11 years ago and has abstained since. He denies alcohol or recreational drug use. Blood pressure is 128/82 mmHg, and body mass index is 28 kg/m². A recent basic metabolic panel and hemoglobin A1c (6.7%) are stable. The physician is planning his health maintenance schedule. Which of the following preventive interventions are indicated for this patient today? (Select all that apply)

A 31-year-old male architect presents to the infectious disease clinic to discuss the results of recent blood work. He recently tested positive for HIV, and subsequent flow cytometry revealed a CD4 T-lymphocyte count of $410 \text{ cells/mm}^3$. The physician advises starting a daily antiretroviral regimen. The patient shakes his head and states, "I run marathons and have never felt better. I saw on a forum that these drugs destroy your liver and cause horrible fatigue. There is no way I am starting them until I actually feel ill." Which of the following is the most appropriate initial response by the physician?

A physician is training medical residents on the use of Motivational Interviewing (MI) techniques for lifestyle modification counseling. The core skills of MI are often summarized by the acronym OARS. Match each of the physician's verbal statements provided below with the specific MI communication technique it best represents.

A 54-year-old man presents to the clinic to establish care. He has not seen a physician in five years. His medical history includes type 2 diabetes mellitus, hypertension, and stage 3a chronic kidney disease. Current medications include lisinopril, amlodipine, metformin, and empagliflozin. He smoked 1.5 packs of cigarettes daily from age 18 until he quit at age 48. His family history is notable for a father who was diagnosed with colorectal cancer at age 65. The patient's last colonoscopy was at age 49 and showed no polyps. He received an annual influenza vaccine at a local pharmacy three weeks ago. His tetanus-diphtheria-acellular pertussis (Tdap) vaccination is up to date, and he completed the hepatitis B vaccine series in his 30s. He has never received a pneumococcal vaccine or a zoster vaccine. Which of the following combinations of preventive interventions is most appropriate for this patient today?

A 61-year-old postmenopausal woman presents to the ambulatory clinic for an annual wellness visit. She has not seen a physician in three years. Medical history is significant for mild hypertension and gastroesophageal reflux disease. Current medications include amlodipine and pantoprazole. Social history is notable for smoking 10 cigarettes a day (25-pack-year history) and drinking 1-2 glasses of wine on weekends. Her mother suffered a femoral neck fracture at age 76. Her preventive care history includes a normal screening mammogram and normal cervical cytology with human papillomavirus (HPV) co-testing one month ago at a health fair. Her last screening colonoscopy was normal at age 55. Physical examination reveals a blood pressure of 128/82 mm Hg, heart rate of 72/min, and a body mass index (BMI) of 22 kg/m². The remainder of the examination is unremarkable. The patient asks if she should be tested for osteoporosis. According to current guidelines, which of the following is the most appropriate next step regarding osteoporosis screening for this patient?

Match each adult patient presenting for a health maintenance or prenatal visit with the most appropriate next step in preventive care based on current guidelines.

A physician is evaluating a 46-year-old man during a routine wellness examination. The patient's past medical history is significant for pancolonic ulcerative colitis diagnosed 12 years ago. His gastrointestinal disease is currently in deep clinical remission, maintained solely on scheduled infliximab infusions. He reports smoking one pack of cigarettes daily for the past 25 years. Due to a prolonged period of uninsurance, he has not undergone any preventive health screenings or received any immunizations over the past decade. Today, he feels well and reports no acute symptoms. Which of the following preventive interventions are indicated for this patient? (Select all that apply)

Emergency medical services bring a 62-year-old gentleman to the trauma bay after he collapsed at home. His wife reports that he has been complaining of severe, unremitting abdominal pain for the past 48 hours. His past medical history includes long-standing osteoarthritis, for which he takes high-dose naproxen daily. On presentation, his temperature is 39.1°C (102.4°F), blood pressure is 82/50 mm Hg, pulse is 128/min, and respirations are 24/min. Physical examination reveals a distended, diffusely tender abdomen with rigid, board-like guarding and rebound tenderness. Bowel sounds are absent. An upright chest radiograph reveals free air under the right hemidiaphragm. Which of the following interventions are indicated immediately in this patient's management? (Select all that apply)