Patient Management

A 31-year-old woman, gravida 2, para 1, presents for her initial prenatal visit at 10 weeks gestation. Her first pregnancy four years ago was uncomplicated, and her prenatal laboratory panel at that time was negative for human immunodeficiency virus (HIV), syphilis, hepatitis B, and hepatitis C. She has been in a monogamous relationship with her husband for six years. Neither has a history of injection drug use, sexually transmitted infections, or occupational blood exposures. Her body mass index is $22 \text{ kg/m}^2$. She feels well and takes a daily prenatal vitamin. Vital signs are within normal limits. In addition to a complete blood count, blood typing with rhesus factor, and screening for HIV, syphilis, and hepatitis B, which of the following screening tests is most appropriate to order for this patient today?

A 65-year-old man presents to the primary care clinic for an annual health maintenance examination. His past medical history is significant for type 2 diabetes mellitus, hypertension, and obesity. He is a former smoker, having smoked 1 pack per day for 40 years before quitting 2 years ago. He feels well and reports no acute symptoms. His vital signs and physical examination are unremarkable.

Review of his preventive health record reveals the following:
- A screening colonoscopy 6 years ago was completely normal, with no polyps identified.
- He received a Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine 12 years ago.
- He received two doses of the recombinant zoster vaccine at age 50.
- He received the seasonal influenza vaccine one month ago.
- He has never undergone abdominal imaging, chest imaging, or bone density screening.
- He has not received any pneumococcal vaccines.

Based on current guidelines, which of the following interventions are indicated for this patient at today's visit? (Select all that apply)

A 29-year-old man is evaluated in the intensive care unit due to sudden-onset hemodynamic instability. He was admitted two days prior for acute respiratory distress syndrome secondary to severe bacterial pneumonia. He is currently intubated and receiving pressure-controlled mechanical ventilation with high positive end-expiratory pressure. A nurse calls the physician to the bedside after the ventilator begins alarming for consistently high peak airway pressures. Current vital signs show a blood pressure of 72/40 mm Hg, a heart rate of 145/min, and an oxygen saturation of 82% despite an $FiO_2$ of $1.0$. Physical examination reveals absent breath sounds over the right hemithorax, hyperresonance to percussion on the right side, and prominently distended jugular veins. The trachea appears deviated to the left. Which of the following is the single most urgent initial step in the stabilization of this patient?

A 74-year-old retired accountant is accompanied to the geriatrics clinic by his son. The family is concerned because the patient has been repeatedly misplacing household items, forgetting recent conversations, and recently got lost while driving a familiar route to the grocery store. These changes have evolved gradually over the past 14 months. The patient feels fine and dismisses the concerns, attributing them to normal aging. Medical history is significant for well-controlled type 2 diabetes mellitus and osteoarthritis. Vital signs are within normal limits. General physical and detailed neurological examinations show no focal deficits, resting tremors, or gait abnormalities. His score on the Montreal Cognitive Assessment is 20/30, with prominent point deductions on delayed recall and visuospatial tasks. Which of the following diagnostic investigations should be ordered concurrently as part of the initial routine evaluation for this patient's cognitive decline? (Select all that apply)

During a scheduled health maintenance visit, a 24-year-old male college student is evaluated. He reports feeling well and has no acute complaints. Two weeks ago, he underwent an emergency splenectomy following a severe mountain biking accident that caused massive splenic rupture. His postoperative recovery has been uncomplicated. He has no other medical conditions and takes no daily medications. He does not smoke, drink alcohol, or use illicit drugs. Review of his immunization records shows that he completed all standard childhood vaccinations, including a single dose of the quadrivalent meningococcal conjugate vaccine (MenACWY) and the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine at age 11. He has not received any vaccines since that time.

Based on current Advisory Committee on Immunization Practices (ACIP) guidelines, administration of which of the following vaccine regimens is the most appropriate next step for this patient today?

A 38-year-old man comes to the outpatient clinic reporting a one-year history of worsening joint pain, excessive sweating, and frequent headaches. He mentions that he recently had to have his wedding band resized because it would no longer fit his finger. He has no significant past medical history and takes no medications. Vital signs show a blood pressure of 152/95 mmHg, heart rate of 78/min, and respiratory rate of 14/min. Physical examination reveals coarse facial features, a prominent jaw, and widening of the spaces between the lower incisors. His hands and feet appear enlarged with thickened skin. Which of the following is the most appropriate next step in the diagnostic workup?

A 19-year-old male college student is brought to the emergency department by his roommates because of confusion and a high fever. His roommates report that he complained of a severe headache and neck stiffness yesterday. Over the past few hours, he has become increasingly lethargic and developed a rapidly spreading purpuric rash on his lower extremities. He is oriented only to his name. His temperature is 39.8°C (103.6°F), blood pressure is 75/40 mmHg, heart rate is 138/min, respiratory rate is 26/min, and oxygen saturation is 94% on room air. The patient is moving all four extremities spontaneously.

Arrange the following management steps in the most appropriate sequential order for this patient.

A primary care clinic is auditing health maintenance records to ensure adherence to 2026 evidence-based preventive care guidelines. Review the specific clinical scenarios below and pair each patient with the uniquely indicated preventive intervention.

A 42-year-old construction worker is brought to the trauma resuscitation bay following a 20-foot fall from a scaffold. On arrival, he is pale and lethargic but moans in response to painful stimuli. His airway is patent, and breath sounds are vesicular and equal bilaterally.

Vital signs are:
Temperature: 36.4°C (97.5°F)
Blood pressure: 72/40 mmHg
Heart rate: 135 /min
Respiratory rate: 24 /min
Oxygen saturation: 97% on high-flow oxygen.

A primary survey reveals a mechanically unstable pelvis that demonstrates mobility on gentle anterior-posterior compression. There are severe abrasions over the lower abdomen and flanks, but no obvious sources of external hemorrhage are identified. Two large-bore peripheral intravenous lines are immediately established.

Which of the following are the most appropriate immediate next steps in management? (Select two)

A 34-year-old man is brought to the emergency department by emergency medical services after being rescued from a closed-space house fire. He was found trapped in a smoke-filled bedroom. On arrival, he is awake but agitated. Physical examination reveals partial- and full-thickness burns over his anterior chest and bilateral upper extremities. He has singed nasal vibrissae, carbonaceous sputum in the oropharynx, and a noticeably hoarse voice. Vital signs are temperature 37.1°C (98.8°F), blood pressure 110/70 mmHg, pulse 115/min, and respirations 28/min. Pulse oximetry shows an oxygen saturation of 94% on a 15 L/min non-rebreather face mask. Which of the following is the most appropriate immediate next step in the stabilization of this patient?

A 28-year-old woman, G2P1, at 26 weeks gestation, presents to the emergency department with acute-onset right-sided pleuritic chest pain and shortness of breath. She has no significant past medical history. Vital signs show a heart rate of 115/min, respiratory rate of 24/min, and oxygen saturation of 94% on room air. Physical examination is unremarkable with clear lungs and normal heart sounds. The patient's presentation is highly suspicious for a pulmonary embolism (PE).

Arrange the following diagnostic modalities in the most appropriate sequential order for the evaluation of this patient, from the initial test to the final definitive imaging study if preceding tests are nondiagnostic.

A 60-year-old woman presents to the clinic for a routine health maintenance examination. She has a history of type 2 diabetes mellitus and early-stage right breast cancer, which was treated with lumpectomy and local radiation therapy at age 52. She declined adjuvant endocrine therapy. Her diabetes is well-controlled with metformin. She has a 35-pack-year smoking history but successfully quit 8 years ago.

Her preventive care history is as follows:
- Colonoscopy at age 54 was completely normal.
- Screening mammogram 2 months ago showed no evidence of malignancy.
- Hepatitis C antibody test at age 55 was negative.
- Received a Tdap booster 4 years ago.
- Completed the sequence of PCV15 followed by PPSV23 one year ago.
- She has never received a zoster vaccine.

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

A 24-year-old woman presents to the outpatient clinic after discovering a lump in her right breast while showering two days ago. She has no significant past medical history and takes no medications other than a combined oral contraceptive pill. Her family history is notable for hypertension in her father, but she has no known family history of breast, ovarian, or other malignancies. Her last menstrual period was 12 days ago. Vital signs are within normal limits. On physical examination, the breasts are symmetric with no overlying skin changes, erythema, dimpling, or nipple discharge. Palpation of the right breast reveals a 2.5-cm, firm, non-tender, highly mobile, and well-circumscribed mass in the upper outer quadrant. There is no palpable axillary or supraclavicular lymphadenopathy. Which of the following is the most appropriate next step in the diagnostic workup?

Match the following patient clinical vignettes to the most appropriate next step in preventive care or screening, based on current evidence-based guidelines.

Emergency medical services bring a 68-year-old woman to the acute care bay for evaluation of severe difficulty breathing. Her husband, who accompanies her, reports a medical history significant for severe emphysema. He notes she has suffered from a progressively worsening productive cough over the preceding four days. On initial evaluation, the patient is profoundly somnolent and opens her eyes only in response to a vigorous sternal rub. She demonstrates marked intercostal retractions with shallow, rapid breathing. Current vital signs are temperature $37.9^\circ\text{C}$ ($100.2^\circ\text{F}$), pulse $124/\text{min}$, respirations $32/\text{min}$, and blood pressure $162/94\text{ mm Hg}$. Oxygen saturation is $76\%$ on room air. Thoracic auscultation reveals globally diminished air entry and faint expiratory wheezing. Which of the following represents the most urgent initial step in this patient's care?

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

A 58-year-old man is brought to the emergency department by his wife due to severe, worsening mid-back pain for the past 5 days. This morning, he developed difficulty walking and states he has been unable to urinate for the past 12 hours. His medical history is significant for poorly controlled type 2 diabetes mellitus and a recent hospitalization for a staphylococcal skin infection. His temperature is 38.8°C (101.8°F), blood pressure is 132/82 mm Hg, pulse is 108/min, and respirations are 18/min. Physical examination reveals exquisite tenderness to percussion over the T8-T10 vertebrae. Neurologic examination shows 3/5 motor strength in the bilateral lower extremities, diminished sensation to pinprick below the umbilicus, and a palpably distended bladder. Laboratory studies reveal a leukocyte count of $16,500/mm^3$. Which of the following is the most appropriate next step in the diagnostic workup of this patient?

A 56-year-old woman comes to the clinic for a routine health maintenance visit. She was diagnosed with severe plaque psoriasis one year ago and is currently maintained on adalimumab and topical corticosteroids, with excellent control of her skin disease. Her past medical history is otherwise notable for hypertension. She is planning a trip to a rural area in South America in two months and wants to ensure all her preventive care and travel vaccinations are up to date. Her social history includes a 10 pack-year smoking history, but she quit 20 years ago. Preventive care records indicate her last colonoscopy at age 51 was normal, cervical cancer screening with primary HPV testing at age 54 was negative, and a screening mammogram at age 55 was normal. She received the recombinant zoster vaccine series at age 51, a tetanus and diphtheria (Td) booster 3 years ago, and both the seasonal influenza and updated COVID-19 vaccines last month. She has never received a pneumococcal or yellow fever vaccine. Which of the following is the most appropriate next step in her preventive care?

A $28$-year-old man is rushed to the emergency department by his friends after abruptly developing extreme difficulty breathing and facial swelling at an outdoor seafood festival. He appears lethargic and is visibly gasping for air. Vital signs include a temperature of $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure of $70/38\text{ mm Hg}$, pulse of $142/\text{min}$, and respiratory rate of $32/\text{min}$. Oxygen saturation is $84\%$ on room air. Physical examination reveals marked lip and tongue edema, pronounced inspiratory stridor, and diffuse expiratory wheezing. His skin is cool to the touch, and there is a widespread erythematous, raised rash across his torso. Large-bore intravenous access is rapidly established. Which of the following initial stabilization steps should be ordered and executed simultaneously? (Select three)

Paramedics arrive at the emergency department with a $24$-year-old graduate student who was discovered obtunded in her apartment. An empty pill container labeled amitriptyline was found nearby. En route, the prehospital crew secured her airway with an advanced device and initiated mechanical ventilation due to severe central nervous system depression. Upon transfer to the resuscitation bay, her temperature is $38.1^\circ\text{C}$ ($100.6^\circ\text{F}$), heart rate is $142/\text{min}$, blood pressure is $76/40\text{ mm Hg}$, and oxygen saturation is $98\%$ on the ventilator. Her pupils are $6\text{ mm}$ and sluggishly reactive to light. A $12$-lead electrocardiogram is immediately obtained and demonstrates sinus tachycardia with a QRS complex duration of $145\text{ ms}$ and a prominent terminal R wave in lead aVR. Which of the following is the most appropriate next step in the stabilization of this patient?