Patient Management

An occupational health clinic is auditing the medical records of several newly onboarded employees to ensure compliance with age- and risk-appropriate preventive care protocols. Match each employee's clinical profile with their most urgently indicated evidence-based screening or immunization intervention.

Paramedics bring a 45-year-old female to the emergency department due to worsening dyspnea, blurred vision, and an intense headache over the past 12 hours. The patient was diagnosed with diffuse cutaneous systemic sclerosis four years ago and takes mycophenolate mofetil. Vital signs show a temperature of 37.1°C (98.8°F), blood pressure of 228/118 mm Hg, pulse of 106/min, and respiratory rate of 24/min. Pulse oximetry is 94% on room air. Physical examination is notable for diffuse skin thickening sparing the clavicles and bilateral basilar crackles.

Laboratory studies reveal:
Hemoglobin: 8.9 g/dL
Platelets: 78,000/mm³
Creatinine: 3.6 mg/dL (baseline: 0.8 mg/dL)
Lactate dehydrogenase: 940 U/L
Urinalysis: 2+ protein, no red blood cell casts

A peripheral blood smear demonstrates fragmented red blood cells. Which of the following is the most appropriate initial pharmacologic intervention?

A 72-year-old man develops massive abdominal distension on postoperative day 4 following a right total knee arthroplasty. He is currently receiving intravenous hydromorphone for pain control. He reports nausea and diffuse abdominal discomfort but denies severe sharp pain or vomiting. He is still passing flatus. His temperature is $37.2^{\circ}\text{C}$ ($99.0^{\circ}\text{F}$), blood pressure is $130/80\text{ mmHg}$, and heart rate is $88/\text{min}$. On physical examination, the abdomen is markedly distended and tympanitic, with high-pitched bowel sounds. There is no involuntary guarding or rebound tenderness. Laboratory studies show a serum sodium of $138\text{ mEq/L}$, potassium of $4.0\text{ mEq/L}$, and calcium of $9.2\text{ mg/dL}$. A CT scan of the abdomen and pelvis with intravenous contrast reveals massive dilation of the cecum, ascending colon, and transverse colon with a maximum cecal diameter of $11.0\text{ cm}$. There is no mechanical transition point, free intraperitoneal air, or bowel wall pneumatosis. Arrange the following procedural and management steps in the correct sequential order for this patient according to standard guidelines, assuming each preceding intervention fails to resolve the condition.

A 67-year-old man comes to the clinic to establish care after moving to a new city. He reports feeling well and has no current symptoms. His past medical history includes essential hypertension, which is well-controlled with lisinopril. He had an appendectomy at age 20. Social history is notable for smoking 1 pack of cigarettes daily from age 18 to age 25, after which he completely quit. He drinks 1 to 2 glasses of wine on the weekends.

His last colonoscopy was 3 years ago and was completely normal. A fasting lipid panel and hemoglobin A1c were checked 2 months ago and were within normal limits. A one-time hepatitis C virus antibody test was negative 5 years ago. At age 65, he received the 20-valent pneumococcal conjugate vaccine (PCV20) and completed the recombinant zoster vaccine series. He received a Tetanus, Diphtheria, Pertussis (Tdap) booster 4 years ago and the seasonal influenza vaccine last week.

Vital signs and physical examination are unremarkable.

Which of the following is the most appropriate next step in this patient's preventive care?

A $28$-year-old woman is evaluated in the psychiatric clinic for an acute manic episode characterized by a decreased need for sleep, grandiosity, and hyperverbosity. She is subsequently diagnosed with bipolar I disorder. Following a comprehensive discussion regarding mood stabilization, the physician decides to initiate therapy with lithium carbonate. In addition to monitoring serum medication concentrations, which of the following laboratory parameters must be evaluated at baseline and periodically monitored during long-term maintenance therapy with this agent? (Select exactly $3$ options)

A physician evaluates a $28$-year-old woman during her first prenatal visit at $8$ weeks of gestation. She has a medical history of primary hypothyroidism due to Hashimoto thyroiditis and has been well-controlled on a stable daily dose of $100 \text{ \mu g}$ of levothyroxine for the past two years. She reports mild fatigue but denies palpitations, heat intolerance, or vaginal bleeding. Her vital signs are within normal limits. Physical examination is unremarkable, with a normal-sized thyroid gland and no palpable nodules. Laboratory studies obtained today reveal a thyroid-stimulating hormone (TSH) level of $4.8 \text{ mIU/L}$ (reference range for the first trimester: $0.1$ to $2.5 \text{ mIU/L}$) and a free thyroxine (T4) level at the lower limit of normal. Which of the following is the most appropriate next step in the management of this patient's thyroid disease?

Following a recent change in her employment benefits, a 50-year-old female schedules an appointment for a comprehensive health evaluation. She mentions that her last medical visit was over a decade ago. She reports feeling well and has no acute or chronic complaints. Her past medical history is notable only for two uncomplicated vaginal deliveries in her twenties. Family history is unremarkable for early-onset malignancies or cardiovascular diseases. She has never smoked, does not consume alcohol, and exercises occasionally. Her blood pressure is 128/78 mmHg, heart rate is 76/min, and body mass index is 33 kg/m^2. Physical examination, including a clinical breast examination and pelvic examination, reveals no abnormalities. Which of the following screening interventions are indicated for this patient at this time? (Select all that apply)

A $68$-year-old man is evaluated in the intensive care unit for worsening lethargy and confusion. He was admitted $5$ days ago for severe community-acquired pneumonia and subsequently developed acute kidney injury. His past medical history is significant for hypertension, type 2 diabetes mellitus, and a focal seizure disorder for which he takes a stable dose of phenytoin. Currently, his temperature is $37.2^\circ$ C ($99.0^\circ$ F), blood pressure is $118/74$ mmHg, and pulse is $88$/min. Physical examination reveals prominent horizontal nystagmus, slurred speech, and bilateral intention tremor. Laboratory studies show:

Blood urea nitrogen: $68$ mg/dL
Serum creatinine: $3.8$ mg/dL
Serum albumin: $2.2$ g/dL
Total serum phenytoin: $12$ mg/L (therapeutic range: $10-20$ mg/L)

Which of the following is the most appropriate next step in the evaluation of this patient?

A 54-year-old woman is evaluated in the hospital on the second day of her admission for a mechanical small bowel obstruction. She originally presented with cramping abdominal pain, bilious vomiting, and failure to pass flatus. Her surgical history is notable for a total abdominal hysterectomy performed $5$ years ago. Initial management included bowel rest, intravenous fluid resuscitation, and nasogastric tube decompression. Over the last $4$ hours, her abdominal pain has transitioned from intermittent cramps to a severe, constant ache. Her temperature is $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), blood pressure is $98/60\text{ mm Hg}$, and pulse is $115/\text{min}$. Physical examination now reveals a rigid, distended abdomen with significant rebound tenderness and involuntary guarding in all four quadrants. Laboratory studies obtained $30\text{ minutes}$ ago show a leukocyte count of $16,500/\text{mm}^3$ and a serum lactate level of $4.2\text{ mmol/L}$. Which of the following is the most appropriate next step in the management of this patient?

A 62-year-old female is hospitalized for an exacerbation of chronic obstructive pulmonary disease. She has been receiving subcutaneous unfractionated heparin for deep vein thrombosis prophylaxis. On hospital day 6, her right leg becomes acutely swollen and painful. Venous duplex ultrasonography reveals a new popliteal vein thrombosis. Her platelet count, which was $240,000/\text{mm}^3$ on admission, is now $95,000/\text{mm}^3$. The clinical team suspects heparin-induced thrombocytopenia (HIT).

Arrange the following pharmacologic management steps in the strict chronological sequence required to safely treat this patient and transition her to long-term anticoagulation.

An internal medicine resident is outlining the longitudinal care plan for a $55$-year-old patient who was recently diagnosed with severe non-ischemic cardiomyopathy. The patient's initial echocardiogram revealed a left ventricular ejection fraction of $22\%$. Prior to hospital discharge yesterday, the patient was successfully stabilized and transitioned to oral quadruple guideline-directed medical therapy, including an angiotensin receptor-neprilysin inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist, and a sodium-glucose cotransporter-$2$ inhibitor. Arrange the following outpatient monitoring and treatment evaluation steps in the most appropriate chronological order.

A 62-year-old woman presents to her primary care physician for a routine health maintenance evaluation. She has no acute medical complaints today and feels well. Her past medical history is notable for hypertension, which is well-controlled on amlodipine, and obesity. Her body mass index is 32 kg/m². Social history reveals she is a former smoker who smoked 1 pack of cigarettes daily for 30 years before quitting 16 years ago. She currently drinks one glass of wine occasionally.

Review of her preventive screening records shows she underwent a screening colonoscopy at age 55 that revealed no polyps or abnormalities. She had a normal screening mammogram 6 months ago. Her last Pap smear with high-risk human papillomavirus (HPV) co-testing was performed at age 59 and was negative for both. Her hepatitis C antibody test was negative 3 years ago. Regarding immunizations, she received an annual influenza vaccine last month and a Tdap booster 4 years ago. She has no history of receiving the recombinant zoster vaccine or any pneumococcal vaccines.

Which of the following is the most appropriate next step in preventive care for this patient?

A $34$-year-old woman comes to the clinic for an acute visit. Four weeks ago, she was diagnosed with Graves disease and was started on methimazole and propranolol. She reports that her palpitations and hand tremors have significantly improved. However, yesterday she developed a mild sore throat and a subjective fever.

Her temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $118/76\text{ mmHg}$, pulse is $82/\text{min}$, and respirations are $14/\text{min}$. Physical examination shows mild pharyngeal erythema without tonsillar exudates, palatal petechiae, or cervical lymphadenopathy. Her thyroid gland is diffusely enlarged, smooth, and non-tender.

Laboratory evaluation reveals the following:

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

A 74-year-old man is evaluated in the cardiology clinic 3 days after being discharged from the hospital. He had been admitted for highly symptomatic, recurrent atrial fibrillation, and oral amiodarone was initiated for rhythm control prior to discharge. His medical history is significant for heart failure with reduced ejection fraction and a mechanical aortic valve replacement performed 4 years ago. His home medications include warfarin, digoxin, metoprolol succinate, and lisinopril. On the day of discharge, his international normalized ratio (INR) was 2.8 (target 2.5–3.5) and his serum digoxin level was 0.9 ng/mL (target 0.5–0.9 ng/mL). Today, the patient reports feeling well with no palpitations, visual disturbances, or bleeding. Vital signs are within normal limits. Which of the following is the most appropriate next step in the management of this patient's pharmacotherapy?

A $31$-year-old man comes to the clinic for a scheduled follow-up evaluation. Six months ago, he presented with a painless penile ulcer and a diffuse maculopapular rash involving his palms and soles. At that time, a rapid plasma reagin (RPR) test was reactive with a titer of $1:64$, and a Treponema pallidum particle agglutination (TP-PA) test was positive. He was diagnosed with secondary syphilis and successfully treated with a single intramuscular injection of $2.4$ million units of benzathine penicillin G. Today, the patient reports feeling well and notes that his rash resolved completely within a few weeks of treatment. He has no new sexual partners and has been consistently using condoms. Vital signs are within normal limits. Physical examination reveals clear skin with no active lesions, rashes, or lymphadenopathy. Neurologic examination shows no abnormalities. Which of the following is the most appropriate next step to evaluate the efficacy of this patient's treatment?

A $64$-year-old male is evaluated in the ambulatory clinic for optimization of his medical regimen following a recent discharge for volume overload. An echocardiogram obtained last week demonstrated a left ventricular ejection fraction of $28\%$. Past medical history is significant for essential hypertension and type 2 diabetes mellitus. He is currently euvolemic, reporting no orthopnea or peripheral edema. His only current medications are oral furosemide and metformin. Vital signs demonstrate a blood pressure of $135/82\text{ mmHg}$ and a heart rate of $76\text{ /min}$. Laboratory studies reveal a serum potassium of $4.2\text{ mEq/L}$, a serum creatinine of $1.1\text{ mg/dL}$, and a hemoglobin A1c of $8.1\%$. Which of the following medications should be simultaneously initiated to optimize this patient's long-term pharmacotherapy and reduce mortality? (Select all that apply)

Match each patient clinical profile with the most appropriate, guideline-concordant preventive care intervention or screening strategy.

A 64-year-old woman is admitted to the hospital with a 3-day history of worsening left lower quadrant abdominal pain, subjective fevers, and nausea. She has a history of diet-controlled type 2 diabetes mellitus and essential hypertension. Her temperature is $38.8^\circ\text{C}$ ($101.8^\circ\text{F}$), blood pressure is $118/76\text{ mm Hg}$, pulse is $108/\text{min}$, and respirations are $18/\text{min}$. Physical examination reveals marked tenderness in the left lower quadrant with voluntary guarding. There is no rebound tenderness or abdominal rigidity. Laboratory studies show a leukocyte count of $16,500/\text{mm}^3$. Intravenous fluids and broad-spectrum antibiotics are initiated. A computed tomography scan of the abdomen and pelvis with intravenous contrast reveals inflammation of the sigmoid colon with an adjacent $5.5\text{-cm}$ fluid collection containing gas bubbles and an enhancing rim. Which of the following is the most appropriate next step in management?

A $62$-year-old woman is admitted to the hospital with a newly diagnosed acute deep vein thrombosis of the right lower extremity. Her past medical history is significant for active gastric adenocarcinoma and chronic kidney disease stage 4, with a recent baseline creatinine clearance of $24\text{ mL/min}$. The clinical team decides to initiate dose-adjusted subcutaneous enoxaparin for therapeutic anticoagulation. Given the patient's comorbidities and pharmacotherapy, which of the following are appropriate monitoring and management strategies? (Select all that apply)

A 71-year-old man comes to his primary care physician for an annual health maintenance examination. His medical history includes hypertension, hyperlipidemia, and osteoarthritis. His current medications are lisinopril, atorvastatin, and acetaminophen as needed. He smoked one pack of cigarettes daily from age 18 until quitting completely at age 48. He drinks one or two alcoholic beverages weekly. The patient received a 20-valent pneumococcal conjugate vaccine at age 66 and completed the 2-dose recombinant zoster vaccine series at age 68. A screening colonoscopy performed at age 63 was entirely normal. He has never undergone any imaging of his chest or abdomen. Vital signs and physical examination today are unremarkable. Which of the following is the most appropriate next step in preventive care for this patient?