Patient Management

An asymptomatic 68-year-old woman is seen in the outpatient clinic for a health maintenance examination. Her medical history includes well-controlled primary hypertension and mild osteoarthritis of the knees. The patient reports smoking one pack of cigarettes daily from age 20 until she quit on her 60th birthday. Her last screening colonoscopy was performed at age 62 and revealed no polyps or abnormalities. A mammogram was obtained 6 months ago with benign findings. Bone densitometry at age 65 showed normal bone mineral density. Current medications include amlodipine and as-needed ibuprofen. Vital signs are within normal limits, and the physical examination shows no significant findings. Which of the following is the most appropriate next step in preventive screening for this patient?

A 72-year-old male presents to the clinic for a routine wellness evaluation. He has a medical history of essential hypertension that is well controlled with amlodipine. He feels well and reports no weight loss, changes in bowel habits, or urinary symptoms. He is a retired teacher who has never smoked and consumes alcohol occasionally. There is no family history of cancer. A review of his electronic medical record shows that his last preventive colonoscopy was performed 10 years ago and was normal. During the visit, the patient asks if he should be tested for prostate cancer, noting that a friend of the same age recently had a prostate-specific antigen (PSA) blood test. Which of the following is the most appropriate next step in managing this patient's preventive care?

A 52-year-old woman establishes care at a primary care clinic for a comprehensive wellness evaluation. She has a past medical history of essential hypertension that is well controlled on amlodipine. She currently smokes half a pack of cigarettes daily and has a 15-pack-year smoking history. She has no history of intravenous drug use, blood transfusions, or high-risk sexual behavior. A review of her lifelong medical records reveals that she has never undergone screening for hepatitis C. Her last screening colonoscopy at age 45 was normal. A screening mammogram performed 6 months ago was normal. Cervical cytology with high-risk human papillomavirus (hrHPV) co-testing was performed 3 years ago and was negative. She received a tetanus, diphtheria, and acellular pertussis (Tdap) booster 4 years ago and had an influenza vaccine last month. Physical examination is unremarkable. Her body mass index is 26 kg/m². Based on current guidelines, which of the following preventive interventions are indicated for this patient during today's visit? (Select all that apply)

A 58-year-old woman is brought to the emergency department by her family due to increased confusion and severe abdominal pain over the past 24 hours. She has a history of decompensated alcoholic cirrhosis and was recently discharged after treatment for esophageal varices. Her home medications include lactulose, rifaximin, spironolactone, furosemide, and propranolol.

Temperature is 38.4°C (101.1°F), blood pressure is 86/54 mmHg, pulse is 114/min, and respirations are 22/min. Physical examination reveals scleral icterus, spider angiomas, and a markedly distended abdomen with a positive fluid wave. There is diffuse, severe abdominal tenderness to palpation without rebound or guarding. Asterixis is present.

Laboratory studies show:
Leukocyte count: $14,500/\mu L$
Platelet count: $88,000/\mu L$
Serum sodium: $132 \text{ mEq/L}$
Serum potassium: $5.3 \text{ mEq/L}$
Serum creatinine: $2.1 \text{ mg/dL}$ (baseline $1.0 \text{ mg/dL}$)
Blood urea nitrogen: $52 \text{ mg/dL}$

Diagnostic paracentesis yields turbid ascitic fluid with a total nucleated cell count of $1,200/\mu L$ and $85\%$ neutrophils ($1,020 \text{ PMNs}/\mu L$).

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

During a routine medication management visit, a 52-year-old man reports a three-day history of worsening nausea, diarrhea, and unsteadiness. He was diagnosed with bipolar I disorder five years ago and has maintained psychiatric stability on a regimen of lithium carbonate. Two weeks prior to this visit, his primary care provider initiated hydrochlorothiazide for newly diagnosed primary hypertension. His temperature is 37.1°C (98.8°F), blood pressure is 122/78 mmHg, and pulse is 86/min. Neurological examination reveals a prominent coarse tremor in both hands and mild ataxia during tandem gait. Which of the following is the most appropriate next step in the management of this patient?

A 65-year-old woman is brought to the emergency department after a witnessed generalized tonic-clonic seizure. Her family reports she has been feeling progressively lethargic and confused over the past 3 days while recovering from a severe gastrointestinal illness. Initial laboratory evaluation reveals a serum sodium level of 112 mEq/L. She is diagnosed with severe symptomatic hyponatremia. Arrange the following management and monitoring steps in the correct chronological sequence, from initial emergency intervention to ongoing maintenance.

A $74$-year-old man is evaluated on the inpatient medical ward for acute agitation. He was admitted $2$ days ago for a complicated urinary tract infection and has been receiving intravenous ceftriaxone. His medical history is significant for Parkinson disease, for which he takes carbidopa-levodopa, and benign prostatic hyperplasia. Temperature is $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure is $134/82\text{ mmHg}$, pulse is $88/\text{min}$, and respiratory rate is $16/\text{min}$. The nursing staff reports that the patient was awake most of the night, shouting at "strangers in the room" and repeatedly attempting to pull out his peripheral intravenous catheter. On examination, the patient is disoriented to time and place, and his attention fluctuates during the interview. He has a baseline resting tremor and upper extremity cogwheel rigidity. Non-pharmacologic interventions, including frequent reorientation, optimizing room lighting, and placing a dedicated sitter in the room, have failed to calm the patient, and he remains highly combative. Which of the following is the most appropriate pharmacologic intervention to manage this patient's acute agitation?

A $68$-year-old man presents to an urgent care clinic with an expanding, warm, and erythematous rash on his left lower extremity. He has a medical history significant for a mechanical mitral valve replacement performed four years ago, for which he takes daily warfarin. His most recent International Normalized Ratio (INR) was $3.1$ two days ago (target range $2.5$ to $3.5$). The physician diagnoses purulent cellulitis and prescribes a $7$-day course of oral trimethoprim-sulfamethoxazole. Which of the following actions are the most appropriate next steps in the management of this patient's anticoagulation? (Select 2 answers)

A 55-year-old man is brought to the emergency department via ambulance for severe shortness of breath, facial swelling, and a diffuse rash. His symptoms began 15 minutes ago while eating at a seafood restaurant. His medical history is significant for hypertension, hyperlipidemia, and a prior myocardial infarction. His home medications include metoprolol, atorvastatin, and aspirin. On physical examination, the patient is in severe respiratory distress with prominent stridor, accessory muscle use, and diffuse expiratory wheezing. Widespread urticaria is noted on his trunk and extremities. Vitals are temperature 37.1°C (98.8°F), blood pressure 72/40 mm Hg, pulse 62/min, and respiratory rate 28/min. Intravenous access is rapidly established by the nursing staff.

Arrange the following pharmacologic interventions in the most appropriate sequential order for the stepwise resuscitation and management of this patient, from the immediate life-saving therapy to the final adjunctive treatment.

An outpatient clinic evaluates a 42-year-old man who is returning for a scheduled visit. Four weeks ago, he was diagnosed with active pulmonary tuberculosis and was started on a standard daily regimen of isoniazid, rifampin, pyrazinamide, and ethambutol. Today, the patient reports significant improvement in his initial respiratory symptoms. He states he has a good appetite and explicitly denies fatigue, nausea, vomiting, abdominal pain, dark-colored urine, or generalized pruritus. His vital signs are within normal limits. Physical examination reveals a non-tender, non-distended abdomen with no palpable hepatomegaly, and there is no evidence of scleral icterus.

Routine laboratory studies obtained earlier today reveal the following:

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

A 60-year-old female is evaluated in the primary care clinic for the management of elevated blood pressure. Over the past three clinic visits, her blood pressure has consistently averaged $154/96$ mmHg. Her past medical history is significant for bipolar I disorder, which has been well controlled on lithium carbonate for the past eight years without mood instability. She also has moderate persistent asthma, managed with a daily inhaled corticosteroid and as-needed albuterol. Her current vital signs are: heart rate $78$/min, respiratory rate $14$/min, and blood pressure $152/94$ mmHg. Physical examination is unremarkable, with clear lungs bilaterally and a regular heart rhythm. Recent laboratory studies reveal a serum creatinine of $0.9$ mg/dL, serum potassium of $4.1$ mEq/L, and a serum lithium level of $0.8$ mEq/L (therapeutic range: $0.6-1.2$ mEq/L). The physician decides to initiate pharmacologic monotherapy for essential hypertension. Which of the following is the most appropriate pharmacologic intervention for this patient?

Match each patient's clinical profile with the most appropriate next step in preventive care screening based on current United States Preventive Services Task Force (USPSTF) guidelines.

A 67-year-old man comes to the clinic for a routine wellness examination. His past medical history includes essential hypertension, hyperlipidemia, and osteoarthritis. He underwent a normal screening colonoscopy at age 65 and had a negative hepatitis C antibody test last year. He reports smoking a pack of cigarettes per day from age 18 to 22 but has not smoked since. He drinks alcohol occasionally. Current medications are lisinopril, atorvastatin, and as-needed ibuprofen. Blood pressure is 128/78 mm Hg, and pulse is 72/min. Cardiopulmonary examination is unremarkable, and abdominal examination reveals no pulsatile masses. Which of the following is the most appropriate next step in preventive care for this patient?

During a post-discharge follow-up visit, a physician evaluates a $65$-year-old male who was hospitalized three weeks ago for an anterior ST-elevation myocardial infarction complicated by acute decompensated heart failure. He currently performs activities of daily living independently but notes mild shortness of breath when walking up a slight incline. His medical history includes hypertension, type 2 diabetes mellitus, and a severe episode of oropharyngeal swelling that required emergency intubation shortly after initiating lisinopril three years ago.

Current medications include aspirin, clopidogrel, atorvastatin, and furosemide as needed.

Vital signs show a blood pressure of $122/78$ mmHg, a heart rate of $70$/min, and a respiratory rate of $16$/min. Physical examination reveals no jugular venous distention, clear lungs on auscultation, and no peripheral edema. A recent echocardiogram demonstrates a left ventricular ejection fraction of $30\%$.

Laboratory results:
- Serum sodium: $138$ mEq/L
- Serum potassium: $4.3$ mEq/L
- Serum creatinine: $1.1$ mg/dL
- Estimated glomerular filtration rate: $68$ mL/min/$1.73 \text{ m}^2$

Which of the following pharmacologic interventions are indicated to improve this patient's long-term survival? (Select all that apply)

A $62$-year-old woman is evaluated in the hospital on postoperative day 6 following a total right knee arthroplasty. Since the surgery, she has been receiving prophylactic subcutaneous unfractionated heparin. Her postoperative course has been otherwise uncomplicated. Today, she reports new-onset swelling and dull pain in her right calf. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), blood pressure $128/82$ mmHg, pulse $88$/min, and respirations $16$/min. Physical examination reveals pitting edema and tenderness in the right lower extremity.

A lower extremity venous duplex ultrasound is performed and confirms a new acute deep vein thrombosis in the right popliteal vein.

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

During a comprehensive health review, a 58-year-old female patient provides her medical history to her new primary care clinician. Her past medical diagnoses include type 2 diabetes mellitus, which is well-controlled on metformin, and a prior hepatitis C infection that was cured with direct-acting antivirals. She had a negative fourth-generation HIV test during her previous hepatitis C workup. She currently feels well and has no acute symptoms. The patient's substance use history is notable for a 25-pack-year smoking habit; however, she emphasizes that she achieved complete cessation 13 years ago. Review of her preventive care documentation reveals a normal screening colonoscopy six years ago and negative cervical cytology with human papillomavirus co-testing three years ago. Her most recent bilateral mammogram was performed two months ago and showed no abnormalities. She received a 20-valent pneumococcal conjugate vaccine upon her diabetes diagnosis and had her seasonal influenza vaccine two weeks ago. Vital signs and physical examination are unremarkable today. Based on current preventive guidelines, which of the following is the most appropriate next step in screening for this patient?

A $72$-year-old man is being evaluated in the intensive care unit for liberation from mechanical ventilation. He was admitted $9$ days ago for acute respiratory distress syndrome secondary to severe influenza A pneumonia. His initial airway management was complicated, requiring three intubation attempts using video laryngoscopy. Today, his condition has markedly improved; he is hemodynamically stable off vasopressor support, and arterial blood gas analysis reveals a PaO $_2$ of $85$ mm Hg on a fraction of inspired oxygen (FiO $_2$) of $0.30$ and a positive end-expiratory pressure (PEEP) of $5$ cm H $_2$ O. The critical care team plans to systematically de-escalate his respiratory support. Arrange the following monitoring and therapeutic de-escalation steps in the most appropriate chronological sequence to safely liberate this patient from mechanical ventilation.

Based on the provided demographic and clinical risk profiles, match each patient with the single most appropriate guideline-concordant preventive screening modality.

A 55-year-old woman is evaluated in the cardiology clinic for follow-up of heart failure with reduced ejection fraction. She reports persistent fatigue and dyspnea when walking up a single flight of stairs. Her current medications include maximum tolerated doses of sacubitril-valsartan, bisoprolol, and dapagliflozin. Blood pressure is 118/76 mmHg and heart rate is 68/min. A recent echocardiogram showed a left ventricular ejection fraction of 30%. The physician decides to add spironolactone to her regimen to improve her long-term outcomes. Which of the following diagnostic tests must be obtained 1 to 2 weeks after initiating this medication? (Select all that apply)

A 47-year-old man presents to the clinic to establish primary care. He has not visited a healthcare provider in over a decade and feels well, with no acute symptoms or concerns. He takes no medications. He has smoked 1 pack of cigarettes daily since age 20. He consumes 1 or 2 alcoholic beverages on the weekends. Family history is notable for a father who died of a myocardial infarction at age 75. Vital signs include a blood pressure of 126/82 mm Hg, heart rate of 74/min, and a body mass index of 27 kg/m². Physical examination is unremarkable. Which of the following is the most appropriate next step in screening for this patient?