Patient Management

A 42-year-old woman is evaluated in the clinic for fatigue and dyspnea on exertion. Laboratory testing reveals a microcytic anemia with a hemoglobin of 8.2 g/dL and a severely depressed serum ferritin. She is diagnosed with iron deficiency anemia secondary to heavy menstrual bleeding and is prescribed daily oral ferrous sulfate. To appropriately monitor the efficacy of her treatment, the physician considers the expected timeline of her hematologic recovery.

Arrange the following laboratory and clinical milestones in the chronological order they are expected to occur, from earliest (first) to latest (last), following the initiation of oral iron therapy.

Emergency medical services bring a 72-year-old male resident of a skilled nursing facility to the acute care setting following a two-day history of worsening confusion, fever, and purulent sputum production. Upon triage, he appears lethargic and is in mild respiratory distress. Vital signs reveal a temperature of 38.9°C (102.0°F), a blood pressure of 88/56 mmHg, a heart rate of 112/min, and a respiratory rate of 26/min. Room air pulse oximetry indicates an oxygen saturation of 89%. Auscultation of the lungs demonstrates dense, coarse crackles localized to the right lower lung base. A portable chest radiograph confirms a new dense consolidation in the right lower lobe. A review of his electronic medical record reveals a prior ischemic stroke complicated by oropharyngeal dysphagia. Notably, he was discharged from the hospital one month ago after being treated for complicated pyelonephritis with a 10-day course of intravenous levofloxacin. Blood and sputum cultures are sent to the laboratory.

Which of the following antimicrobial agents should be included in his initial empiric pharmacologic regimen? (Select all that apply)

An internist is preparing hospital discharge orders for a $69$-year-old male who was admitted four days ago for an acute exacerbation of heart failure. The patient has a known history of ischemic cardiomyopathy with a left ventricular ejection fraction of $25\%$, type 2 diabetes mellitus, and stage 3 chronic kidney disease. Following successful intravenous diuresis, he is now euvolemic and breathing comfortably on room air.

Vital signs today show a blood pressure of $118/74$ mmHg and a heart rate of $72$/min.

Current medications planned for discharge include:
- Lisinopril $20$ mg daily
- Carvedilol $12.5$ mg twice daily
- Dapagliflozin $10$ mg daily
- Oral torsemide $20$ mg daily

To fully optimize guideline-directed medical therapy, the internist plans to prescribe spironolactone before the patient leaves the hospital.

Which of the following is the most appropriate action or instruction regarding the addition of this medication?

A 68-year-old man is evaluated in the hospital on the third day of admission for community-acquired pneumonia. He was initially started on intravenous ceftriaxone and azithromycin. The patient reports feeling significantly better, with a marked decrease in his cough and complete resolution of his shortness of breath. He has been afebrile for the past $24$ hours and is tolerating a regular diet without difficulty.

Vital signs are:
Temperature: $37.1^\circ\text{C}$ ($98.8^\circ\text{F}$)
Blood pressure: $126/78\text{ mm Hg}$
Heart rate: $78/\text{min}$
Respiratory rate: $14/\text{min}$
Oxygen saturation: $96\%$ on room air

Laboratory studies show a leukocyte count of $8,500/\mu\text{L}$, which has decreased from $15,200/\mu\text{L}$ on admission. A chest radiograph obtained this morning demonstrates a persistent right lower lobe consolidation, which is unchanged compared to the admission radiograph.

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

A 52-year-old man comes to the clinic for an urgent evaluation due to new-onset hand tremors and worsening headaches over the past three days. He underwent a deceased-donor renal transplantation eight months ago for end-stage renal disease secondary to polycystic kidney disease. His maintenance immunosuppression regimen consists of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Two weeks ago, he was seen at a local urgent care clinic for a sore throat and thick, white, scrapable plaques on his tongue and buccal mucosa. He was prescribed a 14-day course of an oral medication for this condition. Today, his temperature is 37.1°C (98.8°F), blood pressure is 158/92 mm Hg, and pulse is 88/min. Physical examination is notable for a fine resting tremor in both hands. Laboratory studies reveal a serum creatinine of 2.4 mg/dL, which is significantly elevated from his baseline of 1.3 mg/dL measured one month ago. Which of the following medications was most likely prescribed at the urgent care clinic?

Paramedics bring a 58-year-old woman to the emergency department after her husband witnessed her suddenly collapse and begin shaking. Upon arrival in the resuscitation bay, she is actively experiencing a generalized tonic-clonic seizure. Her husband states the seizure activity has been continuous for approximately 15 minutes without any return to consciousness. She has no known past medical history and takes no daily medications. Vital signs show a blood pressure of 145/90 mmHg, heart rate of 118/min, and oxygen saturation of 94% on a non-rebreather mask. Intravenous access is rapidly established by the nursing staff, and a point-of-care blood glucose level is 102 mg/dL.

Arrange the following pharmacologic interventions in the correct sequential order for the management of this patient's condition, starting from the most immediate initial therapy to the final step for super-refractory disease.

During morning rounds in the intensive care unit, the medical team evaluates a patient receiving treatment for an acute massive pulmonary embolism. The 58-year-old male, who has a documented history of advanced chronic kidney disease (stage G4), was started on a continuous intravenous unfractionated heparin infusion upon admission. Which of the following laboratory parameters must be routinely monitored to ensure the efficacy and safety of this specific anticoagulant therapy? (Select all that apply)

A $76$-year-old woman comes to the outpatient clinic for a routine follow-up. Two weeks ago, she was diagnosed with major depressive disorder, and she is agreeable to starting pharmacotherapy today. A prescription for sertraline is initiated. Her medical history includes essential hypertension, hyperlipidemia, and osteoarthritis. Her daily medications include hydrochlorothiazide, lisinopril, atorvastatin, and as-needed acetaminophen. Her blood pressure is $135/82\text{ mmHg}$ and her heart rate is $74\text{/min}$. Physical examination is unremarkable. In addition to assessing her clinical response to the new medication, which of the following is the most appropriate monitoring plan for this patient?

A 78-year-old female patient is evaluated during a routine ambulatory appointment at a geriatrics clinic. Her daughter, who provides collateral history, expresses concern regarding the patient's escalating confusion and recent onset of urinary dribbling over the past month. The patient's medical history includes major depressive disorder, essential hypertension, type 2 diabetes mellitus, and painful diabetic peripheral neuropathy. Her daily medication regimen consists of metformin, amlodipine, sertraline, amitriptyline (initiated four weeks ago for neuropathy), and over-the-counter diphenhydramine (taken nightly for insomnia).

Vital signs show a heart rate of 92/min. Blood pressure is 138/82 mm Hg while supine and 112/68 mm Hg upon standing. Physical examination is notable for dry oral mucous membranes, delayed capillary refill, and a mildly distended, palpable mass in the suprapubic region. A bedside ultrasound of the bladder demonstrates a postvoid residual volume of 550 mL.

Which of the following is the most appropriate initial pharmacologic intervention?

A $22$-year-old man with type 1 diabetes mellitus is being treated in the intensive care unit for diabetic ketoacidosis. He has been receiving a continuous intravenous regular insulin infusion, intravenous fluids, and potassium replacement for the past $14$ hours. Current laboratory evaluation reveals a blood glucose of $178$ mg/dL, a serum bicarbonate of $20$ mEq/L, and a calculated anion gap of $9$ mEq/L. The patient is awake, alert, and reports feeling hungry. The physician decides to transition the patient to a subcutaneous insulin regimen. Arrange the following management and monitoring steps in the correct chronological sequence to safely accomplish this therapeutic de-escalation.

A 58-year-old man is brought to the emergency department by his wife due to fever, severe headache, and confusion that started 12 hours ago. He has a past medical history of alcohol use disorder, type 2 diabetes mellitus, and hypertension. His temperature is 39.2°C (102.6°F), blood pressure is 110/70 mmHg, and heart rate is 115/min. On physical examination, he is lethargic but arousable. There is significant resistance to passive neck flexion. Funduscopic examination shows no papilledema. Lumbar puncture is performed, and cerebrospinal fluid (CSF) analysis reveals a leukocyte count of 2,400/mm³ (90% neutrophils), a glucose level of 30 mg/dL, and a protein level of 150 mg/dL. Gram stain of the CSF is pending.

Which of the following pharmacologic agents should be included in his immediate empiric regimen? (Select all that apply)

A $67$-year-old male presents to the primary care clinic for a routine follow-up. Five years ago, he underwent a mechanical mitral valve replacement and has been maintained on chronic warfarin therapy. His target international normalized ratio (INR) is between $2.5$ and $3.5$. Over the past year, his laboratory values have been stable on a daily warfarin dose of $5$ mg. Six days ago, he was evaluated at an urgent care facility for a suspected urinary tract infection and was prescribed a $7$-day course of trimethoprim-sulfamethoxazole. The patient reports feeling well today. He denies any epistaxis, hematuria, melena, or easy bruising. Vital signs are within normal limits. Physical examination reveals clear lungs, normal heart sounds with a distinct mechanical click, and no petechiae or ecchymoses. His neurologic examination is unremarkable. A point-of-care INR obtained in the clinic today is $7.4$. Which of the following is the most appropriate next step in management of this patient?

A 42-year-old woman with a history of bipolar I disorder is admitted to the inpatient psychiatric unit with an acute manic episode. She has previously been nonadherent to medications but now agrees to initiate treatment with lithium carbonate. She has no other medical conditions and takes no other medications. Her physical examination is unremarkable. In addition to monitoring serum drug concentrations, which of the following laboratory parameters are necessary to evaluate at baseline and periodically during long-term maintenance therapy with this medication? (Select all that apply)

A 48-year-old man presents to the emergency department with an 8-hour history of severe, unremitting epigastric pain that radiates to his mid-back. He reports that the pain is exacerbated by lying supine and is partially relieved by leaning forward. He has had two episodes of non-bloody, non-bilious emesis since the pain began. His medical history is notable for hypertension treated with amlodipine. He does not use tobacco but drinks 3-4 alcoholic beverages daily. His temperature is $37.8^\circ\text{C}$ ($100^\circ\text{F}$), blood pressure is $138/86\text{ mmHg}$, pulse is $105/\text{min}$, and respiratory rate is $18/\text{min}$. Physical examination shows a distressed patient with marked epigastric tenderness to palpation, but no rebound tenderness or guarding. Bowel sounds are hypoactive. Which of the following diagnostic tests should be included in the initial diagnostic workup of this patient? (Select all that apply)

A 48-year-old woman presents to the emergency department reporting a temperature of 38.4°C (101.1°F) measured at home. She is currently undergoing adjuvant chemotherapy with docetaxel and cyclophosphamide for stage II breast cancer; her last cycle was 10 days ago. She reports mild fatigue but denies chills, cough, dyspnea, abdominal pain, or dysuria. She lives with her husband 15 minutes away from the hospital and has been independently performing all daily activities.

Vital signs on arrival show a blood pressure of 122/78 mmHg, pulse of 88/min, respiratory rate of 14/min, and oxygen saturation of 99% on room air. Physical examination reveals a well-appearing, well-hydrated woman with no focal source of infection. An implanted venous port site shows no erythema or tenderness.

Laboratory studies reveal:
Hemoglobin: 10.5 g/dL
Leukocytes: 800/mm³
Absolute neutrophil count (ANC): 300/mm³
Platelets: 120,000/mm³
Comprehensive metabolic panel: within normal limits

Blood and urine cultures are obtained, and she is promptly given a dose of intravenous cefepime. After 4 hours of observation in the emergency department, she remains afebrile and hemodynamically stable, and she tolerates oral fluids without difficulty. Based on this patient's clinical risk profile and treatment response, which of the following is the most appropriate disposition?

A 68-year-old man is evaluated in the urgent care clinic for a 24-hour history of severe, progressive pain and swelling in his right knee. He is unable to bear weight on the affected leg. His medical history is significant for type 2 diabetes mellitus, hypertension, and stage 4 chronic kidney disease with a baseline estimated glomerular filtration rate (eGFR) of $24 \text{ mL/min/1.73 m}^2$. Current medications include amlodipine, insulin detemir, and calcium acetate. Vital signs are temperature $37.2^\circ\text{C}$ ($99.0^\circ\text{F}$), pulse 88/min, and blood pressure 138/84 mm Hg. Physical examination reveals a swollen, erythematous, and exquisitely tender right knee with a moderate effusion. Arthrocentesis is performed. Synovial fluid analysis reveals a leukocyte count of $28,000/\mu\text{L}$ (85% neutrophils) and the presence of negatively birefringent, needle-shaped crystals under polarized light microscopy. Gram stain is negative. Which of the following is the most appropriate pharmacologic intervention for this patient's acute joint condition?

A 22-year-old male university student is transported to the emergency department after falling approximately 3 meters (10 feet) from a balcony and striking his head on concrete. Emergency medical services report that he was initially conversant at the scene but became increasingly somnolent during transit. Upon arrival, he does not open his eyes to pain, makes no verbal sounds, and withdraws his left arm from painful stimuli. Vital signs demonstrate a blood pressure of 185/105 mmHg, a heart rate of 48/min, and a respiratory rate of 8/min with irregular breathing patterns. Physical examination reveals a right pupil that is 7 mm and unresponsive to light, while the left pupil is 3 mm and briskly reactive. Which of the following is the most appropriate immediate next step in management?

A 54-year-old woman presents to the emergency department after recording a temperature of 38.5°C (101.3°F) at home two hours ago. She has a history of stage II right breast cancer and underwent a lumpectomy six weeks ago. She is currently receiving adjuvant chemotherapy, with her most recent cycle of docetaxel and cyclophosphamide administered 8 days ago. The patient reports mild fatigue but denies chills, cough, shortness of breath, dysuria, abdominal pain, or diarrhea. She has no other significant medical conditions. She lives 10 miles from the hospital with her husband, who drove her to the emergency department today.

Temperature is 38.3°C (100.9°F), blood pressure is 122/78 mm Hg, pulse is 92/min, and respiratory rate is 16/min. Pulse oximetry is 99% on room air. The patient appears comfortable and in no acute distress. The implanted central venous catheter site is clean without erythema, induration, or tenderness. Cardiopulmonary examination is normal. The abdomen is soft and non-tender.

Laboratory studies show:
Leukocyte count: 1,100/µL
Absolute neutrophil count: 350/µL
Hemoglobin: 11.2 g/dL
Platelets: 145,000/µL
Blood urea nitrogen: 14 mg/dL
Serum creatinine: 0.8 mg/dL
Hepatic function panel: Normal

Chest radiograph shows no infiltrates. Urinalysis is unremarkable. The patient is able to tolerate oral fluids in the emergency department without nausea.

Which of the following is the most appropriate disposition for this patient?

A 58-year-old man is evaluated in the hospital for a 5-day history of fever, nonproductive cough, and right-sided pleuritic chest pain. He underwent a deceased-donor renal transplantation eight months ago and is maintained on a daily immunosuppressive regimen of tacrolimus, mycophenolate mofetil, and low-dose prednisone. Vital signs are temperature $38.6^\circ\text{C}$ ($101.5^\circ\text{F}$), pulse $108/\text{min}$, respirations $20/\text{min}$, and blood pressure $138/82\text{ mm Hg}$. Chest computed tomography reveals a dense right upper lobe nodule with a surrounding halo of ground-glass attenuation. Serum galactomannan assay is strongly positive, and bronchoscopy with bronchoalveolar lavage confirms the diagnosis of invasive pulmonary aspergillosis. The medical team decides to initiate the standard first-line targeted intravenous antifungal therapy for this condition. Which of the following concurrent pharmacologic interventions is most appropriate for this patient?

A 68-year-old man is preparing for discharge to a subacute rehabilitation facility following a prolonged hospitalization for acute decompensated heart failure and superimposed hospital-acquired pneumonia. His clinical course necessitated numerous changes to his baseline diuretic, antihypertensive, and diabetic regimens. The discharging physician is executing the formal medication reconciliation process to ensure safe continuity of care and prevent adverse drug events during this care transition. Arrange the following fundamental steps of the standardized medication reconciliation process in the correct chronological sequence.